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Increased risk of adverse perinatal outcome among Somali immigrants in Washington State
SMFM Abstracts S125 433
RACIAL DISPARITY IN PERINATAL MORTALITY - RESULTS FROM THE FASTER TRIAL ANDREW HEALY1, FERGAL MALONE1, GINA PELOSO2, ROBERT BALL3, DAVID LUTHY4, CHRISTINE H. COMSTOCK5, RADEK BUKOWSKI6, RICHARD BERKOWITZ7, SUSAN GROSS8, LORRAINE DUGOFF9, SABRINA CRAIGO10, ILAN TIMOR11, STEPHEN CARR12, HONOR WOLFE13, MARY D’ALTON1, 1Columbia University, New York, New York, 2 DM-STAT, Boston, Massachusetts, 3University of Utah Health Sciences Center, Salt Lake City, Utah, 4Swedish Medical Center, Seattle, Washington, 5 William Beaumont Hospital, Royal Oak, Michigan, 6UTMB, Galveston, Texas, 7 Mount Sinai Medical Center, New York, New York, 8Albert Einstein College of Medicine, New York, New York, 9University of Colorado Health Sciences Center, Denver, Colorado, 10Tufts University, Boston, Massachusetts, 11New York University, New York, New York, 12Brown University, Providence, Rhode Island, 13UNC, Chapel Hill, North Carolina OBJECTIVE: Does access to prenatal care correct the disparity in perinatal mortality between white and minority populations in contemporary obstetric practice? STUDY DESIGN: A prospective database from a large multicenter investigation of singleton pregnancies, the FASTER trial, was studied. This database contains detailed antenatal, birth and pediatric outcomes on a large unselected obstetric population. Elective terminations were excluded from this analysis (n = 36,068). Inclusion in the trial necessitated early first trimester access to prenatal care. Multivariable logistic regression analysis was used to assess the persistent effect of race on perinatal loss in the presence of prenatal care, adjusting for potential confounding factors. RESULTS: Despite controlling for access to prenatal care, minority pregnancies experienced more perinatal mortality when compared to pregnancies in the white population. This disparity was most evident in the black population. When odds ratios were adjusted for demographic differences calculated values remained significant for the black race (OR 3.2 [1.7, 5.8]) and ‘‘others’’ (OR 2.2 [1.1, 4.3]) (Table). CONCLUSION: These findings strongly suggest improving access to prenatal care alone is not sufficient to correct this disparity. Clinicians must strive to identify the etiologies of this adverse outcome within minority populations so that prenatal care systems can be directed toward eliminating racial disparities in perinatal mortality.
435
Birth weight by categories (reference group Caucasian)
Estimation of loss by race (adjusted odds ratios, white population (n = 24,388) as referent population) Race Fetal loss !24 wk Fetal loss R24 wk Neonatal death Perinatal mortality
434
Black (n = 1836)
Hispanic P value (n = 8076)
2.0 (0.9, 4.4)
.08
Other P value (n = 1768)
P value
1.2 (0.6, 2.4) .6
1.9 (0.8, 4.5)
4.5 (1.7, 11.6) .002
1.2 (0.4, 3.5) .7
2.8 (0.8, 10.0) .11
5.0 (2.2, 11.7) .0002
1.0 (0.4, 2.3) .9
3.0 (1.0, 8.9)
.04
3.2 (1.7, 5.8)
1.3 (0.8, 2.3) .3
2.2 (1.1, 4.3)
.02
.0002
TRENDS IN BIRTH WEIGHT OVER TWENTY-FIVE YEARS AMONG WOMEN OF DIFFERING ETHNICITIES LINDA M. HOPKINS1, AARON B. CAUGHEY1, DAVID GLIDDEN2, RUSSELL K. LAROS JR1, 1University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California, 2University of California, San Francisco, Epidemiology and Biostatistics, San Francisco, California OBJECTIVE: To examine whether birth weights have increased among infants of differing ethnicities. STUDY DESIGN: Retrospective cohort study of all women who underwent a term (37-42 weeks) delivery of a live, nonanomalous singleton at a single institution. Predictor variables were ethnicity and delivery year with the primary outcome variable birth weight. Multivariate regression analysis was used to detect trends in birth weight and risk of birth weight !2500 g, >4000 g, and >4500 g. Potential confounders controlled for included gender, nulliparity, gestational age, maternal age, induction, diabetes, preeclampsia, chronic hypertension, tobacco use, socioeconomic status, pregnancy weight gain, and body mass index. RESULTS: 33,581 births met criteria. Linear regression analysis of yearly trends in birth weight revealed a 5 g/year increase in African-American infants (P = .004) and 6.5 g/year increase in Filipino infants (P = .007) with a trend for increasing weight (1.7 g/year) for Caucasians (P = .077). Logistic regression analysis for risk of birth weight !2500 g, >4000, and >4500 g by 5-year increments is depicted in the Table. CONCLUSION: When potential confounders are controlled for, only AfricanAmerican and Filipino women are noted to have significantly increasing birth weights over time. Also, only the latter are experiencing greater numbers of birth weights >4000 g. These results are novel and expand upon previous studies emphasizing the importance of considering individual ethnicities and maternal factors in this type of study.
