Perinatal outcome in Berlin (Germany) among immigrants from Turkey

Equal Alternatives or Lower Standards for Immigrant Women-Analyzing Obstetric Care for Immigrant Women in Berlin Within the Framework of Cultural Health Capital

In obstetric clinics in Berlin, Germany, more than half of the women are immigrants. The main objective of the qualitative study was to explore the staff's experiences with obstetric care for immigrants and juxtapose it with the immigrants' comments on their birth experiences. We analyze potential differences along the framework of a cultural health capital (CHC). Between May and August 2017, semi-structured interviews were carried out with 17 obstetricians and 17 midwives at four obstetric clinics in Berlin. The verbally transcribed interview material was subjected to a qualitative content analysis according to Mayring. Furthermore, a secondary data from an interview study was analyzed in the purpose of providing some insight into the practitioner study participant perspective. Between January and May 2017, in the postpartum ward at the Berlin Charité Campus Virchow Clinic, an interview study guided by the migrant-friendly maternity care questionnaire was conducted among 410 migrant and non-migrant women. For this study, the free-text comments on the pregnancy care were analyzed. The staff interviewees identified language barrier and legal status as risk factors for the late onset of obstetric care. CHC functioning potentially as alternatives to the established health care structures were voiced. Strong family ties among immigrant families bear a high potential for support. Gratefulness was voiced by the staff and immigrant patients as a source of satisfaction with care. Our study shows that obstetric care for immigrant women remains a challenge. CHC of immigrant women might partially compensate for exclusion.

High Incidence of Obstetric Anal Sphincter Injuries among Immigrant Women of Asian Ethnicity

(1) Background: Obstetric anal sphincter injuries (OASI) may complicate vaginal deliveries. The aim of the present study was to explore the incidence and clinical characteristics of OASI among Asian women living in a Western country compared to local Caucasian women. (2) Methods: A retrospective cohort study of 380 women diagnosed with OASI, following singleton vaginal deliveries, during a 10-year period (January 2011 to December 2020). Exclusion criteria: age < 18 years, stillbirth, and breech presentation. Demographic, clinical, and obstetrical data were obtained, and a comparison between Asian and Caucasian women was performed. (3) Results: There were 35 cases of OASI among 997 women of Asian ethnicity compared to 345 cases of OASI among 86,250 Caucasian women (3.5% vs. 0.4%, respectively, p < 0.001). Asian women endured a significantly higher rate of fourth-degree OASI (17.1%) even though they bore smaller newborns (3318 g vs. 3501 g, p = 0.004), and birth weights rarely exceeded 3800 g (2.8% vs. 25.8%, p < 0.001). Asian ethnicity was also associated with a significantly higher risk for blood transfusion following OASI and a lower tendency for postpartum follow up. (4) Conclusions: Immigrant women of Asian ethnicity had a nine-fold higher rate of OASI, much higher than previously reported. Furthermore, Asian women had higher rates of fourth-degree OASI.

Diurnal cortisol variation during pregnancy in Turkish origin and non-migrant women in a German birth cohort study

BACKGROUND

Immigrants from Turkey experience health disadvantages relative to non-immigrant populations in Germany that are manifest from the earliest stages of the lifespan onwards and are perpetuated across generations. Chronic stress and perturbations of stress-responsive physiological systems, including the hypothalamus-pituitary-adrenal (HPA)-axis, are believed to in part mediate this relationship. Cortisol plays an important role in the association between maternal stress during pregnancy and many pregnancy-, birth- and offspring-related outcomes. We therefore examined whether maternal migrant background is associated with diurnal cortisol variation during pregnancy.

METHODS

109 pregnant women (incl. n = 32 Turkish origin women) that participated in a multi-site prospective cohort study in Germany collected saliva samples across the day on two consecutive days around 24 and 32 weeks gestation. Hierarchical linear models were applied to quantify associations between migrant background and diurnal cortisol variation across pregnancy.

RESULTS

Women of Turkish origin exhibited a significantly lower cortisol awakening response (CAR) and a flatter diurnal cortisol slope (DCS) compared to non-migrant women after adjusting for household income. These relationships between migrant status and diurnal cortisol variation were mainly driven by 2nd generation migrants.

DISCUSSION

A potential HPA axis dysregulation of Turkish-origin pregnant women may contribute to the intergenerational transmission of health disadvantages in this group.

Use of pain management in childbirth among migrant women in Iceland: A population-based cohort study

BACKGROUND

Immigration is rapidly increasing in Iceland with 13.6% of the population holding foreign citizenship in 2020. Earlier findings identified inequities in childbirth care for some women in Iceland. To gain insight into the quality of intrapartum midwifery care, migrant women's use of pain management methods during birth in Iceland was explored.

METHODS

A population-based cohort study including all women with a singleton birth in Iceland between 2007 and 2018, in total 48 173 births. Logistic regression analyses with odds ratios (ORs) and 95% confidence intervals (CIs) were used to investigate the relationship between migrant backgrounds defined as holding foreign citizenship and the use of pain management during birth. The main outcome measures were use of nonpharmacological and pharmacological pain management methods.

RESULTS

Data from 6097 migrant women were included. Migrant women had higher adjusted OR (aORs) for no use of pain management (aOR = 1.23 95% CI [1.12, 1.34]), when compared to Icelandic women. Migrant women also had lower aORs for the use of acupuncture (0.73 [0.64, 0.83]), transcutaneous electrical nerve stimulation (TENS) (0.92 [0.01, 0.67]), shower/bath (0.73 [0.66, 0.82]), aromatherapy (0.59 [0.44, 0.78]), and nitrous oxide inhalation (0.89 [0.83, 0.96]). Human Development Index (HDI) scores of countries of citizenship <0.900 were associated with lower aORs for the use of various pain management methods.

CONCLUSIONS

Our results suggest that being a migrant in Iceland is an important factor that limits the use of nonpharmacological pain management, especially for migrant women with citizenship from countries with HDI score <0.900.

