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Trends in and complications associated with mental health condition diagnoses during delivery hospitalizations

Published:September 22, 2021DOI:https://doi.org/10.1016/j.ajog.2021.09.021

      Background

      Mental health conditions during delivery hospitalizations are not well characterized.

      Objective

      This study aimed to characterize the prevalence of maternal mental health condition diagnoses and associated risk during delivery hospitalizations in the United States.

      Study Design

      The 2000 to 2018 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of women aged 15 to 54 years with and without mental health condition diagnoses, including depressive disorder, anxiety disorder, bipolar spectrum disorder, and schizophrenia spectrum disorder, were identified. Temporal trends in mental health condition diagnoses during delivery hospitalizations were determined using the National Cancer Institute’s Joinpoint Regression Program to estimate the average annual percent change with 95% confidence intervals. The trends in chronic conditions associated with mental health condition diagnoses, including asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and substance use, were analyzed. The association between mental health conditions and the following adverse outcomes was determined: (1) severe maternal morbidity, (2) preeclampsia or gestational hypertension, (3) preterm delivery, (4) postpartum hemorrhage, (5) cesarean delivery, and (6) maternal mortality. Regression models for each outcome were performed with unadjusted and adjusted risk ratios as measures of effects.

      Results

      Of 73,109,791 delivery hospitalizations, 2,316,963 (3.2%) had ≥1 associated mental health condition diagnosis. The proportion of delivery hospitalizations with a mental health condition increased from 0.6% in 2000 to 7.3% in 2018 (average annual percent change, 11.4%; 95% confidence interval, 10.3%–12.6%). Among deliveries in women with a mental health condition diagnosis, chronic health conditions, including asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and substance use, increased from 14.9% in 2000 to 38.5% in 2018. Deliveries to women with a mental health condition diagnosis were associated with severe maternal morbidity (risk ratio, 1.88; 95% confidence interval, 1.86–1.90), preeclampsia and gestational hypertension (risk ratio, 1.59; 95% confidence interval, 1.58–1.60), preterm delivery (risk ratio, 1.35; 95% confidence interval, 1.35–1.36), postpartum hemorrhage (risk ratio, 1.37; 95% confidence interval, 1.36–1.38), cesarean delivery (risk ratio, 1.20; 95% confidence interval, 1.20–1.20), and maternal death (risk ratio, 1.31; 95% confidence interval, 1.12–1.56). The increased risk was retained in adjusted models.

      Conclusion

      The proportion of delivery hospitalizations with mental health condition diagnoses increased significantly throughout the study period. Mental health condition diagnoses were associated with other underlying chronic health conditions and a modestly increased risk of a range of adverse outcomes. The findings suggested that mental health conditions are an important risk factor in adverse maternal outcomes.

      Key words

      Introduction

      Mental health conditions, including depressive and anxiety disorders, are common among pregnant and postpartum women.
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      There is a large range of estimates of the prevalence of mental health conditions during pregnancy. However, currently, there are limited data through 2018 on population-level trends in mental health conditions during delivery hospitalizations, their association with comorbid chronic conditions, and risks of adverse outcomes.
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      Previous studies demonstrated rising diagnoses of anxiety and depression during deliveries.
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      To this end, we conducted a serial cross-sectional analysis of a national database to (1) describe trends in the prevalence of depressive disorders, anxiety disorder, bipolar spectrum disorder, and schizophrenia spectrum disorder diagnoses during delivery hospitalizations; (2) to determine to what degree other chronic health conditions, such as diabetes mellitus and chronic hypertension, are present with mental health conditions; and (3) to evaluate whether mental health is associated with increased risk of adverse outcomes.

      Why was this study conducted?

      This study aimed to determine the trends and outcomes associated with mental health condition diagnoses during delivery hospitalizations.

      Key findings

      During the study period, the diagnoses of mental health conditions increased 1097%. Mental health conditions were associated with increasing comorbidity and risk of adverse maternal and obstetrical outcomes.

      What does this add to what is known?

      Our findings suggested that mental health conditions are an increasingly important risk factor for adverse maternal outcomes.

      Materials and Methods

      Data source

      We queried the National Inpatient Sample (NIS) for delivery hospitalization data from 2000 to 2018 for this serial cross-sectional analysis.
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      Historical (retrospective) cohort studies and other epidemiologic study designs in perinatal research.
      The NIS is a publicly available, all-payer dataset maintained by the Healthcare Cost and Utilization Project that captures data from >7 million inpatient hospitalizations annually.
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      Overview of the National (Nationwide) Inpatient Sample (NIS). 2021.
      It approximates a stratified sample of 20% of all hospitals in the United States; when weighted to account for the survey design, the data produce national estimates. Specific weights for evaluating temporal trends in the NIS were applied in this study.
      Healthcare Cost and Utilization Project
      Trend weights for HCUP NIS data. 2021.
      We abstracted International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes for hospitalizations that occurred from January 2000 to December 2014. The transition to International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis and procedure codes occurred on October 1, 2015; for the year 2015, we included both ICD-9-CM and ICD-10-CM codes. For the years 2016 to 2018, ICD-10-CM codes were used. For our analyses, ICD-9-CM codes were converted to their ICD-10-CM equivalents by using the Centers for Medicare and Medicaid Services’ General Equivalence Mappings and reviewing diagnosis groups reported in the literature.
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      ICD-10. 2021.
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      Impact of ICD-10-CM transition on mental health diagnoses recording.

      Study objectives

      This study had 3 objectives. The first objective was to estimate the prevalence of common maternal mental health condition diagnoses during delivery hospitalizations, including depressive disorder, anxiety disorder, bipolar spectrum disorder, and schizophrenia spectrum disorder, and evaluate temporal trends in these conditions from 2000 to 2018. We sought to determine whether the prevalence of these diagnoses during delivery hospitalization was increasing in recent years, as these diagnoses have increased among the overall reproductive-age population.
      BlueCross BlueShield
      The Health of America. The health of millennials. 2019.
      The second objective was to determine whether risks of the following adverse maternal outcomes were associated with mental health condition diagnosis at delivery: (1) severe maternal morbidity, (2) preeclampsia or gestational hypertension, (3) preterm delivery, (4) postpartum hemorrhage, (5) cesarean delivery, and (6) maternal mortality. We defined severe maternal morbidity using composite measures developed by the Centers for Disease Control and Prevention (CDC) and identified through ICD-9-CM and ICD-10-CM codes.
      Centers for Disease Control and Prevention
      Severe maternal morbidity in the United States. 2021.
      This composite measure includes 21 diagnoses and procedures, including blood transfusion, shock, stroke, heart failure, and sepsis, among other conditions; because blood transfusion alone is unlikely to have long-term health consequences and most transfusion diagnosis codes during delivery hospitalizations are not representative of large-volume transfusion associated with major hemorrhage, we excluded transfusion from the composite.
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      Therefore, we evaluated the risk of the 20 remaining diagnoses and procedures.
      The third objective was to determine whether deliveries with mental health conditions were increasingly likely to be associated with the following diagnoses throughout the study period: pregestational diabetes mellitus, chronic hypertension, obesity, asthma, and substance use.
      Finally, as an ancillary objective, we aimed to determine whether there was an interaction between mental health conditions and chronic health conditions, such as pregestational diabetes mellitus, chronic hypertension, obesity, asthma, and substance use in the risk of severe maternal morbidity (Supplemental Table 1).

