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RESEARCH: Marian Knight, Jennifer J Kurinczuk, Patsy Spark, Peter Brocklehurst on behalf of UKOSS Inequalities in maternal health: national cohort study of ethnic variation in severe maternal morbidities BMJ 2009; 338: b542 [Abstract] [Full text]

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Weakness of Ethnicity Argument

Souhail Alouini   (24 March 2009)

The sins of the Fathers (Mothers)

Neal Devitt   (1 April 2009)

Weakness of Ethnicity Argument 24 March 2009
Souhail Alouini, Gynecologist surgeon and Obstetrician, M.D.,Ph.D. Centre Hospitalier Régional d'Orléans, 45000, France Send response to journal: Re: Weakness of Ethnicity Argument	Marian Knight et al (1) report a higher rate of severe maternal morbidity among non-white versus white women in the U.K. without being able to explain it by the characteristics of the studied populations. However, the studied characteristics, e.g. the parity, maternal age, body mass index are largely insufficient to explain the higher morbidity of the non-white women in relation to the peripartum hysterectomy, eclampsia and embolism. Indeed, gestational pathologies such as diabetes or arterial hypertension implied in the preeclampsia were not identified in each population and were not compared. The percentage of previous caesarean section, placenta praevia or accreta which are strongly associated with postpartum haemorrhage and peripartum hysterectomy (2) in non-white and white women is not precised. The weight of foetuses and their number (in case of twins, etc.) is not known in the studied populations. Foetal macrosomia and multiple pregnancies are also to be taken into account as an origin of severe maternal morbidity (haemorrhages, embolisms). The follow-up of the pregnancies was not compared between the two populations (white and non-white women). The samples’ sizes of white women (505) versus African black women (17), or Caribbean (46) are too different to be comparable. Consequently, this study does not inform about the origin of higher maternal morbidity in non-white women because the risk factors and the maternal-foetal pathologies related to the studied morbidities were neither identified nor compared. References 1. Knight M, Kurinczuk JJ, Spark P, Brocklehurst P; UKOSS. Inequalities in maternal health: national cohort study of ethnic variation in severe maternal morbidities. BMJ. 2009 3;338:b542. 2. Glaze S, Ekwalanga P, Roberts G, Lange I, Birch C, Rosengarten A, Jarrell J, Ross S. Peripartum hysterectomy: 1999 to 2006. Obstet Gynecol. 2008;111:732-8 Competing interests: None declared
The sins of the Fathers (Mothers) 1 April 2009
Neal Devitt, Senior Physician La Familia Medical Center 87505 Send response to journal: Re: The sins of the Fathers (Mothers)	I believe that Knight et al have overlooked a mechanism for an occult effect of socioeconomic status upon maternal morbidity. Resultant low birth weight delivery is of course associated with the socioeconomic status of the mother.(1) Low birth weight or prematurity on the part of that mother is associated with development of gestational diabetes(2), preeclampsia(3), and higher blood pressure(4)in her own offspring when they become adults. All these conditions confer increased risk of maternal morbidity when these adults become pregnant. Epigenetics(5) perhaps through the mechanism of environmentally induced DNA methylation(6) offers an explanation of how the socioeconomic status of the mother (first generation impoverished) of a parturient may confer increased risk of pregnancy complications upon that parturient (second generation affluent) when there is no association evident with the present socioeconomic status of that parturient and her present pregnancy morbidity. (1)Joseph KS,Robert M, Liston MB,et al. Socioeconomic status and perinatal outcomes in a setting with universal access to essential health care services. CMAJ 2007;177(6):583-90. (2)Innes KE, Byers TE, Marshall JA, et al. Association of a Woman’s Own Birth Weight With Subsequent Risk for Gestational Diabetes. JAMA. 2002;287:2534-2541. (3)Dempsey JC, Williams MA, Luthy DA, et al. Weight at birth and subsequent risk of preeclampsia as an adult. Am J Obstet Gynecol 2003;189:494-500. (4) Hovi P, Andersson S, Ericksson JG, et al. Glucose Regulation in Young Adults with Very Low Birth Weight. N Engl J Med 2007;356:2053-63. (5)Gallou-Kabani C, Junien C. Nutritional Epigenomics of Metabolic Syndrome New Perspective Against the Epidemic. Diabetes 54:1899–1906, 2005. (6)Jablonka E. Lamb MJ.The epigenetic turn: the challenge of soft inheritance. http://www.mfo.ac.uk/files/images/Jablonka- ms_MPGM_EEEMclean.doc. accessed online March 31, 2009. Competing interests: None declared