Morbidity of Women Who Give Birth

7/23/2019 Morbidity of Women Who Give Birth

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National VitalStatistics ReportsVolume64,Number4 May20,2015

Maternal

Morbidity

for

Vaginal

and

Cesarean

Deliveries,According toPreviousCesareanHistory:NewDataFromtheBirthCertificate,2013

bySallyC.Curtin,M.A.,NationalCenter forHealthStatistics;KimberlyD.Gregory,M.D.,M.P.H.,Cedars-SinaiMedicalCenter;LisaM.Korst,M.D.,Ph.D.,ChildbirthResearchAssociates,LLC;andSayeedhaF.G.Uddin,M.D.,M.P.H.,NationalCenter forHealthStatistics

600

525.1

Vaginal birthNoprevious cesarean

Primary cesarean Vaginal birthPreviouscesarean (VBAC)

Repeat cesarean

Rateper100,0

00livebirths

0

100

200

300

400

500

167.1

366.8

468.7

49.2 43.8

88.9

6.3 11.9

67.551.1

143.1

64.6

383.1

131.4

270.3

Maternal transfusion Ruptured uterus1 Unplanned hysterectomy1 ICU admission

1Difference in rates between primary cesarean and VBAC is not statistically significant.NOTES: The birth certificate reporting area represented 90% of all U.S. births in 2013. ICU is intensive care unit.SOURCE: CDC/NCHS, National Vital Statistics System.

Figure1.Maternalmorbidity,bymethodofdeliveryandpreviouscesareanhistory:41-stateandDistrictofColumbiareportingarea,2013

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and Prevention

National Center for Health StatisticsNational Vital Statistics System


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2 NationalVitalStatisticsReports,Vol.64No.4,May20,2015

Abstract

ObjectivesThisreportpresentsrecentfindingsfor2013onfourmaternal morbidities associated with labor and deliverymaternaltransfusion, ruptured uterus, unplanned hysterectomy, and intensivecareunit(ICU)admissionthatarecollectedonbirthcertificates fora41-stateandDistrictofColumbia reportingarea,which represents90%ofallbirths in theUnitedStates.

MethodsRates

of

maternal

morbidity

(per

100,000

live

births)

by

maternalageandraceandethnicityarepresentedbycurrentmethodofdelivery(vaginalorcesarean)andpreviouscesareanhistory.Totalrates are also presented by current method of delivery, previouscesareanhistory,andwhethera trialof laborwasattempted.

ResultsRates

of

maternal

morbidity

were

higher

for

cesarean

thanvaginaldeliveriesratesoftransfusion(525.1per100,000)andICUadmission(383.1)werehighest forprimarycesareandeliveries,while rates of ruptured uterus (88.9) and unplanned hysterectomy(143.1)werehighest for repeat cesareandeliveries.Higher ratesofmaternalmorbidityforcesareancomparedwithvaginaldeliverieswerefound fornearlyallmaternalagegroupsand forwomenofallraces

and

ethnicities.

Women

with

no

previous

cesarean

delivery

who

had

vaginaldeliverieshadlowerratesforallmaternalmorbiditiescomparedwith those who had cesarean deliveries. Women with a previouscesarean delivery who labored and had vaginal birth generally hadlowerratesformostof themorbidities,butfailedtrialsof laborweregenerally associated with higher morbidity than scheduled repeatcesareandeliveries,especially forruptureduterus,whichwasseventimeshigher(495.4per100,000comparedwith65.6).

Keywords:transfusionruptureduterusICUadmissiontrialoflabor

Introduction

Maternal morbidity was defined recently by the World HealthOrganizationasanyhealthconditionattributedtoand/oraggravatedby pregnancy and childbirth that has a negative impact on thewomans wellbeing (1). These morbidities can have short- andlong-termhealthimplicationsforthemotherandthenewbornandcanlengthen hospital stays and increase health care costs (2). Recentresearch has shown that severe maternal morbidity is increasing inCalifornia, partly due to worsening trends in underlying maternalhealthincreased obesity, diabetes, and hypertension, both beforeand during pregnancy (3). Other clinical factors that have beenassociatedwith therise inmaternalmorbidityare the increaseduseofcesareandeliveryandinductionandaugmentationoflabor(4,5).A

demographic

contributor

to

rising

maternal

morbidity

has

been

the

increasing

proportion

of

births

to

older

women,

who

tend

to

have

more health issues and more labor interventions than youngerwomen (6,7). Racial and ethnic disparities persist in maternalmorbidity,withnon-Hispanicblackwomen inparticularhavinghigherrates,evenafterother factorsare taken intoaccount(8).

Another predictor of maternal morbidity is previous cesareanhistoryresearchhasgenerallyshownthatforwomenwithapreviousbirth, those with a history of previous cesarean delivery are at anincreasedriskofmaternalmorbidity(911).This increasedmorbiditypersistedevenwhenotherrelevantdemographicandhealthriskfactorsweretakenintoaccount(9).Inparticular,issuesinvolvingtheplacenta

(placenta previa and accreta, and placental abruption) are morecommoninwomenwithpreviouscesareandeliveries(10).Additionally,the risk of many serious maternal morbidities has been shown toincreaseprogressivelyasthenumberofpreviouscesareandeliveriesincreased (12).

Given the lower morbidity for vaginal compared with cesareandeliveries,attemptingatrialoflaborisrecommendedformostwomenwithnopreviouscesareanaswellasforlow-riskwomenwithapreviouscesarean

delivery

(13).

However,

although

successful

attempts

at

a

trial

of laboraftercesarean(i.e., leadingtoavaginalbirthaftercesarean[VBAC]) result in lower morbidity than planned repeat procedures,failed trialsof labor result in increasedmorbidity (14).Forexample,although rare, rates of ruptured uterus are higher among womenattemptingatrialoflaborafterapreviouscesareanthanamongwomenwithelectiverepeatprocedures(15).Theattempttoavoidsuchmorbiditiesmayhavecontributed to thedecliningpercentageofwomenwithpreviouscesareandeliveriesattemptinga trialof laborover thelast2decades(16).

Dataonmaternalmorbidityareavailableforthefirsttimeforbirthsregisteredusingthe2003revisionoftheU.S.StandardCertificateof

Live

Birth.

Items

capturing

maternal

morbidity

were

added

to

the

birthcertificatetoestablishanationalsurveillancesystemtomonitorthese

morbidities. Maternal morbidity data are available for 41 states thatadopted the 2003 revised birth certificates as of January 1, 2013,representing90%ofallbirthsintheUnitedStatesin2013;completenationaldatafromallofthestatesareexpectedtobeavailablefordatayear2015.

