Cesarean section rate differences by migration indicators

Cesarean birth rates among migrants in Europe: A systematic review

BACKGROUND

Cesarean birth (CB) rates have increased over recent years with concerns over differences between these rates in migrant communities compared with the rates among women in their receiving country. This review aimed at summarizing the available literature regarding the incidence of CB among migrants in Europe.

METHODS

A systematic search of four electronic databases was carried out, including CINAHL, MEDLINE, Scopus, and Maternity and Infant Care. Identified studies were screened and their quality assessed. Meta-analysis was undertaken using Rev Man 5.4 where sufficient data were available. Otherwise, data were synthesized narratively.

RESULTS

From the 435 records identified in searches, 21 papers were included. Analysis shows that overall CB rates were significantly lower for Syrian refugee women compared with women in their receiving country (Turkey) and higher for Iranian migrants than women in their host country. Emergency CB rates were significantly higher for migrant women from "Sub Saharan Africa" and the "South East Asia, Asia and Pacific" region than rates in the receiving country. Statistical significance was not found between other populations.

CONCLUSIONS

This review highlights differences between CB rates in certain migrant groups in comparison with women native to their host country, which merits further investigation for potential explanations. We also identified a need to standardize definitions and population groupings to enable more meaningful analysis. This review also highlights a substantial lack of data on CB rates between different population groups that could negatively impact the provision of care.

[Relevance of the transcultural approach to improve the care relationship in the perinatal period]

The international literature review highlights higher neonatal morbimortality in migrant patients and their babies. The explanatory hypotheses include late pregnancy follow-up with difficulty accessing care, language barriers, and different cultural representation in pregnancy support. On the one hand, we propose to explain the cultural factors that can impact the caring relationship during the perinatal period. On the other hand, we set out tools for anthropological and psychological understanding to enhance the sharing of cultural representations around pregnancy follow-up, the needs of a baby, and obstetrical or postnatal complications. The request for a specialised transcultural opinion needs to be more systematic; the transcultural posture is adaptable to each care professional. This requires the professional to address explicitly the impact of culture in care and consider their own cultural distance. Specialised advice is recommended in certain situations of cumulative vulnerability (complex trauma, perinatal depression with cultural coding of symptoms), blockage or refusal of care for cultural reasons and to avoid cultural misunderstandings. We detail two modalities: mediation and a discussion group around cultural issues set up in the maternity ward. The institutional work we propose within the multidisciplinary team in the maternity ward also allows the acquisition of transcultural competencies.

Weight of Evidence: Participatory Methods and Bayesian Updating to Contextualize Evidence Synthesis in Stakeholders' Knowledge

Mixed methods research is well-suited to grapple with questions of what counts as valid knowledge across different contexts and perspectives. This article introduces Weight of Evidence as a transformative procedure for stakeholders to interpret, expand on and prioritize evidence from evidence syntheses, with a focus on engaging populations historically excluded from planning and decision making. This article presents the procedure's five steps using pilot data on perinatal care of immigrant women in Canada, engaging family physicians and birth companions. Fuzzy cognitive mapping offers an accessible and systematic way to generate priors to update published literature with stakeholder priorities. Weight of Evidence is a transparent procedure to broaden what counts as expertise, contributing to a more comprehensive, context-specific, and actionable understanding.

Adverse Pregnancy Outcomes and International Immigration Status: A Systematic Review and Meta-analysis

Background:

Disparities in health outcomes between immigrant and native-origin populations, particularly pregnant women, pose significant challenges to healthcare systems. The aim of this systematic-review and meta-analysis was to investigate the risk of adverse pregnancy outcomes among immigrant-women compared to native-origin women in the host country.

Methods:

PubMed (including MEDLINE), Scopus, and Web of Science were searched to retrieve studies published in English language up to September 2020. All observational studies examining the prevalence of at least one of the short-term single pregnancy outcomes for immigrants who crossed international borders compared to native-origin pregnant population were included. The meta-prop method was used for the pooled-estimation of adverse pregnancy-outcomes’ prevalence. For pool-effect estimates, the association between the immigration-status and outcomes of interest, the random-effects model was applied using the model described by DerSimonian and Laird. I² statistic was used to assess heterogeneity. The publication bias was assessed using the Harbord-test. Meta-regression was performed to explore the effect of geographical region as the heterogeneity source.

Findings:

This review involved 11 320 674 pregnant women with an immigration-background and 56 102 698 pregnant women as the native-origin population. The risk of emergency cesarean section (Pooled-OR = 1.1, 95%CI = 1.0–1.2), shoulder dystocia (Pooled-OR = 1.1, 95%CI = 1.0–1.3), gestational diabetes mellites (Pooled-OR = 1.4, 95%CI = 1.2–1.6), small for gestational age (Pooled-OR=1.3, 95%CI = 1.1–0.4), 5-min Apgar less than 7 (Pooled-OR = 1.2, 95%CI = 1.0–1.3) and oligohydramnios (Pooled-OR = 1.8, 95%CI = 1.0–3.3) in the immigrant women were significantly higher than those with the native origin background. The immigrant women had a lower risk of labor induction (Pooled-OR = 0.8, 95%CI = 0.7–0.8), pregnancy induced hypertension (Pooled-OR = 0.6, 95%CI = 0.5–0.7) preeclampsia (Pooled-OR = 0.7, 95%CI = 0.6–0.8), macrosomia (Pooled-OR = 0.8, 95%CI = 0.7–0.9) and large for gestational age (Pooled-OR = 0.8, 95%CI = 0.7–0.8). Also, the risk of total and primary cesarean section, instrumental-delivery, preterm-birth, and birth-trauma were similar in both groups. According to meta-regression analyses, the reported ORs were not influenced by the country of origin.

Conclusion:

The relationship between the immigration status and adverse perinatal outcomes indicated a heterogenous pattern, but the immigrant women were at an increased risk of some important adverse pregnancy outcomes. Population-based studies with a focus on the various aspects of this phenomena are required to explain the source of these heterogenicities.

The Inconsistency Between Women's Preference and Actual Mode of Delivery in China: Findings From a Prospective Cohort Study

Background

Previous studies have found that the rates of cesarean preference were much lower than the actual rates of cesarean births in China. We aimed to observe this inconsistency between preferred and actual modes of delivery and the factors associated with the inconsistency.

