Is severe maternal morbidity a risk factor for postpartum hospitalization with mental health or substance use disorder diagnoses? Findings from a retrospective cohort study in Maryland: 2016-2019

Is severe maternal morbidity a risk factor for postpartum hospitalization with mental health or substance use disorder diagnoses? 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Findings from a retrospective cohort study in Maryland: 2016-2019 Carrie L WOLFSON, Jessica Tsipe ANGELSON, Andreea A CREANGA This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4655614/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Jan, 2025 Read the published version in Maternal Health, Neonatology and Perinatology → Version 1 posted 10 You are reading this latest preprint version Abstract BACKGROUND Perinatal mental health conditions and substance use are leading causes, often co-occurring, of pregnancy-related and pregnancy-associated deaths in the United States. This study compares odds of hospitalization with a mental health condition or substance use disorder or both during the first year postpartum between patients with and without severe maternal morbidity (SMM) during delivery hospitalization. Methods Data are from the Maryland’s State Inpatient Database and include patients with a delivery hospitalization during 2016–2018 (n = 197,749). We compare rate of hospitalization with a mental health condition or substance use disorder or both at 42 days and 42 days to 1 year postpartum by occurrence of SMM during the delivery hospitalization. We use multivariable logistic regression to derive the odds of hospitalization with each outcome for patients by SMM status, adjusted for patient sociodemographic characteristics, presence of mental health condition or substance use disorder diagnoses during the delivery hospitalization, and delivery outcome. SMM, mental health conditions, and substance use disorders are identified using ICD-10 diagnosis and procedure codes. RESULTS Overall, 5,793 patients (2.9%) who delivered during 2016–2018 experienced hospitalization in the year following delivery. Among these patients, 24.3% (n = 1,410) had a mental health condition diagnosis, 10.6% (n = 619) had a substance use disorder diagnosis, and 9.8% (n = 570) had co-occurring mental health condition and substance use disorder diagnoses. Patients with SMM had 3.7 times the odds (95% CI 2.7, 5.2) of hospitalization with a mental health condition diagnosis, 2.7 times the odds (95% CI 1.6, 4.4) of a hospitalization with substance use disorder diagnosis, and 3.0 times the odds (95% CI 1.8, 4.8) of hospitalization with co-occurring mental health condition and substance use disorder diagnoses during the first-year postpartum adjusting for covariates. CONCLUSION Patients who experience SMM during their delivery hospitalization had higher odds of hospitalization with a mental health condition, substance use disorder, and co-occurring mental health condition and substance use disorder in the one-year postpartum period. Treatment and support resources for mental health and substance use providers --including enhanced screening and warm handoffs -- should be made available to patients with SMM upon discharge after delivery, and evidence-based interventions to improve mental health and reduce substance use should be prioritized in these patients. Postpartum depression substance use disorder maternal health postpartum hospitalization Figures Figure 1 BACKROUND The prevalence of perinatal mental health conditions, including depression, anxiety, bipolar disorder, and suicidality, has doubled in the past two decades in the United States, affecting more than 20% of pregnant and postpartum people annually (1–4). Perinatal substance use and substance use disorders have also risen dramatically, with 6.5 cases of opioid use disorder reported per 1,000 delivery hospitalizations in 2016 (5, 6). In fact, mental health conditions and substance use disorders are leading causes of pregnancy-related and pregnancy-associated death in the United States (7, 8), and have also been associated with poor maternal, neonatal, and infant outcomes (9) and increased delivery hospitalization costs (10, 11). Notably, presence of a mental health condition diagnosis during the delivery hospitalization has been shown to be associated with an increased likelihood of severe maternal morbidity (SMM) (3, 10, 12), the rate of which also increased by 22.5% between 2008 and 2021 in the US and is known to have long-term consequences on women’s health (13, 14). Less is known about the relationship between SMM and postpartum mental health, although recent studies indicate an increased risk of such conditions following an SMM event (15, 16). These findings are consistent with qualitative evidence in which patients describe their SMM events as having long-term negative psychological impacts (17–19). Despite the recognized co-occurrence of mental health conditions and substance use disorders (20, 21), these conditions are not usually examined in tandem among peripartum individuals. Data from all hospital admissions within one year postpartum in Maryland offer the opportunity of exploring the association between SMM and postpartum mental health and substance use, both separately and as co-occurring morbidities. The objective of this study is to examine rates of hospitalization with a mental health condition, or substance use disorder, or both during the first year postpartum among patients with and without SMM during delivery hospitalization in Maryland over a 4-year period before the start of the COVID-19 pandemic. MATERIALS AND METHODS We conducted a retrospective cohort study using 2016–2019 Maryland State Inpatient Database (SID) maintained by the Agency for Healthcare Research and Quality for the Healthcare Cost and Utilization Project (HCUP). Delivery discharge records were identified using the International Classification of Diseases 10th Revision, Clinical Modification (ICD-10-CM) diagnosis codes and procedure codes among patients identified as female and of reproductive age (15–49 years). Postpartum hospitalizations were identified using a unique patient identifier which is consistent across admissions and facilities over time in the Maryland SID. The 3 primary outcomes for the analysis were postpartum hospital admission with a mental health condition, a substance use disorder, and both. Outcome assessment was based on the presence of at least one ICD-10-CM diagnosis code for a mental health condition or substance use disorder among the first five ICD-10-CM diagnosis codes listed for each patient (a full list of ICD-10-CM diagnosis codes used to identify outcomes are included in Appendix 1); of note, SID allows up to 30 diagnosis and procedure ICD codes to be listed for each hospital discharge. Within the sample of patients with at least one delivery during 2016–2018, 82.2% of records included at least 5 diagnosis codes, 70.0% had 6 or more diagnosis codes. For deriving the co-occurring disorders outcome, we included individuals with a mental health condition or a substance use disorder diagnosis among the first 5 diagnoses listed who also had a diagnosis code for the other type of disorder listed for the same hospital discharge. Outcomes were identified from the day after discharge from the delivery hospitalization through 365 days following delivery. To examine outcomes one year postpartum, the sample was restricted to patients with deliveries occurring during 2016–2018 to allow for sufficient follow up time in 2019 data. Severe maternal morbidity (SMM) was defined using the Center for Disease Control and Prevention’s SMM ICD-10-CM algorithm based on ICD-10-CM diagnoses and procedures noted during the delivery hospitalization (14). In line with the most recent literature, patients with only blood transfusion ICD-10-CM codes were not deemed as having experienced SMM due to poor positive predictive value of SMM using ICD-10-CM codes for this specific indicator (22). Patient sociodemographic information available and used in this analysis includes age, race/ethnicity (categorized as non-Hispanic Black, non-Hispanic White, Hispanic, and other/multiple races using HCUP’s standard variables for race and ethnicity), income quartile for the patient’s zip code, delivery hospitalization payer (private, public, self-pay/none), and location of residence (urban or rural). We also identified the presence of a maternal mental health condition, or a substance use disorder noted during delivery hospitalization, as well as the delivery outcome (stillbirth or live birth). These characteristics were compared between patients with and without SMM using Pearson chi-square analyses. Rates of hospitalization during the early (within 42 days) and late (42–365 days) postpartum periods were calculated for patients with and without SMM and for each outcome of interest (hospitalization with a mental health condition, a substance use disorder, and co-occurring mental health condition and substance use disorder). Unadjusted and multivariable logistical regression models were fitted to assess the relationship between SMM during delivery hospitalization and postpartum hospitalization with one of the 3 outcomes of interest during the first postpartum year. Adjusted models controlled for patient age, race and ethnicity, median household income for zip code, insurance type, urban/rural residence, presence of a mental health condition or a substance use disorder during delivery, and birth outcome, as well as clustering at the patient level using cluster subcommands to account for patients with multiple deliveries during the period of analysis (n = 26,930; 15.9% of patients with deliveries between 2016 and 2018 in the sample). Analyses were conducted using Stata 15.1 software (College Station, TX). RESULTS A total of 197,749 delivery hospitalizations were identified in Maryland between 2016 and 2018; 0.8% (n = 1,513) involved SMM. Compared to patients without SMM, a higher proportion of patients with SMM were 35–39 years of age (21.6% vs. 17.1%, respectively) and 40 years of age or older (8.3% vs. 3.9%, respectively) (Table 1 ). Patients with SMM were also in higher proportion non-Hispanic Black (46.1% vs. 30.5%, respectively), with incomes in lowest income quartile for ZIP code (33.4% vs. 27.8%, respectively), and covered by public insurance (49.1% vs. 42.4%, respectively) than those without SMM. Also, a higher proportion of patients with than without SMM had a mental health condition (17.1% vs. 9.4%, respectively) or substance use disorder (6.9% vs. 3.6%, respectively) diagnosis documented during the delivery hospitalization. Additionally, the outcome of deliveries complicated by SMM were in higher proportion stillbirth in patients with SMM compared to patients without SMM (6.5% vs. 0.7%, respectively). Table 1 Characteristics of Patients with and without Severe Maternal Morbidity During Delivery Hospitalization No SMM (n = 196,236) SMM (n = 1,513) P-value for difference N % N % Age (years) < 0.000 < 25 38,774 19.8 289 19.1 25–29 54,167 27.6 334 22.1 30–34 62,151 31.7 439 29.0 35–39 33,565 17.1 326 21.6 40+ 7,579 3.9 125 8.3 Race & Ethnicity < 0.000 NH Black 59,838 30.5 697 46.1 NH White 84,723 43.2 462 30.5 Hispanic 29,683 15.1 195 12.9 Other/multiple races 21,992 11.2 159 10.5 Primary Language 0.453 English 118,996 60.6 872 57.6 Non-English 12,473 6.4 99 6.5 Missing/unknown 64,767 33.0 542 35.8 Median household income 1 < 0.000 1st quartile 54,549 27.8 505 33.4 2nd quartile 53,346 27.2 426 28.2 3rd quartile 48,437 24.7 328 21.7 4th quartile 39,374 20.1 252 16.7 Missing/unknown 530 0.3 * < .1 Urban residence 0.217 Urban 191,252 97.5 1,483 98.0 Rural 4,860 2.5 30 2.0 Missing/unknown 124 0.1 0 0 Primary insurance < 0.000 Private 104,314 53.2 694 45.9 Public 83.163 42.4 743 49.1 Self-pay/none 8,675 4.4 75 5.0 Missing/unknown 84 < 0.1 * < 0.1 Comorbidities 2 Mental health condition 18,431 9.4 258 17.1 < 0.000 Substance use 7,107 3.6 104 6.9 < 0.000 Stillbirth 1,346 0.7 99 6.5 < 0.000 Note: SMM, Severe Maternal Morbidity; NH, non-Hispanic. 