The impact of socioeconomic position on

severe maternal morbidity outcomes among

women in Australia: a national case–control
study
A LINDQUIST, N NOOR, E SULLIVAN, M KNIGHT
Introduction
Australians generally enjoy high standards of living and have one of
the longest life expectancies at birth in the world, at just over 80
years

average life expectancy of Indigenous Australians 17 years less than

that of non-Indigenous Australians.

Research conducted in Australia in 2000 looking at health and

socioeconomic status suggested that inequalities in
socioeconomically related mortality had increased for some
conditions
Introduction
there is no national
research into the
association between Identifying high-risk
socioeconomic position women is critical for the
and severe maternal prevention of adverse
morbidity. outcomes

A recent study investigated

the social gradient of
severe maternal morbidity
in the UK
Objective

The aim of this analysis was to explore the independent

impact of socioeconomic position on selected severe
maternal morbidities among women in Australia.
METHODS
Design and study population
• case–control study using data on specific severe maternal morbidities associated with
direct maternal death
• We collectively included women who had amniotic fluid embolism, placenta accreta,
peripartum hysterectomy, eclampsia or pulmonary embolism as ‘severe maternal
morbidity’ cases (n = 623).
• Controls were identified as the two women who had delivered immediately prior to
the identified cases of placenta accreta and peripartum hysterectomy in the same
hospitals (n = 820).
• The main exposure variable of socioeconomic status was the Socio-Economic Indexes
for Areas (SEIFA) quintile.
Table 1. Distribution of missing data for maternal
morbidity cases and controls
Results
Results
 Results
Maternal age was significantly associated
with maternal morbidity, with women aged
30–34 being 1.44 (95%CI 1.04–1.99) times
more likely and women aged 35 or over
being 2.2 (95%CI 1.64–3.15) times more
likely to be cases, compared with controls
after adjustment.
Socioeconomic status was statistically
significantly associated with maternal
morbidity, with cases being twice (95% CI
1.29–3.10) as likely to belong to the lowest
socioeconomic group (SEIFA quintile 1),
1.56 (95%CI 1.02–2.38) times more likely to
fall in SEIFA quintile 2 and 1.79 (95% CI
1.26–2.54) times more likely to be in
quintile 3, compared with controls
 Results
The number of previous caesarean deliveries was
Having a parity of one or two was found to be
also statistically significantly associated with
protective [adjusted odds ratio (aOR) 0.58, 95%CI
maternal morbidity, with women with one
0.43–0.79] against maternal morbidity, once
caesarean delivery having double the odds of
adjusted for age and previous caesarean section
morbidity (95%CI 1.44–2.85), two caesarean
and pregnancy complications, whereas women who
deliveries having 4.10 times the odds (95%CI 2.60–
had reported previous pregnancy complications
6.59) and three or more previous caesarean
were 1.3 (95%CI 1.21– 1.87) times more likely to be
deliveries having 9.35 imes the odds of severe
cases compared with controls
maternal morbidity (95%CI 3.96– 26.00) compared
with women with no previous caesarean delivery.
 DISCUSSION (Main findings)
the independent risk of severe maternal morbidity among women in Australia is
significantly increased by lower socioeconomic position, with women from the
lowest socioeconomic group shown to be twice as likely as women from the
highest socioeconomic group to suffer from severe maternal morbidity

There are association between severe maternal morbidity and older age, as well
as with previous pregnancy problems and prior delivery by caesarean section.
Discussion (Main findings )
Our multicentre, cluster randomised controlled trial revealed that a 1-day,
multi-professional, simulation-based obstetric team training in a simulation
centre, focusing on teamwork skills, did not reduce a composite of obstetric
complications

When we looked at the components of the primary outcome, a two-fold

reduction in neonatal damage due to shoulder dystocia and a two-fold
increase of treatment with ≥4 packed cells of blood transfusion, embolisation
or hysterectomy in the case of a postpartum haemorrhage were found.
Strength Limitation
1. limitation to investigate the independent role of
This is a large, nationwide study and the first some putative risk factors, such as health
Australian national study to investigate the risk of insurance status and remoteness of residence,
severe maternal morbidity among women from as controls may have been more similar to cases
different socioeconomic groups than would have been found from a random
population sample of women giving birth.
2. Insufficient statistical power to detect a small
increase in odds of severe maternal morbidity
among Australia’s small Indigenous population
as statistically significant.
3. the use of an area-based measure, SEIFA,
mapped to large and potentially varied
neighbourhoods potentially diminishes the
accuracy of the classification used in this
analysis.
Interpretation
Past research in Australia has explored, in the setting of cancer
care, the equity of healthcare provision based on need and not
social, location or financial status. In this study, remoteness
was not found to be a significant predictor of outcome.

