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Objective This study utilized the Dr. Foster Global Comparators database to identify pregnancy complications and associated risk factors that led to severe maternal morbidity during delivery hospitalisations in large university hospitals based in the USA, Australia, and England. Design Retrospective cohort. Setting Births in the USA, England and Australia from 2008 to 2013. Sample Data from delivery hospitalisations between 2008 and 2013 were examined using the Dr. Foster Global Comparators database. Methods We identified delivery hospitalisations with life‐threatening diagnoses or use of life‐saving procedures, using algorithms for severe maternal morbidity from the Center for Disease Control. Frequency of severe maternal morbidity was calculated for each country. Main outcome measures Multivariable analysis was used to examine the association between morbidity and socio‐demographic and clinical characteristics within each country. Chi‐square tests assessed differences in covariates between countries. Results From 2008 to 2013, there were 516 781 deliveries from a total of 18 hospitals: 24.5% from the USA, 57.0% from England and 18.4% from Australia. Overall severe maternal morbidity rate was 8.2 per 1000 deliveries: 15.6 in the USA, 5.0 in England, and 8.2 in Australia. The most common codes identifying severe morbidity included transfusion, disseminated intravascular coagulation, acute renal failure, cardiac events/procedures, ventilation, hysterectomy, and eclampsia. Advanced maternal age, hypertension, diabetes, and substance abuse were associated with severe maternal morbidity in all three countries. Conclusion Rates of severe maternal morbidity differed by country. Identification of geographical, socio‐demographic, and clinical differences can help target modifications of practice and potentially reduce severe maternal morbidity. Tweetable abstract Rates of severe maternal morbidity vary, but risk factors associated with adverse outcomes are similar in developed countries.

(BJOG. 2019;126:1223–1230) Despite programs to improve maternal health, maternal mortality in the United States has increased over the past few decades. Other developed countries such as England and Australia, by contrast, have decreasing rates. As the incidence of maternal morbidity increases, evaluating cases of severe maternal morbidity (SMM) functions as a proxy for risk factors of mortality. This study aimed to utilize Centers for Disease Control and Prevention (CDC) SMM diagnostic codes to examine SMM rates in the United States, England, and Australia in the Dr Fosters Global Comparators Project (GC).