1 Median household zip code calculated based on zip code of patient’s residence. 2 Indicated during delivery hospitalization. P-value based on chi-square analysis of difference in distribution between patients with and without SMM during the delivery hospitalization. *Restricted due to small cell size. Source: Healthcare Cost and Utilization project (HCUP) Maryland Inpatient Database, 2016–2018; N = 197,749 deliveries. Among patients with deliveries, 2.9% (n = 5,793) experienced hospitalization in the year following delivery. The rate of postpartum hospitalization was higher across all outcomes and time periods for patients with SMM compared to those without SMM (Fig. 1 ). The relative risk of early postpartum hospitalization for patients with SMM was 6.5 for any hospitalization (95% CI = 5.4–7.6), 8.8 for a hospitalization with a mental health condition diagnosis (95% CI = 5.2–14.7), 9.9 for a substance use disorder diagnosis (95% CI = 4.3, 22.6), and 13.6 for both (95% CI = 5.9–31.6) compared to patients without SMM. In the late postpartum period, the relative risk of postpartum hospitalization between patients with and without SMM for any cause was 5.2 (95% CI = 4.4, 6.1). The relative risk was 4.9 (95% CI = 3.5, 6.9), 3.6 (95% CI = 2.1, 6.2), and 4.1 (95% CI = 2.4, 7.0) for hospitalizations with a mental health condition, substance use disorder, and both, respectively. The rate of hospitalization for any reason was higher in the early postpartum than in the late postpartum period for patients with SMM (85.3 per vs. 83.2 1,000 deliveries, respectively). However, among all patients (with and without SMM) the rate of postpartum hospitalization with a mental health condition or substance use disorder was higher in the late postpartum period. Compared with patient without SMM, those with SMM had significantly higher odds of postpartum hospitalization with a mental health condition diagnosis (OR = 5.7; 95% CI 4.2, 7.6), a substance use disorder (OR = 4.4; 95% CI 2.8, 7.1) and co-occurring mental health conditions and substance use disorder diagnoses (OR = 4.9, 95% CI 3.1, 7.9) (Table 2 ). Odds were attenuated by 34.2–40.2% after adjustment for the sociodemographic and delivery characteristics examined. Table 2 Odds of Postpartum Hospitalization for Patients with a Mental Health Condition or Substance Use Disorder Diagnoses by Severe Maternal Morbidity Status Hospitalization with Mental Health Condition Hospitalization with Substance Use Disorder Hospitalization with Co-Occurring MH & SUD Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI SMM during delivery (no SMM = Ref.) 5.67 4.21, 7.64 3.73 2.69, 5.16 4.44 2.77, 7.1 2.67 1.62, 4.4 4.93 3.08, 7.9 2.95 1.81, 4.8 Age (years) < 25 Ref. Ref. Ref. Ref. Ref. Ref. 25–29 0.61 0.53, 0.72 0.71 0.61, 0.83 0.87 0.7, 1.07 1.05 0.84, 1.3 0.79 0.63, 0.98 0.97 0.77, 1.22 30–34 0.49 0.42, 0.58 0.72 0.61, 0.85 0.48 0.38, 0.61 0.86 0.67, 1.11 0.41 0.31, 0.52 0.74 0.57, 0.97 35–39 0.48 0.4, 0.58 0.73 0.6, 0.89 0.43 0.32, 0.59 0.90 0.66, 1.24 0.43 0.32, 0.58 0.91 0.66, 1.25 40+ 0.38 0.26, 0.56 0.61 0.41, 0.9 0.48 0.28, 0.81 1.18 0.68, 2.04 0.39 0.22, 0.71 0.98 0.53, 1.8 Race & Ethnicity NH White Ref. Ref. Ref. Ref. Ref. Ref. NH Black 1.18 1.04, 1.34 1.01 0.88, 1.16 0.98 0.82, 1.17 0.69 0.56, 0.83 1.06 0.88, 1.28 0.76 0.62, 0.94 Hispanic 0.42 0.33, 0.53 0.45 0.35, 0.59 0.14 0.08, 0.24 0.15 0.09, 0.25 0.15 0.09, 0.26 0.17 0.09, 0.3 Other/multiple races 0.51 0.4, 0.65 0.75 0.58, 0.96 0.33 0.22, 0.5 0.52 0.34, 0.79 0.37 0.24, 0.55 0.61 0.4, 0.95 Median income 1 1st quartile Ref. Ref. Ref. Ref. Ref. Ref. 2nd quartile 0.61 0.53, 0.7 0.87 0.75, 1.01 0.46 0.37, 0.57 0.76 0.61, 0.95 0.47 0.38, 0.58 0.79 0.63, 1 3rd quartile 0.45 0.38, 0.53 0.76 0.64, 0.9 0.37 0.29, 0.47 0.82 0.64, 1.05 0.33 0.26, 0.43 0.76 0.58, 0.99 4th quartile 0.41 0.34, 0.49 0.73 0.6, 0.9 0.24 0.17, 0.33 0.61 0.44, 0.86 0.21 0.15, 0.29 0.56 0.39, 0.81 Primary insurance Private Ref. Ref. Ref. Ref. Ref. Ref. Medicaid 2.82 2.48, 3.21 2.16 1.85, 2.53 7.94 6.2, 10.17 5.25 3.91, 7.06 8.88 6.77, 11.65 5.76 4.2, 7.89 Self-pay/none 1.59 1.16, 2.18 1.61 1.17, 2.2 2.47 1.42, 4.3 2.36 1.35, 4.12 2.40 1.29, 4.47 2.35 1.26, 4.37 Urban residence 1.04 0.7, 1.53 1.25 0.84, 1.85 1.04 0.58, 1.88 1.64 0.9, 2.99 1.02 0.55, 1.89 1.50 0.81, 2.8 Comorbidities during delivery MH condition 8.78 7.81, 9.86 6.58 5.76, 7.53 7.14 6.01, 8.48 3.07 2.5, 3.77 11.23 9.39, 13.43 5.42 0.59, 6.71 SUD 6.14 5.29, 7.13 2.07 1.74, 2.45 23.54 19.89, 27.87 7.39 5.99, 9.13 20.29 16.95, 24.29 5.30 4.27, 6.59 Stillbirth 3.49 2.41, 5.06 2.24 1.48, 3.4 3.32 1.83, 5.99 1.86 1, 3.46 2.52 1.3, 4.87 1.42 0.7, 2.88 Note: SMM, severe maternal morbidity; NH, non-Hispanic; MH, mental health; SUD, substance use disorder. 1 Income is household median for zip code. Adjusted models include all variables in the table. Standard errors adjusted for individual-level clustering. Unadjusted models show the odds of SMM for each characteristic. Source: Healthcare Cost and Utilization Project (HCUP), Maryland Inpatient Database, 2016–2019. N = 197,749 deliveries in 2016–2018. Several sociodemographic and delivery characteristics were associated with the odds of postpartum hospitalization with a mental health condition or substance use disorder or both types of diagnoses. Compared to non-Hispanic White patients, patients who were Hispanic had a lower odds of postpartum hospitalization with a mental health condition (AOR = 0.5, 95% CI 0.4, 0.6), substance use disorder (AOR = 0.2, 95% CI 0.1, 0.3), or co-occurring mental health condition and substance use disorder (AOR = 0.2, 95% CI 0.1, 0.3) compared to patients who were non-Hispanic White. Though patients who were non-Hispanic Black had approximately 20% higher odds of postpartum hospitalization with a mental health condition compared to non-Hispanic White patients (in unadjusted models only), they had approximately 30% lower odds of postpartum hospitalization with a substance use disorder or co-occurring mental health condition and substance use disorder compared to non-Hispanic White patients. By and large, the higher the patient income, the lower the odds of postpartum hospitalization with mental health condition or substance use disorder diagnoses. Compared to patients with private insurance, those with public insurance or no insurance had 1.9 times higher odds of postpartum hospitalization with a mental health condition diagnosis and over 5-times higher odds of postpartum hospitalization with substance use alone or both substance use and mental health condition diagnoses. Importantly, odds of postpartum hospitalization with a mental health condition diagnosis were significantly higher for patients with a mental health condition (AOR = 6.6; 95% CI 5.8, 7.5) or substance use disorder (AOR = 2.1; 95% CI 1.7, 2.5) diagnosis during the delivery hospitalization. Patients with a stillbirth had 2.2 times higher odds for postpartum hospitalization with a mental health condition diagnosis compared to patients with a live born infant. DISCUSSION In this retrospective cohort study of deliveries in Maryland between 2016–2018, patients who experienced SMM during their delivery hospitalization had 3.7, 2.8 and 3 times the odds of postpartum hospitalization with a mental health condition diagnosis, substance use disorder diagnosis and both, respectively, compared to patients who did not experience SMM during delivery. Rates of postpartum hospitalization with such diagnoses were significantly higher among patients with SMM compared to those without SMM during the early and late postpartum periods. Our findings confirm prior research documenting higher rates of postpartum hospitalization among postpartum patients who experience SMM compared to those who did not experience SMM (23), and are supported by clinical plausibility with respect to the associations between SMM and presence of mental health condition and substance use disorder diagnoses. Research has shown that traumatic birth outcomes increase the risk of mental health conditions, particularly posttraumatic stress disorder, during the postpartum period (24–26). Moreover, a study in Sweden found a positive association between SMM at delivery and postpartum treatment for psychiatric disorders (27). Experience of adverse or unexpected outcomes such as preeclampsia, preterm birth, or cesarean delivery have been identified as risk factors for postpartum mental health conditions (28–30). Similarly, the postpartum period is recognized as a particularly vulnerable time for individuals with substance use disorders at risk of relapse, which may be further compounded by the experience of birth trauma or adverse pregnancy outcomes (31). Fear for personal safety or safety of the neonate and negative perceptions of birth, multiple interventions during labor and birth, and anesthesia complications are all associated with postpartum mental health conditions and can be unique vulnerabilities for those with histories of substance use disorders (31, 32). SMM frequently includes multiple interventions as well as anesthesia and is often characterized as a traumatic event by those who experience them, which can explain the relationships we observed