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Adverse Perinatal Outcomes among Immigrant Women from Ethiopia in Israel Ronit Calderon-Margalit, MD, Dan Sherman, MD, Orly Manor, PhD, and Yaffa Kurzweil, MPH ABSTRACT: Background: Immigration from Ethiopia to Israel started about 30 years ago. We aimed to compare birth outcomes between Israeli women of Ethiopian origin and Israeliborn, non-Ethiopian women. We hypothesized a higher frequency of adverse birth outcomes among Ethiopian women and a trend of improvement among those who were raised in Israel since early childhood. Methods: This is a descriptive study, comparing birth outcomes of Ethiopian (n = 1,319) and non-Ethiopian women (n = 27,307) who gave birth in a medical center in Central Israel in 2002 to 2009. Ethiopian women were further categorized by age at immigration. Logistic regressions were constructed to compare the incidence of adverse birth outcomes between Ethiopian and non-Ethiopian women, controlling for potential confounders. Results: Ethiopian women had about twice the incidence of very and extremely preterm births, compared with non-Ethiopians. Ethiopian women had twice the odds for neonates who were either small for gestational age or had low 5-minute Apgar scores. Ethiopian women had about threefold increased risk of stillbirths (OR 2.9 [95% CI 1.87– 4.49]). No trend of improvement was noted for women who were raised in Israel from early childhood. Conclusion: Ethiopian women are at increased risk of adverse birth outcomes. Future research is needed to investigate the underlying causes for the increased risks and lack of improvement among those who were raised in Israel that will lead to effective interventions. (BIRTH 42:2 June 2015)

Key words: age at immigration, Ethiopian, migrant health, perinatal outcomes, stillbirth

Studies on the health of migrants compared with the population of the receiving countries range from better (healthy migrant effect) to worse health status, partly depending on country of origin, recipient country, and time from immigration (1). Comparing migrants either to residents of their countries of origin or to second, third, or higher generation migrants may lead to the identification of environmental risk factors, whereas comparing migrants to the nonimmigrant population of the recipient

country may lead on the one hand to the identification of ethnic-related and genetic risk factors, and on the other hand give essential information on inequalities in health care and level of integration into the receiving society (2). Although migrants are considered in some cases as marginalized groups (1), pregnant women and children are vulnerable populations within migrant groups. Ethiopian Jews have immigrated to Israel over the past 29 years, and by the end of 2011 they reached a

Ronit Calderon-Margalit is a senior lecturer in epidemiology in the Hadassah-Hebrew University Braun School of Public Health, Jerusalem; Dan Sherman is an obstetrician-gynecologist, and former head of obstetrics department, in the Department of Obstetrics and Gynecology at the Assaf-Harofeh Medical Center, Zerifin; Orly Manor is a professor in biostatistics in the Hadassah-Hebrew University Braun School of Public Health, Jerusalem; and Yaffa Kurzweil is nurse, research coordinator and data manager in the Department of Obstetrics and Gynecology at the Assaf-Harofeh Medical Center, Zerifin, Israel.

Address correspondence to Ronit Calderon-Margalit, HadassahHebrew University Braun School of Public Health, POB 12272, Jerusalem 91120, Israel.

Accepted January 21, 2015

© 2015 Wiley Periodicals, Inc.

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126 population of 115,000 (1.6% of the Israeli population), about a third of whom were born in Israel (3). Previous studies on pregnancy and birth outcomes, which were performed closer to the first waves of immigration, showed that this population was at risk for pregnancy complications and adverse birth outcomes, such as low birthweight, preeclampsia, and perinatal mortality (4– 6). A recent study of 576 Ethiopian women and 1,152 controls suggested that gaps between Ethiopian and non-Ethiopian parturients in pregnancy complications and adverse birth outcomes persist (7). None of these studies referred to time since immigration or age at immigration. The objective of the current study was to examine the obstetric and neonatal outcomes of parturient women of Ethiopian origin compared with Israeli-born, non-Ethiopian women, and to study the effect of age at immigration. Our assumption was that women who were raised in Israel since early childhood would be better acculturated to the Israeli lifestyle and health resources, which would reflect higher similarity to the receiving society in birth outcomes, as opposed to women who were raised in Ethiopia and immigrated at an older age.

