Perinatal implications of motor vehicle accident trauma during pregnancy: identifying populations at risk.

OBJECTIVE: The purpose of this study was to examine the association between restraint use, race, and perinatal outcome after motor vehicle accidents (MVAs) during pregnancy. STUDY DESIGN: The Duke Trauma Registry and medical records were searched for information on pregnant women at >14 weeks' gestation who were involved in an MVA and who received care through the Emergency Department and the Obstetric Units. Between January 1994 and December 31, 2010, 126 women were identified. Variables that were collected included type of trauma, gestational age at presentation, and delivery outcomes. A prognostic study was performed that evaluated the associations between maternal demographics, details of the accident that included restraint use, and maternal treatment that was related to the accident in relationship to perinatal outcome. RESULTS: There was no difference in the mean age or median gravidity or parity by race among pregnant women who were cared for after an MVA. There was no difference in mean age or racial distribution between women who were restrained compared with women who were unrestrained; unrestrained women were more likely to be nulliparous. Unrestrained women were more likely to require nonobstetric surgery that was related to the trauma. The overall rate of placental abruption was 6%. There were 6 intrauterine fetal deaths, 3 each in the unrestrained (25%) and restrained groups (3.5%; P = .018). Airbags deployed in 17 accidents. Among the 7 women with placenta abruption, 4 women (57%) experienced air bag deployment. CONCLUSION: Lack of restraint use during pregnancy is associated with an increased risk of fetal death.

Racial disparities in economic and clinical outcomes of pregnancy among Medicaid recipients.

To explore racial-ethnic disparities in adverse pregnancy outcomes among Medicaid recipients, and to estimate excess Medicaid costs associated with the disparities. Cross-sectional study of adverse pregnancy outcomes and Medicaid payments using data from Medicaid Analytic eXtract files on all Medicaid enrollees in fourteen southern states. Compared to other racial and ethnic groups, African American women tended to be younger, more likely to have a Cesarean section, to stay longer in the hospital and to incur higher Medicaid costs. African-American women were also more likely to experience preeclampsia, placental abruption, preterm birth, small birth size for gestational age, and fetal death/stillbirth. Eliminating racial disparities in adverse pregnancy outcomes (not counting infant costs), could generate Medicaid cost savings of $114 to $214 million per year in these 14 states. Despite having the same insurance coverage and meeting the same poverty guidelines for Medicaid eligibility, African American women have a higher rate of adverse pregnancy outcomes than White or Hispanic women. Racial disparities in adverse pregnancy outcomes not only represent potentially preventable human suffering, but also avoidable economic costs. There is a significant financial return-on-investment opportunity tied to eliminating racial disparities in birth outcomes. With the Affordable Care Act expansion of Medicaid coverage for the year 2014, Medicaid could be powerful public health tool for improving pregnancy outcomes.

Impact of fetal death reporting requirements on early neonatal and fetal mortality rates and racial disparities.

OBJECTIVE: Racial disparities in infant and neonatal mortality vary substantially across the U.S. with some states experiencing wider disparities than others. Many factors are thought to contribute to these disparities, but state differences in fetal death reporting have received little attention. We examined whether such reporting requirements may explain national variation in neonatal and fetal mortality rates and racial disparities. METHODS: We used data on non-Hispanic white and non-Hispanic black infants from the U.S. 2000-2002 linked birth/infant death and fetal death records to determine the degree to which state fetal death reporting requirements explain national variation in neonatal and fetal mortality rates and racial disparities. States were grouped depending upon whether they based the lower limit for fetal death reporting on birthweight alone, gestational age alone, both birthweight and gestational age, or required reporting of all fetal deaths. Traditional methods and the fetuses-at-risk approach were used to calculate mortality rates, 95% confidence intervals, and relative and absolute racial disparity measures in these four groups. RESULTS: States with birthweight-alone fetal death thresholds substantially underreported fetal deaths at lower gestations and slightly overreported neonatal deaths at older gestations. This finding was reflected by these states having the highest neonatal mortality rates and disparities, but the lowest fetal mortality rates and disparities. CONCLUSIONS: Using birthweight alone as a reporting threshold may promote some shift of fetal deaths to newborn deaths, contributing to racial disparities in neonatal mortality. The adoption of a uniform national threshold for reporting fetal deaths could reduce systematic differences in live birth and fetal death reporting.