Thisreportfocusesontheincidenceoffourmaternalmorbiditiesreportedonthebirthcertificate:maternaltransfusion,ruptureduterus,unplannedhysterectomy,andICUadmission,allofwhichareusuallyassociatedwithseverecomplicationsoflaborordelivery.Theratesarecompared between vaginal and cesarean deliveries by whether themotherhadapreviouscesareandeliveryandbywhetheratrialoflabor

was

attempted.

This

stratified

analysis

is

possible

with

birth

certificate

databecausetheyarebasedonlargeandalmostcompletecountsofbirth records.

Methods

Data used in this analysis are from the birth certificate andbasedon100%ofbirthsregisteredinthe41statesandtheDistrictofColumbia(D.C.)thathad implemented the2003revisionofthebirthcertificateasofJanuary1,2013.The41statesare:Alaska,California,Colorado, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa,Kansas,Kentucky,Louisiana,Maryland,Massachusetts,Michigan,Min

nesota,

Mississippi,

Missouri,

Montana,

Nebraska,

Nevada,

New

Hampshire,

New

Mexico,

New

York

(including

New

York

City),

North

Carolina,

NorthDakota,Ohio,Oklahoma,Oregon,Pennsylvania,SouthCarolina,SouthDakota,Tennessee,Texas,Utah,Vermont,Virginia,Washington,Wisconsin,andWyoming.

Thebirthsinthe41-stateandD.C.reportingarearepresent90%ofallbirths intheUnitedStates in2013butarenotgeneralizabletothe entire United States in 2013. Some differences between thereportingareaandtheUnitedStatesarenotable,particularlyintheraceandHispanicorigindistributions.BirthstoHispanicwomenandnon-Hispanic black women are slightly overrepresented (23.2% in thereportingareacomparedwith23.1%inthenationforHispanicwomen;


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3NationalVitalStatisticsReports,Vol.64No.4,May20,2015

15.1% compared with 15.0% for non-Hispanic black women), whilebirths toAmerican IndianorAlaskaNativewomen(AIAN)andAsianorPacific Islander(API)womenareslightlyunderrepresented(0.9%comparedwith1.0%forAIANwomen;6.3%comparedwith6.5%forAPIwomen);seeTableDoftheUserGuidetothe2013NatalityPublicUseFile(17).Whilethesedifferencesaresmall,theyarestatisticallysignificant.Bycomparison,almostnostatisticallysignificantdifferenceswereobservedbetween the reportingareaand theUnitedStates inmaternal

age,

marital

status,

and

infant

characteristics.

Although

not

basedonbirthsfromall50states,thesebirthcertificatedataprovidea large number of births to examine rare events such as maternalmorbiditybymethodofdeliveryandhistoryofcesareandelivery.

The2003 revisionof theU.S.StandardCertificateofLiveBirthaddedtheitemofmaternalmorbidity.Theinstructionsforthisitemaretocheckallthatapplyofthefollowingmorbidities:maternaltransfusion,third- orfourth-degreeperineallaceration,ruptureduterus,unplannedhysterectomy,admissiontointensivecareunit(ICU),unplannedoperating room procedure following delivery, or none of the above. Thesourceofthisinformationisrecommendedtobeinthemedicalrecord(18).

Two

of

the

six

listed

morbidities

were

not

included

in

this

report.Third- orfourth-degreeperineallacerationswasnotincludedbecause

this condition almost always occurs in vaginal births (99%), and ananalysisbymethodofdeliveryisnotappropriate.Unplannedoperatingroomprocedurewasnotincludedbecausethedefinitionisconsideredambiguous.Thefourmorbidities inthisreportareusuallyassociatedwithseverematernalmorbidityitscauses (i.e., ruptureduterus)aswellasitstreatments(maternaltransfusion,unplannedhysterectomy,andICUadmission).Transfusionsaremostoftenadministeredtotreatsevereanemiaandhemorrhaging(19).Unplannedhysterectomiesaremost often performed to treat hemorrhaging (4). Some of the mostcommonreasonsforICUadmissionarepregnancy-relatedhypertensive disease, hemorrhaging, cardiac disease, and infections (20).

Records

for

states

in

the

reporting

area

with

missing

information

on

maternalmorbiditynumbered22,064 (of3,548,525births),or0.6%.Informationonwhetherawomanhadapreviouscesareanandthe

numberofpreviouscesareanswasobtainedfromtheRiskfactorsinthis

pregnancy

item

on

the

birth

certificate.

Missing

records

for

this

item

numbered18,956(of3,548,525births),or0.5%.InformationonmethodofdeliverywasobtainedfromtheMethodofdeliveryitemonthebirthcertificate.The three categories ofvaginalbirthsvaginal/spontaneous, vaginal/forceps,andvaginal/vacuumwerecombinedforatotalvaginalbirthscategory.Whilenotexplicitlyrecordedonthebirthcertificate,bytheirverynature,allvaginalbirthsareassumedtohavehadasuccessfultrialoflabor.Ifacesareanbirthwasindicated,thenthequestion,Ifcesarean,wasatrialoflaborattempted,wasusedtoobtaininformationontrialof

labor

for

these

births.

Records

with

missing

information

for

trial

of

labor

numbered34,094(of1,165,708birthsincesareandeliveries),or2.9%ofcesareandeliveries.

Thetermstrialoflaborandlaborareusedinterchangeablyinthis report. Inaddition, the terms cesareandeliverieswithouta trialoflaborandscheduledcesareandeliveriesareusedinterchangeably.

RaceandHispanicoriginarereportedindependentlyonthebirthcertificate. This report includes data for single-race, non-Hispanicwhite, single-race, non-Hispanic black, single-race, non-HispanicAsian,andHispanicbirths.DetailedinformationonNativeHawaiian

orOtherPacificIslander,AIAN,andmultiple-racebirthsisnotshownbecauseofthesmallnumbersofbirthsforthesegroupsinthisreportingarea.Detailedresults forHispanicsubgroupsarealsonotshown.

