Journal of Obstetrics and Gynaecology, 2014; Early Online: 1–5 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2014.987113
ORIGINAL ARTICLE
Pregnancy outcomes in Southeast Asian migrant workers at Southern Thailand T. Hanprasertpong & J. Hanprasertpong
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Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
This retrospective study was conducted to determine the pregnancy outcomes and identify predictive factors of adverse outcomes in pregnant migrant workers who delivered at Songklanagarind Hospital from January 2002 to December 2012. Two hundred and forty migrant worker pregnancies were enrolled. Pre-eclampsia, gestational diabetes mellitus, pre-term birth and foetal intrauterine growth restriction found were 15, 7.9, 13.7 and 3.7%, respectively. No stillbirth was found. Apgar score was ⬍/ ⴝ 7 at 1 and 5 min and neonatal intensive care unit admission was found to be 12.1, 4.2 and 11.3%, respectively. Antenatal care place, low haemoglobin level and the presence of maternal underlying disease were significantly related to increased risk of overall adverse maternal outcomes. Only pre-term birth was significantly related to overall adverse neonatal outcomes. Keywords: Adverse, maternal outcome, migrant, neonatal outcome, predictive factor
Introduction Thailand is a country in the Southeast Asia (SEA) region. The World Bank reported in 2011 that the average income was around 5,281 US dollars per person per year. The rate was the fourth in SEA following Singapore, Brunei and Malaysia, whereas the average income in other countries such as Myanmar, the Lao People’s Democratic Republic (Laos) and Cambodia was 4–5 times lower than that in Thailand. The greater opportunities for work and education and the higher quality of the health care system are attracting migrants to move to Thailand. The Department of Employment of the Ministry of Labour reported that the number of migrant workers has dramatically increased year by year from 805,763 persons in 2008 to 1,719,200 persons in 2012. Providing obstetric care for the migrant population is challenging for both government and individual health care personnel. Some studies of peri-natal health and mortality in migrant obstetric population have found that some migrant populations had a higher risk of serious obstetric complications (Hayes et al. 2011; Naimy et al. 2013; Raimondi et al. 2013). However, all of the studies were conducted in Europe and in the Americas. Songklanagarind Hospital is a tertiary obstetric centre in the lower southern part of Thailand. Our hospital has provided obstetric care for more than 10 years without any pregnancy outcome review. Thus, the present study was conducted to evaluate the obstetric outcomes
of migrant worker pregnancies (MWPs). MWPs are defined as the SEA nations’ pregnant women who worked in Thailand. The main objective was to determine the maternal and neonatal outcomes. The secondary objective was to identify predictive factors for adverse maternal and neonatal outcomes in MWPs at Songklanagarind Hospital
Materials and methods This retrospective chart review was conducted at the Department of Obstetrics and Gynecology, Songklanagarind Hospital, using the inpatient delivery database of the Department of Obstetrics and Gynecology and the hospital computer database of patient records of the Antenatal Clinic, labour records and those of the Obstetric Inpatient Ward. The inclusion criteria were any MWPs delivered at Songklanagarind Hospital from January 2002 to December 2012. The study was approved by our institution’s Ethics Committee. The maternal records along with pregnancy and neonatal outcomes were reviewed. Maternal record data of interest included age, parity, nationality, body mass index (BMI), occupation, antenatal care (ANC) place, haemoglobin (Hb) level, communication capability and serologic status including human immunodeficiency virus (HIV) antibody, syphilis and hepatitis B surface antigen. Communication capability was subjectively documented in all our patient records by the hospital midwife and physician who interviewed the pregnant women at admission. Good and poor communication capability defined as the pregnant women could and could not understand and answer the question on their own, respectively. For ANC place, we divided the patients into 4 groups depending on the main place which the pregnant women visited for ANC. The ANC place of our pregnant women was shown in hospital admission data. Adverse pregnancy outcomes of interest were the following: (1) pre-eclampsia, defined as new onset of hypertension and proteinuria during pregnancy; (2) gestational diabetes mellitus (GDM), glucose intolerance with first recognition during pregnancy; (3) pre-term birth, defined as a live birth before 37 weeks’ gestation; (4) foetal intrauterine growth restriction (IUGR), defined as a birth weight less than the 10th percentile of the normal growth curve; (5) Apgar scores at 1 and 5 min; (6) thick meconium-stained amniotic fluid at the delivery time; (7) neonatal intensive care unit (NICU) admission; (8) stillbirth, defined as death in utero after 24 weeks’ gestation; and (9) post-partum haemorrhage (PPH), defined as estimated blood more than 500 or 1000 ml after vaginal or caesarean
Correspondence: Tharangrut Hanprasertpong, Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand. E-mail: [email protected], [email protected]
2
T. Hanprasertpong & J. Hanprasertpong
Table I. Patients’ basic characteristics.