Ethnicity
!2500 g OR (P value)
O4000 g OR (P value)
O4500 g OR (P value)
Study population African-American Chinese Filipino Latina
.92 .91 .58 .86 .87
.95 .99 .99 1.40 .95
.97 1.21 1.28 1.85 .97
(.126) (.417) (.010) (.413) (.505)
(.030) (.948) (.918) (.012) (.471)
(.549) (.431) (.388) (.049) (.892)
.15
ARE THERE ETHNIC DIFFERENCES IN LENGTH OF LABOR? LINDA M. HOPKINS1, CHRISTINA WASSEL FYR2, MARA GREENBERG1, JEANETTE BROWN1, DAVID THOM3, STEPHEN K. VAN DEN EEDEN4, ARONA I. RAGINS2, AARON B. CAUGHEY1, 1University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California, 2University of California, San Francisco, Epidemiology and Biostatistics, San Francisco, California, 3University of California, San Francisco, Family and Community Medicine, San Francisco, California, 4Kaiser Permanente Division of Research, Oakland, California OBJECTIVE: To determine predictors of labor length among a diverse population-based group of women. STUDY DESIGN: Retrospective study of a population-based cohort of ethnically diverse women using information derived from detailed interviews and chart abstracted labor and delivery records archived since 1946. Women with a singleton vertex presentation who completed at least the first stage of labor were included in the study. Predictors of labor length included ethnicity (Caucasian, African-American, Latina, Asian, Native American), anesthesia, fetal position, oxytocin use, years since last delivery, type of delivery, birth weight, maternal weight, diabetes, education and income. Outcome variables were length of first, second and total labor. Regression analysis was performed controlling for potential confounders with stratification by parity. RESULTS: Among 1307 nulliparous births, African-American women had a significantly longer first stage of labor (+92 minutes, P = .013) as compared to Caucasians. Occiput posterior or transverse positions were also associated with significantly longer first stage (+83 minutes, P = .036) compared to occiput anterior position. For the second stage of labor, significant variables included maternal age (2.4% increase per year, P = .003) and birth weight (.02% change per gram, P ! .001). Among 2577 multiparous births, AfricanAmerican women again had a significantly longer first stage of labor (+37 minutes, P = .035). Length of second stage was significantly longer for occiput posterior or transverse position (36% increase, P ! .001), and regional anesthesia (44% increase, P ! .001). CONCLUSION: African-American ethnicity, occiput posterior and occiput transverse position were associated with a longer length of first stage of labor. Birth weight, maternal age, regional anesthesia and occiput posterior or transverse position were associated with an increased second stage of labor. Ethnic differences in length of labor were limited to differences in the first stage and only for African-American women.