Methods We conducted a cross-sectional study. The study population included women who gave birth at the AssafHarofeh Medical Center, a public hospital that serves both as a community and a tertiary hospital, between June 1, 2002, and December 31, 2009. The hospital provides delivery care to all citizens, free of charge, regardless of their country of birth or ethnic background, and there are no differential guidelines or provision of care by origin. Delivery care of uncomplicated births is supplied by midwives supervised by obstetricians. The catchment area of this medical center includes about 25 percent of the population of Ethiopian origin in Israel. Information related to the countries of birth of each parturient, and her parents, as well as the dates of immigration to Israel (if not Israeli-born) were obtained by linking women’s unique Israeli identification number with the Israeli Population Registry. Study groups were stratified into women who were either born in Ethiopia or had parents who were born in Ethiopia (“Ethiopian women,” n = 1,319) and women who were born in Israel and their parents were not of Ethiopian origin (“non-Ethiopian women,” n = 27,307). The Ethiopian women for whom date of immigration was available were further divided by age at immigration into women who immigrated at or after the age of 8 years (“Ethiopian-Ethiopian,” n = 1,034) and those who were

either born in Israel or immigrated before 8 years of age (“Israeli-Ethiopian,” n = 208). For every participant, only the first delivery in the data set was chosen to avoid over-representation of multiparous women. Data concerning pregnancy complications and perinatal outcomes were collected from the electronic database of the Department of Obstetrics & Gynecology. This electronic database holds data on all deliveries since June 2002. Data collection was concluded in 2009 as a result of transition to another data warehouse. Data collected included demographic information on the country of origin (Ethiopian vs non-Ethiopian) and residential address, data on pregnancy complications as recorded on admission to the delivery room, obstetric information, as recorded during labor, including data on the mode of delivery, obstetric and postpartum complications, and data on the newborn as recorded in the summary of delivery. Data recorded on birthweight, 5-minute Apgar scores, sex, mode of delivery, and perinatal mortality were routinely validated for integrity and completeness. Women were excluded from the relevant analyses in cases where data could not be obtained (< 0.5% per variable). There were no differential losses of information by study groups. Diagnoses of gestational diabetes, pregestational diabetes, chronic hypertension, preeclampsia, and gestational hypertension were retrieved from the physicians’ records on admission and discharge. We validated the diagnoses of a subset of patients and checked the files of a sample of women with no diagnosis to see whether there were missing diagnoses. We found the computerized reporting complete.

Outcome Definition Gestational age was calculated as the number of completed weeks since the date of the last menstrual period and was corrected according to a first-trimester ultrasound scan, if differences were greater than 1 week. A preterm birth was defined as a delivery at gestational age of less than 37 completed weeks, which was further subdivided into extremely preterm birth (< 28 weeks), very preterm birth (28–31 weeks), and moderate to late preterm birth (32–36 weeks). A postterm birth was defined as any delivery that took place after 41 completed weeks. Low birthweight (LBW) was defined as birthweight below 2,500 g, very low birthweight (VLBW) as birthweight < 1,500 g, and extremely low birthweight (ELBW) as birthweight < 1,000 g. Newborns were considered small for gestational age (SGA) if their birthweight was below the 10th percentile for gestational age, or large for gestational age if their birthweight was above the 90th percentile, according to

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the Israeli sex-singleton/multiple birth-specific and gestational age-specific birthweight growth charts (8). Low 5-minute Apgar scores were defined as scores < 7. Stillbirth was defined as a fetal demise that occurred after 22 weeks of gestation or a demise of a fetus which weighed > 500 g. Perinatal mortality included stillbirths and in-hospital deaths of newborns up to 1 week postpartum (early neonatal deaths). Study covariates included maternal age, parity, and singleton/multiple birth. Socioeconomic status (SES) was defined according to place of residence, categorized by the Israeli Central Bureau of Statistics into 10 socioeconomic clusters based on income, education, standards of living, transportation, and income support levels (9). We further categorized these clusters into three levels, according to tertiles distribution of our study sample (low—clusters 1–4, medium—clusters 5– 6, and high—clusters 7–10).

