obstetric outcomes among rural aboriginal victorians
TRANSCRIPT
Australian and New Zealand Journal of Obstetrics and Gynaecology 2005 45 68ndash70
68
Blackwell Publishing Ltd Short CommunicationObstetric outcomes among Aboriginal Victorians
Obstetric outcomes among rural Aboriginal Victorians
David SIMMONS1 Munir A KHAN2 and Glyn TEALE3
1Department of Rural Health University of Melbourne and Waikato Clinical School University of Auckland New Zealand 2Department of Rural Health University of Melbourne and 3Rural Clinical School University of Melbourne Victoria Australia
AbstractTwenty-eight Aboriginal women and 112 age-matched controls were identified from a retrospective chart review ofdeliveries over a 1-year period in northern Victoria Significantly more Aboriginal women were screened for gesta-tional diabetes and met criteria for the diagnosis of gestational diabetes Overall mode of delivery was similaramongst the two groups Babies born to Aboriginal mothers were significantly smaller and less likely to be breastfed than those from the non-Aboriginal group
Key words aboriginal breast feeding gestational diabetes obstetrics rural
Introduction
Studies among Aboriginal women suggest poorer obstetricoutcomes compared with the general Australian population1ndash5
Fear of hospitals feelings of vulnerability miscommunicationloneliness and isolation are reported as the major issues inAboriginal communities6 These occur in a setting whereAboriginal people in general have been shown to experiencelower socio-economic status and poorer health than otherAustralians including higher infant mortality and morbidityin both urban and rural areas4
In 2001 Indigenous people represented 05 of theVictorian total population7 and births to Victorian Aboriginalwomen have increased over the last 5 years However there isa paucity of rural Victorian data on the obstetric outcome ofAboriginal pregnancies their birthing experiences and antenatalfindings The aim of this study was to compare antenatal statusand obstetric outcomes among Aboriginal and non-Aboriginalpregnancies in the Goulburn Valley the area with the largestVictorian Aboriginal population outside of Melbourne
Methods
Hospitals located in Shepparton Cobram Kyabram andNumurkah of rural Victoria agreed to participate in an auditof care as a quality assurance activity for deliveries occurringbetween 1 July 1998 and 30 June 1999 All deliveries atCobram Kyabram and Numurkah hospitals were auditedIn Shepparton where the base hospital is situated 500 caseswere randomly selected from the list of 1000 deliveriesidentified by Diagnosis Related Group coding Charts weremanually reviewed and data extracted from a structured
audit form including demographic past obstetric historyantenatal and perinatal details
Data were entered into a computer file and analysed usingSPSS for windows release 110 (SPSS Inc Chicago Ill USA)Of these records 28 mothers were identified as Aboriginalon the basis of recorded ethnic background As the totalnumber of Aboriginal women was not large and was youngerthan the non-Aboriginal women (24 plusmn 5 vs 28 plusmn 6 yearsrespectively P lt 0001) an age-matched control group wasestablished Controls were randomly selected by computerprogramme within SPSS in the largest ratio possible by age ona yearly basis This was possible with a 14 ratio (ie for eachAboriginal woman 4 non-Aboriginal women were selected)In this way 112 non-Aboriginal women were selected tomatch the 28 Aboriginal women The other records have beenexcluded from the analyses Women were screened for gestationaldiabetes (GDM) using a 50 g glucose challenge test (GCT)followed by a 75 g oral glucose tolerance test (OGTT) if the1-h post load was = 78 mmolL and classified as having GDMif they exceeded the Australasian Diabetes in PregnancySociety (ADIPS) criteria8 The audit was approved by thehospital management as part of a quality initiative and waslinked to a service development with the local Aboriginalhealth service9 As this review conforms to the standardsestablished by the NHMRC for ethical quality review10 ethicsapproval was not sought
Correspondence Professor David Simmons University of Auckland Waikato Clinical School Waikato Hospital Private Bag 3200 Pembroke St Hamilton New Zealand Email simmonsdwaikatodhbgovtnz
Received 22 June 2004 accepted 25 August 2004