436
INCREASED RISK OF ADVERSE PERINATAL OUTCOME AMONG SOMALI IMMIGRANTS IN WASHINGTON STATE BLAIR JOHNSON1, SUSAN REED2, JANE HITTI2, MANEESH BATRA3, 1University of Washington, Obstetrics and Gynecology, Seattle, Washington, 2University of Washington, Obstetrics and Gynecology, Epidemiology, Seattle, Washington, 3University of Washington, Pediatrics, Seattle, Washington OBJECTIVE: To compare maternal and neonatal morbidity among Somali immigrants, US-born Blacks and US-born Whites in Washington state. Secondly, to address concerns of the Somali community that obstetric interventions occur too quickly, frequently and unnecessarily in the United States. STUDY DESIGN: Washington State birth certificate data was linked to hospital discharge records comparing singleton deliveries among Somali immigrants to US-born Blacks and US-born Whites between 1993 and 2001 in a 1:4 ratio. Outcomes were compared using unconditional multiple logistic regression models, calculating odds ratios and 95% confidence intervals. RESULTS: 579 pregnancies from Somali women were compared with 2384 and 2435 pregnancies from US-born Black and White women, respectively. Somali women were more likely to deliver after 42 weeks gestation (OR = 9.0*, OR = 9.0**) and during labor were more likely to have intrapartum oligohydramnios (OR = 3.7*, OR = 7.9**), meconium (OR = 2.6*, OR = 6.4**) and fetal distress (OR = 1.9*, OR = 3.1**), even after controlling for gestational age. Nulliparous Somali women were more likely to have a cesarean delivery (OR = 1.6*, OR = 2.0**); and, cesarean delivery, among both nulliparous and multiparous Somalis, was more commonly associated with fetal distress. Somali women were at increased risk of perineal lacerations, febrile illness, and transfusion. Their newborns were at increased risk for prolonged hospitalization (OR = 1.7*, OR = 2.3**), lower 5-minute Apgar scores (OR = 3.1*, OR = 5.2**), assisted ventilation (OR = 3.8*, OR = 11.1**), and meconium aspiration (OR = 14.4*, OR = 27.7**). *OR comparing Somali to US-born Blacks. **OR comparing Somali to US-born Whites. CONCLUSION: Pregnancy outcomes should be evaluated within ethnically and culturally unique groups. Somali immigrants represent a high-risk subpopulation. In response to our research, several community-wide educational forums have been organized to educate the Somali community about their unique perinatal risks and to address their specific obstetric concerns.
RACIAL DISPARITY IN PERINATAL MORTALITY - RESULTS FROM THE FASTER TRIAL ANDREW HEALY1, FERGAL MALONE1, GINA PELOSO2, ROBERT BALL3, DAVID LUTHY4, CHRISTINE H. COMSTOCK5, RADEK BUKOWSKI6, RICHARD BERKOWITZ7, SUSAN GROSS8, LORRAINE DUGOFF9, SABRINA CRAIGO10, ILAN TIMOR11, STEPHEN CARR12, HONOR WOLFE13, MARY D’ALTON1, 1Columbia University, New York, New York, 2 DM-STAT, Boston, Massachusetts, 3University of Utah Health Sciences Center, Salt Lake City, Utah, 4Swedish Medical Center, Seattle, Washington, 5 William Beaumont Hospital, Royal Oak, Michigan, 6UTMB, Galveston, Texas, 7 Mount Sinai Medical Center, New York, New York, 8Albert Einstein College of Medicine, New York, New York, 9University of Colorado Health Sciences Center, Denver, Colorado, 10Tufts University, Boston, Massachusetts, 11New York University, New York, New York, 12Brown University, Providence, Rhode Island, 13UNC, Chapel Hill, North Carolina OBJECTIVE: Does access to prenatal care correct the disparity in perinatal mortality between white and minority populations in contemporary obstetric practice? STUDY DESIGN: A prospective database from a large multicenter investigation of singleton pregnancies, the FASTER trial, was studied. This database contains detailed antenatal, birth and pediatric outcomes on a large unselected obstetric population. Elective terminations were excluded from this analysis (n = 36,068). Inclusion in the trial necessitated early first trimester access to prenatal care. Multivariable logistic regression analysis was used to assess the persistent effect of race on perinatal loss in the presence of prenatal care, adjusting for potential confounding factors. RESULTS: Despite controlling for access to prenatal care, minority pregnancies experienced more perinatal mortality when compared to pregnancies in the white population. This disparity was most evident in the black population. When odds ratios were adjusted for demographic differences calculated values remained significant for the black race (OR 3.2 [1.7, 5.8]) and ‘‘others’’ (OR 2.2 [1.1, 4.3]) (Table). CONCLUSION: These findings strongly suggest improving access to prenatal care alone is not sufficient to correct this disparity. Clinicians must strive to identify the etiologies of this adverse outcome within minority populations so that prenatal care systems can be directed toward eliminating racial disparities in perinatal mortality.
