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Association Between Severe Maternal Morbidity and Psychiatric Illness Within 1 Year of Hospital Discharge After Delivery

Lewkowitz, Adam K. MD, MPHS; Rosenbloom, Joshua I. MD, MPH; Keller, Matt MS; López, Julia D. PhD, MPH; Macones, George A. MD, MSCE; Olsen, Margaret A. PhD, MPH; Cahill, Alison G. MD, MSCI

doi: 10.1097/AOG.0000000000003434
Contents: Psychiatry: Original Research

OBJECTIVE: To estimate whether severe maternal morbidity is associated with increased risk of psychiatric illness in the year after delivery hospital discharge.

METHODS: This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes within Florida's Healthcare Cost and Utilization Project's databases. The first liveborn singleton delivery from 2005 to 2015 was included; women with ICD-9-CM codes for psychiatric illness or substance use disorder during pregnancy were excluded. The exposure was ICD-9-CM codes during delivery hospitalization of severe maternal morbidity, as per the Centers for Disease Control and Prevention. The primary outcome was ICD-9-CM codes in emergency department encounter or inpatient admission within 1 year of hospital discharge of composite psychiatric morbidity (suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was a composite of ICD-9-CM codes for substance use disorder. We compared women with severe maternal morbidity with those without severe maternal morbidity using multivariable logistic regression adjusting for sociodemographic factors and medical comorbidities. Cox proportional hazard models identified the highest risk period after hospital discharge for the primary outcome.

RESULTS: A total of 15,510 women with severe maternal morbidity and 1,178,458 without severe maternal morbidity were included. Within 1 year of hospital discharge, 2.9% (n=452) of women with severe maternal morbidity had the primary outcome compared with 1.6% (n=19,279) of women without severe maternal morbidity, resulting in an adjusted odds ratio (aOR) 1.74 (95% CI 1.58–1.91). The highest risk interval was within 4 months of discharge (adjusted hazard ratio [adjusted HR] 2.53 [95% CI 2.05–3.12]). Most severe maternal morbidity conditions were associated with higher risk of postpartum psychiatric illness. Women with severe maternal morbidity had nearly twofold higher risk of postpartum substance use disorder (170 [1.1%] vs 6,861 [0.6%]; aOR 1.91 [95% CI 1.64–2.23]).

CONCLUSION: Though absolute numbers were modest, severe maternal morbidity was associated with increased risk of severe postpartum psychiatric morbidity and substance use disorder. The highest period of risk extended to 4 months after hospital discharge.

After delivery of liveborn singletons, the risk of need for acute psychiatric care within 1 year is significantly increased after severe maternal morbidity complications.

Department of Obstetrics and Gynecology, the Center for Administrative Data Research, Department of Medicine, and the Department of Surgery, Washington University in St. Louis, St. Louis, Missouri.

Corresponding author: Adam K. Lewkowitz, MD, MPHS, Department of Obstetrics and Gynecology, Brown University, Women and Infants Hospital of Rhode Island, 101 Plain Street Providence, RI 02905; email:

Dr. Lewkowitz is supported in part by a National Institutes of Health training grant T32-HD-55172-9. The Center for Administrative Data is supported in part by the Washington University Institute of Clinical and Translational Sciences grant UL1 TR002345 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH) and Grant Number R24 HS19455 through the Agency for Healthcare Research and Quality (AHRQ). The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official view of the NIH.

Financial Disclosure Margaret Olsen received funds from Pfizer, Sanofi Pasteur, and Merck for work unrelated to this study. The other authors did not report any potential conflicts of interest.

Presented at the 39th Annual Meeting of the Society for Maternal-Fetal Medicine, February 11–16, 2019, Las Vegas, Nevada.

Each author has confirmed compliance with the journal's requirements for authorship.

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© 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.