Healthcare factors associated with the risk of antepartum and intrapartum stillbirth in migrants in Western Australia (2005-2013): A retrospective cohort study

Autoři: Maryam Mozooni aff001;  Craig E. Pennell aff002;  David B. Preen aff001
Působiště autorů: School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia aff001;  School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia aff002
Vyšlo v časopise: Healthcare factors associated with the risk of antepartum and intrapartum stillbirth in migrants in Western Australia (2005-2013): A retrospective cohort study. PLoS Med 17(3): e32767. doi:10.1371/journal.pmed.1003061
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003061



Migrant 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 findings

A 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.


Late 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.

Klíčová slova:

African people – Antenatal care – Australia – Birth – Health insurance – Pregnancy – Stillbirths – Women's health


1. Lawn JE, Blencowe H, Waiswa P, Amouzou A, Mathers C, Hogan D, et al. Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet. 2016;387(10018):587–603. doi: 10.1016/S0140-6736(15)00837-5 26794078.

2. Flenady V, Wojcieszek AM, Middleton P, Ellwood D, Erwich JJ, Coory M, et al. Stillbirths: recall to action in high-income countries. Lancet. 2016;387(10019):691–702. doi: 10.1016/S0140-6736(15)01020-X 26794070.

3. Pol LG, Thomas RK. The Demography of Health and Healthcare. 3rd ed. Dordrecht: Springer Netherlands 2013.

4. Drysdale H, Ranasinha S, Kendall A, Knight M, Wallace EM. Ethnicity and the risk of late-pregnancy stillbirth. Med J Aust. 2012;197(5):278–81. doi: 10.5694/mja12.10125 22938125.

5. Davies-Tuck ML, Davey MA, Wallace EM. Maternal region of birth and stillbirth in Victoria, Australia 2000–2011: A retrospective cohort study of Victorian perinatal data. PLoS ONE. 2017;12(6):e0178727. doi: 10.1371/journal.pone.0178727 28586367

6. Mozooni M, Preen DB, Pennell CE. Stillbirth in Western Australia, 2005–2013: the influence of maternal migration and ethnic origin. Med J Aust. 2018;209(9):394–400. 30282563.

7. Jayaweera H, Quigley MA. Health status, health behaviour and healthcare use among migrants in the UK: evidence from mothers in the Millennium Cohort Study. Soc Sci Med. 2010;71(5):1002–10. doi: 10.1016/j.socscimed.2010.05.039 20624665.

8. Yelland J, Riggs E, Szwarc J, Casey S, Duell-Piening P, Chesters D, et al. Compromised communication: a qualitative study exploring Afghan families and health professionals’ experience of interpreting support in Australian maternity care. BMJ Quality & Safety. 2016;25(4):e1–e. doi: 10.1136/bmjqs-2014-003837 26089208

9. Chote AA, Koopmans GT, Redekop WK, de Groot CJ, Hoefman RJ, Jaddoe VW, et al. Explaining ethnic differences in late antenatal care entry by predisposing, enabling and need factors in The Netherlands. The Generation R Study. Matern Child Health J. 2011;15(6):689–99. doi: 10.1007/s10995-010-0619-2 20533083

10. Guevarra MV, Stubbs JM, Assareh H, Achat HM. Risk factors associated with late entry to antenatal care visits in NSW in 2014. Aust N Z J Public Health. 2017;41(5):543–4. doi: 10.1111/1753-6405.12668 28616879.

11. Holman CD, Bass AJ, Rosman DL, Smith MB, Semmens JB, Glasson EJ, et al. A decade of data linkage in Western Australia: strategic design, applications and benefits of the WA data linkage system. Aust Health Rev. 2008;32(4):766–77. doi: 10.1071/ah080766 18980573.

12. Holman CD, Bass AJ, Rouse IL, Hobbs MS. Population-based linkage of health records in Western Australia: development of a health services research linked database. Aust N Z J Public Health. 1999;23(5):453–9. doi: 10.1111/j.1467-842x.1999.tb01297.x 10575763.

13. Kelman C, Bass A, Holman C. Research use of linked health data—A best practice protocol. Aust New Zealand J Public Health. 2002;26(3):251–5. 2002449024.

