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Wenzel R, Polasik A, Friedl T, Walter S, Janni W, Friebe-Hoffmann U. Out of pocket health-care services in Germany during pregnancy under consideration of migration and acculturation. Arch Gynecol Obstet 2024:10.1007/s00404-024-07687-9. [PMID: 39150506 DOI: 10.1007/s00404-024-07687-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 08/05/2024] [Indexed: 08/17/2024]
Abstract
PURPOSE More than a quarter of the German population has a migration background (MB). As various studies in the healthcare sector have already shown, ethnic background and migration status can have an influence on individual patient care. The aim of our study was to evaluate whether there are differences in utilization of out of pocket health-care services and the consultation situation in the context of prenatal care, taking into account migration status, acculturation and socio-demographic aspects. METHODS In the period from 01.03.21-01.03.22, a total of 511 women in childbed at the University Women's Hospital Ulm were interviewed in a retrospective survey using a standardized questionnaire translated into 9 languages and asked about their prenatal care. Due to the COVID pandemic, the study had to be terminated after one year. RESULTS Women with MB-particularly 1st generation migrant women-used significantly fewer out of pocket prenatal care services (p < 0.001) and felt less informed and counselled regarding costs and benefits of possible prenatal care examinations (p < 0.001) compared to women without MB. Consistent with these results, there were associations between the assimilation index (AI) of patients with MB and both utilization and perception of individual healthcare services. CONCLUSION Our study indicates that even today there are still differences in the treatment and perception of various health services in the context of prenatal care between women with and those without MB.
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Affiliation(s)
- Robin Wenzel
- Department of Obstetrics and Gynecology, University of Ulm, Ulm, Germany.
| | - Arkadius Polasik
- Department of Obstetrics and Gynecology, University of Ulm, Ulm, Germany
| | - Thomas Friedl
- Department of Obstetrics and Gynecology, University of Ulm, Ulm, Germany
| | - Steffen Walter
- Institute for Medical Psychology and Sociology, University of Ulm, Ulm, Germany
| | - Wolfgang Janni
- Department of Obstetrics and Gynecology, University of Ulm, Ulm, Germany
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Koopmanschap I, Martin L, Gitsels - van der Wal JT, Suurmond J. Counselling for prenatal anomaly screening to migrant women in the Netherlands: An interview study of primary care midwives’ perceived barriers with client–midwife communication. Eur J Midwifery 2022; 6:29. [PMID: 35633755 PMCID: PMC9118623 DOI: 10.18332/ejm/147911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/27/2022] [Accepted: 03/31/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Large ethnic inequalities exist in the prenatal screening offer, counselling, informed decision-making, and uptake of prenatal anomaly tests. More insight into midwives’ experiences with offering prenatal counselling to migrant women may provide better insight into the origins and consequences of these ethnic inequalities. METHODS We conducted interviews with 12 midwives certified as counsellors for prenatal anomaly screening for women they identified as migrants. Interviews were analyzed using thematic analysis. RESULTS Midwives reported most difficulties in communicating with women of ‘non-western migrant background’, which include first- and second-generation migrants from Africa, Latin-America, Asia, and Turkey. They experienced barriers in communication related to linguistics, health literacy, sociocultural and religious differences, with midwife stereotyping affecting all three aspects of counselling: health education, decision-making support, and the client–midwife relation. Health education was difficult because of language barriers and low health-literacy of clients, decision-making support was hampered by sociocultural and religious midwife–client differences, and client–midwife relations were under pressure due to sociocultural and religious midwife–client differences and midwife stereotyping. CONCLUSIONS Barriers to optimal communication seem to contribute to suboptimal counselling, especially for women of ‘non-western migrant background’. Client–midwife communication thus potentially adds to the ethnic disparities observed in the offer of and informed decision-making about prenatal anomaly screening in the Netherlands. The quality of prenatal counselling for women from all ethnic backgrounds might be improved by addressing linguistic, health literacy, sociocultural and religious barriers in future training and continuing education of prenatal counsellors.
