Developing a novel patient-centered definition of severe maternal morbidity

Defining, preventing, and evaluating severe maternal morbidity (SMM) has become an important component of obstetric care delivery, but existing frameworks for SMM do not account for how patients perceive and experience morbidity.

This study evaluated patient values and perceptions related to maternal pregnancy complications with the goal of devising a patient-centered maternal morbidity composite.

This 2-part sequential qualitative to quantitative mixed-methods study first involved semi-structured interviews of postpartum patients recruited from an urban, academic hospital prior to discharge from the delivery admission with purposive sampling by race and mode of delivery. Qualitative data around patient-perceived adverse maternal events were analyzed thematically. These themes were used to develop a survey which prompted ranking the maternal complications derived from these interview data as well as the SMM indicators defined by the Centers for Disease Control and Prevention (CDC) on a scale from 1 ("no big deal") - 5 ("worst thing imaginable"). Responses were compared in bivariate analyses among patients who did and did not personally experience an expanded maternal morbidity composite inclusive of SMM as well as postpartum hemorrhage, re-operation, intensive care unit admission, and endometritis/post-operative infection. All postpartum patients were eligible to participate and recruited participants completed the survey prior to discharge.

18 patients participated in the semi-structured interviews with 9 themes identified distinct from established SMM criteria. 501 patients then completed the survey over 5 months (6/2022 to 11/2022). 60.7% of participants were Black, 6.5% were Hispanic, median maternal age was 31 [IQR 26-34], 40.6% underwent cesarean delivery, 6% experienced a postpartum hemorrhage, and 1.6% (N=8) experienced non-transfusion SMM as defined by the CDC. The 3 maternal morbidity outcomes ranked by patients as "worst" were stroke/seizure, hysterectomy, and heart failure. Other notable findings included that 66.3% of patients ranked severe postpartum depression as a 4 or 5, higher than hemorrhage, transfusion, and long-term physical disability. There were no significant differences in scoring of maternal morbidity types among patients who did and did not personally experience morbidity.

Adverse maternal outcomes important to patients do not correlate directly with established SMM composites. Novel definitions of maternal morbidity incorporating expanded indicators such as severe depression could fuel a patient-centered approach to evaluating and mitigating SMM in research and clinical care.