Factors that mediate racial/ethnic disparities in US fetal death rates.

OBJECTIVES: We sought to determine the importance of socioeconomic factors, maternal comorbid conditions, antepartum and intrapartum complications of pregnancy, and fetal factors in mediating racial disparities in fetal deaths. METHODS. We undertook a mediation analysis on a retrospective cohort study of hospital-based deliveries with a gestational age between 23 and 44 weeks in California, Missouri, and Pennsylvania from 1993 to 2005 (n = 7,104,674). RESULTS: Among non-Hispanic Black women and Hispanic women, the fetal death rate was higher than among non-Hispanic White women (5.9 and 3.6 per 1000 deliveries, respectively, vs 2.6 per 1000 deliveries; P < .01). For Black women, fetal factors mediated the largest percentage (49.6%; 95% confidence interval [CI] = 42.7, 54.7) of the disparity in fetal deaths, whereas antepartum and intrapartum factors mediated some of the difference in fetal deaths for both Black and Asian women. Among Hispanic women, socioeconomic factors mediated 35.8% of the disparity in fetal deaths (95% CI = 25.8%, 46.2%). CONCLUSIONS: The factors that mediate racial/ethnic disparities in fetal death differ depending on the racial/ethnic group. Interventions targeting mediating factors specific to racial/ethnic groups, such as improved access to care, may help reduce US fetal death disparities.

Inadequate prenatal care utilization and risks of infant mortality and poor birth outcome: a retrospective analysis of 28,729,765 U.S. deliveries over 8 years.

OBJECTIVE: To evaluate the association between adequacy of prenatal care utilization and risk of fetal and neonatal mortality and adverse outcomes. METHODS: We conducted a population-based cohort study using the Center for Disease Control and Prevention's Linked Birth-Infant Death and Fetal Death data on all deliveries in the United States between 1995 and 2002. Inclusion criteria were singleton births ≥22 weeks of gestation with no known congenital malformation. Inadequate prenatal care was defined according to the Adequacy of Prenatal Care Utilization Index, and its effect on fetal and neonatal death was estimated using unconditional logistic regression analysis adjusting for maternal age, race, education, and other confounding variables. RESULTS: During our 8-year study period, 32,206,417 births occurred, 28,729,765 (89.2%) of which met inclusion criteria. Inadequate prenatal care utilization occurred in 11.2% of expectant mothers, more commonly among women ≤20 years, black non-Hispanic and Hispanic women, and those without high school education. Relative to adequate care, inadequate care was associated with increased risk of prematurity 3.75 (3.73 to 3.77), stillbirth 1.94 (1.89 to 1.99), early neonatal dearth 2.03 (1.97 to 2.09), late neonatal death 1.67 (1.59 to 1.76), and infant death 1.79 (1.76 to 1.82). CONCLUSION: Risk of prematurity, stillbirth, early and late neonatal death, and infant death increased linearly with decreasing care. Given the population effect of this association, public health initiatives should target program expansion to ensure timely and adequate access, particularly for women ≤20 years, Black non-Hispanic and Hispanic women, and those without high school education.

Disparities in fetal death and first day death: the influence of risk factors in 2 time periods.

OBJECTIVES: We examined how changes in risk factors over time influence fetal, first day, and combined fetal-first day mortality and subsequent racial/ethnic disparities. METHODS: We selected deliveries to US resident non-Hispanic White and Black mothers from the linked live birth-infant death cohort and fetal deaths files (1995-1996; 2001-2002) and calculated changes over time of mortality rates, odds, and relative odds ratios (RORs) overall and among mothers with modifiable risk factors (smoking, diabetes, or hypertensive disorders). RESULTS: Adjusted odds ratios (AORs) for fetal mortality overall (AOR=0.99; 95% confidence interval [CI]=0.96, 1.01) and among Blacks (AOR=0.98; 95% CI=0.93, 1.03) indicated no change over time. Among women with modifiable risk factors, the RORs indicated no change in disparities. The ROR was not significant for fetal mortality (ROR=0.96; 95% CI=0.83, 1.01) among smokers, but there was evidence of some decline. There was evidence of increase in RORs in fetal death among mothers with diabetes and hypertensive disorders, but differences were not significant. CONCLUSIONS: Disparities in fetal, first day, and combined fetal-first day mortality have persisted and reflect discrepancies in care provision or other factors more challenging to measure.

