TRENDS IN FETAL MORTALITY IN UTAH, 19932002: AN ANALYSIS OF ETHNIC AND RACIAL DIFFERENCES

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TRENDS IN FETAL MORTALITY IN UTAH, 1993-2002 AN
ANALYSIS OF ETHNIC AND RACIAL DIFFERENCES

• Shaheen Hossain, PhD1
• Robert Silver, MD2
• Robert Satterfield, Mstat1
• Nan Streeter, MS, RN1
• Pete Barnard, MS, CNM1
• Ned Wilde, BS1

1Utah Department of Health 2 University of
Utah, Division of Maternal-Fetal Medicine 11th
Annual Maternal and Child Health Epidemiology
Conference, Miami 2005
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Background

• Fetal deaths account for a substantial portion of
  perinatal mortality in the U.S.
• Nationally, fetal death rates for Black women are
  twice as high compared to White women
  (12.1 vs 5.3).
• Despite overall declines in fetal death rates,
  racial/ethnic disparities in fetal death rates
  have remained relatively unchanged.

Barfield, W. et al. Racial/Ethnic Trends in
Fetal Mortality --- United States, 19902000.
MMWR 53(24)529-532, 2004. Centers for Disease
Control and Prevention
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Fetal death rates, Utah vs U.S. 1993-2002
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Fetal death rates by maternal race/ethnicity,
Utah 1993-2002

• A wide disparity exists in fetal mortality rates
  among different racial and ethnic populations.

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Population proportions, Utah 1970-2000
Utah 2000 total population 2,233,169
U.S. Census Bureau, Census 2000 Redistricting
Data, Summary File.

• The demographic changes that are expected in the
  future magnify the importance of addressing
  disparities in health status.

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Purpose

• This study was conducted to examine the impact
  of maternal race/ethnicity on fetal death.

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Study question
Is maternal racial/ethnic background
an independent risk factor for fetal death?
Objectives

• What factors
• increase risk
• for fetal death?

• Which
• populations
• are at increased
• risk?

Does a disparity exist among different
race and ethnic populations?
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Methods

• Dataset
• Linked Utah birth and fetal death data
• 1993-2002
• Data exclusion
• Multiple gestations
• Congenital anomalies

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Primary variables

• Outcome variable Fetal death
• (Death that occurs at 20 or more weeks of
  gestation)
• Primary independent variable
• Maternal race/ethnicity
• Non Hispanic Whites
• Non Hispanic Blacks
• Hispanics
• American Indians / Alaskan Natives

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Other variables

• Maternal age (19, 20-34, 35)
• Education (lthigh school, high school, gthigh
  school)
• Marital status (married or unmarried)
• Parity (0, 1-3, 4 or more)
• Tobacco use during pregnancy (yes/no)
• PNC visits (some vs none)
• Clinical gestational age (20-23, 24-27, 28-31,
  32-36, 37)
• Maternal medical conditions (hypertensive
  disorders, diabetes, eclampsia)
• Pregnancy / labor complications (PROM, abruptio
  placenta, cord prolapse, placenta previa)

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Statistical analysis

• Descriptive statistics
• Bivariate analysis
• Multivariate logistic regressions
• Fetal death rate calculation

Number of fetal deaths Fetal
death rate ____________________________ x
1000 Number of fetal deaths
live births
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Results

• Study population
• 419,486 singleton births
• Fetal deaths 1,653
• Overall fetal death rate 3.9

Includes stillbirths or fetal deaths
Excludes fetal deaths with known anomalies Per
1000 live births plus fetal deaths
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Distribution of births by maternal
race/ethnicity, Utah singleton births, 1993-2002
113,664
110,071
63,888
Includes stillbirths or fetal deaths
33,478
25,971

• Minority women accounted for 15.7 of all births.

5,427
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Selected socio-demographic characteristics by
maternal race/ethnicity, Utah singleton births,
1993-2002
Includes stillbirths or fetal deaths
Chi-square test
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Fetal death rates and risks by maternal
race/ethnicity, Utah singleton births, 1993-2002
Includes stillbirths or fetal deaths Per 1000
live births plus fetal deaths

• Black women were almost 3 times more likely to
  experience a fetal death than white women.

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Fetal death rates and risks by maternal age,Utah
singleton births, 1993-2002
Includes stillbirths or fetal deaths
Referent category Unstable rates Per 1000
live births plus fetal deaths
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Fetal death rates and risks by parity and PNC
visits, Utah singleton births, 1993-2002
Includes stillbirths or fetal deaths
Referent category Unstable rates Per 1000
live births plus fetal deaths
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Gestational age-specific fetal death rates, Utah
singleton births, 1993-2002

• Per 1000 live births and fetal deaths in the
  given gestational age category
• Includes stillbirths or fetal deaths

• Fetal death rates tend to decrease with
  increasing gestational age.

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Gestational age-specific fetal death rates by
maternal race/ethnicity, Utah singleton births,
1993-2002
Per 1000 live births and fetal deaths in the
given gestational age category Includes
stillbirths or fetal deaths

• During gestational ages 20-23 wks White women had
  higher fetal death rates.
• Black and Hispanic women had a higher fetal death
  rate from 24-31 wks.

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Risk factors

• Women with the following characteristics were
  more likely to experience a fetal death
• More than 35 yrs of age or less than 20 yrs
• No previous live birth
• More than 3 prior live births
• Less than a high school degree
• Unmarried
• Tobacco use during pregnancy
• No prenatal care visits
• Selected medical conditions
• Selected pregnancy/labor complications

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Risk of fetal death compared to white womenby
maternal race/ethnicity,Utah singleton births,
1993-2002
Includes stillbirths or fetal deaths Adjusted
for maternal age, education, marital status,
parity, tobacco use, PNC visits, selected medical
conditions, and selected pregnancy/labor
complications

• Even after controlling for potential confounders,
  Black and Hispanic women retained a higher risk
  of experiencing a fetal death compared to white
  women (p lt 0.001).

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Factors that might contribute to this disparity

• Socioeconomic Status
• Income
• Occupation
• Assets / wealth
• Poverty
• Health insurance

• Lifestyle and Cultural Practices
• Nutritional/dietary practices
• Religious/spiritual beliefs
• Physical activity
• Help seeking behavior
• Substance abuse

• Psychosocial Status and Social Support
• Stress
• Social networks
• Trauma
• Coping mechanisms
• Abuse

• Health Care
• Access to quality health care
• Cultural / linguistic barriers
• Stereotypes / bias
• Differential treatment / racism

• Social and Environmental Context
• Neighborhood characteristics
• Sense of community
• Housing conditions
• Violence / crime

• Biological and Genetic Factors
• Family medical history
• Genetics/genomics

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Limitations

• Not all possible medical complications are
  captured by vital records
• Use of gestational age at delivery for timing of
  fetal death
• Underreporting of fetal deaths

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Conclusion and public health implications

• This study demonstrated that maternal
  race/ethnicity is associated with an increased
  risk for fetal death.
• Collaborate with health care professionals to
  identify high risk group and recognize the
  importance of cultural differences to tailor
  intervention.
• Utilize multidisciplinary approaches to examine
  the influence of various social, environmental,
  biological, and genetic factors in understanding
  these disparities.
• Further investigation is needed to develop
  appropriate prevention.