14. WA Data Linkage Branch. Midwives notifications: linkage quality statement: Government of Western Australia- Department of Health. 2017. [cited 2020 January 1].

15. Government of Western Australia. Hospital Morbidity Data System. REFERENCE MANUAL PART A: Contacts, Hospital Responsibilities, Data Element Definitions. V1.0. 2017. [cited 2020 January 1].

16. Bower C, Rudy E, Quick J, Rowley A, Watson L, Cosgrove P. Report of the Western Australian Register of Developmental Anomalies 1980–2012. King Edward Memorial Hospital, 2014. [cited 2020 January 1].

17. Government of Western Australia. Western Australia Births, Deaths and Marriages Registration Act 1998: State Law Publisher.$file/Births+Deaths+and+Marriages+Registration+Act+1998.pdf. [cited 2020 January 1].

18. Glasson EJ, de Klerk NH, Bass AJ, Rosman DL, Palmer LJ, Holman CD. Cohort profile: The Western Australian Family Connections Genealogical Project. Int J Epidemiol. 2008;37(1):30–5. doi: 10.1093/ije/dym136 17611241.

19. Australian Institute of Health and Welfare. My Local Area Hospitals. 2019. [cited 2020 January 1].

20. Gee V. Perinatal, Infant and Maternal Mortality in Western Australia, 2006–2010: Department of Health, Perth, Western Australia. 2013. [cited 2018 June 1].

21. Australian Institute of Health and Welfare. Australia’s mothers and babies 2015—in brief. Perinatal statistics series no. 33. Canberra: AIHW; 2017. [cited 2018 June 1].

22. Moller AB, Petzold M, Chou D, Say L. Early antenatal care visit: a systematic analysis of regional and global levels and trends of coverage from 1990 to 2013. Lancet Glob Health. 2017;5(10):e977–e83. doi: 10.1016/S2214-109X(17)30325-X 28911763

23. Blencowe H, Krasevec J, de Onis M, Black RE, An X, Stevens GA, et al. National, regional, and worldwide estimates of low birthweight in 2015, with trends from 2000: a systematic analysis. Lancet Glob Health. 2019;7(7):e849–e60. doi: 10.1016/S2214-109X(18)30565-5 31103470

24. Blencowe H, Cousens S, Oestergaard MZ, Chou D, Moller AB, Narwal R, et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet. 2012;379(9832):2162–72. doi: 10.1016/S0140-6736(12)60820-4 22682464.

25. Ananth CV, Schisterman EF. Confounding, causality, and confusion: the role of intermediate variables in interpreting observational studies in obstetrics. Am J Obstet Gynecol. 2017;217(2):167–75. doi: 10.1016/j.ajog.2017.04.016 28427805

26. VanderWeele TJ, Mumford SL, Schisterman EF. Conditioning on intermediates in perinatal epidemiology. Epidemiology. 2012;23(1):1–9. doi: 10.1097/EDE.0b013e31823aca5d 22157298

27. Australian Bureau of Statistics. An introduction to Socio-Economic Indexes for Areas (SEIFA) Canberra 2006.$File/20390_2006.pdf. [cited 2018 June 1].

28. Department of Health and Aged Care. Occasional Papers: New Series No 14. Measuring Remoteness: Accessibility/Remoteness Index of Australia (ARIA) October 2001.$File/ocpanew14.pdf. [cited 2018 June 1].

29. Small R, Gagnon A, Gissler M, Zeitlin J, Bennis M, Glazier RH, et al. Somali women and their pregnancy outcomes postmigration: Data from six receiving countries. BJOG Int J Obstet Gynaecol. 2008;115(13):1630–40. 2008534619.

30. Gissler M, Alexander S, MacFarlane A, Small R, Stray-Pedersen B, Zeitlin J, et al. Stillbirths and infant deaths among migrants in industrialized countries. Acta Obstet Gynecol Scand. 2009;88(2):134–48. 19096947.