Methods

We conducted a prospective cohort study at the maternity hospital with the largest number of deliveries in Beijing. We collected data through a questionnaire applied in the outpatient department, and medical records from the hospital's information system. Unconditional logistic regression was used to identify factors influencing the inconsistency between preferred and actual delivery mode.

Results

The rates of actual cesarean section and of cesarean preference were 41 and 17%, respectively (χ2 = 82.9, P < 0.0001). The overall inconsistency rate was 31%, with 119 women preferred vaginal delivery but experienced cesarean section, accounting for 67% women undergoing cesarean section. Risk factors for this inconsistency between preferred vaginal delivery and actual cesarean section included: maternal obesity, receiving assisted reproduction, having an abnormal amniotic fluid volume, and fetal distress. Pre-labor rupture of membranes was a unique factor associated with such inconsistency between cesarean section preference and vaginal delivery at delivery.

Conclusions

The inconsistent rate between preferred delivery at late pregnancy and actual delivery is high in China. Further research is needed to understand how to lower cesarean rates in China, taking maternal preferences for vaginal deliveries into account.

Impact of maternal nationality on caesarean section rate variation in a high-income country

BACKGROUND

Caesarean section (CS) rates have been reported to differ between immigrants and native-born women in high-income countries.

OBJECTIVE

We assessed the CS rate and its relationship with the CS rate in country of nationality and other explanatory factors among women of different nationalities including Qatari women who underwent deliveries at our hospital to generate evidence that will quantify and help explain the observed CS rates in our hospital.

METHODS

In this retrospective cross-sectional study conducted at the second-largest public maternity hospital in Qatar, Al-Wakra Hospital (AWH), data for all births delivered in 2019 were retrieved from the hospital's electronic medical records. The CS rates and the crude and adjusted risks of Caesarean delivery for mothers from each nationality were determined, and the common indications for CS were analyzed based on nationality. The association between nationality and Caesarean delivery was examined using binomial logistic regression analysis, with Qatari women as the reference group. The correlation between CS rate in country of nationality and observed CS rates in Qatar was also examined using Pearson's correlation.

RESULTS

The study population consisted of 4816 births by women of 68 nationalities, of which 4513 births were by women from 25 countries. The highest proportion of deliveries (n-1247, 25.9%) was by Indian women. The frequency of CS was the highest and lowest among Egyptian (49.6%) and Yemeni women (17.9%), respectively. Elective CS was predominantly performed in women of Arab nationalities; the most common indication was a history of previous multiple CSs. Emergency CS was primarily performed in women of Asian and Sub-Saharan African nationalities; the most common indications were failure to progress and fetal distress. For most nationalities, the CS rate in Qatar was associated with those of the countries of nationality.

CONCLUSIONS

The observed CS rates varied widely among women of different nationalities. The variation was influenced by maternal factors and medical indications as well as the CS rates in the country of nationality. We posit that cultural preferences, acculturation, and patient expectations influenced observed findings. More efforts are required to reduce primary CS rates and to help women make the most informed decisions regarding modes of delivery. Key Message: CS rates varied widely among women of different nationalities. The variation was influenced by medical indications, maternal preferences, and CS rate in countries of nationality. The solution to reducing CS rates should be a culturally informed response.

Immigration and Adverse Pregnancy Outcomes in an Italian Free Care Hospital

Introduction

The ever-increasing wave of immigration in Italy has posed demanding challenges in the management of the new multiethnic obstetric population. The aim of this study was to compare pregnancy and perinatal outcomes between immigrants and the native population in an Italian public hospital.

Materials and Methods

Singleton pregnant women (≥ 24 weeks of gestation) who delivered during a 3-year period in an Italian free care hospital were included. Long-term (≥ 2 years of residence) immigrant patients were divided into 4 groups according to their ethnic origin: Europeans, Asians, Latin Americans, and Africans. Perinatal indicators of obstetric outcomes were collected and compared between immigrants and Italians.

Results

Of the 3556 patients included, 1092 were immigrants and 2464 Italians. The immigrant cohort experienced a higher rate of macrosomia (1.8% vs 0.6%; p = 0.001), very low birth weight (1.3% vs 0.6%; p = 0.048), very early preterm delivery (1.4% vs 0.4%; p = 0.048), and gestational diabetes mellitus (1.8% vs 0.5%; p = 003) compared with the native population. The overall rate of cesarean sections was greater among Italians (56% vs 45.8%; p < 0.001). Among ethnic groups, Europeans and Latin Americans reported a higher rate of preterm delivery (20.2% and 19%, respectively; p < 0.001). Latin Americans carried also a greater risk of fetal macrosomia (3.6%; p < 0.008), while the rate of very low birth weight was higher among Europeans and Africans (2% and 1.8%, respectively; p < 0.04).

Conclusion

Obstetricians should pay special attention to the potential disparities in pregnancy outcomes between immigrants and the native population. Future efforts should focus on reducing preterm delivery and glucose dysmetabolism among pregnant immigrants.

Cesarean Deliveries Among Immigrant and Canadian-Born Women in a Representative Community Population in Canada: A Retrospective Cohort Study

OBJECTIVE

To examine differences in the rate of cesarean delivery between Canadian-born women and immigrants to Canada and by duration of time in Canada and rate of cesarean delivery in their country-of-origin.

METHODS

We used linked data from hospitalization records and the Canadian Community Health Survey for all deliveries after 20 weeks gestation between 2002 and 2017 in Canada (excluding Québec). Odds of cesarean delivery in recent immigrants (<5 y in Canada) and non-recent immigrants (≥5 y in Canada) were compared with those of Canadian-born women using multivariable logistic regression. Immigrants were further categorized using the cesarean delivery rate in their country-of-origin as low (<10%), medium (≥10 to <35%), or high (≥35%).

