Not included in maternal comorbidity composite as one of ICD-9-CM codes included in severe maternal morbidity composite (2)Appendix 2

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Appendix 1. ICD-9-CM Diagnosis Codes Included for Maternal Comorbidities¹ Medical Condition of Procedure ICD-9-CM

Pulmonary Hypertension 416.0x, 416.8x, 416.9x

Sickle cell disease² 282.4x, 282.6x

Placenta Previa 641.0x, 641.1x

Gestational Hypertension 642.3x (without preeclampsia/eclampsia or preexisting hypertension)

Mild or unspecified preeclampsia 642.4x, 642.7x (without severe preeclampsia/eclampsia) Severe preeclampsia/eclampsia² 642.5x, 642.6x

Chronic renal disease 581.x-583.x, 587.x, 588.x, 646.2x Preexisting hypertension 401.x-405.x, 642.0x-642.2x, 642.7x

Chronic ischemic heart disease 412.x – 414.x

Congenital heart disease 745.0x – 747.4x, 648.5x

Systemic lupus erythematosus 710.0x

Human immunodeficiency virus 042.x, V08.x

Cardiac valvular disease 394.x – 397.x , 424.x

Chronic congestive heart failure 428.22, 428.23, 428.32, 428.33, 428.42, 428.43

Asthma 493.x

Preexisting diabetes mellitus 250.x, 648.0x

Gestational diabetes mellitus 648.x (without pre-existing diabetes)

Obesity 278.0x, 649.1x, V85.3, V85.4

Cystic fibrosis 277.0x

Previous cesarean delivery 654.2x

1. Modified from Bateman BT, Mhyre JM, Hernandez-Diaz S, Hyubrechts KF. Fischer MA, Creanga AA, et al. Development of a comorbidity index for use in obstetric patients. Obstet Gynecol2014;122:957–65.

2. Not included in maternal comorbidity composite as one of ICD-9-CM codes included in severe maternal morbidity composite

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Appendix 2. ICD-9-CM Diagnosis and Procedure Codes Included in the Severe Maternal Morbidity Composite, as per the Centers for Disease Control and Prevention

Medical Condition of Procedure Diagnosis (DX) or

Procedure (PR) ICD-9-CM

Acute myocardial infarction DX 410.xx

Aneurysm DX 441.xx

Acute renal failure DX 584.5, 584.6, 584.7,

584.8, 584.9, 669.3x Adult Respiratory Distress Syndrome DX 518.5x, 518.81, 518.82,

518.84, 799.1

Amniotic Fluid Embolism DX 673.1x

Cardiac arrest/ventricular fibrillation DX 427.41, 427.42, 427.5

Conversion of cardiac rhythm PR 99.6x

Disseminated intravascular coagulation DX 286.6, 286.9, 666.3x

Eclampsia DX 642.6x

Heart failure/arrest during surgery or

procedure DX 997.1

Puerperal cerebrovascular disorders DX

430.xx, 431.xx, 432.xx, 433.xx, 434.xx, 436.xx, 437.xx, 671.5x, 674.0x,

997.02 Pulmonary edema/Acute Heart Failure DX 518.4, 428.1, 428.0,

428.21, 428.23, 428.31, 428.33, 428.41, 428.43 Severe anesthesia complications DX 668.0x, 668.1x, 668.2x

Sepsis DX 038.xx, 995.91, 995.92,

670.2x

Shock DX 669.1x, 785.5x, 995.0,

995.4, 998.0x Sickle cell disease with crisis DX 282.42, 282.62, 282.64,

282.69

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Air and thrombotic embolism DX 415.1x, 673.0x, 673.2x, 673.2x, 673.3x, 673.8x

Blood transfusion PR 99.0x

Hysterectomy PR 68.3x-68.9x

Temporary tracheostomy PR 31.1

Ventilation PR 93.90, 96.01, 96.02,

96.03, 96.05

Data from Centers for Disease Control and Prevention. Severe maternal morbidity indicators and corresponding ICD codes during delivery

hospitalizations. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm. Retrieved May 10, 2018. The Centers for Diease Control and Prevention source cites this reference as the source of the data: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion (https://www.cdc.gov/chronicdisease/index.htm).

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Appendix 3. ICD-9-CM Diagnosis and Procedure Codes Included in the Psychiatric and Substance Use Disorder Composites, the Subsequent Pregnancy Composite

Medical Condition of Procedure Diagnosis (DX) or

Procedure (PR) ICD-9-CM Psychiatric Composite

Acute Stress Response DX 308.0-308.4, 308.9

Adjustment Disorder DX 309.0, 309.1, 309.24, 309.28,

309.4, 309.9

Anxiety DX 300.00, 300.01, 300.02, 300.09

Depression DX 300.4, 301.12, 311x

Post-traumatic stress disorder

(PTSD) DX 309.81

Psychosis DX 298.0-298.4, 298.0, 295.0-

298.9, 299.10, 299.11 Suicide Attempt DX (E-code) E950, E951, E952, E953, E954,

E955 Substance Use Disorder Composite

Alcohol Use, Abuse, or Dependence DX 291.9, 291.81, 291.82, 291.89, 291.0-291.5, 303.00-303.92 Recreational drug use, abuse, or

dependence DX 292.0, 292.11, 292.12, 292.2,

292.3, 292.81-282.89, 292.9, 304.00-304.92, 305.20-305.92 Subsequent Pregnancy Codes