Reasons for a Lower Rate of Epidural Anesthesia During Birth for Immigrant Women in the Eyes of Medical Staff: A Mixed-Methods Analysis

Various studies have shown that immigrant women in comparison to non-immigrant women of the same parity have lower rates of epidural anesthesia (EDA). Data from two studies on immigrant obstetric care in Berlin, Germany were analyzed to answer the following question: What reasons do the medical staff see for the lower rate of EDA in immigrant women? Between May and August 2017, 34 interviews with obstetricians and midwives in four obstetric clinics in Berlin were conducted on the topic of obstetric care for immigrant women. After anonymizing the more than 20 h of interview material, transcripts were coded with MaxQDa and analyzed according to the qualitative content analysis.The quantitative data is from an online survey conducted between May and October 2017, in all but one obstetric clinic in Berlin with obstetricians and midwives. Regarding the research question, 121 questionnaires could be analyzed. In the online survey, (multiple answers were possible), the top reason for a lower rate of EDA given was mostly fear on the part of the immigrant women (64%). A language barrier, which results in logistic and time constrictions, is mentioned as the second most frequent reason (50%). The explorative analysis of the interviews shows that doctors and midwives regard cultural aspects such as different expectations on the birth experience as a reason for a lower EDA rate. Furthermore, within the medical staff the impression persists that in some cases the companion decides on the behalf of the patient about the application of an EDA, which from time to time is against the wish of the immigrant woman giving birth. In the view of the medical staff, the reasons for a lower rate of EDA during birth for immigrant women were varied. On one side, this is attributed to the wishes of the respective women ("demand") but on the other side this can be attributed to the health care system ("supply"). In the case of a language barrier, the "supply" and the access of EDA for immigrant women is limited and can be then shifted to the German-speaking companion to make a decision regarding EDA ("structural deprivation of self-determination").

Association of maternal migrant background with inflammation during pregnancy - Results of a birth cohort study in Germany

BACKGROUND

Health disparities in children of immigrants are prevalent from birth and are hypothesized to - in part - emerge as a biological consequence of migration's unfavorable social and psychological sequelae. The aim of this study was to examine whether maternal migrant background is associated with inflammation during pregnancy - a key pathway by which maternal states and conditions during pregnancy may influence fetal development and subsequent pregnancy, birth, and child developmental and health outcomes.

MATERIAL AND METHODS

Data was available from 126 pregnant women who participated in a population based multi-site prospective birth cohort study in Bielefeld and Berlin, Germany. The study included two study visits in mid- and late pregnancy. At each visit, a composite maternal pro-inflammatory score was derived from circulating levels of plasma inflammatory markers (IL-6, CRP). Migrant background was defined by country of origin of participants and their parents' (Turkey or other) and generation status (1st or 2nd generation). We applied hierarchical linear models (HLM) in order to quantify the relationship between different migrant background variables and inflammation during pregnancy after adjustment for potential confounders (including socioeconomic status).

RESULTS

Migrant background was significantly associated with inflammation during pregnancy. When compared to women without migrant background, levels of inflammation were increased in 1) pregnant women with migrant background in general (B = 0.35, SE = 0.12, p < .01); 2) 1st (B = 0.28, SE = 0.15, p < .10) and 2nd generation (B = 0.40, SE = 0.15, p < .01); 3) women with a Turkish migrant background (B = 0.28, SE = 0.14, p < .10) and women with another migrant background (B = 0.42, SE = 0.15, p < .01); and 4) 2nd generation Turkish origin women (B = 0.38, SE = 0.20, p < .10), 1st generation women with other migrant background (B = 0.44, SE = 0.26, p < .10), and 2nd generation women with other migrant background (B = 0.43, SE = 0.17, p < .05).

DISCUSSION

Our findings support a role for maternal inflammation as a pathway of intergenerational transmission of migration-related health inequalities, suggest that the effect seems to persist in 2nd generation immigrants, and highlight the need for future research and targeted interventions in this context.

Territorial differences in access to prenatal care and health at birth

We assess the impact of prenatal care on health at birth using birth certificates from the Czech Republic. We use a predictive machine learning algorithm to identify the observables affecting birth health outcomes. We control for those observables in our empirical analysis, which indicates that a more intense use of prenatal care is positively correlated with better health outcomes at birth. Exploiting the Czech adhesion to the EU in 2004, we construct an instrument to capture the geographical heterogeneous access to prenatal care across districts. Differently from the OLS results, the IV results do not capture any significant effect of prenatal care, leaving room for the hidden role of unobservable mothers' characteristics when it comes to health behaviors during pregnancy.

Epidural analgesia for labour pain in nulliparous women in Norway in relation to maternal country of birth and migration related factors

OBJECTIVE

To investigate associations between maternal country of birth and other migration related factors (length of residence, reason for migration, paternal origin) and epidural analgesia for labour pain in nulliparous women in Norway.

DESIGN

Population-based register study including nulliparous migrant women (n = 75,922) and non-migrant women (n = 444,496) with spontaneous or induced labour. Data were retrieved from the Medical Birth Registry and Statistics Norway, 1990-2013. Odds ratios (OR) with 95% confidence intervals (CI) were estimated by logistic regression, and adjusted for maternal age, marital status, maternal education, gross income, birth year, hospital size and health region.

MAIN OUTCOME

Epidural analgesia for labour pain.

RESULTS

Epidural analgesia was administered to 38% of migrant women and 31% of non-migrant women. Compared with non-migrants, the odds of having epidural analgesia were lowest in women from Vietnam (adjOR 0.54; CI 0.50-0.59) and Somalia (adjOR 0.63; CI 0.58-0.68) and highest in women from Iran (adjOR 1.32; CI 1.19-1.46) and India (adjOR 1.19; CI 1.06-1.33). Refugees (adjOR 0.83; CI 0.79-0.87) and newly arrived migrants (adjOR 0.92; CI 0.89-0.94) had lower odds of epidural analgesia. Migrant women with a non-migrant partner (adjOR 1.14; CI 1.11-1.17) and those with length of residence ≥10 years (adjOR 1.06; CI 1.02-1.10) had higher odds.

CONCLUSION

The use of epidural analgesia varied by maternal country of birth, reason for migration, paternal origin and length of residence. Midwives and obstetricians should pay extra attention to the provision of adequate information about pain relief options for refugees and newly arrived migrants, who had the lowest use.

Intergenerational transmission of health disparities among Turkish-origin immigrants in Germany: study protocol of a multi-centric cohort study (BaBi-stress and BaBeK study)

BACKGROUND

Immigrants in Germany exhibit higher levels of social disadvantage when compared to the non-immigrated population. Turkish-origin immigrants constitute an important immigrant group in Germany and show disparities in some health domains that are evident from birth onwards. Several studies have shown the mechanisms by which social disadvantage is biologically embedded to affect health over the lifespan. Relatively little, however, is still known about if and how the maternal social situation is transmitted to the next generation. This study therefore aims to analyse the effects of maternal socioeconomic status and migration status on stress-related maternal-placental-fetal (MPF) biological processes during pregnancy on infant birth and health outcomes.