RESULTS

Of the 53 505 women included, 89% were Canadian-born, 4% were recent immigrants and 7% were non-recent immigrants. Overall, 28.6% of women had a cesarean delivery. After adjusting for medical and socio-economic factors, the odds of cesarean delivery among recent immigrants (OR 1.12; 95% CI 0.95-1.34) and non-recent immigrants (OR 1.11; 95% CI 0.98-1.25) did not differ statistically from those of Canadian-born women. Recent immigrants from countries with lower caesarean delivery rates had higher odds of cesarean delivery (OR 1.34; 95% CI 1.05-1.70), whereas the odds of caesarean for recent immigrants from medium- and high-rate countries did not differ from those of Canadian-born women.

CONCLUSION

After accounting for demographic and medical factors, few differences remained in cesarean delivery rates between immigrants and Canadian-born women. Country-of-origin practices are unlikely to reflect preferences for cesarean delivery in immigrant women in Canada.

Caesarean delivery in a migration context: the role of prior delivery in the host country

Migrant women in industrialised countries experience high caesarean section (CS) rates but little is known about the effect of a previous delivery in the host country. This study set out to investigate this effect among migrant women in France, using data from the DSAFHIR study on healthcare access of migrant women living in emergency housing hotels, collected in the Paris Metropolitan area in 2017. Respondents reported life-long history of deliveries. We focused on deliveries occurring in France in 2000–2017: 370 deliveries reported by 242 respondents. We conducted chi-square tests and multivariate logistic regressions, adjusting for the clustering of deliveries among respondents by computing standard errors allowing for intragroup correlation. Mode of delivery was associated with duration of residence among multiparous women with no prior CS, with a higher CS rate with shorter duration of residence (16% vs. 7%, p = 0.04). In this group, a previous delivery in France was associated with a lower CS rate (5% vs. 16%, p = 0.008). In multivariate analysis, compared with women with previous birth in France, women giving birth in France for the first time had a higher risk of CS, regardless of duration of residence (aOR = 4.0, 95% CI = 1.3–12.1 for respondents with short duration of residence, aOR = 4.7, 95% CI = 1.2–18.0 for respondents with longer duration of residence). Efforts directed at decreasing the CS rate among migrant women should target women giving birth in the host country for the first time.

Evaluating Birth Outcomes From a Community-Based Pregnancy Support Program for Refugee Women in Georgia

Refugee women face numerous and unique barriers to sexual and reproductive healthcare and can experience worse pregnancy-related outcomes compared with U.S.-born and other immigrant women. Community-based, culturally tailored programs like Embrace Refugee Birth Support may improve refugee access to healthcare and health outcomes, but empirical study is needed to evaluate programmatic benefits. This community-engaged research study is led by the Georgia Doula Access Working Group, including a partnership between academic researchers, Emory Decatur Hospital nurses, and Embrace. We analyzed hospital clinical records (N = 9,136) from 2016 to 2018 to assess pregnancy-related outcomes of Embrace participants (n = 113) and a comparison group of women from the same community and racial/ethnic backgrounds (n = 9,023). We controlled for race, language, maternal age, parity, insurance status, preeclampsia, and diabetes. Embrace participation was significantly associated with 48% lower odds of labor induction (OR = 0.52, p = 0.025) and 65% higher odds of exclusive breastfeeding intentions (OR = 1.65, p = 0.028). Embrace showed positive but non-significant trends for reduced cesarean delivery (OR = 0.83, p = 0.411), higher full-term gestational age (OR = 1.49, p = 0.329), and reduced low birthweight (OR = 0.77, p = 0.55). We conclude that community-based, culturally tailored pregnancy support programs like Embrace can meet the complex needs of refugee women. Additionally, community-engaged, cross-sector research approaches could ensure the inclusion of both community and clinical perspectives in research design, implementation, and dissemination.

Association between Maternal Origin, Pre-Pregnancy Body Mass Index and Caesarean Section: A Nation-Wide Registry Study

Aims: To explore the association between maternal origin and birthplace, and caesarean section (CS) by pre-pregnancy body mass index (BMI) and length of residence. Methods: We linked records from 118,459 primiparous women in the Medical Birth Registry of Norway between 2013 and 2017 with data from the National Population Register. We categorized pre-pregnancy BMI (kg/m²) into underweight (<18.5), normal weight (18.5–24.9) and overweight/obese (≥25). Multinomial regression analysis estimated crude and adjusted relative risk ratios (RRR) with 95% confidence intervals (CI) for emergency and elective CS. Results: Compared to normal weight women from Norway, women from Sub-Saharan Africa and Southeast Asia/Pacific had a decreased risk of elective CS (aRRR = 0.57, 95% CI 0.37–0.87 and aRRR = 0.56, 0.41–0.77, respectively). Overweight/obese women from Europe/Central Asia had the highest risk of elective CS (aRRR = 1.42, 1.09–1.86). Both normal weight and overweight/obese Sub-Saharan African women had the highest risks of emergency CS (aRRR = 2.61, 2.28-2.99; 2.18, 1.81-2.63, respectively). Compared to women from high-income countries, the risk of elective CS was increasing with a longer length of residence among European/Central Asian women. Newly arrived migrants from Sub-Saharan Africa had the highest risk of emergency CS. Conclusion: Women from Sub-Saharan Africa had more than two times the risk of emergency CS compared to women originating from Norway, regardless of pre-pregnancy BMI.

The risk factors and care measures of surgical site infection after cesarean section in China: a retrospective analysis

BACKGROUND

Surgical site infections after cesarean section are very common clinically, it is necessary to evaluate the risk factors of surgical site infections after cesarean section, to provide evidences for the treatment and nursing care of cesarean section.

METHODS

This study was a retrospective cohort study design. Patients undergone cesarean section in a tertiary hospital of China from May 2017 to May 2020 were identified, we collected the clinical data of the included patients, and we analyzed the infection rate, etiological characteristics and related risk factors of surgical site infection after caesarean section.

RESULTS

A total of 206 patients with cesarean section were included, and the incidence of surgical site infection in patients with cesarean section was 23.30%. A total of 62 cases of pathogens were identified, Enterococcus faecalis (33.87%) and Escherichia coli (29.03%) were the most common pathogens. Both Enterococcus faecalis and Escherichia coli were highly sensitive to Cefoperazone, Meropenem, and Levofloxacin. Logistic regression analyses indicated that Age ≥ 30y (OR 4.18, 95%CI: 1.23-7.09), BMI ≥ 24 (OR 2.39, 95%CI: 1.02-4.55), duration of cesarean section ≥ 1.5 h (OR 3.90, 95%CI: 1.28-5.42), estimated blood loss ≥ 400 ml (OR 2.35, 95%CI: 1.10-4.37) and the duration of urinary catheter ≥ 24 h (OR 3.18, 95% CI: 1.21-5.71) were the independent risk factors of surgical site infection after cesarean section (all p < 0.05).