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Median ⫾ SD or number (%) Age (years) Parity • Nulliparous • Parous Nationality (n, %) • Burmese • Lao • Cambodian • Other BMI (mean,27.20 ⫾ 4.09; range, 14.2–40) • ⬍ 18.5 • 18.5–24.9 • ⬎/ ⫽ 25 Occupation (n, %) • Housewife • Agriculturalist • Employee • Other ANC place (n, %) • PSU • Government hospital • Private clinic • No Hb Level: g/dl (n, %) • ⬍ 11 • ⬎/ ⫽ 11 HIV antibody • Non-reactive • Reactive VDRL status • Non-reactive • Reactive Hepatitis B surface antigen • Positive • Negative
27.8 ⫾ 5.9
Total number with available data 240
111 (46.3) 115 (47.9)
226
206 (85.8) 14 (5.8) 4 (1.7) 16 (6.7)
240
1 (0.6) 45 (28.5) 112 (70.9)
158
4 (1.7) 18 (7.5) 214 (89.2) 4 (1.7)
240
60 (25.0) 130 (54.2) 33 (13.7) 17 (7.1)
240
37 (34.6) 70 (65.4)
107
236 (98.3) 4 (1.7)
240
233 (97.5) 6 (2.5)
239
17 (7.3) 217 (92.7)
234
Results
delivery, respectively; (10) puerperal morbidity, defined as a temperature of 38 degrees Celsius or more on any 2 days of the first 10, excluding the first 24 h; and (11) surgical or episiotomy wound infection. Composite adverse maternal outcome was defined as pre-eclampsia, GDM, pre-term birth, PPH, puerperal morbidity or surgical wound complication. Composite adverse neonatal outcomes were defined as foetal IUGR, Apgar score ⬍/ ⫽ 7 at 1 and 5 min, thick meconium-stained amniotic fluid at delivery time or NICU admission.
Table II. Adverse pregnancy outcome in 240 pregnancies. Adverse pregnancy outcomes Pre-eclampsia GDM Pre-term birth Foetal IUGR Apgar score ⬍/ ⫽ 7 at 1 min Apgar score ⬍/ ⫽ 7 at 5 min Thick meconium-stained amniotic fluid at delivery time NICU admission Stillbirth Post-partum haemorrhage Puerperal morbidity Surgical/episiotomy wound infection
Statistical analysis was performed using STATA version 10 software (StataCorp, College Station, TX). The descriptive data are presented as percentage or mean and standard deviation. The incidence of adverse pregnancy outcomes are described as percentage. All continuous variables were cut into appropriate ranges and their relationships with composite adverse maternal outcome and composite adverse neonatal outcome were examined using Chi-square or Fisher’s exact test. Multivariable analysis was performed using a likelihood ratio test in which all possible predictive variables were initially included. Possible predictive variables identified from p value of ⬍ 0.2 in univariate analysis. A p value of ⬍ 0.05 in multivariate analysis was considered as statistically significant.
Incidence (%) 15.0 7.9 13.7 3.7 12.1 4.2 8.8 11.3 0 7.5 3.3 1.7
Two hundred and forty MWPs were delivered at Songklanagarind Hospital during the study period. Table I shows the patients’ basic characteristics. Burmese nationals were the most common of our participants. All of them were working in the southern regions of Thailand. Nearly 90% were individual employees. A lack of ANC was found in around 7% of the participants. The results of serologic tests yielded the following abnormal results: HIV antibody, 1.67%; syphilis screening test, 2.51% and hepatitis B surface antigen, 7.26%. All participants spontaneously conceived. Table II shows the incidence of adverse pregnancy outcomes. Tables III and IV show univariate and multivariate analysis of possible predictive factors for composite adverse maternal outcome, respectively. Tables V and VI show univariate and multivariate analysis of possible predictive factors for composite adverse neonatal outcome, respectively. ANC place, Hb of less than 11 g/dl and the presence of maternal underlying disease were significant predictors of composite adverse maternal outcome. Only pre-term birth was significantly related to composite adverse neonatal outcome.
