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ORIGINAL RESEARCH |
From the Emory Center on Health Outcomes and Quality, formerly the USQA Center for Health Care Research, Atlanta, Georgia; Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina; and Centers for Disease Control and Prevention, Atlanta, Georgia.
Address reprint requests to: Julie Gazmararian, PhD, Emory Center on Health Outcomes and Quality, Department of Health Policy and Management, 6th Floor, Rollins School of Public Health of Emory University, 1518 Clifton Road, NE, Atlanta, GA 30322; E-mail: jagazma{at}sph.emory.edu.
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ABSTRACT |
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METHODS: We analyzed data from a national managed care organization and determined the occurrence of hospitalizations for 46,179 women who had a live birth or a pregnancy loss in 1997.
RESULTS: Overall, 8.7% of women were hospitalized during their pregnancy. Of these, 5.7% were hospitalized and discharged while pregnant, 0.8% experienced extended stays before a live birth or pregnancy loss, and 2.1% experienced pregnancy loss. Hospitalizations were more common among younger women, women with multiple gestations, and women in the northeastern United States. Women who had a live birth were primarily hospitalized for preterm labor (24%), hyperemesis (9%), hypertension (9%), kidney disorders (6%), and prolonged premature rupture of membranes (6%). Charges totaled over $36 million.
CONCLUSION: Antenatal hospitalizations are common.
Many women experience morbidity during pregnancy, resulting in additional outpatient care, inpatient care while pregnant, pregnancy loss, extended hospitalization before delivery, and complications during labor and delivery. In 1992, for every 100 US hospitalizations involving a birth, an estimated 18.1 nondelivery hospitalizations occurred for complications: 13.7 for antenatal complications and 4.4 for pregnancy loss.1 Similar data have been found among state (25 per 100 deliveries),2 military (26.8% of women hospitalized),3 and clinic-based (17.7% of women hospitalized)4 populations, as well as in other countries.5
The only large datasets available to monitor antenatal morbidity derive from administrative sources. Because these sources usually cannot distinguish routine outpatient antenatal care from such care associated with antenatal morbidity, most antenatal morbidity measurements have used hospitalization as an indicator of severe morbidity. The National Hospital Discharge Survey has been the primary data source for monitoring antenatal hospitalizations.1,6 However, this database has several limitations, notably the inability to determine the number of multiple hospitalizations for one woman, identify prolonged hospitalizations that immediately precede delivery, and provide detailed information about admission diagnoses and associated costs. Additional data could be instrumental in understanding the burden of antenatal hospitalizations by providing information about extended hospitalizations or separate admissions before delivery, as well as the characteristics of these hospitalizations.
We used administrative data from a large managed care organization to examine the prevalence of hospitalizations during pregnancy, factors associated with hospitalizations during pregnancy, the distribution of the number of hospital visits during pregnancy, and the reasons, length of stay, and associated costs of inpatient care. This information may be useful to monitor trends in care and to assess the financial and service burdens associated with severe antenatal morbidity.
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MATERIALS AND METHODS |
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). Women who had insufficient information to determine pregnancy conclusion, had an invalid code (eg, age, sex), or were not continuously enrolled for the 308 days before their delivery or pregnancy loss date were excluded, leaving 46,179 eligible women. Of these, 35 had two pregnancies during the study period, and information from both pregnancies was included.
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Two Institutional Review Boards (USQA Center for Health Care Research, formerly the Prudential Center for Health Care Research, and the Centers for Disease Control and Prevention) reviewed and approved the study protocol.
We included additional data from the administrative database: maternal age, delivery method, plurality, and geographic region. Delivery method was coded either vaginal or cesarean on the basis of standard diagnosis and procedure codes, plurality was coded as either singleton or multiple on the basis of International Classification of Diseases, 9th Revision codes. A unique patient identifier allowed us to examine multiple admissions for each woman in our study population.
For each antenatal hospitalization, we examined the reason for the hospitalization, the length of stay, and the associated costs. We had up to 39 diagnosis and 39 procedure codes for each hospitalization. Two obstetricians (RP, DJ) determined the primary reason for hospitalization by using a predefined list of reasons to independently categorize the diagnosis and procedure codes for each hospitalization. Any discrepancies between observations were jointly reviewed and resolved. For women who had a live birth, we subtracted any costs associated with the delivery from those of the prolonged hospitalization (occurring at least 4 days before delivery) so that the antenatal hospitalization only reflected non-delivery-associated charges. For women who had a pregnancy loss, we included total costs for the hospitalization (antenatal, prolonged hospitalization, and pregnancy loss).
We compared antenatal hospitalization statuses using the available covariates for the study population. Characteristics of women who were hospitalized only for a live birth (n = 42,163) were compared with women who had any hospitalization during pregnancy (including all pregnancy losses, hospitalization and discharge while pregnant, or prolonged hospitalizations). We used 
2 test to assess any significant differences between these two groups. We also examined the distribution of the number of hospital visits separately for women with live births or pregnancy losses. Finally, we examined the distribution for the cause of antenatal hospitalizations, average length of stay, and associated charges. We conducted all analyses using the Statistical Analysis Software package (SAS/STAT User’s Guide, 6, 4th ed., Vol. 1, 1989, SAS Institute, Inc., Cary, NC).