31. Willinger M, Ko CW, Reddy UM. Racial disparities in stillbirth risk across gestation in the United States. Am J Obstet Gynecol. 2009;201(5):469 e1–8. doi: 10.1016/j.ajog.2009.06.057 19762004

32. Ekeus C, Cnattingius S, Essen B, Hjern A. Stillbirth among foreign-born women in Sweden. European journal of public health. 2011;21(6):788–92. doi: 10.1093/eurpub/ckq200 21224278

33. Sørbye IK, Stoltenberg C, Sundby J, Daltveit AK, Vangen S. Stillbirth and infant death among generations of Pakistani immigrant descent: A population-based study. Acta Obstet Gynecol Scand. 2014;93(2):168–74. 24382198

34. Balchin I, Whittaker JC, Patel R, Lamont RF, Steer PJ. Racial variation in the association between gestational age and perinatal mortality: Prospective study. Br Med J. 2007;334(7598):833–5.

35. Engel PJ, Smith R, Brinsmead MW, Bowe SJ, Clifton VL. Male sex and pre-existing diabetes are independent risk factors for stillbirth. Aust N Z J Obstet Gynaecol. 2008;48(4):375–83. doi: 10.1111/j.1479-828X.2008.00863.x 18837843.

36. Vik ES, Aasheim V, Schytt E, Small R, Moster D, Nilsen RM. Stillbirth in relation to maternal country of birth and other migration related factors: a population-based study in Norway. BMC Pregnancy Childbirth. 2019;19(1):5. doi: 10.1186/s12884-018-2140-3 30611227

37. Naimy Z, Grytten J, Monkerud L, Eskild A. Perinatal mortality in non-western migrants in Norway as compared to their countries of birth and to Norwegian women. BMC Public Health. 2013;13:37. 23320559.

38. Sørbye IK, Vangen S, Juarez SP, Bolumar F, Morisaki N, Gissler M, et al. Birthweight of babies born to migrant mothers—What role do integration policies play? SSM Popul Health. 2019;9:100503. 31993489.

39. Bjornholt SM, Leite M, Albieri V, Kjaer SK, Jensen A. Maternal smoking during pregnancy and risk of stillbirth: results from a nationwide Danish register-based cohort study. Acta Obstet Gynecol Scand. 2016;95(11):1305–12. doi: 10.1111/aogs.13011 27580369.

40. Balayla J, Azoulay L, Abenhaim HA. Maternal marital status and the risk of stillbirth and infant death: a population-based cohort study on 40 million births in the United States. Womens Health Issues. 2011;21(5):361–5. doi: 10.1016/j.whi.2011.04.001 21689945.

41. Hirst JE, Villar J, Victora CG, Papageorghiou AT, Finkton D, Barros FC, et al. The antepartum stillbirth syndrome: risk factors and pregnancy conditions identified from the INTERGROWTH-21st Project. BJOG. 2018;125(9):1145–53. doi: 10.1111/1471-0528.14463 28029221.

42. O'Leary CM, Bower C, Knuiman M, Stanley FJ. Changing risks of stillbirth and neonatal mortality associated with maternal age in Western Australia 1984–2003. Paediatr Perinat Epidemiol. 2007;21(6):541–9. Epub 2007/10/17. doi: 10.1111/j.1365-3016.2007.00849.x 17937740.

43. Flenady V, Koopmans L, Middleton P, Froen JF, Smith GC, Gibbons K, et al. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet. 2011;377(9774):1331–40. Epub 2011/04/19. doi: 10.1016/S0140-6736(10)62233-7 21496916.

44. Gardosi J, Madurasinghe V, Williams M, Malik A, Francis A. Maternal and fetal risk factors for stillbirth: population based study. BMJ. 2013;346:f108. doi: 10.1136/bmj.f108 23349424

45. Mondal D, Galloway TS, Bailey TC, Mathews F. Elevated risk of stillbirth in males: systematic review and meta-analysis of more than 30 million births. BMC Med. 2014;12:220. doi: 10.1186/s12916-014-0220-4 25428603

46. Australian Institute of Health and Welfare 2019. Stillbirths and neonatal deaths in Australia 2015 and 2016: in brief. Perinatal statistics series no. 36. Cat. no. PER 102. Canberra: AIHW. [cited 2020 January 1].

47. Abdel-Latif ME, Bajuk B, Oei J, Vincent T, Sutton L, Lui K, et al. Does rural or urban residence make a difference to neonatal outcome in premature birth? A regional study in Australia. Arch Dis Child Fetal Neonatal Ed. 2006;91(4):F251–6. doi: 10.1136/adc.2005.090670 16428354

48. Australian Institute of Health and Welfare 2018. Perinatal deaths in Australia: 2013–2014. Cat. no. PER 94. Canberra: AIHW. [cited 1 December 2019].