      Subjects, demographics, comorbid conditions, and hospital characteristics

      We included women aged 15 to 54 years in the NIS who were hospitalized for delivery from 2000 to 2018. Delivery hospitalizations were identified using algorithms of ICD-9-CM and ICD-10-CM codes that have previously been shown to capture >95% of deliveries.
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      Identification of delivery encounters using international classification of diseases, tenth revision, diagnosis and procedure codes.
      We defined 4 categories of maternal mental health conditions: (1) depressive disorder, (2) anxiety disorder, (3) bipolar spectrum disorder, and (4) schizophrenia spectrum disorder using ICD-9-CM and ICD-10-CM coding groups. These coding groups were ascertained from research by the Mental Health Research Network (MHRN) that demonstrated that the transition from ICD-9-CM to ICD-10-CM seems to have minimal impact on estimates of prevalence for most mental health conditions.
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      Impact of ICD-10-CM transition on mental health diagnoses recording.
      Demographic factors included year of delivery, maternal race and ethnicity, payer (Medicaid, private, Medicare, other, or uninsured), and ZIP code income quartile. Hospital-level factors included location and teaching status (urban teaching, urban nonteaching, and rural) and geographic region (Northeast, Midwest, South, or West). We included obesity, asthma, chronic hypertension, pregestational diabetes mellitus, and substance use as comorbid chronic conditions in our analysis (Supplemental Table 1). These conditions are all associated with adverse outcomes in pregnancy and may be more common among women with mental health conditions.
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      Co-occurrence of physical health conditions and mental health and substance use conditions among adult inpatient stays, 2010 versus 2014. 2018.
      Substance abuse coding groups for alcohol abuse, opioid use disorder, cannabis, cocaine, and other drugs were ascertained from the MHRN (Supplemental Table 1).

      Statistical analysis

      For the first objective, evaluating the prevalence of mental health diagnoses during delivery hospitalizations, we reported the proportion of deliveries with (1) depressive disorder, (2) anxiety disorder, (3) bipolar spectrum disorder, (4) schizophrenia spectrum disorder, or (5) any one or more of 4 mental health conditions.
      To evaluate temporal trends in mental health conditions at delivery, we conducted a trends analysis from 2000 to 2018 using the National Cancer Institute’s Joinpoint Regression Program (version 4.8.0.1).
      National Cancer Institute
      Joinpoint trend analysis software. 2020.
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      This program fits joinpoint models to trends in data to identify changes in trends, test whether those changes are statistically significant, calculate the annual percentage change (APC) between trend-change points, and estimate the average annual percentage change (AAPC) throughout the study period. The AAPC summarizes the average APCs throughout the study interval; it is calculated as the weighted average of APCs from the joinpoint regression model with weights equal to the APC interval length.
      National Cancer Institute
      Average annual percent change (AAPC) and confidence interval. 2020.
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      Results are presented as the AAPC with 95% confidence intervals (CIs).
      For our second objective, evaluating the association between mental health condition diagnoses and adverse maternal outcomes, we created unadjusted and adjusted log-linear regression models with Poisson distribution and log link with robust error variances for each of the outcomes of interest with unadjusted risk ratios (RR) and adjusted RRs (aRRs) with 95% CIs as measures of association.
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      Easy SAS calculations for risk or prevalence ratios and differences.
      The unadjusted models compared the risk of each adverse outcome during delivery hospitalizations based on the presence vs absence of mental health condition diagnoses. The adjusted models compared the risk of each adverse outcome during delivery hospitalizations based on the presence vs absence of mental health condition diagnoses controlling for demographics (maternal age, payer, ZIP code income quartile, and maternal race and ethnicity) and hospital-level factors (hospital location and region). In addition, the adjusted model for severe maternal morbidity was adjusted for underlying comorbid conditions, including asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and substance use. An adjusted model for maternal mortality was not performed because of the small number of maternal deaths.
      For the ancillary objective, evaluating the interactions between chronic health conditions, such as pregestational diabetes mellitus, chronic hypertension, obesity, asthma, and substance use, and risk of severe maternal morbidity, we performed stratified analyses dividing the study population into 2 groups: (1) hospitalizations with mental health condition diagnoses and (2) hospitalizations without mental health condition diagnoses. For each group, we analyzed the relationship between asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and substance use and risk of severe maternal morbidity with unadjusted and adjusted log-linear regression models with Poisson distribution and log link with robust error variances. We sought to determine whether unadjusted RRs and aRRs associated with asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and substance use were higher among deliveries with mental health condition diagnoses. Adjusted models included maternal age, maternal race and ethnicity, payer, ZIP code income quartile, and hospital location and region and the 5 chronic conditions (asthma, chronic hypertension, pregestational diabetes mellitus, obesity, and substance use).
      For the third analysis determining whether trends in pregestational diabetes mellitus, chronic hypertension, obesity, asthma, and substance use among women with mental health condition diagnoses increased over time, we used joinpoint models to calculate the AAPCs for each condition.
      Standardized mean difference (SMD) was used for demographic comparisons based on the presence vs absence of a mental health condition with ≥0.1 (10%) considered to be a meaningful difference.
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      • Dalton J.
      A unified approach to measuring the effect size between two groups using SAS. 2012.
      Aside from the trend analyses performed with the Joinpoint Regression Program, all analyses were performed using SAS (version 9.4; SAS Institute, Cary, NC). We followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for cross-sectional studies for this analysis.
      Equator network
      The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. 2021.
      This study was granted an exemption from the Columbia University’s institutional review board (IRB-AAAE8144), as the NIS is publicly available and does not contain personally identifiable information.

