Original Article
Differences in preterm delivery rates and outcomes in Jews and Bedouins in southern Israel

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Abstract

Objective: (1) To compare the preterm delivery rates in the Bedouin versus the Jewish population. (2) To compare risk factors for preterm delivery in the two populations. (3) To compare outcomes of preterm delivery between the two groups. Study design: 41 669 Jewish singletons births of whom 2816 delivered preterm (23–36 weeks) and 26 495 Bedouin singletons in whom 2064 preterm deliveries occurred, were compared. All births took place in Soroka University Medical Center. Data were obtained from the computerized database of birth discharge records. Results: The incidence of preterm delivery in Bedouin women was significantly higher than the rate in Jewish women (7.8 vs. 6.8%, P<0.01). The grand multiparity rate was higher among Bedouin women (P<0.001), as was the rate of teenage (<19 years) mothers (P<0.001). Gestational diabetes, PIH, and PROM rates were higher in the Jewish population (P<0.001, P=0.017, P<0.001, respectively). A bad obstetric history and previous perinatal mortality is more common in the Bedouin population (P<0.001 for both). In a logistic regression model including all these factors, the ethnic difference in the incidence of preterm delivery remained significant. The neonatal mortality rate was higher in the Bedouin population (P<0.001), as was the rate of congenital malformations (P<0.001). The perinatal mortality of Bedouins was nearly twice that of Jewish neonates with congenital malformations. However, no difference was found when neonates without congenital malformations were compared. Congenital malformations were found to be the strongest predictor of mortality. Ethnicity per se was no longer a predictor of mortality once congenital malformations were included in a logistic regression model, but the interaction of Bedouin ethnicity and congenital malformation was a significant predictor of mortality. Conclusion: The incidence of preterm delivery was significantly higher in Bedouin women than in Jewish women. A full explanation for this difference was not found. However, there were significantly higher rates of congenital malformations in the Bedouin preterm delivered infants. There was a much higher rate of neonatal mortality in the Bedouin population and this ethnic difference was fully explained by the presence of congenital anomalies.

Introduction

Preterm delivery is the leading cause of perinatal mortality and morbidity in the western world [1]. In the medical literature, several demographic, social and medical factors have been related to preterm delivery. Well-established risk factors of preterm delivery are: a past history of preterm labor [2], [3], [4], [5], previous abortions [6], young maternal age [3], [4], [5], anemia [3], nutrition, poor maternal weight gain in pregnancy [4], [6], genitourinary tract infections [3], [5], [6], cervical os incompetence [2], [6], vaginal bleeding in current pregnancy [2], [3], [6], PIH [3], and placental abnormalities [2], [3].

Several studies have demonstrated the correlation between smoking and preterm delivery [2], [3], [4]. In addition, occupational factors were also found to be related to preterm delivery. The relation between a socio-economic status and preterm delivery was observed by Baird and Wyper [7] as early as 1941. Since then, many studies have demonstrated this association. Morrison et al. [8] showed that the preterm delivery rate is significantly higher in women of a low socio-economic state, but this was not found to be an independent risk factor. On the contrary, Wildschut et al. [9] did not find a relationship between a socio-economic state and preterm delivery. Still, most authors agree that a low socio-economic status is a risk factor of preterm delivery [2], [6], [10], [11].

The relationship between race and neonatal outcome has also been studied extensively. It has been repeatedly shown that Afro-American women have significantly more preterm deliveries compared with Caucasian women. Some authors attributed this data to the two population differences in the socio-economic status, demographic, and medical care [6], [12], [13], [14]. Ethnicity is still considered an independent risk factor. Furthermore, Adams et al. [15] showed that even paternal race effects preterm delivery rates, although maternal race has a stronger effect.

It is already known that ethnicity, race and other demographic factors have a direct influence on labor outcome. Sappenfield et al. [16] have demonstrated a difference in survival rates between races; while whites have higher mortality rates in preterm birth than blacks, the latter have higher mortality rates in term birth.

In the Soroka University Medical Center the population is mainly composed of two different ethnic groups: Bedouin-Arabs and Jews. The Bedouins are a Moslem minority undergoing a rapid process of change from semi-nomadism to a sedentary lifestyle. The two groups are different in many aspects. Official data describe the Bedouin population as being of a lower socio-economic status [17]. The two populations differ in life style, especially in the higher rate of consanguineous marriage and fertility rate [17], [18]. A Bedouin parturient is on the average of a higher gravidity and parity for a given age, the interval between births is shorter, and the first birth occurs at a younger age. Although prenatal care services are used less by the Bedouin population in comparison to the Jewish population, almost all labors take place in the hospital. Other differences in smoking habits and alcohol consumption, occupational characteristics and use of prenatal care also exist.

The aims of this study are: (1) to compare the preterm delivery rates in the Bedouin versus the Jewish population; (2) to compare risk factors for preterm delivery in the two populations; (3) to compare outcomes of preterm delivery between the two groups.

Section snippets

Material and methods

All singleton births occurring in Soroka University Medical Center in the years 1989–96 to mothers who had a record of prenatal care (41 669 Jews and 26 495 Bedouins) were included in the study. The exclusion criteria were: (1) preterm delivery in 20–22 weeks gestation (only eight cases were found); (2) no prenatal care (since no information is available about the course of pregnancy); and (3) multiple gestations. In the first phase of the analysis incidence of preterm delivery was compared and

Results

Preterm delivery rates increased significantly in both study populations — Jews and Bedouins between 1989 and 1996 (from 5.6 to 8.2%, P<0.001; and 5.7 to 10.2%, P<0.001, respectively). Fig. 1 represents the distribution of preterm birth during the study period. Among the 26 496 Bedouin births delivered at the Soroka University Medical Center during the study period, 2064 (7.8%) were preterm, and of the 41 670 Jewish births 2816 (6.8%) were preterm. The incidence of preterm delivery in the

Discussion

This study compared risk factors for preterm delivery between two ethnic groups, Bedouin-Arabs and Jews. Bedouin women were found to have higher rates of teenage mothers, grand multiparity and bad obstetric history. On the other hand, PROM, severe PIH, and gestational diabetes are more common in Jewish women. Anthropological and epidemiological studies show that these populations have different social and lifestyle patterns, such as smoking habits, marital and obstetric characteristics, and

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    1

    This study was performed partially as part of the requirements for an M.D. degree for Yaron Melamed.

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