{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,9]],"date-time":"2026-06-09T13:31:06Z","timestamp":1781011866042,"version":"3.54.1"},"reference-count":33,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2021,7,19]],"date-time":"2021-07-19T00:00:00Z","timestamp":1626652800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2021,7,19]],"date-time":"2021-07-19T00:00:00Z","timestamp":1626652800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","award":["UL1TR001876"],"award-info":[{"award-number":["UL1TR001876"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Sci Rep"],"abstract":"<jats:title>Abstract<\/jats:title><jats:p>Obstetric hemorrhage is one of the leading preventable causes of maternal mortality in the United States. Although hemorrhage risk-prediction models exist, there remains a gap in literature describing if these risk-prediction tools can identify composite maternal morbidity. We investigate how well an established obstetric hemorrhage risk-assessment tool predicts composite hemorrhage-associated morbidity. We conducted a retrospective cohort analysis of a multicenter database including women admitted to Labor and Delivery from 2016 to 2018, at centers implementing the Association of Women\u2019s Health, Obstetric, and Neonatal Nurses risk assessment tool on admission. A composite morbidity score incorporated factors including obstetric hemorrhage (estimated blood loss\u2009\u2265\u20091000\u00a0mL), blood transfusion, or ICU admission. Out of 56,903 women, 14,803 (26%) were categorized as low-risk, 26,163 (46%) as medium-risk and 15,937 (28%) as high-risk for obstetric hemorrhage. Composite morbidity occurred at a rate of 2.2%, 8.0% and 11.9% within these groups, respectively. Medium- and high-risk groups had an increased combined risk of composite morbidity (diagnostic OR 4.58; 4.09\u20135.13) compared to the low-risk group. This established hemorrhage risk-assessment tool predicts clinically-relevant composite morbidity. Future randomized trials in obstetric hemorrhage can incorporate these tools for screening patients at highest risk for composite morbidity.<\/jats:p>","DOI":"10.1038\/s41598-021-93413-3","type":"journal-article","created":{"date-parts":[[2021,7,19]],"date-time":"2021-07-19T10:03:18Z","timestamp":1626688998000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":19,"title":["Obstetric hemorrhage risk assessment tool predicts composite maternal morbidity"],"prefix":"10.1038","volume":"11","author":[{"given":"Emer L.","family":"Colalillo","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew D.","family":"Sparks","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jaclyn M.","family":"Phillips","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chinelo L.","family":"Onyilofor","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Homa K.","family":"Ahmadzia","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2021,7,19]]},"reference":[{"issue":"4","key":"93413_CR1","doi-asserted-by":"publisher","first-page":"804","DOI":"10.1097\/AOG.0000000000000173","volume":"123","author":"WA Grobman","year":"2014","unstructured":"Grobman, W. A. et al. Frequency of and factors associated with severe maternal morbidity. Obstet. Gynecol. 123(4), 804\u2013810 (2014).","journal-title":"Obstet. Gynecol."},{"issue":"6","key":"93413_CR2","doi-asserted-by":"publisher","first-page":"e323","DOI":"10.1016\/S2214-109X(14)70227-X","volume":"2","author":"L Say","year":"2014","unstructured":"Say, L. et al. Global causes of maternal death: A WHO systematic analysis. Lancet Glob. Health 2(6), e323\u2013e333 (2014).","journal-title":"Lancet Glob. Health."},{"issue":"5","key":"93413_CR3","doi-asserted-by":"publisher","first-page":"e1","DOI":"10.1016\/j.ajog.2013.07.007","volume":"209","author":"MS Kramer","year":"2013","unstructured":"Kramer, M. S. et al. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am. J. Obstet. Gynecol. 209(5), e1\u2013e7 (2013).","journal-title":"Am. J. Obstet. Gynecol."