Perinatal outcomes following the ultrasound diagnosis of echogenic bowel: an Australian perspective.

INTRODUCTION: The aim of this study was to describe the association between fetal echogenic bowel (FEB) diagnosed during the second trimester and adverse perinatal outcomes in an Australian antenatal population. METHODS: A retrospective analysis of ultrasound scans was performed between March 1, 2004 and March 1, 2009 at The Royal Women's Hospital, Melbourne, Vic., Australia. Cases reported as having FEB on second trimester ultrasound were included. Medical records of each case were reviewed and information concerning additional investigations and perinatal outcomes were extracted. RESULTS: A total of 66 cases were identified in our database. Three patients (5%) were excluded from further analysis as they were lost to follow-up, leaving 63 (95%) cases in this series. Thirty-two fetuses (52%) underwent karyotyping via amniocentesis, 5 (16%) of which were found to have chromosomal defects. Maternal serology for cytomegalovirus (CMV) was performed in 49 (78%) cases. Investigations indicated a total of 5 women who had CMV infection during their pregnancy. Thirty-three pregnancies (53%) were tested for cystic fibrosis (CF) and 1 baby was confirmed to have CF postnatally. Among the 50 liveborn infants, 3 cases of fetal growth restriction were apparent. Overall, 42 of the 50 liveborn infants (84%) and 67% of the entire cohort of 63 patients with a midtrimester diagnosis of FEB had a normal short-term neonatal outcome. CONCLUSION: This study reiterates the increased prevalence of aneuploidy, CMV, CF and fetal growth restriction in pregnancies complicated by the midtrimester sonographic finding of FEB. However, reassuringly, 67% of cases with ultrasound-detected echogenic bowel in the second trimester had a normal short-term neonatal outcome in this multiethnic Australian population.

Trends and risk factors of stillbirth in New Jersey 1997-2005.

INTRODUCTION: The purpose of this study was to examine the trends in the rates of stillbirth by race and ethnicity and to determine the risk factors of stillbirth. METHODS: We used New Jersey data (1997-2005) for live births and fetal deaths. Cox proportional hazards model was used to estimate the risk of stillbirth associated with maternal risk factors and pregnancy complications. RESULTS: The rate of stillbirth was 4.4/1000 total births (3.4 for white and 7.9 for black non-Hispanics and 4.4 for Hispanics/1000 total births). The rates of stillbirth decreased from 3.8 in 1997 to 2.7/1000 total births in 2005 for white non-Hispanics but remained unchanged for other race/ethnicity groups. Adjusted relative risks for the risk factors associated with stillbirth were 1.3 (95% CI, 1.2-1.4) for maternal age ≥ 35 years, 1.9 (95% CI, 1.7-2.1) for black non-Hispanics, 2.8 (95% CI, 2.4-3.3) for no prenatal care, 40.2 (95% CI, 36.9-43.9) for placental abruption, 5.3 (95% CI, 3.4-8.2) for eclampsia, 3.5 (95% CI, 2.8-4.3) for diabetes mellitus and 1.7 (95% CI, 1.3-2.2) for preeclampsia. CONCLUSION: There was a decline in the rate of stillbirth but there were persistent racial disparities with the highest rates of stillbirth for black non-Hispanics.

Spina bifida subtypes and sub-phenotypes by maternal race/ethnicity in the National Birth Defects Prevention Study.

