Prevalence of and Risk Factors for Postpartum Anxiety in a U.S. Cohort With Commercial Insurance

Obstetrics and Gynecology · 2026-02-26

OBJECTIVE: The primary objective of this study was to estimate the prevalence of new-onset anxiety diagnoses in the postpartum period. We also aimed to estimate the prevalence of psychiatric comorbidities, explore changes by year, and identify risk factors for new-onset postpartum anxiety. METHODS: This retrospective cohort study used the Merative™ MarketScan ® Commercial Database and included adult women with commercial insurance who were at least 18 years of age, delivered a singleton or multiple gestation between 2008 and 2021, and did not have a preexisting or prepregnancy diagnosis of depression, anxiety, or posttraumatic stress disorder (PTSD). The primary outcome was a new-onset anxiety diagnosis, based on International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes, during the postpartum period (up to 12 months after childbirth). Secondary outcomes were comorbid anxiety with depression and PTSD. We also estimated the prevalence of each psychiatric condition by year and identified risk factors associated with postpartum anxiety. Univariable and multivariable regression models were constructed to identify risk factors. RESULTS: From the 1,469,121 individuals identified without prenatal mental health disorders, 84,984 individuals (5.8%; 95% CI, 5.7-5.8%) were diagnosed with new-onset postpartum anxiety within 12 months of childbirth, with 9,490 diagnosed in the first month and 75,494 diagnosed between 1 month and 1 year postpartum. Comorbid anxiety and depression occurred in 18.0 per 1,000 individuals in the study cohort (95% CI, 17.8-18.2), and comorbid anxiety and PTSD occurred in 0.9 per 1,000 individuals (95% CI, 0.9-1.0). The prevalence of postpartum anxiety increased from 30.8 per 1,000 individuals in 2008 to 122.9 per 1,000 individuals in 2021 ( P for trend<.001). Independent risk factors for new-onset postpartum anxiety diagnosed 1-12 months postpartum included younger age, North Central U.S. residence, earlier gestational age at delivery, cesarean delivery, antenatal or early postpartum sleep disorders, severe maternal morbidity (including transfusion), neglected medical conditions, and neonatal complications. CONCLUSION: Postpartum anxiety was estimated to affect nearly 6% of patients with commercial insurance in the United States and has increased fourfold since 2008. Risk factors associated with postpartum anxiety may help to identify at-risk individuals who could benefit from early intervention.

Comparative Effectiveness and Safety of Labetalol Versus Nifedipine for Treatment of Chronic Hypertension During Pregnancy

JACC Advances · 2025-08-07 · 7 citations

BACKGROUND: Clinical guidelines recommend treatment of chronic hypertension during pregnancy, with either labetalol or nifedipine as the first-line medication. OBJECTIVES: This study aimed to compare the effectiveness and safety of labetalol and nifedipine for the treatment of chronic hypertension during pregnancy. METHODS: We used a target trial emulation approach to compare new users of labetalol with new users of nifedipine. We analyzed data from the U.S. Merative™ MarketScan® Commercial Database of insurance claims (2007-2022) for pregnant individuals with chronic hypertension and their infants. The effectiveness outcome was a composite of severe preeclampsia/eclampsia, medically indicated preterm birth, placental abruption, or stillbirth. The safety outcome was an infant born small for gestational age. We estimated risk ratios (RRs) and risk differences (RDs) with 95% CIs, adjusting for confounding with stabilized inverse probability of treatment weights. RESULTS: We studied 6,724 pregnant individuals with chronic hypertension who initiated either labetalol (n = 5,504, 82%) or nifedipine (n = 1,220, 18%) in pregnancy. The effectiveness outcome occurred in 42% in the labetalol group and 44% in the nifedipine group, with an adjusted RR of 1.03 (95% CI: 0.96-1.11) and an adjusted RD of 1.35 per 100 births (95% CI: -1.76 to 4.45). The safety outcome of small for gestational age occurred in 13% in the labetalol group and 12% in the nifedipine group, with an adjusted RR of 0.98 (95% CI: 0.82-1.16) and an adjusted RD of -0.26 per 100 births (95% CI: -2.33 to 1.81). CONCLUSIONS: This study suggests that labetalol and nifedipine have similar effectiveness and safety in treating chronic hypertension during pregnancy.