METHODS

This longitudinal cohort study of N = 144 child-mother dyads is located at two study sites in Germany and includes pregnant women of Turkish origin living in Germany as well as pregnant German women. During pregnancy, MPF stress biology markers from maternal blood and saliva samples, maternal socio-economic and migration-related information, medical risk variables and psychological well-being are assessed. After birth, infant anthropometric measures and developmental outcomes are assessed. The same measures will be assessed in and compared to Turkish pregnant women based on a collaboration with BABIP study in Istanbul.

DISCUSSION

This is the first study on intergenerational transmission of health disparities in Germany with a focus on women of Turkish-origin. The study faces similar risks of bias as other birth cohorts do. The study has implemented various measures, e.g. culturally sensitive recruitment strategies, attempt to recruit and follow-up as many pregnant women as possible independent of their social or cultural background. Nevertheless, the response rate among lower-educated families is lower. The possibility to compare results with a cohort from Turkey is a strength of this study. However, starting at different times and with slightly different recruitment strategies and designs may result in cohort effects and may affect comparability of the sub-cohorts.

TRIAL REGISTRATION

N.A. (Observational study, no clinical trial, no interventions on human participants).

The influence of migration on women's use of different aspects of maternity care in the German health care system: Secondary analysis of a comparative prospective study with the Migrant Friendly Maternity Care Questionnaire (MFMCQ)

INTRODUCTION

Approximately 21% of Germany's inhabitants or their parents have been born abroad. There is evidence that immigrant women are starting antenatal care later than nonimmigrants. In Berlin, equality in health care access had improved until 2011-2012, leaving only women with Low German language proficiency and an insecure residence status particularly at risk. With the recent influx of refugees, we analyzed whether access to antenatal and postpartum care differs depending on immigration, residence status, income, and education.

METHODS

At our Berlin tertiary care center, a modified version of the Migrant Friendly Maternity Care Questionnaire was administered to women who delivered in the first half of 2017. Multivariate modeling compared nonimmigrant women, immigrants, and women who are direct descendants of immigrants.

RESULTS

The study included 184 nonimmigrant women, 214 immigrant women, and 62 direct descendants of immigrants. Germany is relatively good in prenatal care for immigrant women, as most are getting adequate prenatal care. However, 21% of immigrants compared with 11% of nonimmigrant women started pregnancy care after the first trimester (P = .03). Low income was a more powerful predictor than immigration status for starting prenatal care after the first trimester. Immigrant women (23%) were less informed on postpartum care availability than nonimmigrants (3%) and used less postpartum midwifery care.

CONCLUSIONS

When designing health care interventions for immigrant women, not only migration-specific factors should be considered but also low income as a barrier to access to maternity care.

Humanitarian migrant women's experiences of maternity care in Nordic countries: A systematic integrative review of qualitative research

BACKGROUND

Maternal morbidity and sub-optimal maternity care are more common in humanitarian migrants in comparison to country-born population in the Nordic countries. Statistical reviews on the issue are plenty, whereas little synthesis on humanitarian migrants' lived experiences exists.

AIM

This systematic integrative literature review investigated humanitarian migrant women's experiences on maternity care in Nordic countries, aiming to address possible hindrances for optimal care.

METHODS

Electronic search in PubMed, CINAHL, SocIndex, Scopus, PsycINFO and Web of Science yielded 474 papers. PICoS inclusion and exclusion criteria were used. Critical appraisal was conducted utilising 32-item COREQ tool. The findings of the review articles were synthesised through thematic analysis.

FINDINGS

Ten qualitative studies were included in the review. Altogether 198 women in Sweden, Norway and Finland had participated interviews or focus group discussions. Analysis of the women's reported experiences of care emerged three themes: Diminished negotiation power on care, Sense of insecurity, and Experienced care-related discrimination.

KEY CONCLUSION

Humanitarian migrant women's maternal morbidity and sub-optimal care has multiple potential explanations, and their experiences of care reflect those earlier reported.

IMPLICATIONS FOR PRACTICE

Recommendations for tackling the addressed hindrances are: (1) enabling humanitarian migrant women's negotiation power by acknowledging their vulnerability but also competency, (2) increasing the sense of security, and (3) improving care providers' cultural competence.

Perceived discrimination and risk of preterm birth among Turkish immigrant women in Germany

BACKGROUND

Health disparities, including adverse birth outcomes, exist between Turkish immigrants and the autochthonous population in Germany. The state of research on the risk of preterm birth (PTB, defined as <37 weeks of gestation), the leading cause of infant mortality and morbidity, among Turkish immigrant women is mixed. Perceived discrimination is discussed in the context of health disparities related to migration. We examined whether PTB risk is also increased in Turkish immigrant women in Germany and whether perceived discrimination due to origin contributes to this risk.

METHODS

We selected a sample from the German Socio-Economic Panel (SOEP) study of German autochthonous and Turkish immigrant women who recently gave birth (between 2002 and 2016) (N = 2,525, incl. n = 217 Turkish immigrant women of which n = 111 completed an item on perceived discrimination). The included variables of central interest were immigrant status, perceived discrimination, gestational age, and socioeconomic situation.

RESULTS

Logistic regression models indicated that PTB risk was significantly higher for Turkish immigrant women than autochthonous women (OR: 2.75, 95% CI [1.79-4.16]), even when adjusting for socioeconomic status. Within the subsample of Turkish immigrant women, perceived discrimination was related to a significantly higher PTB risk (OR: 4.91, 95% CI [1.76-15.06]).

CONCLUSIONS

Our study provides evidence for a higher PTB risk in Turkish immigrant women compared to autochthonous women in Germany. Perceived discrimination may contribute to this higher risk. The findings represent an important first step towards developing targeted interventions to improve pregnancy and birth outcomes in minority groups.

The influence of migration on women's satisfaction during pregnancy and birth: results of a comparative prospective study with the Migrant Friendly Maternity Care Questionnaire (MFMCQ)

INTRODUCTION

Approximately 21% of Germany's inhabitants have been born abroad or are of direct descent of immigrants. A positive birth experience has an effect on a woman's mental health and her future family planning choices. While international studies showed that immigrant women are less satisfied with their birth experience, no such study has been conducted in Germany until now.

METHODS

At our center of tertiary care in Berlin, with approximately 50% immigrants among patients, pregnant women of at least 18 years of age were offered participation in this study. A modified version of the Migrant Friendly Maternity Care Questionnaire (MFMCQ) designed by Gagnon et al. in German, English, French, Spanish, Arabic and Turkish was used. We compared non-immigrant women to immigrant women and women with direct descent of immigrants. For certain analysis, the latter two groups were included together under the category "migration background".