      Results

      Of an estimated 73,109,791 delivery hospitalizations from 2000 to 2018, 2,316,963 (3.2%) had ≥1 associated mental health condition diagnosis (Table 1). The proportion of delivery hospitalizations with a mental health condition grew from 0.6% in 2000 to 7.3% in 2018—a 1097% increase overall with an AAPC of 11.4% (95% CI, 10.3%–12.6%) on joinpoint regression analysis (Figure 1). The proportion of delivery hospitalizations with depressive disorder increased from 0.40% in 2000 to 3.63% in 2018 (AAPC, 9.1%; 95% CI, 7.6–10.5). The proportion of delivery hospitalizations with anxiety disorder rose from 0.11% to 4.78% from 2000 to 2018 (AAPC, 22.5%; 95% CI, 21.7–23.3). The proportion of delivery hospitalizations with bipolar spectrum disorder grew from 0.09% to 0.80% (AAPC, 9.5%; 95% CI, 7.2–11.9), and the proportion with schizophrenia spectrum disorder rose from 0.02% to 0.12% (AAPC, 8.3; 95% CI, 7.7–9.0) from 2000 to 2018.
      Table 1Characteristics of the study population by maternal mental health conditions
      CharacteristicNo mental health condition≥1 mental health conditionAbsolute SMD (%)Depressive disorderAnxiety disorderBipolar spectrum disorderSchizophrenia spectrum disorder
      Demographics
      Year of delivery0.61 (61.5)
       20003,791,581 (5.3)23,268 (1.0)15,321 (1.1)4387 (0.5)3367 (1)894 (2.0)
       20013,719,643 (5.3)30,150 (1.3)20,061 (1.5)5745 (0.6)4464 (1.3)1014 (2.3)
       20023,862,967 (5.5)40,438 (1.8)27,404 (2.0)7852 (0.8)5444 (1.6)1174 (2.7)
       20033,810,295 (5.4)51,768 (2.2)35,980 (2.7)9515 (1.0)7012 (2.1)1193 (2.7)
       20043,930,660 (5.6)68,339 (3.0)47,318 (3.5)13,654 (1.4)8898 (2.7)1626 (3.7)
       20053,930,088 (5.6)79,252 (3.4)54,388 (4.0)15,936 (1.7)11,110 (3.3)1793 (4.1)
       20063,978,175 (5.6)82,328 (3.6)55,399 (4.1)16,101 (1.7)13,100 (3.9)1911 (4.4)
       20074,227,639 (6.0)100,901 (4.4)66,663 (4.9)21,127 (2.2)16,239 (4.8)2085 (4.8)
       20083,899,391 (5.5)112,649 (4.9)71,562 (5.3)26,669 (2.8)18,964 (5.7)1828 (4.2)
       20093,805,851 (5.4)111,215 (4.8)68,875 (5.1)26,092 (2.7)20,121 (6.0)2242 (5.1)
       20103,556,728 (5.0)128,424 (5.5)79,873 (5.9)32,025 (3.3)22,843 (6.8)2333 (5.3)
       20113,514,841 (5.0)132,351 (5.7)81,235 (6.0)38,707 (4.0)21,970 (6.5)2289 (5.2)
       20123,610,281 (5.1)139,395 (6.0)82,025 (6.1)52,645 (5.5)22,995 (6.9)2645 (6.0)
       20133,575,168 (5.1)152,855 (6.6)88,730 (6.6)65,720 (6.9)24,175 (7.2)2875 (6.6)
       20143,610,180 (5.1)174,245 (7.5)100,955 (7.5)81,110 (8.5)26,205 (7.8)3150 (7.2)
       20153,551,260 (5.0)186,805 (8.1)104,730 (7.8)96,265 (10.0)26,875 (8.0)3155 (7.2)
       20163,577,836 (5.1)204,650 (8.8)101,930 (7.6)123,455 (12.9)25,965 (7.7)3625 (8.3)
       20173,470,106 (4.9)232,725 (10.0)115,945 (8.6)148,100 (15.5)26,770 (8.0)3700 (8.4)
       20183,370,139 (4.8)265,205 (11.5)131,950 (9.8)173,750 (18.1)29,250 (8.7)4300 (9.8)
      Maternal race0.43 (42.8)
       Non-Hispanic White3,0704,622 (43.4)1,451,923 (62.7)818,243 (60.6)665,395 (69.4)206,537 (61.5)15,136 (34.5)
       Non-Hispanic Black8,165,805 (11.5)232,067 (10.0)131,534 (9.7)72,937 (7.6)50,225 (15.0)16,641 (38.0)
       Hispanic13,597,104 (19.2)224,933 (9.7)140,410 (10.4)87,826 (9.2)24,878 (7.4)4436 (10.1)
       Other6,485,692 (9.2)106,386 (4.6)62,219 (4.6)44,019 (4.6)12,401 (3.7)2485 (5.7)
       Unknown11,839,605 (16.7)301,652 (13.0)197,938 (14.7)88,676 (9.3)41,726 (12.4)5132 (11.7)
      Maternal age (y)0.09 (9.5)
       15–196,203,875 (8.8)155,456 (6.7)90,872 (6.7)44,848 (4.7)38,701 (11.5)2900 (6.6)
       20–2416,562,553 (23.4)502,983 (21.7)292,211 (21.6)182,138 (19.0)99,943 (29.8)10,618 (24.2)
       25–2919,756,191 (27.9)644,836 (27.8)372,700 (27.6)274,046 (28.6)92,394 (27.5)12,015 (27.4)
       30–3417,663,422 (25.0)609,675 (26.3)352,557 (26.1)279,549 (29.2)66,079 (19.7)10,096 (23.0)
       35–398,642,675 (12.2)324,633 (14.0)193,868 (14.4)144,273 (15.1)31,380 (9.4)6218 (14.2)
       40–541,964,113 (2.8)79,378 (3.4)48,136 (3.6)34,000 (3.6)7270 (2.2)1984 (4.5)
      Payer0.18 (18.2)
       Medicare359,740 (0.5)63,534 (2.7)24,715 (1.8)20,001 (2.1)25,873 (7.7)8234 (18.8)
       Medicaid29,129,665 (41.2)1,046,657 (45.2)601,909 (44.6)388,379 (40.5)211,583 (63.0)28,909 (66.0)
       Private insurance36,999,629 (52.3)1,099,003 (47.4)658,246 (48.8)508,340 (53.0)83,993 (25.0)4565 (10.4)
       Self-pay2,204,548 (3.1)35,006 (1.5)21,554 (1.6)11,722 (1.2)5031 (1.5)1049 (2.4)
       No charge132,557 (0.2)1739 (0.1)1194 (0.1)463 (0.1)219 (0.1)53 (0.1)
       Other1,849,446 (2.6)66,806 (2.9)40,051 (3.0)28,386 (3.0)8510 (2.5)950 (2.2)
       Unknown117,243 (0.2)4216 (0.2)2674 (0.2)1563 (0.2)557 (0.2)70 (0.2)
      ZIP code income quartile0.12 (11.7)
       Income quartile 116,795,415 (23.7)567,003 (24.5)319,995 (23.7)213,356 (22.3)112,012 (33.36)19,859 (45.3)
       Income quartile 217,088,172 (24.1)596,338 (25.7)351,565 (26.0)241,370 (25.2)92,059 (27.42)10,807 (24.7)
       Income quartile 317,203,549 (24.3)597,970 (25.8)355,531 (26.3)255,547 (26.7)74,786 (22.27)7445 (17.0)
       Income quartile 418,583,607 (26.3)524,499 (22.6)305,388 (22.6)238,438 (24.9)51,102 (15.22)4266 (9.7)
       Unknown1,122,085 (1.6)31,151 (1.3)17,865 (1.3)10,142 (1.1)5808 (1.73)1453 (3.3)
      Chronic health conditions
      Any chronic condition6,365,283 (9.0)710,224 (30.7)0.56 (56.5)398,585 (29.5)309,514 (32.3)133,559 (39.8)18,882 (43.1)
       Obesity2,739,204 (3.9)268,793 (11.6)0.29 (29.3)155,359 (11.5)127,865 (13.3)40,321 (12.0)5128 (11.7)
       Pregestational diabetes mellitus617,971 (0.8)46,391 (2.0)0.10 (9.5)27,461 (2.0)17,347 (1.8)8466 (2.5)1978 (4.5)
       Chronic hypertension928,905 (1.4)77,884 (3.4)0.14 (13.6)43,523 (3.2)35,174 (3.7)11,923 (3.6)2134 (4.9)
       Asthma1,939,919 (2.7)281,724 (12.2)0.36 (36.5)157,629 (11.7)122,507 (12.8)54,659 (16.3)6457 (14.7)
       Substance use880,212 (1.2)191,346 (8.3)0.33 (33.4)100,232 (7.4)76,924 (8.0)53,244 (15.9)9045 (20.6)
      Hospital factors
      Hospital location0.22 (22.0)
       Rural7,904,971 (11.1)246,221 (10.6)148,411 (11.0)91,867 (9.6)38,794 (11.6)3735 (8.5)
       Urban nonteaching26,830,713 (37.9)642,894 (27.8)378,010 (28.0)241,625 (25.2)95,718 (28.5)9130 (20.8)
       Urban teaching35,836,071 (50.6)1,421,488 (61.4)819,987 (60.7)623,820 (65.1)200,071 (59.6)30,791 (70.3)
       Missing221,073 (0.31)6359 (0.27)3936 (0.3)1542 (0.2)1184 (0.4)173 (0.4)
      Region0.18 (18.4)
       Northeast11,412,668 (16.1)455,756 (19.7)263,348 (19.5)195,949 (20.4)63,384 (18.9)7537 (17.2)
       Midwest14,954,227 (21.1)607,806 (26.2)376,462 (27.9)241,379 (25.2)84,913 (25.3)9944 (22.7)
       South26,921,560 (38.0)743,078 (32.1)407,669 (30.2)307,052 (32.0)124,357 (37.0)17,604 (40.2)
       West17,504,374 (24.7)510,321 (22.0)302,865 (22.4)214,474 (22.4)63,113 (18.8)8744 (20.0)
      Data are presented as number (percentage), unless otherwise indicated. SMD was calculated for comparison of 0 vs ≥1 mental health condition. Demographic, chronic health conditions, and hospital factors differed significantly based on the presence or absence of a mental health condition (P<.01) based on modified Rao-Scott chi-square test.
      SMD, standardized mean difference; ZIP, Zone Improvement Plan.
      Logue et al. Trends and complications associated with mental health conditions during delivery. Am J Obstet Gynecol 2022.
      Figure thumbnail gr1
      Figure 1Proportion of deliveries with a mental health condition by year
      The figure demonstrates the proportion of delivery hospitalizations with a mental health condition by year. The AAPC rates were as follows: 11.4% (95% CI, 10.3–12.6) for any mental health condition, 9.1% (95% CI, 7.6–10.5) for depressive disorder, 22.5% (95% CI, 21.7–23.3) for anxiety disorder, 9.5% (95% CI, 7.2–11.9) for bipolar spectrum disorder, and 8.3% (95% CI, 7.7–9.0) for schizophrenia spectrum disorder.
