Stillbirth and infant death among generations of Pakistani immigrant descent: a population-based study

Perinatal mortality among pregnant undocumented migrants in Norway 1999-2020: A register-based population study

BACKGROUND

Irregular legal status is a recognized health risk factor in the context of migration. However, undocumented migrants are rarely included in health surveys and register studies. Adverse perinatal outcomes are especially important because they have long-term consequences and societal risk factors are modifiable. In this study, we compare perinatal outcomes in undocumented migrants to foreign-born and Norwegian-born residents, using a population-based register.

METHODS

We included women 18-49 years old giving birth to singletons as registered in the Medical Birth Registry of Norway from 1999 to 2020. Women were categorized as 'undocumented migrants' (without an identity number), 'documented migrants' (with an identity number and born abroad), and 'non-migrants' (with an identity number and born in Norway). The main outcome was perinatal mortality, i.e., death of a foetus ≥ gestational week 22, or neonate up to seven days after birth. We used log-binominal regression to estimate the association between legal status and perinatal mortality, adjusting for several maternal pre-gestational and gestational factors. Direct standardization was used to adjust for maternal region of origin.

ETHICAL APPROVAL

Regional Ethical Committee (REK South East, case number 68329).

RESULTS

We retrieved information on 5856 undocumented migrant women who gave birth during the study period representing 0.5% of the 1 247 537 births in Norway. Undocumented migrants had a relative risk of 6.17 (95% confidence interval 5.29 ̶7.20) of perinatal mortality compared to non-migrants and a relative risk of 4.17 (95% confidence interval 3.51 ̶4.93) compared to documented migrants. Adjusting for maternal region of origin attenuated the results slightly.

CONCLUSION

Being undocumented is strongly associated with perinatal mortality in the offspring. Disparities were not explained by maternal origin or maternal health factors, indicating that social determinants of health through delays in receiving adequate care and factors negatively influencing gestational length may be of importance.

Elevated mortality among the second-generation (children of migrants) in Europe: what is going wrong? A review

INTRODUCTION

The 'second-generation' (i.e. the children of migrants) represent one of the fastest growing subpopulations of the child and young adult populations in Europe today. The research so far appears to indicate that their mortality risk is elevated relative to people with non-migrant backgrounds.

SOURCES OF DATA

Peer-reviewed publications.

AREAS OF AGREEMENT

Second-generation status is a clear marker of elevated mortality risk in Europe in early life (including stillbirth, perinatal, neonatal and infant mortality) and adulthood, particularly if the parent(s) were born outside of Europe. Socioeconomic inequality plays an important, albeit rarely defining, role in these elevated risks.

AREAS OF CONTROVERSY

It remains unclear what causes-of-death are driving these elevated mortality risks. The exact influence of (non-socioeconomic) explanatory factors (e.g. health care, racism & discrimination, and factors related to integration) on the elevated mortality risks of the second-generation also remains unclear.

GROWING POINTS

The second-generation will continue to grow and diversify in Europe; we must intervene to address these inequalities now.

AREAS TIMELY FOR DEVELOPING RESEARCH

Place more emphasis on the complexity of migration background, specific causes-of-death, and understanding the roles of explanatory factors beyond socioeconomic background.

Potentially traumatic experiences pre-migration and adverse pregnancy and childbirth outcomes among women of Somali- and Kurdish-origin in Finland

BACKGROUND

Women in precarious conditions in their countries of origin, especially those who have left the country as refugees, may have been victims of serious mental and physical violence. These potentially traumatic experiences may threaten women's reproductive health. This study examines the prevalence of potentially traumatic experiences pre-migration and female genital mutilation/cutting (FGM/C) and their associations with adverse reproductive outcomes among migrant women of Somali- and Kurdish-origin who have been pregnant in Finland.

METHODS

Survey and register data of the participants of the Finnish Migrant Health and Wellbeing Study (Maamu), conducted in 2010-2012, were used. Women of 18 to 64 years of age, 185 Somali- and 230 Kurdish-origin, who had at least one pregnancy or birth in Finland were included in the analysis. The survey data were linked to the Finnish Medical Birth Register, the Register of Induced Abortions, and the Care Register for Health Care until 2018. For each outcome, logistic regression was used and adjusted for age, body mass index, time lived in Finland, and the number of births.