Comparative Safety of In Utero Exposure to Buprenorphine Combined With Naloxone Versus Buprenorphine Alone

Obstetric Anesthesia Digest · 2025-05-24

( JAMA . 2024;332(10):805–816. doi: 10.1001/jama.2024.11501) The incidence of opioid use disorder (OUD) has been rising across the United States over the past few decades, including among pregnant women. Recent data indicate that 8.2 per 1000 pregnant women are affected, with rates reaching 14.6 per 1000 in those with public insurance. Current guidelines recommend treating OUD during pregnancy with buprenorphine or methadone to improve maternal and fetal outcomes. Buprenorphine is available in 2 formulations: with or without naloxone. However, few studies have examined the safety of buprenorphine combined with naloxone during pregnancy. This study aimed to evaluate the risks of adverse outcomes associated with prenatal exposure to buprenorphine and naloxone compared with buprenorphine alone.

Uterine Tone Numeric Rating Score as an Early Indicator of Major Postpartum Hemorrhage during Cesarean Delivery: A Prospective Observational Study

Obstetric Anesthesia Digest · 2025-04-11 · 3 citations

BACKGROUND: Postpartum hemorrhage (PPH) is the leading preventable cause of maternal mortality. Most PPH cases are caused by uterine atony, which is inconsistently defined in clinical care. The electronic health record was used to prompt communication between the anesthesia and obstetric care teams about uterine tone using a validated 11-point numeric rating scale (NRS) at 0, 5, and 10 min after placental delivery for all cesarean deliveries at our institution. The primary hypothesis was that lower uterine tone NRS would be strongly associated with progression to major PPH. METHODS: This was a single-center, prospective observational study conducted over a 1-yr period. The primary predictor was the 0 to 10 uterine tone NRS recorded 10 min after placental delivery, and the primary outcome was major PPH, defined as quantitative blood loss greater than or equal to 1,500 ml. Area under the receiver operating characteristic curves were created, and the relative risk of major PPH for each 1-point change in the tone score was estimated. Key secondary outcomes analyzed included associations between tone scores, PPH, and blood transfusion. RESULTS: A total of 1,599 consecutive cesarean deliveries were performed by obstetricians from academic (39.3%), county public health (21.1%), and private practice (38.8%) services. Major PPH complicated 9.9% and transfusion 6.7% of cesarean deliveries. Uterine tone NRS was documented at 0 min after placental delivery in 91.6%, 5 min in 97.4%, and 10 min in 97.0% of cesarean deliveries. The 10-min NRS was a strong predictor of major PPH, with an area under the receiver operating characteristic of 0.78 (95% CI, 0.73 to 0.82). Each 1-point decrease in NRS increased the risk of major PPH by 71% (95% CI, 0.58 to 0.86). A 10-min uterine tone NRS less than or equal to 6 had high positive predictive value for major PPH (32.9%), as well as PPH (64.2%) and transfusion (20.6%). CONCLUSIONS: Standardized uterine tone assessments on a 0 to 10 scale are feasible to implement and strongly associated with progression to major PPH and blood transfusion. Future studies should investigate whether implementation of PPH interventions based on uterine tone NRS can reduce major PPH and hemorrhage-associated morbidity.

