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
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I believe that Knight et al have overlooked a mechanism for an occult
effect of socioeconomic status upon maternal morbidity.
Resultant low birth weight delivery is of course associated with the
socioeconomic status of the mother.(1) Low birth weight or prematurity on
the part of that mother is associated with development of gestational
diabetes(2), preeclampsia(3), and higher blood pressure(4)in her own
offspring when they become adults. All these conditions confer increased
risk of maternal morbidity when these adults become pregnant.
Epigenetics(5) perhaps through the mechanism of environmentally
induced DNA methylation(6) offers an explanation of how the socioeconomic
status of the mother (first generation impoverished) of a parturient may
confer increased risk of pregnancy complications upon that parturient
(second generation affluent) when there is no association evident with the
present socioeconomic status of that parturient and her present pregnancy
morbidity.
(1)Joseph KS,Robert M, Liston MB,et al. Socioeconomic status and
perinatal outcomes in a setting
with universal access to essential health care services. CMAJ
2007;177(6):583-90.
(2)Innes KE, Byers TE, Marshall JA, et al. Association of a Woman’s Own
Birth Weight With Subsequent Risk for Gestational Diabetes. JAMA.
2002;287:2534-2541.
(3)Dempsey JC, Williams MA, Luthy DA, et al. Weight at birth and
subsequent risk of preeclampsia as an adult. Am J Obstet Gynecol
2003;189:494-500.
(4) Hovi P, Andersson S, Ericksson JG, et al. Glucose Regulation in Young
Adults with Very Low Birth Weight. N Engl J Med 2007;356:2053-63.
(5)Gallou-Kabani C, Junien C. Nutritional Epigenomics of Metabolic
Syndrome New Perspective Against the Epidemic.
Diabetes 54:1899–1906, 2005.
(6)Jablonka E. Lamb MJ.The epigenetic turn: the challenge of soft
inheritance. http://www.mfo.ac.uk/files/images/Jablonka-
ms_MPGM_EEEMclean.doc. accessed online March 31, 2009.
Competing interests:
None declared
Competing interests: No competing interests
Marian Knight et al (1) report a higher rate of severe maternal
morbidity among non-white versus white women in the U.K. without being
able to explain it by the characteristics of the studied populations.
However, the studied characteristics, e.g. the parity, maternal age, body
mass index are largely insufficient to explain the higher morbidity of the
non-white women in relation to the peripartum hysterectomy, eclampsia and
embolism. Indeed, gestational pathologies such as diabetes or arterial
hypertension implied in the preeclampsia were not identified in each
population and were not compared. The percentage of previous caesarean
section, placenta praevia or accreta which are strongly associated with
postpartum haemorrhage and peripartum hysterectomy (2) in non-white and
white women is not precised. The weight of foetuses and their number (in
case of twins, etc.) is not known in the studied populations. Foetal
macrosomia and multiple pregnancies are also to be taken into account as
an origin of severe maternal morbidity (haemorrhages, embolisms). The
follow-up of the pregnancies was not compared between the two populations
(white and non-white women). The samples’ sizes of white women (505)
versus African black women (17), or Caribbean (46) are too different to be
comparable. Consequently, this study does not inform about the origin of
higher maternal morbidity in non-white women because the risk factors and
the maternal-foetal pathologies related to the studied morbidities were
neither identified nor compared.
References
1. Knight M, Kurinczuk JJ, Spark P, Brocklehurst P; UKOSS.
Inequalities in maternal health: national cohort study of ethnic variation
in severe maternal morbidities. BMJ. 2009 3;338:b542.
2. Glaze S, Ekwalanga P, Roberts G, Lange I, Birch C, Rosengarten A,
Jarrell J, Ross S. Peripartum hysterectomy: 1999 to 2006. Obstet Gynecol.
2008;111:732-8
Competing interests:
None declared
Competing interests: No competing interests
Re: Inequalities in maternal health: national cohort study of ethnic variation in severe maternal morbidities
It is evident from many studies that maternal morbidity rates vary greatly between countries and this becomes very clear especially between developed and developing countries where the economic contexts are vast. These findings validate what is common to the Sub Saharan Africa.
The picture is similar to Kenya where the morbidity rates are equally high leading to high mortality rates of almost 488/100,000 live births. The contributing factors such as age and socio-economic factors and in addition level of education applicable to our context make the situation more worse. Other additions such as smoking and drinking are not a common practice in our set up due cultural beliefs.
This study is one of a kind that opens the eyes of policy makers not only in America but it is a valuable finding for Kenya too as a marker to stepping up service delivery and ensuring even the most marginalized areas are adequately covered to avert maternal morbidities hence reduced rates.
Competing interests: No competing interests