RESULTS

During the study period, 184 non-immigrant, 214 immigrant women and 62 direct descendants of immigrants were included. The most frequent countries of origin were Syria (19%), Turkey (17%), and Lebanon (9%). We found a slight difference between groups regarding age (non-immigrants: mean 33 years versus women with any migration background: mean 31) as well as parity with more non-immigrants delivering their first child. No difference in the satisfaction with care was observed between immigrant and any migration background groups (p ≥ 0.093 in the two-sided Fisher's exact test). At least 75.8% of all participating women reported complete satisfaction with care during labor, birth and after birth. Interestingly, the level of German language proficiency did not influence the immigrant patient's satisfaction with care.

CONCLUSION

The study results show no difference regarding overall satisfaction with care during labor and birth despite a relevant language barrier. We are for the first time providing the MFMCQ in German and Turkish. Further future analyses on the impact of patient expectations on satisfaction with care will be conducted.

A concept analysis of the term migrant women in the context of pregnancy

Aim

This paper explores the concept of migrant women as used in European healthcare literature in context of pregnancy to provide a clearer understanding of the concept for use in research and service delivery.

Methods

Walker and Avant's method of concept analysis.

Results

The literature demonstrates ambiguity around the concept; most papers do not provide an explicit or detailed definition of the concept. They include the basic idea that women have moved from an identifiable region/country to the country in which the research is undertaken but fail to acknowledge adequately the heterogeneity of migrant women. The paper provides a definition of the concept as a descriptive theory and argues that research must include a clear definition of the migrant specific demographics of the women. This should include country/region of origin and host, status within the legal system of host country, type of migration experience, and length of residence.

Conclusion

There is a need for a more systematic conceptualization of the idea of migrant women within European literature related to pregnancy experiences and outcomes to reflect the heterogeneity of this concept. To this end, the schema suggested in this paper should be adopted in future research.

What is already known about this topic?

There is an increasing concern with the health of pregnant migrant women in Europe.

There is a lack of clear definition of what is meant by the concept migrant women in European literature focusing on pregnancy experience and outcomes.

This ambiguity negatively effects the comparability and so utility of research on this topic.

What this paper adds?

An analysis of the use of the concept migrant women in contemporary European health and social care literature focusing on pregnancy experience and outcomes.

A descriptive theory, which provides the basis for a more nuanced conceptualization of this concept.

A schema based on 4 descriptive aspects surrounding pregnant migrant women, which could provide a useful framework for further empirical research.

The implications of this paper:

The implementation of the theory presented would provide a more nuanced basis for research acknowledging the heterogeneity of migrant experience.

A clearer definition of the characteristics of participants in future studies would improve the comparability of research.

The schema offers a practical tool, which could be adopted by future researchers and/or policymakers.

Mental health problems of second generation children and adolescents with migration background

OBJECTIVE

Despite the growing number of young second-generation immigrant (SGI) children and adolescents, studies about their mental health are rare. The objective of this study was to investigate the mental health problems of SGI children and adolescents in Istanbul, Turkey.

METHODS

In a clinical sample the mental health of 54 SGIs and 50 native children and adolescents were examined using the Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime Version (K-SADS-PL) and Children's Global Assessment Scale. The assessments were carried out by a blinded rater.

RESULTS

SGI children had higher rates of psychiatric disorders such as depression (p = 0.001), post-traumatic stress disorder (PTSD) (p = 0.011) and anxiety disorders (p = 0.013), more comorbid disorders and lower functionality scores compared to their native counterparts (p = 0.001).

CONCLUSIONS

SGI children seem to have higher rates of psychiatric disorders most probably due to migration-induced burdens. The professionals treating SGI children should have more awareness for these problems to be able to approach them in a culture and language sensitive way.

Care-Related and Maternal Risk Factors Associated with the Antenatal Nondetection of Intrauterine Growth Restriction: A Case-Control Study from Bremen, Germany

Objective. To identify care-related and maternal risk factors for the antenatal nondetection of IUGR. Methods. In this hospital-based case-control study we compared antenatally undetected IUGR neonates (cases) to detected IUGR neonates (controls). Data were collected using newborn documentation sheets and standardized personal interviews with the mothers. We calculated antenatal detection rates and used uni- and multivariable logistic regression models to assess the association of antenatal nondetection of IUGR and maternal and care-related factors. Results. A total of 161 neonates from three hospitals were included in the study. Suboptimal fetal growth was identified antenatally in n = 77 pregnancies while in n = 84 it was not detected antenatally (antenatal detection rate: 47.8%). Severity of IUGR, maternal complications, and a Doppler examination during the course of pregnancy were associated with IUGR detection. We did not find statistically significant differences regarding parental socioeconomic status and maternal migration background. Conclusions. In our study, about half of all pregnancies affected by suboptimal growth remained undetected. Future in-depth studies with larger study populations should further examine factors that could increase antenatal detection rates for IUGR.

Differences in the Frequency of Use of Epidural Analgesia between Immigrant Women of Turkish Origin and Non-Immigrant Women in Germany - Explanatory Approaches and Conclusions of a Qualitative Study

Introduction: The starting point of this study was the considerably lower rate of epidural analgesia use among women of Turkish origin in Germany compared to non-immigrant women in the German Research Foundation (DFG)-funded study entitled "Perinatal Health and Migration Berlin". The study aimed to identify possible differences in the women's attitudes towards epidural analgesia. Methods: Exploratory study with semi-structured interviews, interviews lasting 17 minutes on average were conducted with 19 women of Turkish origin and 11 non-immigrant women at a Berlin hospital. The interviews were subjected to a qualitative content analysis. Results: Immigrant women of Turkish origin in Germany more frequently ascribe meaning to the pain associated with vaginal delivery. They more frequently categorically reject the use of epidural analgesia, 1) for fear of long-term complications such as paralysis and back pain and 2) based on the view that vaginal delivery with epidural analgesia is not natural. Information on epidural analgesia is frequently obtained from a variety of sources from their social setting, in particular, by word of mouth. The women in both groups stated that they would take the decision to use epidural analgesia independent of their partner's opinion. Discussion: The differences in epidural analgesia use rates observed correspond to the women's attitudes. For the immigrant women of Turkish origin in Germany, the attitude towards using epidural analgesia is based in part on misinformation. In order to enable the women to make an informed decision, epidural analgesia could receive a stronger focus during childbirth courses.