Ratesandpercentagesinthisreportarecomputedbysubtractingthenotstatedvaluesfromthetotallivebirthstoobtainthedenominators.Allmaternalmorbidityratesinthisreportareper100,000livebirths.Ratesinthisreportarecomputedonlywhenthenumberofcasesofaspecifiedmorbidity(thenumerator)isgreaterthanorequalto20,but

some

of

the

rates

in

this

report

are

based

on

cases

numbering

between20and99.Therandomvariabilityofthesesmallnumbersisusually greater in terms of percentage than for larger numbers ofevents.Alldifferencesbetweengroupsdiscussed in thisreportweretested for statistical significance, but caution should be used whenevaluatingratesbasedonfewerthan100events.ThestatisticaltestsusedarebasedonthePoissondistributionwhenthenumberofeventsis fewer than 100, and the normal distribution when the number ofeventsis100orgreater.SeeUserGuidetothe2010NatalityPublicUseFile(21)formoredetailonthesignificancetestingandexamplesofcomputations.

Results

Overallfindings

Maternaltransfusionwasthemostcommonofthefourmorbidities

(280.4 per 100,000), followed by ICU admission (154.8),unplanned hysterectomy (40.7), and ruptured uterus (26.1(Table1).

Women having vaginal deliveries with no previous cesarean

deliveryhad the lowest rates forall fourmorbidities(Figure1). Womenwithprimarycesareandeliverieshadthehighestratesof

transfusion(525.1)andICUadmission(383.1),whilemotherswith

repeat

cesarean

deliveries

had

the

highest

rates

of

ruptured

uterus(88.9)andunplannedhysterectomy (143.1).

WomenwithVBACdeliverieshadlowerratesofallfourmaternalmorbidities compared with women with repeat cesarean deliveries,and lower ratesof transfusionand ICUadmissionscomparedwithprimarycesareandeliveries.

Maternalage

Variationinmaternalmorbiditybymaternalageispartlyassociated with differences by age in rates of cesarean delivery andpreviouscesareanhistory(TableA.)Forexample,thetotalcesareanrateforwomenaged3554(43.0per100births)isnearlytwicethat

of

women

under

age

20

(21.8),

while

the

primary

cesarean

rate

isabout50%higher(29.4comparedwith19.9).About9of10women

withapreviouscesareanhaverepeatproceduresforallagegroups,but thepercentage isslightlyhigherforwomenaged3554 thanforyoungerwomen.Alargerproportionofoldermothershavealsohadapreviouscesarean.Table1containsratesofmaternalmorbiditybymaternalageforallbirths,aswellasratesbymethodofdeliveryandpreviouscesareanhistory.

Total

rates

of

transfusion

(316.3)

and

ICU

admission

(156.4)

by

maternalagewerehigherforteenagedmothersthanformothers


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aged 2034 (262.4 and 135.5, respectively), and highest formothersaged3554 (355.5and252.8,respectively)(Table1).

Totalratesofruptureduterusandunplannedhysterectomygenerally increased with maternal age, with a greater increase forunplannedhysterectomytherateforwomenaged3554(103.8)wasmorethan10timestherateforwomenunderage20(10.1).

Womenunderage20

The

rate

of

transfusion

was

almost

three

times

higher

for

births

inprimarycesareandeliveries(645.4per100,000)thanforvaginalbirthswithnopreviouscesarean(226.9).

The

rate

of

ICU

admission

was

seven

times

higher

for

women

havingprimarycesareandeliveries(496.6)thanforwomenhavingvaginalbirthswithnopreviouscesarean (68.5).

Casesofruptureduterusandunplannedhysterectomyforwomenunderage20weretoofewinnumbertoexaminedifferencesbymethodofdeliveryandpreviouscesareanhistory.

Womenaged2034and3554

Maternal transfusionsweremorecommon formotherswithpri

mary

and

repeat

cesarean

deliveries

and

VBAC

deliveries

than

for

motherswithvaginalbirthswithnopreviouscesarean. Amongthemethod-of-deliverygroupsforwhichdatawereavail

able,ratesofruptureduteruswerehighestforrepeatcesareans(90.6forwomenaged2034and83.1forwomenaged3554),and lowestforvaginalbirthswithnopreviouscesarean(5.7 forwomenaged2034and11.2 forwomenaged3554).

Womenwithvaginalbirthswithnopreviouscesareanhadlowerratesofunplannedhysterectomy thanwomenwhohadprimaryorrepeatcesareanbirths.Ratesofunplannedhysterectomywerehigher

for

repeat

cesarean

deliveries

than

for

primary

cesarean

deliveries.

WomenwithvaginaldeliverieswithnopreviouscesareanhadthelowestICUadmissionrates(58.9forwomenaged2034and97.3forwomenaged3554).Womenwithprimarycesareandeliverieshad higher rates of ICU admission than women with repeatcesareandeliveries(344.3comparedwith231.3,respectively,forwomenaged2034;502.2comparedwith397.1forwomenaged3554).

RaceandethnicityVariationinmaternalmorbiditybymaternalraceandethnicityis

partly associated with differences by race and ethnicity in rates ofcesarean delivery and previous cesarean history (TableA). Forexample, non-Hispanic white women had the lowest total cesareanrate(31.8per100births)andthehighestpercentageofwomenwithnopreviouscesarean(86.3).Hispanicwomenhadthelowestprimarycesareanrate(21.1),butthehighestproportionofwomenwithtwoormoreprevious cesareandeliveries (5.7%).Table2contains rates ofmaternalmorbiditybymaternalraceandethnicityforallbirthsaswellasratesbymethodofdeliveryandpreviouscesareanhistory.DuetoinsufficientcasesinsomeinstancesforbirthsinVBACdeliveriesandtonon-HispanicAsianwomen,rateswerenotcomputed forsomeof

the

morbidities

by

race

and

ethnicity.

Non-Hispanicblackwomenhad thehighestratesof transfusion(332.3)and ICUadmission (239.5)amongall racialandethnicgroups.

Non-Hispanicblack(39.2)andnon-HispanicAsian(32.1)womenhad thehighestratesof ruptureduterus.

Forcategorieswithsufficientcases tocompute rates,maternal

morbiditywashigherforwomenwhohadcesareandeliveriesthantheir counterparts who had vaginal deliveries with no previouscesarean forallof theracialandethnicgroups.

Inmost instances,ratesofruptureduterusandunplannedhys

terectomy were higher for repeat cesarean deliveries than for

TableA.Total,primary,andrepeatcesareanratesandpreviouscesareanhistory,bymaternalageandraceandethnicity:41-stateandDistrictofColumbiareportingarea,2013

Previous

cesarean

history

Total Primary Repeat

cesarean

cesarean

cesarean

Two

or

Maternal

age

and

race

and

ethnicity

Number

rate1 rate2 rate3 Total

None

One

more

Per100births

Allbirths4 . . . . . . . . . . . . . . . . . . . 3,548,525 32.6 22.8 89.4 100.0 85.4 10.3 4.4

Maternalage(years):

Under

20

. . . . . . . . . . . . . . . . .