Pregnancy-related inpatient

hospitalization codes DX

656.40, 656.41, 656.31, 651.00, 651.03, 651.10, 651.11, 651.13,

651.20, 651.21, 651.23, 640-679

Delivery DX 650, V270, V271

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Appendix 4. Comparison of Preexisting Psychiatric Comorbidities Among Women Who Had a Liveborn, Singleton Neonate With and Without Severe Maternal Morbidity (SMM)

Outcome: SMM

Pre-existing psychiatric morbidity

Liveborn, singleton with SMM

(n=16,408)

Liveborn, singleton without SMM

(n=1,213,427) P value Attributable Risk due to pre-existing psychiatric morbidity Composite Psychiatric Morbidity

(n (%)) 898 (5.5) 34,969 (2.9) <0.0001 2.6%

Suicide Attempt¹ -- 328 (0.03) 0.009 --

Depression 419 (2.6) 16,934 (1.4) <0.0001 1.2%

Anxiety 321 (2.0) 11,150 (0.9) <0.0001 1.1%

Psychosis 240 (1.5) 9282 (0.8) <0.0001 0.7%

PTSD 14 (0.09) 676 (0.06) 0.1 0.03%

Acute Stress Reaction -- 257 (0.02) 0.004 --

Adjustment Disorders 43 (0.3) 903 (0.07) <0.0001 0.23%

Composite Substance Use Disorder

(n (%)) 460 (2.8) 18,374 (1.5) <0.0001 1.3%

Drug Use and Dependence 439 (2.7) 17,641 (1.5) <0.0001 1.2%

Alcohol Use and Dependence 57 (0.4) 1650 (0.1) <0.0001 0.3%

1 Unable to report (less than 11 women had this morbidity).

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Interactions Between Independent Variables Analyzed Within the Multivariable Analyses and the Dependent Variable (SMM) for the Primary Psychiatric Outcome

Appendix 5. Comparison of Baseline Characteristics Among Women Without Coding for Preexisting Psychiatric Illness in the Nine Months Prior to Delivery of Liveborn Singleton and the Odds of Postpartum Psychiatric Morbidity

Adjusted Odds Ratio (95%

Confidence Interval (CI))¹ p value for interaction

Maternal age at delivery (n (%)) <0.0001

< 18 years (n=46,108) 1.30 (0.86 – 1.96) 18-34 years (n=970,787) 1.75 (1.57 – 1.95) 35-39 years (n=140,469) 2.04 (1.55 – 2.68)

≥ 40 years (n==37,324) 1.40 (0.83 – 2.36)

Race/Ethnicity (n (%))² 0.003

White (n=602,918) 1.49 (1.29 – 1.71) Black (n=258,183) 1.97 (1.67 – 2.33) Latina (n=239,955) 2.17 (1.71 – 2.75) Other (n=77144) 1.84 (1.13 – 2.99)

Insurance Type (n (%)) 0.07

Private Insurance (n=580,846) 1.99 (1.66 – 2.38) Public Insurance (n=577,693) 1.65 (1.47 – 1.85) Other (n=36,149) 1.96 (1.17 – 3.26)

Income Quartile, based on Zip code (n (%))³ <0.0001

Quartile 1 (Poorest) (n=313,840) 1.71 (1.45 – 2.01) Quartile 2 (n=305,658) 1.56 (1.29 – 1.88) Quartile 3 (n=262,206) 1.76 (1.41 – 2.21) Quartile 4 (Wealthiest) (n=113,687) 1.68 (1.12 – 2.54)

Mode of Delivery (n (%)) 0.05

Spontaneous Vaginal (n=691,063) 1.48 (1.23 – 1.79) Operative Vaginal (n=54,887) 1.63 (0.98 – 2.69)

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Cesarean Section (n=448,738) 1.86 (1.66 – 2.08) Maternal Comorbidity Composite (n (%))⁴

(n=285,940) 1.91 (1.66 – 2.20) <0.0001

1Adjusted for maternal age, race/ethnicity, insurance type, income quartile by zip code, mode of delivery, and maternal medical comorbidities, excluding the variable of interest

2Missing data from 180 women with postpartum psychiatric morbidity and 16,301 women without psychiatric morbidity

3Missing data from 3124 women with postpartum psychiatric morbidity and 196,071 women without psychiatric morbidity

4Data from Bateman BT, Mhyre JM, Hernandez-Diaz S, Huybrechts KF, Fischer MA, Creanga AA, et al. Development of a comorbidity index for use in obstetric patients. Obstet Gynecol 2013;122:957–65.

