Racial and ethnic differences in perinatal mortality: the role of fetal death

Maternal Race and Stillbirth: Cohort Study and Systematic Review with Meta-Analysis

Accurate identification of independent predictors of stillbirth is needed to define preventive strategies. We aim to examine the independent contribution of maternal race in the risk of stillbirth after adjusting for maternal characteristics and medical history. There are two components to the study: first, prospective screening in 168,966 women with singleton pregnancies coordinated by the Fetal Medicine Foundation (FMF) and second, a systematic review and meta-analysis of studies reporting on race and stillbirth. In the FMF study, logistic regression analysis found that in black women, the risk of stillbirth, after adjustment for confounders, was higher than in white women (odds ratio 1.78, 95% confidence interval 1.50 to 2.11). The risk for other racial groups was not significantly different. The literature search identified 20 studies that provided data on over 6,500,000 pregnancies, but only 10 studies provided risks adjusted for some maternal characteristics; consequently, the majority of these studies did not provide accurate contribution of different racial groups to the prediction of stillbirth. It is concluded that in women of black origin, the risk of stillbirth, after adjustment for confounders, is about twofold higher than in white women. Consequently, closer surveillance should be granted for these women.

Developing routinely recorded clinical data from electronic patient records as a national resource to improve neonatal health care: the Medicines for Neonates research programme

Background

Clinical data offer the potential to advance patient care. Neonatal specialised care is a high-cost NHS service received by approximately 80,000 newborn infants each year.

Objectives

(1) To develop the use of routinely recorded operational clinical data from electronic patient records (EPRs), secure national coverage, evaluate and improve the quality of clinical data, and develop their use as a national resource to improve neonatal health care and outcomes. To test the hypotheses that (2) clinical and research data are of comparable quality, (3) routine NHS clinical assessment at the age of 2 years reliably identifies children with neurodevelopmental impairment and (4) trial-based economic evaluations of neonatal interventions can be reliably conducted using clinical data. (5) To test methods to link NHS data sets and (6) to evaluate parent views of personal data in research.

Design

Six inter-related workstreams; quarterly extractions of predefined data from neonatal EPRs; and approvals from the National Research Ethics Service, Health Research Authority Confidentiality Advisory Group, Caldicott Guardians and lead neonatal clinicians of participating NHS trusts.

Setting

NHS neonatal units.

Participants

Neonatal clinical teams; parents of babies admitted to NHS neonatal units.

Interventions

In workstream 3, we employed the Bayley-III scales to evaluate neurodevelopmental status and the Quantitative Checklist of Autism in Toddlers (Q-CHAT) to evaluate social communication skills. In workstream 6, we recruited parents with previous experience of a child in neonatal care to assist in the design of a questionnaire directed at the parents of infants admitted to neonatal units.

Data sources

Data were extracted from the EPR of admissions to NHS neonatal units.

Main outcome measures

We created a National Neonatal Research Database (NNRD) containing a defined extract from real-time, point-of-care, clinician-entered EPRs from all NHS neonatal units in England, Wales and Scotland (n = 200), established a UK Neonatal Collaborative of all NHS trusts providing neonatal specialised care, and created a new NHS information standard: the Neonatal Data Set (ISB 1595) (see http://webarchive.nationalarchives.gov.uk/±/http://www.isb.nhs.uk/documents/isb-1595/amd-32–2012/index_html; accessed 25 June 2018).

Results

We found low discordance between clinical (NNRD) and research data for most important infant and maternal characteristics, and higher prevalence of clinical outcomes. Compared with research assessments, NHS clinical assessment at the age of 2 years has lower sensitivity but higher specificity for identifying children with neurodevelopmental impairment. Completeness and quality are higher for clinical than for administrative NHS data; linkage is feasible and substantially enhances data quality and scope. The majority of hospital resource inputs for economic evaluations of neonatal interventions can be extracted reliably from the NNRD. In general, there is strong parent support for sharing routine clinical data for research purposes.

