OBJECTIVE: To describe racial and ethnic disparities in the incidence of severe maternal morbidity during delivery hospitalizations in the United States. METHODS: We conducted a pooled, cross-sectional analysis of 2012–2015 data from the National Inpatient Sample to define the prevalence of chronic conditions and incidence of severe maternal morbidity among deliveries to non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, and Native American or Alaska Native women. We used weighted multivariable logistic regression and predictive margins to generate prevalence and incidence estimates. Adjusted rate ratios and differences were calculated to quantify disparities across racial and ethnic categories. Subgroup analyses were performed to examine the incidence of severe maternal morbidity among deliveries to women with comorbid physical health conditions, behavioral health conditions, and multiple chronic conditions within each racial and ethnic category. RESULTS: The incidence of severe maternal morbidity was significantly higher among deliveries to women in every racial and ethnic minority category compared with deliveries among non-Hispanic white women. Severe maternal morbidity occurred in 231.1 (95% CI 223.6–238.5) and 139.2 (95% CI 136.4–142.0) per 10,000 delivery hospitalizations among non-Hispanic black and non-Hispanic white women, respectively (P<.001). When excluding cases in which blood transfusion was the only indicator of severe maternal morbidity, only deliveries to non-Hispanic black women had a higher incidence of severe maternal morbidity compared with deliveries among non-Hispanic white women: 50.2 (95% CI 47.6–52.9) and 40.9 (95% CI 39.6–42.3) per 10,000 delivery hospitalizations, respectively (risk ratio 1.2 [95% CI 1.2–1.3], risk difference 9.3 [95% CI 6.5–12.2] per 10,000 delivery hospitalizations; P<.001 for each comparison). Among deliveries to women with comorbid physical and behavioral health conditions, significant differences in severe maternal morbidity were identified among racial and ethnic minority compared with non-Hispanic white women and the largest disparities were identified among women with multiple chronic conditions. CONCLUSION: Programs for reducing racial and ethnic disparities in severe maternal morbidity may have the greatest effect focusing on women at highest risk for blood transfusion and maternity care management for women with comorbid chronic conditions, particularly multiple chronic conditions.

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Key Points Question What are the current trends in frequency and costs of amphetamine-related hospitalizations in the United States? Findings In this cross-sectional study of approximately 1.3 million amphetamine-related US hospitalizations between 2003 and 2015, hospitalizations increased substantially by 2015, with the highest frequency being in the western United States and the predominant payer being Medicaid. Meaning Amphetamine use may be an emerging public health issue; pharmacologic and nonpharmacologic therapies that effectively treat amphetamine use disorder are needed.

Objective To estimate trends in the prevalence and socio-economic distribution of chronic conditions among women hospitalized for obstetric delivery in the United States. Methods A retrospective, serial cross-sectional analysis was conducted using 2005 to 2014 data from the National Inpatient Sample. We estimated the prevalence of eight common, chronic conditions, each associated with obstetric morbidity and mortality, among all childbearing women and then across socio-economic predictors of obstetric outcomes. Differences over time were measured and compared across rural vs. urban residence, income, and payer subgroups for each condition. Results We identified 8,193,707 delivery hospitalizations, representing 39,273,417 delivery hospitalizations occurring nationally between 2005 and 2014. Identification of at least one chronic condition increased significantly between 2005–2006 and 2013–2014 (66.9 per 1,000 delivery hospitalizations in 2005–2006 vs. 91.8 per 1,000 delivery hospitalizations in 2014–2015). The prevalence of multiple chronic conditions also increased during the study period, from 4.7 (95% CI 4.2–5.2) to 8.1 (95% CI 7.8–8.4) per 1,000 delivery hospitalizations between 2005–2006 and 2013–2014. Chronic respiratory disease, chronic hypertension, substance use disorders, and pre-existing diabetes were the disorders with the greatest increases in prevalence over time Increasing disparities over time were identified across all socio-economic subgroups analyzed including rural vs. urban residence, income, and payer. Key areas of concern include the rate at which substance use disorders rose among rural women and the disproportionate burden of each condition among women from the lowest income communities and among women with Medicaid as their primary payer. Conclusion From 2005–2006 through 2013–2014, the prevalence of chronic conditions increased across all segments of the childbearing population. Widening disparities were identified over time, with key areas of concern including disproportionate, progressive increases in the burden of chronic conditions among women from rural and low income communities and those with deliveries funded by Medicaid.

