David Ellwood
Griffith University - School of Medicine
Griffth Health Centre, Gold Coast campus, , Southport, Queensland 4222
Australia
Clinicians involved in perinatal care have always been excellent
recorders of data around the time of birth and now most high-income
countries maintain comprehensive registers, which give insight into
pregnancy and birth and help us to understand how maternal and other
characteristics contribute to outcomes. The paper by Faulks et al (BJOG
2023) is illustrative of the way in which well-maintained registers of
perinatal data can be used to allow researchers to interrogate the
information and draw important conclusions. This Victorian study of over
a million women and their babies, using data collected over nearly two
decades, shows very clearly that, even in a high-income country such as
Australia with a well-resourced and highly organised health system,
social disadvantage is a strong predictor of health outcomes.
So, what should we do with this information? I can think of three main
areas of health policy and practice which should be influenced by these
findings. Firstly, those involved in designing prediction models and
risk assessment tools should consider using objective measures of social
disadvantage in the algorithms, as it is likely that the current
approach underestimates actual risk of adverse perinatal outcomes.
Secondly, prevention strategies must go beyond the clinical and look at
how models of care, such as continuity of midwifery care, can help to
overcome the likely contributors to adverse outcomes such as access,
cultural and social safety, and lack of emotional and social support.
Thirdly, the message for governments must be that improving perinatal
outcomes is as much about social interventions as delivering effective
health systems. In 2023, Australians are experiencing serious cost of
living pressures, increasing housing insecurity and homelessness. A
better start to life for the next generation requires urgent attention
to these social determinants of perinatal health or else a repeat study
in 15 or 20 years will paint an even bleaker picture.
There is one strong positive from these data and one important negative.
The smoking rate after 20 weeks of pregnancy was only 6%, and given
that the most recent of these data are nearly 7 years old the current
situation may be even better. This is a mark of success of public
policy, although we can still do better and strive to improve smoking
cessation strategies and reduce this rate further to below 5%. The
negative is that the authors were unable to comment on the impact of
Indigenous status on the relationship between social disadvantage and
adverse perinatal outcomes. Efforts to close the gap in perinatal health
outcomes should make it mandatory that more effort is put into ensuring
that all health registers record this information.
Finally, it is of interest that the only outcome not related to social
disadvantage was caesarean section. There are many ways to interpret
this, but it is likely that the high rate of caesarean section in less
disadvantaged women receiving private obstetric care has skewed the
data. Whether this means that there are too many operative births for
those without disadvantage, or too few being performed for those who are
disadvantaged, requires further data analysis.