Limitations

We were only able to include data from all English neonatal units from 2012 onwards and conduct only limited cross validation of NNRD data directly against data in paper case notes. We were unable to conduct qualitative analyses of parent perspectives. We were also only able to assess the utility of trial-based economic evaluations of neonatal interventions using a single trial. We suggest that results should be validated against other trials.

Conclusions

We show that it is possible to obtain research-standard data from neonatal EPRs, and achieve complete population coverage, but we highlight the importance of implementing systematic examination of NHS data quality and completeness and testing methods to improve these measures. Currently available EPR data do not enable ascertainment of neurodevelopmental outcomes reliably in very preterm infants. Measures to maintain high quality and completeness of clinical and administrative data are important health service goals. As parent support for sharing clinical data for research is underpinned by strong altruistic motivation, improving wider public understanding of benefits may enhance informed decision-making.

Future work

We aim to implement a new paradigm for newborn health care in which continuous incremental improvement is achieved efficiently and cost-effectively by close integration of evidence generation with clinical care through the use of high-quality EPR data. In future work, we aim to automate completeness and quality checks and make recording processes more ‘user friendly’ and constructed in ways that minimise the likelihood of missing or erroneous entries. The development of criteria that provide assurance that data conform to prespecified completeness and quality criteria would be an important development. The benefits of EPR data might be extended by testing their use in large pragmatic clinical trials. It would also be of value to develop methods to quality assure EPR data including involving parents, and link the NNRD to other health, social care and educational data sets to facilitate the acquisition of lifelong outcomes across multiple domains.

Study registration

This study is registered as PROSPERO CRD42015017439 (workstream 1) and PROSPERO CRD42012002168 (workstream 3).

Funding

The National Institute for Health Research Programme Grants for Applied Research programme (£1,641,471). Unrestricted donations were supplied by Abbott Laboratories (Maidenhead, UK: £35,000), Nutricia Research Foundation (Schiphol, the Netherlands: £15,000), GE Healthcare (Amersham, UK: £1000). A grant to support the use of routinely collected, standardised, electronic clinical data for audit, management and multidisciplinary feedback in neonatal medicine was received from the Department of Health and Social Care (£135,494).

Perinatal Disparities Between American Indians and Alaska Natives and Other US Populations: Comparative Changes in Fetal and First Day Mortality, 1995-2008

To compare fetal and first day outcomes of American Indian and Alaskan Natives (AIAN) with non-AIAN populations. Singleton deliveries to AIAN and non-AIAN populations were selected from live birth-infant death cohort and fetal deaths files from 1995-1998 and 2005-2008. We examined changes over time in maternal characteristics of deliveries and disparities and changes in risks of fetal, first day (<24 h), and cause-specific deaths. We calculated descriptive statistics, odds ratios and confidence intervals, and ratio of odds ratios (RORs) to indicate changes in disparities. Along with black mothers, AIANs exhibited the highest proportion of risk factors including the highest proportion of diabetes in both time periods (4.6 and 6.5 %). Over time, late fetal death for AIANs decreased 17 % (aOR = 0.83, 95 % CI 0.72-0.97), but we noted a 47 % increased risk over time for Hispanics (aOR = 1.47, 95 % CI 1.40-1.55). Our data indicated no change over time among AIANs for first day death. For AIANs compared to whites, increased risks and disparities persisted for mortality due to congenital anomalies (ROR = 1.28, 95 % CI 1.03-1.60). For blacks compared to AIANs, the increased risks of fetal death (2005-2008: aOR = 0.60, 95 % CI 0.53-0.68) persisted. For Hispanics, lower risks compared to AIANs persisted, but protective effect declined over time. Disparities between AIAN and other groups persist, but there is variability by race/ethnicity in improvement of perinatal outcomes over time. Variability in access to care and pregnancy management should be considered in relation to health equity for fetal and early infant deaths.