Spina bifida refers to a collection of neural tube defects, including myelomeningocele, meningocele, and myelocele (SB(M) ), as well as lipomyelomeningocele and lipomeningocele (SB(L) ). Maternal race/ethnicity has been associated with an increased risk for spina bifida among offspring. To better understand this relationship, we evaluated different spina bifida subtypes (SB(M) vs. SB(L) ) and sub-phenotypes (anatomic level or presence of additional malformations) by maternal race/ethnicity using data from the National Birth Defects Prevention Study. This study is a large, multisite, population-based study of nonsyndromic birth defects. Prevalence estimates were obtained using data from spina bifida cases (live births, fetal deaths, and elective terminations) and total live births in the study regions. From October 1997 through December 2005, 1,046 infants/fetuses with spina bifida were delivered, yielding a prevalence of 3.06 per 10,000 live births. Differences in the prevalences of SB(M) vs. SB(L) , isolated versus non-isolated SB(M) , and lesion level in isolated SB(M) among case offspring were observed by maternal race/ethnicity. Compared to non-Hispanic (NH) White mothers, offspring of Hispanic mothers had higher prevalences of each subtype and most sub-phenotypes, while offspring of NH Black mothers generally had lower prevalences. Furthermore, differences in race/ethnicity among those with isolated SB(M) were more pronounced by sex. For instance, among male offspring, the prevalence of isolated SB(M) was significantly higher for those with Hispanic mothers compared to NH White mothers [prevalence ratio (PR): 1.55, 95% confidence interval: 1.23-1.95]. These findings provide evidence that certain spina bifida subtypes and sub-phenotypes may be etiologically distinct.

Estimating the effects of cigarette taxes on birth outcomes.

Employing provincial data from 1979 to 2004 allows us to exploit the significant (45 percent to 60 percent) reduction in excise taxes in Eastern Canada enacted in February 1994 to estimate the impacts of cigarette taxes on birth outcomes. Empirical estimates suggest that an increase in cigarette taxes is significantly associated with lower infant mortalities. However, we also find some evidence of a counter-intuitive positive correlation between taxes and fetal deaths. Overall, conditional on methodology, we find increased lagged per capita health expenditures and the number of physicians to be significantly associated with improvements in birth outcomes.

Maternal and fetal factors associated with mortality and morbidity in a multi-racial/ethnic registry of anti-SSA/Ro-associated cardiac neonatal lupus.

BACKGROUND: Cardiac manifestations of neonatal lupus include conduction disease and, rarely, an isolated cardiomyopathy. This study was initiated to determine the mortality and morbidity of cardiac neonatal lupus and associated risk factors in a multi-racial/ethnic US-based registry to provide insights into the pathogenesis of antibody-mediated injury and data for counseling. METHODS AND RESULTS: Three hundred twenty-five offspring exposed to maternal anti-SSA/Ro antibodies with cardiac neonatal lupus met entry criteria. Maternal, fetal echocardiographic, and neonatal risk factors were assessed for association with mortality. Fifty-seven (17.5%) died, 30% in utero. The probability of in utero death was 6%. The cumulative probability of survival at 10 years for a child born alive was 86%. Fetal echocardiographic risk factors associated with increased mortality in a multivariable analysis of all cases included hydrops and endocardial fibroelastosis. Significant predictors of in utero death were hydrops and earlier diagnosis, and of postnatal death were hydrops, endocardial fibroelastosis, and lower ventricular rate. Isolated heart block was associated with a 7.8% case fatality rate, whereas the concomitant presence of dilated cardiomyopathy or endocardial fibroelastosis quadrupled the case fatality rate. There was a significantly higher case fatality rate in minorities compared with whites, who were at a lower risk of hydrops and endocardial fibroelastosis. Pacing was required in 70%; cardiac transplantation was required in 4 children. CONCLUSION: Nearly one fifth of fetuses who develop cardiac neonatal lupus die of complications predicted by echocardiographic abnormalities consistent with antibody-associated disease beyond the atrioventricular node. The disparity in outcomes observed between minorities and whites warrants further investigation.

Use of active surveillance methodologies to examine over-reporting of stillbirths on fetal death certificates.