Discussion Most studies of migrant pregnancy have been conducted in developed countries such as Europe and America where the geography, health care system facilities, and social and cultural factors are different from the developing countries in SEA. (Hayes et al. 2011; Naimy et al. 2013; Raimondi et al. 2013; Boerleider et al. 2013) Although a previous study reported on pregnancy outcomes of SEA compared with that in the Thai population, the factors that influenced the adverse maternal and neonatal outcomes were not shown. (Phadungkiatwattana et al. 2011) Compared with those studies, our study has a higher number of pregnant migrant women and more adverse pregnancy outcomes of interest. The incidence of adverse pregnancy including pre-eclampsia, GDM, pre-term birth, foetal IUGR, Apgar scores at 1 and 5 min less than or equal 7, NICU admission, post-partum haemorrhage and puerperal morbidity in the current study were higher than that in the normal pregnant Thai women population in our previous study. (Hanprasertpong et al. 2013) However, this current study was not designed as a comparison with normal pregnant Thai women so this conclusion is tentative but will be tested in a subsequent study. We found that ANC place and the presence of maternal underlying disease significantly influenced the composite adverse maternal outcomes in MWP. The effect of communication capability level has been reported in a few studies (Hayes et al.
Pregnancy outcome in migrant workers 3 Table III. Univariate analysis for potentially predictive factors for composite adverse maternal outcome.
Variable Age, years
Parity Nationality
BMI
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Occupation
ANC place
Hb Level: g/dl HIV antibody VDRL status Hepatitis B surface antigen Communication capability Maternal underlying disease
Level • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
15–24 25–34 35–44 Nulliparous Parous Burmese Lao Cambodian Other ⬍ 18.5 18.5–24.9 ⬎/ ⫽ 25 Housewife Agriculturalist Employee Other PSU Government hospital Private clinic No ⬍ 11 ⬎/ ⫽ 11 Non-reactive Reactive Non-reactive Reactive Positive Negative Good Poor Presence Absence
Total number
Adverse neonatal outcome, number (%)
80 124 32 111 111 215 16 1 4 1 44 111 4 17 211 4 59 127 33 17 37 67 232 4 229 6 17 213 141 95 16 220
20 (35.1) 31 (54.4) 6 (10.5) 29 (26.1) 36 (32.4) 69 (32.1) 4 (25.0) 0 0 1 (100.0) 11 (25.0) 32 (28.8) 1 (25.0) 7 (41.2) 64 (30.3) 1 (25.0) 15 (25.4) 49 (38.6) 4 (12.1) 5 (29.4) 11 (29.7) 33 (49.3) 71 (30.6) 2 (50.0) 71 (31.0) 1 (16.7) 3 (17.6) 69 (32.4) 35 (24.8) 38 (40.0) 12 (75.0) 61 (27.7)
p value∗ 0.745
0.302 0.451
0.248
0.801
0.020
0.054 0.405 0.246 0.335 0.013 ⬍ 0.001
∗p value: Pearson X2 and Fisher’s exact test.
2011; Boerleider et al. 2013) with the finding that poor language proficiency affected the knowledge of the health care system in MWPs and increased the maternal mortality and serious morbidity. But it was different with our present study in which communication capability did not influence the maternal morbidity. However, a maternal learning course for MWP practice during antenatal, childbirth and post-partum period, and intensive language lessons teaching common necessary words for the mother should be specially prepared for MWPs and at medical support team’s convenience especially in emergency condition. Additionally, hospitals should provide a language translator or healthcare provider who understands other SEA languages
for patient assistance. For the ANC place, we postulate that the ratio of the number of pregnant women to health care providers in government hospitals was higher than in private clinics, and Songklanagarind Hospital. Moreover, the medical facilities including the maternal foetal medicine specialist centre a Songklanagarind Hospital are better equipped than other places. So, the composite adverse maternal outcome is expected to be lower than that at other government hospitals. The effective detection of women who have underlying diseases during antenatal care and appropriate referral to tertiary care if needed should be assumed to reduce the composite adverse maternal outcome.
Table IV. Multivariate analysis for potentially predictive factors for composite adverse maternal outcome. Variable ANC place
Hb Level: g/dl
Maternal underlying disease
Level • • • • • • • • •
PSU Government hospital Private clinic No ⬎/ ⫽ 11 ⬍ 11 Missing Absence Presence
OR, Odd ratio; CI, Confidence interval. ∗p value: Likelihood ratio test.
OR 1 1 1.42 3.12 1 3.03 0.62 1 7.12
95% CI
P value
0.08, 12.07 – 0.65, 3.13 1.36, 71.8 – 1.14, 8.05 0.23, 1.67 – 1.92, 26.31
0.026
0.022
0.002
4
T. Hanprasertpong & J. Hanprasertpong Table V. Univariate analysis for potentially predictive factors for composite adverse neonatal outcome.