248,842

21.8

19.9

89.5

100.0

97.3

2.5

0.2

2034 . . . . . . . . . . . . . . . . . . . 2,758,010 31.5 21.9 89.3 100.0 85.8 10.1 4.2

3554

. . . . . . . . . . . . . . . . . . .

541,673

43.0

29.4

89.9

100.0

77.7

14.9

7.4

Maternal

race

and

ethnicity:

Non-Hispanicwhite. . . . . . . . . . . . . 1,880,350 31.8 22.6 89.1 100.0 86.3 10.0 3.7

Non-Hispanic

black

. . . . . . . . . . . . .

511,132

35.9

25.7

89.0

100.0

84.0

10.7

5.3

Non-HispanicAsia n . . . . . . . . . . . . . 206,651 33.9 24.6 89.4 100.0 85.6 12.0 2.4

Hispanic

. . . . . . . . . . . . . . . . . .

818,006

32.3

21.1

90.4

100.0

83.9

10.4

5.7

1Numberofbirthsbycesareandeliveryper100 totalbirths.2Number

of

births

by

cesarean

delivery

per

100

births

to

women

with

no

previous

cesarean

delivery.

3Number

of

births

by

cesarean

delivery

per

100

births

to

women

with

a

previous

cesarean

delivery.

4Includesbirthswith raceandethnicitynotstated.

NOTES:

Race

and

Hispanic

origin

are

reported

separately

on

the

birth

certificate.

Race

categories

are

consistent

with

1997

Office

of

Management

and

Budget

standards;

see

Methods.

Data

by

race

are

non-Hispanic

and

exclude

mothers

reporting

multiple

races.

Reporting

area

includes

Alaska,

California,

Colorado,

Delaware,

District

of

Columbia,

Florida,

Georgia,

Idaho,

Illinois,

Indiana,

Iowa,

Kansas,

Kentucky,

Louisiana,

Maryland,

Massachusetts,

Michigan,

Minnesota,

Mississippi,

Missouri,

Montana,

Nebraska,

Nevada,

New

Hampshire,

New

Mexico,

New

York,

North

Carolina,

North

Dakota,Ohio,Oklahoma,Oregon,Pennsylvania,SouthCarolina,SouthDakota,Tennessee,Texas,Utah,Vermont,Virginia,Washington,Wisconsin,andWyoming.


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primarycesareandeliveriesfortheracialandethnicgroups.Theexceptions were ruptured uterus for Hispanic women (44.4 forprimarycomparedwith51.2forrepeatcesarean,notsignificantlydifferent) and unplanned hysterectomy for non-Hispanic Asianwomen (110.9 for primary compared with 124.5 for repeatcesarean,notsignificantlydifferent).

RatesofICUadmissionwerehigherforprimarycesareandeliveriesthanforrepeatcesareandeliveriesforallracialandethnicgroups.

Trialof laborandmethodofdelivery

Another importantconsideration inexamining ratesofmaternalmorbidity by previous cesarean history is whether a womanattempted a trial of labor with her current delivery. Rates of trial oflabor and trial-of-labor success rates differ markedly by previouscesarean

history

(Table

B

and

Figure

2).

Almost

9

of

10

women

with

nohistoryofapreviouscesareanattemptatrialof labor(87%),andthevastmajorityaresuccessful(89%).Incontrast,only1in5womenwhohadonepreviouscesareanattemptatrialoflaboraftercesarean(20%), although 70% of these are successful. Less than 1 in 10women

with

a

history

of

two

or

more

previous

cesarean

deliveries

attemptedatrialoflabor(7%),withaboutone-halfoftheseresultinginsuccessfulvaginaldeliveries(51%).

Womenwithnopreviouscesareandelivery

Table3andFigure3presentmaternalmorbidityratesforwomenwith no previous cesarean delivery by whether a trial of labor wasattemptedandwhether the laborresulted inavaginaldelivery.

Womenwhoattemptedatrialoflaborandhadasuccessfulvaginaldeliveryhadlowerratesforallofthemorbiditiescomparedwithwomenwhohadcesareandeliveries,eitherwithorwithoutlabor.

Women

with

cesarean

deliveries

who

did

not

labor

had

higherratesofICUadmission(420.6per100,000)thanwomenwhohad

failedtrialsoflabor(318.4),butlowerratesofmaternaltransfusion(486.9comparedwith600.9,respectively).

Theratesofruptureduterusandunplannedhysterectomywerenotstatisticallydifferentbywhetheratrialoflaborwasattemptedfor women who had cesarean deliveries with no history of apreviouscesarean.

Women

with

a

previous

cesarean

Table4andFigure4presentmaternalmorbidityratesforwomenwithapreviouscesareandeliverybywhethertheyattemptedatrialoflaborandwhether this laborultimately resulted inaVBACdelivery.

Womenwhoattemptedatrialoflaboraftercesareanandhadasuccessful VBAC delivery had lower rates of transfusion,unplannedhysterectomy,andICUadmissionthandidwomenwithcesareandeliverieswithoutlabor.RatesofruptureduteruswerenotsignificantlydifferentbetweensuccessfulVBACbirths (43.8per100,000)andcesareanbirths (65.6)withouta trialof labor.

WomenwithsuccessfultrialsoflaborresultinginVBACdeliverieshad lowerrates forallof themorbiditiescomparedwithwomen

who

had

failed

trials

of

labor

resulting

in

repeat

cesarean

deliveries.

Womenwhohadfailedtrialsoflaborresultinginrepeatcesareandeliverieshadhigherratesforthreeofthemorbiditiescomparedwith women with repeat cesareans without labor (transfusion,ruptureduterus,and ICUadmission).Thegreatestdifference inrateswasforruptureduterustherateforwomenwithfailedtrialsof

labor

(495.4

per

100,000)

was

more

than

seven

times

higher

thanforwomenwithrepeatcesareandeliverieswhodidnotlabor(65.6).

Discussion

This report presents recent data from the birth certificate onmaternalmorbidityassociatedwithlaboranddelivery.Thedatausedin this analysis from the 41-state and D.C. reporting area in 2013represent 90% of all U.S. births, and complete national data onmaternal morbidity are expected with the 2015 data year. Theestimatesofmaternalmorbidityfromthisstudymaynotbenationallyrepresentative, because births to Hispanic and non-Hispanic blackwomen are slightly overrepresented. Findings from the birth certificate data are generally consistent with previous research, althoughsome new findings for which previous research is not available arealsopresented.

