Obstetric risks and outcomes of refugee women at a single centre in Toronto.

OBJECTIVES: Women who are refugees during pregnancy may be exposed to homelessness, poor nutrition, and limited access to health care, yet the pregnancy outcomes of this vulnerable population have not been systematically evaluated. We undertook a study to determine the risk of adverse obstetric and perinatal outcomes among refugee women in Toronto. METHODS: Using a retrospective cohort design, we examined pregnancy outcomes for refugee and non-refugee women delivering at St. Michael's Hospital in Toronto, between January 1, 2008, and December 31, 2010. The primary outcome measures were preterm delivery (< 37 weeks' gestational age), low birth weight (< 2500 g), and delivery by Caesarean section. RESULTS: Multiparous refugee women had a significantly higher rate of delivery by Caesarean section (36.4%), and a 1.5-fold increase in rate of low birth weight infants when compared with non-refugee women. In subgroup analysis by region of origin, women from Sub-Saharan Africa had significantly higher rates of low birth weight infants and Caesarean section than non-refugee control subjects. Further, compared with non-refugee control subjects, refugee women had significantly increased rates of prior Caesarean section, HIV-positive status, homelessness, social isolation, and delays in accessing prenatal care. CONCLUSIONS: Refugee women constitute a higher-risk population with increased rates of adverse obstetric and perinatal outcomes. These findings provide preliminary data to guide targeted public health interventions towards meeting the needs for obstetric care of this vulnerable population. Recent changes to the Interim Federal Health Program have highlighted the importance of identifying and diminishing disparities in health outcomes between refugee and non-refugee populations.

Objectifs : Pendant la grossesse, les réfugiées pourraient être exposées à l'itinérance, à des carences alimentaires et à un accès limité aux soins de santé, et pourtant, les issues de grossesse que connaît cette population vulnérable n'ont pas fait l'objet d'une évaluation systématique. Nous avons entrepris de mener une étude visant à déterminer le risque de constater des issues obstétricales et périnatales indésirables chez les réfugiées de Toronto. Méthodes : Au moyen d'un devis d'étude de cohorte rétrospective, nous nous sommes penchés sur les issues de grossesse connues par les réfugiées et les non-réfugiées ayant accouché au St. Michael's Hospital de Toronto entre le 1er janvier 2008 et le 31 décembre 2010. Les critères d'évaluation primaires ont été l'accouchement préterme (âge gestationnel < 37 semaines), le faible poids de naissance (< 2 500 g) et l'accouchement par césarienne. Résultats : Les réfugiées multipares présentaient un taux considérablement accru d'accouchement par césarienne (36,4 %) et un taux de nouveau-nés de faible poids de naissance équivalant à une fois et demie celui qui était associé aux non-réfugiées. Dans le cadre d'une analyse de sous-groupe par région d'origine, nous avons constaté que les femmes d'Afrique subsaharienne présentaient des taux considérablement plus élevés de césarienne et de nouveau-nés de faible poids de naissance que ceux des non-réfugiées (groupe témoin). De surcroît, par comparaison avec ces dernières, les réfugiées présentaient des taux considérablement accrus d'antécédents de césarienne, de séropositivité pour le VIH, d'itinérance, d'isolement social et de délais pour ce qui est de l'accès aux soins prénataux. Conclusions : Les réfugiées constituent une population exposée à des risques élevés qui présente des taux accrus d'issues obstétricales et périnatales indésirables. Ces constatations offrent des données préliminaires qui permettent d'orienter la mise en œuvre d'interventions de santé publique ciblées visant à répondre aux besoins de cette population vulnérable en matière de soins obstétricaux. Les récentes modifications qui ont été apportées au Programme fédéral de santé intérimaire ont souligné l'importance de l'identification et de l'atténuation des écarts constatés en matière d'issues de santé entre les populations réfugiées et non réfugiées.

Cesarean delivery surveillance system at a maternity hospital in Kabul, Afghanistan.

OBJECTIVE: To use an active facility-based maternal and newborn surveillance system to describe cesarean delivery practices and outcomes in a resource-poor setting. METHODS: Using data from operating room logbooks, 392 cesarean deliveries were evaluated between April 1 and June 30 2006 at a large public maternity hospital in Kabul, Afghanistan. RESULTS: The perinatal mortality rate was 89 per 1000 births: 57% antepartum and 37% intrapartum stillbirths. Fetuses with normal birth weight comprised 85% of intrapartum stillbirths. Obstructed labor, uterine rupture, and malpresentation accounted for more than 50% of perinatal deaths. The cesarean delivery rate was 10.2% and there were 2 maternal deaths. CONCLUSION: The high percentage of intrapartum stillbirths among normal birth weight fetuses suggests a need for improved labor monitoring and surgical obstetric practices. The use of a facility-based perinatal surveillance system is critical in guiding such quality assurance initiatives.

Monitoring perinatal outcomes in hospitals in Kabul, Afghanistan: The first step of a quality assurance process.

OBJECTIVE: Afghanistan is one of the countries with highest maternal and perinatal mortality in the world. Lack of reliable data, however, makes it difficult to select and prioritise the interventions that would be most cost effective. To gain some evidence, we review and analyse perinatal outcomes in facilities in Kabul and examine the role of patient risk and clinical practice factors. METHODS: We used data for 2006 from a facility-based maternal and newborn surveillance system based on labour and delivery logbooks in the four government hospitals with maternity services in Kabul to analyse perinatal mortality and understanding potentially modifiable factors. RESULTS: Data was collected for 53,524 births during 2006. Perinatal mortality was 43.5 per 1000 total births and the stillbirth rate was 38. For babies with a birthweight of > or =2500 g, the risk of perinatal death if delivered by cesarean section was 3.57 (CI = 3.08-4.13) times the risk of those delivered vaginally. Babies born of mothers with risk factors were 6.49 (CI = 5.64-7.48) times more likely to die. The perinatal mortality rate in babies of women with risk factors undergoing cesarean section was 220.5 per 1000 total births. CONCLUSIONS: Facility-based monitoring of perinatal health is possible in resource-limited settings. The situation in hospitals in Kabul is precarious with high levels of perinatal mortality. Improved intrapartum care, especially for women with risk factors, is needed to positively impact perinatal health.