According to the Agency for Healthcare Research and Quality, or AHRQ as it's known, in 2008, 94.1% of all of the 4.2 million deliveries reported at least one pregnancy complication. Nearly 5% of total hospital costs in the United States, are charged to stays for pregnant or delivering women with complications. In 2008, this amounted to $17.4 billion. These figures include all complications which required hospitalization. And not all of those were severe or life threatening. However, for every woman who dies in the United States, 50 suffer major complications and life threatening conditions. Some term these near misses because under other circumstances. They might have resulted in death and just missed death this time because of better care or other mitigating circumstances. Major complications requiring hospitalization increased 75% from 2000 to 2009. This included a 100% increase in diagnosis of shock, and at least 70% increase in diagnosis of thrombotic embolism, heart attack, and acute renal failure. As noted from maternal mortality in our last segment. A tremendous improvement in anesthesia complications was also recorded. A 61% decline from 2000 to 2009. Severe maternal morbidity does not yet have a standard definition. As its study is still a relatively new field. We will use the CDC definition and review recent results that paint a fairly clear picture of major gaps in women's healthcare. More than 50,000 women per year suffer a severe complication in the United States. CDC has published a list of 25 specific ICD 9 CM diagnosis and procedure codes that include indicators of organ system failure, in their words, that likely represent specific. Well defined severe events. The source of data for which they track severe maternal morbidity is the AHRQ sponsored, nationwide in patient sample, or NIS, which is the largest, all payer hospital, in patient care database for US hospitals. The NIS is a stratified random sample of about 20% of community hospitals. The strata include urban, rural, number of beds, region, teaching status, and ownership. In 2011, 1,045 hospitals participated, representing 46 states. Statistics are weighted to represent all hospital admissions. What this survey reveals is a more than doubling of severe maternal morbidity from 1998 to 2011. This is a significant and strong trend. With similarity to the increase in maternal mortality, the increase in severe maternal morbidity is associated with increasing maternal age, obesity, and chronic medical conditions. But in addition, the rise in C sections in this country contributes to morbidity but not mortality. For example, one study reported that chronic heart disease was a factor in 65% of acute myocardial infarction 58% of cardiac arrest, or ventricular fibrillation, 28% of in hospital mortality, and 26% of adult respiratory distress syndrome among hospitalized pregnant women, between nine, 2004 and 2006. Postpartum hemmhorage is on the increase. Not only in the United States, but also in Australia, Canada, and the United Kingdom. And except for the United Kingdom, the observed increase is limited to cases of immediate atonic postpartum hemmorrhage, which may be related to the noted increase in chronic hypertension among pregnant women. Severe sepsis and sepsis associated mortality is also on the rise in the US. And women with certain chronic diseases including congestive heart failure are at particularly high risk. In a seven state study of racial and ethnic disparities in severe maternal morbidity. The investigators added blood transfusion to the CDC list. Blood transfusion may be a poor indicator in such statistics because the number of units is not provided. Therefore, the analysis included results both with and without blood transfusion. This table shows that after controlling for age, insurance coverage, average income by zip code, and chronic medical conditions, all other racial and ethnic groups had higher risks of severe maternal morbidity with, with blood transfusion than did. Non Hispanic white women. And the risk ratios ranged from 1.2 for Asian/Pacific Islanders to 2.1 for non-Hispanic black women. In addition, very young and very old women, as well as women with chronic health tod, conditions, had elevated risks of severe, maternal morbidity. The findings were similar when blood transfusion was not included. As you can see the risk for African American non Hispanic women was 2.4 after adjusting for those other conditions. And the other racial and ethnic group ranged around 1.2 to 1.3. This study highlighted the need for improved methods to screen women at risk and treat or refer them.