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RESULTS |
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). The majority of women in this study were over age 30 years, had a singleton pregnancy or lived in the South. Compared with women who were only hospitalized for a live birth, women who had a hospitalization (hospitalized and discharge while pregnant, extended stay before a live birth or pregnancy loss, or pregnancy loss) were less than age 20, had a multiple birth, or lived in the northeastern United States.
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). Among women with a live birth, 15.7% (472 of 3003) were hospitalized more than once (7.8 antenatal admissions per 100 live births, 3619 of 46,179). Of the women with a pregnancy loss outcome, 2.9% (29 of 1013) were prior to the pregnancy loss (2.3 antenatal admissions per 100 pregnancy losses, 1043 of 46,179).
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). The overall mean length of stay for hospitalizations was 4.1 days, and the total charges were almost $28 million in 1997. Within this group, the top two reasons for delivery-associated hospitalizations were premature rupture of membranes (35.6%) and pregnancy-associated hypertension (27.0%) (data not shown). Among women with a pregnancy loss, 35.3% were hospitalized for ectopic pregnancy (Table 4). Pregnancy loss hospitalizations resulted in close to $9 million in charges.
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DISCUSSION |
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This is the first study that uses data from a large national managed care population to monitor inpatient care received by women during their pregnancies. (We searched the entire MEDLINE database using the terms antepartum, hospitalization, maternal morbidity, and pregnancy complications. The search was last updated when we completed final revisions to the manuscript.) Our data allowed us to examine multiple admissions, as well as pregnancy losses and live birth deliveries, in a large population of women. Moreover, because we had detailed diagnosis and procedure codes and cost data, we could further examine the reasons for and impact of antenatal hospitalizations. Despite these advantages, there were three major limitations. First, our data represented an insured population and did not include uninsured and other vulnerable populations. Second, the available information from our administrative dataset was limited. For example, we were unable to explore relationships between hospitalizations and use of outpatient care, reproductive health history, demographic factors (eg, race), and antenatal risk factors. The absence of some of this information also limits the generalizability of the findings. Moreover, we may have missed severe morbidity that resulted in immediate delivery. Finally, our sample only included women whose pregnancy ended in a hospital, regardless of outcome. Although we were able to provide some insight to pregnancy loss-related hospitalizations, additional research is needed to accurately understand the experiences of women with a pregnancy loss who were never hospitalized.
Maternal morbidity, as measured by antenatal hospitalization, is an important health problem in terms of prevalence and costs. Further study of antenatal hospitalizations may identify specific reasons for these hospitalizations, determine whether they can be prevented, and ultimately meet our goal of decreasing maternal and fetal morbidity. Research is also needed to help determine whether hospitalizations are cost-effective. A few studies have suggested that outpatient management of placenta previa,11–13 hypertension during pregnancy,14,15 and premature rupture of membranes16 is just as effective as inpatient management and could therefore present an alternative to hospitalization. In addition to outpatient services, expanded patient education, improved screening, and more targeted provider and patient monitoring for at-risk groups17 may be used to possibly reduce the risk of maternal and fetal morbidity and mortality and thus the occurrence of antenatal hospitalizations.
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Footnotes |
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Received July 31, 2001. Received in revised form February 5, 2002. Accepted February 28, 2002.
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REFERENCES |
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2. Scott CL, Chavez GF, Atrash HK, Taylor DJ, Shah RS, Rowley D. Hospitalizations for severe complications of pregnancy, 1987–1992. Obstet Gynecol 1997;90:225–9.[Abstract]
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15. Crowther CA, Bouwmeester AM, Ashurst HM. Does admission to hospital for bed rest prevent disease progression or improve fetal outcome in pregnancy complicated by non-proteinuric hypertension? Br J Obstet Gynaecol 1992;99:13–7.
16. Carlan SJ, O’Brien WF, Parsons MT, Lense JJ. Preterm premature rupture of membranes: A randomized study of home versus hospital management. Obstet Gynecol 1993; 81:61–4.
17. Brooten D, Kaye J, Poutasse SM, Nixon-Jensen A, McLean H, Brooks LM, et al. Frequency, timing, and diagnoses of antenatal hospitalizations in women with high-risk pregnancies. J Perinatol 1998;18:372–6.[Medline]
This article has been cited by other articles:
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  F. C. Bruce, C. J. Berg, M. C. Hornbrook, E. P. Whitlock, W. M. Callaghan, D. J. Bachman, R. Gold, and P. M. Dietz Maternal Morbidity Rates in a Managed Care Population Obstet. Gynecol., May 1, 2008; 111(5): 1089 - 1095. [Abstract] [Full Text] [PDF]
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