Findings

from

the

birth

certificate

compared

withotherstudies

The findings in this study that womenwithcesarean deliverieshavemoremorbiditythanwomenwithvaginaldeliveriesisconsistentwith many other studies (25,9,12). History of a previous cesareanhas been generally associated with increased morbidity (911) andwas found in thisstudy forruptureduterusandunplannedhysterectomy, which had higher rates for repeat compared with primarycesareandeliveries.Giventhispattern,thehigherratesoftransfusionand ICU admission for primary cesareans compared with repeatcesareanswassomewhatunexpected.However,amulticenterU.S.

TableB.Methodofdeliveryand trialof labor,bypreviouscesareanhistory:41-stateandDistrictofColumbiareportingarea,2013

Previous

cesarean

history

Two or

Trial

of

labor

and

method

of

delivery

Total

None

One

more

Allb i r t h s . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0

Successful

trial

of

laborvaginal

deliveries

(includesVBAC1) . . . . . . . . . . . . . . 67.8 77.6 13.8 3.5

Failed trialof laborcesareandelivery . . . . 8.5 9.1 5.8 3.3

No

trial

of

laborcesarean

delivery

. . . . . .

23.7

13.3

80.4

93.2

Successratewhen trialof

labor

is

attempted2. . . . . . . . . . . . . .

88.8

89.5

70.4

51.4

1Vaginalbirthaftercesarean.2Percentage

of

vaginal

births

when

a

trial

of

labor

is

attempted.

NOTE:Reportingarea includesAlaska,California,Colorado,Delaware,DistrictofColumbia,Florida,Georgia, Idaho, Illinois, Indiana, Iowa,Kansas,Kentucky,Louisiana,Maryland,Massachusetts,Michigan,Minnesota,Mississippi,Missouri,Montana,Nebraska,Nevada,NewHampshire,

New

Mexico,

New

York,

North

Carolina,

North

Dakota,

Ohio,

Oklahoma,

Oregon,

Pennsylvania,

South

Carolina,

South

Dakota,

Tennessee,

Texas,

Utah,

Vermont,

Virginia,

Washington,

Wisconsin,

and

Wyoming.


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studythatfocusedspecificallyontransfusionsforwomenundergoing

cesarean

delivery

also

found

an

increased

incidence

in

primarycomparedwith repeatcesareandeliveries(19).The findings for ICU

admission

are

new,

with

no

other

large

U.S.

studies

available

that

examine this specifically by method of delivery and previouscesareanhistory.

Oldermothersandnon-Hispanicblackmothershavehigherratesof maternal morbidity, but this reflects, to some extent, their highercesarean rates. However, these groups generally have higher morbidity,evenwhenotherrelevant factorsareconsidered(9).Althoughratescouldnotbecomputedforsomegroupsduetoinsufficientcases,theelevatedmorbidityforcesareancomparedwithvaginaldeliverieswas generally found in all age groups and for all racial and ethnicgroups.

For

women

with

no

history

of

previous

cesarean,

morbidity

was

always lower forvaginalbirthscomparedwithwomenwithbirthsbycesareandeliveries,eitherwithorwithout labor.Resultsweremixedfor primary cesarean deliveries by whether a trial of labor wasattemptedfailed trials of labor were associated with elevatedmorbidityfortransfusionsrelativetocesareandeliverieswithoutlabor,butassociatedwithlowerratesofICUadmission.Becausemostwomenwithnopreviouscesareanattempt labor(almost9of10),thosewithscheduledcesareandeliveriesaremorelikelytohaveunderlyinghealthconditions or problematic pregnanciesmore preeclampsia, pluralgestations,

malpresentations,

and

suspected

macrosomic

fetuses

(weighing more than 4,000 grams)while a very small percentage

have elective procedures (22,23). Admission to the ICU has been

shown

to

be

associated

with

both

underlying

maternal

health

(chieflyhypertensive and cardiac issues) as well as issues associated with

labor

and

delivery

(hemorrhaging

and

infection)

(20).

Forwomenwithapreviouscesareandelivery,successfulVBACdeliveriesweregenerallyassociatedwithlowermorbiditythanscheduledrepeatprocedures(withtheexceptionofruptureduterus,whichwas not significantly different). However, failed trials of labor wereassociatedwithincreasedratesforthreeofthemorbiditiescomparedwithscheduledrepeatprocedures,whichisconsistentwithmanyotherstudies(2427)andespeciallytrueforruptureduterus.Attemptingatrialoflaborwiththecurrentdeliveryafterapreviouscesareandeliveryisaconsistentpredictorof ruptureduterus (15,27,28),although thismorbidity isstillveryrare.

Dataqualityofhealth information frombirthcertificates

Medicalandhealth informationhavebeen traditionallyunderreportedonthebirthcertificate(29,30).TheNationalCenterforHealthStatistics(NCHS) fieldeda recentvaliditystudybasedondata fromthe2003 revision thatdidnot includematernalmorbiditydue to therarityofsomeoftheitems(31).Otherrelevantmedicalitems(methodofdelivery,numberofpreviouscesareandeliveries,andtrialoflabor)were

included

in

the

NCHS

validity

study

conducted

in

two

states.

Theprimarymeasurementofdataquality forcheckbox items in the

NOTES: Total trial of labor is Vaginal plus CesareanFailed trial of labor. The birth certificate reporting area represented 90% of all U.S. births in 2013.SOURCE: CDC/NCHS, National Vital Statistics System.

0 20 40 60

Percent

80 100

CesareanNo trial of laborCesareanFailed trial of laborVaginal

Two or more 4 3 93

One 14 6 80

None 78 9 13

Number of previouscesarean deliveries

Total trial of labor = 87%



Figure2.Trialof laborandmethodofdelivery,bynumberofpreviouscesareandeliveries:41-stateandDistrictofColumbiareportingarea,2013


7/14


quality report was sensitivity, or the true positive rate. This is

measured

as

the

percentage

of

birth

records

for

which

a

specific

item

was reported when it was indicated on the medical record. Formethodofdelivery, thisstudy foundhighsensitivity,above90%, forvaginalandcesareandeliveriesinbothstates.Fortheitemsmotherhadapreviouscesareandeliveryand trialof labor,onestatehadsubstantial sensitivity, between 75.0% and 89.9%, and the otherstate had moderate sensitivity, between 60.0% and 74.9%. Thenumberofpreviouscesareandeliveriesisnotacheckboxitem,butacontinuous variable. The exact agreement between the birth certificateandthemedicalrecord(theprimaryqualitymeasure)wasabove90%

in

both

states.

