Inequalities in maternal health: national cohort study of ethnic variation in severe maternal morbidities
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b542 (Published 04 March 2009) Cite this as: BMJ 2009;338:b542
- Marian Knight, UKOSS clinical coordinator/honorary consultant in public health,
- Jennifer J Kurinczuk, reader in perinatal epidemiology,
- Patsy Spark, programmer,
- Peter Brocklehurst, professor of perinatal epidemiology
- on behalf of UKOSS
- Correspondence to: M Knight marian.knight{at}npeu.ox.ac.uk
- Accepted 1 December 2008
Abstract
Objective To describe on a national basis ethnic differences in severe maternal morbidity in the United Kingdom.
Design National cohort study using the UK Obstetric Surveillance System (UKOSS).
Setting All hospitals with consultant led maternity units in the UK.
Participants 686 women with severe maternal morbidity between February 2005 and February 2006.
Main outcome measures Rates, risk ratios, and odds ratios of severe maternal morbidity in different ethnic groups.
Results 686 cases of severe maternal morbidity were reported in an estimated 775 186 maternities, representing an estimated incidence of 89 (95% confidence interval 82 to 95) cases per 100 000 maternities. 74% of women were white, and 26% were non-white. The estimated risk of severe maternal morbidity in white women was 80 cases per 100 000 maternities, and that in non-white women was 126 cases per 100 000 (risk difference 46 (27 to 66) cases per 100 000; risk ratio 1.58, 95% confidence interval 1.33 to 1.87). Black African women (risk difference 108 (18 to 197) cases per 100 000 maternities; risk ratio 2.35, 1.45 to 3.81) and black Caribbean women (risk difference 116 (59 to 172) cases per 100 000 maternities; risk ratio 2.45, 1.81 to 3.31) had the highest risk compared with white women. The risk in non-white women remained high after adjustment for differences in age, socioeconomic and smoking status, body mass index, and parity (odds ratio 1.50, 1.15 to 1.96).
Conclusions Severe maternal morbidity is significantly more common among non-white women than among white women in the UK, particularly in black African and Caribbean ethnic groups. This pattern is very similar to reported ethnic differences in maternal death rates. These differences may be due to the presence of pre-existing maternal medical factors or to factors related to care during pregnancy, labour, and birth; they are unlikely to be due to differences in age, socioeconomic or smoking status, body mass index, or parity. This highlights to clinicians and policy makers the importance of tailored maternity services and improved access to care for women from ethnic minorities. National information on the ethnicity of women giving birth in the UK is needed to enable ongoing accurate study of these inequalities.
Footnotes
This study would not have been possible without the contribution and enthusiasm of the UKOSS reporting clinicians who notified cases and completed the data collection forms. We particularly thank Carole Harris, who administered the data collection, and Ali Macfarlane and Mary Grinsted for providing Hospital Episode Statistics denominator ethnicity data. We also acknowledge the members of the UKOSS Steering Committee who provided advice throughout the study. The support of the Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Obstetric Anaesthetists Association, Faculty of Public Health, National Childbirth Trust, and the Confidential Enquiry into Maternal and Child Health contributed greatly to the success of UKOSS.
Contributors: MK designed the study, coordinated data collection, coded the data, did the analysis, and wrote the first draft of the paper. JJK assisted with the design of the study, supervised the data collection and analysis, and contributed to writing the paper. PS assisted with data coding and did data validation and some analysis. PB had the original idea for the surveillance system, provided advice at every stage of the study, and contributed to the writing and editing of the paper. PB is the guarantor.
Funding: MK is funded by the National Coordinating Centre for Research Capacity Development of the Department of Health. JJK was partially funded by a national public health career scientist award from the Department of Health and NHS R&D (PHCS 022). This paper reports on an independent study which is funded by the Policy Research Programme in the Department of Health. The views expressed are not necessarily those of the department. The authors are independent of all funders.
Competing interests: None declared.
Ethical approval: The London Multi-centre Research Ethics Committee approved UKOSS general methodology (04/MRE02/45) and the studies of individual severe morbidities (04/MRE02/46, 04/MRE02/71, 04/MRE02/72, 04/MRE02/73, 04/MRE02/74).
UKOSS Steering Committee: Catherine Nelson-Piercy (chair), Guys and St Thomas’ Hospital; Jenny Furniss (vice-chair), lay member; Sabaratnam Arulkumaran, Royal College of Obstetricians and Gynaecologists; Jean Chapple, Faculty of Public Health; Cynthia Clarkson, National Childbirth Trust; Natasha Crowcroft, Health Protection Agency; Andrew Dawson, Nevill Hall Hospital; James Dornan, Royal College of Obstetricians and Gynaecologists; Shona Golightly, Confidential Enquiry into Maternal and Child Health; Ian Greer, University of York; Mervi Jokinen, Royal College of Midwives; Gwyneth Lewis, Department of Health; Richard Lilford, Department of Public Health and Epidemiology, University of Birmingham; Margaret McGuire, Scottish Executive Health Department; Richard Pebody, Health Protection Agency; Derek Tuffnell, Bradford Hospitals NHS Trust; James Walker, National Patient Safety Agency; Steve Yentis, Chelsea and Westminster Hospital; Carole Harris, National Perinatal Epidemiology Unit; Marian Knight, National Perinatal Epidemiology Unit; Jennifer Kurinczuk, National Perinatal Epidemiology Unit; Peter Brocklehurst, National Perinatal Epidemiology Unit.
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