RESULTS

A total of 67% of Somali-origin and 71% of Kurdish-origin women had experienced potentially traumatic experiences pre-migration and 64% of Somali- and 32% of Kurdish-origin women had also undergone FGM/C. In Kurdish-origin women, complications during pregnancy (e.g. bleeding in the first trimester, known or suspected fetal abnormality, signs of fetal hypoxia, death of the fetus and other problems) were significantly more common among women without potentially traumatic experiences (70%) than among women with potentially traumatic experiences (48%) (p-value 0.005). No associations between potentially traumatic experiences or FGM/C and other adverse reproductive outcomes were observed among Somali- or Kurdish-origin women.

CONCLUSION

Past trauma is common among Somali- and Kurdish-origin women and this needs to be evaluated in maternity care. However, we found no association between potentially traumatic experiences pre-migration and adverse reproductive outcomes.

A Systematic Review and Meta-Analysis of the Risk of Stillbirth, Perinatal and Neonatal Mortality in Immigrant Women

Objectives: This study aimed to investigate the risk of stillbirth, perinatal and neonatal mortality in immigrant women compared to native-origin women in host countries. Methods: A systematic literature review and meta-analysis was conducted. Relevant studies were identified using a thorough literature search and their quality was appraised. The analysis of heterogeneous data was carried out using the random effects model and publication bias was assessed using the Harbord-test. Also, the pooled odds ratio of events was calculated through the DerSimonian and Laird, and inverse variance methods. Results: In the search process 45 studies were retrieved consisting of 8,419,435 immigrant women and 40,113,869 native-origin women. The risk of stillbirth (Pooled OR = 1.35, 95% CI = 1.22-1.50), perinatal mortality (Pooled OR = 1.50, 95% CI = 1.35-1.68), and neonatal mortality (Pooled OR = 1.09, 95% CI = 1.00-1.19) in the immigrant women were significantly higher than the native-origin women in host countries. According to the sensitivity analyses, all results were highly consistent with the main data analysis results. Conclusion: The immigrant women compared to the native-origin women had the higher risks of stillbirth, perinatal and neonatal mortality. Healthcare providers and policy makers should improve the provision of maternal and neonatal healthcare for the immigrant population.

Ethnic variation in causes of stillbirth in high income countries: A systematic review and meta-analysis

OBJECTIVE

Inequities in stillbirth rate according to ethnicity persist in high income nations. The objective of the present study is to investigate whether causes of stillbirth differ by ethnicity in high-income nations.

METHODS

The following databases were searched since their inception to 1 February 2021: Medline, Embase, Scopus, CINAHL, Cochrane Library, and Global Health. Cohort, cross-sectional, and retrospective studies were included. Causes of stillbirth were aligned to the International Classification of Disease 10 for Perinatal Mortality (ICD10-PM) and pooled estimates were derived by meta-analysis.

RESULTS

Fifteen reports from three countries (72 555 stillbirths) were included. Seven ethnic groups - "Caucasian" (n = 11 studies), "African" (n = 11 studies), "Hispanic" (n = 7 studies), "Indigenous Australian" (n = 4 studies), "Asian" (n = 2 studies), "South Asian" (n = 2 studies), and "American Indian" (n = 1 study) - were identified. There was an overall paucity of recent, high-quality data for many ethnicities. For those with the greatest amount of data - Caucasian, African, and Hispanic - no major differences in the causes of stillbirth were identified.

CONCLUSION

There is a paucity of high-quality information on causes of stillbirth for many ethnicities. Improving investigation and standardizing classification of stillbirths is needed to assess whether causes of stillbirth differ across more diverse ethnic groups.

Social and ethnic disparities in stillbirth and infant death in Denmark, 2005-2016

Ethnic disparity in stillbirth and infant death has been demonstrated in Europe. As the relation between migration and health change over time, this population based register study investigated the recent figures and explored if potential differences could be explained by the well-known educational and income inequalities in stillbirth and infant death using a novel approach. Stillbirth and infant mortality varied considerably according to country of origin, with only immigrants from China, Norway, and Poland having an overall lower risk than Danish women. Women of Pakistani, Turkish, and Somali origin had a particularly high risk of both outcomes. Women from recent high conflict areas displayed a pattern with increased stillbirth risk. An observed excess risks across generations was found, which is disturbing and rule out factors related to language barriers or newness. Differences in educational level and household income explained only part of the observed inequalities. Strengthening of the maternity care system to better understand and meet the needs of immigrant women seems needed to mitigate the disparities.