Asanaggregatecomparison,twoofthematernalmorbidities in

this

report,

maternal

transfusions

and

unplanned

hysterectomy,

are

also

included

to

some

extent

on

the

Center

for

Disease

Control

and

Preventions(CDCs)listofseverematernalmorbidityindicators(32).Thesedataarecollectedfromanationallyrepresentativesurveybasedon International Classification of Diseases, Ninth Revision, ClinicalModification(ICD9CM)codesfromhospitaldischargerecordsintheUnitedStates.Theirestimateofmaternaltransfusionsforthelatestdatayear,20102011,was117per10,000deliveries(or1,170per100,000)comparedwithabout280per100,000forbirthcertificatedatain2013.Theirestimateofhysterectomywas9per10,000deliveries(or90per100,000),comparedwithabout41per100,000forbirthcertificatedata.Notethatthedefinitionsandmethodofascertainmentofthesemorbidities

differbetween the twodatasources,whichcould, inpart,explain these

discrepancies.

For

example,

the

CDC

indicator

for

hysterectomy

does

not

differentiate the procedure according to whether it was planned orunplanned,whereas the itemonthebirthcertificate isspecificabout itsbeing unplanned.However, given that these hysterectomies are performedatthetimeofdelivery,themajorityareemergentandunplanned(33). Despite the limitations, this comparison of the severe maternalmortalityindicatorsandthebirthcertificatedatasuggestsunderreportingof thesemorbiditieson thebirthcertificate.Thedifferentials inmorbidityamong groups featured in this report are generally consistent with theliterature,buttheoverall levelsaremost likelyunderestimated.

No

large-scale,

recent

studies

exist

to

use

as

comparisons

for

ruptureduterusandICUadmission,andpreviousestimatesofruptured

uterus

vary

widely

(34).

Problems

in

identifying

ruptured

uterus

with

ICD9CM

codes

have

been

documented

and

may

extend

to

birth

certificate data as well (35). In particular, ICD9CM codes do notdistinguish between a ruptured uterus and a less serious condition,uterinedehiscence.Astudythatcomparesbirthcertificateentrieswiththemedicalrecordwouldbenecessarytoascertainwhetherthisissuealsoexists forbirthcertificatedata.

Maternalmorbiditiesarerarebut importantmaternalhealth issues,andtheyaredifficulttoexaminewithmostsamplesurveydata.Studiesthatassessthevalidityofthebirthcertificatedataareneeded.Itishopedthatthesefindingswillinformresearchersandcliniciansaswellassuggestavenuesoffurtherresearchusingthesenewdata.

1Difference in rates between Primary cesareanFailed trial of labor and Primary cesareanNo trial of labor is not statistically significant.NOTES: The birth certificate reporting area represented 90% of all U.S. births in 2013. ICU is intensive care unit.SOURCE: CDC/NCHS, National Vital Statistics System.

Rateper100,0

00livebirths

0

100

200

300

400

500

600

700 Primary cesareanFailed trial of labor Primary cesareanNo trial of laborVaginal

ICU admissionUnplanned hysterectomy1Ruptured uterus1Maternal transfusion

167.1

600.9

486.9

55.0 46.5

11.9

70.4 66.6 64.6

318.4

420.6

6.3

Figure3.Maternalmorbidityforwomenwithnopreviouscesareandelivery,bymethodofdeliveryand trialof labor:41-stateandDistrictofColumbiareportingarea,2013


8/14


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41-state

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10

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and

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of

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area,

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. . . . . . . . . . . . . . . . . . . . . . .

12

4.

Maternal

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for

women

with

a

previous

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delivery,

by method of delivery and trial of labor: 41-state and District ofColumbiareportingarea,2013. . . . . . . . . . . . . . . . . . . . . . . 13
ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlhttp://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.htmlftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2010.pdfhttp://www.cdc.gov/nchs/data/dvs/guidetocompletefacilitywks.pdfftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdf


10/14


Table1.Maternalmorbidity,reportingarea,2013

[Ratesarenumberof livebirthswith

bypreviouscesareanhistory,methodofdelivery,

specifiedmorbidityper100,000 livebirths inspecifiedgroup]

andageofmother:41-stateandDistrictofColumbia

Age(years)andmaternalmorbidityAll

births

Previouscesareanhistoryandmethodofdelivery

Withoutpreviouscesareandelivery Withpreviouscesareandelivery

Vaginal Primarycesarean VBAC1 Repeatcesarean

2All

ages

Totalnumber . . . . . . . . . . . . . . . . Notstated3 . . . . . . . . . . . . . . . . .

Condition reported:

Maternal transfusion. . . . . . . . . . . Ruptureduterus . . . . . . . . . . . . . Unplannedhysterectomy . . . . . . . . Admission to intensivecareunit. . . .

Condition reported:


Under

age

20


Condition reported:


Aged2034


Condition reported:

Maternal transfusion. . . . . . . . . . . Ruptureduterus . . . . . . . . . . . . . Unplanned

hysterectomy

. . . . . . . .

Admission to intensivecareunit. . . .

Aged3554


Condition reported:


3,548,52522,064

9,888922

1,4375,460

280.426.140.7

154.8

248,8421,327

316.311.7 10.1

156.4

2,758,01016,566

262.424.531.2

135.5

541,6734,171

355.541.1

103.8252.8

2,322,3203,863

3,875146 277

1,497

167.16.3

11.964.6

192,901289

226.9* *

68.5

1,834,9402,965

157.85.79.4

58.9

294,479609

186.111.231.697.3

Number

of

686,1941,558

3,595337 462

2,623

Rate

525.149.267.5

383.1

Number

of

47,823100

Rate

645.4* *

496.6

Numberof

515,5361,086

Rate

489.345.350.5

344.3

Numberof

122,835372

Rate

628.873.5

158.4502.2

births

births

births

births

54,933140

20124 2872

366.843.851.1

131.4

7121

** **

42,02198

333.9*

50.1

109.7

12,20041

468.8**

213.8

464,3801,154

2,171412 663

1,252

468.788.9

143.1270.3

6,04310

480.7* **

349,709813

462.090.6

114.4

231.3

108,628331

489.483.1

239.2397.1

*

Figure

does

not

meet

standards

of

reliability

or

precision;

based

on

fewer

than

20

births

in

the

numerator.

