The Journal of Maternal-Fetal & Neonatal Medicine

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The East Timorese: a high-risk ethnic minority in UK obstetrics: a cohort study Fionnuala Mone, Beverley Adams, John G. Manderson & Fionnuala M. McAuliffe To cite this article: Fionnuala Mone, Beverley Adams, John G. Manderson & Fionnuala M. McAuliffe (2015) The East Timorese: a high-risk ethnic minority in UK obstetrics: a cohort study, The Journal of Maternal-Fetal & Neonatal Medicine, 28:13, 1594-1597, DOI: 10.3109/14767058.2014.962507 To link to this article: http://dx.doi.org/10.3109/14767058.2014.962507

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Date: 06 November 2015, At: 21:38

http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2015; 28(13): 1594–1597 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.962507

ORIGINAL ARTICLE

The East Timorese: a high-risk ethnic minority in UK obstetrics: a cohort study Fionnuala Mone1,2, Beverley Adams3, John G. Manderson4, and Fionnuala M. McAuliffe1,2 1

UCD Obstetrics and Gynaecology, School of Medicine and Medical Science, University College Dublin, National Maternity Hospital, Dublin, Ireland, Department of Obstetrics and Gynaecology, National Maternity Hospital, Dublin, Ireland, 3Department of Obstetrics and Gynaecology, Craigavon Area Hospital, Craigavon, UK, and 4Department of Obstetrics and Gynaecology, Ulster Hospital, Dundonald, UK

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2

Abstract

Keywords

Objective: To observe the incidence of antenatal risk-factors and adverse maternal outcome in women of East Timorese origin within a UK population. Methods: This retrospective cohort study assessed a sample of women of East Timorese Origin (N ¼ 42) attending UK maternity services from 01/2011 to 09/2012 compared to a control group of a standard UK maternity population (N ¼ 7210). Data on the rate of pregnancy related riskfactors and complications were obtained from a computerized patient note database (NIMATS). Results: The East Timorese were at significant risk antenatally of anaemia (OR 19.5 (95% CI 10.2–37.2) (p50.001)), gestational diabetes (OR 10.6 (95% CI 4.6–24.4) (p50.001)) and hypertension in pregnancy (OR 4.6 (95% CI 1.4–15.3) (p50.01)) as well as late booking for care (OR 19.5 (95% CI 10.2–37.2) p50.001). In terms of post-partum complications there was a significant risk of admission to the intensive-care unit (OR 20.0 (95% CI 4.5–89.0) p50.001) and of postpartum hemorrhage (OR 15.9 (95% CI 7.7–33.0) p50.001). In 72 documented occasions an interpreter could not be obtained. Conclusions: Women from East Timor are a high-risk ethnic minority who, with added riskfactors of late booking and difficulty in obtaining interpreters are at greater risk of complications in pregnancy and the puerperium.

Global Health, interpreter, maternal medicine, Timor-Leste

Introduction Women from ethnic minorities in the United Kingdom (UK) are at significantly increased risk of maternal and perinatal morbidity and mortality due to a number of factors [1]. Studies suggest that non-western immigrants are at significant risk of severe acute maternal morbidity, which may be partially, but not fully, explained by a tendency towards being of a lower socio-economic status, unemployment, and high parity [2]. In addition to the risk of socio-economic deprivation, practical issues with problems in communication also contribute to the problems that have been reported in this group. The Centre of Maternal and Child Enquiries (CMACE) report of the 2006–2008 triennium noted that 42% of direct and 24% of indirect maternal deaths within the UK occurred in black or other ethnic minority groups, with a significant difference between ethnic minority and white groups. Additionally, this report noted a recurring problem in the use and availability of professional interpreting services [1]. Address for correspondence: Dr Fionnuala Mone, UCD Obstetrics and Gynaecology, School of Medicine and Medical Science, University College Dublin, National Maternity Hospital, Dublin, Ireland. Tel: +353 (1) 637 3100. Fax: +353 (1) 637 3436. E-mail: [email protected]