Obstetric outcomes among Aboriginal Victorians
Australian and New Zealand Journal of Obstetrics and Gynaecology 2005 45 68ndash70 69
Statistics
Discrete variables were compared using Chi squared andcontinuous variables using analysis of variance All tests aretwo tailed with P lt 005 considered to be significant Mean plusmnstandard deviation are shown
Results
Women were of similar age (25 plusmn 5 years) Aboriginalwomen had greater gravidity but similar parity (3 plusmn 22 plusmn 1vs 2 plusmn 12 plusmn 1 P lt 0001ns) More Aboriginal women hadhad ge 1 past spontaneous miscarriage (393 vs 152P = 0004) Although the proportion who currently smokedwas greater among Aborigines (680 vs 248 P lt 0001)the number of cigarettes reported smoked per day wassimilar (Aborigines vs non-Aborigines 12 plusmn 2 vs 10 plusmn 7)Aboriginal women were also more likely to drink alcohol(500 vs 107 P lt 0001) and smoke marijuana (107vs 18 P = 0023) There were no significant differencesin family history of diabetes (357 vs 375) or hyperten-sion (429 vs 304) previous induced abortions (64overall) or ectopic pregnancies (14 overall) and no womanhad a prior stillbirth Gestational age at booking was lateramong Aboriginal women (15 plusmn 8 vs 12 plusmn 6 weeks P =0010) with a greater proportion booking ge 20 weeks (250vs 98 P = 0032)
Aboriginal women were more likely to receive iron therapy(Table 1) There was no difference in the proportion receiv-ing folate therapy (100) Aboriginal women were morelikely to be screened for GDM and have an OGTT Similarproportions of women had a positive GCT (214 overall)and went on to OGTT (571) Although similar proportionshad an ultrasound in the first (164) and second trimester(607) Aborigines were more likely to have an ultrasoundin the third trimester At 37 weeks there were no differencesin mean blood pressure (available for 21 Aborigines and 84non-Aborigines 116 plusmn 1271 plusmn 9 mmHg) or weight (available
for 24 Aborigines and 77 non-Aborigines 78 plusmn 16 vs 82 plusmn18 kg respectively)
There was no difference in the average length of stay (48 plusmn34 days) Numbers were too few to compare rates of antepar-tum haemorrhage and intrauterine growth retardation (14overall each) Hypertension in pregnancy was similar (57overall) There were no differences in proportions having epiduralanalgesia meconium stained liquor at delivery or paediatri-cians in attendance There were no differences in gestation atdelivery Aboriginal babies were significantly smaller Therewas no difference in APGAR scores at 1 or 5 min Aborig-inal mothers were significantly more likely to bottle feedtheir babies
Discussion
In spite of the relative size of the indigenous community fora rural Victorian area the number of Aboriginal womenidentified is small While the sample size is too small to justifymultivariate analyses these data do give an insight into theobstetric and neonatal outcomes for the largest rural VictorianAboriginal community
Within the limitations of the data collected it is interest-ing to note that Aboriginal women were more likely to bescreened for gestational diabetes to be prescribed iron therapyin pregnancy to have a third trimester ultrasound scan and(non-significantly) less likely to have a Caesarean sectionThe basis of these differences is uncertain but may reflect arealisation of the increased perinatal mortality rates amongstAboriginal women111 and thus a tendency to treat Aboriginalwomen as a high-risk obstetric group Alternatively it mayreflect the high-quality of antenatal care provided by the localAboriginal Antenatal Support services There is much qualitativeevidence to support the benefits of these services112 Despitethis there are clearly still barriers with the significantly later book-ing and lower breastfeeding rates amongst Aboriginal women
The magnitude of the reduction in birth weight amongAboriginal babies was comparable to that described among
Table 1 Comparison of antenatal and perinatal characteristics between Aboriginal and-non-Aboriginal women in the Goulburn Valley
Aboriginal Non-Aboriginal sig
Iron therapy this pregnancy 286 116 0025Asthma therapy 71 27 nsScreened for GDM 857 661 0042Had OGTT 286 125 0037GDM 107 45 nsUltrasound in third trimester 607 179 lt 0001Gestational age at delivery 389 plusmn 14 weeks 393 plusmn 12 weeks nsLabour induced 429 270 nsNormal vaginal delivery 714 685 nsCaesarean section 143 207 nsBirthweight (g) 3190 plusmn 520 3490 plusmn 460 0003 birthweight le 25 kg 107 27 0060Neonatal intensive care 179 112 nsBottle feeding only 321 125 0012