Maternal mortality and severe morbidity in a migration perspective

Among migrants in high-income countries, maternal mortality and severe morbidity generally occur more frequently as compared to host populations. There is marked variation between groups of migrants and host countries, with much elevated risks in some groups and no elevated risk at all in others. Those without a legal resident permit are most vulnerable. A reason for these elevated risks could be a different risk profile in migrants, but risk factors are unevenly distributed and not always present. Another reason is substandard care, which is identified more frequently in migrants, and comprises patient delays, for example, due to a lack of knowledge about the health system in the host country, and health worker delays, often compounded by communication barriers. Improvements in family planning and antenatal services are needed, and audits and confidential enquiries should be extended to include maternal morbidity and ethnic background. This requires scientific and political efforts.

Care-related factors associated with antepartal diagnosis of intrauterine growth restriction: a case-control study

Background

Antenatal care is of core importance for maternal and child health and is therefore a central aspect of mother and child health care. One of the main goals of effective screening in antenatal care is the detection of suboptimal fetal growth. However, the sensitivity of antenatal diagnostic of suboptimal fetal growth (i.e. intrauterine growth restriction; IUGR) through clinical routine fetal ultrasonography has been observed to be low. A study conducted in Germany found that only 30% of IUGR cases and 40% of congenital malformations were diagnosed antenatally. Reasons for this low detection rate remain unclear.

Methods/Design

In the first of two study components, all mothers who delivered or will deliver a small for gestational age (SGA) newborn in one of three hospitals in Bremen (Germany) during recruitment phase are eligible for inclusion in a hospital based case–control study. Cases are defined as neonates with an IUGR that was not detected antenatally, while controls are defined as neonates whose IUGR was identified or at least suspected antenatally. Data collection instruments include a newborn documentation sheet, a standardized, computer-assisted personal interview with mothers, and a copy of pregnancy record books. The second component is a survey among all private practice-based gynecologists in the federal states of Bremen and Lower Saxony. The aim of this survey was to obtain detailed information e.g. on quality of ultrasonography equipment and examiner’s ultrasonography experience and qualification level.

Discussion

To our knowledge, this is one of the few German studies explicitly addressing care-related as well as maternal-related factors influencing the (non-) detection of IUGR by conducting comprehensive interviews with mothers and private practice-based gynecologists. Over the last 15 years there have been substantial technological advances in ultrasonography equipment in gynecological practices; hence there is the need to evaluate whether the detection rates of IUGR in Germany are still as low as previously reported in the late 1990ies. Our study results will contribute to a better understanding of core risk factors for low early detection rates of intrauterine growth restrictions and may support quality development in this important health care sector.

Disparities in Access to Prenatal Care Services for African Immigrant Women in Spain

This retrospective cohort study compares the utilization of prenatal care between African immigrant and native Spanish women. For 2007-2010, we identified 231 pregnant African immigrant women. The native-born population sample was obtained by simple random sampling in a 1:3 ratio. The Kessner Index (KI) and our Own Index (OI) were applied to rate prenatal care adequacy in three categories (adequate, intermediate, and inadequate). Odds ratios (ORs) were estimated using non-conditional logistic regression. Prenatal care was adequate according to the indexes (KI or OI) in 21.3 and 25.8% of North Africans and in 22.5 and 30.4% of sub-Saharan Africans. The ORs of inadequacy when adjusted for maternal age, social risk factors, and previous reproductive outcomes were 30.32 and 35.47 (KI or OI) in North and 64.43 and 67.93 in sub- Saharan Africans. These results suggest significant differences in obtaining adequate prenatal care between immigrant and native Spanish women.

Comparison of Perinatal Data of Immigrant Women of Turkish Origin and German Women - Results of a Prospective Study in Berlin

Aims: The aim of the study was to compare obstetrical process indicators and outcomes for German women with women of Turkish origin residing in Germany. Do women of Turkish origin attend antenatal examinations as frequently as non-immigrant women? Are high-risk pregnancies and anemia more common among immigrant women? Are the rates for epidural analgesia (PDA) and combined spinal-epidural analgesia (CSE) during delivery the same for immigrant women compared to German women? Are there identifiable differences in the mode of delivery and in perinatal outcomes? Patient Population/Methods: Data were obtained from 3 maternity clinics in Berlin for the period 2011 to 2012. The questionnaires covered socio-demographic factors and information on prenatal care as well as immigration/acculturation. The data obtained from these questionnaires was supplemented by information obtained from the official maternal record of prenatal and natal care (Mutterpass) and perinatal data recorded by the clinic. Results: The response rate was 89.6 %; the data of 1277 women of Turkish origin who had immigrated to Germany or whose family had immigrated and of 2991 non-immigrant women in Germany were included in the study. Regression analysis showed no statistically significant difference in the number of antenatal examinations between immigrant and non-immigrant women. Women of Turkish origin born in Germany had a significantly higher risk of postpartum anemia. PDA/CSE rate, arterial umbilical cord pH and 5-minute Apgar scores did not differ. The incidence of cesarean sections (elective and secondary) was significantly lower in the population of immigrant women of Turkish origin. Conclusion: Outcomes for most perinatal parameters were comparable for immigrant and non-immigrant women. These results indicate that the achieved standards of antenatal care and medical care during pregnancy are similar for Turkish immigrant women compared to non-immigrant women in maternity clinics in Berlin. The higher rates of anemia among immigrant women should be targeted by preventive measures.

Factors associated with lack of adherence to antenatal care in African immigrant women and Spanish women in northern Spain: the role of social risk factors in combination with language proficiency

OBJECTIVE

to examine the association and interaction between language proficiency, social risk factors and lack of adherence to antenatal care in African immigrant women (AIW).

METHODOLOGY

retrospective cohort study. Two hundred and thirty-one AIW with delivery dates from 2007 to 2010 were identified, and data were collected on knowledge of Spanish, referral to a social worker because of social risk factors, and adequacy of antenatal care using the Kessner Index (KI) and the authors' own index (OI). The Spanish-born population sample was obtained by simple random sampling in a 1:3 ratio. Odds ratios (OR) were estimated by non-conditional logistic regression. The term 'language*referral to social worker' was included in the logistic models to study interaction.

FINDINGS

eighty-four per cent of AIW had insufficient knowledge of Spanish, and 47% had been referred to a social worker. Of the AIW who had not been referred to a social worker, the association between poor knowledge of Spanish and inadequate antenatal care was weak and not significant (OR for KI 1.31). On the contrary, of the AIW who had been referred to a social worker, the association was stronger and significant (OR for KI 8.98; p interaction=0.026). Social risk factors were the main independent factors associated with inadequate antenatal care in Spanish women (adjusted OR 3.17; 95% confidence interval 1.42-7.06).

CONCLUSIONS

this study found that the main factor associated with inadequate antenatal care in AIW is insufficient language proficiency, but only in the presence of social risk factors, which have also been associated with worse antenatal care in Spanish women.