The provision of epidural analgesia during labor according to maternal birthplace: a Norwegian register study

BACKGROUND

The provision of epidural analgesia during labor is ideally a shared decision between the woman and her health care provider. However, immigrant characteristics such as maternal birthplace could affect decision-making and thus access to pain relief. We aimed to assess disparities in the provision of epidural analgesia in planned vaginal birth according to maternal region of birth.

METHODS

We performed a nation-wide register study of 842,496 live-born singleton deliveries in Norway between 2000 and 2015. Maternal birthplace was categorized according to the Global Burden of Disease framework. The provision of epidural analgesia was compared in regression models stratified by parity and mode of delivery.

RESULTS

Compared to native-born women, primiparous women from Latin America/Caribbean countries with an instrumental vaginal delivery were most likely to be provided epidural analgesia (OR 2.12, 95%CI 1.69-2.66), whilst multiparous women from Sub-Saharan Africa with a spontaneous vaginal delivery were least likely to be provided epidural analgesia (OR 0.42, 95% C 0.39-0.44). Longer residence time was associated with a higher likelihood of being provided analgesia, whereas effects of maternal education varied by Global Burden of Disease group.

CONCLUSIONS

Disparities in the likelihood of being provided epidural analgesia were observed by maternal birthplace. Further studies are needed to consider whether the identified disparities represent women's own preferences or if they are the result of heterogeneous access to analgesia during labor.

ehealth literacy and health literacy among immigrants and their descendants compared with women of Danish origin: a cross-sectional study using a multidimensional approach among pregnant women

OBJECTIVE

To explore ehealth literacy, ability to actively engage with healthcare providers and health system navigation among pregnant immigrant women and their descendants compared with women of Danish origin.

DESIGN AND SETTING

A cross-sectional survey at antenatal clinics in 2016, Denmark.

PARTICIPANTS

Pregnant women attending antenatal care (n=405).

OUTCOME MEASURES

The eHealth Literacy Questionnaire (eHLQ) and two domains from the Health Literacy Questionnaire (HLQ): ability to actively engage with healthcare providers and health system navigation. Range of response options for eHLQ (1-4) and HLQ (1-5). With mixed-effect linear regressions, eHLQ and HLQ among immigrants and their descendants compared with women of Danish origin were assessed.

RESULTS

The response rate was 75%. The overall trend was lower ehealth literacy and HLQ domains among immigrants and their descendants compared with women of Danish origin. For ehealth literacy, the results suggest that challenges related more to digital abilities than motivation, trust and access to technology. The mean ability to engage with digital services was 3.20 (SD 0.44) for women of Danish origin. Non-Western descendants (-0.14, 95% CI -0.31 to 0.02), non-Western (-0.20, 95% CI -0.34 to -0.06) and Western (-0.22, 95% CI -0.39 to -0.06) immigrants had lower adjusted means of this outcome. No differences in motivation to engage with digital services were found for descendants (-0.00, 95% CI -0.17 to 0.17), non-Western (0.03, 95% CI -0.11 to 0.18) or Western (-0.06, 95% CI -0.23 to 0.10) immigrants compared with the mean of the reference (2.85, SD 0.45). Lower ability to engage with healthcare providers was found for non-Western born immigrants (-0.15, CI 95% -0.30 to -0.01) compared with the mean of women with Danish origin (4.15, SD 0.47).

CONCLUSION

Generally, descendant and immigrant women had lower levels of ehealth literacy and health literacy than women of Danish origin. These differences are potentially antecedents of adverse birth outcomes and could inform structural efforts to mitigate health inequalities.

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

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.

Inherited predisposition to stillbirth: an intergenerational analysis of 26,788 mother-daughter pairs

BACKGROUND

Previous evidence suggests that placental dysfunction, which includes preeclampsia, is inherited from mother to daughter, but heritability of stillbirth has never been investigated.

OBJECTIVE

The purpose of this study was to investigate whether there is an inherited predisposition to stillbirth that is transmitted from mother to daughter.

STUDY DESIGN

We carried out a nested case-control study within the intergenerational cohort held in the Aberdeen Maternity and Neonatal Databank. All mothers who had at least 1 daughter in Aberdeen, United Kingdom, between 1949 and 2000 were included. Mother-daughter pairs were linked with the use of the Scottish Community Health Index number. The main exposure was the mother's history of stillbirth. The primary outcome was stillbirth in any of the daughter's pregnancies. A population average model that used generalized estimating equations with robust standard errors was used to estimate odds of a mother's history of stillbirth in daughters with a stillbirth compared with daughters with only livebirths. This method accounted for clustering of daughters within mothers, and multi-adjusted analyses were performed to include confounders at the daughter's pregnancy level.