in our study. Efforts to reduce preventable SMM and its effects should include recognition and management of mental health and substance use in pregnancy and postpartum, and particularly the late postpartum period. In our study, postpartum hospitalization rates for patients with mental health and substance use disorders were higher during the late postpartum period compared to the early postpartum period. Similarly, studies of pregnancy-associated mortality have identified higher rates of deaths due to overdose and suicide in the late postpartum period (33, 34). Together, these suggest the late postpartum period is a particularly vulnerable time for these behavioral health conditions. Patients with SMM often receive inadequate information about their morbidity (35). Recommendations following an SMM event include offering patients a debriefing by their clinician before hospital discharge, social support, referrals and warm hand-off to mental health and substance use providers and services, including specialized treatment (35). Such interventions have been found to be moderately effective in reducing mental health symptoms among patients with traumatic births (36, 37). The US Preventive Services Task Force recommends that clinicians provide or refer postpartum persons at increased risk for perinatal depression to counseling interventions due to sufficient evidence of their effectiveness (38). Increased risk includes those with a history of depression, current depressive symptoms, socioeconomic risk factors, or a history of significant negative life events. Findings from this analysis suggest that experience of SMM should also be considered as a risk factor. Our findings demonstrate no significant difference in the in adjusted odds of postpartum hospitalization with a mental health condition between non-Hispanic Black and White patients who experience SMM, but lower odds of postpartum hospitalization for substance use disorders and both mental health conditions and substance use disorders. Additionally,, odds of hospitalization with a mental health condition or substance use disorder were significantly lower among Hispanic patients and other racial/ethnic minority groups compared to white patients. More research is needed to determine whether these differences are due to true lower rates of mental health conditions and substance use disorders or differences in rates of diagnosis and recognition. Our study has limitations. While there are indications that SMM precipitates postpartum mental health conditions and substance use, these relationships may be bidirectional, such that a history of mental health conditions or substance use predisposes pregnant individuals to SMM, which in turn exacerbates the risk of the same in the postpartum period (16). Clearly establishing the directionality and causality of this relationship will require further, more robust longitudinal studies. In addition, examining the relationship of SMM with specific types of mental health conditions as well as co-occurring mental health conditions and substance use should be the focus of research when a larger sample size than ours is available. We used the first five diagnosis codes for each patient to ascertain our outcomes of interest – this cut-off point was used to examine postpartum hospitalizations where mental health conditions and substance use disorders represented important reason(s) for the hospitalizations. However, we may have missed patients who were admitted to the hospital for these conditions but, for which, only direct pregnancy complications were noted with the first five conditions codes. We may have also missed patients who do not disclose their mental health condition or symptoms, or their substance use to a healthcare provider, or those who are less likely to be screened for such conditions including birthing people of color and those with low incomes (39). The data are limited to conditions identified during hospitalizations, whereas many of these conditions do not result in hospitalization and may be identified in outpatient settings and treated through medication, therefore we are unable to adjust for prenatal depression and substance use, unless identified during the delivery hospitalization; moreover, only SMM during delivery hospitalization is examined, thus excluding SMM events that occur in antepartum and postpartum hospitalizations. In addition, residual confounding may be present due to the exclusion of other chronic health conditions and the limited sociodemographic variables available through hospital records. Furthermore, reliance on administrative data, which are primarily collected for billing purposes, has other limitations because all health conditions present during a hospital admission may not be consistently and accurately reported and the algorithm used to identify SMM based on this data is not well suited to identify all cases of SMM events involving hemorrhage (22). However, the study has some important strengths. It uses a large, statewide database analyzed longitudinally over several years before the start of the COVID-19 pandemic – this was only possible given the inclusion of a unique patient identifier in the Maryland SID. The use of ICD-10 codes for outcome ascertainment has the strength of consistency in identifying cases over the study period and offers some reassurance that they represent true cases of patients with mental health conditions or substance use disorders. CONCLUSION Patients who experience SMM have a higher odds of hospitalization with a mental health condition or substance use disorder or both in the postpartum period. Treatment and support resources for mental health and substance use providers --including enhanced screening and warm handoffs -- should be made available to patients with SMM upon discharge after delivery, and evidence-based interventions to improve mental health and reduce substance use should be prioritized in these patients. Abbreviations SMM, Severe Maternal Morbidity Declarations Ethics approval and consent to participate The study was deemed non-human subjects research by the Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health because the HCUP data are de-identified and do not contain personally identifiable information. Consent for publication Not applicable Availability of data and materials The data that support the findings of this study are publicly available from The Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project. HCUP State Inpatient Databases (SID). Healthcare Cost and Utilization Project (HCUP). 2015-2019. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/sidoverview.jsp Competing interests The authors declare that they have no competing interests. Funding Funding for this study is from the Eunice Kennedy Shriver National Institute of Child Health and Human Development NICHD, Award Number 1R01HD112442-01. The sponsor had no role in the study design; collection, analysis, and interpretation of data; in the writing of the report; or the decision to submit the article for publication. Authors’ Contributions All authors collectively conceived and designed the analysis. CW performed the analysis. CW and JA wrote the manuscript and AC provided critical review and feedback. All authors reviewed and approved the final manuscript. Acknowledgements Not applicable References Getahun D, Oyelese Y, Peltier M, Yeh M, Chiu VY, Takhar H, et al. Trends in Postpartum Depression by Race/Ethnicity and Pre-pregnancy Body Mass Index. American Journal of Obstetrics and Gynecology. 2023;228(1):S122-S3. Admon LK, Dalton VK, Kolenic GE, Ettner SL, Tilea A, Haffajee RL, et al. 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Elmir R, Schmied V, Jackson D, Wilkes L. Between life and death: women's experiences of coming close to death, and surviving a severe postpartum haemorrhage and emergency hysterectomy. Midwifery. 2012;28(2):228-35. Snowdon C, Elbourne D, Forsey M, Alfirevic Z. Information-hungry and disempowered: a qualitative study of women and their partners' experiences of severe postpartum haemorrhage. Midwifery. 2012;28(6):791-9. Hinton L, Locock L, Knight M. Support for mothers and their families after life-threatening illness in pregnancy and childbirth: a qualitative study in primary care. Br J Gen Pract. 2015;65(638):e563-9. Conway K, Compton W, Stinson F, Grant B. DSM-IV Mood and Anxiety Disorders and Specific Drug Use Disorders: Results From the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2006;67. Manuel JI, Gandy ME, Rieker D. Trends in hospital discharges and dispositions for episodes of co-occurring severe mental illness and substance use disorders. Adm Policy Ment Health. 2015;42(2):168-75. Main EK, Abreo A, McNulty J, Gilbert W, McNally C, Poeltler D, et al. Measuring severe maternal morbidity: validation of potential measures. Am J Obstet Gynecol. 2016;214(5):643 e1- e10. Matas JL, Mitchell LE, Sharma SV, Louis JM, Salemi JL. Severe maternal morbidity at delivery and postpartum readmission in the United States. Paediatr Perinat Epidemiol. 2021;35(6):627-34. Di Florio A, Jones L, Forty L, Gordon-Smith K, Craddock N, Jones I. Bipolar disorder, miscarriage, and termination. Bipolar Disord. 2015;17(1):102-5. Lewkowitz AK, Rosenbloom JI, Keller M, Lopez JD, Macones GA, Olsen MA, et al. Association between stillbirth >/=23 weeks gestation and acute psychiatric illness within 1 year of delivery. Am J Obstet Gynecol. 2019;221(5):491 e1- e22. Modarres M, Afrasiabi S, Rahnama P, Montazeri A. Prevalence and risk factors of childbirth-related post-traumatic stress symptoms. BMC Pregnancy Childbirth. 2012;12. Wall-Wieler E, Carmichael SL, Urquia ML, Liu C, Hjern A. Severe maternal morbidity and postpartum mental health-related outcomes in Sweden: a population-based matched-cohort study. Arch Womens Ment Health. 2019;22(4):519-26. Caropreso L, de Azevedo Cardoso T, Eltayebani M, Frey BN. Preeclampsia as a risk factor for postpartum depression and psychosis: a systematic review and meta-analysis. Arch Womens Ment Health. 2020;23(4):493-505. Ayers S, Bond R, Bertullies S, Wijma K. The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework. Psychol Med. 2016;46(6):1121-34. Sun L, Wang S, Li X-Q. Association between mode of delivery and postpartum depression: A systematic review and network meta-analysis. Australian & New Zealand Journal of Psychiatry. 2021;55. Martin CE, Parlier-Ahmad AB. Addiction treatment in the postpartum period: an opportunity for evidence-based personalized medicine. Int Rev Psychiatry. 2021;33(6):579-90. Simpson M, Schmied V, Dickson C, Dahlen HG. Postnatal post-traumatic stress: An integrative review. Women Birth. 