Article

Racial disparities in stillbirth risk across gestation in the United States

Center for Developmental Biology and Perinatal Medicine, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.
American journal of obstetrics and gynecology (Impact Factor: 3.97). 09/2009; 201(5):469.e1-8. DOI: 10.1016/j.ajog.2009.06.057
Source: PubMed

ABSTRACT We sought to determine factors associated with racial disparities in stillbirth risk.
Stillbirth hazard was analyzed using 5,138,122 singleton gestations from the National Center of Health Statistics perinatal mortality and birth files, 2001-2002.
Black women have a 2.2-fold increased risk of stillbirth compared with white women. The black/white disparity in stillbirth hazard at 20-23 weeks is 2.75, decreasing to 1.57 at 39-40 weeks. Higher education reduced the hazard for whites more than for blacks and Hispanics. Medical, pregnancy, and labor complications accounted for 30% of the hazard in blacks and 20% in whites and Hispanics. Congenital anomalies and small for gestational age contributed more to preterm stillbirth risk among whites than blacks. Pregnancy and labor conditions contributed more to preterm stillbirth risk among blacks than whites.
The excess stillbirth risk for blacks was greatest at preterm gestations, and factors contributing to stillbirth risk vary by race and gestational age.

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    • "In the United States (U.S.), an estimated 70 stillbirths occur each day, on average 25,000 each year, with a disproportionately higher rate among African American and Native American women [1-4]. Stillbirth is one of the most devastating losses a parent can experience, and it is a high-risk indicator for post-traumatic stress and depression in mothers and in couples [5-9]. "
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    ABSTRACT: Background In the United States, an estimated 70 stillbirths occur each day, on average 25,000 each year. Research into the prevalence and causes of stillbirth is ongoing, but meanwhile, many parents suffer this devastating loss, largely in silence, due to persistent stigma and taboo; and many health providers report feeling ill equipped to support grieving parents. Interventions to address bereavement after neonatal death are increasingly common in U.S. hospitals, and there is growing data on the nature of parent bereavement after a stillbirth. However, further research is needed to evaluate supportive interventions and to investigate the parent-clinician encounter during hospitalization following a stillbirth. Qualitative inquiry offers opportunities to better understand the lived experience of parents against the backdrop of clinicians’ beliefs, intentions, and well-meaning efforts to support grieving parents. Methods We present a secondary qualitative analysis of transcript data from 3 semi-structured focus groups conducted with parents who had experienced a stillbirth and delivered in a hospital, and 2 focus groups with obstetrician-gynecologists. Participants were drawn from the greater Seattle region in Washington State. We examine parents’ and physicians’ experiences and beliefs surrounding stillbirth during the clinical encounter using iterative discourse analysis. Results Women reported that the cheery, bustling environment of the labor and delivery setting was a painful place for parents who had had a stillbirth, and that the well-meaning attempts of physicians to offer comfort often had the opposite effect. Parents also reported that their grief is deeply felt but not socially recognized. While physicians recognized patients’ grief, they did not grasp its depth or duration. Physicians viewed stillbirth as an unexpected clinical tragedy, though several considered stillbirth less traumatic than the death of a neonate. In the months and years following a stillbirth, these parents continue to memorialize their children as part of their family. Conclusions Hospitals need to examine the physical environment for deliveries and, wherever possible, offer designated private areas with staff trained in stillbirth care. Training programs in obstetrics need to better address the bereavement needs of parents following a stillbirth, and research is needed to evaluate effective bereavement interventions, accounting for cultural variation. Critical improvements are also needed for mental health support beyond hospitalization. Finally, medical professionals and parents can play an important role in reversing the stigma that surrounds stillbirth.
    BMC Pregnancy and Childbirth 11/2012; 12(1):137. DOI:10.1186/1471-2393-12-137 · 2.15 Impact Factor
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    • "International studies have reported several demographic risk factors associated with stillbirth, including; advanced maternal age [11,12], obesity [13,14] smoking in pregnancy [15], low socio-economic status [16] and extremes of parity [17,18]. Many previous studies that have reported ethnic disparity in the risk of stillbirth were retrospective in design and had insufficient variables to enable appropriate adjustment for confounders [6,7,9]. "