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Primary and Secondary Outcomes, Including Only Psychiatric Codes for Inpatient Hospitalizations (ED visits excluded)

Appendix 6. Risk of Psychiatric Morbidity Coded During Inpatient Hospitalization Within One Year of Delivery of a Liveborn Singleton Neonate With Versus Without Severe Intrapartum Morbidity Among Women Without Preexisting Psychiatric Conditions

Outcomes Including Inpatient Hospitalizations only (ED visits excluded)

Outcome

Liveborn singleton with SMM (n=15,510)

Liveborn singleton without SMM (n=1,178,458)

Adjusted Odds Ratio (95% Confidence Interval)¹ Composite Psychiatric Morbidity

(n (%)) 230 (1.5) 7041 (0.6) 2.36 (2.07 – 2.70)

Suicide Attempt 0 (0.0) 0 (0.0) --

Depression 103 (0.7) 2814 (0.2) 2.66 (2.18 – 3.24)

Anxiety 85 (0.6) 1849 (0.2) 3.34 (2.68 – 4.16)

Psychosis 66 (0.4) 3129 (0.3) 1.54 (1.20 – 1.97)

PTSD² -- 246 (0.02) 2.16 (1.02 – 4.61)

Acute Stress Reaction² -- 88 (0.01) 1.69 (0.41 – 6.92)

Adjustment Disorders 29 (0.2) 551 (0.05) 3.58 (2.45 – 5.23)

Composite Substance Use Disorder Morbidity

(n (%)) 88 (0.6) 2838 (0.2) 2.38 (1.92 – 2.96)

Drug use and dependence 79 (0.5) 2439 (0.2) 2.46 (1.96 – 3.09)

Alcohol use and dependence 20 (0.1) 773 (0.07) 2.07 (1.33 – 3.24)

1 Adjusted for mode of delivery and maternal age, race, insurance type, income quartile by zip code, and maternal co-morbidities

2 Unable to report data (<11 women had this outcome)

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Appendix 7. Risk of Inpatient Hospitalization Within One Year of Delivery of a Liveborn Singleton Neonate Coded for Psychiatric Morbidity With and Without Severe Intrapartum Morbidity, Among Women Without Preexisting

Psychiatric Illness in the Nine Months Prior to Delivery

Composite Psychiatric Morbidity during Inpatient Hospitalizations

Liveborn singleton with SMM

(n (%))

Liveborn singleton without SMM (n=1,178,458)

Adjusted Odds Ratio (95% Confidence

Interval)¹ Overall Severe Maternal Morbidity Composite

(N=15,510) 230 (1.5) 7041 (0.6) 2.36 (2.07 – 2.70)

Transfusion (N=9780) 130 (1.3) 7141 (0.6) 2.08 (1.74 – 2.47)

Composite Severe Maternal Morbidity Without

Transfusion (N=5730) 100 (1.7) 7171 (0.6) 2.77 (2.27 – 3.38)

Acute Myocardial Infarction²(N=28) -- -- 11.65 (2.73 –

49.68)

Aneurysm (N=11) 0 (0.0) 7271 (0.6) --

Acute renal failure (N=541) 22 (4.1) 7249 (0.6) 6.09 (3.96 – 9.35) Adult Respiratory Distress Syndrome (N =983) 39 (4.0) 7232 (0.6) 6.11 (4.42 – 8.45)

Amniotic Fluid Embolism² (N=51) 0 (0.0) 7271 (0.6) --

Cardiac Arrest / Ventricular Fibrillation²(N=104) -- -- 7.34 (2.97 – 18.13)

Conversion of Cardiac arrhythmia² (N=209) -- -- 4.42 (1.96 – 9.98)

Disseminated Intravascular Coagulation (N=2552) 24 (0.9) 7247 (0.6) 1.60 (1.07 – 2.39) Eclampsia (N=1137) 19 (1.7) 7252 (0.6) 2.46 (1.56 – 3.88) Heart Failure/Arrest During Surgery or Procedure²

(N=167) -- -- 2.83 (0.90 – 8.88)

Puerperal Cerebrovascular Disorder (N=359) 14 (3.9) 7257 (0.6) 6.28 (3.67 – 10.75) Pulmonary Edema / Acute heart failure (N=618) 16 (2.6) 7255 (0.6) 3.72 (2.26 – 6.13)

Severe Anesthesia Complication²(N=218) -- -- 2.01 (0.64 – 6.28)

Sepsis (N=426) 17 (4.0) 7254 (0.6) 6.14 (3.77 – 10.00) Shock (N=314) 12 (3.8) 7259 (0.6) 6.22 (3.48 – 11.11)

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Sickle Cell Disease with Crisis (N=212) 22 (10.4) 7249 (0.6) 19.19 (12.27 – 30.00)

Air and Thrombotic Embolism²(N=197) -- -- 3.08 (1.14 – 8.31)

Hysterectomy (N=879) 15 (1.7) 7256 (0.6) 2.81 (1.68 – 4.70)

Temporary tracheostomy²(N=43) -- -- 24.65 (10.29 –

59.07)

Ventilation²(N=101) -- -- 2.72 (0.67 – 11.07)

1Adjusted for maternal age, race/ethnicity, insurance type, income quartile by zip code, mode of delivery, and maternal medical comorbidities

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Primary and Secondary Outcomes With Exclusion Period for Psychiatric Morbidity of Two Years Prior to Delivery Hospitalization