Migrant women's utilization of prenatal care: a systematic review

Our objectives were to determine whether migrant women in Western industrialized countries have higher odds of inadequate prenatal care (PNC) compared to receiving-country women and to summarize factors that are associated with inadequate PNC among migrant women in these countries. We conducted searches of electronic databases (MEDLINE, EMBASE, and PsycINFO), reference lists, known experts, and an existing database of the Reproductive Outcomes And Migration international research collaboration for articles published between January, 1995 and April, 2010. Title and abstract review and quality appraisal were conducted independently by 2 reviewers using established criteria, with consensus achieved through discussion. In this systematic review of 29 studies, the majority of studies demonstrated that migrant women were more likely to receive inadequate PNC than receiving-country women, with most reporting moderate to large effect sizes. Rates of inadequate PNC among migrant women varied widely by country of birth. Only three studies explored predictors of inadequate PNC among migrant women. These studies found that inadequate PNC among migrant women was associated with being less than 20 years of age, multiparous, single, having poor or fair language proficiency, education less than 5 years, an unplanned pregnancy, and not having health insurance. We concluded that migrant women as a whole were more likely to have inadequate PNC and the magnitude of this risk differed by country of origin. Few studies addressed predictors of PNC utilization in migrant women and this limits our ability to provide effective PNC in this population.

The social determinants of infant mortality and birth outcomes in Western developed nations: a cross-country systematic review

Infant mortality (IM) and birth outcomes, key population health indicators, have lifelong implications for individuals, and are unequally distributed globally. Even among western industrialized nations, striking cross-country and within-country patterns are evident. We sought to better understand these variations across and within the United States of America (USA) and Western Europe (WE), by conceptualizing a social determinants of IM/birth outcomes framework, and systematically reviewing the empirical literature on hypothesized social determinants (e.g., social policies, neighbourhood deprivation, individual socioeconomic status (SES)) and intermediary determinants (e.g., health behaviours). To date, the evidence suggests that income inequality and social policies (e.g., maternal leave policies) may help to explain cross-country variations in IM/birth outcomes. Within countries, the evidence also supports neighbourhood SES (USA, WE) and income inequality (USA) as social determinants. By contrast, within-country social cohesion/social capital has been underexplored. At the individual level, mixed associations have been found between individual SES, race/ethnicity, and selected intermediary factors (e.g., psychosocial factors) with IM/birth outcomes. Meanwhile, this review identifies several methodological gaps, including the underuse of prospective designs and the presence of residual confounding in a number of studies. Ultimately, addressing such gaps including through novel approaches to strengthen causal inference and implementing both health and non-health policies may reduce inequities in IM/birth outcomes across the western developed world.

Obstetric outcome of ethnic Turkish women in London: a retrospective case-control study

There is concern that the maternal mortality in ethnic minority women is significantly greater than that of Caucasian British women. The objective of this study was to compare the demographic and obstetric outcomes between these two groups. Data were collected retrospectively over a 2-year period from 148 index and 148 control cases. The study group had statistically similar maternal age, labour duration, blood loss and mode of delivery compared with Caucasian British women (p > 0.05). A total of 68% of Turkish women spoke little or no English; were more likely to be non-smokers and also more likely to be married to unemployed spouses (p = 0.0001). This is the first study comparing obstetric outcomes of immigrant Turkish women with their Caucasian British counterparts. There was no significant difference in maternal or fetal outcomes, which could be attributed to the 'healthy migrant' theory, coupled with increased vigilance in ethnic minority pregnancies.

Migration and maternity: insights of context, health policy, and research evidence on experiences and outcomes from a three country preliminary study across Germany, Canada, and the United kingdom

A group from Germany, Canada, and the United Kingdom undertook country-specific scoping reviews and stakeholder consultations before joining to holistically compare migration and maternity in all three countries. We examined four interlinking dimensions to understand how international migrant/minority maternal health might be improved upon using transnational research: (a) wider sociopolitical context, (b) health policy arena, (c) constellation, outcomes, and experiences of maternity services, and (d) existing research contexts. There was clear evidence that the constellation and delivery of services may undermine good experiences and outcomes. Interventions to improve access and quality of care remain small scale, short term, and lacking in rigorous evaluation.

Migration and health in an increasingly diverse Europe

The share of migrants in European populations is substantial and growing, despite a slowdown in immigration after the global economic crisis. This paper describes key aspects of migration and health in Europe, including the scale of international migration, available data for migrant health, barriers to accessing health services, ways of improving health service provision to migrants, and migrant health policies that have been adopted across Europe. Improvement of migrant health and provision of access for migrants to appropriate health services is not without challenges, but knowledge about what steps need to be taken to achieve these aims is increasing.

The Brazilian preference: cesarean delivery among immigrants in Portugal

Objective

To evaluate how the country of origin affects the probability of being delivered by cesarean section when giving birth at public Portuguese hospitals.

Study Design

Women delivered of a singleton birth (n = 8228), recruited from five public level III maternities (April 2005–August 2006) during the procedure of assembling a birth cohort, were classified according to the country of origin and her migration status as Portuguese (n = 7908), non-Portuguese European (n = 84), African (n = 77) and Brazilian (n = 159). A Poisson model was used to evaluate the association between country of birth and cesarean section that was measured by adjusted prevalence ratio (PR) and respective 95% confidence intervals (95%CI).

Results

The cesarean section rate varied from 32.1% in non-Portuguese European to 48.4% in Brazilian women (p = 0.008). After adjustment for potential confounders and compared to Portuguese women as a reference, Brazilian women presented significantly higher prevalence of cesarean section (PR = 1.26; 95%CI: 1.08–1.47). The effect was more evident among multiparous women (PR = 1.39; 95%CI: 1.12–1.73) and it was observed when cesarean section was performed either before labor (PR = 1.43; 95%CI: 0.99–2.06) or during labor (PR = 1.30; 95%CI: 1.07–1.58).

Conclusions

The rate of cesarean section was significantly higher among Brazilian women and it was independent of the presence of any known risk factors or usual clinical indications, suggesting that cultural background influences the mode of delivery overcoming the expected standard of care and outcomes in public health services.

Ethnic disparities: Genetics vs (social) environment

To define “ethnicity” in the context of perinatal care is a tough job. The word makes us think: “racial, social, cultural, national…”. An ethnic group is generally considered a group of people with a common history, usually (but not always) a common religion and language, sharing aspects of culture such as nutrition and traditions concerning pregnancy, childbirth, the way they care for children. As procreation occurs mostly in-group, every ethnic group will demonstrate a higher prevalence of, more or less well-known, genes and their connected diseases. For some populations, such as Ashkenazi Jewish people, the prevalence and associated risks of these autosomal diseases are well known, as in the case of “Jewish genetic disease”, and specific screening programs are available.

