title: Regionalization of care for obstetric hemorrhage and its effect on maternal mortality.
abstract: OBJECTIVE
  To examine factors that influence the morbidity and mortality of peripartum hysterectomy and analyze the effect of hospital volume on maternal mortality.
  
  
  METHODS
  We examined women who underwent peripartum hysterectomy at the time of cesarean delivery in a quality and resource utilization database. Procedure-associated intraoperative, perioperative, and postoperative medical complications, length of stay, intensive care unit use, and maternal mortality were analyzed. Hospitals were stratified into tertiles based on procedure volume and complications and compared using adjusted generalized estimating equations. Results are reported as odds ratios.
  
  
  RESULTS
  Maternal mortality among the 2,209 women who underwent peripartum hysterectomy was 1.2%. After adjusting for other clinical and demographic factors, perioperative mortality was 71% (odds ratio 0.29, 95% confidence interval 0.10-0.88) lower in women who underwent operation at high-volume hospitals compared with those treated at low-volume facilities. Hospital volume had no effect on the rates of intraoperative injuries, medical complications, length of stay, or transfusion. In contrast, compared with women treated at low-volume centers, patients who underwent operation at high-volume hospitals had a lower incidence of perioperative surgical complications (odds ratio 0.66, 95% confidence interval 0.47-0.93) and a lower rate of intensive care unit usage (odds ratio 0.53, 95% confidence interval 0.34-0.83).
  
  
  CONCLUSIONS
  Peripartum hysterectomy is associated with substantial morbidity and mortality. Maternal mortality is lower when the procedure is performed in high-volume hospital settings.
  
  
  METHODS
  II.
authors.affiliation: From the Division of Gynecologic Oncology and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York.
authors.forename: Jason D
authors.initials: JD
authors.lastname: Wright
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Herzog
authors.forename: Monjri
authors.initials: M
authors.lastname: Shah
authors.forename: Clarissa
authors.initials: C
authors.lastname: Bonanno
authors.forename: Sharyn N
authors.initials: SN
authors.lastname: Lewin
authors.forename: Kirsten
authors.initials: K
authors.lastname: Cleary
authors.forename: Lynn L
authors.initials: LL
authors.lastname: Simpson
authors.forename: Sreedhar
authors.initials: S
authors.lastname: Gaddipati
authors.forename: Xuming
authors.initials: X
authors.lastname: Sun
authors.forename: Mary E
authors.initials: ME
authors.lastname: D'Alton
authors.forename: Patricia
authors.initials: P
authors.lastname: Devine
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D006276:Health Facility Size; D006801:Humans; D007044:Hysterectomy / Q000401:mortality*; D007431:Intraoperative Complications / Q000401:mortality; D008875:Middle Aged; D054238:Perinatal Mortality; D011183:Postoperative Complications / Q000401:mortality; D006473:Postpartum Hemorrhage / Q000401:mortality / Q000601:surgery*; D011247:Pregnancy; D012017:Referral and Consultation; D014481:United States / Q000453:epidemiology; D016526:Workload; D055815:Young Adult