Statistical Analysis The characteristics of the study population were described by study group, comparing Ethiopian women with non-Ethiopian women using chi squared or Student’s t tests as appropriate. Logistic regression models were constructed to examine the association between Ethiopian origin and perinatal outcome, controlling where applicable for maternal age, SES, parity, multiple births, and gestational age. We further constructed logistic regression models studying the association of adverse outcomes by study group, where Israeli-Ethiopian and Ethiopian-Ethiopian women were compared with non-Ethiopian women. Statistical analyses were performed using SPSS statistical package ver. 18 (Chicago, IL, USA). We report odds ratios (OR) and 95% confidence intervals (CI). The study protocol was approved by the Institutional Review Board of AssafHarofeh Medical Center.

Results Although the mean age at birth was similar among Ethiopian and Non-Ethiopian women (29.5 and 29.2 years, respectively), higher proportions of Ethiopian parturients were either adolescents (3.3%) or older than 41 years (5.5%), compared with non-Ethiopian women (2.4 and 1.8%, respectively, p < 0.001) (Table 1). Fewer of the Ethiopian women were married (78.3 vs 93.6%, Ethiopian vs non-Ethiopian, respectively, p < 0.001). Parity among Ethiopian women was higher than non-Ethiopian women. Non-Ethiopian women had a mean of 2.4 pregnancies and 2.0 births, whereas Ethio-

pian women had 3.2 pregnancies and 2.8 births (p < 0.001 for both). Ethiopian women had lower rate of multiple births, compared with non-Ethiopians (1.2 vs 3.2%, respectively, p < 0.001). Neonatal birthweight in the Ethiopian study group was lower than the non-Ethiopian (3,090 vs 3,160 g, respectively, p < 0.001). The overall preterm delivery rate was similar in nonEthiopian and Ethiopian women (9.3 and 8.3%, respectively); however, very preterm birth was the outcome of 0.8 and 1.4 percent of births among non-Ethiopian and Ethiopian women, respectively, yielding a crude OR of 1.82 (95% CI 1.14–2.93) (Table 2). Extremely preterm births complicated 0.5 percent of births among non-Ethiopian women, whereas among Ethiopian women, extremely preterm births were the outcomes of 1.1 percent of deliveries, yielding an OR of 2.02 (95% CI 1.16–3.50). Controlling for maternal age, SES, parity, and multiple pregnancy, yielded OR 2.32 (95% CI 1.42–3.78) and OR 2.44 (95% CI 1.18–3.77) for very preterm birth and extremely preterm birth, respectively. These associations remained similar with the introduction of preeclampsia to the multivariable models, with adjusted ORs of 1.89 (95% CI 1.15–3.10) and 1.92 (95% CI 1.09–3.38) for very and extremely preterm birth, respectively. Among Ethiopian women, the rate of postterm deliveries was 8.2 percent, compared with 2.0 percent among non-Ethiopians (OR 4.36 [95% CI 3.52–5.39]). Adjusting for age, parity and SES, postterm births remained highly associated with Ethiopian origin (aOR 3.45 [95% CI 2.76–4.31]). Among newborns born to Ethiopian women, 11.4 percent were LBW, compared with 9.2 percent among non-Ethiopians, yielding a crude OR of 1.21 (95% CI 1.02–1.45), and a maternal age, SES, parity, multiple pregnancy, and gestational age adjusted OR of 1.63 (95% CI 1.29–2.07). Similarly, VLBW and ELBW were more prevalent among newborns to Ethiopian women with crude OR 1.87 (95% CI 1.31–2.67) and OR 2.18 (95% CI 1.34–3.56), respectively, however, these associations with VLBW and ELBW disappeared in multivariable models. Among newborns born to Ethiopian women, 15.4 percent were SGA, compared with 8.5 percent of those born to non-Ethiopians, yielding an OR of 1.95 (95% CI 1.67–2.28). This association remained practically unchanged after adjustment for maternal age, parity, and SES (OR 2.10 [95% CI 1.79–2.46]), and further adjustment for preeclampsia (OR 1.91 [95% CI 1.60– 2.27]). Newborns of Ethiopian women had a higher prevalence of low 5-minute Apgar scores compared with non-Ethiopian women (2.5 vs 0.9%, respectively), yielding a crude OR of 2.95 (95% CI 2.03–4.28).

