Healthcare factors associated with the risk of antepartum and intrapartum stillbirth in migrants in Western Australia (2005-2013): A retrospective cohort study

Abstract

Background

Migrant women, especially from Indian and African ethnicity, have a higher risk of stillbirth than native-born populations in high-income countries. Differential access or timing of ANC and the uptake of other services may play a role. We investigated the pattern of healthcare utilisation among migrant women and its relationship with the risk of stillbirth (SB)—antepartum stillbirth (AnteSB) and intrapartum stillbirth (IntraSB)—in Western Australia (WA).

Methods and findings

A retrospective cohort study using de-identified linked data from perinatal, birth, death, hospital, and birth defects registrations through the WA Data Linkage System was undertaken. All ( N = 260,997) non-Indigenous births (2005–2013) were included. Logistic regression analysis was used to estimate odds ratios and 95% CI for AnteSB and IntraSB comparing migrant women from white, Asian, Indian, African, Māori, and ‘other’ ethnicities with Australian-born women controlling for risk factors and potential healthcare-related covariates. Of all the births, 66.1% were to Australian-born and 33.9% to migrant women. The mean age (years) was 29.5 among the Australian-born and 30.5 among the migrant mothers. For parity, 42.3% of Australian-born women, 58.2% of Indian women, and 29.3% of African women were nulliparous. Only 5.3% of Māori and 9.2% of African migrants had private health insurance in contrast to 43.1% of Australian-born women. Among Australian-born women, 14% had smoked in pregnancy whereas only 0.7% and 1.9% of migrants from Indian and African backgrounds, respectively, had smoked in pregnancy. The odds of AnteSB was elevated in African (odds ratio [OR] 2.22, 95% CI 1.48–2.13, P < 0.001), Indian (OR 1.64, 95% CI 1.13–2.44, P = 0.013), and other women (OR 1.46, 95% CI 1.07–1.97, P = 0.016) whereas IntraSB was higher in African (OR 5.24, 95% CI 3.22–8.54, P < 0.001) and ‘other’ women (OR 2.18, 95% CI 1.35–3.54, P = 0.002) compared with Australian-born women. When migrants were stratified by timing of first antenatal visit, the odds of AnteSB was exclusively increased in those who commenced ANC later than 14 weeks gestation in women from Indian (OR 2.16, 95% CI 1.18–3.95, P = 0.013), Māori (OR 3.03, 95% CI 1.43–6.45, P = 0.004), and ‘other’ (OR 2.19, 95% CI 1.34–3.58, P = 0.002) ethnicities. With midwife-only intrapartum care, the odds of IntraSB for viable births in African and ‘other’ migrants (combined) were more than 3 times that of Australian-born women (OR 3.43, 95% CI 1.28–9.19, P = 0.014); however, with multidisciplinary intrapartum care, the odds were similar to that of Australian-born group (OR 1.34, 95% CI 0.30–5.98, P = 0.695). Compared with Australian-born women, migrant women who utilised interpreter services had a lower risk of SB (OR 0.51, 95% CI 0.27–0.96, P = 0.035); those who did not utilise interpreters had a higher risk of SB (OR 1.20, 95% CI 1.07–1.35, P < 0.001). Covariates partially available in the data set comprised the main limitation of the study.

Conclusion

Late commencement of ANC, underutilisation of interpreter services, and midwife-only intrapartum care are associated with increased risk of SB in migrant women. Education to improve early engagement with ANC, better uptake of interpreter services, and the provision of multidisciplinary-team intrapartum care to women specifically from African and ‘other’ backgrounds may reduce the risk of SB in migrants.

Abstract

Maryam Mozooni and colleagues reveal the higher risk of intrapartum stillbirth for migrant women in Australia compared to Australian born women.

Author summary

Why was this study done?

• Despite the availability of advanced pregnancy and childbirth care, the rate of stillbirth (SB) is unacceptably high among ethnic groups and migrant populations living in high-income countries.

• Nonwhite ethnic and migrant groups, especially those from African and other non-English speaking backgrounds, have a higher risk of SB compared with white and/or nonmigrant populations.

• Known risk factors do not explain the observed increased risk, and more investigation is needed to identify influential factors specific to those populations.

What did the researchers do and find?

• Using routinely collected administrative health and registry data, this study investigated all births to the non-Indigenous population of Western Australia (WA) from 2005 to 2013, including 260,997 live births and SBs.

• Health-service related factors were investigated to identify the pattern of service utilisation that may contribute to the increased rate of SBs in at-risk populations.

• Late commencement of ANC, not utilised interpreter services, lack of private health insurance, and midwife-only care during birth were associated with increased risk of SB in specific ethnic groups of migrants.

What do these findings mean?

• Engaging women with ANC early in pregnancy, offering interpreter service proactively, providing more frequent ultrasound surveillance, and involving a team (both doctor and midwife) for care during birth for specific at-risk groups may reduce the risk of SB.

• A culturally responsive health system can meet the educational and healthcare needs of at-risk populations.

• Cautious interpretation of findings is recommended. Enhanced data records on obesity, ANC, and labour care information can strengthen studies like this even further to inform policy and practice.