Variable
Level
Age, years
Parity Nationality
BMI
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Occupation
ANC place
Hb Level: g/dl HIV antibody VDRL status Hepatitis B surface antigen Maternal GDM Maternal Hypertension Pre-term birth Communication capability Maternal underlying disease
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Total number
Adverse neonatal outcome, number (%)
80 124 32 111 111 215 16 1 4 1 44 111 4 17 211 4 59 127 33 17 37 67 232 4 229 6 17 213 19 217 36 200 29 207 141 95 16 220
20 (25.0) 31 (25.0) 6 (18.85) 29 (26.1) 21 (18.9) 52 (24.2) 5 (31.3) 0 0 0 13 (29.5) 18 (16.2) 0 4 (23.5) 51 (24.2) 2 (50) 9 (15.3) 39 (30.7) 6 (18.2) 3 (17.6) 9 (24.3) 17 (25.4) 56 (24.1) 1 (25) 55 (24.0) 1 (16.7) 2 (11.8) 53 (24.9) 5 (26.3) 52 (24.0) 11 (30.6) 46 (23.0) 17 (58.6) 40 (19.3) 29 (20.6) 28 (29.5) 4 (25.0) 53 (24.1)
15–24 25–34 35–44 Nulliparous Parous Burmese Lao Cambodian Other ⬍ 18.5 18.5–24.9 ⬎/ ⫽ 25 Housewife Agriculturalist Employee Other PSU Government hospital Private clinic No ⬍ 11 ⬎/ ⫽ 11 Non-reactive Reactive Non-reactive Reactive Positive Negative Presence Absence Presence Absence Presence Absence Good Poor Yes No
p value∗ 0.745
0.199 0.566
0.152
0.434
0.087
0.906 0.968 0.190 0.414 0.818 0.330 ⬍0.001 0.117 0.935
∗p value: Pearson X2 and Fisher’s exact test.
Adverse neonatal outcomes such as foetal IUGR, pre-term birth, NICU admission, stillbirth and meconium aspiration syndrome in MWPs were higher than that among non-migrant pregnancies in several reports. (Maslovitz et al. 2005; Zanconato et al. 2011; Kirby 2011; Wilson-Mitchell and Rummens 2013) Moreover, a previous systematic review of stillbirth and infant deaths of migrant pregnancy in industrialised countries revealed similar findings and reported that pre-term birth was a leading cause of neonatal death. (Gissler et al. 2009). In conclusion, ANC place, low Hb level and the presence of maternal underlying disease significantly influenced the overall adverse maternal outcomes. Thus, early and adequate antenatal care in the appropriate place, intensive communication training,
anemic improvement and pre-term birth prevention programmes should be provided to reduce adverse maternal and neonatal outcomes of MWP in the southern part of Thailand.
Acknowledgements None. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Table VI. Multivariate analysis for potentially predictive factors for composite adverse neonatal outcome. Variable Pre-term birth
Level
OR
95% CI
P value
Absence Presence
1 5.91
– 2.61, 13.37
⬍ 0.001
∗p value: Likelihood ratio test.
Boerleider AW, Wiegers TA, Mannien J, Francke A, Deville WL. 2013. Factors affecting the use of prenatal care by non-western women in industrialized western countries: a systematic review. BMC Pregnancy & Childbirth 13:81. Gissler M, Alexander S, Macfarlane A, Small R, Stray-Pederson S, Zeitlin J et al. 2009. Stillbirths and infant deaths among migrants in industrialized countries. Acta Obstetricia et Gynecologica Scandinavica 88:134–148. Hayes I, Enohumah K, McCaul C. 2011. Care of the migrant obstetric population. International Journal of Obstetric Anesthesia 20:321–329.
