Ethnic differences in perinatal mortality A perinatal audit on the role of substandard care Marianne E. Alderliesten a, * , Karien Stronks b , Jan M.M. van Lith a , Bert J. Smit c , Marcel F. van der Wal d , Gouke J. Bonsel a,b , Otto P. Bleker a a Academic Medical Center Amsterdam, Department of Obstetrics and Gynecology, P.B. 22660, 1100 DDAmsterdam, The Netherlands b Department of Social Medicine, P.B. 22660, 1100 DD Amsterdam, The Netherlands c Erasmus MC—Sophia Children’s Hospital, University Medical Center Rotterdam, Department of Neonatology, P.B. 2200, 1000 CE Amsterdam, The Netherlands d Dr. Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands, Municipal Health Service Amsterdam, P.B. 2200, 1000 CE Amsterdam, The Netherlands Received 17 July 2005; received in revised form 23 May 2007; accepted 10 August 2007 Abstract Objectives: The objective was to investigate the contribution of substandard care to ethnic inequalities in perinatal mortality. Study design: Perinatal audit in Amsterdam, the Netherlands. The study population consisted of 137 consecutive perinatal death cases (16 weeks GA—28 days after delivery). A standardized procedure to establish the cause of death and substandard care by perinatal audit was developed. The main outcome measures were perinatal mortality rates in ethnic groups, cause of death classified by extended Wigglesworth classification, presence of substandard care (unlikely to be, possibly or likely to be related to perinatal death), and component of care considered to be substandard. Results: In Surinamese and other non-Western mothers (mainly from Ghana) perinatal mortality, beyond 16 weeks’ gestation, was statistically significantly higher than among native Dutch mothers. (4.01, 2.50, and 1.07%, respectively). In Surinamese and Moroccan mothers, we observed a higher rate of early preterm deliveries. The prevalence of substandard care differed statistically significantly among ethnic groups ( p = 0.034), with the highest prevalence among Surinamese mothers. These differences were especially apparent in the prevalence of (more) maternal substandard care factors among Surinamese and Moroccan mothers. These factors consisted of a later start date for antenatal care or a later notification by the caregiver about obstetrical problems (e.g. rupturing of membranes, decrease in foetal movements). Conclusions: The higher perinatal mortality in Surinamese and other non-Western groups is mainly due to a higher rate of early preterm deliveries. No differences in care were observed among ethnic groups during labour and delivery. Among Surinamese mothers, however, the results indicate that substandard care with maternal involvement plays a role in explaining their higher perinatal mortality rates. # 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Ethnicity; Perinatal mortality; Perinatal audit; Substandard care 1. Introduction In most European countries perinatal mortality is reported as being higher among ethnic minorities than among the native population, in registries as well as in specific studies [1–5]. The literature reports that several determinants of perinatal mortality, e.g. maternal age and obstetrical history, are related to ethnic background [3,6,7]. Though often put forward as a potential explanation [8] little is known about the systematic role of antenatal and perinatal care in explaining ethnic differences in perinatal mortality. Recently, a Swedish study suggested that substandard care was an important indicator for the higher perinatal mortality among East African women compared with native Swedish www.elsevier.com/locate/ejogrb European Journal of Obstetrics & Gynecology and Reproductive Biology 138 (2008) 164–170 * Corresponding author. Tel.: +31 20 5663557/6820955; fax: +31 20 6963489. E-mail address: Marianne@alderliesten.com (M.E. Alderliesten). 0301-2115/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2007.08.022