The results of this study confirmed the association between

severe maternal morbidity and several known risk factors,
including advanced maternal age and previous caesarean
section.
The results of this study showed that women from the lowest socioeconomic group
generally report a poorer experience of care during pregnancy, while having a higher
risk of antenatal hospital admission, transfer during labour and caesarean delivery, in
addition to being less likely to have had any antenatal care, or to have been seen by a
midwife or GP for a routine 6–8-week postnatal review.

It is possible that similar differences in health-seeking behaviour, access to maternity

services and treatment of women by healthcare professionals also contribute to
differences in maternity outcomes by socioeconomic group in Australia
Conclusion
This study suggests that future
efforts in improving maternity
care provision and maternal
outcomes in Australia and other
countries with accessible
healthcare systems should
include socioeconomic position
as an independent risk factor
for adverse outcome.
CRITICAL APPRAISAL
 • Woman who had specific severe maternal
morbidities associated with direct maternal death
POPULATION

• women who had amniotic fluid embolism, placenta accreta, peripartum

hysterectomy, eclampsia or pulmonary embolism as ‘severe maternal
INTERVENTION morbidity’ cases

• women who had delivered immediately (control)

COMPARISON

• Severe maternal morbidity

OUTCOME • the Socio-Economic Indexes for Areas (SEIFA) quintile.
Is the aim clearly stated?

Yes, the authors to explore the independent impact of

socioeconomic position on selected
elaborated the severe maternal morbidities among
objective clearly women in Australia
Were the basic data adequately
described?
Yes it is adequately described.
women who had amniotic fluid embolism, placenta accreta, peripartum
hysterectomy, eclampsia or pulmonary embolism as ‘severe maternal
morbidity’ cases (n = 623).

Controls were identified as the two women who had delivered

immediately prior to the identified cases of placenta accreta and
peripartum hysterectomy in the same hospitals (n = 820).
Was the sample size justified?

We collected identical data for cases and controls, apart from

the details of the management and outcomes of the severe
morbidity defining the case
 Was the statistical significance
assessed?

Yes it is

We assessed the fit of the final multivariable mode using the Hosmer–Lemeshow
goodness-of-fit test. Given the 623 cases and 820 controls, and a prevalence of
8.9% for the lowest socioeconomic quintile, our analysis had an 80% power to
detect as statistically significant (P < 0.05) odds of 1.36 or greater.
Are the statistical methods described?

descriptive analysis to examine the distribution of maternal

characteristics and SEIFA quintiles in the case and control groups
using chi-squared tests.

We performed unconditional logistic regression analysis to

investigate the association between severe maternal morbidity and
SEIFA quintiles, adjusted for potential confounding factors. Results
are presented as odds ratios (OR) with 95% confidence intervals (CI).
 Where are the biases?
Selection bias  yes  Convenience controls,
selected from the same hospitals as cases, were
used for comparison, and this may have limited
our ability to investigate the independent role
of some putative risk factors, such as health
insurance status and remoteness of residence
Information bias  yes  the number of
indigenous women affected was low, and the
study did not have sufficient statistical power to
detect a small increase in odds of severe
maternal morbidity among Australia’s small
Indigenous population as statistically significant.
the use of an area-based measure, SEIFA,
mapped to large and potentially varied
neighbourhoods potentially diminishes the
accuracy of the classification used in this
analysis.
 Did untoward events occur during the study?

No, Untoward events

occurred
How do the results compare with previous
reports? (1)

Past research in Australia has explored, in the

setting of cancer care, the equity of
healthcare provision based on need and not
social, location or financial status. In this
study, remoteness was not found to be a
significant predictor of outcome.
How do the results compare with previous
reports? (2)

The results of this study confirmed the association between severe

maternal morbidity and several known risk factors, including
advanced maternal age and previous caesarean section.
Various studies in other countries have demonstrated similar
findings.In contrast to the UK,the results did not suggest that
ethnicity (defined by country of birth) was associated with a
significant increase in risk of morbidity.
How do the results compare with previous
reports? (3)
The findings of this study demonstrate that
socioeconomic position in Australia is a significant
and independent risk factor for severe maternal
morbidity and this has wide-ranging implications
for health policy and the provision of maternity
services
In 2009, the Australian Government conducted a
review of national maternity services. the report
states that ‘the range of targeted initiatives and
services, both within and outside the health
sector, that currently exist or could be considered
by government to address these inequalities are
recognised by the Review but have not been part
of its detailed considerations’, leaving a gap in the
planned service provision for socially
disadvantaged women.
What implications does the study have for your
practice?

future efforts in improving maternity care provision

and maternal outcomes in Australia and other
countries with accessible healthcare systems should
include socioeconomic position as an independent
risk factor for adverse outcome.
Thank you