GDM gestational diabetes OGTT oral glucose tolerance test ns not significant
D Simmons et al
70 Australian and New Zealand Journal of Obstetrics and Gynaecology 2005 45 68ndash70
Aborigines in other areas across Australia34 and is known tobe associated with higher perinatal mortality13 (although nodeaths occurred in this cohort) The origins of reducedbirthweight among Aborigines have been debated at lengthMathematical models and serial ultrasound growth measure-ments have suggested that gestational age misclassification isunlikely to be the cause1415 The differences may in somepopulations be explained on the basis of earlier deliveryamong certain groups In our study population there was nodifference in gestational age at delivery As in previous studiesbehaviours known to be associated with a reduction in averagebirth weight were more common amongst Aboriginal mothersthan the comparative group Thus smoking use of marijuanaand excessive alcohol intake were all significantly increasedamong Aboriginal women in the present study16
In conclusion we have found in a retrospective audit thatthe disparity in Aboriginal birth weight described in severalareas of Australia exists in rural Victoria Antenatal care andits outcomes are likely to have been impacted upon by laterbooking and some lifestyle choices (eg smoking) Pre-conceptual educational programmes should be considered toaugment existing services and efforts to encourage breast-feeding need to be targeted more effectively
Acknowledgements
We would like to thank Nalifur Talat Denise Little SusanGumley and Desiree Yap formerly of the Department ofRural Health The University of Melbourne Shepparton fortheir contributions to this work We would like to thank thelocal health services for their support for this audit projectThe Department of Rural Health receives funding from theCommonwealth Department of Health and Ageing
References
1 Powell J Dugdale AE Obstetric outcomes in an Aboriginalcommunity a comparison with the surrounding rural areaAust J Rural Health 1999 7 13ndash17
2 Watson J Hodson K Johnson R Kemp K The maternityexperiences of indigenous women admitted to an acute caresetting Aust J Rural Health 2002 10 154ndash160
3 OrsquoConnor M Bush A Pregnancy outcomes of AustralianAboriginals and Torres Strait Islanders Med J Aust 1996 164516ndash517
4 AIHW Australiarsquos Health 2002 Canberra Australian Instituteof Health and Welfare 2002 Available from httpwwwaihwgovaupublicationsausah02ah02pdf
5 Najman J Williams GM Bor W Anderson MJ Morrison JObstetrical outcomes of Aboriginal pregnancies at a majorurban hospital Aust J Public Health 1994 18 185ndash189
6 Territory Health Services And the women said hellip Reportingon birthing services of Aboriginal women from remote top endcommunities Darwin Territory Health Services 1999
7 ABS Census of Population and Housing 2001 MelbourneAustralian Bureau of Statistics 2002 Available from httpwwwabsgovauausstatsabscensusnsf321OpenView
8 Hoffman L Nolan C Wilson JD Oats JJN Simmons D Con-sensus statement Gestational diabetes mellitusndashmanagementguidelines The Australasian Diabetes in Pregnancy SocietyMed J Aust 1998 169 93ndash97
9 Yap D Final report June 1999ndashJune 2001 RHSET SeniorLecturer in Obstetrics and Gynaecology University ofMelbourne Melbourne 2001
10 Humphrey M Editorial comment ANZJOG 2003 43 18911 de Costa C Child A Pregnancy outcomes in urban Aboriginal
women Med J Australia 1996 164 523ndash52612 Mackerras D Birthweight changes in the pilot phase of the strong
women strong babies strong culture program in the NorthernTerritory Aust NZ J Public Health 2001 25 35ndash40
13 Day P Sullivan EA Lancaster P Indigenous mothers and theirbabies Australia 1994ndash1996 Randwick NSW AustralianInstitute of Health and Welfare National Perinatal StatisticsUnit 1999
14 Coory M Does gestational age misclassification explain thedifference in birthweights for Australian Aborigines andwhites Int J Epidemiol 1996 25 980ndash988
15 Humphrey M Holzheimer D Fetal growth charts for Aborig-inal fetuses Aust N Z Obstet Gynaecol 2000 40 388ndash393