The 2007 los angeles mommy and baby study: a multilevel, population-based study of maternal and infant health in los angeles county

Objectives. In order to comprehensively examine the risks and resources associated with racial-ethnic disparities in adverse obstetric outcomes, the Los Angeles County Department of Public Health and the University of California, Los Angeles, joined efforts to design and implement the 2007 Los Angeles Mommy and Baby (LAMB) study. This paper aims to present the conceptual frameworks underlying the study's development, highlight the successful collaboration between a research institution and local health department, describe the distinguishing characteristics of its methodology, and discuss the study's implications for research, programs, and policies. Methods. The LAMB study utilized a multilevel, multistage cluster design with a mixed-mode methodology for data collection. Two samples were ultimately produced: the multilevel sample (n = 4,518) and the augmented final sample (n = 6,264). Results. The LAMB study allowed us to collect multilevel data on the risks and resources associated with racial-ethnic disparities in adverse obstetric outcomes. Both samples were more likely to be Hispanic, aged 20-34 years, completed at least 12 years of schooling, and spoke English. Conclusions. The LAMB study represents the successful collaboration between an academic institution and local health department and is a theoretically based research database and surveillance system that informs effective programmatic and policy interventions to improve outcomes among LAC's varied demographic groups.

Infant mortality: a call to action overcoming health disparities in the United States

Among all of the industrialized countries, the United States has the highest infant mortality rate. Racial and ethnic disparities continue to plague the United States with a disproportionally high rate of infant death. Furthermore, racial disparities among infant and neonatal mortality rates remain a chronic health problem in the United States. These risks are based on the geographical variations in mortality and disparities among differences in maternal risk characteristics, low birth weights, and lack of access to health care.

Impact of fetal death reporting requirements on early neonatal and fetal mortality rates and racial disparities

OBJECTIVE

Racial disparities in infant and neonatal mortality vary substantially across the U.S. with some states experiencing wider disparities than others. Many factors are thought to contribute to these disparities, but state differences in fetal death reporting have received little attention. We examined whether such reporting requirements may explain national variation in neonatal and fetal mortality rates and racial disparities.

METHODS

We used data on non-Hispanic white and non-Hispanic black infants from the U.S. 2000-2002 linked birth/infant death and fetal death records to determine the degree to which state fetal death reporting requirements explain national variation in neonatal and fetal mortality rates and racial disparities. States were grouped depending upon whether they based the lower limit for fetal death reporting on birthweight alone, gestational age alone, both birthweight and gestational age, or required reporting of all fetal deaths. Traditional methods and the fetuses-at-risk approach were used to calculate mortality rates, 95% confidence intervals, and relative and absolute racial disparity measures in these four groups.

RESULTS

States with birthweight-alone fetal death thresholds substantially underreported fetal deaths at lower gestations and slightly overreported neonatal deaths at older gestations. This finding was reflected by these states having the highest neonatal mortality rates and disparities, but the lowest fetal mortality rates and disparities.

CONCLUSIONS

Using birthweight alone as a reporting threshold may promote some shift of fetal deaths to newborn deaths, contributing to racial disparities in neonatal mortality. The adoption of a uniform national threshold for reporting fetal deaths could reduce systematic differences in live birth and fetal death reporting.

Biracial couples and adverse birth outcomes: a systematic review and meta-analyses

BACKGROUND

Differences in birth outcomes such as low birthweight (LBW), preterm births (PTB), stillbirth, differences in birthweight in Black vs. White race are well known. Infants born to biracial parents (mother and father from either Black or White races) also experience higher adverse birth outcomes.

OBJECTIVE

To systematically review and meta-analyze birth outcomes among parents of mixed racial background compared to parents of same race.

SEARCH STRATEGY

Medline, Embase, CINAHL and bibliographies of identified articles were searched for English language studies.