      AAPC, average annual percent change; CI, confidence interval.
      Logue et al. Trends and complications associated with mental health conditions during delivery. Am J Obstet Gynecol 2022.
      Mental health condition diagnoses were more common among deliveries to non-Hispanic White women and less common among deliveries to Hispanic women (SMD, 42.8% for maternal race), to women with Medicaid and Medicare insurance compared with women with commercial insurance (SMD, 18.2% for payer), and to women from lower ZIP code income quartiles compared with women from higher ZIP code income quartiles (SMD, 11.7%) (Table 1). Moreover, deliveries occurring at urban teaching hospitals (SMD, 22.0% for hospital location) and in the Northeast (SMD, 18.4% for region) were more likely to be associated with mental health condition diagnoses.
      Compared with deliveries without a mental health condition diagnosis, deliveries with mental health conditions diagnoses were more likely to be associated with ≥1 chronic health condition (30.7% vs 9.0%; SMD, 56.5%) (Figures 2 and 3). Deliveries with a mental health conditions diagnosis were more likely to be associated with obesity (11.6% vs 3.9%; SMD, 29.3%), pregestational diabetes mellitus (2.0% vs 0.8%; SMD, 9.5%), chronic hypertension (3.4% vs 1.4%; SMD, 13.6%), asthma (12.2% vs 2.7%; SMD, 36.5%), and substance abuse (8.3% vs 1.2%) (Table 1). Among deliveries with a mental health condition diagnosis, the proportion of deliveries with a chronic health condition increased from 14.9% in 2000 to 38.5% in 2018 (Figure 2). In comparison, among deliveries without a mental health condition diagnosis, the proportion of deliveries with a chronic health condition increased from 3.6% in 2000 to 17.5% in 2018 (Figure 3).
      Figure thumbnail gr2
      Figure 2Chronic conditions among deliveries with mental health condition diagnoses
      The figure demonstrates the proportion of delivery hospitalizations with a chronic condition among women with a mental health condition diagnosis by year. The AAPC rates were as follows: 5.4% (95% CI, 4.9–6.0) for any chronic condition, 4.3% (95% CI, 3.8–4.9) for asthma, 4.9% (95% CI, 4.0–5.9) for chronic hypertension, 3.1% (95% CI, 2.4–3.9) for pregestational diabetes mellitus, 12.5% (95% CI, 10.7–14.3) for obesity, and 3.4% (95% CI, 2.6–4.2) for substance use.
      AAPC, average annual percent change; CI, confidence interval.
      Logue et al. Trends and complications associated with mental health conditions during delivery. Am J Obstet Gynecol 2022.
      Figure thumbnail gr3
      Figure 3Chronic conditions among deliveries without mental health condition diagnose
      The figure demonstrates the proportion of delivery hospitalizations with a chronic condition among women without a mental health condition by year. The AAPC rates were as follows: 9.2% (95% CI, 8.8–9.6) for any chronic condition, 6.8% (95% CI, 6.0–7.6) for asthma, 5.8% (95% CI, 5.3–6.3) for chronic hypertension, 3.4% (95% CI, 3.1–3.7) for pregestational diabetes mellitus, 16.7% (95% CI, 14.8–18.6) for obesity, and 6.2% (95% CI, 5.5–6.9).
      AAPC, average annual percent change; CI, confidence interval.
      Logue et al. Trends and complications associated with mental health conditions during delivery. Am J Obstet Gynecol 2022.
      In unadjusted analyses, a mental health condition diagnosis was associated with an increased risk of all adverse maternal outcomes (Table 2; Supplemental Table 2). These associations retained significance after adjustment. In adjusted analyses, mental health condition diagnoses were associated with an increased risk of nontransfusion severe maternal morbidity (aRR, 1.54; 95% CI, 1.52–1.56), preeclampsia and gestational hypertension (aRR, 1.51; 95% CI, 1.50–1.52), preterm delivery (aRR, 1.32; 95% CI, 1.31–1.32), postpartum hemorrhage (aRR, 1.34; 95% CI, 1.33–1.35), and cesarean delivery (aRR, 1.18; 95% CI, 1.18–1.19).
      Table 2Unadjusted and adjusted risks of adverse outcomes in the setting of a maternal mental health condition
      OutcomeRR (95% CI)Adjusted RR (95% CI)
      Adverse outcomes
       Severe maternal morbidity excluding transfusion1.88 (1.86–1.90)1.54 (1.52–1.56)
       Preeclampsia and gestational hypertension1.59 (1.58–1.60)1.51 (1.50–1.52)
       Preterm delivery1.35 (1.35–1.36)1.32 (1.31–1.32)
       Postpartum hemorrhage1.37 (1.36–1.38)1.34 (1.33–1.35)
       Cesarean delivery1.20 (1.20–1.20)1.18 (1.18–1.19)
       Maternal death1.32 (1.12–1.56)N/A
      Estimates in the table demonstrate risks in the presence vs absence of a maternal mental health condition. All adjusted models include maternal age, race, payer, ZIP code income quartile, and hospital location and region. In addition, adjusted models for severe maternal morbidity include presence of chronic comorbidities (asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and/or substance use). Adjusted analyses were not performed for maternal death given the small numerators involved.
      CI, confidence interval; N/A, not available; RR, risk ratio; ZIP, Zone Improvement Plan.
      Logue et al. Trends and complications associated with mental health conditions during delivery. Am J Obstet Gynecol 2022.
      In the stratified analyses for severe maternal morbidity, chronic health conditions were associated with a higher risk of severe maternal morbidity when mental health disorder diagnoses were present (Table 3). The unadjusted risk associated with severe maternal morbidity was higher for asthma (RR, 1.17 [95% CI, 1.13–1.21] vs 1.72 [95% CI, 1.69–1.74]), chronic hypertension (RR, 1.64 [95% CI, 1.56–1.73] vs 1.98 [95% CI, 1.94–2.01]), pregestational diabetes mellitus (RR, 2.44 [95% CI, 2.31–2.58] vs 2.77 [95% CI, 2.72–2.82]), obesity (RR, 1.54 [95% CI, 1.50–1.59] vs 1.96 [95% CI, 1.95–1.99]), and substance abuse (RR, 1.39 [95% CI 1.34–1.44] vs 1.79 [95% CI, 1.76–1.83]) among deliveries with mental health disorder diagnoses. The increased risks of adverse outcomes associated with chronic health conditions in the setting of mental health disorder diagnoses were retained in the adjusted analyses.
      Table 3Stratified analyses for severe morbidity based on the presence or absence of a maternal mental health condition
      VariableMaternal mental health condition absentMaternal mental health condition present
      RR (95% CI)RR (95% CI)
      Risk factor
       Asthma1.17 (1.13–1.21)1.72 (1.69–1.74)
       Chronic hypertension1.64 (1.56–1.73)1.98 (1.94–2.01)
       Pregestational diabetes mellitus2.44 (2.31–2.58)2.77 (2.72–2.82)
       Obesity1.54 (1.50–1.59)1.97 (1.95–1.99)
       Substance use1.39 (1.34–1.44)1.79 (1.76–1.83)
      Adjusted RR (95% CI)Adjusted RR (95% CI)
      Risk factor
       Asthma1.10 (1.07–1.14)1.58 (1.55–1.60)
       Chronic hypertension1.27 (1.21–1.34)1.50 (1.48–1.53)
       Pregestational diabetes mellitus1.91 (1.81–2.02)2.23 (2.19–2.27)
       Obesity1.36 (1.31–1.40)1.70 (1.68–1.72)
       Substance use1.27 (1.22–1.32)1.63 (1.60–1.66)
      Adjusted models were performed stratified for the presence or absence of maternal mental health conditions. Both adjusted models include maternal age, maternal race, payer, ZIP code income quartile, hospital location and region, and 5 chronic health conditions (asthma, chronic hypertension, pregestational diabetes mellitus, obesity, and substance abuse).
      CI, confidence interval; RR, risk ratio; ZIP, Zone Improvement Plan.
      Logue et al. Trends and complications associated with mental health conditions during delivery. Am J Obstet Gynecol 2022.