16 Rousham EK Gracey M Factors affecting birthweight ofrural Australian Aborigines Ann Human Biol 2002 29 363ndash372
Obstetric outcomes among Aboriginal Victorians
Australian and New Zealand Journal of Obstetrics and Gynaecology 2005 45 68ndash70 69
Statistics
Discrete variables were compared using Chi squared andcontinuous variables using analysis of variance All tests aretwo tailed with P lt 005 considered to be significant Mean plusmnstandard deviation are shown
Results
Women were of similar age (25 plusmn 5 years) Aboriginalwomen had greater gravidity but similar parity (3 plusmn 22 plusmn 1vs 2 plusmn 12 plusmn 1 P lt 0001ns) More Aboriginal women hadhad ge 1 past spontaneous miscarriage (393 vs 152P = 0004) Although the proportion who currently smokedwas greater among Aborigines (680 vs 248 P lt 0001)the number of cigarettes reported smoked per day wassimilar (Aborigines vs non-Aborigines 12 plusmn 2 vs 10 plusmn 7)Aboriginal women were also more likely to drink alcohol(500 vs 107 P lt 0001) and smoke marijuana (107vs 18 P = 0023) There were no significant differencesin family history of diabetes (357 vs 375) or hyperten-sion (429 vs 304) previous induced abortions (64overall) or ectopic pregnancies (14 overall) and no womanhad a prior stillbirth Gestational age at booking was lateramong Aboriginal women (15 plusmn 8 vs 12 plusmn 6 weeks P =0010) with a greater proportion booking ge 20 weeks (250vs 98 P = 0032)
Aboriginal women were more likely to receive iron therapy(Table 1) There was no difference in the proportion receiv-ing folate therapy (100) Aboriginal women were morelikely to be screened for GDM and have an OGTT Similarproportions of women had a positive GCT (214 overall)and went on to OGTT (571) Although similar proportionshad an ultrasound in the first (164) and second trimester(607) Aborigines were more likely to have an ultrasoundin the third trimester At 37 weeks there were no differencesin mean blood pressure (available for 21 Aborigines and 84non-Aborigines 116 plusmn 1271 plusmn 9 mmHg) or weight (available
for 24 Aborigines and 77 non-Aborigines 78 plusmn 16 vs 82 plusmn18 kg respectively)
There was no difference in the average length of stay (48 plusmn34 days) Numbers were too few to compare rates of antepar-tum haemorrhage and intrauterine growth retardation (14overall each) Hypertension in pregnancy was similar (57overall) There were no differences in proportions having epiduralanalgesia meconium stained liquor at delivery or paediatri-cians in attendance There were no differences in gestation atdelivery Aboriginal babies were significantly smaller Therewas no difference in APGAR scores at 1 or 5 min Aborig-inal mothers were significantly more likely to bottle feedtheir babies
Discussion
In spite of the relative size of the indigenous community fora rural Victorian area the number of Aboriginal womenidentified is small While the sample size is too small to justifymultivariate analyses these data do give an insight into theobstetric and neonatal outcomes for the largest rural VictorianAboriginal community
Within the limitations of the data collected it is interest-ing to note that Aboriginal women were more likely to bescreened for gestational diabetes to be prescribed iron therapyin pregnancy to have a third trimester ultrasound scan and(non-significantly) less likely to have a Caesarean sectionThe basis of these differences is uncertain but may reflect arealisation of the increased perinatal mortality rates amongstAboriginal women111 and thus a tendency to treat Aboriginalwomen as a high-risk obstetric group Alternatively it mayreflect the high-quality of antenatal care provided by the localAboriginal Antenatal Support services There is much qualitativeevidence to support the benefits of these services112 Despitethis there are clearly still barriers with the significantly later book-ing and lower breastfeeding rates amongst Aboriginal women
The magnitude of the reduction in birth weight amongAboriginal babies was comparable to that described among
Table 1 Comparison of antenatal and perinatal characteristics between Aboriginal and-non-Aboriginal women in the Goulburn Valley
Aboriginal Non-Aboriginal sig