Appendix 8. Comparison of Baseline Characteristics Among Women Who Did Not Present to the Emergency Department or Hospital for Psychiatric Illness in the Two Years Prior to Delivery of a Liveborn Singleton Neonate With Versus Without Severe Maternal Morbidity (SMM)

Excluding women with psychiatric illness or substance use disorder in the two years prior to index delivery

Liveborn singleton without SMM

(n=804,023) p value Maternal age at delivery (n (%))

< 18 years 549 (4.8) 31,359 (3.9)

<0.0001 18-34 years 8685 (75.8) 652,792 (81.2)

35-39 years 1611 (14.0) 93,857 (11.7)

≥ 40 years 606 (5.3) 26,015 (3.2) Race/Ethnicity (n (%))¹

White 4613 (40.9) 397,471 (50.2)

<0.0001 Black 3688 (32.7) 172,482 (21.8)

Latina 2230 (19.7) 165,992 (20.9) Other 754 (6.7) 56,531 (7.1) Insurance Type (n (%))

Private Insurance 4831 (42.2) 384,971 (47.9)

<0.0001 Public Insurance 6221 (54.3) 393,755 (49.0)

Other 399 (3.5) 25,297 (3.1) Income Quartile, based on zip

code (n (%))²

Quartile 1 (Poorest) 4059 (35.8) 250,067 (31.4)

<0.0001 Quartile 2 3522 (31.1) 244,443 (30.7)

Quartile 3 2680 (23.7) 212,053 (26.7) Quartile 4 (Wealthiest) 1061 (9.4) 88,626 (11.2) Mode of Delivery (n (%))

Spontaneous Vaginal 3466 (30.3) 461,348 (57.4)

<0.0001 Operative Vaginal 479 (4.2) 37,547 (4.6)

Cesarean 7506 (65.5) 305,128 (38.0) Maternal Comorbidity

Composite (n (%))³ 6326 (55.2) 237,165 (29.5) <0.0001

1Missing data from 167 deliveries with SMM and 11,547 deliveries without SMM

2Missing data from 129 deliveries with SMM and 8834 deliveries without SMM

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Appendix 9. Risk of Psychiatric Morbidity Coded During an Emergency Department (ED) or Hospitalization Within One Year of Delivery of a Liveborn Singleton With Versus Without Severe Intrapartum Morbidity Among Women Without Psychiatric Morbidity Two Years Prior to Delivery

Excluding women with psychiatric illness or substance use disorder in the two years prior to index delivery

Outcome

(n=804,023)

Adjusted Odds Ratio (95% Confidence

Interval)¹ Composite Psychiatric Morbidity

(excluding psychosis) (n (%))² 300 (2.6) 12,584 (1.6) 1.62 (1.44 – 1.83)

Suicide Attempt³ -- 332 (0.04) 1.05 (0.43 – 2.54)

Depression 116 (1.0) 4818 (0.6) 1.66 (1.38 – 2.00)

Anxiety 160 (1.4) 6585 (0.8) 1.67 (1.42 – 1.95)

Psychosis 59 (0.5) 2781 (0.4) 1.44 (1.11 – 1.87)

PTSD -- 234 (0.03) 2.40 (1.18 – 4.87)

Acute Stress Reaction 12 (0.1) 395 (0.05) 2.02 (1.13 – 3.60)

Composite Substance Use Disorder

(n,%) 113 (1.0) 4440 (0.6) 1.81 (1.50 – 2.18)

Drug Use and Dependence 88 (0.8) 3353 (0.4) 1.85 (1.50 – 2.30)

Alcohol Use and Dependence 37 (0.3) 1506 (0.2) 1.77 (1.27 – 2.45)

2 Includes suicide attempt, depression, anxiety, PTSD, acute stress reaction, or adjustment disorders. Psychosis excluded.

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Appendix 10. Risk of an Emergency Department (ED) Encounter or Hospitalization Coded for Psychiatric Morbidity Within One Year of Delivery of a Liveborn Singleton Neonate With and Without Severe Intrapartum Morbidity, Among Women Without Preexisting Psychiatric Illness in the Two Years Prior to Delivery

Composite Psychiatric Morbidity, Excluding Women with Psychiatric Morbidity in Two Years Prior to Index Delivery

(n (%))

Liveborn singleton without SMM (n=804,023)

(n (%))

(N=11,451) 300 (2.6) 12,584 (1.6) 1.62 (1.44 – 1.83)

Transfusion (N=7583) 190 (2.5) 12,694 (1.6) 1.54 (1.33 – 1.79)

Transfusion (N=3868) 110 (2.8) 12,774 (1.6) 1.75 (1.45 – 2.12)

Acute Myocardial Infarction2(N=18) -- -- 13.34 (3.75 – 47.49)

Aneurysm (N<11) 0 (0.0) 12,884 (1.6) --

Acute renal failure (N=405) 24 (5.9) 12,860 (1.6) 3.60 (2.37 – 5.46) Adult Respiratory Distress Syndrome (N =709) 42 (5.9) 12,842 (1.6) 3.69 (2.69 – 5.07)