SELECTION CRITERIA

Studies reporting association between parental mixed racial status and LBW, PTB, or small-for-gestational age (SGA) outcomes were included. DATA COLLECTION AND ANALYSES: After exclusion of duplicate cohorts in different publications, data from White mother-Black father (WMBF), Black mother-White father (BMWF) and Black mother-Black father (BMBF) groups were compared with the White mother-White father (WMWF) group.

RESULTS

Eight English language studies from of 26 335 596 singleton births were included and reviewed. Compared to the WMWF group, the adjusted odds ratio (95% confidence intervals) were: (a) low birthweight; 1.21 (1.10-1.33) for WMBF, 1.75(1.64-1.87) for BMWF, and 2.08 (1.81-2.38) for BMBF; (b) preterm births; 1.17 (1.05-1.31) for WMBF, 1.37 (1.18-1.59) for BMWF, and 1.78 (1.59-2.00) for BMBF; and (c) stillbirths; 1.43 (0.92-2.21) for WMBF, 1.51 (1.09-2.08) for BMWF, and 1.85 (1.47-2.32) for BMBF.

CONCLUSION

Biracial status of parents was associated with higher risk for adverse pregnancy outcomes than both White parents but lower than both Black parents, with maternal race having a greater influence than paternal race on pregnancy outcomes.

Factors that mediate racial/ethnic disparities in US fetal death rates

OBJECTIVES

We sought to determine the importance of socioeconomic factors, maternal comorbid conditions, antepartum and intrapartum complications of pregnancy, and fetal factors in mediating racial disparities in fetal deaths. METHODS. We undertook a mediation analysis on a retrospective cohort study of hospital-based deliveries with a gestational age between 23 and 44 weeks in California, Missouri, and Pennsylvania from 1993 to 2005 (n = 7,104,674).

RESULTS

Among non-Hispanic Black women and Hispanic women, the fetal death rate was higher than among non-Hispanic White women (5.9 and 3.6 per 1000 deliveries, respectively, vs 2.6 per 1000 deliveries; P < .01). For Black women, fetal factors mediated the largest percentage (49.6%; 95% confidence interval [CI] = 42.7, 54.7) of the disparity in fetal deaths, whereas antepartum and intrapartum factors mediated some of the difference in fetal deaths for both Black and Asian women. Among Hispanic women, socioeconomic factors mediated 35.8% of the disparity in fetal deaths (95% CI = 25.8%, 46.2%).

CONCLUSIONS

The factors that mediate racial/ethnic disparities in fetal death differ depending on the racial/ethnic group. Interventions targeting mediating factors specific to racial/ethnic groups, such as improved access to care, may help reduce US fetal death disparities.

Disparities in fetal death and first day death: the influence of risk factors in 2 time periods

OBJECTIVES

We examined how changes in risk factors over time influence fetal, first day, and combined fetal-first day mortality and subsequent racial/ethnic disparities.

METHODS

We selected deliveries to US resident non-Hispanic White and Black mothers from the linked live birth-infant death cohort and fetal deaths files (1995-1996; 2001-2002) and calculated changes over time of mortality rates, odds, and relative odds ratios (RORs) overall and among mothers with modifiable risk factors (smoking, diabetes, or hypertensive disorders).

RESULTS

Adjusted odds ratios (AORs) for fetal mortality overall (AOR=0.99; 95% confidence interval [CI]=0.96, 1.01) and among Blacks (AOR=0.98; 95% CI=0.93, 1.03) indicated no change over time. Among women with modifiable risk factors, the RORs indicated no change in disparities. The ROR was not significant for fetal mortality (ROR=0.96; 95% CI=0.83, 1.01) among smokers, but there was evidence of some decline. There was evidence of increase in RORs in fetal death among mothers with diabetes and hypertensive disorders, but differences were not significant.

CONCLUSIONS

Disparities in fetal, first day, and combined fetal-first day mortality have persisted and reflect discrepancies in care provision or other factors more challenging to measure.