Hospital birth volume and rurality: Associations with pregnancy outcomes among individuals with chronic hypertension

Pregnancy · 2025-09-01

Introduction: Chronic hypertension in pregnancy has doubled in prevalence over the past 15 years, but little is known about pregnancy outcomes at hospitals with different characteristics. We evaluated the association between hospital birth volume and rurality with risk of adverse pregnancy outcomes among individuals with chronic hypertension. Methods: We conducted a population-based study using linked vital statistics and birth hospitalization discharge data from Michigan, Oregon, South Carolina (2008-2020), and Pennsylvania (2008-2018). We classified hospitals based on federal rural-urban county classifications and annual birth volume. The primary outcome was a composite measure of adverse pregnancy outcomes, including superimposed preeclampsia or eclampsia, severe obstetric morbidities, and fetal/neonatal morbidities. We used multivariable modified Poisson regression models with hospital fixed effects and robust standard errors to estimate the risk ratios (RRs) with 95% confidence intervals (CIs) for the primary outcome and the component outcomes for each hospital group compared with high-volume urban hospitals. Results: Among 106,991 births to individuals with chronic hypertension, the crude incidence of the primary adverse pregnancy outcome was highest in high-volume urban hospitals (49.5%) and lowest in low-volume rural hospitals (34.4%). Additionally, a higher proportion of individuals giving birth at high-volume urban hospitals had a high (≥10) obstetric comorbidity score (45% vs. 24-27% at rural and low-volume urban hospitals). After robust adjustment for clinical characteristics in regression models, however, no differences between hospital groups were evident. Among primary outcome components, only the risk of superimposed preeclampsia or eclampsia was higher in low-volume urban hospitals (adjusted RR: 1.21; 95% CI: 1.09-1.34) and medium-volume rural hospitals (adjusted RR: 1.26; 95% CI: 1.05-1.50). Conclusions: Adverse pregnancy outcomes among individuals with chronic hypertension were largely similar across hospital volume and rurality groups, after accounting for differences in case mix. However, superimposed preeclampsia or eclampsia was highest at medium-volume rural and low-volume urban hospitals, suggesting potential opportunities for improved prenatal clinical management of chronic hypertension.

Z-Drug Use in the First Trimester of Pregnancy and Risk of Congenital Malformations

JAMA Psychiatry · 2025-12-23

Importance: Sleep disturbances are common in pregnancy and often treated with nonbenzodiazepine sedative hypnotics (Z-drugs). However, there is limited evidence on the fetal safety of Z-drugs. Objective: To evaluate whether Z-drug exposure in the first trimester of pregnancy is associated with an increased risk of congenital malformations. Design, Setting, and Participants: This US population-based cohort study evaluated health care utilization data from publicly insured beneficiaries in the Medicaid database (2000-2018) and commercially insured beneficiaries in the Merative MarketScan database (2003-2020). Participants were pregnant individuals and their liveborn infants, with maternal enrollment from 90 days before pregnancy to 30 days after delivery and infant enrollment for 90 days after birth unless death occurred sooner. Data analysis was performed from November 2023 to April 2025. Exposure: At least 1 dispensing of Z-drugs (zaleplon, eszopiclone, or zolpidem) in the first trimester of pregnancy compared with no dispensing. Main Outcomes and Measures: Major congenital malformations were identified using linked maternal and infant claims. The risks of any major congenital malformation, organ-specific malformations, and individual malformations in pregnancies with Z-drug exposure in the first trimester were compared with the risks in unexposed pregnancies. Relative risks (RRs) and 95% CIs were estimated. Propensity score fine stratification weights were used to control for confounders. Results: A total of 4 281 579 pregnancies were identified (mean [SD] maternal age at delivery, 25.2 [6.0] years in Medicaid and 31.6 [4.6] years in MarketScan). First-trimester Z-drug exposure was identified in 11 652 (0.5%) of 2 506 106 pregnancies in Medicaid and 10 862 (0.6%) of 1 775 473 pregnancies in MarketScan; 92.1% of exposed pregnancies had zolpidem exposure. The adjusted pooled RR for malformations overall was 1.01 (95% CI, 0.95-1.08). While adjusted pooled RRs were increased for abdominal wall defects (1.46; 95% CI, 0.89-2.38), tetralogy of Fallot (1.45; 95% CI, 0.86-2.46), and neural tube defects (1.62; 95% CI, 0.96-2.74), these associations were imprecisely estimated, driven by the Medicaid cohort and not replicated in the MarketScan cohort. Results were consistent across multiple sensitivity analyses. Conclusions and Relevance: These findings suggest that Z-drug exposure in the first trimester of pregnancy is not associated with a meaningful elevation in the risk of congenital malformations overall, nor was there a consistent signal observed for organ-specific or uncommon, individual malformations examined.