BACKGROUND: Data from Iowa fetal death certificates (FDCs) suggest that reportable stillbirths (unintended fetal deaths ≥ 20 weeks gestation and/or weighing ≥ 350 grams) occur in about 1 in 200 deliveries. In 2005, the Iowa Department of Public Health and the Iowa Registry for Congenital and Inherited Disorders (IRCID) collaborated with other state stakeholders to establish the Iowa Stillbirth Surveillance Project. The goal of this project was to use population-based, active surveillance methodologies to identify reportable stillbirths delivered by Iowa residents since January 1, 2000. METHODS: To conduct stillbirth surveillance, the IRCID expanded its existing public health authority and electronic abstract application for birth defects surveillance. The expanded application was piloted using a random sample (n = 250 of 989) of FDCs reported from January 2000 through December 2004. RESULTS: IRCID procedures for active case finding and medical record abstraction verified 192 (76.8%) as reportable stillbirths. Stillbirths not verified as reportable were due to findings of elective terminations (n = 30), live births (n = 3), induced deliveries (n = 2), and FDC entries for gestational age and/or delivery weight that were either inaccurately recorded (n = 13) or accurately recorded but did not meet Iowa FDC reporting criteria (n = 9); medical records for one FDC were unavailable. Infant malformations were more common among unverified stillbirths, whereas the cause of death due to maternal-related conditions was higher among verified stillbirths. CONCLUSIONS: These results suggest that over-reporting limits the use of FDCs as a primary ascertainment source for stillbirth surveillance in Iowa. Continued expansion of the IRCID active surveillance methodologies to monitor stillbirths in Iowa is recommended.

Risk factors for intrauterine fetal death (1988-2009).

OBJECTIVE: To determine risk factors for intrauterine fetal death (IUFD). STUDY DESIGN: A retrospective population-based study, of all singleton deliveries between the years 1988-2009 was conducted. Intrapartum deaths, postpartum death, and multiple gestations were excluded. A multiple logistic regression model was used to determine independent risk factors. RESULTS: During the study period, out of 228,239 singleton births, 1694 IUFD cases were recorded (7.4 per 1000 births). The following independent risk factors were identified in the logistic regression executed: Oligohydramnios (OR 2.6, 95% CI 2.1-3.2, p-value < 0.001), polyhydramnios (OR 1.8, 95% CI 1.4-2.2, p-value < 0.001), previous adverse perinatal outcome (OR 1.7, 95% CI 1.5-2.1, p-value < 0.001), congenital malformations (OR 2.0, 95% CI 1.8-2.3, p-value < 0.001), true knot of cord (OR 3.7, 95% CI 2.8-4.9, p-value < 0.001), meconium stained amniotic fluid (OR 2.7, 95% CI 2.3-3.0, p-value<0.001), placental abruption (OR 2.9, 95% CI 2.4-3.5, p-value < 0.001), advanced maternal age (OR 1.03, 95% CI 1.02-1.04, p-value < 0.001), and hypertensive disorders (OR 1.24, 95% CI 1.0-1.4, p-value = 0.026). Jewish ethnicity (versus Bedouin - OR 0.64, 95% CI 0.57-0.72, p-value < 0.001), gestational diabetes (OR 0.7, 95% CI 0.5-0.8, p-value = 0.001), previous cesarean section (OR 0.8, 95% CI 0.7-0.97, p-value = 0.019), and recurrent abortions (OR 0.8, 95% CI 0.6-0.9, p-value = 0.011) were negatively associated with IUFD. CONCLUSION: Several independent risk factors were identified, suggesting a possible cause of death. Other pathologic conditions that facilitate tighter pregnancy surveillance and active management were found protective, pointing the benefit of such management approaches in high-risk pregnancies.

Racial and ethnic variations in temporal changes in fetal deaths and first day infant deaths.

The purpose was to examine changes in overall and gestational age-specific proportions and rates of fetal death, first day death (<24 h), and combined fetal-first day death from 1990-1991 to 2001-2002. Changes were considered by race/ethnicity. Deliveries to U.S. white, black, and Hispanic mothers were selected from the NCHS linked live birth-infant death cohort and fetal deaths files (1990-1991 and 2001-2002). There was an overall improvement in mortality, but improvements were not uniform across all racial/ethnic groups or by gestational age. The fetal mortality rate among whites and Hispanics declined 4.32 and 12.82 percent, respectively. For blacks, the fetal mortality rate increased 4.06 percent between 1990-1991 and 2001-2002. Despite overall reductions in perinatal and <24 h mortality, black rates in all outcomes maintained a twofold disparity. The overall black: white fetal mortality rate ratio increased from 2.17 to 2.36 over time. The gestational age-specific black: white combined fetal-first day mortality rate ratios were greater than 1 at later gestational ages. In some cases, the ratio increased over time, indicating that despite reductions, fetal mortality did not decline uniformly among whites and blacks at term and post-term. Despite overall improvements in fetal, first day, and combined fetal-first day mortality, racial disparities persisted and in some cases widened. This study identifies lack of improvements in fetal death in the black population compared to the white or Hispanic population at later gestational ages.