CONCLUSIONS

Age, BMI, duration of surgery, blood loss and urinary catheter use were associated with higher risk of the surgical site infection after cesarean section. Clinical preventions and interventions are warranted for those population to reduce the occurrence of surgical site infection.

Association between migration status and caesarean section delivery based on a modified Robson classification in China

Background

China has one of the highest caesarean section (C-Section) rates in the world. In recent years, China has been experiencing a massive flow of migration due to rapid urbanization. In this study, we aimed to differentiate the rates of C-Section between migrants and residents, and explore any possible factors which may moderate the association between migrant status and C-Section rates.

Methods

We conducted a retrospective cohort study in Shanghai, China. All deliveries were classified using the modified Robson Classification. The association between women’s migrant status and C-Section rates was assessed using the Poisson regression of sandwich estimation, after adjusting for possible factors.

Results

Of the 40,621 women included in the study, 66.9% were residents and 33.1% were internal migrants. The rate of C-Section in migrants was lower than that of residents in all subjects (39.9 and 47.7%) and in group 1 subjects (based on the Robson Classification) using a modified Robson Classification. There was an association between migrant status and caesarean delivery on maternal request that was statistically significant (RR = 0.664, p < 0.001), but the association was weakened after adjusting for such factors as maternal age at delivery (aRR = 0.774, p = 0.02), ethnicity (aRR = 0.753, p < 0.001), health insurance (aRR = 0.755, p < 0.001), and occupation (aRR = 0.747, p = 0.004), but had no significant changes when adjusting for health conditions (aRR = 0.668, p = 0.001) and all considering variables (aRR = 0.697, p = 0.002). In group 1 subjects, the effect of migrant status on maternal requested intrapartum C-Section was also statistically significant (RR = 0.742, p = 0.004).

Conclusion

C-Section rates are lower among migrant women than residents, especially on maternal request. The medical practitioners should further reinforce the management of elective C-Section in resident women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03708-6.

Factors obstetricians, family physicians and midwives consider when counselling women about a trial of labour after caesarean and planned repeat caesarean: a qualitative descriptive study

BACKGROUND

Repeat caesarean sections (CSs) are major contributors to the high rate of CS in Canada and globally. Women's decisions to have a planned repeat CS (PRCS) or a trial of labour after CS (TOLAC) are influenced by their maternity care providers. This study explored factors maternity care providers consider when counselling pregnant women with a previous CS, eligible for a TOLAC, about delivery method.

METHODS

A qualitative descriptive design was implemented. Semi-structured, one-to-one in-depth telephone interviews were conducted with 39 maternity care providers in Ontario, Canada. Participants were recruited at 2 maternity care conferences and with the use of snowball sampling. Interviews were audio recorded and transcribed verbatim. Data were uploaded into the data management software, NVIVO 10.0 and analyzed using qualitative content analysis.

RESULTS

Participants consisted of 12 obstetricians, 13 family physicians and 14 midwives. Emergent themes, reflecting the factors maternity care providers considered when counselling on mode of delivery, were organized under the categories clinical/patient factors, health system factors and provider preferences. Maternity care providers considered clinical/patient factors, including women's choice … with conditions, their assessment of women's chances of a successful TOLAC, their perception of women's risk tolerance, women's preferred delivery method, and their perception of women's beliefs and attitudes about childbirth. Additionally, providers considered health system factors which included colleague support for TOLAC and time needed to mount an emergency CS. Finally, provider factors emerged as considerations when counselling. They included provider preference for PRCS or TOLAC, provider scope of practice, financial incentives and convenience related to PRCS, past experiences with TOLAC and PRCS and providers' perspectives on risk of TOLAC.

CONCLUSION

The findings highlight the multiplicity of factors maternity care providers consider when counselling women. Effectively addressing clinical, health care system and personal factors that influence counselling may help decrease non-medically indicated PRCS.

The Effect of Immigration on Adverse Perinatal Outcomes: Analysis of Experiences at a Turkish Tertiary Hospital

Introduction

In literature, it is well documented that migration is associated with adverse perinatal outcomes in many countries over the world. But in Turkey, health care providers and obstetricians had to face the effects of migration for the first time after civil war in Syria. Hence, this situation motivated us to conduct the current research in Turkey. Also we aimed to evaluate the effect of immigration on adverse perinatal outcomes, comparing the obstetric results of a native population and an immigrant population, and focusing on relevant indicators of perinatal health.

Methods

Information from the hospital database of pregnant women who had vaginal or cesarean delivery was evaluated. The patients were divided into two groups, native women and immigrant women, according to their ethnic origin. Adverse perinatal outcomes were compared between groups using multivariate regression models. Adjusted odds ratio (aOR) and 95% confidence interval (CI) were calculated.

Results

A total of 6311 patients were evaluated, of which 4271 were classified as native and 2040 were classified as immigrants. Mean hemoglobin level before delivery was significantly lower in the immigrant group. Preterm delivery (aOR: 1.41; 95% CI: 1.19–1.65), stillbirth (aOR: 1.88; 95% CI: 1.09–3.23), red blood cell transfusion requirement (aOR: 3.12; 95% CI: 2.02–3.98), unplanned birth rates before hospital arrival (aOR: 2.25; 95% CI: 1.53–3.31), and postpartum infection rates (aOR:2.12; 95% CI: 1.48–3.08) were significantly increased in the immigrant group compared with native group, even considering adjustment for potential confounders.

Conclusion

The immigration may be an important and independent risk factor for some adverse maternal and neonatal outcomes.

Quality of health care for refugees - a systematic review

OBJECTIVE

The aim of this systematic review was to identify quality indicators (QI) developed for health care for refugees.