Iron therapy this pregnancy 286 116 0025Asthma therapy 71 27 nsScreened for GDM 857 661 0042Had OGTT 286 125 0037GDM 107 45 nsUltrasound in third trimester 607 179 lt 0001Gestational age at delivery 389 plusmn 14 weeks 393 plusmn 12 weeks nsLabour induced 429 270 nsNormal vaginal delivery 714 685 nsCaesarean section 143 207 nsBirthweight (g) 3190 plusmn 520 3490 plusmn 460 0003 birthweight le 25 kg 107 27 0060Neonatal intensive care 179 112 nsBottle feeding only 321 125 0012
GDM gestational diabetes OGTT oral glucose tolerance test ns not significant
D Simmons et al
70 Australian and New Zealand Journal of Obstetrics and Gynaecology 2005 45 68ndash70
Aborigines in other areas across Australia34 and is known tobe associated with higher perinatal mortality13 (although nodeaths occurred in this cohort) The origins of reducedbirthweight among Aborigines have been debated at lengthMathematical models and serial ultrasound growth measure-ments have suggested that gestational age misclassification isunlikely to be the cause1415 The differences may in somepopulations be explained on the basis of earlier deliveryamong certain groups In our study population there was nodifference in gestational age at delivery As in previous studiesbehaviours known to be associated with a reduction in averagebirth weight were more common amongst Aboriginal mothersthan the comparative group Thus smoking use of marijuanaand excessive alcohol intake were all significantly increasedamong Aboriginal women in the present study16
In conclusion we have found in a retrospective audit thatthe disparity in Aboriginal birth weight described in severalareas of Australia exists in rural Victoria Antenatal care andits outcomes are likely to have been impacted upon by laterbooking and some lifestyle choices (eg smoking) Pre-conceptual educational programmes should be considered toaugment existing services and efforts to encourage breast-feeding need to be targeted more effectively
Acknowledgements
We would like to thank Nalifur Talat Denise Little SusanGumley and Desiree Yap formerly of the Department ofRural Health The University of Melbourne Shepparton fortheir contributions to this work We would like to thank thelocal health services for their support for this audit projectThe Department of Rural Health receives funding from theCommonwealth Department of Health and Ageing
References
1 Powell J Dugdale AE Obstetric outcomes in an Aboriginalcommunity a comparison with the surrounding rural areaAust J Rural Health 1999 7 13ndash17
2 Watson J Hodson K Johnson R Kemp K The maternityexperiences of indigenous women admitted to an acute caresetting Aust J Rural Health 2002 10 154ndash160
3 OrsquoConnor M Bush A Pregnancy outcomes of AustralianAboriginals and Torres Strait Islanders Med J Aust 1996 164516ndash517
4 AIHW Australiarsquos Health 2002 Canberra Australian Instituteof Health and Welfare 2002 Available from httpwwwaihwgovaupublicationsausah02ah02pdf
5 Najman J Williams GM Bor W Anderson MJ Morrison JObstetrical outcomes of Aboriginal pregnancies at a majorurban hospital Aust J Public Health 1994 18 185ndash189
6 Territory Health Services And the women said hellip Reportingon birthing services of Aboriginal women from remote top endcommunities Darwin Territory Health Services 1999
7 ABS Census of Population and Housing 2001 MelbourneAustralian Bureau of Statistics 2002 Available from httpwwwabsgovauausstatsabscensusnsf321OpenView
8 Hoffman L Nolan C Wilson JD Oats JJN Simmons D Con-sensus statement Gestational diabetes mellitusndashmanagementguidelines The Australasian Diabetes in Pregnancy SocietyMed J Aust 1998 169 93ndash97
9 Yap D Final report June 1999ndashJune 2001 RHSET SeniorLecturer in Obstetrics and Gynaecology University ofMelbourne Melbourne 2001
10 Humphrey M Editorial comment ANZJOG 2003 43 18911 de Costa C Child A Pregnancy outcomes in urban Aboriginal
women Med J Australia 1996 164 523ndash52612 Mackerras D Birthweight changes in the pilot phase of the strong
women strong babies strong culture program in the NorthernTerritory Aust NZ J Public Health 2001 25 35ndash40
13 Day P Sullivan EA Lancaster P Indigenous mothers and theirbabies Australia 1994ndash1996 Randwick NSW AustralianInstitute of Health and Welfare National Perinatal StatisticsUnit 1999
14 Coory M Does gestational age misclassification explain thedifference in birthweights for Australian Aborigines andwhites Int J Epidemiol 1996 25 980ndash988