RESULTS

Among the daughters, 384 had a history of ≥1 stillbirths (cases); 26,404 only ever had livebirths (control subjects). We found no statistically significant association between mothers' history of stillbirth (adjusted odds ratio, 0.63; 95% confidence interval, 0.24-1.63) or miscarriage (adjusted odds ratio, 1.01; 95% confidence interval, 0.71-1.42) and stillbirth in daughters.

CONCLUSION

This is the first study to investigate an inherited predisposition to stillbirth. There was no evidence of an inherited predisposition to stillbirth transmitted from mother to daughter.

Stillbirth in relation to maternal country of birth and other migration related factors: a population-based study in Norway

BACKGROUND

Migrant women's overall increased risk of adverse pregnancy outcomes is well known. The aim of this study was to investigate possible associations between stillbirth and maternal country of birth and other migration related factors (paternal origin, reason for immigration, length of residence and birthplace of firstborn child) in migrant women in Norway.

METHODS

Nationwide population-based study including births to primiparous and multiparous migrant women (n = 198,520) and non-migrant women (n = 1,156,444) in Norway between 1990 and 2013. Data from the Medical Birth Registry of Norway and Statistics Norway. Associations were investigated by multiple logistic regression and reported as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Primiparous women from Sri-Lanka and Pakistan, and multiparous women from Pakistan, Somalia, the Philippines and Former Yugoslavia had higher odds of stillbirth when compared to non-migrant women (adjusted OR ranged from 1.58 to 1.79 in primiparous and 1.50 to 1.71 in multiparous women). Primiparous migrant women whose babies were registered with Norwegian-born fathers had decreased odds of stillbirth compared to migrant women whose babies were registered with foreign-born fathers (aOR = 0.73; CI 0.58-0.93). Primiparous women migrating for work or education had decreased odds of stillbirth compared to Nordic migrants (aOR = 0.58; CI 0.39-0.88). Multiparous migrant women who had given birth to their first child before arriving in Norway had higher odds of stillbirth in later births in Norway compared with multiparous migrant women who had their first child after arrival (aOR = 1.28; CI 1.06-1.55). Stillbirth was not associated with length of residence in Norway.

CONCLUSIONS

This study identifies sub-groups of migrant women who are at an increased risk of stillbirth, and highlights the need to improve care for them. More attention should be paid to women from certain countries, multiparous women who had their first baby before arrival and primiparous women whose babies have foreign-born fathers.

Stillbirth in relation to maternal country of birth and other migration related factors: a population-based study in Norway

Background

Migrant women’s overall increased risk of adverse pregnancy outcomes is well known. The aim of this study was to investigate possible associations between stillbirth and maternal country of birth and other migration related factors (paternal origin, reason for immigration, length of residence and birthplace of firstborn child) in migrant women in Norway.

Methods

Nationwide population-based study including births to primiparous and multiparous migrant women (n = 198,520) and non-migrant women (n = 1,156,444) in Norway between 1990 and 2013. Data from the Medical Birth Registry of Norway and Statistics Norway. Associations were investigated by multiple logistic regression and reported as odds ratios (ORs) with 95% confidence intervals (CIs).

Results

Primiparous women from Sri-Lanka and Pakistan, and multiparous women from Pakistan, Somalia, the Philippines and Former Yugoslavia had higher odds of stillbirth when compared to non-migrant women (adjusted OR ranged from 1.58 to 1.79 in primiparous and 1.50 to 1.71 in multiparous women). Primiparous migrant women whose babies were registered with Norwegian-born fathers had decreased odds of stillbirth compared to migrant women whose babies were registered with foreign-born fathers (aOR = 0.73; CI 0.58–0.93). Primiparous women migrating for work or education had decreased odds of stillbirth compared to Nordic migrants (aOR = 0.58; CI 0.39–0.88). Multiparous migrant women who had given birth to their first child before arriving in Norway had higher odds of stillbirth in later births in Norway compared with multiparous migrant women who had their first child after arrival (aOR = 1.28; CI 1.06–1.55). Stillbirth was not associated with length of residence in Norway.