METHODS

We conducted a systematic review of international QI databases such as the Agency for Health care Research and Quality in addition to a systematic search in PubMed, Cochrane library and Web of Science, using the terms "refugee" and "quality indicator", complemented by a search in reference lists and grey literature. All papers which included QIs for refugees, especially for health care were included. In a first step all existing QIs were screened for their relevance to refugees. In a second step, all health care QIs were extracted. In a final step, these health care QIs were classified into process, structure and outcome indicators.

RESULTS

Of 474 papers, 23 were selected for a full-text review. Of these 23 publications, 6 contained 115 QIs for health and health care for refugees. The main health care topics identified were reproductive health, health care service and health status.

CONCLUSIONS

Most indicators were indicators for outcome and structure quality, the smallest group were process indicators. Within the area of refugee health care, most QIs that have been found were QIs regarding reproductive health. QI databases do not yet include indicators specifically related to refugees.

Length of residence and caesarean section in migrant women in Sweden: a population-based study

Background

Prior studies have reported substantial differences in caesarean rates between migrant and non-migrant women. In this study we investigate whether the association between maternal country of birth and caesarean section is modified by length of residence in Sweden.

Methods

Population-based register study. A total of 106 760 migrant and 473 881 Swedish-born women having singleton, first births were studied using multinomial multiple regression models to estimate odds ratios (OR) and 95% confidence intervals for mode of birth. Random effect meta-analyses were conducted to assess true heterogeneity between categories of length of residence.

Results

Longer duration of residence was associated with an increased overall risk of both unplanned and planned caesarean section among migrant women. This pattern was more pronounced among countries grouped as having higher prevalence (compared to Swedes) of unplanned: OR≤1=1.41 (1.32-1.50); OR>1-<6=1.49 (1.42-1.57); OR6-<10=1.61 (1.50-1.72); OR≥10=1.71 (1.64-1.79) and planned caesarean section [OR≤1=1.14 (0.95-1.36); OR>1-<6=1.30 (1.13-1.51); OR6-<10=1.97 (1.64-2.37]; OR≥10=1.82 (1.67-1.98)]. The results were robust to social, obstetric and health adjustments. There were some country-of-origin-specific findings.

Conclusions

The fact that the risk of unplanned and planned caesarean section tended to increase with length of residence, even with adjustment for social, obstetric and health factors, suggests that receiving country-specific factors are playing an important role in caesarean section.

The Personal Social Networks of Resettled Bhutanese Refugees During Pregnancy in the United States: A Social Network Analysis

Women comprise 50% of the refugee population, 25% of whom are of reproductive age. Female refugees are at risk for experiencing significant hardships associated with the refugee experience, including after resettlement. For refugee women, the strength of their personal social networks can play an important role in mitigating the stress of resettlement and can be an influential source of support during specific health events, such as pregnancy. A personal social network analysis was conducted among 45 resettled Bhutanese refugee women who had given birth within the past 2 years in the Akron Metropolitan Area of Northeast Ohio. Data were collected using in-depth interviews conducted in Nepali over a 6-month period in 2016. Size, demographic characteristics of ties, frequency of communication, length of relationship, and strength of connection were the social network measures used to describe the personal networks of participants. A qualitative analysis was also conducted to assess what matters were commonly discussed within networks and how supportive participants perceived their networks to be. Overall, participants reported an average of 3 close personal connections during their pregnancy. The networks were comprised primarily of female family members whom the participant knew prior to resettlement in the U.S. Participants reported their networks as "very close" and perceived their connections to be supportive of them during their pregnancies. These results may be used to guide future research, as well as public health programming, that seeks to improve the pregnancy experiences of resettled refugee women.

Refugee maternal and perinatal health in Ontario, Canada: a retrospective population-based study

OBJECTIVES

Immigrants are thought to be healthier than their native-born counterparts, but less is known about the health of refugees or forced migrants. Previous studies often equate refugee status with immigration status or country of birth (COB) and none have compared refugee to non-refugee immigrants from the same COB. Herein, we examined whether: (1) a refugee mother experiences greater odds of adverse maternal and perinatal health outcomes compared with a similar non-refugee mother from the same COB and (2) refugee and non-refugee immigrants differ from Canadian-born mothers for maternal and perinatal outcomes.

DESIGN

This is a retrospective population-based database study. We implemented two cohort designs: (1) 1:1 matching of refugees to non-refugee immigrants on COB, year and age at arrival (±5 years) and (2) an unmatched design using all data.

SETTING AND PARTICIPANTS

Refugee immigrant mothers (n=34 233), non-refugee immigrant mothers (n=243 439) and Canadian-born mothers (n=615 394) eligible for universal healthcare insurance who had a hospital birth in Ontario, Canada, between 2002 and 2014.

PRIMARY OUTCOMES

Numerous adverse maternal and perinatal health outcomes.

RESULTS

Refugees differed from non-refugee immigrants most notably for HIV, with respective rates of 0.39% and 0.20% and an adjusted OR (AOR) of 1.82 (95% CI 1.19 to 2.79). Other elevated outcomes included caesarean section (AOR 1.04, 95% CI 1.00 to 1.08) and moderate preterm birth (AOR 1.08, 95% CI 0.99 to 1.17). For the majority of outcomes, refugee and non-refugee immigrants experienced similar AORs when compared with Canadian-born mothers.

CONCLUSIONS

Refugee status was associated with a few adverse maternal and perinatal health outcomes, but the associations were not strong except for HIV. The definition of refugee status used herein may not sensitively identify refugees at highest risk. Future research would benefit from further refining refugee status based on migration experiences.

Caesarean Birth is Associated with Both Maternal and Paternal Origin in Immigrants in Sweden: a Population-Based Study

BACKGROUND

To investigate the association between maternal country of birth and father's origin and unplanned and planned caesarean birth in Sweden.

METHODS

Population-based register study including all singleton births in Sweden between 1999 and 2012 (n = 1 311 885). Multinomial regression was conducted to estimate odds ratios (OR) for unplanned and planned caesarean with 95% confidence intervals for migrant compared with Swedish-born women. Analyses were stratified by parity.