2018;31(5):367-79. Han B, Compton WM, Einstein EB, Elder E, Volkow ND. Pregnancy and Postpartum Drug Overdose Deaths in the US Before and During the COVID-19 Pandemic. JAMA Psychiatry. 2024;81(3):270-83. Zivin K, Zhong C, Rodriguez-Putnam A, Spring E, Cai Q, Miller A, et al. Suicide Mortality During the Perinatal Period. JAMA Netw Open. 2024;7(6):e2418887. Furniss M, Conroy M, Filoche S, MacDonald EJ, Geller SE, Lawton B. Information, support, and follow-up offered to women who experienced severe maternal morbidity. Int J Gynaecol Obstet. 2018;141(3):384-8. Baxter JD, McCourt C, Jarrett PM. What is current practice in offering debriefing services to post partum women and what are the perceptions of women in accessing these services: a critical review of the literature. Midwifery. 2014;30(2):194-219. Gamble J, Creedy D, Moyle W, Webster J, McAllister M, Dickson P. Effectiveness of a counseling intervention after a traumatic childbirth: a randomized controlled trial. Birth. 2005;32(1):11-9. US Preventive Services Task Force, Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, et al. Interventions to Prevent Perinatal Depression: US Preventive Services Task Force Recommendation Statement. JAMA. 2019;321(6):580-7. Sidebottom A, Vacquier M, LaRusso E, Erickson D, Hardeman R. Perinatal depression screening practices in a large health system: identifying current state and assessing opportunities to provide more equitable care. Arch Womens Ment Health. 2021;24(1):133-44. Additional Declarations No competing interests reported. Supplementary Files TABLEA1.docx Cite Share Download PDF Status: Published Journal Publication published 02 Jan, 2025 Read the published version in Maternal Health, Neonatology and Perinatology → Version 1 posted Editorial decision: Revision requested 26 Aug, 2024 Reviews received at journal 21 Aug, 2024 Reviews received at journal 18 Aug, 2024 Reviewers agreed at journal 04 Aug, 2024 Reviewers agreed at journal 02 Aug, 2024 Reviewers agreed at journal 10 Jul, 2024 Reviewers invited by journal 10 Jul, 2024 Editor assigned by journal 01 Jul, 2024 Submission checks completed at journal 01 Jul, 2024 First submitted to journal 28 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4655614","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":329619127,"identity":"c7c9ae40-cf9d-4049-9425-61251e21f41e","order_by":0,"name":"Carrie L WOLFSON","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvklEQVRIiWNgGAWjYHACxgMVDAxy/AxnQBxm4vQcACo2lmwgVUvihgM8RGrhn5F84MCBPzaMmw+ePSbBUGGd2EBIi8SNtIQDB9vSmM0OnEuTYDiTTliLgXSOweGPDYfZzA6cMZNgbDtMnBagww7zGDeAtPwjWgvbYQkDBpCWBiK0SNx/BvaLgcSBM8YWCcfSjQlq4e85fPABMMTq+2ecMbzxocZalqAWJPsOMDAkEK8cbB8Jxo+CUTAKRsHIAgBjFkeZiu+kGgAAAABJRU5ErkJggg==","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Carrie","middleName":"L","lastName":"WOLFSON","suffix":""},{"id":329619131,"identity":"d78e1909-b71f-4078-ac43-7d1888bcb661","order_by":1,"name":"Jessica Tsipe ANGELSON","email":"","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Jessica","middleName":"Tsipe","lastName":"ANGELSON","suffix":""},{"id":329619133,"identity":"b0ffa9f8-8e3d-4d16-aeec-e1b31423763e","order_by":2,"name":"Andreea A CREANGA","email":"","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Andreea","middleName":"A","lastName":"CREANGA","suffix":""}],"badges":[],"createdAt":"2024-06-28 15:12:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4655614/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4655614/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40748-024-00198-0","type":"published","date":"2025-01-02T15:57:27+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60945025,"identity":"66a3d14a-a7c8-4132-b19b-1970090a607f","added_by":"auto","created_at":"2024-07-23 22:19:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":128111,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePostpartum Hospitalization Rates Overall and among Patients with a Mental Health Condition or Substance Use Disorder Diagnoses by Severe Maternal Morbidity Status During Delivery Hospitalization\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNote: SMM, Severe Maternal Morbidity; MH, mental health; SUD, substance use disorder. Postpartum hospitalization rate is number of hospitalizations following delivery hospitalization discharge per 1,000 deliveries.\u003c/p\u003e\n\u003cp\u003eSource: Healthcare Cost and Utilization Project (HCUP), Maryland Inpatient Database, 2016-2019. N=197,749 deliveries in 2016-2018.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4655614/v1/7458a0ae07d4597532b85d06.png"},{"id":73093285,"identity":"c096cdb0-b001-41eb-a6bc-e1c3b939deab","added_by":"auto","created_at":"2025-01-06 16:12:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":899629,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4655614/v1/c015a4e4-79a3-44b9-9171-a01c2d37adfd.pdf"},{"id":60944418,"identity":"558ac6e3-33bd-4c61-8891-f9ad040e1433","added_by":"auto","created_at":"2024-07-23 22:11:00","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25586,"visible":true,"origin":"","legend":"","description":"","filename":"TABLEA1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4655614/v1/07fe39c4d4251606b3515902.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Is severe maternal morbidity a risk factor for postpartum hospitalization with mental health or substance use disorder diagnoses? Findings from a retrospective cohort study in Maryland: 2016-2019","fulltext":[{"header":"BACKROUND","content":"\u003cp\u003eThe prevalence of perinatal mental health conditions, including depression, anxiety, bipolar disorder, and suicidality, has doubled in the past two decades in the United States, affecting more than 20% of pregnant and postpartum people annually (1\u0026ndash;4). Perinatal substance use and substance use disorders have also risen dramatically, with 6.5 cases of opioid use disorder reported per 1,000 delivery hospitalizations in 2016 (5, 6). In fact, mental health conditions and substance use disorders are leading causes of pregnancy-related and pregnancy-associated death in the United States (7, 8), and have also been associated with poor maternal, neonatal, and infant outcomes (9) and increased delivery hospitalization costs (10, 11). Notably, presence of a mental health condition diagnosis during the delivery hospitalization has been shown to be associated with an increased likelihood of severe maternal morbidity (SMM) (3, 10, 12), the rate of which also increased by 22.5% between 2008 and 2021 in the US and is known to have long-term consequences on women\u0026rsquo;s health (13, 14). Less is known about the relationship between SMM and postpartum mental health, although recent studies indicate an increased risk of such conditions following an SMM event (15, 16). These findings are consistent with qualitative evidence in which patients describe their SMM events as having long-term negative psychological impacts (17\u0026ndash;19). Despite the recognized co-occurrence of mental health conditions and substance use disorders (20, 21), these conditions are not usually examined in tandem among peripartum individuals.\u003c/p\u003e \u003cp\u003eData from all hospital admissions within one year postpartum in Maryland offer the opportunity of exploring the association between SMM and postpartum mental health and substance use, both separately and as co-occurring morbidities. The objective of this study is to examine rates of hospitalization with a mental health condition, or substance use disorder, or both during the first year postpartum among patients with and without SMM during delivery hospitalization in Maryland over a 4-year period before the start of the COVID-19 pandemic.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eWe conducted a retrospective cohort study using 2016\u0026ndash;2019 Maryland State Inpatient Database (SID) maintained by the Agency for Healthcare Research and Quality for the Healthcare Cost and Utilization Project (HCUP). Delivery discharge records were identified using the International Classification of Diseases 10th Revision, Clinical Modification (ICD-10-CM) diagnosis codes and procedure codes among patients identified as female and of reproductive age (15\u0026ndash;49 years). Postpartum hospitalizations were identified using a unique patient identifier which is consistent across admissions and facilities over time in the Maryland SID.\u003c/p\u003e \u003cp\u003eThe 3 primary outcomes for the analysis were postpartum hospital admission with a mental health condition, a substance use disorder, and both. Outcome assessment was based on the presence of at least one ICD-10-CM diagnosis code for a mental health condition or substance use disorder among the first five ICD-10-CM diagnosis codes listed for each patient (a full list of ICD-10-CM diagnosis codes used to identify outcomes are included in Appendix 1); of note, SID allows up to 30 diagnosis and procedure ICD codes to be listed for each hospital discharge. Within the sample of patients with at least one delivery during 2016\u0026ndash;2018, 82.2% of records included at least 5 diagnosis codes, 70.0% had 6 or more diagnosis codes. For deriving the co-occurring disorders outcome, we included individuals with a mental health condition or a substance use disorder diagnosis among the first 5 diagnoses listed who also had a diagnosis code for the other type of disorder listed for the same hospital discharge. Outcomes were identified from the day after discharge from the delivery hospitalization through 365 days following delivery. To examine outcomes one year postpartum, the sample was restricted to patients with deliveries occurring during 2016\u0026ndash;2018 to allow for sufficient follow up time in 2019 data.\u003c/p\u003e \u003cp\u003eSevere maternal morbidity (SMM) was defined using the Center for Disease Control and Prevention\u0026rsquo;s SMM ICD-10-CM algorithm based on ICD-10-CM diagnoses and procedures noted during the delivery hospitalization (14). In line with the most recent literature, patients with only blood transfusion ICD-10-CM codes were not deemed as having experienced SMM due to poor positive predictive value of SMM using ICD-10-CM codes for this specific indicator (22). Patient sociodemographic information available and used in this analysis includes age, race/ethnicity (categorized as non-Hispanic Black, non-Hispanic White, Hispanic, and other/multiple races using HCUP\u0026rsquo;s standard variables for race and ethnicity), income quartile for the patient\u0026rsquo;s zip code, delivery hospitalization payer (private, public, self-pay/none), and location of residence (urban or rural). We also identified the presence of a maternal mental health condition, or a substance use disorder noted during delivery hospitalization, as well as the delivery outcome (stillbirth or live birth).