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I n the 15 yr since the publication of the Institute of Medicine report highlighting the need to reduce medical errors and improve patient safety, 1 complications after childbirth have become more common, not less common. 2,3 The number of pregnancy-related deaths in the United States increased from 7.2 to 17.3 per 100,000 between 1987 and 2013. 4 Many pregnancy-related deaths, such as those due to hemorrhage and preeclampsia, are preventable 5,6 and the quality of obstetrical care across U.S. hospitals is uneven. 7,8 Rising rates of maternal deaths and severe morbidity led the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists to create the Maternal Quality Improvement Program (Washington, D.C.) outcomes registry to serve as a platform for reporting risk-adjusted outcome metrics and improving the quality of obstetrical care. 9 Currently available outcome measures for obstetrical care 10-13 are limited because they are not risk-adjusted and do not account for differences in hospital case mix. To differentiate between obstetrical teams that provide aBStract Background: The number of pregnancy-related deaths and severe maternal complications continues to rise in the United States, and the quality of obstetrical care across U.S. hospitals is uneven. Providing hospitals with performance feedback may help reduce the rates of severe complications in mothers and their newborns. The aim of this study was to develop a risk-adjusted composite measure of severe maternal morbidity and severe newborn morbidity based on administrative and birth certificate data. Methods: This study was conducted using linked administrative data and birth certificate data from California. Hierarchical logistic regression prediction models for severe maternal morbidity and severe newborn morbidity were developed using 2011 data and validated using 2012 data. The composite metric was calculated using the geometric mean of the risk-standardized rates of severe maternal morbidity and severe newborn morbidity. results: The study was based on 883,121 obstetric deliveries in 2011 and 2012. The rates of severe maternal morbidity and severe newborn morbidity were 1.53% and 3.67%, respectively. Both the severe maternal morbidity model and the severe newborn models exhibited acceptable levels of discrimination and calibration. Hospital risk-adjusted rates of severe maternal morbidity were poorly correlated with hospital rates of severe newborn morbidity (intraclass correlation coefficient, 0.016). Hospital rankings based on the composite measure exhibited moderate levels of agreement with hospital rankings based either on the maternal measure or the newborn measure (κ statistic 0.49 and 0.60, respectively.) However, 10% of hospitals classified as average using the composite measure had below-average maternal outcomes, and 20% of hospitals classified as average using the composite measure had below-average newborn outcomes. conclusions: Maternal and newborn outcomes should be jointly reported because hospital ...