Pregnancy outcome in migrant workers 5
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Hanprasertpong T, Kor-anantakul O, Leetanaporn R, Suntharasaj T, Suwanrath C, Pruksanusak N et al. 2013. Pregnancy outcomes amongst thalassemia trait. Archives of Gynecology and Obstetrics 288:1051–1054. Kirby RS. 2011. Perinatal outcomes and nativity: does place of birth really influence infant health? Birth 38:354–356 Maslovitz S, Kupferminc MI, Lessing JB, Many A. 2005. Perinatal outcome among non-residents in Israel. Israel Medical Association Journal 7: 315–319. Naimy Z, Grytten J, Monkerud L, Eskild A. 2013. Perinatal mortality in non-western migrants in Norway as compared to their countries of birth and to Norwegian women. BMC Public Health 13:37. Phadungkiatwattana P, Rujiwetpongstorn J, Tansathit T, Srisantiroj N. 2011. Pregnancy outcomes of Southeast Asian immigrant pregnant women
compared with Thai Pregnant women in Rajavithi Hospital. Journal of the Medical Association of Thailand 94:147–151. Raimondi D, Rey CE, Testa MV, Camoia ED, Torreguitar A, Meritano J. 2013. Migrant population and perinatal health. Archivos Argentinos de Pediatria 111:213–217. Wilson-Mitchell K, Rummens JA. 2013. Perinatal outcomes of uninsured immigrant, refugee and migrant mothers and newborns living in Toronto, Canada. International Journal of Environmental Research and Public Health 10:2198–2213. Zanconato G, Lacovella C, Parazzini F, Bergamini V, Franchi M. 2011. Pregnancy outcome of migrant women delivering in a public institution in Northern Italy. Gynecologic and Obstetric Investigation 72:157–162.
ORIGINAL ARTICLE
Pregnancy outcomes in Southeast Asian migrant workers at Southern Thailand T. Hanprasertpong & J. Hanprasertpong
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Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
This retrospective study was conducted to determine the pregnancy outcomes and identify predictive factors of adverse outcomes in pregnant migrant workers who delivered at Songklanagarind Hospital from January 2002 to December 2012. Two hundred and forty migrant worker pregnancies were enrolled. Pre-eclampsia, gestational diabetes mellitus, pre-term birth and foetal intrauterine growth restriction found were 15, 7.9, 13.7 and 3.7%, respectively. No stillbirth was found. Apgar score was ⬍/ ⴝ 7 at 1 and 5 min and neonatal intensive care unit admission was found to be 12.1, 4.2 and 11.3%, respectively. Antenatal care place, low haemoglobin level and the presence of maternal underlying disease were significantly related to increased risk of overall adverse maternal outcomes. Only pre-term birth was significantly related to overall adverse neonatal outcomes. Keywords: Adverse, maternal outcome, migrant, neonatal outcome, predictive factor
Introduction Thailand is a country in the Southeast Asia (SEA) region. The World Bank reported in 2011 that the average income was around 5,281 US dollars per person per year. The rate was the fourth in SEA following Singapore, Brunei and Malaysia, whereas the average income in other countries such as Myanmar, the Lao People’s Democratic Republic (Laos) and Cambodia was 4–5 times lower than that in Thailand. The greater opportunities for work and education and the higher quality of the health care system are attracting migrants to move to Thailand. The Department of Employment of the Ministry of Labour reported that the number of migrant workers has dramatically increased year by year from 805,763 persons in 2008 to 1,719,200 persons in 2012. Providing obstetric care for the migrant population is challenging for both government and individual health care personnel. Some studies of peri-natal health and mortality in migrant obstetric population have found that some migrant populations had a higher risk of serious obstetric complications (Hayes et al. 2011; Naimy et al. 2013; Raimondi et al. 2013). However, all of the studies were conducted in Europe and in the Americas. Songklanagarind Hospital is a tertiary obstetric centre in the lower southern part of Thailand. Our hospital has provided obstetric care for more than 10 years without any pregnancy outcome review. Thus, the present study was conducted to evaluate the obstetric outcomes
of migrant worker pregnancies (MWPs). MWPs are defined as the SEA nations’ pregnant women who worked in Thailand. The main objective was to determine the maternal and neonatal outcomes. The secondary objective was to identify predictive factors for adverse maternal and neonatal outcomes in MWPs at Songklanagarind Hospital
Materials and methods This retrospective chart review was conducted at the Department of Obstetrics and Gynecology, Songklanagarind Hospital, using the inpatient delivery database of the Department of Obstetrics and Gynecology and the hospital computer database of patient records of the Antenatal Clinic, labour records and those of the Obstetric Inpatient Ward. The inclusion criteria were any MWPs delivered at Songklanagarind Hospital from January 2002 to December 2012. The study was approved by our institution’s Ethics Committee. The maternal records along with pregnancy and neonatal outcomes were reviewed. Maternal record data of interest included age, parity, nationality, body mass index (BMI), occupation, antenatal care (ANC) place, haemoglobin (Hb) level, communication capability and serologic status including human immunodeficiency virus (HIV) antibody, syphilis and hepatitis B surface antigen. Communication capability was subjectively documented in all our patient records by the hospital midwife and physician who interviewed the pregnant women at admission. Good and poor communication capability defined as the pregnant women could and could not understand and answer the question on their own, respectively. For ANC place, we divided the patients into 4 groups depending on the main place which the pregnant women visited for ANC. The ANC place of our pregnant women was shown in hospital admission data. Adverse pregnancy outcomes of interest were the following: (1) pre-eclampsia, defined as new onset of hypertension and proteinuria during pregnancy; (2) gestational diabetes mellitus (GDM), glucose intolerance with first recognition during pregnancy; (3) pre-term birth, defined as a live birth before 37 weeks’ gestation; (4) foetal intrauterine growth restriction (IUGR), defined as a birth weight less than the 10th percentile of the normal growth curve; (5) Apgar scores at 1 and 5 min; (6) thick meconium-stained amniotic fluid at the delivery time; (7) neonatal intensive care unit (NICU) admission; (8) stillbirth, defined as death in utero after 24 weeks’ gestation; and (9) post-partum haemorrhage (PPH), defined as estimated blood more than 500 or 1000 ml after vaginal or caesarean
Correspondence: Tharangrut Hanprasertpong, Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand. E-mail: [email protected], [email protected]
2
T. Hanprasertpong & J. Hanprasertpong
Table I. Patients’ basic characteristics.
