Ethnicity, migrant status and the outcome of pregnancy
Alison Macfarlane
Department of Midwifery
City University
2
Interpreting routine data from local and national systems
ONS mortality statistics, Series DH3
In depth analysis of ONS infant mortality linked data
Fetal and Infant Death in East London
Confidential Enquiries into Maternal Deaths
3
Routine data from civil registration
Ethnic group is not currently routinely linked to birth registration or death registration
Current analyses are by mother’s country of birth
Father’s country of birth is also recorded but not usually analysed
4
Infant mortality rates for selected mothers' countries of birth, England and Wales, 2001-03
0
2
4
6
8
10
12
UnitedKingdom
Bangladesh India Pakistan East Africa SouthernAfrica
Rest ofAfrica
Caribbean
Source: ONS Mortality Statistics, Series DH3
Dea
ths
/ 1,0
00 li
ve b
irth
s
Postneonatal
Neonatal
5
Birthweights under 2500g for selected mothers' countries of birth, England and Wales, 2003
0
2
4
6
8
10
12
14
UnitedKingdom
Bangladesh India Pakistan East Africa SouthernAfrica
Rest ofAfrica
Caribbean
Source: ONS Mortality statistics, Series DH3
Perc
ent
age
of
live
bir
ths
2000-2499
1500-1999
1000-1499
Under 1000g
6
Infant mortality among babies weighing under 2,500g by mothers' countries of birth, England and Wales, 2003
0
10
20
30
40
50
60
70
80
UnitedKingdom
Bangladesh India Pakistan East Africa SouthernAfrica
Rest ofAfrica
Caribbean
Source: ONS Mortality statistics, Series DH3
Dea
ths
/ 1,0
00 li
ve b
irth
s
7
Infant mortality rates for selected mothers' countries of birth, England and Wales, 2001-03
0
2
4
6
8
10
12
UnitedKingdom
Bangladesh India Pakistan East Africa SouthernAfrica
Rest ofAfrica
Caribbean
Source: ONS Mortality statistics, Series DH3
Dea
ths
/ 1,0
00 li
ve b
irth
s
Congenital anomalies
Other causes
Immaturity-related conditions
8
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Ethnic group differences in infant mortality
No consistent association with low birthweight, or with smoking or breast feeding
Marked difference between mortality of babies born to mothers from South Asian countries
High mortality in babies with mothers born in Pakistan attributed to congenital anomalies
High mortality in babies with mothers from West Africa and the Caribbean attributed to immaturity in groups in high rates of very low birthweight.
Monitoring inequalities in the outcome of pregnancy
Collaboration between researchers at City University, ONS LSHTM, the universities of Oxford, Ulster and
Glasgow
Focus of the project was on trends and variations in inequalities in the outcome of pregnancy and about
babies in their first year of life
11
Based on 11,401,247 live births in England and Wales from 1983 to 2001
Focused on countries of birth that contribute to the main ethnic minority groups in England and Wales
Caribbean, West Africa, East Africa, India, Pakistan, Bangladesh, Former Yugoslavia, Rest of Eastern Europe, Republic of Ireland
Methods and definitions
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Percentage of live singleton births by birthweight and mother’s country of birth
0
1
2
3
4
5
6
7
8
9
10
11
1983-1986 1987-1990 1991-1994 1995-1998 1999-2001 1983-1986 1987-1990 1991-1994 1995-1998 1999-2001
Percentage
Under 1,500g (very low birthweight) 1,500 - 2,499g
UK
Caribbean and West Africa
South Asia
13
Percentage of live singleton births by birthweight and mother’s country of birth
0
1
2
3
4
5
6
7
8
9
10
11
1983-1986 1987-1990 1991-1994 1995-1998 1999-2001 1983-1986 1987-1990 1991-1994 1995-1998 1999-2001
Percentage
UK
Former Yugoslavia
Rest of Eastern Europe
Republic of Ireland
Northern Ireland
Under 1,500g (very low birthweight)
1,500 - 2,499g
14
Percentage of multiple births by mother’s country of birth
0.0
1.0
2.0
3.0
4.0
1983-1986 1987-1990 1991-1994 1995-1998 1999-2001
Percentage
West Africa
Caribbean
East AfricaUK
India
Pakistan
Bangladesh
15
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Limitations
Analysis excludes babies born to second and subsequent generation migrants
Variables such as gestation and parity were not analysed in association with birthweight as they are either not available or provide only partial information
East Africa category assumes women are mainly of Indian origin
Fetal and Infant Death in East London
Alison Macfarlane
Lisa Hilder
Julia Hancock
Jane Grant
Michelle Lyne
Kate Costeloe, Queen Mary and Homerton NHS Trust
Michael Hird, Barts and the London NHS Trust
18
Infant mortality in East London compared with England and Wales, 1999-2001
0 1 2 3 4 5 6 7 8
City and Hackney
Newham
Tower Hamlets
England and Wales
Rate per 1,000 live births
Neonatal
Postneonatal
Source: ONS, VS tables
19
Fetal and infant death in East London
Literature review
Analysis of routine data from child health systems and other sources
Case note review at Homerton and Royal London Hospitals
20
Previous research in East London
Variations by class
Variations by mother’s country of birth and ethnicity