49. Alessandri LM, Stanley FJ, Waddell VP, Newnham J. Stillbirths in Western Australia 1980–1983: influence of race, residence and place of birth. Aust N Z J Obstet Gynaecol. 1988;28(4):284–92. Epub 1988/11/01. doi: 10.1111/j.1479-828x.1988.tb01684.x 3250446.

50. Marufu TC, Ahankari A, Coleman T, Lewis S. Maternal smoking and the risk of still birth: systematic review and meta-analysis. BMC Public Health. 2015;15:239. doi: 10.1186/s12889-015-1552-5 25885887

51. Adams N, Tudehope D, Gibbons KS, Flenady V. Perinatal mortality disparities between public care and private obstetrician-led care: a propensity score analysis. BJOG. 2018;125(2):149–58. doi: 10.1111/1471-0528.14903 28856777.

52. Bursac Z, Gauss CH, Williams DK, Hosmer DW. Purposeful selection of variables in logistic regression. Source Code Biol Med. 2008;3:17. doi: 10.1186/1751-0473-3-17 19087314

53. Nybo Andersen AM, Gundlund A, Villadsen SF. Stillbirth and congenital anomalies in migrants in Europe. Best Pract Res Clin Obstet Gynaecol. 2016;32:50–9. doi: 10.1016/j.bpobgyn.2015.09.004 26545588.

54. Gould JB, Madan A, Qin C, Chavez G. Perinatal outcomes in two dissimilar immigrant populations in the United States: a dual epidemiologic paradox. Pediatrics. 2003;111(6 Pt 1):e676–82. doi: 10.1542/peds.111.6.e676 12777585.

55. Sparks TN, Cheng YW, McLaughlin B, Esakoff TF, Caughey AB. Fundal height: a useful screening tool for fetal growth? J Matern Fetal Neonatal Med. 2011;24(5):708–12. doi: 10.3109/14767058.2010.516285 20849205.

56. Buck Louis GM, Grewal J, Albert PS, Sciscione A, Wing DA, Grobman WA, et al. Racial/ethnic standards for fetal growth: the NICHD Fetal Growth Studies. Am J Obstet Gynecol. 2015;213(4):449 e1–e41. doi: 10.1016/j.ajog.2015.08.032 26410205

57. Anderson NH, Sadler LC, McKinlay CJD, McCowan LME. INTERGROWTH-21st vs customized birthweight standards for identification of perinatal mortality and morbidity. Am J Obstet Gynecol. 2016;214(4):509 e1–e7. doi: 10.1016/j.ajog.2015.10.931 26546850.

58. Villar J, Papageorghiou AT, Pang R, Ohuma EO, Cheikh Ismail L, Barros FC, et al. The likeness of fetal growth and newborn size across non-isolated populations in the INTERGROWTH-21st Project: the Fetal Growth Longitudinal Study and Newborn Cross-Sectional Study. The lancet Diabetes & endocrinology. 2014;2(10):781–92. doi: 10.1016/S2213-8587(14)70121-4 25009082.

59. Sovio U, White IR, Dacey A, Pasupathy D, Smith GCS. Screening for fetal growth restriction with universal third trimester ultrasonography in nulliparous women in the Pregnancy Outcome Prediction (POP) study: a prospective cohort study. Lancet. 2015;386(10008):2089–97. doi: 10.1016/S0140-6736(15)00131-2 26360240

60. Cresswell JA, Yu G, Hatherall B, Morris J, Jamal F, Harden A, et al. Predictors of the timing of initiation of antenatal care in an ethnically diverse urban cohort in the UK. BMC Pregnancy Childbirth. 2013;13:103. doi: 10.1186/1471-2393-13-103 23642084

61. Romero R, Nicolaides KH, Conde-Agudelo A, O'Brien JM, Cetingoz E, Da Fonseca E, et al. Vaginal progesterone decreases preterm birth </ = 34 weeks of gestation in women with a singleton pregnancy and a short cervix: an updated meta-analysis including data from the OPPTIMUM study. Ultrasound Obstet Gynecol. 2016;48(3):308–17. doi: 10.1002/uog.15953 27444208

62. Rolnik DL, Wright D, Poon LC, O'Gorman N, Syngelaki A, de Paco Matallana C, et al. Aspirin versus Placebo in Pregnancies at High Risk for Preterm Preeclampsia. N Engl J Med. 2017;377(7):613–22. doi: 10.1056/NEJMoa1704559 28657417.