History Received 30 June 2014 Accepted 3 September 2014 Published online 29 September 2014

The ethnic minority groups addressed in CMACE were mainly immigrants, refugees and asylum seekers. Within the UK there are increasing numbers of such groups within the population, and hence the health service has a duty to provide a level of care equal to that of citizens. Ethnic minorities tend to have difficulty accessing interpreter services inclusive of accompanying interpreters or telephone interpreters due to cost limitations. Communication breakdown also causes poor access to care and facilities such as ante-natal classes and clinics, which has a knock on the effect on maternal and perinatal mortality [3]. In light of the aforementioned issues, this study has the primary objective of observing an ethnic minority, the East Timorese. East Timor is a democratic republic in South-East Asia with high levels of maternal and neonatal mortality quoted at 370 per 100 000 and 270 per 100 000, respectively [4]. This may be partly explained by limited availability of maternity services, with only 18% of births being attended to by medical personnel [4]. Within Northern Ireland, there is a cluster of East Timorese. The aim of this study was to expand knowledge of this population in a developed world setting in terms of complications and risk factors in the antenatal and post-natal period.

Obstetric complications in East Timorese

DOI: 10.3109/14767058.2014.962507

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Methods A retrospective cohort study was performed after obtaining research governance approval from the local research governance department. Written consent was not obtained from patients as this was not required due to the retrospective anonymised descriptive nature of the study. The study was conducted in a district general obstetric unit, which has approximately 4000 deliveries per annum; British-Irish Caucasian is the predominating nationality and ethnicity, hence routine screening for haemoglobinopathies such as thalassaemia is not routinely performed. All women of East Timorese Origin delivered within the unit from January 2011 to September 2012 were included in analysis (n ¼ 42). A population of predominantly Caucasian BritishIrish women who delivered within the same time period as the aforementioned group were used as a control group (n ¼ 77 210). Data were obtained from the Northern Ireland Maternity System (NIMATs) database and individual clinical case-notes by means of a Microsoft ExcelÕ database, using anonymised linkage data to preserve anonymity. Data obtained included patient demographic factors, e.g. age, parity, body mass index (kg/m2), in addition to the presence of ante-natal, intra-partum and post-partum riskfactors and/or complications such as maternal gestational diabetes [5], anaemia (hemoglobin 510.5 g/dL at 28-weeks gestation) [6], late booking attendance (after 13 weeks and six days) [6], antenatal, intrapartum and postpartum hemorrhage (estimated blood loss 4500 mls) and maternal admission to the intensive-care unit. In addition, within the East Timor sample, data were obtained on the number of times there were difficulties in obtaining an interpreter when requested, as well as the number of women who requested an ambulance when in labour. A second sub-analysis was performed on East-Timorese women found to have anaemia at 28-weeks gestation, as to the number of patients who were assessed by the Family Origin Questionnaire or who underwent liquid chromatography (as recommended by the National Institute for Clinical Excellence when anaemia is diagnosed) [6]. Statistical analysis was performed using IBM SPSS statistics version 20 (Armonk, NY) and a statistician was consulted. The odds ratio (OR) of adverse outcomes was calculated with the corresponding significance value. A p value of 50.05 was considered to be significant.

Results The study population included 42 East Timorese women and 7210 UK women. Demographic features comparing both groups are demonstrated in Table 1. In terms of antenatal risk factors, women from East Timor were at significantly increased risk of developing of gestational diabetes (as defined by World Health Organization criteria) [5], maternal anaemia (Hemoglobin 510.5 g/d) [6], attending late for booking (13 weeks and six days gestation) [6] and infections in pregnancy (Hepatitis B and Syphilis) compared to the native population. Table 2 demonstrates the ORs of antenatal risk factors between groups.

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Table 1. Demographic characteristics of sample East Timorese and UK control group in mean and corresponding standard deviations (SD) or range.