Amniotic Fluid Embolism (N=31) 0 (0.0) 12,884 (1.6) --

Disseminated Intravascular Coagulation (N=1839) 36 (2.0) 12,848 (1.6) 1.31 (0.94 – 1.83) Eclampsia (N=792) 25 (3.2) 12,859 (1.6) 1.81 (1.21 – 2.71) Heart Failure/Arrest During Surgery or Procedure²(N=119) -- -- 2.70 (1.10 – 6.64) Puerperal Cerebrovascular Disorder (N=221) 13 (5.9) 12,871 (1.6) 3.58 (2.03 – 6.30) Pulmonary Edema / Acute heart failure (N=409) 16 (3.9) 12,868 (1.6) 2.26 (1.37 – 3.74)

Severe Anesthesia Complication²(N=136) -- -- 0.79 (0.20 – 3.21)

Sepsis (N=301) 16 (5.3) 12,868 (1.6) 3.16 (1.90 – 5.25)

Shock² (N=237) -- -- 2.44 (1.25 – 4.78)

Sickle Cell Disease with Crisis (N=144) 19 (13.2) 12,865 (1.6) 10.15 (6.24 – 16.53)

Hysterectomy (N=597) 15 (2.5) 12,869 (1.6) 1.71 (1.02 – 2.86)

Temporary tracheostomy²(N=32) -- -- 17.27 (7.34 – 40.66)

Ventilation²(N=76) -- -- 0.70 (0.10 – 5.06)

1 Adjusted for maternal age, race/ethnicity, insurance type, income quartile by zip code, mode of delivery, and maternal medical comorbidities

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2 Unable to report (less than 11 women)

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Appendix 11. Risk of an Emergency Department (ED) Encounter or Hospitalization Coded for Substance Use Disorder Within One Year of Delivery of a Liveborn Singleton Neonate With and Without Severe Intrapartum Morbidity Among Women Without

Preexisting Psychiatric Illness in the Two Years Prior to Delivery

Composite Substance Use Disorder Excluding Women with Psychiatric Morbidity in Two Years Prior to Index Delivery Liveborn singleton

with SMM (n (%))

Liveborn singleton without SMM (n=804,023)

(n (%))

(N=11,451) 113 (1.0) 4440 (0.6) 1.81 (1.50 – 2.18)

Transfusion (N=7583) 71 (1.6) 4482 (0.6) 1.68 (1.33 – 2.13)

Transfusion (N=3868) 42 (1.1) 4511 (0.6) 2.00 (1.47 – 2.71)

Acute Myocardial Infarction(N=18) 0 (0.0) 4553 (0.6) --

Aneurysm (N<11) 0 (0.0) 4553 (0.6) --

Acute renal failure² (N=405) -- -- 3.59 (2.37 – 5.45)

Adult Respiratory Distress Syndrome² (N =709) -- -- 2.60 (1.39 – 4.88)

Amniotic Fluid Embolism (N=31) 0 (0.0) 4553 (0.6) --

Disseminated Intravascular Coagulation (N=1839) 15 (0.8) 4538 (0.6) 1.68 (1.01 – 2.80)

Eclampsia² (N=792) -- -- 0.61 (0.20 – 1.91)

Heart Failure/Arrest During Surgery or Procedure(N=119) 0 (0.0) 4553 (0.6) --

Puerperal Cerebrovascular Disorder² (N=221) -- -- 0.77 (0.11 – 5.52)

Pulmonary Edema / Acute heart failure² (N=409) -- -- 2.26 (1.37 – 3.74)

Severe Anesthesia Complication(N=136) 0 (0.0) 4553 (0.6) --

Sepsis² (N=301) -- -- 3.16 (1.90 – 5.25)

Shock² (N=237) -- -- 2.46 (0.79 – 7.74)

Hysterectomy² (N=597) -- -- 1.90 (0.78 – 4.60)

Temporary tracheostomy²(N=32) -- -- 6.21 (0.83 – 46.34)

Ventilation²(N=76) -- -- 2.11 (0.29 – 15.30)

2 Unable to report (less than 11 women).

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Primary and Secondary Outcomes, Excluding All Women With Medical Comorbidities¹

Appendix 12. Comparison of Baseline Characteristics Among Women Who Did Not Present to the Emergency Department or Hospital for Psychiatric Illness in the Nine Months Prior to Delivery of a Liveborn Singleton Neonate With Versus Without Severe Maternal Morbidity (SMM) and Who Were Not Coded for Any Conditions Within a Maternal Comorbidity Composite¹ During Delivery Hospitalization

Excluding women with Medical Comorbidities Liveborn singleton

with SMM (n=9716)

(n=898,490) p value Maternal age at delivery (n (%))

< 18 years 627 (6.5) 41,665 (4.6)

<0.0001

18-34 years 7745 (79.7) 750,637 (83.5)

35-39 years 1010 (10.4) 85,811 (9.6)

≥ 40 years 334 (3.4) 20,377 (2.3)

Race/Ethnicity (n (%))²

White 4210 (44.0) 462,550 (52.2)

<0.0001

Black 2934 (30.6) 189,847 (21.4)

Latina 1830 (19.1) 176,513 (19.9)

Other 599 (6.3) 56,833 (6.4)

Insurance Type (n (%))