},{"issue":"8","key":"93413_CR4","doi-asserted-by":"publisher","first-page":"810","DOI":"10.1016\/S1701-2163(16)34984-2","volume":"33","author":"MS Kramer","year":"2011","unstructured":"Kramer, M. S., Dahhou, M., Vallerand, D., Liston, R. & Joseph, K. S. Risk factors for postpartum hemorrhage: Can we explain the recent temporal increase? J. Obstet. Gynaecol. Can. 33(8), 810\u2013819 (2011).","journal-title":"J. Obstet. Gynaecol. Can."},{"issue":"3","key":"93413_CR5","doi-asserted-by":"publisher","first-page":"237","DOI":"10.1016\/j.ijgo.2007.03.011","volume":"98","author":"JB Ford","year":"2007","unstructured":"Ford, J. B., Roberts, C. L., Simpson, J. M., Vaughan, J. & Cameron, C. A. Increased postpartum hemorrhage rates in Australia. Int. J. Gynecol. Obstet. 98(3), 237\u2013243 (2007).","journal-title":"Int. J. Gynecol. Obstet."},{"issue":"7","key":"93413_CR6","doi-asserted-by":"publisher","first-page":"1542","DOI":"10.1007\/s10995-011-0919-1","volume":"16","author":"JB Ford","year":"2012","unstructured":"Ford, J. B., Algert, C. S., Kok, C., Choy, M. A. & Roberts, C. L. Hospital data reporting on postpartum hemorrhage: Under-estimates recurrence and over-estimates the contribution of uterine atony. Matern. Child Health J. 16(7), 1542\u20131548 (2012).","journal-title":"Matern. Child Health J."},{"issue":"6","key":"93413_CR7","doi-asserted-by":"publisher","first-page":"751","DOI":"10.1111\/j.1471-0528.2007.01316.x","volume":"114","author":"KS Joseph","year":"2007","unstructured":"Joseph, K. S. et al. Investigation of an increase in postpartum haemorrhage in Canada. BJOG Int. J. Obstet. Gynaecol. 114(6), 751\u2013759 (2007).","journal-title":"BJOG Int. J. Obstet. Gynaecol."},{"issue":"4","key":"93413_CR8","doi-asserted-by":"publisher","first-page":"353.e1","DOI":"10.1016\/j.ajog.2010.01.011","volume":"202","author":"WM Callaghan","year":"2010","unstructured":"Callaghan, W. M., Kuklina, E. V. & Berg, C. J. Trends in postpartum hemorrhage: United States, 1994\u20132006. Am. J. Obstet. Gynecol. 202(4), 353.e1-353.e6 (2010).","journal-title":"Am. J. Obstet. Gynecol."},{"key":"93413_CR9","doi-asserted-by":"publisher","first-page":"272","DOI":"10.1016\/j.ajog.2014.07.012","volume":"212","author":"LE Shields","year":"2015","unstructured":"Shields, L. E., Wiesner, S., Fulton, J. & Pelletreau, B. Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am. J. Obstet. Gynecol. 212, 272\u2013280 (2015).","journal-title":"Am. J. Obstet. Gynecol."},{"issue":"10","key":"93413_CR10","doi-asserted-by":"publisher","first-page":"833","DOI":"10.1055\/s-0033-1333674","volume":"30","author":"JR Lappen","year":"2013","unstructured":"Lappen, J. R., Seidman, D., Burke, C., Goetz, K. & Grobman, W. A. Changes in care associated with the introduction of a postpartum hemorrhage patient safety program. Am. J. Perinatol. 30(10), 833\u2013838. https:\/\/doi.org\/10.1055\/s-0033-1333674 (2013).","journal-title":"Am. J. Perinatol."},{"issue":"1","key":"93413_CR11","doi-asserted-by":"publisher","first-page":"120","DOI":"10.1097\/AOG.0b013e3182941c78","volume":"122","author":"AJ Dilla","year":"2013","unstructured":"Dilla, A. J., Waters, J. H. & Yazer, M. H. Clinical validation of risk stratification criteria for peripartum hemorrhage. Obstet. Gynecol. 122(1), 120\u2013126 (2013).","journal-title":"Obstet. Gynecol."},{"issue":"16","key":"93413_CR12","doi-asserted-by":"publisher","first-page":"1661","DOI":"10.3109\/14767058.2013.872095","volume":"27","author":"AJ Wikkels\u00f8","year":"2014","unstructured":"Wikkels\u00f8, A. J., Hjort\u00f8e, S., Gerds, T. A., M\u00f8ller, A. M. & Langhoff-Roos, J. Prediction of postpartum blood transfusion\u2014Risk factors and recurrence. J. Matern. Neonatal Med. 27(16), 1661\u20131667. https:\/\/doi.org\/10.3109\/14767058.2013.872095 (2014).","journal-title":"J. Matern. Neonatal Med."},{"issue":"4","key":"93413_CR13","doi-asserted-by":"publisher","first-page":"399","DOI":"10.1111\/aogs.12352","volume":"93","author":"CM Koopmans","year":"2014","unstructured":"Koopmans, C. M. et al. Prediction of postpartum hemorrhage in women with gestational hypertension or mild preeclampsia at term. Acta Obstet. Gynecol. Scand. 93(4), 399\u2013407. https:\/\/doi.org\/10.1111\/aogs.12352 (2014).","journal-title":"Acta Obstet. Gynecol. Scand."