      Discussion

      Main findings

      In this serial cross-sectional study, there were 4 main findings. The first main finding was that the proportion of delivery hospitalizations with ≥1 mental health condition diagnosis increased >10-fold throughout the study period from 2000 to 2018. Although most of this increase was because of increased diagnoses of anxiety disorder and depressive disorder, findings noted by previous studies,
      • Pino E.C.
      • Zuo Y.
      • Schor S.H.
      • et al.
      Temporal trends of co-diagnosis of depression and/or anxiety among female maternal and non-maternal hospitalizations: results from Nationwide Inpatient Sample 2004-2013.
      ,
      • Haight S.C.
      • Byatt N.
      • Moore Simas T.A.
      • Robbins C.L.
      • Ko J.Y.
      Recorded diagnoses of depression during delivery hospitalizations in the United States, 2000-2015.
      bipolar and schizophrenia spectrum disorder diagnoses also increased significantly throughout the study period. The second main finding was that mental health condition diagnoses were associated with a modestly increased risk of a range of adverse maternal and obstetrical outcomes. The third main finding was that mental health conditions were increasingly associated with underlying chronic health conditions, such that nearly 40% of hospitalizations with a mental health condition diagnosis had a diagnosis of pregestational diabetes mellitus, obesity, chronic hypertension, asthma, or substance abuse by the end of the study period. The fourth main finding was that in the setting of mental health condition diagnoses, underlying health conditions were associated with a greater magnitude of risk of severe maternal morbidity.