OBJECTIVE: To describe delivery-related severe maternal morbidity and mortality among indigenous women compared with non-Hispanic white (white) women, distinguishing rural and urban residents. METHODS: We used 2012–2015 maternal hospital discharge data from the National Inpatient Sample to conduct a pooled, cross-sectional analysis of indigenous and white patients who gave birth. We used weighted multivariable logistic regression and predictive population margins to measure health conditions and severe maternal morbidity and mortality (identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes) among indigenous and white patients, to test for differences across both groups, and to test for differences between rural and urban residents within each racial category. RESULTS: We identified an estimated 7,561,729 (unweighted n=1,417,500) childbirth hospitalizations that were included in the analyses. Of those, an estimated 101,493 (unweighted n=19,080) were among indigenous women, and an estimated 7,460,236 (unweighted n=1,398,420) were among white women. The incidence of severe maternal morbidity and mortality was greater among indigenous women compared with white women (2.0% vs 1.1%, respectively; relative risk [RR] 1.8, 95% CI 1.6–2.0). Within each group, incidence was higher among rural compared with urban residents (2.3% for rural indigenous women vs 1.8% for urban indigenous women [RR 1.3, 95% CI 1.0–1.6]; 1.3% for rural white women vs 1.2% for urban white women [RR 1.1, 95% CI 1.1–1.2]). CONCLUSION: Severe maternal morbidity and mortality is elevated among indigenous women compared with white women. Incidence is highest among rural indigenous residents. Efforts to improve maternal health should focus on populations at greatest risk, including rural indigenous populations.

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Objectives. To estimate trends in incidence, outcomes, and costs among hospital deliveries related to amphetamines and opioids. Methods. We analyzed 2004-to-2015 data from the National Inpatient Sample, a nationally representative sample of hospital discharges in the United States compiled by the Healthcare Cost and Utilization Project, by using a repeated cross-sectional design. We estimated the incidence of hospital deliveries related to maternal amphetamine or opioid use with weighted logistic regression. We measured clinical outcomes and costs with weighted multivariable logistic regression and generalized linear models. Results. Amphetamine- and opioid-related deliveries increased disproportionately across rural compared with urban counties in 3 of 4 census regions between 2008 to 2009 and 2014 to 2015. By 2014 to 2015, amphetamine use was identified among approximately 1% of deliveries in the rural West, which was higher than the opioid-use incidence in most regions. Compared with opioid-related and other hospital deliveries, amphetamine-related deliveries were associated with higher incidence of preeclampsia, preterm delivery, and severe maternal morbidity and mortality. Conclusions. Increasing incidence of amphetamine and opioid use among delivering women and associated adverse gestational outcomes indicate that amphetamine and opioid use affecting birth represent worsening public health crises.

OBJECTIVE: To measure the association between race–ethnicity and insurance status at preconception, delivery, and postpartum and the frequency of insurance gaps and transitions (disruptions) across these time points. METHODS: We conducted a cross-sectional analysis of survey data from 107,921 women in 40 states participating in the Centers for Disease Control and Prevention's Pregnancy Risk Assessment and Monitoring System from 2015 to 2017. We calculated unadjusted estimates of insurance status at preconception, delivery, and postpartum and continuity across these time points for seven racial–ethnic categories (white non-Hispanic, black non-Hispanic, indigenous, Asian or Pacific Islander, Hispanic Spanish-speaking, Hispanic English-speaking, and mixed race or other). We also examined unadjusted estimates of uninsurance at each perinatal time period by state of residence. We calculated adjusted differences in the predicted probability of uninsurance at preconception, delivery, and postpartum using logistic regression models with interaction terms for race–ethnicity and income. RESULTS: For each perinatal time point, all categories of racial–ethnic minority women experienced higher rates of uninsurance than white non-Hispanic women. From preconception to postpartum, 75.3% (95% CI 74.7–75.8) of white non-Hispanic women had continuous insurance compared with 55.4% of black non-Hispanic women (95% CI 54.2–56.6), 49.9% of indigenous women (95% CI 46.8–53.0) and 20.5% of Hispanic Spanish-speaking women (95% CI 18.9–22.2). In adjusted models, lower-income Hispanic women and indigenous women had a significantly higher predicted probability of uninsurance in the preconception and postpartum period compared with white non-Hispanic women. CONCLUSION: Disruptions in perinatal insurance coverage disproportionately affect indigenous, Hispanic, and black non-Hispanic women. Differential insurance coverage may have important implications for racial–ethnic disparities in access to perinatal care and maternal–infant health.