},{"issue":"1","key":"93413_CR14","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1186\/s12884-016-0805-3","volume":"16","author":"WKBA Owiredu","year":"2016","unstructured":"Owiredu, W. K. B. A., Osakunor, D. N. M., Turpin, C. A. & Owusu-Afriyie, O. Laboratory prediction of primary postpartum haemorrhage: A comparative cohort study. BMC Pregn. Childbirth 16(1), 17. https:\/\/doi.org\/10.1186\/s12884-016-0805-3 (2016).","journal-title":"BMC Pregn. Childbirth"},{"key":"93413_CR15","unstructured":"The American College of Obstetricians and Gynecologists. Safe Motherhood Initiative: Obstetric Hemorrhage (2015). http:\/\/www.acog.org\/community\/districts-and-sections\/district-ii\/programs-and-resources\/safe-motherhood-initiative\/obstetric-hemorrhage(Accessed 27 March 2020)."},{"issue":"5","key":"93413_CR16","doi-asserted-by":"publisher","first-page":"707","DOI":"10.1016\/j.jogn.2018.05.002","volume":"47","author":"D Bingham","year":"2018","unstructured":"Bingham, D., Scheich, B. & Bateman, B. T. Structure, process, and outcome data of AWHONN\u2019s postpartum hemorrhage quality improvement project. J. Obstet. Gynecol. Neonatal Nurs. 47(5), 707\u2013718 (2018).","journal-title":"J. Obstet. Gynecol. Neonatal Nurs."},{"issue":"6","key":"93413_CR17","doi-asserted-by":"publisher","first-page":"1308","DOI":"10.1097\/AOG.0000000000003574","volume":"134","author":"T Kawakita","year":"2019","unstructured":"Kawakita, T., Mokhtari, N., Huang, J. C. & Landy, H. J. Evaluation of risk-assessment tools for severe postpartum hemorrhage in women undergoing cesarean delivery. Obstet. Gynecol. 134(6), 1308\u20131316. https:\/\/doi.org\/10.1097\/AOG.0000000000003574 (2019).","journal-title":"Obstet. Gynecol."},{"key":"93413_CR18","unstructured":"The American College of Obstetricians and Gynecologists. Safe Motherhood Initiative. Maternal Safety Bundle for Obstetric Hemorrhage (2015)."},{"key":"93413_CR19","volume-title":"CMQCC Obstetric Hemorrhage Hospital Level Implementation Guide","author":"D Bingham","year":"2010","unstructured":"Bingham, D., Melsop, K. & Main, E. CMQCC Obstetric Hemorrhage Hospital Level Implementation Guide (The California Maternal Quality Care Collaborative (CMQCC), 2010)."},{"issue":"11","key":"93413_CR20","doi-asserted-by":"publisher","first-page":"e1915628","DOI":"10.1001\/jamanetworkopen.2019.15628","volume":"2","author":"DDCA Henriquez","year":"2019","unstructured":"Henriquez, D. D. C. A. et al. Association of timing of plasma transfusion with adverse maternal outcomes in women with persistent postpartum hemorrhage. JAMA Netw. Open 2(11), e1915628 (2019).","journal-title":"JAMA Netw. Open"},{"issue":"11","key":"93413_CR21","doi-asserted-by":"publisher","first-page":"1473","DOI":"10.1111\/aogs.13679","volume":"98","author":"PI Ramler","year":"2019","unstructured":"Ramler, P. I. et al. Comparison of outcome between intrauterine balloon tamponade and uterine artery embolization in the management of persistent postpartum hemorrhage: A propensity score-matched cohort study. Acta Obstet. Gynecol. Scand. 98(11), 1473\u20131482. https:\/\/doi.org\/10.1111\/aogs.13679 (2019).","journal-title":"Acta Obstet. Gynecol. Scand."},{"key":"93413_CR22","doi-asserted-by":"publisher","DOI":"10.1080\/14767058.2019.1583736","author":"MJ Blitz","year":"2019","unstructured":"Blitz, M. J. et al. Twin pregnancy and risk of postpartum hemorrhage. J. Matern Neonatal Med. https:\/\/doi.org\/10.1080\/14767058.2019.1583736 (2019).","journal-title":"J. Matern Neonatal Med."},{"issue":"2","key":"93413_CR23","doi-asserted-by":"publisher","first-page":"e1","DOI":"10.1016\/j.ajog.2018.04.049","volume":"219","author":"L Marcellin","year":"2018","unstructured":"Marcellin, L. et al. Placenta percreta is associated with more frequent severe maternal morbidity than placenta accreta. Am. J. Obstet. Gynecol. 219(2), e1\u2013e9 (2018).","journal-title":"Am. J. Obstet. Gynecol."},{"issue":"11","key":"93413_CR24","doi-asserted-by":"publisher","first-page":"e0187555","DOI":"10.1371\/journal.pone.0187555","volume":"12","author":"A Gillissen","year":"2017","unstructured":"Gillissen, A. et al. The effect of tranexamic acid on blood loss and maternal outcome in the treatment of persistent postpartum hemorrhage: A nationwide retrospective cohort study. PLoS ONE 12(11), e0187555 (2017).","journal-title":"PLoS ONE"},{"key":"93413_CR25","unstructured":"Severe Maternal Morbidity in the United States. Centers for Disease Control and Prevention (2020)."