Opioid Analgesic Exposure During the First Trimester of Pregnancy and the Risk of Major Congenital Malformations in Infants: A Systematic Review and Meta-analysis

Obstetric Anesthesia Digest · 2025-08-20

( Anaesthesia . 2024;79(9):967-977. doi: 10.1111/anae.16307) Though pregnancy induces many symptoms that increase discomfort, both patients and providers often hesitate to use analgesics or other medications due to concerns about fetal safety. As some medications have been shown to affect fetal development and/or health, limiting available pain management strategies. It is still unclear whether opioid analgesics are related to major congenital malformations due to ethical and legal concerns surrounding research in this area as well as challenges regarding sample size and statistical power for rare outcomes. This study sought to assess available evidence on the risk of major congenital malformations in infants following first trimester exposure to any opioid analgesic as well as to individual opioids.

Trends in Neuraxial Labor Analgesia Utilization: Reply

Anesthesiology · 2025-08-12

Opioid overdose associated with concomitant use of hydrocodone and selective serotonin reuptake inhibitors

BMC Medicine · 2025-11-28

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) are frequently co-prescribed with opioids, increasing the risk of pharmacokinetic and pharmacodynamic interactions. Hydrocodone, a commonly prescribed opioid metabolized by cytochrome (CYP) 2D6 and CYP3A4, may be affected by enzyme inhibition from certain SSRIs. However, it remains unclear whether all SSRIs pose equal overdose risk or if some may be safer options for patients requiring both medications. Thus, we aimed to evaluate comparative risks of opioid overdose among patients initiating SSRIs while on hydrocodone. METHODS: This population-based cohort study utilized US public and commercial health insurance claims data from 2004 to 2022 and included patients who initiated a SSRI (citalopram, escitalopram, fluoxetine, paroxetine, or sertraline) while receiving hydrocodone treatment. The outcome was hospitalization or emergency department visit due to opioid overdose. We balanced baseline covariates via propensity score matching weights. A weighted Cox proportional hazards model compared rates across the five SSRIs. RESULTS: Among 1,486,583 patients who initiated an SSRI while on hydrocodone, 403,488 (27.1%) initiated sertraline, 348,484 (23.4%) initiated citalopram, 311,375 (21.0%) initiated escitalopram, 258,957 (17.4%) initiated fluoxetine, and 164,279 (11.1%) initiated paroxetine. During a median on-treatment follow-up of 28 days, 1500 primary endpoints occurred. Weighted hazard ratios (HRs) for opioid overdose, using sertraline as the reference, were 1.21 (95% CI 1.02-1.42) for citalopram, 1.19 (1.00-1.41) for escitalopram, 1.29 (1.09-1.54) for fluoxetine, and 1.17 (0.95-1.43) for paroxetine. Using citalopram as the reference, HRs were 0.99 (0.83-1.17) for escitalopram, 1.07 (0.91-1.27) for fluoxetine, and 0.97 (0.79-1.18) for paroxetine. Relative to escitalopram, HRs were 1.09 (0.92-1.30) for fluoxetine and 0.98 (0.80-1.20) for paroxetine, and relative to fluoxetine, the HR was 0.90 (0.74-1.10) for paroxetine. Comparisons among SSRIs other than sertraline showed similar risks of overdose. Intention-to-treat analysis yielded similar findings, although the associations were attenuated. CONCLUSIONS: In this cohort study, based on data from US healthcare claims databases, initiating citalopram, escitalopram, fluoxetine, or paroxetine while on hydrocodone was associated with an increased risk of opioid overdose compared with sertraline. No substantial risk differences were observed across SSRIs other than sertraline.

Long-Term Pain Therapy With Opioids—Reply

JAMA · 2025-12-22