Conclusions

This study identifies sub-groups of migrant women who are at an increased risk of stillbirth, and highlights the need to improve care for them. More attention should be paid to women from certain countries, multiparous women who had their first baby before arrival and primiparous women whose babies have foreign-born fathers.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2140-3) contains supplementary material, which is available to authorized users.

The association of maternal country of birth and education with hypertensive disorders of pregnancy: A population-based study of 960 516 deliveries in Norway

INTRODUCTION

Previous studies estimating the association of maternal country of birth and education with hypertensive disorders of pregnancy (HDP) have shown conflicting results. The aim of the study was to assess the prevalence of HDP and estimate the association of maternal country of birth and education level with preeclampsia/eclampsia and gestational hypertension in Norway.

MATERIAL AND METHODS

We performed a population-based observational cohort study linking two population datasets: The Medical Birth Registry of Norway and Statistics Norway (SSB). Singleton deliveries in Norway between 1999 and 2014 (907 048 deliveries) were stratified by parity. Multiple regression analysis was performed.

RESULTS

In 20% of the deliveries the woman was born outside of Norway. Foreign-born women had lower risk of preeclampsia/eclampsia and gestational hypertension compared with Norwegian-born women. High education reduced the risk for preeclampsia/eclampsia by 34% (adjusted odds ratio 0.66, 95% CI 0.62-0.69), compared with women with secondary education among nulliparous women, and by 39% (adjusted odds ratio 0.61, 95% CI 0.57-0.65) among parous women. Poorly educated women had no increased risk of HDP compared with women with secondary education. Among highly educated nulliparous women the risk of preeclampsia/eclampsia was lower but the risk of gestational hypertension higher compared with women of similar parity with secondary education. Adjustment for confounding variables had minimal effect on these estimates.

CONCLUSIONS

Maternal country of birth and education were associated with HDP. Women with higher education had the lowest risk of HDP, and Norwegian-born women had the highest risk of HDP, regardless of parity and other confounding factors.

Effects of maternal anthropometrics on pregnancy outcomes in South Asian women: a systematic review

AIM

This systematic review investigates associations between maternal pre-pregnancy/early-pregnancy anthropometrics (e.g. weight and body fat), anthropometric change and pregnancy outcomes in South Asian and White women.

METHODS

Twelve electronic literature databases, reference lists and citations of all included studies were searched. Observational studies published in the English language were included. Descriptive synthesis was used to summarize the evidence base.

RESULTS

Twenty-two studies met the inclusion criteria (403,609 births [351,856 White and 51,753 South Asian]). Nine were prospective cohort studies, nine were retrospective cohort studies and two were cross-sectional studies. Results suggested that in South Asian women, maternal pre-pregnancy/early-pregnancy anthropometrics were associated with anthropometric change, birthweight, mode of delivery and gestational diabetes mellitus (GDM). Gestational anthropometric change was found to be associated with GDM. There was limited evidence to suggest that there may be associations between maternal pre-anthropometrics/early anthropometrics and hypertensive disorders, stillbirth, congenital anomalies, post-natal weight retention and post-natal impaired glucose tolerance. The evidence suggested a combined effect of pre-pregnancy/early-pregnancy anthropometrics and gestational anthropometric change on both GDM and post-natal weight retention.

CONCLUSION

The increased risk of adverse pregnancy outcomes in South Asian women should be considered in guidelines for weight management before and during pregnancy.

Stillbirth and congenital anomalies in migrants in Europe

The risk of giving birth to a stillborn child or a child with severe congenital anomaly is higher for women who have immigrated to Europe as compared to the majority population in the receiving country. The literature, however, reveals great differences between migrant groups, even within migrants from low-income countries, although there is no clear pattern regarding refugee or non-refugee status. This heterogeneity argues against a particular migration-related explanation. There are social disparities in stillbirth risk worldwide, and it has been suggested that the demonstrated ethnic disparity is a result of the socioeconomic disadvantage most migrants face. Consanguinity has been considered as another cause for the increased stillbirth risk and the high risk of congenital anomaly observed in many migrant groups. Utilization and quality of care during pregnancy and childbirth is the third major aspect. All three factors seem to contribute to stillbirth risk, and they should be considered in clinical practice and public health.

