Variability in Intensive Care Unit Admission Practice Among Pregnant and Postpartum Women in Canada
CCCF ePoster library. Aoyama K. Nov 9, 2018; 233445
Dr. Kazuyoshi Aoyama
Dr. Kazuyoshi Aoyama
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Abstract
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Introduction:

Severe maternal morbidity and pregnancy-related critical illness result in approximately 300,000 deaths globally each year. However, it is not known if regional variability in access to intensive care (ICU) in developed countries influences the risk of severe maternal morbidity and mortality.

Objective:

To describe variation in ICU admission and the contribution of patient- and hospital-based factors in ICU admission among Canadian hospitals for pregnant and postpartum women.

Methods:

Design, Setting, and Population


A nationwide cohort study, excluding residents of Quebec, was completed between 2004-2015, comprising all identifiable women who were pregnant or within the 6-week postpartum period and admitted to a Canadian hospital.

Main outcomes and Measures

The primary outcome was ICU admission. Secondary outcomes were i) severe maternal morbidity and ii) maternal death. The proportion of total variability in ICU admission rates due to differences among hospitals was described using median odds ratios and the variance partitioning coefficient.

Results:

There were 3,157,248 identifiable pregnancies among women admitted to 342 Canadian hospitals. The overall ICU admission rate was 3.2 per 1,000 pregnancies. The rate of severe maternal morbidity was 15.8 per 1,000 pregnancies, of which 10% of women were admitted to an ICU. The most common severe maternal morbidity events included postpartum hemorrhage (n=16,364, 0.52%) and sepsis (n=11,557, 0.37%). Of the 195 maternal deaths (6.2 per 100,000 pregnancies), only 130 (67%) were admitted to an ICU. For two pregnant women with similar characteristics at different hospitals, the average (median) odds of being admitted to ICU was 1.92 in one hospital compared to another, The proportion of total variability in ICU admission due to hospital level factors was 18.6%. Hospital-level factors associated with ICU admission included urban location (OR 1.30, 95%CI: 0.94 – 1.79) and admission to hospital in specific provinces. Hospitals admitting the fewest number of pregnant patients had the highest incidence of severe maternal morbidity and mortality. Hospitals admitting the fewest number of pregnant patients were also more likely to be in rural areas, and had a higher proportion of patients in lower income quintiles. Patient-level factors associated with ICU admission were maternal comorbidity index (Odds Ratio (OR) 1.88 per 1 unit increase, 95% CI: 1.86 – 1.99); urban residence (OR 1.09, 95% CI: 1.02 – 1.16); and residing at the lowest income quintile (OR 1.44, 95% CI: 1.34 – 1.55).

Conclusions:

Most women who experience severe maternal morbidity are not admitted to an ICU. There exists wide hospital- and provincial-level variability in ICU admission, with patients living in urban locations and patients of lowest income levels most likely to be admitted to ICU.


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