J Obstet Gynaecol Downloaded from informahealthcare.com by University of Cincinnati on 12/31/14 For personal use only.
Median ⫾ SD or number (%) Age (years) Parity • Nulliparous • Parous Nationality (n, %) • Burmese • Lao • Cambodian • Other BMI (mean,27.20 ⫾ 4.09; range, 14.2–40) • ⬍ 18.5 • 18.5–24.9 • ⬎/ ⫽ 25 Occupation (n, %) • Housewife • Agriculturalist • Employee • Other ANC place (n, %) • PSU • Government hospital • Private clinic • No Hb Level: g/dl (n, %) • ⬍ 11 • ⬎/ ⫽ 11 HIV antibody • Non-reactive • Reactive VDRL status • Non-reactive • Reactive Hepatitis B surface antigen • Positive • Negative
27.8 ⫾ 5.9
Total number with available data 240
111 (46.3) 115 (47.9)
226
206 (85.8) 14 (5.8) 4 (1.7) 16 (6.7)
240
1 (0.6) 45 (28.5) 112 (70.9)
158
4 (1.7) 18 (7.5) 214 (89.2) 4 (1.7)
240
60 (25.0) 130 (54.2) 33 (13.7) 17 (7.1)
240
37 (34.6) 70 (65.4)
107
236 (98.3) 4 (1.7)
240
233 (97.5) 6 (2.5)
239
17 (7.3) 217 (92.7)
234
Results
delivery, respectively; (10) puerperal morbidity, defined as a temperature of 38 degrees Celsius or more on any 2 days of the first 10, excluding the first 24 h; and (11) surgical or episiotomy wound infection. Composite adverse maternal outcome was defined as pre-eclampsia, GDM, pre-term birth, PPH, puerperal morbidity or surgical wound complication. Composite adverse neonatal outcomes were defined as foetal IUGR, Apgar score ⬍/ ⫽ 7 at 1 and 5 min, thick meconium-stained amniotic fluid at delivery time or NICU admission.
Table II. Adverse pregnancy outcome in 240 pregnancies. Adverse pregnancy outcomes Pre-eclampsia GDM Pre-term birth Foetal IUGR Apgar score ⬍/ ⫽ 7 at 1 min Apgar score ⬍/ ⫽ 7 at 5 min Thick meconium-stained amniotic fluid at delivery time NICU admission Stillbirth Post-partum haemorrhage Puerperal morbidity Surgical/episiotomy wound infection
Statistical analysis was performed using STATA version 10 software (StataCorp, College Station, TX). The descriptive data are presented as percentage or mean and standard deviation. The incidence of adverse pregnancy outcomes are described as percentage. All continuous variables were cut into appropriate ranges and their relationships with composite adverse maternal outcome and composite adverse neonatal outcome were examined using Chi-square or Fisher’s exact test. Multivariable analysis was performed using a likelihood ratio test in which all possible predictive variables were initially included. Possible predictive variables identified from p value of ⬍ 0.2 in univariate analysis. A p value of ⬍ 0.05 in multivariate analysis was considered as statistically significant.
