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

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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

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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

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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

UK

Former Yugoslavia

Rest of Eastern Europe

Republic of Ireland

Northern Ireland

Under 1,500g (very low birthweight)

1,500 - 2,499g

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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

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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

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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

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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

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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

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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

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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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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.