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128 Table 1. Characteristics of the Study Population by Origin

Ethiopian n = 1,319 No. (%) Sociodemographic characteristics Maternal age, mean (SD) < 20 years 20–40 years > 40 years Marital status Married Single parenthood Low socioeconomic status (SES) Pregestational diabetes Chronic hypertension Pregnancy-related characteristics Parity Primipara Parity 2–4 Parity ≥ 5 (Grandmultipara) Multiple pregnancy Pregnancy complications Gestational diabetes Preeclampsia Malpresentation Mode of delivery Instrumental delivery Cesarean delivery Epidural analgesia

Non-Ethiopian n = 27,307 No. (%)

29.5 44 1,219 66

(6.2) (3.3) (91.7) (5.0)

29.2 659 26,168 480

(5.3) (2.4) (95.8) (1.8)

1,032 287 684 3 16

(78.3) (21.7) (51.9) (0.2) (1.2)

25,559 1,748 9,257 25 382

(93.6) (6.4) (33.9) (0.3) (1.4)

487 564 268 16

(36.9) (42.8) (20.3) (1.2)

13,653 12,288 1,366 874

(50.0) (45.0) (5.0) (3.2)

p

0.062

< 0.001 < 0.001 < 0.001 0.71 0.59

< 0.001 < 0.001

43 (3.3) 75 (5.7) 70 (5.3)

1,201 (4.4) 683 (2.5) 1,666 (6.1)

0.05 < 0.001 0.22

102 (7.7) 294 (22.3) 210 (21.5)

1,802 (6.6) 4,997 (18.3) 12,110 (54.3)

0.052 < 0.001 < 0.001

Adjusting for maternal age, SES, parity, multiple pregnancy, and gestational age, slightly weakened the association (OR 1.88 [95% CI 1.11–3.19]). Stillbirth rates were 19 and 6.4 per 1,000 live births among Ethiopian and non-Ethiopian women, respectively, yielding an age, SES, parity, and multiple birth adjusted OR of 2.90 (95% CI 1.87–4.49). Women of Ethiopian origin experienced an increased risk of perinatal mortality (aOR = 2.93 [95% CI 1.92–4.47]) (Table 2).

The association between Ethiopian origin and perinatal outcomes by age at immigration Stratifying by age at immigration, compared with Israeli-Ethiopian women, Ethiopian-Ethiopian women were older, of lower SES (proportion with low SES: 53.1 vs 45.7%, Ethiopian-Ethiopian vs Israeli-Ethiopians, respectively), and had higher parity (mean parity of 3.16 and 1.29, respectively, data not shown).

The association between Ethiopian origin and perinatal outcomes by age at immigration is shown in Table 3. Associations with multiple pregnancies, and lack of association with all preterm births were similar among the Ethiopian-Ethiopian and the Israeli-Ethiopian women. However, 1.6 percent of births to Ethiopian-Ethiopian women were very preterm, leading to an adjusted OR of 2.70 (95% CI 1.62–4.50), whereas no differences were noted between Israeli-Ethiopian women and controls. Extremely preterm births were significantly increased among Israeli-Ethiopian women compared with non-Ethiopian women (1.9 vs 0.5%, respectively; aOR 3.46 [95% CI 1.26–9.51]). No association was noted between Ethiopian-Ethiopian women and non-Ethiopian women in extremely preterm births. Associations with LBW, VLBW, and ELBW seemed stronger among Israeli-Ethiopian than Ethiopian-Ethiopian women, however, differences attenuated in multivariable models; no differences were noted in the associations with SGA between the groups. There was no improvement in the association between Ethiopian