15 Humphrey M Holzheimer D Fetal growth charts for Aborig-inal fetuses Aust N Z Obstet Gynaecol 2000 40 388ndash393
16 Rousham EK Gracey M Factors affecting birthweight ofrural Australian Aborigines Ann Human Biol 2002 29 363ndash372
D Simmons et al
70 Australian and New Zealand Journal of Obstetrics and Gynaecology 2005 45 68ndash70
Aborigines in other areas across Australia34 and is known tobe associated with higher perinatal mortality13 (although nodeaths occurred in this cohort) The origins of reducedbirthweight among Aborigines have been debated at lengthMathematical models and serial ultrasound growth measure-ments have suggested that gestational age misclassification isunlikely to be the cause1415 The differences may in somepopulations be explained on the basis of earlier deliveryamong certain groups In our study population there was nodifference in gestational age at delivery As in previous studiesbehaviours known to be associated with a reduction in averagebirth weight were more common amongst Aboriginal mothersthan the comparative group Thus smoking use of marijuanaand excessive alcohol intake were all significantly increasedamong Aboriginal women in the present study16
In conclusion we have found in a retrospective audit thatthe disparity in Aboriginal birth weight described in severalareas of Australia exists in rural Victoria Antenatal care andits outcomes are likely to have been impacted upon by laterbooking and some lifestyle choices (eg smoking) Pre-conceptual educational programmes should be considered toaugment existing services and efforts to encourage breast-feeding need to be targeted more effectively
Acknowledgements
We would like to thank Nalifur Talat Denise Little SusanGumley and Desiree Yap formerly of the Department ofRural Health The University of Melbourne Shepparton fortheir contributions to this work We would like to thank thelocal health services for their support for this audit projectThe Department of Rural Health receives funding from theCommonwealth Department of Health and Ageing
References
1 Powell J Dugdale AE Obstetric outcomes in an Aboriginalcommunity a comparison with the surrounding rural areaAust J Rural Health 1999 7 13ndash17
2 Watson J Hodson K Johnson R Kemp K The maternityexperiences of indigenous women admitted to an acute caresetting Aust J Rural Health 2002 10 154ndash160
3 OrsquoConnor M Bush A Pregnancy outcomes of AustralianAboriginals and Torres Strait Islanders Med J Aust 1996 164516ndash517
4 AIHW Australiarsquos Health 2002 Canberra Australian Instituteof Health and Welfare 2002 Available from httpwwwaihwgovaupublicationsausah02ah02pdf
5 Najman J Williams GM Bor W Anderson MJ Morrison JObstetrical outcomes of Aboriginal pregnancies at a majorurban hospital Aust J Public Health 1994 18 185ndash189
6 Territory Health Services And the women said hellip Reportingon birthing services of Aboriginal women from remote top endcommunities Darwin Territory Health Services 1999
7 ABS Census of Population and Housing 2001 MelbourneAustralian Bureau of Statistics 2002 Available from httpwwwabsgovauausstatsabscensusnsf321OpenView
8 Hoffman L Nolan C Wilson JD Oats JJN Simmons D Con-sensus statement Gestational diabetes mellitusndashmanagementguidelines The Australasian Diabetes in Pregnancy SocietyMed J Aust 1998 169 93ndash97
9 Yap D Final report June 1999ndashJune 2001 RHSET SeniorLecturer in Obstetrics and Gynaecology University ofMelbourne Melbourne 2001
10 Humphrey M Editorial comment ANZJOG 2003 43 18911 de Costa C Child A Pregnancy outcomes in urban Aboriginal
women Med J Australia 1996 164 523ndash52612 Mackerras D Birthweight changes in the pilot phase of the strong
women strong babies strong culture program in the NorthernTerritory Aust NZ J Public Health 2001 25 35ndash40
13 Day P Sullivan EA Lancaster P Indigenous mothers and theirbabies Australia 1994ndash1996 Randwick NSW AustralianInstitute of Health and Welfare National Perinatal StatisticsUnit 1999
14 Coory M Does gestational age misclassification explain thedifference in birthweights for Australian Aborigines andwhites Int J Epidemiol 1996 25 980ndash988
15 Humphrey M Holzheimer D Fetal growth charts for Aborig-inal fetuses Aust N Z Obstet Gynaecol 2000 40 388ndash393
16 Rousham EK Gracey M Factors affecting birthweight ofrural Australian Aborigines Ann Human Biol 2002 29 363ndash372