RESULTS

Women from Ethiopia, India, South Korea, Chile, Thailand, Iran, and Finland had statistically significantly higher odds of experiencing unplanned (primiparous OR 1.10-2.19; multiparous OR 1.13-2.02) and planned caesarean (primiparous OR 1.18-2.25; multiparous OR 1.13-2.46). Only women from Syria, the former Yugoslavia and Germany had consistently lower risk than Swedish-born mothers (unplanned: primiparous OR 0.76-0.86; multiparous OR 0.74-0.86. Planned; primiparous OR 0.75-0.82; multiparous OR 0.60-0.94). Women from Iraq and Turkey had higher odds of an unplanned caesarean but lower odds of a planned one (among multiparous). In most cases, these results remained after adjustment for available social characteristics, maternal health factors, and pregnancy complications. Both parents being foreign-born increased the odds of unplanned and planned caesarean in primiparous and multiparous women.

CONCLUSIONS

Unplanned and planned caesarean birth varied by women's country of birth, with both higher and lower rates compared with Swedish-born women, and the father's origin was also of importance. These variations were not explained by a wide range of social, health, or pregnancy factors.

Scoping Review on Maternal Health among Immigrant and Refugee Women in Canada: Prenatal, Intrapartum, and Postnatal Care

The last fifteen years have seen a dramatic increase in both the childbearing age and diversity of women migrating to Canada. The resulting health impact underscores the need to explore access to health services and the related maternal health outcome. This article reports on the results of a scoping review focused on migrant maternal health within the context of accessible and effective health services during pregnancy and following delivery. One hundred and twenty-six articles published between 2000 and 2016 that met our inclusion criteria and related to this group of migrant women, with pregnancy/motherhood status, who were living in Canada, were identified. This review points at complex health outcomes among immigrant and refugee women that occur within the compelling gaps in our knowledge of maternal health during all phases of maternity. Throughout the prenatal, intrapartum, and postnatal periods of maternity, barriers to accessing healthcare services were found to disadvantage immigrant and refugee women putting them at risk for challenging maternal health outcomes. Interactions between the uptake of health information and factors related to the process of immigrant settlement were identified as major barriers. Availability of appropriate services in a country that provides universal healthcare is discussed.

Predictors of Unplanned Cesareans among Low-Risk Migrant Women from Low- and Middle-Income Countries Living in Montreal, Canada

BACKGROUND

Research has yielded little understanding of factors associated with high cesarean rates among migrant women (i.e., women born abroad). The objective of this study was to identify medical, migration, social, and health service predictors of unplanned cesareans among low-risk migrant women from low- and middle-income countries (LMICs).

METHODS

We used a case-control research design. The sampling frame included migrant women from LMICs living in Canada less than 8 years, who gave birth at one of three Montreal hospitals between March 2014 and January 2015. Data were collected from medical records and by interview-administration of the Migrant-Friendly Maternity Care Questionnaire. We performed multi-variable logistic regression for low-risk women (i.e., vertex, singleton, term pregnancies) who delivered vaginally (1,615 controls) and by unplanned cesarean indicated by failure to progress, fetal distress, or cephalopelvic disproportion (233 cases).

RESULTS

Predictors of unplanned cesarean included being from sub-Saharan Africa/Caribbean (OR 2.37 [95% CI 1.02-5.51]) and admission for delivery during early labor (OR 5.43 [95% CI 3.17-9.29]). Among women living in Canada less than 2 years predictors were having a humanitarian migration classification (OR 4.24 [95% CI 1.16-15.46]) and admission for delivery during early labor (OR 7.68 [95% CI 3.12-18.88]).

CONCLUSION

Migrant women from sub-Saharan Africa/Caribbean and recently arrived migrant women with a humanitarian classification are at greater risk for unplanned cesareans compared with other low-risk migrant women from LMICs after controlling for medical factors. Strategies to prevent cesareans should consider the circumstances of migrant women that may be contributing to the use of unplanned cesareans in this population.

International migration as a determinant of emergency caesarean

BACKGROUND

High caesarean rates are of concern given associated risks. International migrant women (women born abroad) represent a substantial proportion of women giving birth in high-income countries (HICs) and face social conditions that may exacerbate childbearing health risks. Among migrant women, emergency rather than planned caesareans, tend to be more prevalent. This method of delivery can be stressful, physically harmful and result in an overall negative birth experience. Research establishing evidence of risk factors for emergency caesareans in migrants is insufficient.

AIMS

(1) Describe potential pathways (with a focus on modifiable factors) by which migration, using internationally recommended migration indicators: country of birth, length of time in country, fluency in receiving-country language, migration classification and ethnicity, may lead to emergency caesarean; and (2) propose a framework to guide future research for understanding "potentially preventable" emergency caesareans in migrant women living in HICs.

DISCUSSION

"Potentially preventable" emergency caesareans in migrant women are likely due to several modifiable, interrelated factors pre-pregnancy, during pregnancy and during labour. Migration itself is a determinant and also shapes other determinants. Complications and ineffective labour progress and/or foetal distress and ultimately the decision to perform an emergency caesarean may be the result of poor health (i.e., physiological effects), lack of support and disempowerment (i.e., psychological effects) and sub-optimal care.

CONCLUSION

Understanding the direct and indirect effects of migration on emergency caesarean is crucial so that targeted strategies can be developed and implemented for reducing unnecessary caesareans in this vulnerable population.

Contribution of HIV to Maternal Morbidity Among Refugee Women in Canada

OBJECTIVES

We compared severe maternal morbidity (SMM) and SMM subtypes, including HIV, of refugee women with those of nonrefugee immigrant and nonimmigrant women.

METHODS

We linked 1,154,421 Ontario hospital deliveries (2002-2011) to immigration records (1985-2010) to determine the incidence of an SMM composite indicator and its subtypes. We determined SMM incidence according to immigration periods, which were characterized by lifting restrictions for all HIV-positive immigrants (in 1991) and refugees who may place "excessive demand" on government services (in 2002).

RESULTS

Refugees had a higher risk of SMM (17.1 per 1000 deliveries) than did immigrants (12.1 per 1000) and nonimmigrants (12.4 per 1000). Among SMM subtypes, refugees had a much higher risk of HIV than did immigrants (risk ratio [RR] = 7.94; 95% confidence interval [CI] = 5.64, 11.18) and nonimmigrants (RR = 17.37; 95% CI = 12.83, 23.53). SMM disparities were greatest after the 2002 policy came into effect. After exclusion of HIV cases, SMM disparities disappeared.