\u003c/p\u003e \u003cp\u003eThese characteristics were compared between patients with and without SMM using Pearson chi-square analyses. Rates of hospitalization during the early (within 42 days) and late (42\u0026ndash;365 days) postpartum periods were calculated for patients with and without SMM and for each outcome of interest (hospitalization with a mental health condition, a substance use disorder, and co-occurring mental health condition and substance use disorder). Unadjusted and multivariable logistical regression models were fitted to assess the relationship between SMM during delivery hospitalization and postpartum hospitalization with one of the 3 outcomes of interest during the first postpartum year. Adjusted models controlled for patient age, race and ethnicity, median household income for zip code, insurance type, urban/rural residence, presence of a mental health condition or a substance use disorder during delivery, and birth outcome, as well as clustering at the patient level using cluster subcommands to account for patients with multiple deliveries during the period of analysis (n\u0026thinsp;=\u0026thinsp;26,930; 15.9% of patients with deliveries between 2016 and 2018 in the sample). Analyses were conducted using Stata 15.1 software (College Station, TX).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 197,749 delivery hospitalizations were identified in Maryland between 2016 and 2018; 0.8% (n\u0026thinsp;=\u0026thinsp;1,513) involved SMM. Compared to patients without SMM, a higher proportion of patients with SMM were 35\u0026ndash;39 years of age (21.6% vs. 17.1%, respectively) and 40 years of age or older (8.3% vs. 3.9%, respectively) (Table\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e). Patients with SMM were also in higher proportion non-Hispanic Black (46.1% vs. 30.5%, respectively), with incomes in lowest income quartile for ZIP code (33.4% vs. 27.8%, respectively), and covered by public insurance (49.1% vs. 42.4%, respectively) than those without SMM. Also, a higher proportion of patients with than without SMM had a mental health condition (17.1% vs. 9.4%, respectively) or substance use disorder (6.9% vs. 3.6%, respectively) diagnosis documented during the delivery hospitalization. Additionally, the outcome of deliveries complicated by SMM were in higher proportion stillbirth in patients with SMM compared to patients without SMM (6.5% vs. 0.7%, respectively).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eCharacteristics of Patients with and without Severe Maternal Morbidity During Delivery Hospitalization\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNo SMM\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;196,236)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSMM\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1,513)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP-value for difference\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38,774\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e289\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u0026ndash;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54,167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e334\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u0026ndash;34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62,151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e439\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u0026ndash;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33,565\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e326\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,579\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRace \u0026amp; Ethnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNH Black\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59,838\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e697\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNH White\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84,723\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e462\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29,683\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther/multiple races\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21,992\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary Language\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.453\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEnglish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e118,996\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e60.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e872\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-English\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,473\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing/unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64,767\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e542\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian household income\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1st quartile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54,549\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e505\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2nd quartile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53,346\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e426\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3rd quartile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48,437\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e328\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4th quartile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39,374\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing/unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e530\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrban residence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.217\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e191,252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e97.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,483\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,860\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing/unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e104,314\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e694\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83.163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e743\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-pay/none\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,675\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing/unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComorbidities\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMental health condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18,431\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e258\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSubstance use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStillbirth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,346\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eNote: SMM, Severe Maternal Morbidity; NH, non-Hispanic. \u003csup\u003e1\u003c/sup\u003eMedian household zip code calculated based on zip code of patient\u0026rsquo;s residence. \u003csup\u003e2\u003c/sup\u003eIndicated during delivery hospitalization. P-value based on chi-square analysis of difference in distribution between patients with and without SMM during the delivery hospitalization. *Restricted due to small cell size.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eSource: Healthcare Cost and Utilization project (HCUP) Maryland Inpatient Database, 2016\u0026ndash;2018; N\u0026thinsp;=\u0026thinsp;197,749 deliveries.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAmong patients with deliveries, 2.9% (n\u0026thinsp;=\u0026thinsp;5,793) experienced hospitalization in the year following delivery. The rate of postpartum hospitalization was higher across all outcomes and time periods for patients with SMM compared to those without SMM (Fig.\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e). The relative risk of early postpartum hospitalization for patients with SMM was 6.5 for any hospitalization (95% CI\u0026thinsp;=\u0026thinsp;5.4\u0026ndash;7.6), 8.8 for a hospitalization with a mental health condition diagnosis (95% CI\u0026thinsp;=\u0026thinsp;5.2\u0026ndash;14.7), 9.9 for a substance use disorder diagnosis (95% CI\u0026thinsp;=\u0026thinsp;4.3, 22.6), and 13.6 for both (95% CI\u0026thinsp;=\u0026thinsp;5.9\u0026ndash;31.6) compared to patients without SMM. In the late postpartum period, the relative risk of postpartum hospitalization between patients with and without SMM for any cause was 5.2 (95% CI\u0026thinsp;=\u0026thinsp;4.4, 6.1). The relative risk was 4.9 (95% CI\u0026thinsp;=\u0026thinsp;3.5, 6.9), 3.6 (95% CI\u0026thinsp;=\u0026thinsp;2.1, 6.2), and 4.1 (95% CI\u0026thinsp;=\u0026thinsp;2.4, 7.0) for hospitalizations with a mental health condition, substance use disorder, and both, respectively. The rate of hospitalization for any reason was higher in the early postpartum than in the late postpartum period for patients with SMM (85.3 per vs. 83.2 1,000 deliveries, respectively). However, among all patients (with and without SMM) the rate of postpartum hospitalization with a mental health condition or substance use disorder was higher in the late postpartum period.\u003c/p\u003e\n\u003cp\u003eCompared with patient without SMM, those with SMM had significantly higher odds of postpartum hospitalization with a mental health condition diagnosis (OR\u0026thinsp;=\u0026thinsp;5.7; 95% CI 4.2, 7.6), a substance use disorder (OR\u0026thinsp;=\u0026thinsp;4.4; 95% CI 2.8, 7.1) and co-occurring mental health conditions and substance use disorder diagnoses (OR\u0026thinsp;=\u0026thinsp;4.9, 95% CI 3.1, 7.9) (Table\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e). Odds were attenuated by 34.2\u0026ndash;40.2% after adjustment for the sociodemographic and delivery characteristics examined.