Complicating Conditions Listed for 94.1 Percent of 4.2 Million U.S. Births in 2008
Friday, May 27, 2011 at 3:17PM
By Jill Arnold
AHRQ’s Healthcare Cost and Utilization Project (HCUP) conducted a Nationwide Inpatient Sample (NIS) on pregnancy and childbirth hospitalizations with complicating conditions in 2008. “Complicating conditions” in the document include all ICD-9-CM diagnosis codes under “Complications of Pregnancy, Childbirth, and the Puerperium.”
From the brief:
There were 4,673,700 pregnancy and delivery hospital stays recorded in these hospital discharge data among females ages 15 to 44 years in 2008. As shown in table 1, there were 473,700 non-delivery maternal hospital stays with complicating conditions as a principal or secondary diagnosis. Among the 4.2 million deliveries in 2008, the vast majority (94.1 percent) listed some type of complicating condition. [Emphasis mine]
Summary of complicating conditions:
Non-delivery stays
As shown in table 2, among non-delivery maternal stays, the following complicating conditions occurred at a rate of 100 or more for every 1,000 hospital stays:
- early or threatened labor (208 per 1,000 stays)
- infections of genitourinary tract (132 per 1,000 stays)
- hypertension including eclampsia and pre-eclampsia (113 per 1,000 stays)
The following complicating conditions occurred at a rate of 50-99 for every 1,000 hospital stays:
- anemia (99 per 1,000 stays)
- diabetes or abnormal glucose tolerance (82 per 1,000 stays)
- hyperemesis gravidarum (vomiting) (63 per 1,000 stays)
- poor fetal growth (60 per 1,000 stays)
- ectopic pregnancy (56 per 1,000 stays)
- advanced maternal age (56 per 1,000 stays)
- hemorrhage (52 per 1,000 stays)
Delivery stays
Among maternal stays with delivery, the following common complicating conditions occurred at a rate of 100 or more for every 1,000 deliveries:
- umbilical cord complications (233 per 1,000 stays)
- perineal lacerations (158 1st degree and 168 2nd degree lacerations per 1,000 stays)
- previous cesarean section (167 per 1,000 stays)
- abnormality in fetal heart rate or rhythm (148 per 1,000 stays)
- prolonged pregnancy (121 per 1,000 stays)
- polyhydramnios and problems of the amniotic cavity (117 per 1,000 stays)
- advanced maternal age (117 per 1,000 stays)
- anemia during pregnancy (112 per 1,000 stays)
- fetal distress and abnormal forces of labor (111 per 1,000 stays)
The following complicating conditions occurred at a rate of 50-99 for every 1,000 deliveries:
- hypertension including eclampsia and pre-eclampsia (94 per 1,000 stays)
- early or threatened labor (81 per 1,000 stays)
- malposition, malpresentation (80 per 1,000 stays)
- diabetes or abnormal glucose tolerance (68 per 1,000 stays)
- poor fetal growth (54 per 1,000 stays)
- fetopelvic disproportion (54 per 1,000 stays)
Read the brief: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb113.jsp
Reader Comments (19)
I guess there is a small amount of woman 'perfect' for childbearing ;)
So they list a previous c-section as a complication-- sorry, "complicating condition" in nearly 17% of stays with delivery. Yet for some reason they barely hesitate to do something that will be a complicating factor for the mother in the future? And 94.1%?!? I must be REALLY lucky with my home births then, as well as the dozen or so other homebirthers I know.
So much for the notion that complications in pregnancy are rare and that childbirth should be "trusted." Complications are remarkably common.
The difference between now and 100 years ago is not the number of complications, or the rate of complications (with the exception of those related to previous C-section and the use of fetal monitoring), but the survival rate from the complications.
Pregnancy appears safe to many lay people because most complications can be treated with the typical interventions of modern obstetrics. Without those interventions, a substantial proportion of women with complications died. The American maternal mortality rate 100 years ago was approximately 100X higher (99,000%) than it is today.
Well, if you relable all normal variations of pregnancy as 'complications' of course all pregnancies are going to have 'complications'. This is no different that saying '91% of people are deformed', true if you define 'normal' as 5'8", 160lbs, red hair +/- 1 inch of the shoulders, male, between the ages of 25 and 26. Looking at their list of 'complications' a pregnancy apears 'normal' if: a single baby is born to a woman between 18 and 35 who has no prior or current medical history, gained no more than 15 lbs and weighs no more than 150lbs total, the labor began spontaneously at 37 to 39 weeks 6 days, progressed from start to finish in less than 10 hours with baby born over an intact perinium with a long loose cord and 10/10 apgar scores and weighs between 6 and 8 lbs, the placenta detaches spontaneously immediately after the birth and mom has no bleeding. Oh, and baby has to sing the Star Spangled Banner within 30 min of birth! Okay, so I'm being a bit vacisious, but not by much!