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Affiliation(s)
- Isabel Koopmanschap
- Amsterdam University Medical Center, Department of Public and Occupational Health, University of Amsterdam, Amsterdam, Netherlands
| | - Linda Martin
- Department of Midwifery Science, Academy Midwifery Amsterdam and Groningen (AVAG), Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Janneke T. Gitsels - van der Wal
- Department of Midwifery Science, Academy Midwifery Amsterdam and Groningen (AVAG), Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Jeanine Suurmond
- Amsterdam University Medical Center, Department of Public and Occupational Health, University of Amsterdam, Amsterdam, Netherlands
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van der Meij KRM, Kooij C, Bekker MN, Galjaard RJH, Henneman L. Non-invasive prenatal test uptake in socioeconomically disadvantaged neighborhoods. Prenat Diagn 2021; 41:1395-1400. [PMID: 34505288 PMCID: PMC9291196 DOI: 10.1002/pd.6043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/18/2021] [Accepted: 09/03/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Non-Invasive Prenatal Testing (NIPT) is increasingly being implemented worldwide. In public health programs, equitable access to healthcare is a fundamental principle which also applies to fetal aneuploidy screening. However, the out-of-pocket costs of NIPT may lead to sociodemographic disparities in uptake of screening. This study assessed whether there is a difference in the uptake of NIPT in socioeconomically disadvantaged neighborhoods compared to all other neighborhoods in the Netherlands, where NIPT is implemented in a national screening program (TRIDENT-2 study). METHOD NIPT uptake, postal code and age of 156,562 pregnant women who received pre-test counselling for prenatal screening in 2018 were retrieved from the national prenatal screening database. Postal codes were used as a proxy to categorize neighborhoods as being either socioeconomically disadvantaged or other. The out-of-pocket costs for NIPT were €175. RESULTS NIPT uptake in socioeconomically disadvantaged neighborhoods was 20.3% whereas uptake in all other neighborhoods was 47.6% (p < 0.001). The difference in NIPT uptake between socioeconomic disadvantaged neighborhoods and other areas was smaller for the youngest maternal age-group (≤25 years) compared to other age-groups. CONCLUSION The variation in uptake suggest underlying disparities in NIPT uptake, which undermines the goals of a national fetal aneuploidy screening program of providing reproductive autonomy and equitable access. This has ethical and policy implications for ensuring fair and responsible implementation of fetal aneuploidy screening.
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Affiliation(s)
- Karuna R M van der Meij
- Department of Human Genetics and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Caroline Kooij
- Department of Human Genetics and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mireille N Bekker
- Department of Obstetrics and Gynecology, Utrecht University Medical Center, Utrecht, The Netherlands
| | | | - Lidewij Henneman
- Department of Human Genetics and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Yarrington CD, Smith-Lin C, Neuhalfen R, Hanchate A, Connors P, Wang C. Racial and ethnic differences in uptake of cell-free fetal DNA aneuploidy screening in an urban safety net hospital. Prenat Diagn 2021; 41:1389-1394. [PMID: 34369603 DOI: 10.1002/pd.6029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/30/2021] [Accepted: 08/04/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To identify racial disparities in cell-free fetal DNA (cffDNA) first-line aneuploidy screening use among advanced maternal age women at a safety net hospital. STUDY DESIGN This retrospective cohort study of women 35 and older who delivered at Boston Medical Center from 2012 to 2015 compared to women who used cffDNA for first-line aneuploidy screening to those who did not. Maternal conventional demographics and social determinants of health were collected. We investigated the relationship between race and odds of cffDNA use, adjusting for covariates by stepwise logistic regression. RESULTS We identified 1223 women. Seventy-two percent were publicly insured. Upon adjusting for parity, prenatal care site, year of delivery, and insurance status, odds of cffNDA use remained lower for Black and Hispanic women (adjusted odds ratio [aOR] 0.47, 95% confidence interval [CI] 0.30, 0.71 and aOR 0.34 [0.21, 0.55]) compared to White women. Language proved to be an effect modifier among Hispanic women that attenuated but did not resolve the disparity in use among Hispanic compared to White women. Racial differences in cffDNA use persisted across the study period. CONCLUSION Disparity in cffDNA screening uptake exists by race in this diverse urban population. The gap in utilization between Hispanic and White women may be related to primary preferred language.