Other 329 (3.4) 27,499 (3.0)

Income Quartile, based on zip code (n (%))³

<0.0001 Quartile 2 2623 (31.0) 231,403 (30.8)

<0.0001

Operative Vaginal 536 (5.5) 48,021 (5.4)

Cesarean 5312 (54.7) 247,373 (27.5)

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Appendix 13. Risk of Psychiatric Morbidity Coded During an Emergency Department (ED) or Hospitalization Within One Year of Delivery of a Liveborn Singleton With Versus Without Severe Intrapartum Morbidity Among Women Without Psychiatric

Morbidity Nine Months Prior to Delivery and Without Medical Comorbidities Excluding Women with Medical Comorbidities¹

Outcome

Liveborn singleton with SMM (n=9716)

(n=898,490)

Interval)² Composite Psychiatric Morbidity

(n (%)) 246 (2.5) 13,924 (1.6) 1.62 (1.42 – 1.84)

Suicide Attempt³ -- 417 (0.05) 0.64 (0.21 – 2.01)

Depression 99 (1.0) 5379 (0.6) 1.72 (1.41 – 2.11)

Anxiety 123 (1.3) 6845 (0.8) 1.64 (1.37 – 1.97)

Psychosis 58 (0.6) 3386 (0.4) 1.55 (1.19 – 2.01)

PTSD³ -- 248 (0.03) 1.87 (0.77 – 4.55)

Acute Stress Reaction³ -- 460 (0.05) 1.56 (0.77 – 3.15)

Composite Substance Use Disorder

(n (%)) 100 (1.0) 5262 (0.6) 1.81 (1.48 – 2.22)

1 Diagnosis codes for sickle cell disease or eclampsia included

2Adjusted for maternal age, race/ethnicity, insurance type, income quartile by zip code and mode of delivery

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Appendix 14.Risk of an Emergency Department (ED) Encounter or Hospitalization Coded for Psychiatric Morbidity Within One Year of Delivery of a Liveborn Singleton Neonate With and Without Severe Intrapartum Morbidity, Among Women Without Preexisting Psychiatric Illness in the Nine Months Prior to Delivery and Without Medical Comorbidities

Composite Psychiatric Morbidity, Excluding Women with Medical Comorbidities¹

(n (%))

(n=898,490) (n (%))

Interval)² Overall Morbidity Composite (N=9716) 246 (2.5) 13,924 (1.6) 1.62 (1.42 – 1.84)

Transfusion (N=6269) 154 (2.5) 14,016 (1.6) 1.54 (1.31 – 1.81)

Composite Morbidity Without Transfusion (N=3447) 92 (2.7) 14,078 (1.6) 1.73 (1.40 – 2.13)

Acute Myocardial Infarction(N=12) 0 (0.0) 14,170 (1.6) --

Aneurysm (N<11) 0 (0.0) 14,170 (1.6) --

Amniotic Fluid Embolism (N=25) 0 (0.0) 14,170 (1.6) --

Cardiac Arrest / Ventricular Fibrillation³(N=46) -- -- 1.39 (0.19 – 10.17)

Conversion of Cardiac arrhythmia³ (N=110) -- -- 1.74 (0.55 – 5.50)

Disseminated Intravascular Coagulation (N=1688) 26 (1.5) 14,144(1.6) 1.08 (0.73 – 1.59) Eclampsia (N=861) 33 (3.8) 14,137 (1.6) 2.23 (1.57 – 3.16) Heart Failure/Arrest During Surgery or Procedure³(N=80) -- -- 1.61 (0.39 – 6.57)

Puerperal Cerebrovascular Disorder³ (N=213) -- -- 2.53 (1.24 – 5.14)

Pulmonary Edema / Acute heart failure³ (N=230) -- -- 1.60 (0.71 – 3.62)

Severe Anesthesia Complication³(N=136) -- -- 2.21 (0.90 – 5.43)

Sepsis (N=257) 14 (5.5) 14,156 (1.6) 3.43 (1.99 – 5.90)

Shock³ (N=179) -- -- 3.29 (1.61 – 6.72)

Sickle Cell Disease with Crisis (N=155) 16 (10.3) 14,154 (1.6) 7.67 (4.55 – 12.92)

Air and Thrombotic Embolism³(N=96) -- -- 4.98 (2.29 – 10.82)

Hysterectomy³ (N=351) -- -- 2.17 (1.15 – 4.08)

Temporary tracheostomy³(N=23) -- -- 9.03 (2.64 – 30.87)

Ventilation³(N=34) -- -- 1.80 (0.25 – 13.29)

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Appendix 15. Risk of an Emergency Department (ED) Encounter or Hospitalization Coded for Substance Use Disorder Composite Within One Year of Delivery of a Liveborn Singleton Neonate With and Without Severe Intrapartum Morbidity, Among Women Without Preexisting Psychiatric Illness in the Nine Months Prior to Delivery and Without Medical Comorbidities

Substance Use Disorder Composite, Excluding Women with Medical Comorbidities¹

(n (%))

(n=898,490) (n (%))

Interval)² Overall Morbidity Composite (N=9716) 100 (1.0) 5262 (0.6) 1.80 (1.47 – 2.20)