435
Birth weight by categories (reference group Caucasian)
Estimation of loss by race (adjusted odds ratios, white population (n = 24,388) as referent population) Race Fetal loss !24 wk Fetal loss R24 wk Neonatal death Perinatal mortality
434
Black (n = 1836)
Hispanic P value (n = 8076)
2.0 (0.9, 4.4)
.08
Other P value (n = 1768)
P value
1.2 (0.6, 2.4) .6
1.9 (0.8, 4.5)
4.5 (1.7, 11.6) .002
1.2 (0.4, 3.5) .7
2.8 (0.8, 10.0) .11
5.0 (2.2, 11.7) .0002
1.0 (0.4, 2.3) .9
3.0 (1.0, 8.9)
.04
3.2 (1.7, 5.8)
1.3 (0.8, 2.3) .3
2.2 (1.1, 4.3)
.02
.0002
TRENDS IN BIRTH WEIGHT OVER TWENTY-FIVE YEARS AMONG WOMEN OF DIFFERING ETHNICITIES LINDA M. HOPKINS1, AARON B. CAUGHEY1, DAVID GLIDDEN2, RUSSELL K. LAROS JR1, 1University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California, 2University of California, San Francisco, Epidemiology and Biostatistics, San Francisco, California OBJECTIVE: To examine whether birth weights have increased among infants of differing ethnicities. STUDY DESIGN: Retrospective cohort study of all women who underwent a term (37-42 weeks) delivery of a live, nonanomalous singleton at a single institution. Predictor variables were ethnicity and delivery year with the primary outcome variable birth weight. Multivariate regression analysis was used to detect trends in birth weight and risk of birth weight !2500 g, >4000 g, and >4500 g. Potential confounders controlled for included gender, nulliparity, gestational age, maternal age, induction, diabetes, preeclampsia, chronic hypertension, tobacco use, socioeconomic status, pregnancy weight gain, and body mass index. RESULTS: 33,581 births met criteria. Linear regression analysis of yearly trends in birth weight revealed a 5 g/year increase in African-American infants (P = .004) and 6.5 g/year increase in Filipino infants (P = .007) with a trend for increasing weight (1.7 g/year) for Caucasians (P = .077). Logistic regression analysis for risk of birth weight !2500 g, >4000, and >4500 g by 5-year increments is depicted in the Table. CONCLUSION: When potential confounders are controlled for, only AfricanAmerican and Filipino women are noted to have significantly increasing birth weights over time. Also, only the latter are experiencing greater numbers of birth weights >4000 g. These results are novel and expand upon previous studies emphasizing the importance of considering individual ethnicities and maternal factors in this type of study.