Incidence (%) 15.0 7.9 13.7 3.7 12.1 4.2 8.8 11.3 0 7.5 3.3 1.7
Two hundred and forty MWPs were delivered at Songklanagarind Hospital during the study period. Table I shows the patients’ basic characteristics. Burmese nationals were the most common of our participants. All of them were working in the southern regions of Thailand. Nearly 90% were individual employees. A lack of ANC was found in around 7% of the participants. The results of serologic tests yielded the following abnormal results: HIV antibody, 1.67%; syphilis screening test, 2.51% and hepatitis B surface antigen, 7.26%. All participants spontaneously conceived. Table II shows the incidence of adverse pregnancy outcomes. Tables III and IV show univariate and multivariate analysis of possible predictive factors for composite adverse maternal outcome, respectively. Tables V and VI show univariate and multivariate analysis of possible predictive factors for composite adverse neonatal outcome, respectively. ANC place, Hb of less than 11 g/dl and the presence of maternal underlying disease were significant predictors of composite adverse maternal outcome. Only pre-term birth was significantly related to composite adverse neonatal outcome.
Discussion Most studies of migrant pregnancy have been conducted in developed countries such as Europe and America where the geography, health care system facilities, and social and cultural factors are different from the developing countries in SEA. (Hayes et al. 2011; Naimy et al. 2013; Raimondi et al. 2013; Boerleider et al. 2013) Although a previous study reported on pregnancy outcomes of SEA compared with that in the Thai population, the factors that influenced the adverse maternal and neonatal outcomes were not shown. (Phadungkiatwattana et al. 2011) Compared with those studies, our study has a higher number of pregnant migrant women and more adverse pregnancy outcomes of interest. The incidence of adverse pregnancy including pre-eclampsia, GDM, pre-term birth, foetal IUGR, Apgar scores at 1 and 5 min less than or equal 7, NICU admission, post-partum haemorrhage and puerperal morbidity in the current study were higher than that in the normal pregnant Thai women population in our previous study. (Hanprasertpong et al. 2013) However, this current study was not designed as a comparison with normal pregnant Thai women so this conclusion is tentative but will be tested in a subsequent study. We found that ANC place and the presence of maternal underlying disease significantly influenced the composite adverse maternal outcomes in MWP. The effect of communication capability level has been reported in a few studies (Hayes et al.
Pregnancy outcome in migrant workers 3 Table III. Univariate analysis for potentially predictive factors for composite adverse maternal outcome.
Variable Age, years
Parity Nationality
BMI
J Obstet Gynaecol Downloaded from informahealthcare.com by University of Cincinnati on 12/31/14 For personal use only.
Occupation
ANC place
Hb Level: g/dl HIV antibody VDRL status Hepatitis B surface antigen Communication capability Maternal underlying disease
Level • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
15–24 25–34 35–44 Nulliparous Parous Burmese Lao Cambodian Other ⬍ 18.5 18.5–24.9 ⬎/ ⫽ 25 Housewife Agriculturalist Employee Other PSU Government hospital Private clinic No ⬍ 11 ⬎/ ⫽ 11 Non-reactive Reactive Non-reactive Reactive Positive Negative Good Poor Presence Absence
Total number
Adverse neonatal outcome, number (%)
80 124 32 111 111 215 16 1 4 1 44 111 4 17 211 4 59 127 33 17 37 67 232 4 229 6 17 213 141 95 16 220
20 (35.1) 31 (54.4) 6 (10.5) 29 (26.1) 36 (32.4) 69 (32.1) 4 (25.0) 0 0 1 (100.0) 11 (25.0) 32 (28.8) 1 (25.0) 7 (41.2) 64 (30.3) 1 (25.0) 15 (25.4) 49 (38.6) 4 (12.1) 5 (29.4) 11 (29.7) 33 (49.3) 71 (30.6) 2 (50.0) 71 (31.0) 1 (16.7) 3 (17.6) 69 (32.4) 35 (24.8) 38 (40.0) 12 (75.0) 61 (27.7)
p value∗ 0.745
0.302 0.451
0.248
0.801
0.020
0.054 0.405 0.246 0.335 0.013 ⬍ 0.001
∗p value: Pearson X2 and Fisher’s exact test.
