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Supplemental Digital Content Table 1: Etiologies of PPH*, Risk Factors for PPH, Morbidity Associated with PPH, and Their Associated ICD-9? CodesICD-9 Code(s)Uterine atony 666.1xRetained placenta (including accreta)666.0xDelayed PPH (>24 hours after delivery)666.2xCoagulopathy666.3x, 286.6, 286.9Blood transfusion99.0xHysterectomy68.3x-68.9xPrior cesarean delivery654.2xPrior uterine surgery654.9xPrevia641.0x, 641.1xPlacental abruption641.2xUterine rupture665.0x, 665.1xRetained placenta 667.xChronic hypertension401.x, 402.x, 403.x, 404.x, 405.x, 642.0x, 642.1x, 642.2x, 642.7xGestational hypertension642.3xPre-eclampsia642.4x, 642.7x, 642.5xEclampsia642.6xDiabetes mellitus250.x, 648.0x, 648.8xPolyhydramnios657.xChorioamnionitis658.4xRupture of membranes >24 hours658.2xPrecipitous delivery661.3xLong labor662.xInduction of labor73.4Macrosomia766.0x, 766.1x, 775.0x, 656.6x, 653.5xObstructed labor660.0x, 660.1x, 660.2x, 660.3x, 660.9x, 660.8xMultiple gestationV27.2-V27.8, 651.xGrand multiparity659.4xStillbirth656.4, 768.0, 768.1, V27.1, V27.3, V27.4, V27.7Pregnancy affected by infertilityV23.0Presence of uterine fibroids 654.1xAcute respiratory failure518.81, 518.82, 518.84, 518.5, 799.1, 518.7xMechanical ventilation93.90, 96.01, 96.02, 96.03, 96.05, 96.72Sepsis038.xx, 995.91, 995.95, 670.2xAcute Renal Failure584.5, 584.6, 584.7, 584.8, 584.9, 669.3xVenous thromboembolism415.1x, 673.0x, 673.2x, 673.3x, 673.8x, 453.4, 453.8Pulmonary embolism673.x, 415.1xMaternal cardiac arrest427.5, 427.41, 427.42, 668.1Legend: * Postpartum Hemorrhage ? International Classification of Diseases, Ninth Revision Supplemental Digital Content Table 2: Frequencies of PPH and Related Morbidity by Hospital Type Per 1,000 Deliveries, According to Year of Delivery20102011201220132014Odds Ratios (95% CI) Per Year IncreaseTotal Deliveries3,715,8363,669,042 3,764,0413,739,6733,799,465Postpartum Hemorrhage (95% CI)28.6 (26.7-30.6)29.2 (26.3-32.1)30.7 (29.6-31.8)31.5 (30.4-32.6)32.1 (31.0-33.3)1.03 (1.01-1.05)Hospital TypeRural29.0 (25.8-32.1)29.7 (26.5-32.9)29.4 (27.6-31.1)31.4 (29.6-33.2)31.7 (29.8-33.7)1.03 (0.99-1.06)Urban nonteaching22.8 (20.7-25.0)22.4 (20.6-24.2)23.3 (22.2-24.3)23.8 (22.7-24.9)23.3 (22.0-24.6)1.01 (0.98-1.04)Urban teaching33.5 (29.8-37.1)34.3 (28.6-40.0)36.7 (24.8-28.7)37.4 (35.5-39.3)35.7 (34.1-37.4)1.02 (0.99-1.05)Unknown42.1 (29.6-54.6)50.5 (26.0-75.1)NA1NANANE2Postpartum Hemorrhage Related Morbidity* Per 1,000 Deliveries7.3 (6.5-8.1)7.8 (6.9-8.7)7.8 (7.4-8.1)7.9 (7.5-8.2)7.8 (7.4-8.1)1.02 (0.99-1.04)Hospital TypeRural7.6 (6.1-9.1)7.3 (5.8-8.8)7.2 (6.5-8.0) 7.6 (6.8-8.4)7.4 (6.7-8.1)1.00 (0.95-1.06)Urban nonteaching5.4 (4.9-5.9)5.9 (5.2-6.6) 5.9 (5.5-6.3)5.9 (5.5-6.3) 5.7 (5.2-6.1)1.01 (0.98-1.04)Urban teaching9.0 (7.3-1.1)9.5 (7.8-11.3)9.3 (8.7-9.9)9.5 (8.9-10.0)8.7 (8.2-9.2)0.99 (0.95-1.03)Unknown6.7 (4.0-9.4)8.8 (4.3-13.3)NANANANELegend:1NA: not available2NE: not evaluated*Patients with postpartum hemorrhage and one of the following morbidities: coagulopathy, hysterectomy, blood transfusion, acute respiratory failure, mechanical ventilation, sepsis, acute renal failure, venous thromboembolism, pulmonary embolism, maternal cardiac arrest, maternal death, discharge other than home, or length of stay >7 daysSupplemental Digital Content Table 3: Patient Characteristics Stratified by Year, N(%)All deliveries (Weighted frequency)Characteristics2010 (n=3,715,836)2011 (n=3,669,042)2012 (n=3,764,041)2013 (n=3,739,673)2014 (n=3,799,465)Total (n=18,688,056)Postpartum Hemorrhage106,398 (2.9%)107,223 (2.9%)115,505 (3.1%)117,810 (3.2%)122,150 (3.2%)569,086 (3.1%)AgeAge <20356,240 (9.6%)313,033 (8.5%)298,545 (7.9%)268,680 (7.2%)244,895 (6.5%)1,481,393 (7.9%)Age 20-342,832,234 (76.2%)2,817,676 (76.8%)2,909,096 (77.3%)2,898,259 (77.5%)2,961,015 (77.9%)14,418,279 (77.2%)Age 35-39423,570 (11.4%)432,745 (11.8%)448,220 (11.9%)461,485 (12.3%)482,425 (12.7%)2,248,445 (12.0%)Age >40103,793 (2.8%)105,588 (2.9%)108,180 (2.9%)111,250 (3.0%)111,130 (2.9%)539,940 (2.9%)Delivery ModeVaginal Delivery2,487,185 (66.9%)2,448,482 (66.7%)2,508,201 (66.6%)2,500,289 (66.9%)2,556,795 (67.3%)12,500,951 (66.9%)Cesarean Delivery1,228,650 (33.1%)1,220,560 (33.3%)1,255,840 (33.4%)1,239,385 (33.1%)1,242,670 (32.7%)6,187,105 (33.1%)Cesarean without labor646,234 (17.4%)651,513 (17.8%)672,165 (17.9%)669,855 (17.9%)671,555 (17.7%)3,311,322 (17.7%)Cesarean with labor582,416 (15.7%)569,047 (15.5%)583,675 (15.5%)569,530 (15.2%)571,115 (15.0%)2,875,783 (15.4%)Prior Cesarean Delivery616,759 (16.6%)619,116 (16.9%)646,385 (17.2%)652,465 (17.5%)673,660 (17.7%)3,208,384 (17.2%)Prior Uterine Surgery5,943 (0.2%)7,465 (0.2%)6,895 (0.2%)6,720 (0.2%)6,670 (0.2%)33,693 (0.2%)Placenta Previa20,595 (0.6%)20,222 (0.6%)21,425 (0.6%)21,250 (0.6%)22,575 (0.6%)106,066 (0.6%)Placental Abruption40,410 (1.1%)39,204 (1.1%)39,750 (1.1%)39,200 (1.1%)39,865 (1.1%)198,429 (1.1%)Uterine Rupture1,878 (0.1%)2,193 (0.1%)2,380 (0.1%)2,155 (0.1%)2,355 (0.1%)10,961 (0.1%)Chronic Hypertension79,296 (2.1%)80,032 (2.2%)86,330 (2.3%)89,420 (2.4%)92,590 (2.4%)427,668 (2.3%)Gestational Hypertension123,695 (3.3%)131,841 (3.6%)134,285 (3.6%)142,435 (3.8%)151,440 (4.0%)683,696 (3.7%)Pre-Eclampsia162,335 (4.4%)158,357 (4.3%)164,825 (4.4%)167,180 (4.5%)174,680 (4.6%)827,377 (4.4%)Eclampsia2,697 (0.1%)2,479 (0.1%)2,600 (0.1%)2,465 (0.1%)2,515 (0.1%)12,756 (0.1%)Diabetes Mellitus250,890 (6.8%)266,666 (7.3%)288,805 (7.7%)290,755 (7.8%)305,335 (8.0%)1,402,451 (7.5%)Polyhydramnios31,949 (0.9%)32,208 (0.9%)35,365 (0.9%)37,275 (1.0%)40,845 (1.1%)177,642 (1.0%)Chorioamnionitis66,132 (1. 8%)70,884 (1.9%)71,025 (1.9%)72,920 (2.0%)79,085 (2.1%)360,046 (1.9%)Rupture of Membranes >24 Hours44,238 (1.2%)44,469 (1.2%)42,590 (1.1%)42,575 (1.1%)46,260 (1.2%)220,131 (1.2%)Precipitous Delivery80,441 (2.2%)75,944 (2.1%)76,490 (2.0%)75,105 (2.0%)75,165 (2.0%)383,145 (2.1%)Long Labor32,598 (0.9%)28,461 (0.8%)31,450 (0.8%)31,510 (0.8%)30,485 (0.8%)154,504 (0.8%)Induction of Labor662,837 (17.8%)695,441 (19.0%)698,330 (18.6%)696,065 (18.6%)714,615 (18.8%)3,467,288 (18.6%)Macrosomia103,865 (2.8%)102,096 (2.8%)104,685 (2.8%)102,095 (2.7%)103,375 (2.7%)516,116 (2.8%)Obstructed Labor82,283 (2.2%)79,771 (2.2%)76,280 (2.0%)71,780 (1.9%)85,170 (2.2%)395,284 (2.1%)Multiple Gestation68,477 (1.8%)66,569 (1.8%)69,190 (1.8%)69,825 (1.9%)71,080 (1.9%)345,142 (1.9%)Grand Multiparity23,226 (0.6%)23,629 (0.6%)27,130 (0.7%)27,985 (0.8%)30,895 (0.8%)132,865 (0.7%)Stillbirth22,517 (0.6%)21,754 (0.6%)22,725 (0.6%)22,325 (0.6%)23,390 (0.6%)112,711 (0.6%)Pregnancy Affected By Infertility3,761 (0.1%)5,724 (0.2%)5,175 (0.1%)5,655 (0.2%)5,815 (0.2%)26,130 (0.1%)Presence of Uterine Fibroids42,097 (1.1%)44,128 (1.2%)45,235 (1.2%)46,635 (1.3%)49,975 (1.3%)228,070 (1.2%)Race/EthnicityEthnicity- Caucasian1,723,011 (46.4%)1,719,787 (46.9%)1,894,560 (50.3%)1,868,144 (50.0%)1,905,125 (50.1%)9,110,626 (48.8%)Ethnicity- African American501,843 (13.5%)464,836 (12.7%)510,456 (13.6%)509,300 (13.6%)509,765 (13.4%)2,496,200 (13.4%)Ethnicity- Hispanic739,546 (19.9%)781,170 (21.3%)730,420 (19.4%)733,450 (19.6%)736,890 (19.4%)3,721,476 (19.9%)Ethnicity- Asian173,187 (4.7%)164,002 (4.5%)193,495 (5.1%)192,255 (5.1%)206,825 (5.4%)929,764 (5.0%)Ethnicity- Other or Unknown578,249 (15.6%)539,246 (14.7%)435,110 (11.6%)436,525 (11.7%)440,860 (11.6%)2,429,990 (13.0%)Expected Primary Payer Medicare22,271 (0.6%)24,987 (0.7%)28,815 (0.8%)25,445 (0.7%)27,280 (0.7%)128,799 (0.7%)Medicaid1,676,416 (45.1%)1,589,498 (43.3%)1,657,611 (44.0%)1,623,939 (43.4%)1,631,825 (43.0%)8,179,289 (43.8%)Private Insurance1,784,925 (48.0%)1,858,591 (50.7%)1,856,495 (49.3%)1,871,224 (50.3%)1,924,135 (50.6%)9,295,369 (49.7%)Self Pay117,603 (3.2%)78,418 (2.1%)90,735 (2.4%)98,735 (2.6%)101,750 (2.7%)487,241 (2.6%)No Charge8,633 (0.2%)4,891 (0.1%)2,885 (0.1%)3,440 (0.1%)2,575 (0.1%)22,424 (0.1%)Unknown105,988 (2.9%)112,656 (3.1%)127,500 (3.4%)116,890 (3.1%)111,900 (3.0%)574,934 (3.1%)Supplemental Digital Content Table 4: Frequency of Severe Maternal Morbidity Over Time Among Patients with Postpartum Hemorrhage, Per 1,000 DeliveriesCharacteristics20102011201220132014Odds Ratios (95% CI) Per Year IncreaseFrequency (95% CI)Coagulopathy85.6 (71.6-99.6)81.4 (71.6-91.2)76.7 (70.8-82.6)74.7 (69.1-80.2)67.2 (61.9-72.5)0.94 (0.90-0.98)Hysterectomy21.0 (18.3-23.7)23.9 (21.0-26.7)22.4 (20.3-24.4)22.9 (20.8-25.0)21.5 (19.6-23.4)1.00 (0.97-1.04)Blood Transfusion139.7 (126.9-152.5)168.2 (157.7-178.6)154.6 (147.7-161.6)154.7 (147.8-161.6)154.8 (148.0-161.6)1.01 (0.99-1.04)Acute Respiratory Failure7.7 (6.3-9.0)7.2 (5.9-8.5)3.9 (3.1-4.6)4.3 (3.5-5.2)4.7 (3.8-5.6)0.85 (0.80-0.91)Mechanical Ventilation1.3 (0.7-1.8)1.7 (1.1-2.3)1.0 (0.6-1.3)0.9 (0.5-1.3)1.3 (0.8-1.8)0.95 (0.83-1.08)Sepsis2.4 (1.8-3.1)2.6 (1.9-3.2)2.5 (1.8-3.3)2.9 (2.2-3.6)4.5 (3.6-5.5)1.17 (1.08-1.28)Acute Renal Failure5.0 (4.0-6.0)5.8 (4.8-6.8)5.2 (4.3-6.2)7.2 (6.1-8.3)7.1 (6.1-8.2)1.10 (1.04-1.16)Venous Thromboembolism0.9 (0.5-1.2)0.7 (0.3-1.1)0.9 (0.5-1.3)1.1 (0.7-1.6)1.1 (0.7-1.6)1.11 (0.97-1.27)Pulmonary Embolism1.8 (1.2-2.4)1.6 (1.0-2.2)1.6 (1.1-2.1)2.0 (1.4-2.6)1.6 (1.0-2.1)0.99 (0.89-1.10)Maternal Cardiac Arrest1.0 (0.6-1.5)0.7 (0.4-1.1)0.7 (0.4-1.1) 0.8 (0.5-1.2)0.9 (0.5-1.3)0.98 (0.85-1.15)Maternal Death0.7 (0.3-1.1)0.9 (0.5-1.4)SuppressedSuppressed0.5 (0.2-0.7)0.83 (0.70-1.00)Discharge Other Than Home36.2 (15.8-56.7)28.2 (17.9-38.5)31.2 (24.3-38.1)29.0 (23.8-34.2)24.3 (20.0-28.6)0.92 (0.80-1.06)Length of Stay >7 days26.8 (23.5-30.1)28.6 (23.3-33.9)24.5 (22.1-26.9)25.6 (23.0-28.1)26.4 (23.7-29.2)0.99 (0.95-1.03)Supplemental Figure 1: Prevalence of Postpartum Hemorrhage Stratified by Etiology, -82867555245000Timing, and Outcome, 2010-2014X Axis: Year (2010, 2011, 2012, 2013, 2014)Y Axis: Per 1000 Deliveries (0, 10, 20, 30)Groups: Postpartum hemorrhage, Postpartum hemorrhage >24 hrs after delivery, Postpartum hemorrhage from atony, Postpartum hemorrhage from coagulopathy, Postpartum hemorrhage from retained placenta, Postpartum hemorrhage with transfusion ................
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