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Higher hospital delivery volume was associated with higher route-specific complications. Discussion SMM significantly underestimates the incidence of maternal complications. Complicated deliveries have much higher charges and length of stay, although ICD-10 coding intensity may influence incidence. New outcome measures based on more detailed clinical data and linked antepartum and postpartum care will be necessary to improve obstetric quality of care measurement.Chronic obstructive pulmonary disease (COPD) poses a major risk for publi