Racial differences in gestational age-specific neonatal morbidity: further evidence for different gestational lengths

OBJECTIVE

We sought to quantify the gestational age-specific morbidity of black vs white neonates.

STUDY DESIGN

This was a population-based retrospective cohort study of singleton live births in Ohio from 2006 through 2007. The primary outcome was a composite of adverse neonatal outcomes of ≥ 1 morbidity: Apgar score < 7 at 5 minutes, assisted ventilation > 6 hours, seizures, or neonatal transport to a tertiary care facility. Generalized linear regression estimated the relative risk of adverse neonatal outcome by week of gestation after adjustment for influential coexistent risk factors.

RESULTS

The frequency distribution curve of composite morbidity by gestational age were similar, but shifted to left (earlier gestational age) for black compared with white neonates. Adverse outcome was lower for black compared with white births at each preterm week of gestational age. The lowest adverse outcome rate for black neonates was at 38 weeks and 39 weeks for white neonates, each increasing by week of gestation thereafter.

CONCLUSION

These data suggest that pregnancies in black women perhaps have a shorter physiologic gestational length.

Racial and ethnic variations in temporal changes in fetal deaths and first day infant deaths

The purpose was to examine changes in overall and gestational age-specific proportions and rates of fetal death, first day death (<24 h), and combined fetal-first day death from 1990-1991 to 2001-2002. Changes were considered by race/ethnicity. Deliveries to U.S. white, black, and Hispanic mothers were selected from the NCHS linked live birth-infant death cohort and fetal deaths files (1990-1991 and 2001-2002). There was an overall improvement in mortality, but improvements were not uniform across all racial/ethnic groups or by gestational age. The fetal mortality rate among whites and Hispanics declined 4.32 and 12.82 percent, respectively. For blacks, the fetal mortality rate increased 4.06 percent between 1990-1991 and 2001-2002. Despite overall reductions in perinatal and <24 h mortality, black rates in all outcomes maintained a twofold disparity. The overall black: white fetal mortality rate ratio increased from 2.17 to 2.36 over time. The gestational age-specific black: white combined fetal-first day mortality rate ratios were greater than 1 at later gestational ages. In some cases, the ratio increased over time, indicating that despite reductions, fetal mortality did not decline uniformly among whites and blacks at term and post-term. Despite overall improvements in fetal, first day, and combined fetal-first day mortality, racial disparities persisted and in some cases widened. This study identifies lack of improvements in fetal death in the black population compared to the white or Hispanic population at later gestational ages.

Resuscitation of likely nonviable infants: a cost-utility analysis after the Born-Alive Infant Protection Act

OBJECTIVE

The purpose of this study was to compare the effects of universal vs selective resuscitation on maternal utilities, perinatal costs, and outcomes of preterm delivery and termination of pregnancy at 20-23 weeks 6 days' gestation.

STUDY DESIGN

We used studies on medical practices, prematurity outcomes, costs, and maternal utilities to construct decision-analytic models for a cohort of annual US deliveries after preterm delivery or induced termination. Outcome measures were (1) the numbers of infants who survived intact or with mild, moderate, or severe sequelae; (2) maternal quality-adjusted life years (QALYs); and (3) incremental cost-effectiveness ratios.

RESULTS

Universal resuscitation of spontaneously delivered infants between 20-23 weeks 6 days' gestation increases costs by $313.1 million and decreases QALYs by 329.3 QALYs; after a termination, universal resuscitation increases costs by $15.6 million and decreases QALYs by 19.2 QALYs. With universal resuscitation, 153 more infants survive: 44 infants are intact or mildly affected; 36 infants are moderately impaired, and 73 infants are severely disabled.

CONCLUSION

Selective intervention constitutes the highest utility and least costly treatment for infants at the margin of viability.

Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis

BACKGROUND

Stillbirth rates in high-income countries have shown little or no improvement over the past two decades. Prevention strategies that target risk factors could be important in rate reduction. This systematic review and meta-analysis was done to identify priority areas for stillbirth prevention relevant to those countries.