Ethnicity
!2500 g OR (P value)
O4000 g OR (P value)
O4500 g OR (P value)
Study population African-American Chinese Filipino Latina
.92 .91 .58 .86 .87
.95 .99 .99 1.40 .95
.97 1.21 1.28 1.85 .97
(.126) (.417) (.010) (.413) (.505)
(.030) (.948) (.918) (.012) (.471)
(.549) (.431) (.388) (.049) (.892)
.15
ARE THERE ETHNIC DIFFERENCES IN LENGTH OF LABOR? LINDA M. HOPKINS1, CHRISTINA WASSEL FYR2, MARA GREENBERG1, JEANETTE BROWN1, DAVID THOM3, STEPHEN K. VAN DEN EEDEN4, ARONA I. RAGINS2, AARON B. CAUGHEY1, 1University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California, 2University of California, San Francisco, Epidemiology and Biostatistics, San Francisco, California, 3University of California, San Francisco, Family and Community Medicine, San Francisco, California, 4Kaiser Permanente Division of Research, Oakland, California OBJECTIVE: To determine predictors of labor length among a diverse population-based group of women. STUDY DESIGN: Retrospective study of a population-based cohort of ethnically diverse women using information derived from detailed interviews and chart abstracted labor and delivery records archived since 1946. Women with a singleton vertex presentation who completed at least the first stage of labor were included in the study. Predictors of labor length included ethnicity (Caucasian, African-American, Latina, Asian, Native American), anesthesia, fetal position, oxytocin use, years since last delivery, type of delivery, birth weight, maternal weight, diabetes, education and income. Outcome variables were length of first, second and total labor. Regression analysis was performed controlling for potential confounders with stratification by parity. RESULTS: Among 1307 nulliparous births, African-American women had a significantly longer first stage of labor (+92 minutes, P = .013) as compared to Caucasians. Occiput posterior or transverse positions were also associated with significantly longer first stage (+83 minutes, P = .036) compared to occiput anterior position. For the second stage of labor, significant variables included maternal age (2.4% increase per year, P = .003) and birth weight (.02% change per gram, P ! .001). Among 2577 multiparous births, AfricanAmerican women again had a significantly longer first stage of labor (+37 minutes, P = .035). Length of second stage was significantly longer for occiput posterior or transverse position (36% increase, P ! .001), and regional anesthesia (44% increase, P ! .001). CONCLUSION: African-American ethnicity, occiput posterior and occiput transverse position were associated with a longer length of first stage of labor. Birth weight, maternal age, regional anesthesia and occiput posterior or transverse position were associated with an increased second stage of labor. Ethnic differences in length of labor were limited to differences in the first stage and only for African-American women.
436
INCREASED RISK OF ADVERSE PERINATAL OUTCOME AMONG SOMALI IMMIGRANTS IN WASHINGTON STATE BLAIR JOHNSON1, SUSAN REED2, JANE HITTI2, MANEESH BATRA3, 1University of Washington, Obstetrics and Gynecology, Seattle, Washington, 2University of Washington, Obstetrics and Gynecology, Epidemiology, Seattle, Washington, 3University of Washington, Pediatrics, Seattle, Washington OBJECTIVE: To compare maternal and neonatal morbidity among Somali immigrants, US-born Blacks and US-born Whites in Washington state. Secondly, to address concerns of the Somali community that obstetric interventions occur too quickly, frequently and unnecessarily in the United States. STUDY DESIGN: Washington State birth certificate data was linked to hospital discharge records comparing singleton deliveries among Somali immigrants to US-born Blacks and US-born Whites between 1993 and 2001 in a 1:4 ratio. Outcomes were compared using unconditional multiple logistic regression models, calculating odds ratios and 95% confidence intervals. RESULTS: 579 pregnancies from Somali women were compared with 2384 and 2435 pregnancies from US-born Black and White women, respectively. Somali women were more likely to deliver after 42 weeks gestation (OR = 9.0*, OR = 9.0**) and during labor were more likely to have intrapartum oligohydramnios (OR = 3.7*, OR = 7.9**), meconium (OR = 2.6*, OR = 6.4**) and fetal distress (OR = 1.9*, OR = 3.1**), even after controlling for gestational age. Nulliparous Somali women were more likely to have a cesarean delivery (OR = 1.6*, OR = 2.0**); and, cesarean delivery, among both nulliparous and multiparous Somalis, was more commonly associated with fetal distress. Somali women were at increased risk of perineal lacerations, febrile illness, and transfusion. Their newborns were at increased risk for prolonged hospitalization (OR = 1.7*, OR = 2.3**), lower 5-minute Apgar scores (OR = 3.1*, OR = 5.2**), assisted ventilation (OR = 3.8*, OR = 11.1**), and meconium aspiration (OR = 14.4*, OR = 27.7**). *OR comparing Somali to US-born Blacks. **OR comparing Somali to US-born Whites. CONCLUSION: Pregnancy outcomes should be evaluated within ethnically and culturally unique groups. Somali immigrants represent a high-risk subpopulation. In response to our research, several community-wide educational forums have been organized to educate the Somali community about their unique perinatal risks and to address their specific obstetric concerns.