Abstract

BackgroundMigrant 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 findingsA 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.ConclusionLate 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.

Highlights

  • Despite the availability of quality antenatal and obstetric care in most developed nations, disparities in rates of stillbirth (SB) within and between countries continue to be reported [1,2]

  • 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)

  • The odds of AnteSB was elevated in African, Indian, and other women whereas IntraSB was higher in African and ‘other’ women compared with Australian-born women

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Summary

Introduction

Despite the availability of quality antenatal and obstetric care in most developed nations, disparities in rates of stillbirth (SB) within and between countries continue to be reported [1,2]. We observed an increased rate of antepartum stillbirth (AnteSB) in migrant women from African, Indian, and ‘other’ nonwhite ethnic backgrounds [6]. We reported an increased rate of intrapartum stillbirth (IntraSB) in African and ‘other’ nonwhite migrant ethnicities despite adjusting for several well-established risk factors for SB [6]. This warranted an investigation for additional factors that may explain the higher risk of SB in migrant populations. Targeting such specific factors in these at-risk populations is imperative for evidence-based practice and a precise public health plan for reducing risk of SB in migrants. 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).

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