Date of Award


Degree Name

PhD Nursing

Dissertation Committee

Ruth Bush, PhD, Chairperson Cynthia D. Connelly, PhD, RN, FAAN, Committee Member Sarah E. Giron, PhD, CRNA, FAAN, Committee Member


Maternal hemorrhage, blood transfusion, cesarean delivery, demographics, behaviors, coexisting medical conditions, clinical treatments, medical procedures, odds risk ratio, maternal health disparities


Background/Purpose: Maternal hemorrhage is the second highest cause of direct maternal death and the leading cause of morbidity and mortality in the United States. This public health crisis is highlighted by the economic burden of over $30.8 million annually in the United States. The greatest tragedy in the review of maternal mortality is that 84% of pregnancy-related deaths were determined preventable. Identifying trends of factors that predispose women to hemorrhage can mitigate rates of severe maternal morbidity and mortality. This study describes relationships among demographic factors (maternal age, race, and ethnicity), clinical and physiologic factors, which include coexisting medical conditions (preoperative laboratory values, American Society of Anesthesiologists [ASA] physical status classification, obesity, anemia, smoking, hypertension, diabetes, chronic steroid use, and bleeding disorders) with maternal hemorrhage. Peripartum and postpartum clinical outcome analytic variables include postoperative diagnosis, blood transfusion administration, sepsis occurrence, and days from operation to discharge. The relationship between clinical treatment variables and independent variables was also explored within the context of medical procedure metrics such as total operative time, preoperative blood transfusion, principal anesthetic technique, and additional anesthesia technique.

Conceptual Basis: Donabedian (2005) triad of components contributes to quality in healthcare in the Model of Healthcare Quality: structure, process, and outcome. Linking maternal hemorrhage outcomes to the interplay of structure of risk assessment and process of quality interventions may reduce maternal morbidity outcomes.

Method: A retrospective, descriptive, comparative design analysis of cesarean deliverypatients (N = 59,302) from the American College of Surgeons National Surgical Quality Improvement Program during 2019-2022 was conducted. Descriptive and bivariate logistic regression were conducted to identify the factors associated with peripartum hemorrhage and blood transfusion in cesarean deliveries.

Results: Within this sample, 59,302 cesarean deliveries from 2019-2022, hemorrhage occurred in 831 cases (1.4%). The mean age among those who hemorrhaged was 31 years. Hemorrhage was associated with being Asian, Black, and Hispanic; having diabetes; being a smoker within the past year, and in ASA physical classification III or IV. Receiving a preoperative blood transfusion, having an abnormal preoperative white blood cell (WBC) count, and total operative time greater than 120 minutes were also associated with hemorrhage. Of these, ASA physical classification III or IV (OR 2.01, 95% CI [1.70, 2.38]) and preoperative transfusion (OR 4.60, 95% CI [2.57, 8.22]) were most strongly associated with hemorrhage when controlling for variables in the multivariate logistic regression. A preoperative hematocrit (HCT) ≥ to 36% (OR 0.56, 95% CI [0.48, 0.65], Body Mass Index (BMI) >30 kg/m² (OR 0.32, 95% CI [0.25, 0.40]), and having an anesthesia type other than general anesthesia were protective for hemorrhage; epidural (OR 0.16, 95% CI [0.13, 0.21]), regional/local (OR 0.26, 95% CI [0.18, 0.37]), spinal (OR 0.30, 95% CI [0.25, 0.36]), monitored anesthesia care (MAC)/sedation (OR 0.32, 95% CI [0.22, 0.48]).

Conclusions and Implications: This study identified strong significant associations between ASA classification III or IV (OR 2.01, 95% CI [1.70, 2.38]) and preoperative transfusion (OR 4.60, 95% CI [2.57, 8.22]) with hemorrhage in this sample. The analysis also demonstrated associations among demographics, behaviors, coexisting medical conditions, clinical treatments, and medical procedures in peripartum hemorrhage in cesarean deliveries. This study highlights variables associated with temporal trends in hemorrhage and transfusion in cesarean delivery parturients. This descriptive and multivariate logistic regression analysis identified variables that describe odds risk ratios for maternal hemorrhage. The associations identified in this study further support variables included in the maternal hemorrhage risk-assessment instruments, maternal safety bundles, and hemorrhage management to reduce maternal hemorrhage and transfusion trends.

Keywords: maternal hemorrhage, blood transfusion, cesarean delivery, disparities in maternal health, demographics, behaviors, coexisting medical conditions, clinical treatments, medical procedures, odds risk ratio.

Document Type

Dissertation: Open Access



Available for download on Friday, May 01, 2026