Ethnic disparity in severe acute maternal morbidity: a nationwide cohort study in the Netherlands.
BACKGROUND
There are concerns about ethnic disparity in outcome of obstetric health care in high-income countries. Our aim was to assess these differences in a large cohort of women having experienced severe acute maternal morbidity (SAMM) during pregnancy, delivery and puerperium.


METHODS
All women experiencing SAMM were prospectively collected in a nationwide population-based design from August 2004 to August 2006. Women delivering in the same period served as reference cohort. Population-based risks were calculated by ethnicity and by type of morbidity. Additionally, non-Western and Western women having experienced SAMM were compared in multivariable logistic regression analysis.


RESULTS
All 98 Dutch maternity units participated. There were 371 021 deliveries during the study period. A total of 2506 women with SAMM were included, 21.1% of whom were non-Western immigrants. Non-Western immigrants showed a 1.3-fold [95% confidence interval (CI) 1.2-1.5] increased risk to develop SAMM. Large differences were observed among different ethnic minority groups, ranging from a non-increased risk for Moroccan and Turkish women to a 3.5-fold (95% CI 2.8-4.3) increased risk for sub-Saharan African women. Low socio-economic status, unemployment, single household, high parity and prior caesarean were independent explanatory factors for SAMM, although they did not fully explain the differences. Immigration-related characteristics differed by ethnic background.


CONCLUSIONS
Non-Western immigrants have an increased risk of developing SAMM as compared to Western women. Risks varied largely by ethnic origin. Immigration-related characteristics might partly explain the increased risk. The results suggest that there are opportunities for quality improvement by targeting specific disadvantaged groups.
Zwart
Joost J
JJ
Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands. j.j.zwart@lumc.nl
Jonkers
Marina D
MD
Richters
Annemiek
A
Ory
Ferko
F
Bloemenkamp
Kitty W
KW
Duvekot
Johannes J
JJ
van Roosmalen
Jos
J
D000328:Adult; D015331:Cohort Studies; D005006:Ethnicity / Q000706:statistics & numerical data*; D005260:Female; D054625:Healthcare Disparities / Q000208:ethnology*; D006801:Humans; D015994:Incidence; D008428:Maternal Mortality / Q000208:ethnology; D009017:Morbidity; D009426:Netherlands / Q000453:epidemiology; D009773:Obstetric Nursing; D011247:Pregnancy; D011248:Pregnancy Complications / Q000401:mortality*; D011446:Prospective Studies; D012307:Risk Factors; D055815:Young Adult