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Table 2. The Association of Ethiopian Origin with Perinatal Outcomes, According to Univariate and Multivariable Logistic Regression Models

Multiple pregnanciesa Preterm birthb All preterm births Very preterm birth Extremely preterm birth Postterm birthb Low birthweightc Very low birthweightc Extremely low birthweightc Small for gestational agea Large for gestational agea 5-minute Apgar < 7c Stillbirthb Perinatal mortalityb

Ethiopian (n = 1,319) %

Non Ethiopian (n = 27,307) %

Univariate model* OR (95% CI)

Multivariable model* OR (95% CI)

1.2

3.2

0.37 (0.23–0.61)

0.43 (0.26–0.70)

8.3 1.4 1.1 8.2 11.2 2.6 1.4 15.4 6.9 2.5 19.0 20.0

9.3 0.8 0.5 2.0 9.4 1.4 0.6 8.5 8.8 0.9 6.4 6.8

1.09 1.82 2.02 4.36 1.24 1.87 2.18 1.95 0.76 2.95 2.98 3.02

1.02 2.32 2.11 3.40 1.63 1.26 0.82 2.10 0.69 1.88 2.90 2.93

(0.82–1.25) (1.14–2.93) (1.16–3.50) (3.52–5.39) (1.02–1.45) (1.31–2.67) (1.34–3.56) (1.67–2.28) (0.61–0.95) (2.03–4.28) (1.95–4.54) (2.00–4.53)

(0.82–1.26) (1.42–3.78) (1.18–3.77) (2.72–4.25) (1.29–2.07) (0.59–2.71) (0.32–2.11) (1.79–2.46) (0.55–0.86) (1.11–3.19) (1.87–4.49) (1.92–4.47)

*Israeli non-Ethiopian women are the reference category. Multivariate models adjusted for: amaternal age, socioeconomic status, parity. bmaternal age, parity, socioeconomic status, multiple pregnancy. cmaternal age, parity, socioeconomic status, multiple pregnancy, gestational age.

Table 3. The Association of Ethiopian Origin with Perinatal Outcomes by Age at Immigration to Israel, Results of the Univariate and Multivariable Analyses

Univariate analysis* Ethiopian-Ethiopian (n = 1,034) OR (95% CI) Preterm birthb Very preterm birthb Extremely preterm birthb Postterm birthb Low birthweightc Very low birthweightc Extremely low birthweightc Small for gestational agea 5-minute Apgar < 7c Stillbirthb Perinatal mortalityb

0.83 2.05 1.70 4.72 1.07 1.68 1.69 1.81 2.72 2.68 2.56

(0.66–1.03) (2.26–3.33) (0.89–3.25) (3.77–5.91) (0.87–1.32) (1.11–2.55) (0.92–3.13) (1.50–2.18) (1.76–4.18) (1.66–4.32) (1.57–4.16)

Multivariable analysis*

Israeli-Ethiopian (n = 208) OR (95% CI) 1.15 0.61 3.70 2.47 1.82 2.82 4.68 2.27 4.65 4.58 5.77

(0.74–1.79) (0.08–4.34) (1.36–10.1) (1.30–4.68) (1.25–2.65) (1.38–5.76) (2.05–10.68) (1.58–3.26) (2.27–9.52) (2.00–10.45) (2.81–11.87)

Ethiopian-Ethiopian OR (95% CI) 0.96 2.70 1.83 3.66 1.48 1.02 0.68 2.03 1.79 2.67 2.87

(0.75–1.23) (1.62–4.50) (0.92–3.64) (2.90–4.63) (1.18–1.96) (0.43–2.41) (0.24–1.96) (1.69–2.44) (0.99–3.24) (1.60–4.46) (1.33–6.20)