Demographic

East Timor sample (Mean ± SD) N ¼ 42

UK sample (Mean ± SD) N ¼ 7210

Maternal age (yrs) 29 (5) 30 (6) Parity 1 (range 0–5) 1 (range 0–8) Body mass index (kg/m2) 23.5 (5.05) 26.0 (5.34) Gestation at booking (weeks) 17 (7) 11 (4) Haemoglobin pre-delivery (g/dL) 10.36 (1.27) 12.8 (0.90) Average birth-weight (g) 3020 (483) 3458 (581)

In terms of intrapartum and postpartum complications, women from East Timor were at significantly increased risk of third-degree tear, post-partum hemorrhage (estimated blood loss of greater than 500 mls) and admission to intensive care compared to the native population. There was no difference in the rate of delivery by emergency caesarean or instrumental between the groups. These findings with associated ORs are demonstrated in Table 3. Of the 42 East Timorese women, there were 72 documented cases of difficulties obtaining an interpreter. There were five cases where there was no interpreter at the booking visit, 18 cases where there was none in labour, four cases where no interpreter was available at the time of obtaining written consent and 13 documented cases where a relative was used to interpret. Sixteen of the 42 patients called an ambulance when in labour. Of the East Timorese women who were anaemic at 28weeks gestation, 20 of the 26 women had a mean corpuscular haemoglobin 527 g/dL, yet only two of these patients (10%) were documented as having underwent liquid chromatography. No patients were documented as being assessed by the Family Origin Questionnaire for haemoglobinopathy [6].

Discussion This study has demonstrated that women from East Timor are an ethnic minority, which are at significant risk of antenatal risk factors and postpartum complications, but are no more likely to require obstetric intervention in labour compared to a standard UK cohort. The East Timorese women may be more vulnerable due to a lack of interpreting services and the fact that they attend late for the antenatal booking visit. Additionally, management of their anaemia is not in keeping with advised management for at-risk ethnicities. The strength of this study is that compared to any other studies – this is the first one of its kind to assess this at risk group and the findings are relevant to clinical practice and how ethnic minorities are managed. The limitations of our study include the fact there are small numbers within the EastTimor group, n ¼ 42, which means that results must be interpreted with caution. Additionally, not all adverse outcomes or risk factors could be assessed due to limitations in data collection from the control group, hence not all of the conditions originally assessed within the East Timor group, e.g. small-for-gestational age fetuses, could be directly compared. Also, as the East Timorese are a rare ethnic

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J Matern Fetal Neonatal Med, 2015; 28(13): 1594–1597

Table 2. Antenatal risk factors in the sample East Timor and UK control group with associated percentiles and odds ratios with 95% confidence intervals (CI). East Timor sample N ¼ 42 N and percentile

Antenatal risk factors Hepatitis B Syphilis Gestational diabetes Pregnancy-induced hypertension/preeclampsia Hb510.5 d/dl pre-delivery Grand-multiparity Late bookers

4.8 7.1 16.7 7.0 61.9 7.1 66.7

UK sample N ¼ 7210 N and percentile

(2/42) (3/42) (7/42) (3/42) (26/42) (3/42) (28/42)

0.04 0.29 1.8 1.62 1.17 1.0 9.3

(3/7210) (21/7210) (133/7210) (117/7210) (83/7077) (74/7210) (670/7210)

p value

OR

95% CI

50.01 50.01 50.001 ¼0.01 50.001 ¼0.001 50.001

120.1 26.3 10.6 4.6 136.9 7.42 19.5

19.5–738.4 7.5–91.9 4.6–24.4 1.4–15.3 70.8–264.7 2.2–24.5 10.2–37.2

Table 3. Antenatal risk factors in the sample East Timor and UK control group with associated percentiles and odds ratios with 95% confidence intervals (CI).