METHODS

Population-based studies addressing risk factors for stillbirth were identified through database searches. The factors most frequently reported were identified and selected according to whether they could potentially be reduced through lifestyle or medical intervention. The numbers attributable to modifiable risk factors were calculated from data relating to the five high-income countries with the highest numbers of stillbirths and where all the data required for analysis were available. Odds ratios were calculated for selected risk factors, from which population-attributable risk (PAR) values were calculated.

FINDINGS

Of 6963 studies initially identified, 96 population-based studies were included. Maternal overweight and obesity (body-mass index >25 kg/m(2)) was the highest ranking modifiable risk factor, with PARs of 8-18% across the five countries and contributing to around 8000 stillbirths (≥22 weeks' gestation) annually across all high-income countries. Advanced maternal age (>35 years) and maternal smoking yielded PARs of 7-11% and 4-7%, respectively, and each year contribute to more than 4200 and 2800 stillbirths, respectively, across all high-income countries. In disadvantaged populations maternal smoking could contribute to 20% of stillbirths. Primiparity contributes to around 15% of stillbirths. Of the pregnancy disorders, small size for gestational age and abruption are the highest PARs (23% and 15%, respectively), which highlights the notable role of placental pathology in stillbirth. Pre-existing diabetes and hypertension remain important contributors to stillbirth in such countries.

INTERPRETATION

The raising of awareness and implementation of effective interventions for modifiable risk factors, such as overweight, obesity, maternal age, and smoking, are priorities for stillbirth prevention in high-income countries.

FUNDING

The Stillbirth Foundation Australia, the Department of Health and Ageing, Canberra, Australia, and the Mater Foundation, Brisbane, Australia.

Perinatal grief in Latino parents

Extensive research exists that describes the meaning of perinatal loss to some parents, but the experience of loss from the perspective of Latino parents is not clearly understood. Additionally, current perinatal bereavement practices used often to facilitate memory making for parents (such as viewing or holding the baby, taking photographs, or collecting mementos) are based on research done primarily with non-Latino families. Are these common practices appropriate for this population? Because there is a paucity of research on this topic, this article describes what has been written over the past 30 years on the topic of grief and perinatal loss in Latino culture.

Relationship between obesity, ethnicity and risk of late stillbirth: a case control study

Background

In high income countries there has been little improvement in stillbirth rates over the past two decades. Previous studies have indicated an ethnic disparity in the rate of stillbirths. This study aimed to determine whether maternal ethnicity is independently associated with late stillbirth in New Zealand.

Methods

Cases were women with a singleton, late stillbirth (≥28 weeks' gestation) without congenital abnormality, born between July 2006 and June 2009 in Auckland, New Zealand. Two controls with ongoing pregnancies were randomly selected at the same gestation at which the stillbirth occurred. Women were interviewed in the first few weeks following stillbirth, or at the equivalent gestation for controls. Detailed demographic data were recorded. The study was powered to detect an odds ratio of 2, with a power of 80% at the 5% level of significance, given a prevalence of the risk factor of 20%. A multivariable regression model was developed which adjusted for known risk factors for stillbirth, as well as significant risk factors identified in the current study, and adjusted odds ratios and 95% confidence intervals were calculated.

Results

155/215 (72%) cases and 310/429 (72%) controls consented. Pacific ethnicity, overweight and obesity, grandmultiparity, not being married, not being in paid work, social deprivation, exposure to tobacco smoke and use of recreational drugs were associated with an increased risk of late stillbirth in univariable analysis. Maternal overweight and obesity, nulliparity, grandmultiparity, not being married and not being in paid work were independently associated with late stillbirth in multivariable analysis, whereas Pacific ethnicity was no longer significant (adjusted Odds Ratio 0.99; 0.51-1.91).

Conclusions

Pacific ethnicity was not found to be an independent risk factor for late stillbirth in this New Zealand study. The disparity in stillbirth rates between Pacific and European women can be attributed to confounding factors such as maternal obesity and high parity.