If perineal lacerations are a complication, then the rate of complications used to be close to or at 100%, since episiotomies used to be used nearly 100% of the time.
Also, "advanced maternal age" is a complication? Weird.
And as C. Pratt commented, a previous C-section is a complication, but an iatrogenic one, and probably most "fetal distress and abnormal forces of labor" are too -- "Pit to Distress", anyone?
I wonder what an "umbilical cord complication" is -- everything from a simple nuchal cord that presents no problems to a prolapsed cord or cord rupture that kills (or threatens to kill) the baby?
I also wonder of what value some of these categories of "complications" really are -- so 117/1,000 women were 35+, but does that mean that their pregnancies were in any way different from the <34? Being at higher risk of X does not mean that X will definitely happen, nor that X actually complicated the pregnancy or birth.
Jill, oh Stats Queen, is there any good source re postpartum complications, by the way? I've always been curious about rates of infection, injury, etc. but have never seen a good set of numbers.
Also I thought hyperemesis gravidarum was *severe* vomiting, not just vomiting--most pregnant and many laboring women vomit, but not always to any detriment.
These confuse me also:
Non-delivery stays
early or threatened labor (208 per 1,000 stays)--early I get, but false alarms are a complication? Or do they mean early labor they manage to stave off? How early?
Delivery stays:
prolonged pregnancy (121 per 1,000 stays)--does this mean simply over 40 weeks?
advanced maternal age (117 per 1,000 stays)--over 35? over 40?
This is taken from coding data, and therefore completely unreliable as any kind of method of data gathering. You can't really even look at it as that most care providers see these as complications.
When it comes to coding, we are taught to code absolutely everything possible. EVERYTHING. Also, notice that things like 1st degree lacerations (even if they are not repaired) are listed as a complication.
I don't believe in Advanced Maternal Age as a diagnosis. It is entirely overinflated. But do I code it? Yes. If it means that our coder can wave her magic wand and get more income for our community clinic, then it means more women I can serve.
What this really is is a reflection of how messed up our billing and coding system is in the US. People are fighting for every possible penny, and having to do so in some weird and wacky ways.
What they fail to recognize is that most of these can be handled easily (and often better) at home by the mother or midwife. With my second child: Malposition, prolonged pregnancy (I'm assuming they mean past 40 weeks? she was 41), risk of early labor, previous c-section, water broke and labor went past 24 hours, labor "stalled" for half a day, labored 42 hours. Born perfectly fine at home! With my third child: Premature (35 weeks), labor "stalled" (never really got consistent at all), previous c-section, labored 71 hours. Born perfectly fine at home! If I was in the hospital, both would have been dangerous repeat c-sections justified by some "complication" that was easily managed at home.
I agree that to call many of these "complications" is....weird. If that's how we're defining complications, then sure, yeah, lots of births have complications. I wonder what the exact definitions of these are, if any.
Plus, as someone mentioned above, coding is, in my experience, iffy at best. I know that I've had u/s coded as some variant of complication, just to get TRICARE to pay for it. I also know that my IUD was coded as something that meant a correction of my menstrual cycle - because I was in a Catholic system and "oh god please no more babies right now" wouldn't fly.
Here's the things I would question as a complication:
Definition of an early or threatened labor(we would send many, many women home thinking they were in labor, but weren't-are these included in these numbers?
Diabetes-how many of these were diet controlled and not needing medical intervention?
Advanced maternal age?-not sure why this is considered a complication unless something else was wrong.
hemorrhage-many hemorrhages can be handled with non medical means-were these hemorrhages that just needed some fundal pressure to stop, or what else was done to stop the bleeding?
Umbilical cord complications-not sure what the definition is for this, but most umbilical cord "problems" can be dealt with efficiently and effectively without a lot of fuss or problem. I've seen a lot of funky umbilical cord stuff that was really not a big deal.