      Clinical interpretation

      The relationship between mental health conditions and other underlying health conditions is complex and multidirectional,
      • Farr S.L.
      • Hayes D.K.
      • Bitsko R.H.
      • Bansil P.
      • Dietz P.M.
      Depression, diabetes, and chronic disease risk factors among US women of reproductive age.
      ,
      • Katon W.J.
      Clinical and health services relationships between major depression, depressive symptoms, and general medical illness.
      and causation cannot be inferred from our study given the cross-sectional data source. However, findings from this analysis supported that mental health conditions are of increasing clinical significance in the obstetrical population as they are becoming more prevalent in absolute terms and in relation to other chronic conditions. The increased risk from conditions such as chronic hypertension, pregestational diabetes mellitus, obesity, substance abuse, and asthma that was seen in the setting of mental health condition diagnoses may be a consequence of mental health conditions functioning as an obstacle to disease-specific optimal care, which may indicate a need for more intensive surveillance and management during pregnancy. Moreover, mental health conditions may be associated with poorer preconceptional healthcare as patients with these diagnoses may be less likely to access optimal nonobstetrical medical care.
      • Mitchell A.J.
      • Malone D.
      • Doebbeling C.C.
      Quality of medical care for people with and without comorbid mental illness and substance misuse: systematic review of comparative studies.
      ,
      • Kelly R.H.
      • Danielsen B.H.
      • Golding J.M.
      • Anders T.F.
      • Gilbert W.M.
      • Zatzick D.F.
      Adequacy of prenatal care among women with psychiatric diagnoses giving birth in California in 1994 and 1995.
      Finally, it is possible that untreated or inadequately treated mental health disorders contribute to chronic health conditions through multisystem dysregulation (via the hypothalamic-pituitary-adrenal axis and immune functioning) and compromised lifestyle factors (including diet, sleep, and physical exercise).
      • McEwen B.S.
      Neurobiological and systemic effects of chronic stress.
      ,
      • Juster R.P.
      • McEwen B.S.
      • Lupien S.J.
      Allostatic load biomarkers of chronic stress and impact on health and cognition.
      Further research is needed to determine to what degree the prevalence of and risk associated with mental health condition conditions are associated with social determinants of health and other complicated exposures.
      Although available evidence supports screening for mental health conditions in pregnancy, the optimal timing and frequency of screening have not yet been established.
      • O’Connor E.
      • Rossom R.C.
      • Henninger M.
      • Groom H.C.
      • Burda B.U.
      Primary care screening for and treatment of depression in pregnant and postpartum women: evidence report and systematic review for the US Preventive Services Task Force.
      The American College of Obstetricians and Gynecologists recommends screening for depression and anxiety symptoms at least once perinatally and once after birth, with the initiation of treatment or referral to mental health services for women who screen positive for mental health conditions.
      ACOG Committee Opinion No
      757: screening for perinatal depression.
      The American Psychiatric Association supports screening for mood and anxiety disorders at least twice during pregnancy and bipolar disorder at least once.
      American Psychiatric Association
      Position statement on screening and treatment of mood and anxiety disorders during pregnancy and postpartum. 2020.
      Mental health conditions are underdiagnosed and undertreated in pregnancy,
      • Vesga-López O.
      • Blanco C.
      • Keyes K.
      • Olfson M.
      • Grant B.F.
      • Hasin D.S.
      Psychiatric disorders in pregnant and postpartum women in the United States.
      ,
      • Kelly R.
      • Zatzick D.
      • Anders T.
      The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in obstetrics.
      and optimization of screening, diagnosis, and management before and during pregnancy could improve maternal outcomes. Further research is needed to determine to what degree improved identification and management of these conditions mitigate maternal and obstetrical risks.

      Strengths and limitations

      This study was subject to several limitations. First, our analysis was based on administrative hospital discharge data only; the NIS does not capture information on other healthcare encounters, such as outpatient, hospital, or emergency department visits. We could not assess the management of mental health conditions during pregnancy, including prescription of medications or psychotherapy, and we could not comment on their severity or whether management was successful. Second, the unit of analysis in the NIS was acute care hospitalizations.
      • Khera R.
      • Angraal S.
      • Couch T.
      • et al.
      Adherence to methodological standards in research using the national inpatient sample.
      We could not account for multiple delivery hospitalizations to individual women in our modeling. Third, given the cross-sectional nature of the data, we could not make causal inferences about the association between mental health and chronic conditions or between mental health conditions and adverse outcomes. Fourth, concerns related to administrative data included under ascertainment and misclassification. We could not exclude the possibility that, to some degree, mental health conditions may be more “risk markers” that cluster with morbidity and mortality-associated demographic and chronic conditions rather than risk factors in and of themselves. Fifth, billing diagnoses do not include granular clinical details and criteria related to diagnoses. Given this lack of detail, we were limited inferentially in determining to what degree increased diagnoses were associated with truly increased prevalence of mental health disorders vs better ascertainment throughout the study period. An increase in the diagnoses throughout the study period may be secondary to improved ascertainment. For the same reason, we were limited in interpreting our finding that delivery hospitalizations were more likely to be associated with mental health conditions in non-Hispanic White women than in non-Hispanic Black women (similar to previous analyses in the NIS
      • Pino E.C.
      • Zuo Y.
      • Schor S.H.
      • et al.
      Temporal trends of co-diagnosis of depression and/or anxiety among female maternal and non-maternal hospitalizations: results from Nationwide Inpatient Sample 2004-2013.
      ), whereas other studies have shown higher screen-positive rates of mental health conditions among pregnant non-Hispanic Black women.
      • Mukherjee S.
      • Trepka M.J.
      • Pierre-Victor D.
      • Bahelah R.
      • Avent T.
      Racial/ethnic disparities in antenatal depression in the United States: a systematic review.
      ,
      • Cook C.A.
      • Flick L.H.
      • Homan S.M.
      • Campbell C.
      • McSweeney M.
      • Gallagher M.E.
      Psychiatric disorders and treatment in low-income pregnant women.
      For a significant proportion of the population, race was unknown, limiting inference related to race. Sixth, the study period of analysis included 2 major changes in the NIS database, the first consisting of a change in the sampling approach in 2012 and the second a change in diagnosis and procedure coding in 2015.
      Healthcare Cost and Utilization Project
      Overview of the National (Nationwide) Inpatient Sample (NIS). 2021.
      These study limitations supported the importance of further research to characterize trends in the prevalence of psychiatric diseases during pregnancy and associated risks and the complex role of social determinants of health.
      Study strengths included the use of a database specifically designed to produce national estimates and analyze temporal trends, a long study interval that allowed us to ascertain trends over time, and contemporary data through 2018. In addition, our analysis was powered to detect associations among mental health conditions, chronic conditions, and a range of adverse outcomes, including rare complications. Furthermore, these findings were compatible with other large recent analyses, demonstrating a nearly 50% increase in mental health conditions among reproductive women aged 18 to 34 years from 2013 to 2016.
      • BlueShield B.C.
      Major depression: the impact on overall health. 2018.

      Conclusion

      This study found that the proportion of delivery hospitalizations of women with mental health condition diagnoses has increased significantly. Mental health condition diagnoses were associated with other underlying chronic health conditions and a modestly increased risk of a range of adverse outcomes. In the setting of mental health condition diagnoses, underlying health conditions were associated with a greater magnitude of risk of severe maternal morbidity. These findings suggested that mental health conditions are an increasingly important risk factor in adverse maternal and obstetrical outcomes.