2011; Boerleider et al. 2013) with the finding that poor language proficiency affected the knowledge of the health care system in MWPs and increased the maternal mortality and serious morbidity. But it was different with our present study in which communication capability did not influence the maternal morbidity. However, a maternal learning course for MWP practice during antenatal, childbirth and post-partum period, and intensive language lessons teaching common necessary words for the mother should be specially prepared for MWPs and at medical support team’s convenience especially in emergency condition. Additionally, hospitals should provide a language translator or healthcare provider who understands other SEA languages
for patient assistance. For the ANC place, we postulate that the ratio of the number of pregnant women to health care providers in government hospitals was higher than in private clinics, and Songklanagarind Hospital. Moreover, the medical facilities including the maternal foetal medicine specialist centre a Songklanagarind Hospital are better equipped than other places. So, the composite adverse maternal outcome is expected to be lower than that at other government hospitals. The effective detection of women who have underlying diseases during antenatal care and appropriate referral to tertiary care if needed should be assumed to reduce the composite adverse maternal outcome.
Table IV. Multivariate analysis for potentially predictive factors for composite adverse maternal outcome. Variable ANC place
Hb Level: g/dl
Maternal underlying disease
Level • • • • • • • • •
PSU Government hospital Private clinic No ⬎/ ⫽ 11 ⬍ 11 Missing Absence Presence
OR, Odd ratio; CI, Confidence interval. ∗p value: Likelihood ratio test.
OR 1 1 1.42 3.12 1 3.03 0.62 1 7.12
95% CI
P value
0.08, 12.07 – 0.65, 3.13 1.36, 71.8 – 1.14, 8.05 0.23, 1.67 – 1.92, 26.31
0.026
0.022
0.002
4
T. Hanprasertpong & J. Hanprasertpong Table V. Univariate analysis for potentially predictive factors for composite adverse neonatal outcome.
Variable
Level
Age, years
Parity Nationality
BMI
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Occupation
ANC place
Hb Level: g/dl HIV antibody VDRL status Hepatitis B surface antigen Maternal GDM Maternal Hypertension Pre-term birth Communication capability Maternal underlying disease
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Total number
Adverse neonatal outcome, number (%)
80 124 32 111 111 215 16 1 4 1 44 111 4 17 211 4 59 127 33 17 37 67 232 4 229 6 17 213 19 217 36 200 29 207 141 95 16 220
20 (25.0) 31 (25.0) 6 (18.85) 29 (26.1) 21 (18.9) 52 (24.2) 5 (31.3) 0 0 0 13 (29.5) 18 (16.2) 0 4 (23.5) 51 (24.2) 2 (50) 9 (15.3) 39 (30.7) 6 (18.2) 3 (17.6) 9 (24.3) 17 (25.4) 56 (24.1) 1 (25) 55 (24.0) 1 (16.7) 2 (11.8) 53 (24.9) 5 (26.3) 52 (24.0) 11 (30.6) 46 (23.0) 17 (58.6) 40 (19.3) 29 (20.6) 28 (29.5) 4 (25.0) 53 (24.1)
15–24 25–34 35–44 Nulliparous Parous Burmese Lao Cambodian Other ⬍ 18.5 18.5–24.9 ⬎/ ⫽ 25 Housewife Agriculturalist Employee Other PSU Government hospital Private clinic No ⬍ 11 ⬎/ ⫽ 11 Non-reactive Reactive Non-reactive Reactive Positive Negative Presence Absence Presence Absence Presence Absence Good Poor Yes No
p value∗ 0.745
0.199 0.566
0.152
0.434
0.087
0.906 0.968 0.190 0.414 0.818 0.330 ⬍0.001 0.117 0.935
∗p value: Pearson X2 and Fisher’s exact test.
Adverse neonatal outcomes such as foetal IUGR, pre-term birth, NICU admission, stillbirth and meconium aspiration syndrome in MWPs were higher than that among non-migrant pregnancies in several reports. (Maslovitz et al. 2005; Zanconato et al. 2011; Kirby 2011; Wilson-Mitchell and Rummens 2013) Moreover, a previous systematic review of stillbirth and infant deaths of migrant pregnancy in industrialised countries revealed similar findings and reported that pre-term birth was a leading cause of neonatal death. (Gissler et al. 2009). In conclusion, ANC place, low Hb level and the presence of maternal underlying disease significantly influenced the overall adverse maternal outcomes. Thus, early and adequate antenatal care in the appropriate place, intensive communication training,
anemic improvement and pre-term birth prevention programmes should be provided to reduce adverse maternal and neonatal outcomes of MWP in the southern part of Thailand.
Acknowledgements None. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Table VI. Multivariate analysis for potentially predictive factors for composite adverse neonatal outcome. Variable Pre-term birth
Level
OR
95% CI
P value
Absence Presence
1 5.91
– 2.61, 13.37
⬍ 0.001
∗p value: Likelihood ratio test.
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J Obstet Gynaecol Downloaded from informahealthcare.com by University of Cincinnati on 12/31/14 For personal use only.
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