Race-based Care:

is that good medicine?

Professor Euan M Wallace

The Ritchie Centre, Monash Institute of Medical Research

Department of Obstetrics and Gynaecology, Monash University

Monash Women’s Services, Monash Health

the RITCHIE CENTRE

the RITCHIE CENTRE

What defines a good pregnancy outcome?

a satisfied mother

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What defines a good pregnancy outcome?

- normal vaginal birth

- intact perineum

- successful breastfeeding

- healthy baby

- no postnatal depression

- no “other” complication (bleeding, infection)

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no mention of race or ethnicity

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75% Australian born mothers

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40% Australian born mothers

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Is ethnicity associated with pregnancy outcome?

- normal vaginal birth

- intact perineum

- successful breastfeeding

- healthy baby

- no postnatal depression

- no “other” complication (bleeding, infection)

What defines a good pregnancy outcome?

the RITCHIE CENTRE

Is ethnicity associated with pregnancy outcome?

- normal vaginal birth

- intact perineum

- successful breastfeeding

- healthy baby

- no postnatal depression

- no “other” complication (bleeding, infection)

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Monash Medical Centre level 6 maternity unit

3800 births pa

Dandenong Hospital level 5 maternity unit

2500 births pa

Casey Hospital level 4 maternity unit

1500 births pa

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ns

p<0.01

p<0.01

Mode of birth, by maternal region of birth N

o (

%)

wo

me

n

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South Asian women are twice as likely as Australian-born

women to have an emergency intrapartum caesarean section

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ns

P<0.01

Pregnancy & birth outcomes, by maternal region of birth

ns

ns P<0.05

P<0.05

No

(%

) w

om

en

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South East/East Asian women are almost half as likely as

Australian-born women to have an intact perineum following

vaginal birth

South Asian women are twice as likely as Australian-born

women to have severe perineal trauma

Odds ratio (95%CI) of stillbirth ≥ 37 weeks 1.0 2.4 (1.4-4.0) 0.7 (0.4-1.2) <0.0001

= RR for >41 wks

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customized fetal growth charts

Customized growth charts will likely increase the stillbirth rate, not reduce it

Customised charts assumes that variations in birthweight related to maternal

characteristics are physiological and not associated with pathological (adverse)

outcomes.

Inclusion of maternal characteristics that have a pathological (adverse) influence on

growth would inappropriately normalise SGA in an infant at increased risk of

stillbirth (ie “hide” the at risk fetus)

So, do customised growth charts normalise (hide) the at risk SGA fetus?

1. Infants of small mothers are more likely to be SGA than larger mothers

2. SGA infants of small mothers are at higher risk of stillbirth than AGA infants

Customized defined SGA

Population defined SGA NNM hazard ratio vs whites: 2.10

Revealed SGA hazard ratio vs whites: 2.16

Revealed SGA hazard ratio vs whites: 1.10

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Pregnancy outcomes differ by maternal ethnicity?

- need for post-term induction

- risk of intrapartum fetal compromise

- rate of intact perineum

- rate of severe perineal trauma

- rate of growth restriction

- rate of late pregnancy stillbirth

the challenge is to identify mechanisms and tailor care accordingly

the RITCHIE CENTRE

the RITCHIE CENTRE

Acknowledgements

Monash Health Michelle Knight

Amanda Knight

The Ritchie Centre Miranda Davies-Tuck

Henry Drysdale

Monash University Mary Anne Biro

Christine East