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Affiliation(s)
- Christina D Yarrington
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston, Massachusetts, USA
| | - Carolyn Smith-Lin
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston, Massachusetts, USA.,Department of Obstetrics and Gynecology, Christus St. Vincent Hospital, Gallup, New Mexico, USA
| | - Rachel Neuhalfen
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston, Massachusetts, USA
| | - Amresh Hanchate
- Boston University School of Public Health, Boston, Massachusetts, USA.,Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Philip Connors
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston, Massachusetts, USA
| | - Catharine Wang
- Boston University School of Public Health, Boston, Massachusetts, USA
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Bunnik EM, Kater-Kuipers A, Galjaard RJH, de Beaufort I. Why NIPT should be publicly funded. JOURNAL OF MEDICAL ETHICS 2020; 46:783-784. [PMID: 32277019 PMCID: PMC7656139 DOI: 10.1136/medethics-2020-106218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/26/2020] [Indexed: 05/16/2023]
Abstract
Asking pregnant women to (co)pay for non-invasive prenatal testing (NIPT) out of pocket leads to unequal access across socioeconomic strata. To avoid these social justice issues, first-trimester prenatal screening should be publicly funded in countries such as the Netherlands, with universal coverage healthcare systems that offer all other antenatal care services and screening programmes free of charge. In this reply, we offer three additional reasons for public funding of NIPT. First, NIPT may not primarily have medical utility for women and children, but rather offers relevant information and reproductive options, and thus serves important autonomy interests of women. Second, public funding of NIPT can be justified because it results in a reduction of collectively borne costs associated with care and support for children with chromosomal abnormalities. It is important to note that this is not an argument for individual women to take part in screening or to terminate an affected pregnancy. However, it is a legitimate argument in policy making regarding funding arrangements for screening programmes. Finally, public funding would help to amend current misunderstandings among pregnant women (eg, that they are not at risk), and thus to support informed consent for first-trimester prenatal screening.
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Affiliation(s)
- Eline Maria Bunnik
- Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Adriana Kater-Kuipers
- Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Robert-Jan H Galjaard
- Clinical Genetics, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Inez de Beaufort
- Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Heetkamp KM, Peters IA, Bertens LCM, Knapen MFCM. An unwanted pregnancy and language proficiency level are associated with first antenatal visit after the first trimester: Results from a prospective cohort study. Midwifery 2020; 89:102784. [PMID: 32592981 DOI: 10.1016/j.midw.2020.102784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/08/2020] [Accepted: 06/09/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To study the association between the reasons for a 'late' first antenatal visit and the influence of several maternal determinants and practical limitations on the timing of the first antenatal visit. DESIGN A prospective cohort study. SETTING Southwest region of The Netherlands, mainly characterised by large urban and suburban areas. PARTICIPANTS Women receiving information and counselling about prenatal screening between April 2010 and December 2010 were included (n = 9,268). MEASUREMENTS AND FINDINGS Timing of first antenatal visit, categorised as: 'in time' (<12+0 weeks of gestation), 'late' (≥12-23+6 weeks of gestation) and 'very late' (≥24 weeks of gestation). An unplanned or unwanted pregnancy was the most frequently reported reason for delay of the first antenatal visit (30.7%) especially in Surinamese women (79%), and women younger than 20 years (63%) or older than 40 years (50.0%). Compared to women who timed their first antenatal visit 'in time', women with a delay in their first visit were more often younger than 20 or older than 40 years of age, high order multiparous (P ≥3), with a previous miscarriage, and had an absent Dutch language proficiency level. The latter showed the strongest association with a 'very late' first antenatal visit (OR 4.96, 95%CI 2.45-10.05). KEY CONCLUSIONS Language proficiency level was highly associated with a delay in the timing of the first antenatal visit. When women timed their first antenatal visit late, having an unplanned or unwanted pregnancy was the most frequently reported reason for this delay. IMPLICATIONS FOR PRACTICE Findings from this study can be used to inform and develop interventions to improve timely antenatal care use.
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Affiliation(s)
- Kirsten M Heetkamp
- Rotterdam University of Applied Sciences, Research Centre Innovations in Care, Rotterdam, The Netherlands; Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Ingrid A Peters
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Loes C M Bertens
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maarten F C M Knapen
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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Satisfaction with obstetric care in a population of low-educated native Dutch and non-western minority women. Focus group research. PLoS One 2019; 14:e0210506. [PMID: 30703116 PMCID: PMC6354976 DOI: 10.1371/journal.pone.0210506] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/24/2018] [Indexed: 11/30/2022] Open
Abstract
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.
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