\u003c/p\u003e\n\u003cdiv\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eOdds of Postpartum Hospitalization for Patients with a Mental Health Condition or Substance Use Disorder Diagnoses by Severe Maternal Morbidity Status\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"15\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eHospitalization with\u003c/p\u003e\n \u003cp\u003eMental Health Condition\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eHospitalization with\u003c/p\u003e\n \u003cp\u003eSubstance Use Disorder\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eHospitalization with\u003c/p\u003e\n \u003cp\u003eCo-Occurring MH \u0026amp; SUD\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eUnadjusted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAdjusted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eUnadjusted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAdjusted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eUnadjusted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAdjusted\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSMM during delivery (no SMM\u0026thinsp;=\u0026thinsp;Ref.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.21, 7.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.69, 5.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.77, 7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.62, 4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.08, 7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.81, 4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u0026ndash;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.53, 0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61, 0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7, 1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.84, 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.63, 0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.77, 1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u0026ndash;34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.42, 0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61, 0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.38, 0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.67, 1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.31, 0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.57, 0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u0026ndash;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4, 0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6, 0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.32, 0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.66, 1.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.32, 0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.66, 1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.26, 0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.41, 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.28, 0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.68, 2.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.22, 0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.53, 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRace \u0026amp; Ethnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNH White\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNH Black\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.04, 1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.88, 1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.82, 1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.56, 0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.88, 1.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.62, 0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.33, 0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.35, 0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.08, 0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.09, 0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.09, 0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.09, 0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther/multiple races\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4, 0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.58, 0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.22, 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.34, 0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.24, 0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4, 0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian income\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1st quartile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2nd quartile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.53, 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.75, 1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.37, 0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61, 0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.38, 0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.63, 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3rd quartile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.38, 0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.64, 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.29, 0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.64, 1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.26, 0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.58, 0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4th quartile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.34, 0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6, 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.17, 0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.44, 0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.15, 0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.39, 0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRef.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedicaid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.48, 3.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.85, 2.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.2, 10.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.91, 7.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.77, 11.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.2, 7.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-pay/none\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.16, 2.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.17, 2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.42, 4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.35, 4.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.29, 4.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.26, 4.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrban residence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7, 1.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.84, 1.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.58, 1.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9, 2.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.55, 1.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.81, 2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComorbidities during delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMH condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.81, 9.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.76, 7.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.01, 8.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.5, 3.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.39, 13.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.59, 6.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSUD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.29, 7.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.74, 2.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.89, 27.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.99, 9.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.95, 24.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.27, 6.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStillbirth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.41, 5.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.48, 3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.83, 5.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1, 3.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3, 4.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7, 2.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"15\"\u003eNote: SMM, severe maternal morbidity; NH, non-Hispanic; MH, mental health; SUD, substance use disorder. \u003csup\u003e1\u003c/sup\u003eIncome is household median for zip code. Adjusted models include all variables in the table. Standard errors adjusted for individual-level clustering. Unadjusted models show the odds of SMM for each characteristic.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"15\"\u003eSource: Healthcare Cost and Utilization Project (HCUP), Maryland Inpatient Database, 2016\u0026ndash;2019. N\u0026thinsp;=\u0026thinsp;197,749 deliveries in 2016\u0026ndash;2018.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eSeveral sociodemographic and delivery characteristics were associated with the odds of postpartum hospitalization with a mental health condition or substance use disorder or both types of diagnoses. Compared to non-Hispanic White patients, patients who were Hispanic had a lower odds of postpartum hospitalization with a mental health condition (AOR\u0026thinsp;=\u0026thinsp;0.5, 95% CI 0.4, 0.6), substance use disorder (AOR\u0026thinsp;=\u0026thinsp;0.2, 95% CI 0.1, 0.3), or co-occurring mental health condition and substance use disorder (AOR\u0026thinsp;=\u0026thinsp;0.2, 95% CI 0.1, 0.3) compared to patients who were non-Hispanic White. Though patients who were non-Hispanic Black had approximately 20% higher odds of postpartum hospitalization with a mental health condition compared to non-Hispanic White patients (in unadjusted models only), they had approximately 30% lower odds of postpartum hospitalization with a substance use disorder or co-occurring mental health condition and substance use disorder compared to non-Hispanic White patients.\u003c/p\u003e\n\u003cp\u003eBy and large, the higher the patient income, the lower the odds of postpartum hospitalization with mental health condition or substance use disorder diagnoses. Compared to patients with private insurance, those with public insurance or no insurance had 1.9 times higher odds of postpartum hospitalization with a mental health condition diagnosis and over 5-times higher odds of postpartum hospitalization with substance use alone or both substance use and mental health condition diagnoses. Importantly, odds of postpartum hospitalization with a mental health condition diagnosis were significantly higher for patients with a mental health condition (AOR\u0026thinsp;=\u0026thinsp;6.6; 95% CI 5.8, 7.5) or substance use disorder (AOR\u0026thinsp;=\u0026thinsp;2.1; 95% CI 1.7, 2.5) diagnosis during the delivery hospitalization. Patients with a stillbirth had 2.2 times higher odds for postpartum hospitalization with a mental health condition diagnosis compared to patients with a live born infant.