63. Newnham JP, Sahota DS, Zhang CY, Xu B, Zheng M, Doherty DA, et al. Preterm birth rates in Chinese women in China, Hong Kong and Australia—The price of Westernisation. Aust New Zealand J Obstet Gynaecol. 2011;51(5):426–31. 2011567501.

64. Reid C. Comment: Interpreter services essential for safe medical practice. Medicus. 2017;57(5):34. Available from:;dn=474015546844070;res=IELHEA. [cited 2020 January 1].

65. White J, Plompen T, Osadnik C, Tao L, Micallef E, Haines T. The experience of interpreter access and language discordant clinical encounters in Australian health care: a mixed methods exploration. Int J Equity Health. 2018;17(1):151. doi: 10.1186/s12939-018-0865-2 30249270

66. Phillips CB, Travaglia J. Low levels of uptake of free interpreters by Australian doctors in private practice: secondary analysis of national data. Aust Health Rev. 2011;35(4):475–9. doi: 10.1071/AH10900 22126952.

67. Phillips C. Using interpreters—a guide for GPs. Australian Family Physician. 2010;39(4):188–95. 20372676.

68. Huang Y-T, Phillips C. Telephone interpreters in general practice: bridging the barriers to their use. Australian Family Physician. 2009;38:443–6. 19521589.

69. Wernham E, Gurney J, Stanley J, Ellison-Loschmann L, Sarfati D. A Comparison of Midwife-Led and Medical-Led Models of Care and Their Relationship to Adverse Fetal and Neonatal Outcomes: A Retrospective Cohort Study in New Zealand. PLoS Med Journal Translated Name PLoS Med. 2016;13(9):e1002134.

70. Tracy SK. Study claims midwifery care harms babies: A critique of flawed research. Women Birth. 2016;29(6):471–2. 27989369

71. von Katterfeld B. Motherhood after migration: perinatal health and wellbeing among culturally and linguistically diverse foreign-born women in Western Australia 2011. [cited 2018 June 1].

72. Brown E, Carroll J, Fogarty C, Holt C. "They get a C-section …they gonna die": Somali women's fears of obstetrical interventions in the United States. J Transcult Nurs. 2010;21(3):220–7. Epub 2010/06/04. doi: 10.1177/1043659609358780 20519725.

73. Akl N, Coghlan EA, Nathan EA, Langford SA, Newnham JP. Aeromedical transfer of women at risk of preterm delivery in remote and rural Western Australia: why are there no births in flight? Aust N Z J Obstet Gynaecol. 2012;52(4):327–33. doi: 10.1111/j.1479-828X.2012.01426.x 22494047.

74. Department of Health Western Australia. Framework for the care of neonates in Western Australia Perth: Health Networks Branch, Department of Health, Western Australia; 2009. [cited 2019 December 1].

75. Neogi SB, Sharma J, Negandhi P, Chauhan M, Reddy S, Sethy G. Risk factors for stillbirths: how much can a responsive health system prevent? BMC Pregnancy Childbirth. 2018;18(1):33. doi: 10.1186/s12884-018-1660-1 29347930

76. Heller G, Bauer E, Schill S, Thomas T, Louwen F, Wolff F, et al. Decision-to-Delivery Time and Perinatal Complications in Emergency Cesarean Section. Dtsch Arztebl Int. 2017;114(35–36):589–96. doi: 10.3238/arztebl.2017.0589 28927497

77. Cnattingius S, Villamor E. Weight change between successive pregnancies and risks of stillbirth and infant mortality: A nationwide cohort study. Lancet. 2016;387(10018):558–65. 26651225 Embase Accession Number 20160121586

78. Downey F. A validation study of the Western Australian Midwives’ Notification System. 2005 data. Perth: Department of Health, Western Australia.; 2007. [cited 2018 June 1].

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