Overall infant mortality rates by ethnicity from highest to lowest: Pakistani, African and West Indian, White, Bangladeshi
Due to SIDS: Pakistani, West Indian, White, Indian, Bangladeshi and African
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Previous research in East London
Challenges perception that immigrants in deprived areas necessarily have poor outcomes
Or represent a ‘drain’ on resources’
Suggestion that ‘assimilation’ over time may also bring poor outcomes of local white population
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Analyses of routine data
Used birth notification data from the late Regional Interactive Child Health System (RICHS)
All births to residents of City and Hackney, Newham and Tower Hamlets, 1999-2001
All stillbirths and infant deaths among these
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Preterm birth in East London, 1999-2001
0 1 2 3 4 5 6 7 8 9 10
City and Hackney
Newham
Tower Hamlets
East London
England, 2001/02
Percentage of live and still births
20-2324-2728-3132-36
Source: RICHS, England data estimated from Maternity HES
Gestational age, weeks
24
Preterm birth rates in East London by ethnicity, 1999-2001
0 2 4 6 8 10 12 14 16
City & Hackney
African
'West Indian'
White
Newham
African
'West Indian'
White
Tower Hamlets
African
'West Indian'
Bangladeshi
White
Percentage of total births
Before 28 weeks28-31 weeks32-36 weeks
Source: RICHS
25
FIDEL 1999-2001
African
Caribbean
Bangladeshi
White
rates per 1000 live births during the interval
0 10 20 30 40 50 60
Gestation-specific neonatal mortality rates and 95%CI
Preterm
Term
African
Caribbean
Bangladeshi
White
0 1 2 3
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Conclusions of review of routine data
High rates of preterm and very preterm birth, especially in City and Hackney
Black women have both high rates of preterm birth and the neonatal mortality for their babies is higher
Stillbirth rates at term are higher and infant mortality of babies is lower for Bangladeshi women
Stillbirth and infant mortality rates are high among women with no record of booking but not among those who book late
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29
Further work
Extending the analyses to more recent years
Case control study of very preterm birth in Hackney
plus nine other projects being undertaken by a range of statutory and voluntary organisations, funded by Team Hackney, the Local Strategic Partnership
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Maternal mortality
‘Of the 166 unbooked women, 37 were of West African origin, six were Asian, and two were non-British European. There is a need for health education among women, who because of language barriers or cultural differences, may not appreciate the need for antenatal care and do not avail themselves of maternity services.’
Confidential Enquiry into Maternal Deaths, 1967-69
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Estimated relative risk of maternal death by ethnic group, England only 2000-02
Ethnic group Number Relative risk 95% CI
White 151 1.0
Black African 30* 6.7 4.5-9.9
Black Caribbean 13 2.4 1.4-4.2
Pakistani 10 1.2 0.6-2.2
All non white 72 2.9 2.2-3.9
*Including 10 refugee/ asylum seeking womenSource: Confidential Enquiry Into Maternal Deaths, 2000-02
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Social factors and maternal deaths
Highest death rates among Black African women
Raised death rates among Black Caribbean women
Fourteen women who died were recent migrants
Of these ten classified as refugees or asylum seekers
Fifteen women who died did not speak English
Nearly a fifth of those who died were single mothers
51 women had a history of domestic violence
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‘Race’ or ‘ethnicity’What are we measuring?
Racial group
Ethnic or cultural origin
Skin colour
Immigrant or migrant status
Religion
Nationality
National identity
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Conclusions and questions
Major differences between minority ethnic and migrant groups both in socio-demographic composition and in outcome.
When comparing between groups, associations between birthweight and outcome are not straightforward.
Some groups are known to be concentrated in deprived areas, but deprivation is not the only factor.
For the future, we need to record both country of birth and ethnic group in order to compare outcomes for first and second generation.
Data about gestational age and socio-economic status are also important.
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Challenges
Bureaucratic hurdles in accessing routine data. Delays caused by Ethics Committees, Caldicott Guardians, PIAG, disclosure control and ONS’ Microdata Release Panel.
Collaboration has become difficult because of cuts in ONS staff and relocation leading to loss of experienced staff in ONS and in the Information Centre for Health and Social Care.
Poor quality of NHS data, made worse not better by National Programme for IT.
Lack of funding for maternity research, apart from RCTs.