Israeli-Ethiopian OR (95% CI) 1.33 0.65 3.46 2.03 2.02 1.85 1.88 1.91 2.86 4.66 5.50

(0.84–2.09) (0.09–4.71) (1.26–9.51) (1.03–3.99) (1.23–3.31) (0.35–9.82) (0.17–21.44) (1.32–2.75) (0.86–9.50) (2.01–10.78) (1.37–22.09)

*Non-Ethiopian women are the reference category. Ethiopian-Ethiopian women are those who immigrated to Israel at age ≥ 8 years. EthiopianIsraeli women are those who were either born in Israel or immigrated when they were < 8 years. aMultivariable models adjusted for maternal age, socioeconomic status, parity. bMultivariable models adjusted for maternal age, parity, socioeconomic status, multiple pregnancy. cMultivariable models adjusted for maternal age, parity, socioeconomic status, multiple pregnancy, gestational age.

origin and stillbirths or perinatal mortality among those who immigrated at a young age, with adjusted OR for stillbirths of 2.67 (95% CI 1.60–4.46) and 4.66 (95% CI 2.01–10.8) among Ethiopian-Ethiopian and IsraeliEthiopian women, respectively (Table 3).

Discussion Compared with non-Ethiopian women, women of Ethiopian origin were at increased risk of having very and extremely preterm births, and stillbirths. Offspring of

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130 Ethiopian women were at increased risk of LBW, SGA, and low Apgar scores. No improvement was noted among Ethiopian-origin women who were either born in Israel or immigrated at a very young age. Our results demonstrated no association between Ethiopian origin and overall preterm delivery. A previous Israeli study from the 1980s found that Ethiopian immigrants had twice the rate of preterm deliveries compared with controls in the first half of the 1980s, and only 33 percent more preterm deliveries in the second half of that decade (6). However, a recent small study from Israel failed to show an unadjusted association between Ethiopian origin and either preterm deliveries in general, or very preterm births in particular (7). Our findings of twofold increased risks for both very and extremely preterm birth among women of Ethiopian origin are consistent with findings from the United States and United Kingdom of higher very preterm birth rates among black than among white women (10,11). Although these associations might be partially explained by ethnicity, it is possible that there was residual confounding or mediation by unmeasured factors, such as stress levels (12). In our study, women of Ethiopian origin had higher odds of LBW. Associations were even stronger and more robust with SGA (OR 2.10 [95% CI 1.79–2.46]), suggesting a mechanism other than preterm birth. Whether neonates born to women of Ethiopian origin should have different growth charts is yet to be studied; nevertheless, in a study from the United States, no association was found between Ethiopian origin and LBW, compared with whites (13). A meta-analysis of immigration and LBW (14) showed different results by country of origin and destination. For example, women from sub-Saharan Africa were at increased risk for LBW compared with native European women (OR 1.75 [95% CI 1.44–2.12]); however, no association was evident among women from sub-Saharan Africa who immigrated to the United States. Moreover, African immigrants had lower risk of LBW compared with United States-born African-Americans. Women of Ethiopian origin had almost three times the risk of having a stillbirth compared with non-Ethiopians. Similar to our results, a recent meta-analysis (15) demonstrated an increased risk of stillbirth among nonrefugee migrants from non-European to European countries (RR 1.88). Furthermore, in studies from the United States and the United Kingdom, non-Hispanic Black women had about twice the risk of stillbirth compared with White women (16,17). A study of risk factors for stillbirths demonstrated undetected IUGR as the single strongest risk factor for stillbirths with a population attributable risk of 32 percent (17). This is consistent with our finding of increase SGA risk among women of Ethiopian origin.

