Obstetric care quality indicators and outcomes based on the degree of acculturation of immigrants-results from a cross-sectional study in Berlin

Perinatal outcome of immigrant women with and without refugee status compared to non-immigrant women: results of the pregnancy and obstetric care for refugees (PROREF) cross-sectional study

PURPOSE

International studies show conflicting evidence regarding the perinatal outcome of immigrant women with and without refugee status compared to non-immigrant women. There are few studies about the situation in Germany. The research question of this article is: Is the perinatal outcome (Apgar, UApH (umbilical artery pH), NICU (neontatal intensive care unit) transfer, c-section rate, preterm birth, macrosomia, maternal anemia, higher degree perinatal tear, episiotomy, epidural anesthesia) associated with socio-demographic/clinical characteristics (migration status, language skills, household income, maternal education, parity, age, body mass index (BMI))?

METHODS

In the Pregnancy and Obstetric Care for Refugees (PROREF)-study (subproject of the research group PH-LENS), funded by the German Research Foundation (DFG), women giving birth in three centers of tertiary care in Berlin were interviewed with the modified Migrant Friendly Maternity Care Questionnaire between June 2020 and April 2022. The interview data was linked to the hospital charts. Data analysis was descriptive and logistic regression analysis was performed to find associations between perinatal outcomes and migration data.

RESULTS

During the research period 3420 women (247 with self-defined (sd) refugee status, 1356 immigrant women and 1817 non-immigrant women) were included. Immigrant women had a higher c-section rate (36.6% vs. 33.2% among non-immigrant women and 31.6% among women with sd refugee status, p = 0.0485). The migration status did not have an influence on the umbilical artery pH, the preterm delivery rate and the transfer of the neonate to the intensive care unit. Women with self-defined refugee status had a higher risk for anemia (31.9% vs. 26.3% immigrant women and 23.4% non-immigrant women, p = 0.0049) and were less often offered an epidural anesthesia for pain control during vaginal delivery (42.5% vs. 54% immigrant women and 52% non-immigrant women, p = 0.0091). In the multivariate analysis maternal education was explaining more than migration status.

CONCLUSION

Generally, the quality of care for immigrant and non-immigrant women in Berlin seems high. The reasons for higher rate of delivery via c-section among immigrant women remain unclear. Regardless of their migration status women with low degree of education seem at increased risk for anemia.

Acculturation Experiences and Preterm Birth in Berlin: Does Acculturative Stress Contribute to Preterm Birth?

Acculturation and acculturative stress are potential risk factors for adverse perinatal outcomes. This study investigates whether and how acculturative stress affects preterm birth (PTB) in a sample of migrant women in Berlin. We interviewed 955 women who recently gave birth using standardized questionnaires (Frankfurt Acculturation Scale and Acculturative Stress Index). Multivariable logistic regression analyses assessed the effects of acculturation and acculturative stress on PTB. Women with migrant backgrounds did not have significantly higher PTB rates than German natives. First-generation migrants experienced higher acculturative stress levels than second-generation migrants, 38.8% vs. 13.2%. Acculturative stress could not be identified as a risk factor for PTB in our sample. These results need to be considered in the context of an international city and the wide use of antenatal care services in our population, which could be responsible for similarly good perinatal outcomes and highlights the potential of good access to perinatal care for vulnerable groups.

The influence of acculturation on the risk of preterm birth and low birthweight in migrant women residing in Western Australia

BACKGROUND

The risk of preterm birth (PTB) and low birthweight (LBW) may change over time the longer that immigrants reside in their adopted countries. We aimed to study the influence of acculturation on the risk of these outcomes in Australia.

METHODS

A retrospective cohort study using linked health data for all non-Indigenous births from 2005-2013 in Western Australia was undertaken. Acculturation was assessed through age on arrival, length of residence, interpreter use and having an Australian-born partner. Adjusted odds ratios (aOR) for term-LBW and PTB (all, spontaneous, medically-indicated) were calculated using multivariable logistic regression in migrants from six ethnicities (white, Asian, Indian, African, Māori, and 'other') for different levels of acculturation, compared to the Australian-born population as the reference.