      Supplementary Data

      Supplementary Materials

      Supplemental Table 1Diagnosis and procedure codes used in the analysis
      VariableICD-9-CMICD-10-CM
      Comorbid medical and obstetrical factors
       Obesity278.x, 649.x, 793.91, V85.3x, V85.4x, V85.5x09122x, Z683x, Z684x, E660, E6601, E6609, E661, E662, E668, E669
       Pregestational diabetes mellitus249.x–250.x, 648.0x, excluding 648.8xE0800, E0801, E0810, E0811, E0821, E0822, E0829, E08311, E08319, E083211, E083212, E083213, E083219, E083291, E083292, E083293, E083299, E083311, E083312, E083313, E083319, E083391, E083392, E083393, E083399, E083411, E083412, E083413, E083419, E083491, E083492, E083493, E083499, E083511, E083512, E083513, E083519, E083521, E083522, E083523, E083529, E083531, E083532, E083533, E083539, E083541, E083542, E083543, E083549, E083551, E083552, E083553, E083559, E083591, E083592, E083593, E083599, E0836, E0837X1, E0837X2, E0837X3, E0837X9, E0839, E0840, E0841, E0842, E0843, E0844, E0849, E0851, E0852, E0859, E08610, E08618, E08620, E08621, E08622, E08628, E08630, E08638, E08641, E08649, E0865, E0869, E088, E089, E0900, E0901, E0910, E0911, E0921, E0922, E0929, E09311, E09319, E093211, E093212, E093213, E093219, E093291, E093292, E093293, E093299, E093311, E093312, E093313, E093319, E093391, E093392, E093393, E093399, E093411, E093412, E093413, E093419, E093491, E093492, E093493, E093499, E093511, E093512, E093513, E093519, E093521, E093522, E093523, E093529, E093531, E093532, E093533, E093539, E093541, E093542, E093543, E093549, E093551, E093552, E093553, E093559, E093591, E093592, E093593, E093599, E0936, E0937X1, E0937X2, E0937X3, E0937X9, E0939, E0940, E0941, E0942, E0943, E0944, E0949, E0951, E0952, E0959, E09610, E09618, E09620, E09621, E09622, E09628, E09630, E09638, E09641, E09649, E0965, E0969, E098, E099, E1010, E1011, E1021, E1022, E1029, E10311, E10319, E103211, E103212, E103213, E103219, E103291, E103292, E103293, E103299, E103311, E103312, E103313, E103319, E103391, E103392, E103393, E103399, E103411, E103412, E103413, E103419, E103491, E103492, E103493, E103499, E103511, E103512, E103513, E103519, E103521, E103522, E103523, E103529, E103531, E103532, E103533, E103539, E103541, E103542, E103543, E103549, E103551, E103552, E103553, E103559, E103591, E103592, E103593, E103599, E1036, E1037X1, E1037X2, E1037X3, E1037X9, E1039, E1040, E1041, E1042, E1043, E1044, E1049, E1051, E1052, E1059, E10610, E10618, E10620, E10621, E10622, E10628, E10630, E10638, E10641, E10649, E1065, E1069, E108, E109, E1100, E1101, E1110, E1111, E1121, E1122, E1129, E11311, E11319, E113211, E113212, E113213, E113219, E113291, E113292, E113293, E113299, E113311, E113312, E113313, E113319, E113391, E113392, E113393, E113399, E113411, E113412, E113413, E113419, E113491, E113492, E113493, E113499, E113511, E113512, E113513, E113519, E113521, E113522, E113523, E113529, E113531, E113532, E113533, E113539, E113541, E113542, E113543, E113549, E113551, E113552, E113553, E113559, E113591, E113592, E113593, E113599, E1136, E1137X1, E1137X2, E1137X3, E1137X9, E1139, E1140, E1141, E1142, E1143, E1144, E1149, E1151, E1152, E1159, E11610, E11618, E11620, E11621, E11622, E11628, E11630, E11638, E11641, E11649, E1165, E1169, E118, E119, E1300, E1301, E1310, E1311, E1321, E1322, E1329, E13311, E13319, E133211, E133212, E133213, E133219, E133291, E133292, E133293, E133299, E133311, E133312, E133313, E133319, E133391, E133392, E133393, E133399, E133411, E133412, E133413, E133419, E133491, E133492, E133493, E133499, E133511, E133512, E133513, E133519, E133521, 133522, E133523, E133529, E133531, E133532, E133533, E133539, E133541, E133542, E133543, E133549, E133551, E133552, E133553, E133559, E133591, E133592, E133593, E133599, E1336, E1337X1, E1337X2, E1337X3, E1337X9, E1339, E1340, E1341, E1342, E1343, E1344, E1349, E1351, E1352, E1359, E13610, E13618, E13620, E13621, E13622, E13628, E13630, E13638, E13641, E13649, E1365, E1369, E138, E139, O24011, O24012, O24013, O2402, O2403, O24111, O24112, O24113, O2412, O2413, O24311, O24312, O24313, O2432, O2433, O24811, O24812, O24813, O2482, O2483, O24911, O24912, O24913, O2492, O2493
       Chronic hypertension401.xx–405.xx, 642.xx (excluding 642.3x, 642.4x, 642.5x, 642.7x)I10, I110, I119, I120, I129, I130, I1310, I1311, I132, I150, I151, I152, I158, I159, I160, I161, I169, N262, O10011, O10012, O10013, O10019, O1002, O1003, O10111, O10112, O10113, O10119, O1012, O1013, O10211, O10212, O10213, O10219, O1022, O1023, O10311, O10312, O10313, O10319, O1032, O1033, O10411, O10412, O10413, O10419, O1042, O1043, O10911, O10912, O10913, O10919, O1092, O1093, O111, O112, O113, O114, O115, O119
       Asthma493.xJ45.x
      Substance abuse30303, 30393, 30503, 2910, 2911, 2912, 2913, 2914, 2915, 29181, 29182, 29189, 2919, 30300, 30301, 30302, 30390, 30391, 30392, 30500, 30501, 30502, 30403, 30473, 30553, 30400, 30401, 30402, 30470, 30471, 30472, 30550, 30551, 30552, 30423, 30563, 30420, 30421, 30422, 30560, 30561, 30562, 30433, 30523, 30430, 30431, 30432, 30520, 30521, 30522, 30413, 30443, 30453, 30463, 30483, 30493, 30533, 30543, 30573, 30583, 30593, 2920, 29211, 29212, 2922, 29281, 29282, 29283, 29284, 29289, 2929, 30410, 30411, 30412, 30440, 30441, 30442, 30450, 30451, 30452, 30460, 30461, 30462, 30480, 30481, 30482, 30490, 30491, 30492, 30530, 30531, 30532, 30540, 30541, 30542, 30570, 30571, 30572, 30580, 30581, 30582, 30590, 30591, 