Perineal lacerations-I wouldn't call a 1st that doesn't need a repair much of a complication. My kids get those kind of laceration just by playing baseball.
abnormality is fhr-what is their definition of this? If they have a deceleration, is that an abnormality? How low and how long are the abnormalities persisting/ There is so much disagreement on what is ok and not ok is this area, that I would only call those that need intervention and abnormality and even then many can just be corrected by a change in position. I'm not sure I would categorize it an abnormality unless there were a persistent number of late deceleration or decelerations which are getting lower and more prolonged for an extended amount of time.
Prolonged pregnancy is only a complication if there are complications associated with it.
fetal distress-again, no clear definition as to what this means.
malposition-again, this is only a complication if their are complications associated with it.
Anyways, I think most of these are poorly defined and many are present in a normal labor with no complications, or easily dealt with without medical intervention.
So basically pregnancy is one giant complication...? Although philosophically this sounds like an ironic statement, medically it is a little concerning IMO.
I found it distressing that this site which is supposed to be dedicated to providing information about the c-section epidemic has become another forum where childbirth risks are minimized, e.g. complications are "easily managed at home." I'm sure the women who have been negatively affected by some of these complications that are so breezily dismissed might disagree about how "easily" they are managed. Shrug- "Babies die" is the next step to "complications are easily managed."
Anonymous, sorry you're distressed. You're quoting something that's not in the post-- a post which has absolutely nothing to do with home birth.
Emjaybee, I found out after posting that real stats royalty (not just a princess) are working on a formal response. Might or might not be public, but I'll let you know.
Carrie, CNM... Thanks for your comment. I was waiting for a care provider to say exactly what you did. This stats brief simply reports on how things are coded for billing purposes, in which case it's an issue of economics. Incentives are incentives.
Anon: I think the questions are more "what exactly are these complications? how are they defined? how do they affect labor? must they affect labor?" etc. and therfore fit precisely with the concern about the rising C-section rate. If more complicated deliveries tends to sections (or not), that may require a particular method of action to reduce the rate. As for the homebirth commemt, that was made by a commenter, and may or may not be true, although I would think a complication easily* handled at home (assuming any of these can be) would also easily be handled by care providers working with a woman in hospital.
* You may define "easily" as you will.
I'm very interested in what is defined as a "complication".
I'm another homebirther, so I may be seen as biased. The only time I had what I would consider a complication was a PPH in a hospital, caused by a managed third stage. It subsequently was "handled" at home by simply letting my body birth my placentas in their own time, with no pulling on the cord, avoiding the "complication" in the first place ;)
I've had some of the things listed - OP babe, anaemia, hyperemesis gravidarum, cord around the neck, prolonged pregnancies (all three) etc etc. But I wouldn't consider them complications. They are part of the normal variations in birth. Pregnancy and birth don't follow the textbooks, as much as it would be easier for hospitals if they did. Like any other activity that we do, there will be differences between one person and another, one pregnancy and another.
We worry about the risk managment and complications without considering whether some complications really ARE complications, and whether we cause more problems and increase women's risks by "managing" where we should be standing back and watching.
Help is only help when it is needed. Otherwise, it's called interference ;)
we strive to find reasons why woman arent fit to give birth in this country its very sad...
LOL at the predictability of Dr. Amy's response. Interestingly, I see this as evidence of pregnancy and childbirth being pathologized, not that they are inherently pathological (which 94+% implies). Opposing Dr. Amy's comment, of course, is that even these numbers do not "prove" that "childbirth is (inherently) extraordinarily risky, anything can go wrong at any time, thus all birthing women should be in a hospital etc., etc."
Even by these numbers it is clear that "having had a previous C/S" IN ITSELF or "advanced maternal age" IN ITSELF-- those things AS the complication itself-- can be eliminated as actual emergencies necessitating a hospital stay. They are more risks (at best) than complications, and so it's not as though "94% of women had 'something go wrong' that proved they needed to be in the hospital."
Moreover, of course, is that many of these "complications" are clearly iatrogenic, and virtually all may have some iatrogenic component.
Just going through this quickly-- specifically looking for complications that retroactively indicate these women should birth/have birthed in a hospital, we have:
Non-delivery:
* early or threatened labor-- Definitely a possible contraindication for homebirth! Then again, some of these could have been nervous primips with Braxton Hicks.
* infections of genitourinary tract-- Okay, as mentioned earlier, a lot of these are just "codes." This is definitely one of them-- in 99% of cases-- if we're looking specifically for "reasons women should birth in the hospital"
* hypertension including eclampsia and pre-eclampsia (113 per 1,000 stays)-- Definitely a possible reason to birth in the hospital.