High perinatal mortality rate among immigrants in Brussels

BACKGROUND

The relation between immigration status and perinatal mortality is unclear. The objective of this study is to describe and measure inequalities in perinatal mortality and causes of perinatal deaths according to maternal nationality and socioeconomic status.

METHODS

A population-based cohort study related to all babies born during the period of 1998-2006 whose mothers were living in Brussels, irrespective of the place of delivery. Perinatal and post-perinatal mortality were analysed according to the nationality and sociodemographic characteristics of the mothers at birth. We used logistic regression to estimate the odds ratios (ORs) for the association between mortality and nationality.

RESULTS

The women of sub-Saharan Africa experience a 50% excess in perinatal mortality, which primarily reflects a high rate of preterm deliveries and low birth weight, as well as a low socioeconomic level. Paradoxically, despite their favourable rates of preterm and low-birth-weight births, Maghrebian and Turkish women experience a strong excess (50-70%) of perinatal mortality caused primarily by congenital anomalies. Differences in age, parity distributions and multiple births play no significant role, and the excess does not reflect low socioeconomic levels. This excess of perinatal mortality contrasts with the absence of an excess of post-perinatal mortality.

CONCLUSION

In Brussels, patterns of inequalities in perinatal mortality and causes of perinatal deaths vary according to nationality; perinatal mortality is increased in particular ethnic groups independently of socioeconomic status and maternal characteristics.

Health disparities: a primer for public health social workers

In 2001, the U.S. Department of Health and Human Services published Healthy People 2010, which identified objectives to guide health promotion and to eliminate health disparities. Since 2001, much research has been published documenting racial and ethnic disparities in healthcare. Although progress has been made in eliminating the disparities, ongoing work by public health social workers, researchers, and policy analysts is needed. This paper focuses on racial and ethnic health disparities, why they exist, where they can be found, and some of the key health/medical conditions identified by the U.S. Department of Health and Human Services to receive attention. Finally, there is a discussion of what policy, professional and community education, and research can to do to eliminate racial and ethnic disparities in healthcare.

Prematurity and low birth weight as potential mediators of higher stillbirth risk in mixed black/white race couples

OBJECTIVE

Although births of multiracial and multiethnic infants are becoming more common in the United States, little is known about birth outcomes and risks for adverse events. We evaluated risk of fetal death for mixed race couples compared with same race couples and examined the role of prematurity and low birth weight as potential mediating risk factors.

METHODS

We performed a retrospective cohort analysis using data from the 1998-2002 California Birth Cohort to evaluate the odds of fetal death, low birth weight, and prematurity for couples with a mother and father who were categorized as either being of same or different racial groups. Risk of prematurity (birth prior to 37 weeks gestation) and low birth weight (<2500 g) were also tested to see if the model could explain variations among groups.

RESULTS

The analysis included approximately 1.6 million live births and 1749 stillbirths. In the unadjusted model, compared with two white parents, black/black and black/white couples had a significantly higher risk of fetal death. When all demographic, social, biological, genetic, congenital, and procedural risk factors except gestational age and birth weight were included, the odds ratios (OR) were all still significant. Black/black couples had the highest level of risk (OR 2.11, CI 1.77-2.51), followed by black mother/white father couples (OR 2.01, CI 1.16-3.48), and white mother/black father couples (OR 1.84, CI 1.33-2.54). Virtually all of the higher risk of fetal death was explainable by higher rates of low birth weight and prematurity.

CONCLUSIONS

Mixed race black and white couples face higher odds of prematurity and low birth weight, which appear to contribute to the substantially higher demonstrated risk for stillbirth. There are likely additional unmeasured factors that influence birth outcomes for mixed race couples.

Racial disparities in stillbirth risk across gestation in the United States

OBJECTIVE

We sought to determine factors associated with racial disparities in stillbirth risk.