Cesarean section rate differences by migration indicators

PURPOSE

To answer the question: are there differences in cesarean section rates among childbearing women in Canada according to selected migration indicators?

METHODS

Secondary analyses of 3,500 low-risk women who had given birth between January 2003 and April 2004 in one of ten hospitals in the major Canadian migrant-receiving cities (Montreal, Toronto, Vancouver) were conducted. Women were categorized as non-refugee immigrant, asylum seeker, refugee, or Canadian-born and by source country world region. Stratified analyses were performed.

RESULTS

Cesarean section rates differed by migration status for women from two source regions: South East and Central Asia (non-refugee immigrants 26.0 %, asylum seekers 28.6 %, refugees 56.7 %, p = 0.001) and Latin America (non-refugee immigrants 37.7 %, asylum seekers 25.6 %, refugees 10.5 %, p = 0.05). Of these, low-risk refugee women who had migrated to Canada from South East and Central Asia experienced excess cesarean sections, while refugees from Latin America experienced fewer, compared to Canadian-born (25.4 %, 95 % CI 23.8-27.3). Cesarean section rates of African women were consistently high (31-33 %) irrespective of their migration status but were not statistically different from Canadian-born women. Although it did not reach statistical significance, risk for cesarean sections also differed by time since migration (≤2 years 29.8 %, >2 years 47.2 %).

CONCLUSION

Migration status, source region, and time since migration are informative migration indicators for cesarean section risk.

Socio-demographic and obstetrical correlates of pre-pregnancy body mass index and gestational weight gain

Both pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) are important determinants of a healthy pregnancy outcome and may show important variation. To study the influence of socio-demographic and obstetrical correlates on pre-pregnancy BMI and GWG, data of 54 022 singleton term pregnancies were analysed using adjusted regression models. In 2009, in the Northern region of Belgium, one-third of women were overweight (21.6%) or obese (10.1%) and GWG as recommended by the Institute of Medicine occurred in only 28% of obese women. A high pre-pregnancy BMI was significantly associated with low maternal education, high maternal age and multiparity, belonging to ethnic minority groups and a lower professional state. Compared to adequate GWG, excessive GWG was more common in younger (<20 years) women, with higher pre-pregnancy BMI and pregnancy-induced hypertension. Moreover, younger (20-24 years), single women, belonging to ethnic minority groups showed higher odds for excessive as well as insufficient GWG, while those with high/highest educational level had lower odds for excessive (odds ratio [OR] 0.76; confidence interval [CI] 0.72-0.80) and insufficient (OR 0.93; CI 0.89-0.98) GWG. The results of this study highlight the scale of the problem of maternal obesity and excessive GWG for this region and offer opportunities to target educational campaigns and intervention programmes in the clinical setting.

Ethnic differences in the use of intrapartum epidural analgesia

Background

Obstetric epidural analgesia (EA) is widely applied, but studies have reported that its use may be less extensive among immigrant women or those from minority ethnic groups. Our aim was to examine whether this was the case in our geographic area, which contains an important immigrant population, and if so, to describe the different components of this phenomenon.

Methods

Cross-sectional observational study. Setting: general acute care hospital, located in Marbella, southern Spain. Analysis of computer records of deliveries performed from 2004 to 2010. Comparison of characteristics of deliveries according to the mothers’ geographic origins and of vaginal deliveries noting whether EA was received, using univariate and bivariate statistical analysis and multiple logistic regression (MLR).

Results

A total of 21,034 deliveries were recorded, and 37.4% of these corresponded to immigrant women. EA was provided to 61.1% of the Spanish women and to 51.5% of the immigrants, with important variations according to geographic origin: over 52% of women from other European countries and South America received EA, compared with around 45% of the African women and 37% of the Asian women. These differences persisted in the MLR model after adjusting for the mother's age, type of labor initiation, the weight of the neonate and for single or multiple gestation. With the Spanish patients as the reference category, all the other countries of origin presented lower probabilities of EA use. This was particularly apparent for the patients from Asia (OR 0.38; 95%CI 0.31-0.46), Morocco (OR 0.49; 95%CI 0.43-0.54) and other Africa (OR 0.55; 95%CI 0.37-0.81).

Conclusions

We observed a different use of EA in vaginal deliveries, according to the geographic origin of the women. The explanation for this involves a complex set of factors, depending both on the patient and on the healthcare staff.

Risk factors associated with epidural use

Background

Identify variables associated with intrapartum epidural use.

Methods

Odds ratios were calculated to quantify associations between selected variables and epidural use using a population-based case-control study of Washington State birth certificate data from 2009.

Results

Non-Whites had 10 - 45% lower odds of epidural use relative to Whites. Foreign-born women had 25 - 45% lower odds of epidural use compared to their US-born counterparts, except for Asians. Women who smoked or induced labor had higher roughly 2-fold higher odds of epidural use compared with non-smokers or women giving birth spontaneously, respectively. Women without a high school diploma or equivalent had lower odds of epidural use relative to those who graduated. Delivering at perinatal units, rural hospitals, or non-profit hospitals had ~50% lower odds of epidural use compared with secondary/teritiary perinatal units, urban hospitals or for-profit hospitals, respectively. 

Conclusion

Several individual and health service-related variables were associated with epidural use. These findings elucidate the clinical relevance of epidural use, and dispariaties in its utilization and in quality of care during delivery.

Keywords

Epidural use; Foreign birth; Labor; Racial disparities

Stillbirth differences according to regions of origin: an analysis of the German perinatal database, 2004-2007

BACKGROUND

Stillbirth is a sensitive indicator for access to, and quality of health care and social services in a society. If a particular population group e.g. migrants experiences higher rates of stillbirth, this might be an indication of social deprivation or barriers to health care. This study examines differences in risk of stillbirth for women of different regions of origin compared to women from Germany in order to identify high risk groups/target groups for prevention strategies.

METHODS

We used the BQS dataset routinely compiled to examine perinatal outcomes in Germany nationwide. Participation of hospitals and completeness of data has been about 98% in recent years. Data on all live births and stillbirths were obtained for the period 2004 to 2007 (N = 2,670,048). We calculated crude and stratified mortality rates as well as corresponding relative mortality risks.