CONCLUSIONS

An apparent higher risk of SMM among refugee women in Ontario, Canada is explained by their high prevalence of HIV, which increased over time parallel to admission policy changes favoring humanitarian protection.

Caesarean births among migrant women in high-income countries

High caesarean birth rates among migrant women living in high-income countries are of concern. Women from sub-Saharan Africa and South Asia consistently show overall higher rates compared with non-migrant women, whereas women from Latin America and North Africa/Middle East consistently show higher rates of emergency caesarean. Higher rates are more common with emergency caesareans than with planned caesareans. Evidence regarding risk factors among migrant women for undergoing a caesarean birth is lacking. Research suggests that pathways leading to caesarean births in migrants are complex, and they are likely to involve a combination of factors related to migrant women's physical and psychological health, their social and cultural context and the quality of their maternity care. Migration factors, including length of time in receiving country and migration classification, have an influence on delivery outcome; however, their effects appear to differ by women's country/region of origin.

Immigrants from conflict-zone countries: an observational comparison study of obstetric outcomes in a low-risk maternity ward in Norway

Background

Immigrants have higher risks for some adverse obstetric outcomes. Furthermore, refugees are reported to be the most vulnerable group. This study compared obstetric outcomes between immigrant women originating from conflict-zone countries and ethnic Norwegians who gave birth in a low-risk setting.

Methods

This was a population-based study linking the Medical Birth Registry of Norway to Statistics Norway. The study included the first registered birth during the study period of women from Somalia (n = 278), Iraq (n = 166), Afghanistan (n = 71), and Kosovo (n = 67) and ethnic Norwegians (n = 6826) at Baerum Hospital from 2006–2010. Background characteristics and obstetric outcomes of each immigrant group were compared with ethnic Norwegians with respect to proportions and risks calculated by logistic regression models.

Results

In total, 7408 women and their births were analyzed. Women from Somalia were most at risk for adverse obstetric outcomes. Compared with ethnic Norwegians, they had increased odds ratios (OR) for emergency cesarean section (OR 1.81, CI 1.17–2.80), postterm birth (OR 1.93, CI 1.29–2.90), meconium-stained liquor (OR 2.39, CI 1.76–3.25), and having a small-for-gestational-age infant (OR 3.97, CI 2.73–5.77). They had a reduced OR for having epidural analgesia (OR 0.40, CI 0.28–0.56) and a large-for-gestational-age infant (OR 0.32, CI 0.16–0.64). Women from Iraq and Afghanistan had increased risk of having a small-for-gestational-age infant with OR of 2.21 (CI 1.36–3.60) and 2.77 (CI 1.42–5.39), respectively. Iraqi women also had reduced odds ratio of having a large-for-gestational-age infant (OR 0.35, CI 0.15–0.83). Women from Kosovo did not differ from ethnic Norwegians in any of the outcomes we tested.

Conclusions

Even in our low-risk maternity ward, women originating from Somalia were at the greatest risk for adverse obstetric outcomes in the compared groups. We could not find the same risk among the other immigrant women, also originating from conflict-zone countries. Several factors may influence these findings, and this study suggests that immigrant women from Somalia need more targeted care during pregnancy and childbirth.

Maternal health and pregnancy outcomes comparing migrant women born in humanitarian and nonhumanitarian source countries: a retrospective, observational study

BACKGROUND

The relationship between migration and pregnancy outcomes is complex, with little insight into whether women of refugee background have greater risks of adverse pregnancy outcomes than other migrant women. This study aimed to describe maternal health, pregnancy care, and pregnancy outcomes among migrant women from humanitarian and nonhumanitarian source countries.

METHODS

Retrospective, observational study of singleton births, at a single maternity service in Australia 2002-2011, to migrant women born in humanitarian source countries (HSCs, n = 2,713) and non-HSCs (n = 10,606). Multivariable regression analysis assessed associations between maternal HSC-birth and pregnancy outcomes.

RESULTS

Compared with women from non-HSCs, the following were more common in women from HSCs: age < 20 years (0.6 vs 2.9% p < 0.001), multiparity (51 vs 76% p < 0.001), body mass index (BMI) ≥ 25 (38 vs 50% p < 0.001), anemia (3.2 vs 5.9% p < 0.001), tuberculosis (0.1 vs 0.4% p = 0.001), and syphilis (0.4 vs 2.5% p < 0.001). Maternal HSC-birth was independently associated with poor or no pregnancy care attendance (OR 2.5 [95% CI 1.8-3.6]), late first pregnancy care visit (OR 1.3 [95% CI 1.1-1.5]), and postterm birth (> 41 weeks gestation) (OR 2.5 [95% CI 1.9-3.4]). Stillbirth (0.8 vs 1.2% p = 0.04, OR 1.5 [95% CI 1.0-2.4]) and unplanned birth before arrival at the hospital (0.6 vs 1.2% p < 0.001, OR 1.3 [95% CI 0.8-2.1]) were more common in HSC-born women but not independently associated with maternal HSC-birth after adjusting for age, parity, BMI and relative socioeconomic disadvantage.

CONCLUSIONS

These findings suggest areas where women from HSCs may have additional needs in pregnancy compared with women from non-HSCs. Refugee-focused strategies to support engagement in pregnancy care and address maternal health needs would be expected to improve health outcomes in resettlement countries.

Maternal health and pregnancy outcomes among women of refugee background from African countries: a retrospective, observational study in Australia

Background

Women of refugee background from Africa are reported to have a greater risk of adverse pregnancy outcomes compared to women born in resettlement countries. However, there is currently little insight into whether adverse pregnancy outcomes are more common among migrant women of refugee background, compared to women who have migrated for non-humanitarian reasons. To inform whether women of refugee background require additional services in pregnancy compared to non-refugee migrant women from similar world regions we aimed to describe and compare maternal health, pregnancy care attendance and pregnancy outcomes among migrant women from Africa with or without a refugee background.

Methods

Retrospective, observational study of singleton births at a single, metropolitan, maternity service in Australia 2002–2011, to women born in humanitarian source countries (HSC) and non-HSC from North Africa (n = 1361), Middle and East Africa (n = 706) and West Africa (n = 106).