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this retrospective cohort study of deliveries in Maryland between 2016\u0026ndash;2018, patients who experienced SMM during their delivery hospitalization had 3.7, 2.8 and 3 times the odds of postpartum hospitalization with a mental health condition diagnosis, substance use disorder diagnosis and both, respectively, compared to patients who did not experience SMM during delivery. Rates of postpartum hospitalization with such diagnoses were significantly higher among patients with SMM compared to those without SMM during the early and late postpartum periods. Our findings confirm prior research documenting higher rates of postpartum hospitalization among postpartum patients who experience SMM compared to those who did not experience SMM (23), and are supported by clinical plausibility with respect to the associations between SMM and presence of mental health condition and substance use disorder diagnoses. Research has shown that traumatic birth outcomes increase the risk of mental health conditions, particularly posttraumatic stress disorder, during the postpartum period (24\u0026ndash;26). Moreover, a study in Sweden found a positive association between SMM at delivery and postpartum treatment for psychiatric disorders (27). Experience of adverse or unexpected outcomes such as preeclampsia, preterm birth, or cesarean delivery have been identified as risk factors for postpartum mental health conditions (28\u0026ndash;30). Similarly, the postpartum period is recognized as a particularly vulnerable time for individuals with substance use disorders at risk of relapse, which may be further compounded by the experience of birth trauma or adverse pregnancy outcomes (31). Fear for personal safety or safety of the neonate and negative perceptions of birth, multiple interventions during labor and birth, and anesthesia complications are all associated with postpartum mental health conditions and can be unique vulnerabilities for those with histories of substance use disorders (31, 32). SMM frequently includes multiple interventions as well as anesthesia and is often characterized as a traumatic event by those who experience them, which can explain the relationships we observed in our study.\u003c/p\u003e \u003cp\u003eEfforts to reduce preventable SMM and its effects should include recognition and management of mental health and substance use in pregnancy and postpartum, and particularly the late postpartum period. In our study, postpartum hospitalization rates for patients with mental health and substance use disorders were higher during the late postpartum period compared to the early postpartum period. Similarly, studies of pregnancy-associated mortality have identified higher rates of deaths due to overdose and suicide in the late postpartum period (33, 34). Together, these suggest the late postpartum period is a particularly vulnerable time for these behavioral health conditions.\u003c/p\u003e \u003cp\u003ePatients with SMM often receive inadequate information about their morbidity (35). Recommendations following an SMM event include offering patients a debriefing by their clinician before hospital discharge, social support, referrals and warm hand-off to mental health and substance use providers and services, including specialized treatment (35). Such interventions have been found to be moderately effective in reducing mental health symptoms among patients with traumatic births (36, 37). The US Preventive Services Task Force recommends that clinicians provide or refer postpartum persons at increased risk for perinatal depression to counseling interventions due to sufficient evidence of their effectiveness (38). Increased risk includes those with a history of depression, current depressive symptoms, socioeconomic risk factors, or a history of significant negative life events. Findings from this analysis suggest that experience of SMM should also be considered as a risk factor.\u003c/p\u003e \u003cp\u003eOur findings demonstrate no significant difference in the in adjusted odds of postpartum hospitalization with a mental health condition between non-Hispanic Black and White patients who experience SMM, but lower odds of postpartum hospitalization for substance use disorders and both mental health conditions and substance use disorders. Additionally,, odds of hospitalization with a mental health condition or substance use disorder were significantly lower among Hispanic patients and other racial/ethnic minority groups compared to white patients. More research is needed to determine whether these differences are due to true lower rates of mental health conditions and substance use disorders or differences in rates of diagnosis and recognition.\u003c/p\u003e \u003cp\u003eOur study has limitations. While there are indications that SMM precipitates postpartum mental health conditions and substance use, these relationships may be bidirectional, such that a history of mental health conditions or substance use predisposes pregnant individuals to SMM, which in turn exacerbates the risk of the same in the postpartum period (16). Clearly establishing the directionality and causality of this relationship will require further, more robust longitudinal studies. In addition, examining the relationship of SMM with specific types of mental health conditions as well as co-occurring mental health conditions and substance use should be the focus of research when a larger sample size than ours is available. We used the first five diagnosis codes for each patient to ascertain our outcomes of interest \u0026ndash; this cut-off point was used to examine postpartum hospitalizations where mental health conditions and substance use disorders represented important reason(s) for the hospitalizations. However, we may have missed patients who were admitted to the hospital for these conditions but, for which, only direct pregnancy complications were noted with the first five conditions codes. We may have also missed patients who do not disclose their mental health condition or symptoms, or their substance use to a healthcare provider, or those who are less likely to be screened for such conditions including birthing people of color and those with low incomes (39). The data are limited to conditions identified during hospitalizations, whereas many of these conditions do not result in hospitalization and may be identified in outpatient settings and treated through medication, therefore we are unable to adjust for prenatal depression and substance use, unless identified during the delivery hospitalization; moreover, only SMM during delivery hospitalization is examined, thus excluding SMM events that occur in antepartum and postpartum hospitalizations. In addition, residual confounding may be present due to the exclusion of other chronic health conditions and the limited sociodemographic variables available through hospital records. Furthermore, reliance on administrative data, which are primarily collected for billing purposes, has other limitations because all health conditions present during a hospital admission may not be consistently and accurately reported and the algorithm used to identify SMM based on this data is not well suited to identify all cases of SMM events involving hemorrhage (22).\u003c/p\u003e \u003cp\u003eHowever, the study has some important strengths. It uses a large, statewide database analyzed longitudinally over several years before the start of the COVID-19 pandemic \u0026ndash; this was only possible given the inclusion of a unique patient identifier in the Maryland SID. The use of ICD-10 codes for outcome ascertainment has the strength of consistency in identifying cases over the study period and offers some reassurance that they represent true cases of patients with mental health conditions or substance use disorders.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003ePatients who experience SMM have a higher odds of hospitalization with a mental health condition or substance use disorder or both in the postpartum period. Treatment and support resources for mental health and substance use providers --including enhanced screening and warm handoffs -- should be made available to patients with SMM upon discharge after delivery, and evidence-based interventions to improve mental health and reduce substance use should be prioritized in these patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cem\u003eSMM, Severe Maternal Morbidity\u003c/em\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was deemed non-human subjects research by the Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health because the HCUP data are de-identified and do not contain personally identifiable information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are publicly available from The Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project. HCUP State Inpatient Databases (SID). Healthcare Cost and Utilization Project (HCUP). 2015-2019. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/sidoverview.jsp\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this study is from the Eunice Kennedy Shriver National Institute of Child Health and Human Development NICHD, Award Number 1R01HD112442-01. The sponsor had no role in the study design; collection, analysis, and interpretation of data; in the writing of the report; or the decision to submit the article for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; Contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAll authors collectively conceived and designed the analysis. CW performed the analysis. CW and JA wrote the manuscript and AC provided critical review and feedback. All authors reviewed and approved the final manuscript.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNot applicable\u0026nbsp;\u003c/em\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGetahun D, Oyelese Y, Peltier M, Yeh M, Chiu VY, Takhar H, et al. Trends in Postpartum Depression by Race/Ethnicity and Pre-pregnancy Body Mass Index. American Journal of Obstetrics and Gynecology. 2023;228(1):S122-S3.\u003c/li\u003e\n\u003cli\u003eAdmon LK, Dalton VK, Kolenic GE, Ettner SL, Tilea A, Haffajee RL, et al. Trends in Suicidality 1 Year Before and After Birth Among Commercially Insured Childbearing Individuals in the United States, 2006-2017. JAMA Psychiatry. 2021;78(2):171-6.