Transfusion (N=6269) 62 (1.0) 5300 (0.6) 1.70 (1.32 – 2.18)

Composite Morbidity Without Transfusion (N=3447) 38 (1.1) 5324 (0.6) 1.98 (1.43 – 2.73)

Aneurysm (N<11) 0 (0.0) 5362 (0.6) --

Acute renal failure (N=227) -- -- 1.64 (0.41 – 6.63)

Adult Respiratory Distress Syndrome (N =446) -- -- 3.13 (1.54 – 6.33)

Cardiac Arrest / Ventricular Fibrillation(N=46) 0 (0.0) 5362 (0.6) --

Conversion of Cardiac arrhythmia (N=110) 0 (0.0) 5362 (0.6) --

Eclampsia³ (N=861) -- -- 0.92 (0.38 – 2.23)

Puerperal Cerebrovascular Disorder³ (N=213) -- -- 0.85 (0.12 – 6.10)

Pulmonary Edema / Acute heart failure³ (N=230) -- -- 4.60 (2.03 – 10.42)

Sepsis (N=257) -- -- 1.98 (0.63 – 6.19)

Shock³ (N=179) -- -- 2.34 (0.58 – 9.46)

Air and Thrombotic Embolism³(N=96) 0 (0.0) 5362 (0.6) --

Hysterectomy³ (N=351) -- -- 3.14 (1.29 – 7.63)

Ventilation³(N=34) -- -- 5.20 (0.70 – 38.66)

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Primary and Secondary Outcomes, Excluding Psychosis as a Condition Within the Psychiatric Morbidity Composite and as an Exclusion for Preexisting Psychiatric Condition

Appendix 16. Comparison of Baseline Characteristics Among Women Who Did Not Present to the Emergency Department or Hospital for Psychiatric Illness (Excluding Psychosis) in the Nine Months Prior to Delivery of a Liveborn Singleton Neonate With Versus Without Severe Maternal Morbidity (SMM)

Excluding psychosis as condition within psychiatric morbidity composite and as exclusion for preexisting psychiatric condition

Liveborn, singleton with SMM (n=15,680)

Liveborn, singleton without SMM

(n=1,185,554) p value Maternal age at delivery (n (%))

< 18 years 735 (4.7) 45,802 (3.9)

<0.0001 18-34 years 11,901 (75.9) 964,137 (81.3)

35-39 years 2243 (14.3) 138,879 (11.7)

≥ 40 years 801 (5.1) 36,736 (3.1) Race/Ethnicity (n (%))²

White 6415 (41.5) 601,060 (51.4)

<0.0001 Black 5113 (33.1) 254,232 (21.7)

Latina 2949 (19.0) 237,592 (20.3)

Other 987 (6.4) 76,335 (6.5)

Insurance Type (n (%))

Other 528 (3.4) 35,854 (3.0)

Income Quartile, based on zip code (n (%))³

<0.0001 Quartile 2 4229 (31.2) 303,260 (30.7)

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<0.0001 Operative Vaginal 633 (4.0) 54,502 (4.6)

Cesarean 10,297 (65.7) 441,084 (37.2) Maternal Comorbidity Composite

(n (%))⁴ 8890 (56.7) 353,955 (29.9) <0.0001

1Unless otherwise noted.

4Data from Bateman BT, Mhyre JM, Hernandez-Diaz S, Huybrechts KF, Fischer MA, Creanga AA, et al. Development of a comorbidity index for use in obstetric patients.

Obstet Gynecol 2013;122:957–65.

4Unable to report (<11 persons)

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Appendix 17. Risk of Psychiatric Morbidity Coded During an Emergency Department (ED) or Hospitalization Within One Year of Delivery of a Liveborn Singleton With Versus Without Severe Intrapartum Morbidity Among Women Without Preexisting

Psychiatric Conditions

Excluding psychosis as condition within psychiatric morbidity composite and as exclusion for preexisting psychiatric condition

Outcome

Liveborn, singleton with SMM (n=15,680)

Liveborn, singleton without SMM (n=1,185,554)

Interval)¹ Composite Psychiatric Morbidity

(excluding psychosis) (n (%))² 440 (2.8) 17,657 (1.5) 1.83 (1.66 – 2.02)

Suicide Attempt³ -- 588 (0.05) 0.73 (0.33 – 1.64)

Depression 208 (1.3) 8072 (0.7) 1.91 (1.66 – 2.19)

Anxiety 244 (1.6) 10,042 (0.9) 1.77 (1.56 – 2.02)

PTSD 11 (0.07) 397 (0.03) 2.06 (1.13 – 3.77)

Acute Stress Reaction 15 (0.1) 647 (0.05) 1.64 (0.98 – 2.75)

Composite Substance Use Disorder

(n (%)) 192 (1.2) 7441 (0.6) 1.95 (1.69 – 2.26)

2 Includes suicide attempt, depression, anxiety, PTSD, acute stress reaction, or adjustment disorders. Psychosis excluded.