30592F1021, F1010, F10120, F10121, F10129, F1014, F10150, F10151, F10159, F10180, F10181, F10182, F10188, F1019, F1020, F10220, F10221, F10229, F10230, F10231, F10232, F10239, F1024, F10250, F10251, F10259, F1026, F1027, F10280, F10281, F10282, F10288, F1029, F10920, F10921, F10929, F1094, F10950, F10951, F10959, F1096, F1097, F10980, F10981, F10982, F10988, F1099, F1121, F1110, F11120, F11121, F11122, F11129, F1114, F11150, F11151, F11159, F11181, F11182, F11188, F1119, F1120, F11220, F11221, F11222, F11229, F1123, F1124, F11250, F11251, F11259, F11281, F11282, F11288, F1129, F1190, F11920, F11921, F11922, F11929, F1193, F1194, F11950, F11951, F11959, F11981, F11982, F11988, F1199, F1421, F1410, F14120, F14121, F14122, F14129, F1414, F14150, F14151, F14159, F14180, F14181, F14182, F14188, F1419, F1420, F14220, F14221, F14222, F14229, F1423, F1424, F14250, F14251, F14259, F14280, F14281, F14282, F14288, F1429, F1490, F14920, F14921, F14922, F14929, F1494, F14950, F14951, F14959, F14980, F14981, F14982, F14988, F1499, F1221, F1210, F12120, F12121, F12122, F12129, F12150, F12151, F12159, F12180, F12188, F1219, F1220, F12220, F12221, F12222, F12229, F12250, F12251, F12259, F12280, F12288, F1229, F1290, F12920, F12921, F12922, F12929, F12950, F12951, F12959, F12980, F12988, F1299, F1321, F1521, F1621, F1821, F1921, F1310, F13120, F13121, F13129, F1314, F13150, F13151, F13159, F13180, F13181, F13182, F13188, F1319, F1320, F13220, F13221, F13229, F13230, F13231, F13232, F13239, F1324, F13250, F13251, F13259, F1326, F1327, F13280, F13281, F13282, F13288, F1329, F1390, F13920, F13921, F13929, F13930, F13931, F13932, F13939, F1394, F13950, F13951, F13959, F1396, F1397, F13980, F13981, F13982, F13988, F1399, F1510, F15120, F15121, F15122, F15129, F1514, F15150, F15151, F15159, F15180, F15181, F15182, F15188, F1519, F1520, F15220, F15221, F15222, F15229, F1523, F1524, F15250, F15251, F15259, F15280, F15281, F15282, F15288, F1529, F1590, F15920, F15921, F15922, F15929, F1593, F1594, F15950, F15951, F15959, F15980, F15981, F15982, F15988, F1599, F1610, F16120, F16121, F16122, F16129, F1614, F16150, F16151, F16159, F16180, F16183, F16188, F1619, F1620, F16220, F16221, F16229, F1624, F16250, F16251, F16259, F16280, F16283, F16288, F1629, F1690, F16920, F16921, F16929, F1694, F16950, F16951, F16959, F16980, F16983, F16988, F1699, F1810, F18120, F18121, F18129, F1814, F18150, F18151, F18159, F1817, F18180, F18188, F1819, F1820, F18220, F18221, F18229, F1824, F18250, F18251, F18259, F1827, F18280, F18288, F1829, F1890, F18920, F18921, F18929, F1894, F18950, F18951, F18959, F1897, F18980, F18988, F1899, F1910, F19120, F19121, F19122, F19129, F1914, F19150, F19151, F19159, F1916, F1917, F19180, F19181, F19182, F19188, F1919, F1920, F19220, F19221, F19222, F19229, F19230, F19231, F19232, F19239, F1924, F19250, F19251, F19259, F1926, F1927, F19280, F19281, F19282, F19288, F1929, F1990, F19920, F19921, F19922, F19929, F19930, F19931, F19932, F19939, F1994, F19950, F19951, F19959, F1996, F1997, F19980, F19981, F19982, F19988, F1999
      Adverse outcomes
       Preeclampsia and gestational hypertension642.3x, 642.4x, 642.5x, 642.7xO141x, O142x, O150x, O140x, O149x, O13x, O11x
       Preterm delivery644.2xO601xXx, O600x, O470x
       Postpartum hemorrhage666.xO72x
       Cesarean delivery669.7x10D00Z0, 10D00Z1, 10D00Z2
      Mental health conditions
      Anxiety disorder30000, 30001, 30002, 30009, 30020, 30021, 30022, 30023, 30029, 3003, 30921, 30924, 30981F4000, F4001, F4002, F4010, F4011, F40210, F40218, F40220, F40228, F40230, F40231, F40232, F40233, F40240, F40241, F40242, F40243, F40248, F40290, F40291, F40298, F408, F409, F410, F411, F413, F418, F419, F42, F422, F423, F424, F428, F429, F4310, F4311, F4312, F4322, F930
      Bipolar spectrum disorder29600, 29601, 29602, 29603, 29604, 29605, 29606, 29610, 29611, 29612, 29613, 29614, 29615, 29616, 29640, 29641, 29642, 29643, 29644, 29645, 29646, 29650, 29651, 29652, 29653, 29654, 29655, 29656, 29660, 29661, 29662, 29663, 29664, 29665, 29666, 2967, 29680, 29681, 29689, 30111F3010, F3011, F3012, F3013, F302, F303, F304, F308, F309, F310, F3110, F3111, F3112, F3113, F312, F3130, F3131, F3132, F314, F315, F3160, F3161, F3162, F3163, F3164, F3170, F3171, F3172, F3173, F3174, F3175, F3176, F3177, F3178, F3181, F3189, F319, F340
      Depressive disorder29620, 29621, 29622, 29623, 29624, 29625, 29626, 29630, 29631, 29632, 29633, 29634, 29635, 29636, 29682, 2980, 3004, 30112, 30113, 3090, 3091, 30928, 311F320, F321, F322, F323, F324, F325, F328, F329, F330, F331, F332, F333, F3340, F3341, F3342, F338, F339, F341, F4321, F4323
      Schizophrenia spectrum disorder29500, 29501, 29502, 29503, 29504, 29505, 29510, 29511, 29512, 29513, 29514, 29515, 29520, 29521, 29522, 29523, 29524, 29525, 29530, 29531, 29532, 29533, 29534, 29535, 29540, 29541, 29542, 29543, 29544, 29545, 29550, 29551, 29552, 29553, 29554, 29555, 29560, 29561, 29562, 29563, 29564, 29565, 29570, 29571, 29572, 29573, 29574, 29575, 29580, 29581, 29582, 29583, 29584, 29585, 29590, 29591, 29592, 29593, 29594, 29595F200, F201, F202, F203, F205, F2081, F2089, F209, F250, F251, F258, F259
      ICD-9-CM and ICD-10-CM codes for severe maternal morbidity were ascertained from the Centers for Disease Control and Prevention available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm
      ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification; ICD-10, International Classification of Diseases, Tenth Revision, Clinical Modification.
      Logue et al. Trends and complications associated with mental health conditions during delivery. Am J Obstet Gynecol 2022.
      Supplemental Table 2Outcomes by presence or absence of maternal mental health conditions
      OutcomeNo mental health condition, n (%)Maternal mental health condition, n (%)
      Adverse outcomes
       Severe maternal morbidity472,113 (0.67)29,037 (1.25)
       Preeclampsia and gestational hypertension5,349,129 (7.56)278,500 (12.02)
       Preterm delivery4,611,737 (6.51)204,312 (8.82)
       Postpartum hemorrhage2,089,095 (2.95)93,402 (4.03)
       Cesarean delivery21,712,537 (30.67)852,773 (36.81)
       Maternal death3448 (0.005%)149 (0.006)
      Severe maternal morbidity was based on a composite from the Centers for Disease Control and Prevention, excluding transfusion.
      Logue et al. Trends and complications associated with mental health conditions during delivery. Am J Obstet Gynecol 2022.

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