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

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          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.

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          Most cited references 63

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          National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications.

          Preterm birth is the second largest direct cause of child deaths in children younger than 5 years. Yet, data regarding preterm birth (<37 completed weeks of gestation) are not routinely collected by UN agencies, and no systematic country estimates nor time trend analyses have been done. We report worldwide, regional, and national estimates of preterm birth rates for 184 countries in 2010 with time trends for selected countries, and provide a quantitative assessment of the uncertainty surrounding these estimates. We assessed various data sources according to prespecified inclusion criteria. National Registries (563 datapoints, 51 countries), Reproductive Health Surveys (13 datapoints, eight countries), and studies identified through systematic searches and unpublished data (162 datapoints, 40 countries) were included. 55 countries submitted additional data during WHO's country consultation process. For 13 countries with adequate quality and quantity of data, we estimated preterm birth rates using country-level loess regression for 2010. For 171 countries, two regional multilevel statistical models were developed to estimate preterm birth rates for 2010. We estimated time trends from 1990 to 2010 for 65 countries with reliable time trend data and more than 10,000 livebirths per year. We calculated uncertainty ranges for all countries. In 2010, an estimated 14·9 million babies (uncertainty range 12·3-18·1 million) were born preterm, 11·1% of all livebirths worldwide, ranging from about 5% in several European countries to 18% in some African countries. More than 60% of preterm babies were born in south Asia and sub-Saharan Africa, where 52% of the global livebirths occur. Preterm birth also affects rich countries, for example, USA has high rates and is one of the ten countries with the highest numbers of preterm births. Of the 65 countries with estimated time trends, only three (Croatia, Ecuador, and Estonia), had reduced preterm birth rates 1990-2010. The burden of preterm birth is substantial and is increasing in those regions with reliable data. Improved recording of all pregnancy outcomes and standard application of preterm definitions is important. We recommend the addition of a data-quality indicator of the per cent of all live preterm births that are under 28 weeks' gestation. Distinguishing preterm births that are spontaneous from those that are provider-initiated is important to monitor trends associated with increased caesarean sections. Rapid scale up of basic interventions could accelerate progress towards Millennium Development Goal 4 for child survival and beyond. Bill & Melinda Gates Foundation through grants to Child Health Epidemiology Reference Group (CHERG) and Save the Children's Saving Newborn Lives programme; March of Dimes; the Partnership for Maternal Newborn and Childe Health; and WHO, Department of Reproductive Health and Research. Copyright © 2012 Elsevier Ltd. All rights reserved.
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            Purposeful selection of variables in logistic regression

            Background The main problem in many model-building situations is to choose from a large set of covariates those that should be included in the "best" model. A decision to keep a variable in the model might be based on the clinical or statistical significance. There are several variable selection algorithms in existence. Those methods are mechanical and as such carry some limitations. Hosmer and Lemeshow describe a purposeful selection of covariates within which an analyst makes a variable selection decision at each step of the modeling process. Methods In this paper we introduce an algorithm which automates that process. We conduct a simulation study to compare the performance of this algorithm with three well documented variable selection procedures in SAS PROC LOGISTIC: FORWARD, BACKWARD, and STEPWISE. Results We show that the advantage of this approach is when the analyst is interested in risk factor modeling and not just prediction. In addition to significant covariates, this variable selection procedure has the capability of retaining important confounding variables, resulting potentially in a slightly richer model. Application of the macro is further illustrated with the Hosmer and Lemeshow Worchester Heart Attack Study (WHAS) data. Conclusion If an analyst is in need of an algorithm that will help guide the retention of significant covariates as well as confounding ones they should consider this macro as an alternative tool.
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              Stillbirths: rates, risk factors, and acceleration towards 2030.

              An estimated 2.6 million third trimester stillbirths occurred in 2015 (uncertainty range 2.4-3.0 million). The number of stillbirths has reduced more slowly than has maternal mortality or mortality in children younger than 5 years, which were explicitly targeted in the Millennium Development Goals. The Every Newborn Action Plan has the target of 12 or fewer stillbirths per 1000 births in every country by 2030. 94 mainly high-income countries and upper middle-income countries have already met this target, although with noticeable disparities. At least 56 countries, particularly in Africa and in areas affected by conflict, will have to more than double present progress to reach this target. Most (98%) stillbirths are in low-income and middle-income countries. Improved care at birth is essential to prevent 1.3 million (uncertainty range 1.2-1.6 million) intrapartum stillbirths, end preventable maternal and neonatal deaths, and improve child development. Estimates for stillbirth causation are impeded by various classification systems, but for 18 countries with reliable data, congenital abnormalities account for a median of only 7.4% of stillbirths. Many disorders associated with stillbirths are potentially modifiable and often coexist, such as maternal infections (population attributable fraction: malaria 8.0% and syphilis 7.7%), non-communicable diseases, nutrition and lifestyle factors (each about 10%), and maternal age older than 35 years (6.7%). Prolonged pregnancies contribute to 14.0% of stillbirths. Causal pathways for stillbirth frequently involve impaired placental function, either with fetal growth restriction or preterm labour, or both. Two-thirds of newborns have their births registered. However, less than 5% of neonatal deaths and even fewer stillbirths have death registration. Records and registrations of all births, stillbirths, neonatal, and maternal deaths in a health facility would substantially increase data availability. Improved data alone will not save lives but provide a way to target interventions to reach more than 7000 women every day worldwide who experience the reality of stillbirth.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: Writing – original draft
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: SupervisionRole: VisualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: VisualizationRole: Writing – review & editing
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS Med
                plos
                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, CA USA )
                1549-1277
                1549-1676
                17 March 2020
                March 2020
                : 17
                : 3
                Affiliations
                [1 ] School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
                [2 ] School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
                Columbia University Mailman School of Public Health, UNITED STATES
                Author notes

                The authors have declared that no competing interests exist.

                Article
                PMEDICINE-D-19-03175
                10.1371/journal.pmed.1003061
                7077810
                32182239
                © 2020 Mozooni et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 4, Tables: 5, Pages: 25
                Product
                Funding
                Funded by: The University of Western Australia
                Award ID: University Postgraduate Award
                Award Recipient :
                Funded by: Red Nose
                Award ID: Grant Number 0060/2017
                Award Recipient :
                Funded by: Red Nose
                Award ID: Grant Number 0060/2017
                Award Recipient :
                Funded by: Red Nose
                Award ID: Grant Number 0060/2017
                Award Recipient :
                MM received a University Postgraduate Award from the University of Western Australia. CP, MM, and DP received a grant (Grant Number 0060/2017) from Red Nose (formerly SIDS and Kids). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
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                Women's Health
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                Custom metadata
                Our ethics approval does not allow for the sharing of data with any third-party. Data are available from the Data Linkage Branch of WA Department of Health and the data custodians for each administrative dataset. Completing relevant procedures as well as ethics approval through Human Research Ethics Committee of WA Department of Health will be required. Please refer to the WA Data Linkage System website at https://www.datalinkage-wa.org.au/apply or email DataServices@ 123456health.wa.gov.au for any enquiry.

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