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Appendix 18. Risk of an Emergency Department (ED) Encounter or Hospitalization Within One Year of Delivery of a Liveborn, Singleton Neonate at ≥ 37 Weeks Gestation Coded for Psychiatric Morbidity, With and Without Severe Intrapartum Morbidity, Among Women Without Preexisting Psychiatric Illness in the Nine Months Prior To Delivery

Composite Psychiatric Morbidity Excluding Psychosis¹ Liveborn, singleton

with SMM (n (%))

Liveborn, singleton without SMM (N=1,185,554)

(n (%))

Interval)² Overall Severe Maternal Morbidity Composite

(N=15,680) 440 (2.8) 17,657 (1.5) 1.83 (1.66 – 2.02)

Transfusion (N=9881) 260 (1.4) 17,837 (1.5) 1.69 (1.49 – 1.91)

Transfusion (N=5799) 180 (1.0) 17,917 (1.5) 2.03 (1.75 – 2.36)

Acute Myocardial Infarction³(N=29) -- -- 7.36 (2.18 – 24.84)

Aneurysm (N=11) 0 (0.0) 18,097 (1.5) --

Amniotic Fluid Embolism³ (N=51) -- -- 1.20 (0.17 – 8.73)

Disseminated Intravascular Coagulation (N=2567) 46 (1.8) 18,051 (1.5) 1.26 (0.94 – 1.69) Eclampsia (N=1151) 44 (3.8) 18,053 (1.5) 2.35 (1.74 – 3.19) Heart Failure/Arrest During Surgery or Procedure³(N=168) -- -- 2.79 (1.30 – 5.98) Puerperal Cerebrovascular Disorder (N=366) 15 (4.1) 18,082 (1.5) 2.69 (1.60 – 4.52) Pulmonary Edema / Acute heart failure (N=627) 23 (3.7) 18,074 (1.5) 2.20 (1.44 – 3.34)

Sepsis (N=437) 28 (6.4) 18,069 (1.5) 4.08 (2.77 – 6.01) Shock (N=322) 15 (4.7) 18,082 (1.5) 3.10 (1.84 – 5.23) Sickle Cell Disease with Crisis (N=214) 29 (13.6) 18,068 (1.5) 11.25 (7.58 – 16.71)

Hysterectomy (N=891) 23 (2.6) 18,074 (1.5) 1.80 (1.19 – 2.74)

Ventilation³(N=103) -- -- 1.64 (0.52 – 5.20)

1 Psychiatric composite composed of suicide attempt, depression, anxiety, PTSD, acute stress reaction, and adjustment disorder. Psychosis not included

3 Unable to report (less than 11 women had this outcome)

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Lewkowitz AK Rosenbloom JI, Keller M, López JD, Macones GA, Olsen MA, et al. Association between severe maternal morbidity and psychiatric illness within one year of hospital discharge after delivery. Obstet Gynecol 2019;134.

The authors provided this information as a supplement to their article.

Appendix 19. Risk of an Emergency Department (ED) Encounter or Hospitalization Coded for Substance Use Disorder Within One Year of Delivery of a Liveborn Singleton Neonate With and Without Severe Intrapartum Morbidity, Among Women Without Preexisting Psychiatric Illness in the Nine Months Prior to Delivery (Excluding Psychosis)

Composite Substance Use Disorder, Excluding Psychosis¹ Liveborn, singleton

With SMM (n (%))

Liveborn, singleton without SMM (N=1,190,882)

(n (%))

Interval)² Overall Severe Maternal Morbidity Composite

(N=15,680) 192 (1.2) 7441 (0.6) 1.94 (1.68 – 2.24)

Transfusion (N=9881) 108 (1.4) 7525 (0.6) 1.69 (1.39 – 2.04)

Transfusion (N=5799) 84 (1.5) 7549 (0.6) 2.36 (1.89 – 2.93)

Aneurysm (N=11) 0 (0.0) 7633 (0.6) --

Acute renal failure (N=556) 11 (2.0) 7622 (0.6) 3.83 (2.70 – 5.44) Adult Respiratory Distress Syndrome (N =997) 15 (1.5) 7618 (0.6) 2.37 (1.42 – 3.96)

Eclampsia³ (N=1151) -- -- 1.26 (0.68 – 2.36)

Puerperal Cerebrovascular Disorder (N=366) -- -- 1.71 (0.64 – 4.60)

Pulmonary Edema / Acute heart failure (N=627) 17 (2.7) 7616 (0.6) 2.20 (1.44 – 3.34)

Sepsis³ (N=437) -- -- 3.09 (1.59 – 6.01)

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Lewkowitz AK Rosenbloom JI, Keller M, López JD, Macones GA, Olsen MA, et al. Association between severe maternal morbidity and psychiatric illness within one year of hospital discharge after delivery. Obstet Gynecol 2019;134.

The authors provided this information as a supplement to their article.

Shock³ (N=322) -- -- 2.01 (0.75 – 5.40)

Hysterectomy (N=891) 12 (1.4) 7621 (0.6) 2.54 (1.43 – 4.51)

Ventilation³(N=103) -- -- 4.11 (1.29 – 13.07)

1 Women coded for ED visits or inpatient hospitalizations for psychosis during pregnancy not excluded

3 Unable to report (less than 11 women had this outcome).