Racial disparities in infant mortality: what has birth weight got to do with it and how large is it?

BACKGROUND: It has been hypothesized that birth weight is not on the causal pathway to infant mortality, at least among "normal" births (i.e. those located in the central part of the birth weight distribution), and that US racial disparities (African American versus European American) may be underestimated. Here these hypotheses are tested by examining the role of birth weight on racial disparities in infant mortality. METHODS: A two-component Covariate Density Defined mixture of logistic regressions model is used to decompose racial disparities, 1) into disparities due to "normal" versus "compromised" components of the birth cohort, and 2) further decompose these components into indirect effects, which are associated with birth weight, versus direct effects, which are independent of birth weight. RESULTS: The results indicate that a direct effect is responsible for the racial disparity in mortality among "normal" births. No indirect effect of birth weight is observed despite significant disparities in birth weight. Among "compromised" births, an indirect effect is responsible for the disparity, which is consistent with disparities in birth weight. However, there is also a direct effect among "compromised" births that reduces the racial disparity in mortality. This direct effect is responsible for the "pediatric paradox" and maybe due to differential fetal loss. Model-based adjustment for this effect indicates that racial disparities corrected for fetal loss could be as high as 3 or 4 fold. This estimate is higher than the observed racial disparities in infant mortality (2.1 for both sexes). CONCLUSIONS: The results support the hypothesis that birth weight is not on the causal pathway to infant mortality among "normal" births, although birth weight could play a role among "compromised" births. The overall size of the US racial disparities in infant mortality maybe considerably underestimated in the observed data possibly due to racial disparities in fetal loss.

Cost of racial disparity in preterm birth: evidence from Michigan.

This study examined the economic costs associated with racial disparity in preterm birth and preterm fetal death in Michigan. Linked 2003 Michigan vital statistics and hospital discharge data were used for data analysis. Thirteen percent of the singleton births among non-Hispanic Blacks were before 37 completed weeks of gestation, compared with only 7.7% among non-Hispanic Whites (risk ratio = 1.66, 95% confidence interval: 1.59-1.72; p<.0001). One thousand one hundred and eighty four (1,184) non-Hispanic Black, singleton preterm births and preterm fetal deaths would have been avoided in 2003 had their preterm birth rate been the same as Michigan non-Hispanic Whites. Economic costs associated with these excess Black preterm births and preterm fetal deaths amounted to $329 million (range: $148 million-$598 million) across their lifespan over and above the costs if they were born at term, including costs associated with the initial hospitalization, productivity loss due to perinatal death, and major developmental disabilities. Hence, racial disparity in preterm birth and preterm fetal death has substantial cost implications for society. Improving pregnancy outcomes for African American women and reducing the disparity between Blacks and Whites should continue to be a focus of future research and interventions.

The prevalence and predictors of anencephaly and spina bifida in Texas.

Texas shares a 1255-mile border with Mexico and encompasses a variety of ecosystems, industries and other potential environmental exposures. The Texas Birth Defects Registry is an active surveillance system which covers all pregnancy outcomes (livebirths, fetal deaths and elective pregnancy terminations). This study describes the occurrence and the predictors of neural tube defects (anencephaly and spina bifida) in Texas between 1999 and 2003. Birth prevalence, crude and adjusted prevalence ratios and 95% confidence intervals were calculated using Poisson regression, for each defect, by fetal/infant sex, delivery year and maternal sociodemographic characteristics. Among approximately 1.8 million livebirths, a total of 1157 neural tube defects cases were ascertained by the Registry, resulting in an overall prevalence of 6.33 cases per 10 000 livebirths. The prevalences of anencephaly and spina bifida were 2.81 and 3.52 per 10 000 livebirths respectively. Prevalences of both defects were highest in Hispanics, among mothers living along the border with Mexico, among women of higher parity and among mothers who were 40+ years of age. In addition, the prevalence of each defect was higher among women with no record of prenatal care and among women with less than 7 years of education. Hispanic ethnicity was an important predictor for anencephaly, along with sex, maternal age, parity and border residence. However, only border residence and delivery year were significant predictors for spina bifida.

Ethnic differences in perinatal mortality. A perinatal audit on the role of substandard care.

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.