},{"issue":"Suppl 1","key":"93413_CR26","doi-asserted-by":"publisher","first-page":"98","DOI":"10.1186\/s12978-018-0527-2","volume":"15","author":"SE Geller","year":"2018","unstructured":"Geller, S. E. et al. A global view of severe maternal morbidity: Moving beyond maternal mortality. Reprod. Health 15(Suppl 1), 98 (2018).","journal-title":"Reprod. Health"},{"key":"93413_CR27","first-page":"1","volume":"2014","author":"LE Shields","year":"2015","unstructured":"Shields, L. E., Rn, S. W., Rn, J. F. & Rn, B. P. Protocols reduce the use of blood products and improve patient safety. Am. J. Obstet. Gynecol. 2014, 1\u20139 (2015).","journal-title":"Am. J. Obstet. Gynecol."},{"issue":"1","key":"93413_CR28","doi-asserted-by":"publisher","first-page":"155","DOI":"10.1097\/AOG.0000000000000869","volume":"126","author":"EK Main","year":"2015","unstructured":"Main, E. K. et al. National partnership for maternal safety. Obstet. Gynecol. 126(1), 155\u2013162 (2015).","journal-title":"Obstet. Gynecol."},{"key":"93413_CR29","unstructured":"Association of Women\u2019s Health, Obstetric and Neonatal Nurses (AWHONN). Postpartum Hemorrhage Project: A Multi-Hospital Quality Improvement Program (2017)."},{"issue":"1","key":"93413_CR30","doi-asserted-by":"publisher","first-page":"e0211360","DOI":"10.1371\/journal.pone.0211360","volume":"14","author":"HK Ahmadzia","year":"2019","unstructured":"Ahmadzia, H. K., Phillips, J. M., James, A. H., Rice, M. M. & Amdur, R. L. Correction: Predicting peripartum blood transfusion in women undergoing cesarean delivery: A risk prediction model. PLoS ONE 14(1), e0211360 (2019).","journal-title":"PLoS ONE"},{"issue":"6","key":"93413_CR31","doi-asserted-by":"publisher","first-page":"1247","DOI":"10.1007\/s00404-015-3771-5","volume":"292","author":"A Ekin","year":"2015","unstructured":"Ekin, A. et al. Predictors of severity in primary postpartum hemorrhage. Arch. Gynecol. Obstet. 292(6), 1247\u20131254 (2015).","journal-title":"Arch. Gynecol. Obstet."},{"issue":"9","key":"93413_CR32","doi-asserted-by":"publisher","first-page":"905","DOI":"10.1089\/jwh.2011.3398","volume":"21","author":"SJ Kilpatrick","year":"2012","unstructured":"Kilpatrick, S. J., Prentice, P., Jones, R. L. & Geller, S. Reducing maternal deaths through state maternal mortality review. J. Womens Health (Larchmt) 21(9), 905\u2013909 (2012).","journal-title":"J. Womens Health (Larchmt)"},{"key":"93413_CR33","doi-asserted-by":"publisher","DOI":"10.1055\/s-0040-1710501","author":"HK Ahmadzia","year":"2020","unstructured":"Ahmadzia, H. K. et al. Hemorrhage risk assessment on admission: Utility for prediction of maternal morbidity. Am. J. Perinatol. https:\/\/doi.org\/10.1055\/s-0040-1710501 (2020).","journal-title":"Am. J. Perinatol."}],"container-title":["Scientific Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.nature.com\/articles\/s41598-021-93413-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41598-021-93413-3","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41598-021-93413-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,12,3]],"date-time":"2022-12-03T11:41:42Z","timestamp":1670067702000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.nature.com\/articles\/s41598-021-93413-3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,7,19]]},"references-count":33,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2021,12]]}},"alternative-id":["93413"],"URL":"https:\/\/doi.org\/10.1038\/s41598-021-93413-3","relation":{},"ISSN":["2045-2322"],"issn-type":[{"value":"2045-2322","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,7,19]]},"assertion":[{"value":"2 December 2020","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"17 June 2021","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"19 July 2021","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The authors declare no competing interests.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"14709"}}