Hospital stays:
* anemia (99 per 1,000 stays)-- Could be an issue.
* diabetes or abnormal glucose tolerance (82 per 1,000 stays)-- Could be an issue, though it is not infrequently misdiagnosed.
* hyperemesis gravidarum (vomiting) (63 per 1,000 stays)-- Again, depends on how this is actually diagnosed.
* poor fetal growth (60 per 1,000 stays)-- As above.
* ectopic pregnancy (56 per 1,000 stays)-- This is kind of a non-issue when it comes to "homebirth"-- I mean, really. It's also not a good argument for women being in the hospital when they give birth, because it's contraindicated for BIRTH of any kind.
* advanced maternal age (56 per 1,000 stays)-- This is-- at best-- a risk, and not an actual bad outcome.
* hemorrhage (52 per 1,000 stays)-- Could definitely be an issue. Could, of course, also be iatrogenic in many cases.
Delivery stays:
* umbilical cord complications (233 per 1,000 stays)-- This is way too vague to be of use. If we're talking about babies with nuchal cords, usually a non-issue, then what are we really talking about?
* perineal lacerations (158 1st degree and 168 2nd degree lacerations per 1,000 stays)-- Does this include episiotomies themselves? Even if not, there is much evidence to suggest that many lacerations are directly or indirectly iatrogenic. But the larger issue here is that 1st and 2nd degree tears are not contraindications for homebirth.
* previous cesarean section (167 per 1,000 stays)-- This goes along with advanced maternal age.
* abnormality in fetal heart rate or rhythm (148 per 1,000 stays)-- Definitely a possible issue-- though not necessarily a "bad outcome"-- clearly often iatrogenic or misdiagnosed, though.
* prolonged pregnancy (121 per 1,000 stays)-- As defined by? And again, by itself, this is a possible risk, not "something that went wrong."
* polyhydramnios and problems of the amniotic cavity (117 per 1,000 stays)-- The second half of this is really too vague to comment on.
* advanced maternal age (117 per 1,000 stays)-- Been there, done that.
* anemia during pregnancy (112 per 1,000 stays)-- As above.
* fetal distress and abnormal forces of labor (111 per 1,000 stays)-- This goes with abnormality in heart rate or rhythm.
The following complicating conditions occurred at a rate of 50-99 for every 1,000 deliveries:
* hypertension including eclampsia and pre-eclampsia (94 per 1,000 stays)-- Already addressed.
* early or threatened labor (81 per 1,000 stays)-- Same.
* malposition, malpresentation (80 per 1,000 stays)-- Absolutely sometimes an issue, also can be iatrogenic.
* diabetes or abnormal glucose tolerance (68 per 1,000 stays)-- Already addressed.
* poor fetal growth (54 per 1,000 stays)-- Same.
* fetopelvic disproportion (54 per 1,000 stays)-- I think this is just so clearly iatrogenic/misdiagnosed in the majority of cases that it's rarely a contraindication for homebirth.
So basically we're looking at a much lower rate of serious issues (among the common ones) and an even lower rate if we try to figure in even SOME degree of iatrogenic contribution that is almost inherently more common in the hospital. Then you'd have to add in iatrogenic contributions at home, etc., and then we'd be talking about something.
As it is, all that's really evident from these numbers is that you need to specifically "code" a condition that is usually non-pathological or mildly pathological to get insurance companies to pay for it, so in the end, you are semantically pathologizing it... in the case of pregnancy and childbirth, they didn't need much help. But when insurance codes become medical, scientific justification, you see a perversion of medicine and the scientific method to align with them. Kind of like how you saw, within a decade or two, doctors genuinely seeming to be convinced that VBAC is incredibly dangerous, with no real scientific evidence of that-- ultimately based almost exclusively on the change in policy by the ACOG, itself based on capitulation to insurance companies. This is where we get truly bizarre and unscientific justifications from some OBs-- justifications that sometimes make them seem downright dangerously stupid and ignorant-- because their brains are (somewhat understandably) trying to reconcile a highly unscientific and often injurious set of practices with the idea that they "first, do no harm."
That's what we get (and to some extent, do get) when these numbers are viewed and the conclusion is that pregnancy and birth are "really, really dangerous, most of the time."
But my "real" comment, LOL, is that this ties in to what I've long observed as the myth of exceptionalism, particularly when it comes to birth. Dr. Amy's comment actually touched on this, though I know she was headed in the opposite direction.