1Vaginalbirthaftercesarean;98%ofvaginalbirthswere towomenwithnopreviouscesarean,while2%wereVBAC.Forsomegroups,maternalmorbiditycaseswere too few(less than20) forVBACto

show

rates

by

age

category.

2

Includes

births

with

previous

cesarean

history,

method

of

delivery,

or

maternal

morbidity

not

stated.

3Noresponse reported formaternalmorbidity item; includesbirths toresidentsofstatesusing the2003U.S.StandardCertificateofLiveBirthbutoccurring instatesusing the1989U.S.StandardCertificateofLiveBirth (0.3%).

NOTE:

Reporting

area

includes

Alaska,

California,

Colorado,

Delaware,

District

of

Columbia,

Florida,

Georgia,

Idaho,

Illinois,

Indiana,

Iowa,

Kansas,

Kentucky,

Louisiana,

Maryland,

Massachusetts,

Michigan,

Minnesota,

Mississippi,

Missouri,

Montana,

Nebraska,

Nevada,

New

Hampshire,

New

Mexico,

New

York,

North

Carolina,

North

Dakota,

Ohio,

Oklahoma,

Oregon,

Pennsylvania,

South

Carolina,

South

Dakota,

Tennessee,

Texas,

Utah,

Vermont,

Virginia,

Washington,

Wisconsin,

and

Wyoming.


11/14

NationalVitalStatisticsReports,Vol.64No.4,May20,2015 11

Table2.Maternalmorbidity,bypreviouscesareanhistory,methodofdelivery,andDistrictofColumbiareportingarea,2013

[Ratesarenumberof livebirthswithspecifiedmorbidityper100,000 livebirths inspecifiedgroup]

andraceandHispanicoriginofmother:41-state

Raceand

andHispanicoriginmaternalmorbidity

Allbirths

Previouscesareanhistoryandmethodofdelivery

Withoutpreviouscesareandelivery Withpreviouscesareandelivery

Vaginal Primarycesarean VBAC1 Repeatcesarean

2All

races

Totalnumber . . . . . . . . . . . . . . . . Not stated3 . . . . . . . . . . . . . . . . .

Condition reported:

Maternal transfusion. . . . . . . . . . . Ruptured uterus . . . . . . . . . . . . . Unplannedhysterectomy . . . . . . . . Admission to intensivecareunit. . . .

Condition reported:


Non-Hispanicwhite


Condition reported:


Non-Hispanicblack


Condition reported:

Maternal transfusion. . . . . . . . . . . Ruptured uterus . . . . . . . . . . . . .

Unplanned

hysterectomy

. . . . . . . .Admission to intensivecareunit. . . .

Non-HispanicAsian


Condition reported:


Hispanic


Condition

reported:


3,548,52522,064

9,888922

1,4375,460

280.426.140.7

154.8

1,880,3505,590

276.724.338.9

120.1

511,1323,474

332.339.2

46.1239.5

206,651743

251.632.147.6

150.6

818,0062,234

247.120.340.1

182.0

2,322,3203,863

3,875146 277

1,497

167.16.3

11.964.6

1,250,4261,826

172.54.7

11.847.7

316,9721,042

156.410.1

13.080.7

133,109312

155.1**

67.8

539,552478

150.86.9

11.392.8

Number

of

686,1941,558

3,595337 462

2,623

Rate

525.149.267.5

383.1

Numberof

365,751730

Rate

532.044.965.2

309.8

Numberof

109,553474

Rate

584.967.8

59.6572.1

Numberof

43,385117

Rate

487.750.8

110.9367.5

Numberof

144,342185

Rate

453.044.465.2

428.0

births

births

births

births

births

54,933140

20124 2872

366.843.851.1

131.4

28,17450

334.2**

88.9

8,99559

402.9*

**

3,16410

****

12,67620

331.9**

173.8

464,3801,154

2,171412663

1,252

468.788.9

143.1270.3

230,594514

421.695.6

140.8215.1

72,924368

704.3118.5

165.4436.9

26,58469

335.7113.1124.5211.2

119,360160

419.551.2

139.3286.9

*

Figure

does

not

meet

standards

of

reliability

or

precision;

based

on

fewer

than

20

births

in

the

numerator.

1Vaginalbirthaftercesarean;98%ofvaginalbirthswere towomenwithnopreviouscesarean,while2%wereVBAC.Forsomegroups,maternalmorbiditycaseswere too few(less than20) forVBACto

show

rates

by

racial

and

ethnic

categories.

2Includesbirthswithpreviouscesareanhistory,methodofdelivery,maternalmorbidity, or raceandethnicitynotstated.3Noresponse reported formaternalmorbidity item; includesbirths toresidentsofstatesusing the2003U.S.StandardCertificateofLiveBirthbutoccurring instatesusing the1989U.S.StandardCertificateofLiveBirth (0.3%).

NOTE:Reportingarea includesAlaska,California,Colorado,Delaware,DistrictofColumbia,Florida,Georgia, Idaho, Illinois, Indiana, Iowa,Kansas,Kentucky,Louisiana,Maryland,Massachusetts,Michigan,

Minnesota,

Mississippi,

Missouri,

Montana,

Nebraska,

Nevada,

New

Hampshire,

New

Mexico,

New

York,

North

Carolina,

North

Dakota,

Ohio,

Oklahoma,

Oregon,

Pennsylvania,

South

Carolina,

South

Dakota,

Tennessee,

Texas,

Utah,

Vermont,

Virginia,

Washington,

Wisconsin,

and

Wyoming.


12/14


Table3.District

[Ratesare

Maternalmorbidity forwomenwithnopreviouscesareandelivery,ofColumbiareportingarea,2013

numberof livebirthswithspecifiedmorbidityper100,000 livebirths inspecifiedgroup]

bymethodofdeliveryandtrialof labor:41-stateand

Trialof labor

Attempted None

MaternalmorbiditySuccessful,

vaginalFailed,

primarycesareanPrimary

cesarean

Total1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . Notstated2 . . . . . . . . . . . . . . . . . . . . . . . . .

Condition reported:Maternal transfusion. . . . . . . . . . . . . . . . . . Ruptureduterus . . . . . . . . . . . . . . . . . . . . Unplannedhysterectomy . . . . . . . . . . . . . . . Admission to intensivecareunit. . . . . . . . . . .