RESULTS

A significantly elevated stillbirth rate was found for women from the Middle East and North Africa (incl. Turkey) (RR 1.34, CI 1.22-1.55). The risk was slightly attenuated for low SES. An elevated risk was also found for women from Asia (RR 1.18, CI 1.02-1.65) and from Mediterranean countries (RR 1.14, CI 0.93-1.28). No considerable differences either in use and timing of antenatal care or preterm birth and low birthweight were observed between migrant and non-migrant women. After stratification for light for gestational age, the relative risk of stillbirth for women from the Middle East/North Africa increased to 1.63 (95% CI 1.25-2.13). When adjusted for preterm births with low birthweight, women from Eastern Europe and the Middle East/North Africa experienced a 26% (43%) higher risk compared with women from Germany.

CONCLUSIONS

We found differences in risk of stillbirth among women from Middle East/North Africa, especially in association with low SES and low birthweight for gestational age. Our findings suggest a need for developing and evaluating socially and culturally sensitive health promotion and prevention programmes for this group. The findings should also stimulate discussion about the quality and appropriateness of antenatal and perinatal care of pregnant women and newborns with migrant backgrounds.

Pregnancy outcome of migrant women delivering in a public institution in northern Italy

BACKGROUND/AIM

European societies are facing a wave of incoming immigrants and the needs of a new multiethnic obstetrical population. It remains controversial whether native and immigrant women have equivalent pregnancy outcomes.

METHODS

Perinatal indicators of the obstetric outcome were monitored in all delivering women during a 5-year period in a large academic public general hospital. We compared rates of preterm deliveries, low birth weight, cesarean section during labor, perineal tears, and fetal acidemia in the native and immigrant parturients.

RESULTS

Immigrant women experienced very low birth weight (p < 0.005) and preterm deliveries (p < 0.05), more often than natives did. Among ethnic groups, data singled out Sub-Saharan African women to be at a higher risk for very small premature babies and cesarean section during labor.

CONCLUSIONS

There are differences in perinatal outcome between immigrant and Italian woman; within the large migrant population, ethnic groups show wide disparities and challenge the health provider differently. Special attention to women at a higher risk may reduce fetal-maternal morbidities.

Ethnic variations in mortality in pre-school children in Denmark, 1973-2004

The objective of the study was to describe ethnic differences in under-five-years mortality in Denmark according to maternal country of origin. We conducted a large registry-linkage study of all singleton live-born children from mothers born in Denmark and from the ten largest migrant groups (n = 1,841,450). Study outcomes were death before the age of 5 years from all causes combined and the most frequent death causes. Results showed that children of mothers of Turkish, Pakistani, Somali and Iraqi origin had an elevated risk of dying before the age of five compared to offspring of mothers born in Denmark, with hazards ratios and 95% confidence intervals of 1.48 (1.31-1.67), 1.97 (1.68-2.32), 1.70 (1.29-2.25), and 1.92 (1.41-2.62), respectively. Ethnic differences were also observed in the underlying causes of death. Children of mothers born in Former Yugoslavia, Lebanon, Norway, Sweden, Iran, and Afghanistan did not differ in under-five-years mortality from ethnic Danish children. Adjustments for household income did not attenuate the risk estimates. In conclusion, we found excess child mortality in some migrant groups, but not in all. The differences could not be explained by socioeconomic status.

Perinatal outcomes among immigrant mothers over two periods in a region of central Italy

Background

The number of immigrants has increased in Italy in the last twenty years (7.2% of the Italian population), as have infants of foreign-born parents, but scanty evidence on perinatal outcomes is available. The aim of this study was to investigate whether infants of foreign-born mothers living in Italy have different odds of adverse perinatal outcomes compared to those of native-born mothers, and if such measures changed over two periods.

Methods

The source of this area-based study was the regional hospital discharge database that records perinatal information on all births in the Lazio region. We analysed 296,739 singleton births born between 1996-1998 and 2006-2008. The exposure variable was the mother's region of birth. We considered five outcomes of perinatal health. We estimated crude and adjusted odds ratios and 95% confidence intervals (CIs) to evaluate the association between mother's region of birth and perinatal outcomes.

Results

Perinatal outcomes were worse among infants of immigrant compared to Italian mothers, especially for sub-Saharan and west Africans, with the following crude ORs (in 1996-1998 and 2006-2008 respectively): 1.80 (95%CI:1.44-2.28) and 1.95 (95%CI:1.72-2.21) for very preterm births, and 1.32 (95%CI:1.16-1.50) and 1.32 (95%CI:1.25-1.39) for preterm births; 1.18 (95%CI:0.99-1.40) and 1.17 (95%CI:1.03-1.34) for a low Apgar score; 1.22 (95%CI:1.15-1.31) and 1.24 (95%CI:1.17-1.32) for the presence of respiratory diseases; 1.47 (95%CI:1.30-1.66) and 1.45 (95%CI:1.34-1.57) for the need for special or intensive neonatal care/in-hospital deaths; and 1.03 (95%CI:0.93-1.15) and 1.07 (95%CI:1.00-1.15) for congenital malformations. Overall, time did not affect the odds of outcomes differently between immigrant and Italian mothers and most outcomes improved over time among all infants. None of the risk factors considered confounded the associations.

Conclusion

Our findings suggest that migrant status is a risk factor for adverse perinatal health. Moreover, they suggest that perinatal outcomes improved over time in some immigrant women. This could be due to a general improvement in immigrants' health in the past decade, or it may indicate successful application of policies that increase accessibility to mother-child health services during the periconception and prenatal periods for legal and illegal immigrant women in Italy.

Does immigration background influence outcomes after renal transplantation?

Migration implies differences in lifestyle, dietary and health behavior practice, and adherence, all of which are relevant factors in terms of disease outcome. However, renal transplantation in immigrant groups has been rarely studied in Europe. We have investigated the effect of immigration on outcomes in all children who underwent renal transplantation (RTx) at the Medical University of Vienna. From 1978 to 2007, 196 children underwent 236 RTx. In comparison to native recipients, immigrant recipients (31 boys, 17 girls) tended to be younger and male, with a higher rate of congenital renal diseases. The percentage of adolescent immigrant recipients tended to be lower, and living donation tended to be higher. In both the immigrant and native groups, RTx outcomes at 1, 5, and 10 years, including acute rejection rate (34 vs. 44, 55 vs. 62, 74 vs. 78%, respectively) and patient (98 vs. 92, 88 vs. 91, 80 vs. 82%, respectively) and graft survival (83 vs. 82, 79 vs. 65, 66 vs. 51%, respectively) were similar. All outcomes improved over time. In conclusion, this study demonstrates that outcomes in RTx are equivalent in immigrants and native recipients. Potential barriers to success among the Austrian immigrant recipient population may have been overcome by protective factors. These results should serve as a catalyst to retrieve data from larger databases to verify these single-center results.