Results

Compared to non-HSC groups, age < 20 years (0–1.4% vs 2.3-13.3%), living in relatively socio-economically disadvantaged geographic areas (26.2-37.3% vs 52.9-77.8%) and interpreter need (0–23.9% vs 9.7-51.5%) were generally more common in the HSC groups. Compared to non-HSC groups, female genital mutilation (0.3-3.3% vs 5.1-13.8%), vitamin D insufficiency (8.7-21.5% vs 23.3-32.0%), syphilis (0–0.3% vs 1.2-7.5%) and hepatitis B (0–1.1% vs 1.2-18%) were also generally more common among the HSC groups. Unplanned birth before arrival at the hospital (3.6%) was particularly high in the North African HSC group. HSC-birth was associated with gestational diabetes mellitus (odds ratio = 3.5, 95% confidence interval: 1.8-7.1) among women from Middle and East Africa, after adjusting for maternal age, parity, body mass index and relative socio-economic disadvantage of area of residence. The West African HSC group had the highest stillbirth incidence (4.4%).

Conclusions

Migrant women of refugee background from different African regions appear to be at greater risk of specific adverse pregnancy outcomes compared to migrant women without a refugee background. Awareness of differing risks and health needs would assist provision of appropriate pregnancy care to improve the health of African women and their babies.

Caesarean section by immigrants' length of residence in Norway: a population-based study

BACKGROUND

Immigrants to Europe account for a significant proportion of births in a context of rising caesarean rates. We examined the risk of planned and emergency caesarean section (CS) by immigrants' length of residence in Norway, and compared the results with those of non-immigrants.

METHODS

We linked population-based birth registry data to immigration data for first deliveries among 23 147 immigrants from 10 countries and 385 306 non-immigrants between 1990-2009. Countries were grouped as having low CS levels (<16%; Iraq, Pakistan, Poland, Turkey, Yugoslavia, Vietnam) or high CS levels (>22%; the Philippines, Somalia, Sri Lanka, Thailand). Associations between length of residence and planned/emergency CS were estimated as relative risks (RR) with 95% confidence intervals (CI) in multivariable models.

RESULTS

In the immigrant group with low CS levels, planned, but not emergency, CS was independently associated with longer length of residence. Compared with recent immigrants (<1 year), the risk of planned CS was 70% greater among immigrants with residency of 2-5 years (RR 1.70, CI: 1.19-2.42), and twice as high in those with residency of ≥ 6 years. (RR 2.01, CI: 1.28-3.17). Compared with non-immigrants, immigrants in the low group with residency <2 years had lower risk of planned CS, while those with residency >2 years had greater risk of emergency CS. In the high group, the risk of planned CS was similar to non-immigrants, while emergency CS was 51-75% higher irrespective of length of residency.

CONCLUSION

Efforts to improve immigrants' labour outcomes should target subgroups with sustained high emergency caesarean risk.

A descriptive phenomenology study of newcomers' experience of maternity care services: Chinese women's perspectives

BACKGROUND

Maternity health care available in Canada is based on the needs of women born in Canada and often lacks the flexibility to meet the needs of immigrant women. The purpose of this study was to explore immigrant Chinese women's experiences in accessing maternity care, the utilization of maternity health services, and the obstacles they perceived in Canada.

METHODS

This descriptive phenomenology study used in-depth semi-structured interviews to examine immigrant Chinese women's experiences. Fifteen participants were recruited from the Chinese community in Toronto, Canada by using purposive sampling. The interviews were digitally recorded and transcribed verbatim into written Chinese. The transcripts were analyzed using Colaizzi's (1978) phenomenological method.

RESULTS

Six themes were extracted from the interviews: (1) preference for linguistically and culturally competent healthcare providers, with obstetricians over midwives, (2) strategies to deal with the inconvenience of the Canadian healthcare system (3) multiple resources to obtain pregnancy information, (4) the merits of the Canadian healthcare system, (5) the need for culturally sensitive care, and (6) the emergence of alternative supports and the use of private services.

CONCLUSIONS

The findings provide new knowledge and understanding of immigrant Chinese women's experiences in accessing maternity health services within a large metropolitan Canadian city. Participants described two unique experiences within the themes: preference for linguistically and culturally competent healthcare providers, with obstetricians over midwives, and the emergence of alternative supports and the use of private services. Few studies of immigrant maternity service access have identified these experiences which may be linked to cultural difference. Further investigation with women from different cultural backgrounds is needed to develop a comprehensive understanding of immigrant women's experiences with maternity care.

International migration and caesarean birth: a systematic review and meta-analysis

Background

Perinatal health disparities including disparities in caesarean births have been observed between migrant and non-migrant women and some literature suggests that non-medical factors may be implicated. A systematic review was conducted to determine if migrants in Western industrialized countries consistently have different rates of caesarean than receiving-country-born women and to identify the reasons that explain these differences.

Methods

Reports were identified by searching 12 literature databases (from inception to January 2012; no language limits) and the web, by bibliographic citation hand-searches and through key informants. Studies that compared caesarean rates between international migrants and non-migrants living in industrialized countries and that did not have a ‘fatal flaw’ according to the US Preventative Services Task Force criteria were included. Studies were summarized, analyzed descriptively and where possible, meta-analyzed.

Results

Seventy-six studies met inclusion criteria. Caesarean rates between migrants and non-migrants differed in 69% of studies. Meta-analyses revealed consistently higher overall caesarean rates for Sub-Saharan African, Somali and South Asian women; higher emergency rates for North African/West Asian and Latin American women; and lower overall rates for Eastern European and Vietnamese women. Evidence to explain the consistently different rates was limited. Frequently postulated risk factors for caesarean included: language/communication barriers, low SES, poor maternal health, GDM/high BMI, feto-pelvic disproportion, and inadequate prenatal care. Suggested protective factors included: a healthy immigrant effect, preference for a vaginal birth, a healthier lifestyle, younger mothers and the use of fewer interventions during childbirth.

Conclusion

Certain groups of international migrants consistently have different caesarean rates than receiving-country-born women. There is insufficient evidence to explain the observed differences.