Ethnic differences in perinatal mortality: A perinatal audit on the role of substandard care

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Abstract

Objectives

The objective was to investigate the contribution of substandard care to ethnic inequalities in perinatal mortality.

Study design

Perinatal audit in Amsterdam, the Netherlands. The study population consisted of 137 consecutive perinatal death cases (16 weeks GA—28 days after delivery). A standardized procedure to establish the cause of death and substandard care by perinatal audit was developed. The main outcome measures were perinatal mortality rates in ethnic groups, cause of death classified by extended Wigglesworth classification, presence of substandard care (unlikely to be, possibly or likely to be related to perinatal death), and component of care considered to be substandard.

Results

In Surinamese and other non-Western mothers (mainly from Ghana) perinatal mortality, beyond 16 weeks’ gestation, was statistically significantly higher than among native Dutch mothers. (4.01, 2.50, and 1.07%, respectively). In Surinamese and Moroccan mothers, we observed a higher rate of early preterm deliveries. The prevalence of substandard care differed statistically significantly among ethnic groups (p = 0.034), with the highest prevalence among Surinamese mothers. These differences were especially apparent in the prevalence of (more) maternal substandard care factors among Surinamese and Moroccan mothers. These factors consisted of a later start date for antenatal care or a later notification by the caregiver about obstetrical problems (e.g. rupturing of membranes, decrease in foetal movements).

Conclusions

The higher perinatal mortality in Surinamese and other non-Western groups is mainly due to a higher rate of early preterm deliveries. No differences in care were observed among ethnic groups during labour and delivery. Among Surinamese mothers, however, the results indicate that substandard care with maternal involvement plays a role in explaining their higher perinatal mortality rates.

Introduction

In most European countries perinatal mortality is reported as being higher among ethnic minorities than among the native population, in registries as well as in specific studies [1], [2], [3], [4], [5]. The literature reports that several determinants of perinatal mortality, e.g. maternal age and obstetrical history, are related to ethnic background [3], [6], [7]. Though often put forward as a potential explanation [8] little is known about the systematic role of antenatal and perinatal care in explaining ethnic differences in perinatal mortality. Recently, a Swedish study suggested that substandard care was an important indicator for the higher perinatal mortality among East African women compared with native Swedish mothers [9]. This single observation requires confirmation and further elaboration. In addition, more insight should be obtained into the background of substandard care, (such as cause of death, duration of pregnancy) as this may indicate possible improvements that can be made.

The present study compares the perinatal death rates among ethnic groups living in the city of Amsterdam, the Netherlands, as indicator for perinatal care. We first studied differences in perinatal mortality among ethnic groups. This was followed by an audit procedure to specifically elicit the role of care inadequacies as causal factors, including the possible involvement of the mother.

Section snippets

Methods

We included all consecutive cases of perinatal mortality from 16 weeks’ gestation onwards until 28 days after delivery from February until October 1999.

Perinatal deaths were included from 16 weeks’ gestation since there is a known difference in the prevalence of very early preterm deliveries among ethnic groups [1].

Perinatal death is registered in the Dutch birth register from 16 weeks’ gestation onwards. The numbers of perinatal deaths are presented in Table 1, Table 2, Table 3, Table 4, Table

Results

During the study period, 137 consecutive cases of extended perinatal death were included (beyond 16 weeks’ gestation and including the first 4 weeks of life). A total of 6922 deliveries occurred during the study period in the city of Amsterdam [12].

Forty-two percent of the women were nulliparous. The median maternal age was 31, with no difference among ethnic groups. Only one mother was under 18 years of age. All but three deliveries occurred at the hospital under the supervision of the

Discussion

In line with previous studies, we observed a higher perinatal mortality rate among Surinamese women and women from other non-Western countries, with a similar trend among Turkish and Moroccan mothers. Among Moroccan mothers early preterm deliveries account for all excess perinatal mortality. In Surinamese mothers too, preterm delivery was a major cause of perinatal death. Despite thorough postmortem analysis, one-third of cases were unexplained antepartum foetal deaths.

Substandard care (all

Acknowledgements

We would like to thank D.J. Bekedam, P.J.E. Bindels, A.B. Dijkman, K.F. Heins, N. Jorna, J.C. Kaandorp, M. Knuist, J.H. Kok, D. Lesscher, G.L.M. Lips, S. Logtenberg, N. Menelik, J.A.M. van der Post, J.I. Puyenbroek, M.K. Sanders, L. van Toledo, A.J. van Veelen, G. van Waveren, M. Wieringa-de Waard, who participated in the Amsterdam perinatal audit.

Financial support for this study was granted by the Health Insurance Fund of the city of Amsterdam.

All researchers were independent of the

References (20)

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