STUDY DESIGN

Stillbirth hazard was analyzed using 5,138,122 singleton gestations from the National Center of Health Statistics perinatal mortality and birth files, 2001-2002.

RESULTS

Black women have a 2.2-fold increased risk of stillbirth compared with white women. The black/white disparity in stillbirth hazard at 20-23 weeks is 2.75, decreasing to 1.57 at 39-40 weeks. Higher education reduced the hazard for whites more than for blacks and Hispanics. Medical, pregnancy, and labor complications accounted for 30% of the hazard in blacks and 20% in whites and Hispanics. Congenital anomalies and small for gestational age contributed more to preterm stillbirth risk among whites than blacks. Pregnancy and labor conditions contributed more to preterm stillbirth risk among blacks than whites.

CONCLUSION

The excess stillbirth risk for blacks was greatest at preterm gestations, and factors contributing to stillbirth risk vary by race and gestational age.

Perinatal and maternal outcomes in women with sickle or hemoglobin C trait

OBJECTIVE

Recent studies have reported increased fetal loss and preeclampsia in women with sickle cell trait (hemoglobin [Hb] AS). There is a paucity of studies of outcomes in carriers of hemoglobin C. We examined the prevalence of hemoglobin C and S carrier status (Hb AC and Hb AS, respectively) and their effect on pregnancy outcomes.

METHODS

This was a retrospective cohort study using data prospectively collected from 1991 to 2006. Perinatal and maternal outcomes for African-American women with Hb AS and Hb AC were compared with those with normal hemoglobin (Hb AA). Multivariable regression was performed by applying generalized estimating equations to account for correlation between births from the same woman.

RESULTS

Among 22,096 eligible African-American women (36,897 pregnancies) with routine antenatal hemoglobin electrophoresis, 88.5% had a normal (Hb AA) pattern. Hemoglobin AS was identified in 8.2% and Hb AC in 2.4% of women. Hemoglobin SS and Hb SC each accounted for less than 0.2% and Hb CC for 0.01%. Prevalence and relative risks for adverse outcomes in 3,019 AS pregnancies (3,062 births) and 875 AC (886 births), compared with 32,724 AA pregnancies (33,213 births), were not increased. Adjusted relative risks (95% confidence intervals) for perinatal mortality and preeclampsia were 0.7 (0.5-1.0) and 1.0 (0.8-1.2), respectively, for AS and 0.7 (0.3-1.4) and 1.0 (0.6-1.3), respectively, for AC. Risks of stillbirths and pregnancy-associated hypertension were also not increased.

CONCLUSION

Contrary to other recent reports, perinatal mortality and preeclampsia are not increased in carriers of sickle cell trait or hemoglobin C.

LEVEL OF EVIDENCE

II.

Brief intervention for alcohol use by pregnant women

OBJECTIVES

We examined the efficacy of brief intervention as a technique to help pregnant women achieve abstinence from alcohol. A second aim was to assess newborn outcomes as a function of brief intervention.

METHODS

Two hundred fifty-five pregnant women who were participants in the Public Health Foundation Enterprises Management Solutions Special Supplemental Nutrition Program for Women, Infants, and Children and who reported drinking alcohol were assigned to an assessment-only or a brief intervention condition and followed to their third trimester of pregnancy. Brief intervention consisted of 10- to 15-minute sessions of counseling by a nutritionist, who used a scripted manual to guide the intervention. Newborn outcomes of gestation, birth-weight, birth length, and viability were assessed.

RESULTS

Women in the brief intervention condition were 5 times more likely to report abstinence after intervention compared with women in the assessment-only condition. Newborns whose mothers received brief intervention had higher birthweights and birth lengths, and fetal mortality rates were 3 times lower (0.9%) compared with newborns in the assessment-only (2.9%) condition.

CONCLUSIONS

The success of brief intervention conducted in a community setting by nonmedical professionals has significant implications for national public health policies.