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    ABSTRACT: In high income countries there has been little improvement in stillbirth rates over the past two decades. Previous studies have indicated an ethnic disparity in the rate of stillbirths. This study aimed to determine whether maternal ethnicity is independently associated with late stillbirth in New Zealand. Cases were women with a singleton, late stillbirth (≥ 28 weeks' gestation) without congenital abnormality, born between July 2006 and June 2009 in Auckland, New Zealand. Two controls with ongoing pregnancies were randomly selected at the same gestation at which the stillbirth occurred. Women were interviewed in the first few weeks following stillbirth, or at the equivalent gestation for controls. Detailed demographic data were recorded. The study was powered to detect an odds ratio of 2, with a power of 80% at the 5% level of significance, given a prevalence of the risk factor of 20%. A multivariable regression model was developed which adjusted for known risk factors for stillbirth, as well as significant risk factors identified in the current study, and adjusted odds ratios and 95% confidence intervals were calculated. 155/215 (72%) cases and 310/429 (72%) controls consented. Pacific ethnicity, overweight and obesity, grandmultiparity, not being married, not being in paid work, social deprivation, exposure to tobacco smoke and use of recreational drugs were associated with an increased risk of late stillbirth in univariable analysis. Maternal overweight and obesity, nulliparity, grandmultiparity, not being married and not being in paid work were independently associated with late stillbirth in multivariable analysis, whereas Pacific ethnicity was no longer significant (adjusted Odds Ratio 0.99; 0.51-1.91). Pacific ethnicity was not found to be an independent risk factor for late stillbirth in this New Zealand study. The disparity in stillbirth rates between Pacific and European women can be attributed to confounding factors such as maternal obesity and high parity.
    BMC Pregnancy and Childbirth 01/2011; 11(1):3. DOI:10.1186/1471-2393-11-3 · 2.15 Impact Factor
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    • "Increased risk of miscarriage of pregnancy before 24 weeks of gestation and stillbirth at or after 24 weeks are associated with certain maternal characteristics, including increasing maternal age and maternal weight, previous miscarriage and African racial origin (Spencer et al., 2006; Smith and Fretts 2007; Willinger et al., 2009). These pregnancy complications are also associated with abnormal results of first-trimester screening for aneuploidies, including increased fetal nuchal translucency (NT) thickness, reversed A-wave in the fetal ductus venosus and low maternal serum pregnancyassociated plasma protein-A (PAPP-A) (Souka et al., 2001, 2005; Spencer et al., 2006; Bilardo et al., 2007; Smith et al., 2007; Dugoff et al., 2008; Maiz et al., 2008). "
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    ABSTRACT: To derive models for estimating risk of miscarriage and stillbirth from maternal characteristics and findings of first-trimester screening for aneuploidies and to define the procedure-related risk of chorionic villus sampling (CVS) after adjusting for these factors. We examined 33 856 singleton pregnancies at 11(+0) to 13(+6) weeks, and in 2396 CVS was carried out. Logistic regression analysis was used to examine the factors contributing to miscarriage and stillbirth. There were 33 310 (98.4%) livebirths, 404 (1.2%) miscarriages and 142 (0.4%) stillbirths. Models combining maternal characteristics, nuchal translucency, pregnancy-associated plasma protein-A (PAPP-A) and flow in the ductus venosus detected 36.9% of miscarriages and 35.2% of stillbirths, at a 10% false-positive rate. The risk of miscarriage and stillbirth increased with maternal age and weight, in women of African racial origin, in those with previous miscarriages or stillbirths and in those with low serum PAPP-A and reversed A-wave in the ductus venosus. The risk of miscarriage increased in women with pre-existing diabetes mellitus, in those conceiving on ovulation-induction drugs and in those with high fetal nuchal translucency, and the risk of stillbirth increased in women with chronic hypertension and in cigarette smokers. The expected number of miscarriages and stillbirths in the CVS group and the models derived from the non-CVS group were 45 (95% prediction intervals 32-58) and 18 (95% prediction intervals 9-26), respectively. These expected numbers were not significantly different from the observed 44 and 15 cases (p = 0.881 and 0.480), respectively. A high proportion of fetal losses can be predicted at 11 to 13 weeks. A model for such predictions can be used to assess the procedure-related risks from CVS.
    Prenatal Diagnosis 01/2011; 31(1):38-45. DOI:10.1002/pd.2644 · 3.27 Impact Factor
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