\u003c/li\u003e\n\u003cli\u003eMcKee K, Admon LK, Winkelman TNA, Muzik M, Hall S, Dalton VK, et al. Perinatal mood and anxiety disorders, serious mental illness, and delivery-related health outcomes, United States, 2006-2015. BMC Womens Health. 2020;20(1):150.\u003c/li\u003e\n\u003cli\u003eHanson M, Hellem T, Alexander-Ruff J, Newcomer SR. Systematic Review of Barriers to and Facilitators of Screening for Postpartum Depression at Well-Child Visits in the United States. Nurs Womens Health. 2024;28(3):213-21.\u003c/li\u003e\n\u003cli\u003eRodriguez JJ, Smith VC. 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JAMA Netw Open. 2023;6(6):e2317641.\u003c/li\u003e\n\u003cli\u003eHealth DoR. How Does CDC Identify Severe Maternal Morbidity? 2023 [Available from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm.\u003c/li\u003e\n\u003cli\u003eLewkowitz AK, Rosenbloom JI, Keller M, Lopez JD, Macones GA, Olsen MA, et al. Association Between Severe Maternal Morbidity and Psychiatric Illness Within 1 Year of Hospital Discharge After Delivery. Obstet Gynecol. 2019;134(4):695-707.\u003c/li\u003e\n\u003cli\u003eAttanasio L, Jeung C, Geissler KH. Association of Postpartum Mental Illness Diagnoses with Severe Maternal Morbidity. J Womens Health (Larchmt). 2023.\u003c/li\u003e\n\u003cli\u003eElmir R, Schmied V, Jackson D, Wilkes L. Between life and death: women\u0026apos;s experiences of coming close to death, and surviving a severe postpartum haemorrhage and emergency hysterectomy. 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Am J Obstet Gynecol. 2019;221(5):491 e1- e22.\u003c/li\u003e\n\u003cli\u003eModarres M, Afrasiabi S, Rahnama P, Montazeri A. Prevalence and risk factors of childbirth-related post-traumatic stress symptoms. BMC Pregnancy Childbirth. 2012;12.\u003c/li\u003e\n\u003cli\u003eWall-Wieler E, Carmichael SL, Urquia ML, Liu C, Hjern A. Severe maternal morbidity and postpartum mental health-related outcomes in Sweden: a population-based matched-cohort study. Arch Womens Ment Health. 2019;22(4):519-26.\u003c/li\u003e\n\u003cli\u003eCaropreso L, de Azevedo Cardoso T, Eltayebani M, Frey BN. Preeclampsia as a risk factor for postpartum depression and psychosis: a systematic review and meta-analysis. Arch Womens Ment Health. 2020;23(4):493-505.\u003c/li\u003e\n\u003cli\u003eAyers S, Bond R, Bertullies S, Wijma K. The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework. Psychol Med. 2016;46(6):1121-34.\u003c/li\u003e\n\u003cli\u003eSun L, Wang S, Li X-Q. Association between mode of delivery and postpartum depression: A systematic review and network meta-analysis. Australian \u0026amp; New Zealand Journal of Psychiatry. 2021;55.\u003c/li\u003e\n\u003cli\u003eMartin CE, Parlier-Ahmad AB. Addiction treatment in the postpartum period: an opportunity for evidence-based personalized medicine. Int Rev Psychiatry. 2021;33(6):579-90.\u003c/li\u003e\n\u003cli\u003eSimpson M, Schmied V, Dickson C, Dahlen HG. Postnatal post-traumatic stress: An integrative review. Women Birth. 2018;31(5):367-79.\u003c/li\u003e\n\u003cli\u003eHan B, Compton WM, Einstein EB, Elder E, Volkow ND. Pregnancy and Postpartum Drug Overdose Deaths in the US Before and During the COVID-19 Pandemic. JAMA Psychiatry. 2024;81(3):270-83.\u003c/li\u003e\n\u003cli\u003eZivin K, Zhong C, Rodriguez-Putnam A, Spring E, Cai Q, Miller A, et al. Suicide Mortality During the Perinatal Period. JAMA Netw Open. 2024;7(6):e2418887.\u003c/li\u003e\n\u003cli\u003eFurniss M, Conroy M, Filoche S, MacDonald EJ, Geller SE, Lawton B. Information, support, and follow-up offered to women who experienced severe maternal morbidity. Int J Gynaecol Obstet. 2018;141(3):384-8.\u003c/li\u003e\n\u003cli\u003eBaxter JD, McCourt C, Jarrett PM. What is current practice in offering debriefing services to post partum women and what are the perceptions of women in accessing these services: a critical review of the literature. Midwifery. 2014;30(2):194-219.\u003c/li\u003e\n\u003cli\u003eGamble J, Creedy D, Moyle W, Webster J, McAllister M, Dickson P. Effectiveness of a counseling intervention after a traumatic childbirth: a randomized controlled trial. Birth. 2005;32(1):11-9.\u003c/li\u003e\n\u003cli\u003eUS Preventive Services Task Force, Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, et al. Interventions to Prevent Perinatal Depression: US Preventive Services Task Force Recommendation Statement. JAMA. 2019;321(6):580-7.\u003c/li\u003e\n\u003cli\u003eSidebottom A, Vacquier M, LaRusso E, Erickson D, Hardeman R. Perinatal depression screening practices in a large health system: identifying current state and assessing opportunities to provide more equitable care. Arch Womens Ment Health. 2021;24(1):133-44.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"maternal-health-neonatology-and-perinatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mhnp","sideBox":"Learn more about [Maternal Health, Neonatology and Perinatology](http://mhnpjournal.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/mhnp/default.aspx","title":"Maternal Health, Neonatology and Perinatology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Postpartum depression, substance use disorder, maternal health, postpartum hospitalization","lastPublishedDoi":"10.21203/rs.3.rs-4655614/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4655614/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e \u003cp\u003ePerinatal mental health conditions and substance use are leading causes, often co-occurring, of pregnancy-related and pregnancy-associated deaths in the United States. This study compares odds of hospitalization with a mental health condition or substance use disorder or both during the first year postpartum between patients with and without severe maternal morbidity (SMM) during delivery hospitalization.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData are from the Maryland\u0026rsquo;s State Inpatient Database and include patients with a delivery hospitalization during 2016\u0026ndash;2018 (n\u0026thinsp;=\u0026thinsp;197,749). We compare rate of hospitalization with a mental health condition or substance use disorder or both at 42 days and 42 days to 1 year postpartum by occurrence of SMM during the delivery hospitalization. We use multivariable logistic regression to derive the odds of hospitalization with each outcome for patients by SMM status, adjusted for patient sociodemographic characteristics, presence of mental health condition or substance use disorder diagnoses during the delivery hospitalization, and delivery outcome. SMM, mental health conditions, and substance use disorders are identified using ICD-10 diagnosis and procedure codes.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eOverall, 5,793 patients (2.9%) who delivered during 2016\u0026ndash;2018 experienced hospitalization in the year following delivery. Among these patients, 24.3% (n\u0026thinsp;=\u0026thinsp;1,410) had a mental health condition diagnosis, 10.6% (n\u0026thinsp;=\u0026thinsp;619) had a substance use disorder diagnosis, and 9.8% (n\u0026thinsp;=\u0026thinsp;570) had co-occurring mental health condition and substance use disorder diagnoses. Patients with SMM had 3.7 times the odds (95% CI 2.7, 5.2) of hospitalization with a mental health condition diagnosis, 2.7 times the odds (95% CI 1.6, 4.4) of a hospitalization with substance use disorder diagnosis, and 3.0 times the odds (95% CI 1.8, 4.8) of hospitalization with co-occurring mental health condition and substance use disorder diagnoses during the first-year postpartum adjusting for covariates.\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e \u003cp\u003ePatients who experience SMM during their delivery hospitalization had higher odds of hospitalization with a mental health condition, substance use disorder, and co-occurring mental health condition and substance use disorder in the one-year postpartum period. Treatment and support resources for mental health and substance use providers --including enhanced screening and warm handoffs -- should be made available to patients with SMM upon discharge after delivery, and evidence-based interventions to improve mental health and reduce substance use should be prioritized in these patients.\u003c/p\u003e","manuscriptTitle":"Is severe maternal morbidity a risk factor for postpartum hospitalization with mental health or substance use disorder diagnoses? Findings from a retrospective cohort study in Maryland: 2016-2019","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-23 22:10:56","doi":"10.21203/rs.3.rs-4655614/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-26T12:19:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-21T18:18:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-18T18:03:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"331869029308000534113812479025289494909","date":"2024-08-04T13:42:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"224542583075380328993934570104988507479","date":"2024-08-02T14:41:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259511704177428815495979139424808135233","date":"2024-07-10T13:32:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-10T10:08:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-01T07:37:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-01T07:36:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Maternal Health, Neonatology and Perinatology","date":"2024-06-28T15:11:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"maternal-health-neonatology-and-perinatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mhnp","sideBox":"Learn more about [Maternal Health, Neonatology and Perinatology](http://mhnpjournal.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/mhnp/default.aspx","title":"Maternal Health, Neonatology and Perinatology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"380829dd-2f3c-40ff-ab80-1a80e2f72c80","owner":[],"postedDate":"July 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-06T16:01:58+00:00","versionOfRecord":{"articleIdentity":"rs-4655614","link":"https://doi.org/10.1186/s40748-024-00198-0","journal":{"identity":"maternal-health-neonatology-and-perinatology","isVorOnly":false,"title":"Maternal Health, Neonatology and Perinatology"},"publishedOn":"2025-01-02 15:57:27","publishedOnDateReadable":"January 2nd, 2025"},"versionCreatedAt":"2024-07-23 22:10:56","video":"","vorDoi":"10.1186/s40748-024-00198-0","vorDoiUrl":"https://doi.org/10.1186/s40748-024-00198-0","workflowStages":[]},"version":"v1","identity":"rs-4655614","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4655614","identity":"rs-4655614","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}