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Intra-partum and post-partum complications Emergency caesarean section Third degree tear Manual removal of placenta Postpartum haemorrhage Intensive care admission

East Timor sample N ¼ 42 N and percentile 16.7 35.7 7.1 23.8 4.8

(7/42) (10/28) (2/28) (10/42) (2/42)

minority, the results of this study may only be applicable within isolated centers where these women reside. In line with current evidence, this study suggests that, even in the setting of a developed country, ethnic minority groups have poorer pregnancy outcomes than native women [7]. A tendency to book late increases vulnerability by missing earlier opportunities to screen for infection and hemoglobin and fetal anatomy as well as the opportunity for clinicians to make a plan for ante-natal care and delivery. Findings of this study are comparable to that of the latest CMACE report which found that women from ethnic minorities were significantly more likely to experience maternal morbidity (120 per 100 000) than those of white British/Irish origin (80 per 100 000). Reasons for increased rates were attributed to little or no engagement with maternity services and lack of interpreters, similar to the findings of this study. If the obstetric care of ethnic minorities is to improve, clinicians and health care workers must increase knowledge and awareness of the variation in social and cultural and practices between ethnic groups [8,9]. The East Timorese are at significant risk of anaemia in pregnancy and are within an ethnic region where hemoglobinopathies (notably thalassemias) are of increased prevalence. It is important that screening for carriers of these traits is performed through the Family Origin Questionnaire, and if there is a persistent MCH 527 g/dL, that liquid chromatography is performed to assess for the presence of a hemoglobinopathy so that management of the pregnancy can be tailored and genetic counseling provided [6,10]. Problems in obtaining an interpreter with the addition of cultural differences lead to a breakdown in communication between women from ethnic minorities and native health care workers. In the case of the East Timorese, this is an additional risk factor that may be associated with their increased risk of adverse maternal outcomes. Based upon the findings of this study, it is reasonable to recommend that women from East Timor have consultant-led antenatal care with input from the multi-disciplinary team inclusive

UK sample N ¼ 7210 N and percentile 13.8 3.28 3.0 2.0 0.25

(994/7210) (175/5334) (159/5334) (139/7210) (18/7210)

p value

OR

95% CI

0.6 50.001 0.2 50.001 50.001

1.3 16.4 2.5 15.9 20.0

0.6–2.8 7.5–40.0 0.6–10.6 7.7–33.0 4.5–89.0

of social working services and that they deliver within an obstetric facility due to their significant risk of postpartum hemorrhage. Additionally, care must be tailored to ensure screening for maternal infections and anaemia, hemoglobinopathies, hypertension and diabetes in pregnancy with optimization of an interpreting service. This information also underlines the need to work closely with the East Timorese community in Northern Ireland so as to work together to educate women of child bearing age of the health services available, methods of accessing these services and the importance of good quality antenatal care from the beginning of pregnancy. In conclusion, as the proportion of ethnic minorities requiring maternity services within the UK increases, it is vital that obstetric units nationwide address their protocols and tailor management to address the additional risks that such women have for adverse maternal outcome and minimise the additional risk factor of poor communication by optimizing interpreting services.

Acknowledgements Authors thank Dr Mary Higgins, UCD Obstetrics and Gynecology, University College Dublin, National Maternity Hospital, Dublin, Ireland.

Declaration of interest The authors report no declarations of interest

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from: http://www.nice.org.uk/nicemedia/live/11947/40115/40115. pdf [last accessed 26 April 2014]. Henderson J, Geo H, Redshaw M. Experiencing maternity care: the care received and perceptions of women from different ethnic groups. BMC Pregnancy Childbirth 2013;13:196. Cresswell JA, Yu G, Renton A. Predictors of the timing of initiation of antenatal care in an ethically diverse urban cohort in the UK. BMC Pregnancy Childbirth 2013;13:103. Alderliesten ME, Vrijkotte TG, van der Wal MF, Bonsel GJ. Late start of ante-natal care among ethnic minorities in a large cohort of pregnant women. BJOG 2007;114:1232–9. Weatherall DJ. The definition and epidemiology of non-transfusion-dependent thalassemia. Blood Rev 2012;26: S3–6.

The East Timorese: a high-risk ethnic minority in UK obstetrics: a cohort study.

To observe the incidence of antenatal risk-factors and adverse maternal outcome in women of East Timorese origin within a UK population...
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