Our study’s limitations include place of residence as a source for determining SES, limiting our ability to exclude residual confounding by SES. However, the association of low SES with preterm birth and stillbirth may be at least partially mediated by smoking (18,19), whereas smoking is less prevalent among Ethiopian adults in Israel compared with Israeli-born adults, supporting an association that is beyond SES gaps per se (20). Our study was also limited by the small sample size of Israeli-Ethiopian women, precluding further analyses. This study was based on a single center, which raises the question of generalizability. However, the catchment area of this medical center includes about 25 percent of the population of Ethiopian origin, suggesting that our results are generalizable. Our study’s strengths include the large unselected study population admitted to a medical center that serves many of the Ethiopian women, the use of an unbiased computerized data set, and the analysis by age at immigration. In conclusion, our study suggests disparities in birth outcomes among women of Ethiopian origin in Israel, and a lack of improvement among Ethiopian-origin women who were raised in Israel. These disparities may stem either from ethnic differences or from immigration-related factors that may be associated with stress, degree of acculturation, and differential use of health services, despite a universal coverage of care. The sources for these disparities should be further investigated to illuminate mechanisms of adverse birth outcomes among migrant women and to allow the planning and implementation of effective interventions.

Conflict of Interests All authors report no conflict of interest.

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5. Medical and epidemiological aspects of the Ethiopian immigration to Israel. Isr J Med Sci 1991;27:241–299. 6. Segal S, Gemer O, Yaniv M. The outcome of pregnancy in an immigrant Ethiopian population in Israel. Arch Gynecol Obstet 1996;258:43–46. 7. Salim R, Mfra A, Garmi G, Shalev E. Comparison of intrapartum outcome among immigrant women from Ethiopia and the general obstetric population in Israel. Int J Gynaecol Obstet 2012;118: 161–165. 8. Dollberg S, Haklai Z, Mimouni FB, et al. Birth weight standards in the live-born population in Israel. Isr Med Assoc J 2005;7: 311–314. 9. Israeli Central Bureau of Statistics. Socioeconomic clusters. Available at: http://cbs.gov.il/census. 10. MacDorman MF. Race and ethnic disparities in fetal mortality, preterm birth, and infant mortality in the United States: An overview. Semin Perinatol 2011;35:200–208. 11. Aveyard P, Cheng KK, Manaseki S, Gardosi J. The risk of preterm delivery in women from different ethnic groups. BJOG 2002;109:894–899. 12. Rosenthal L, Lobel M. Explaining racial disparities in adverse birth outcomes: Unique sources of stress for Black American women. Soc Sci Med 2011;72:977–983. 13. Wasse H, Holt VL, Daling JR. Pregnancy risk factors and birth outcomes in Washington State: A comparison of Ethiopian-born and US-born women. AmJ Public Health 1994;84:1505–1507.

131 14. Gagnon AJ, Zimbeck M, Zeitlin J, et al. Migration to western industrialised countries and perinatal health: A systematic review. Soc Sci Med 2009;69:934–946. 15. Gissler M, Alexander S, MacFarlane A, et al. Stillbirths and infant deaths among migrants in industrialized countries. Acta Obstet Gynecol Scand 2009;88:134–148. 16. Hogue CJ, Parker CB, Willinger M, et al. A population-based case-control study of stillbirth: The relationship of significant life events to the racial disparity for African Americans. Am J Epidemiol 2013;177:755–767. 17. Gardosi J, Madurasinghe V, Williams M, et al. Maternal and fetal risk factors for stillbirth: Population based study. BMJ 2013;346:f108. 18. Raisanen S, Gissler M, Saari J, et al. Contribution of risk factors to extremely, very and moderately preterm births – register-based analysis of 1,390,742 singleton births. PLoS ONE 2013;8: e60660. 19. Gray R, Bonellie SR, Chalmers J, et al. Contribution of smoking during pregnancy to inequalities in stillbirth and infant death in Scotland 1994-2003: Retrospective population based study using hospital maternity records. BMJ 2009;339:b3754. 20. Shani M, Band Y, Kidon MI, et al. The second generation and asthma: Prevalence of asthma among Israeli born children of Ethiopian origin. Respir Med 2013;107:519–523.

Adverse Perinatal Outcomes among Immigrant Women from Ethiopia in Israel.

Immigration from Ethiopia to Israel started about 30 years ago. We aimed to compare birth outcomes between Israeli women of Ethiopian origin and Israe...
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