title: Unexpected complications of low-risk pregnancies in the United States.
abstract: OBJECTIVE
  Determining appropriate sites of care for any type of medical issue assumes successful matching of patient risks to facility capabilities and resources. In obstetrics, predicting patients who will have a need for additional resources beyond routine obstetric and neonatal care is difficult. Women without prenatal risk factors and their newborns may experience unexpected complications during delivery or postpartum. In this study, we report the risk of unexpected maternal and newborn complications among pregnancies without identified prenatal risk factors.
  
  
  METHODS
  We conducted a cross-sectional investigation utilizing US natality data to analyze 10 million birth certificate records from 2011 through 2013. We categorized pregnancies as low risk (no prenatal risk factors) or high risk (at least 1 prenatal risk factor) according to 19 demographic, medical, and pregnancy characteristics. We evaluated 21 individual unexpected or adverse intrapartum and postpartum outcomes in addition to a composite indicator of any adverse outcome.
  
  
  RESULTS
  Among 10,458,616 pregnancies, 38% were identified as low risk and 62% were identified as high risk for unexpected complications. At least 1 unexpected complication was indicated on the birth certificate for 46% of all pregnancies, 29% of low-risk pregnancies, and 57% of high-risk pregnancies. While the risk for unexpected or adverse outcomes was greatly reduced for the low-risk group compared to the high-risk group overall and for several of the individual outcomes, low-risk pregnancies had higher risks of vacuum delivery, forceps delivery, meconium staining, and chorioamnionitis compared to high-risk pregnancies.
  
  
  CONCLUSIONS
  Of births, 29% identified to be low risk had an unexpected complication that would require nonroutine obstetric or neonatal care. Additionally, for select outcomes, risks were higher in the low-risk group compared to the group with identified risk factors. This information is important for planning location of birth and evaluating birthing centers and hospitals for necessary resources to ensure quality care and patient safety.
authors.affiliation: Department of Epidemiology, Brown University School of Public Health, and Division of Research, Women & Infants Hospital of Rhode Island, Providence, RI. Electronic address: valery_danilack@brown.edu.
authors.forename: Valery A
authors.initials: VA
authors.lastname: Danilack
authors.affiliation: Optum Epidemiology, Providence, RI.
authors.forename: Anthony P
authors.initials: AP
authors.lastname: Nunes
authors.affiliation: Department of Epidemiology, Brown University School of Public Health, and Division of Research, Women & Infants Hospital of Rhode Island, Providence, RI; Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, RI.
authors.forename: Maureen G
authors.initials: MG
authors.lastname: Phipps
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007232:Infant, Newborn, Diseases / Q000453:epidemiology*; D007744:Obstetric Labor Complications / Q000453:epidemiology; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology*; D018570:Risk Assessment; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: labor and delivery; labor complications; obstetric delivery; pregnancy; pregnancy outcomes