The idea that we should just inherently "trust birth" at all costs and in all situations is FAR on the fringe of even the homebirth/NCB "movement," but the truth that low-/no-intervention birth usually goes pretty darned smoothly is a simple fact. Even those who believe (with no credible evidence) that the risks of homebirth are unacceptably high do not (often) claim that homebirth does not, the majority of the time, go smoothly. (After all, even with an outrageous 10% death rate and 30% serious complication rate-- far from actual rates-- you could still say it "usually" goes "pretty smoothly.")
But the point being that this "94%" number, if taken purely at face value, actually points to the dangerous dichotomy I think we've all observed, that goes to the heart of our often abusive system. That is the twin ideas that "birth is usually pretty normal/not terribly risky" but "I was the exception" and how they coexist in an oppressive way.
In my experience, it is more often DOCTORS that push the idea that most births are pretty textbook (i.e., lacking in significant complications). By doing this-- buoyed by the fact that most women have little exposure to actual birth before becoming mothers-- they can cement the idea that if something DOES "go wrong" it is because the woman is an "exception." Often because she and/or her baby are defective in some way, but regardless... If the hospital system and society push the idea that birth usually goes fairly smoothly (outside of the scary, scary pain, of course), then, when something "goes wrong" in a woman's birth, she can avoid cognitive dissonance (and the difficulty of fighting a powerful system) by believing she is an "exception."
Now, I do not mean to imply manipulative forethought in this process, because in most cases I don't believe it's there. But it's not really in the best interests of "the system" (hospitals, society) to tell women that they and/or their children usually end up having significant, sometimes very serious, complications. Saying that birth usually has a bad outcome IF not "performed" in a hospital-- saying THAT is condoned, essentially encouraged. But that's not what I'm talking about. I am talking about the fact that birth usually has some sort of "bad outcome" in the hospital, even in the 21st century, even with all of "our" medical technology. Obviously this is not something that it is in "the system's" best interest to advertise, but it is true.
Yes, it's true. In this day and age, I think it's fair to say that MOST women who give birth in hospitals in the USA will experience one or more of the following:
-C/S and all of its complications
-Episiotomy
-2nd+ degree tearing
-PPH
-Significant fever
-Severe pain caused by Pitocin
-Significant complications from an epidural, such as headaches, shaking, etc.
-Significant PP infection
-Infant distress, illness, fever or injury
This is aside from rarer death and/or significant lasting disabilities, any sort of PTSD that might exist and, of course, complications that are as likely to occur at home or elsewhere. Not all of the above, of course, are exclusive to hospitals (though some are), but most are far more common.
But the point is that, "even*" with the Absolutely Essential Care of Obtetricians in Hospitals, MOST women have significant complications during birth.
However, if women were well-exposed to this fact, too many would question the system. Instead, it better serves society and hospitals specifically to pathologize individual women as "exceptions" to the "rule" that birth in hospitals "usually" goes quite smoothly.
If you believe you are an exception, you can still believe in the rule.
If you realize that most people are exceptions, then there is no rule.
This is all part and parcel of the same underlying philosophy that "breast is best"-- which has been refuted much more eloquently than I could. To say that something is "best" instead of "normal" in American society is to unproductively pedestalize it-- making it seem unobtainable (indeed, MAKING it nearly unobtainable in fact) and guilting those who don't practice or achieve it for not doing "what is clearly best."
And yet, simultaneously denigrating those who do this "best practice" as if they-- who are actually doing something made more difficult by society-- were the ones responsible for making others feel bad. Not to mention denigrating the "best" practice itself as if it were naturally unattainable and thus unworthy of being a "reach goal" at all.
Along those lines, women are consistently reassured by society that birth usually goes fine as long as you do it in a hospital, but when it doesn't "go fine"-- and it usually doesn't-- women and their babies are made the "exception" in order to reaffirm the basic rightness of the system.
Basically... if not 94% of women, then certainly more than 50% really do experience significant complications in hospital births. There is absolutely no evidence to credibly suggest this means that all women should birth in hospitals, rather than that most women should not. But what it does suggest is that women are being sold a bill of goods when told-- as they often are-- that if they just do everything the doctor says and the hospital requires, "everything will be fine." Funny that I hear this much more often from the mouths of hospital practitioners than homebirth attendants.
*Of course I put "even" in quotes because "bad outcomes" are often enough caused by obstetric care.