A Register-Based Study of Diseases With an Autosomal Recessive Origin in Small Children in Denmark According to Maternal Country of Origin

BACKGROUND

Compared with children born of Danish mothers, the mortality of children, born and living in Denmark, is significantly increased in those with a mother from Afghanistan, Iraq, Pakistan, Somalia, and Turkey. Consanguinity has been suggested to account for part of this disparity. Since information on consanguinity is lacking, this suggestion is difficult to test. With an indirect approach, we addressed this question by comparing the risk of diseases with autosomal recessive inheritance in children born in Denmark of Danish-born women and of women born in these five countries, respectively.

METHODS

All children born in Denmark (1994-2010) were followed until 5 years of age or end-of-study period for the risk of hospitalisation with diseases of autosomal recessive aetiology, and therefore considered consanguinity-related. Diagnoses of autosomal recessive diseases were identified using two different methods: a literature review of consanguinity-associated diseases and a search in the Online Catalogue of Human Genes and Genetic Disorders. Risks were also calculated for diseases with known non-autosomal recessive aetiology (considered non-consanguinity-related). We estimated adjusted hazard ratios for the diseases in children of foreign-born women compared with children of Danish-born women.

RESULTS

Compared with offspring of Danish-born women, the risk of a consanguinity-related disease was significantly increased in children of foreign-born women, although the absolute risk was low. The risk of non-consanguinity-related diseases did not differ between the groups compared.

CONCLUSIONS

The findings support the hypothesis that consanguinity accounts for some, however a minor part, of the disparity in child mortality among migrants in Denmark.

UK Pakistani views on the adverse health risks associated with consanguineous marriages

This is a qualitative study exploring the perceptions of members from the Pakistani/Kashmiri community living in Luton, UK, on the adverse health risks associated with consanguineous marriages. Rates of stillbirths and infant mortality are higher than the national average in Luton and the existing evidence base suggests that these higher rates may be associated with consanguinity (especially first cousin marriages) in highly consanguineous populations, such as the Pakistani/Kashmiri ethnic group. This qualitative study included 9 focus groups and 10 one to one in-depth interviews (n = 58) with members from the Pakistani/Kashmiri community in Luton during 2012. Audio-recorded transcripts were analysed using framework analysis. Emerging themes included a limited knowledge, opposition to evidence and need for a more culturally sensitive health services approach. Findings from the focus group and interview discussions indicated that participants had a limited and varied understanding of genetic risk and indicated a lack of discussion within the community regarding genetic risk. They also opposed evidence that may link consanguineous marriages with infant mortality, stillbirth or genetic disorders that led to disability. The participants stressed the need for culturally sensitive and locally constructed services for information on genetic risk and services. These findings may be used to address higher rates of infant mortality and adverse health impacts associated with higher rates of consanguinity in Luton and elsewhere, through a partnership approach, improve upon current services and develop culturally appropriate services.

The neuropathology of stillbirth - correlation with apolipoprotein genotype in a Scottish population based study

BACKGROUND

The neuropathology of stillbirths has been widely studied but rarely on a population basis. Whether foetal apolipoprotein E (APOE) genotype exerts any influence has been little investigated, despite well known effects in adult brains.

AIMS

To establish the neuropathology of a population cohort of stillbirths and compare with the APOE genotype.

STUDY DESIGN AND SUBJECTS

The brains of 191 stillbirths (≥24weeks of gestation) were recruited from a Scottish population cohort and grouped by clinical history. APOE genotype was available for 97%.

RESULTS AND CONCLUSIONS

One or more neuropathological features, most appearing relatively recent, were found in 54% of 157 antepartum singletons, 44% of 9 abruption-associated stillbirths, 85% of 13 in multiple pregnancies but in only 19% of 12 intrapartum stillbirths. White matter injury (WMI) occurred in 36% of preterm and 21% mature stillbirths. Fresh petechial haemorrhages were common in all groups (29%) but germinal matrix haemorrhage (GMH) (7%) and periventricular leucomalacia (1%) were confined to preterm. GMH was significantly associated with WMI (p=0.003). Placental inflammation was common in intrapartum stillbirths (50%), compared with antepartum (15%), multiple pregnancy (23%) and abruption (0%). β-Amyloid precursor protein (βAPP) positive axons (36% stillbirths overall) correlated closely with WMI (p<0.0001), justifying future routine inclusion in foetal neuropathological investigation. This study highlights the paucity of brain damage in intrapartum stillbirths. While APOE2 was significantly overrepresented in stillbirths, there was no correlation between APOE genotype and neuropathological findings. We conclude that APOE does not influence neuropathological outcomes in stillbirths.