2,322,3203,863

167.16.3

11.9 64.6

273,120528

600.955.070.4

318.4

398,736705

486.946.566.6

420.6

1Includesbirthswithmaternalmorbiditynotstated.2Noresponse reported formaternalmorbidity item; includesbirths toresidentsofstatesusing the2003U.S.CertificateofLiveBirth (0.3%).

NOTE:Reportingarea includesAlaska,California,Colorado,Delaware,DistrictofColumbia,Florida,Georgia,Michigan,

Minnesota,

Mississippi,

Missouri,

Montana,

Nebraska,

Nevada,

New

Hampshire,

New

Mexico,

New

Carolina,

South

Dakota,

Tennessee,

Texas,

Utah,

Vermont,

Virginia,

Washington,

Wisconsin,

and

Wyoming.

StandardCertificateofLiveBirthbutoccurring instatesusing the1989U.S.Standard

Idaho, Illinois, Indiana, Iowa,Kansas,Kentucky,Louisiana,Maryland,Massachusetts,York,

North

Carolina,

North

Dakota,

Ohio,

Oklahoma,

Oregon,

Pennsylvania,

South


13/14

NationalVitalStatisticsReports,Vol.64No.4,May20,2015 13

Table4.District

[Ratesare

MaternalmorbidityforwomenwithapreviousofColumbiareportingarea,2013

numberof livebirthswithspecifiedmorbidityper100,000 live

cesareandelivery,

births inspecifiedgroup]

bymethodofdeliveryand trialof labor:41-stateand

Trialof labor

Attempted None

MaternalmorbiditySuccessful,

VBAC1Failed,

repeatcesareanRepeat

cesarean

Total2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . Not stated3 . . . . . . . . . . . . . . . . . . . . . . . . .

Condition reported:Maternal transfusion . . . . . . . . . . . . . . . . . . Ruptured uterus . . . . . . . . . . . . . . . . . . . . Unplannedhysterectomy . . . . . . . . . . . . . . . Admission to intensivecareunit. . . . . . . . . . .

54,933140

366.843.851.1

131.4

25,92686

731.4495.4158.7356.0

432,547928

458.065.6

143.9265.3

1Vaginalbirthaftercesarean.2Includesbirthswithmaternalmorbiditynotstated.3No

response

reported

for

maternal

morbidity

item;

includes

births

to

residents

of

states

using

the

2003

U.S.

CertificateofLiveBirth (0.3%).

NOTE:Reportingarea includesAlaska,California,Colorado,Delaware,DistrictofColumbia,Florida,Georgia,Michigan,Minnesota,Mississippi,Missouri,Montana,Nebraska,Nevada,NewHampshire,NewMexico,NewCarolina,

South

Dakota,

Tennessee,

Texas,

Utah,

Vermont,

Virginia,

Washington,

Wisconsin,

and

Wyoming.

Standard

Certificate

of

Live

Birth

but

occurring

in

states

using

the

1989

U.S.

Standard

Idaho, Illinois, Indiana, Iowa,Kansas,Kentucky,Louisiana,Maryland,Massachusetts,York,NorthCarolina,NorthDakota,Ohio,Oklahoma,Oregon,Pennsylvania,South


14/14

NationalVitalStatisticsReports,Vol.64No.4,May20,2015

U.S.DEPARTMENTOF

HEALTH&HUMANSERVICES

Centers forDiseaseControlandPreventionNationalCenter forHealthStatistics3311ToledoRoad,Room5419Hyattsville,MD207822064

FIRSTCLASSMAIL

POSTAGE&FEESPAID

CDC/NCHS

PERMIT

NO.

G-284

OFFICIALBUSINESSPENALTYFORPRIVATEUSE,$300

FormoreNCHSNVSRs,visit:http://www.cdc.gov/nchs/products/nvsr.htm.

Contents

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Overall findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Maternal age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Race and ethnicity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Trial of labor and method of delivery . . . . . . . . . . . . . . . . . . . . . 5

Discussion

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Findings from thebirthcertificatecomparedwithotherstudies. . . . . . 5

Dataqualityofhealth information frombirthcertificates . . . . . . . . . . 6

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

List of Detailed Tables. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Acknowledgments

This report was prepared under the general direction of Delton Atkinson, Director of the Division of Vital Statistics (DVS), and Amy M. Branum, Chief of the Reproductive Statistics Branch (RSB). Joyce A. Martin, RSB LeadStatistician, provided helpful suggestions for the analysis in this report.Sharon E. Kirmeyer provided content review. This report was edited andproduced by NCHS Office of Information Services, Information Design andPublishing Staff: Jane Sudol edited the report; typesetting was done byJacqueline M. Davis; and graphics were produced by Odell Eldridge(contractor).

Suggestedcitation

CurtinSC,GregoryKD,KorstLM,UddinSFG.

Maternalmorbidityforvaginalandcesarean

deliveries,according topreviouscesarean

history:Newdatafromthebirthcertificate,

2013.Nationalvitalstatisticsreports;vol64

no4.Hyattsville,MD:NationalCenter for

HealthStatistics.2015.

Copyright information

Allmaterialappearing in thisreport is inthepublicdomainandmaybereproducedorcopiedwithoutpermission;citationas tosource,however, isappreciated.

NationalCenterforHealthStatistics

CharlesJ.Rothwell,M.S.,M.B.A.,Director

NathanielSchenker,Ph.D.,DeputyDirector

JenniferH.Madans,Ph.D.,AssociateDirectorfor

Science

DivisionofVitalStatistics

DeltonAtkinson,M.P.H.,M.P.H.,P.M.P.,Director

Fore-mailupdatesonNCHSpublicationreleases,subscribeonlineat:http://www.cdc.gov/nchs/govdelivery.htm.

Forquestionsorgeneral informationaboutNCHS:Tel:1800CDCINFO(18002324636)TTY:18882326348

Internet:http://www.cdc.gov/nchsOnlinerequest form:http://www.cdc.gov/info

DHHSPublicationNo.20151120CS255967
http://www.cdc.gov/nchs/products/nvsr.htmhttp://www.cdc.gov/nchs/govdelivery.htmhttp://www.cdc.gov/nchshttp://www.cdc.gov/infohttp://www.cdc.gov/nchs/products/nvsr.htmhttp://www.cdc.gov/nchs/govdelivery.htmhttp://www.cdc.gov/nchshttp://www.cdc.gov/info

Morbidity of Women Who Give Birth

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