RESULTS

The least acculturated migrant women, those from non-white non-Māori ethnic backgrounds who immigrated at age ≥18 years, had an overseas-born partner, lived in Australia for < 5 years and used a paid interpreter, had 58% (aOR 1.58, 95% CI 1.15-2.18) higher the risk of term-LBW and 40% (aOR 0.60, 95% CI 0.45-0.80) lower risk of spontaneous PTB compared to the Australian-born women. The most acculturated migrant women, those from non-white non-Māori ethnic backgrounds who immigrated at age <18 years, had an Australian-born partner, lived in Australia for > 10 years and did not use an interpreter, had similar risk of term-LBW but 43% (aOR 1.43, 95% CI 1.14-1.78) higher risk of spontaneous PTB than the Australian-born women.

CONCLUSION

Acculturation is an important factor to consider when providing antenatal care to prevent PTB and LBW in migrants. Acculturation may reduce the risk of term-LBW but, conversely, may increase the risk of spontaneous PTB in migrant women residing in Western Australia. However, the effect may vary by ethnicity and warrants further investigation to fully understand the processes involved.

Perinatales Outcome bei Frauen mit Gestationsdiabetes unter besonderer Berücksichtigung eines Migrationshintergrundes – Ergebnisse einer prospektiven Studie in Berlin

Hintergrund Etwa 25 % der Bevölkerung Deutschlands haben einen Migrationshintergrund (MH), der mit einem schlechteren perinatalen Outcome einhergehen kann. Der Gestationsdiabetes (GDM) gehört zu den häufigsten Schwangerschaftserkrankungen; von ihm sind Frauen mit MH in höherem Maße betroffen. Bisher liegen keine systematisch erhobenen Daten zur Betreuung von Migrantinnen mit GDM vor.

Fragestellung Ziel der Studie war es, Auswirkungen eines MH auf Schwangerschaften von Frauen mit GDM zu evaluieren: Haben Immigrantinnen und ihre Nachkommen ein schlechteres perinatales Outcome als Frauen ohne MH in den Parametern Geburtseinleitung, Sectio, Makrosomie, Apgar, Nabelschnur-pH-Wert, Verlegung auf eine neonatologische Intensivstation, Frühgeburt und prä-/postpartale Hb-Differenz? Beeinflusst ein MH außerdem den Zeitpunkt der ersten Schwangerenvorsorge sowie die Zahl der Vorsorgeuntersuchungen?

Methoden Datenerhebung an drei Berliner Geburtskliniken 2011/2012 unmittelbar in der Kreißsaalaufnahme über 12 Monate anhand standardisierter Interviews (Fragebogenset) in deutscher, türkischer und anderen Sprachen. Fragen zu soziodemografischen Aspekten, Schwangerenvorsorge sowie ggf. Migration und Akkulturation. Verknüpfung der Befragungsdaten mit Mutterpass- und klinischen Perinataldaten. Adjustierung für Alter, BMI, Parität und sozioökonomischen Status erfolgte in Regressionsmodellen.

Ergebnisse Die Daten von n = 2878 Frauen mit MH (GDM: 4,7 %) und n = 2785 Frauen ohne MH (GDM: 4,8 %) konnten verglichen werden. Eine multiple Regressionsanalyse zeigte keine Unterschiede in den Chancen der beiden Gruppen mit GDM hinsichtlich Sectio, Makrosomie, Apgar, Nabelschnur-pH-Werten, Verlegungen auf eine neonatologische Intensivstation sowie Zeitpunkt der ersten Schwangerenvorsorge ≥ 12 SSW und Zahl der Vorsorgeuntersuchungen < 10. Sowohl für Frauen mit GDM und MH (OR 1,57; 95 %-KI 1,08–2,27) als auch für solche mit GDM ohne MH (OR 1,47; 95 %-KI 1,01–2,14) bestand eine signifikant höhere Chance der Geburtseinleitung.

Schlussfolgerung Frauen mit GDM und MH zeigen ein ähnlich gutes Schwangerschaftsergebnis wie solche mit GDM und ohne MH, was auf eine hohe Qualität der peripartalen Betreuung und Versorgung hinweist. Im Vergleich zu Frauen ohne GDM wird bedingt durch diesen und den höheren BMI unabhängig vom MH vermehrt eingeleitet. Die Ergebnisse für Frauen mit GDM lassen unabhängig vom MH auf einen ähnlichen Standard der Inanspruchnahme von Vorsorgeuntersuchungen in der Schwangerschaft schließen.

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.

Giving birth in Switzerland: a qualitative study exploring migrant women's experiences during pregnancy and childbirth in Geneva and Zurich using focus groups

Background

Migrant mothers in high-income countries often encounter more complications during pregnancy, delivery, and the postpartum period. To enlighten health care providers concerning potential barriers, the objective of this study was to explore positive and negative experiences with maternal health services in the University Hospitals of Geneva and Zurich and to describe barriers to maternity services from a qualitative perspective.

Methods

In this qualitative study, six focus groups (FGs) were conducted involving 33 women aged 21 to 40 years. All FG discussions were audio-recorded and later transcribed. Data were analysed using a thematic analysis approach assisted by the Atlas.ti qualitative data management software.

Results

Positive experiences included not only the availability of maternity services, especially during emergency situations and the postpartum period, but also the availability of specific maternity services for undocumented migrants in Geneva.

Negative experiences were classified into either personal or structural barriers. On the personal level, the main barriers were a lack of social support and a lack of health literacy, whereas the main themes on the structural level were language barriers and a lack of information.

Conclusion

Structural adaptation is necessary to meet the needs of the extremely diverse population. The needs include (1) the provision of specific information for migrant women in multiple languages, (2) the availability of trained interpreters who are easily accessible to health care providers, (3) specifically trained nurses or social assistance providers to guide migrants through the health system, and (4) a cultural competence-training programme for health care providers.

Satisfaction with obstetric care in a population of low-educated native Dutch and non-western minority women. Focus group research

Background

Low-educated native Dutch and non-western minority women have inadequate access to obstetric care. Moreover, the care they receive lacks responsiveness to their needs and cultural competences. Gaining a deeper understanding of their experiences and satisfaction with antenatal, birthing and maternity care will help to adjust healthcare responsiveness to meet their needs during pregnancy, childbirth and the postpartum period.

Methods

We combined the World Health Organization conceptual framework of healthcare responsiveness with focus group research to measure satisfaction with antenatal, birthing and maternity care of women with a low-educated native Dutch and non-western ethnic background.

Results

From September 2011 until December 2013, 106 women were recruited for 20 focus group sessions. Eighty-five percent of the women had a non-western immigrant background and 89% a low or intermediate educational attainment. The study population was mostly positive about the provided care during the antenatal phase. They were less positive about the other two phases of care. Moreover, the obstetric healthcare systems’ responsiveness in all phases of care (antenatal, birthing and maternity) did not meet these women’s needs. The ‘respect for persons’ domains ‘autonomy’, ‘communication’ and ‘dignity’ and the ‘client orientation’ domain ‘prompt attention’ were judged most negatively.

Conclusions

The study findings give contextual meaning and starting points for improvement of responsiveness in the provision of obstetric care within a multi-ethnic women’s population.

Does an Immigrant Background Affect the Indication, Incidence or Outcome of Emergency Cesarean Section? Results of the Prospective Data Collection of 111 Births

OBJECTIVES

Does the incidence and/or indication(s) for emergency cesarean section differ if the pregnant woman has an immigrant background (IB)? Does a lack of language proficiency (communication problems) and a low acculturation level result in a longer decision-to-delivery interval (D-D interval)? Are neonates born to women with IB by emergency cesarean section in a poorer condition post delivery?

PATIENT COHORTS AND METHOD

Standardized interviews were carried out before or immediately after delivery in three Berlin obstetric hospitals. Questions were asked about the sociodemographic background and care aspects as well as about immigration and level of acculturation. Collected data were linked to information obtained from the expectant mother's antenatal records and to care data and perinatal data routinely recorded by the hospitals. Data was analyzed using regression models which adjusted for age, parity, and socio-economic status.

RESULTS

The total patient population consisted of 7100 women (rate of response: 89.6%); of these women, 111 required emergency cesarean section (50 women without IB, 61 immigrant women). Risk factors such as late first antenatal check-up, gestational diabetes, pregnancy-induced hypertension, fetal macrosomia, smoking, and weight gain were similar in both patient cohorts. The incidence of and indications for emergency cesarean section and the D-D interval were similar for both groups. Limited German language proficiency and low levels of acculturation among immigrant women did not prolong the D-D interval. There were no statistically relevant differences between immigrant and non-immigrant cohorts with regard to adverse neonatal conditions (5-minute Apgar score ≤ 7, umbilical cord arterial pH < 7.00) or with regard to immediate transfer of the neonate to a pediatric clinic following emergency cesarean section.

CONCLUSION

The factor "immigrant background" did not affect the indication or obstetric outcome following emergency cesarean section.