Obstetric Risks and Outcomes of Refugee Women at a Single Centre in Toronto

Are rates of clinical interventions during pregnancy and childbirth different for refugees and asylum seekers in high-income countries? A scoping review

BACKGROUND

Adequate maternity care and appropriate clinical interventions during labour and delivery can reduce adverse perinatal outcomes, but unnecessary interventions may cause harm. While studies have shown that refugees and asylum seekers face important barriers when accessing maternity care, there is a lack of high-quality quantitative data on perinatal health interventions, such as induction of labour or caesarean sections, among refugees and asylum seekers and the findings reported in the literature tend to be inconsistent. Our goal was to examine and synthesise the evidence regarding the rates of intrapartum clinical interventions in women who are refugees and asylum seekers in high-income countries compared to other population groups.

METHODS

We conducted a scoping review of peer-reviewed studies published in English since 2011 that report original quantitative findings regarding intrapartum clinical interventions among refugees and asylum seekers in high-income countries compared to those in non refugee, non asylum seeker populations. We examined reported rates of clinical pain relief, labour induction and augmentation, episiotomies, instrumental deliveries, and caesarean sections.

RESULTS

Twenty-five papers were included in the review. Findings indicate that refugees and asylum seekers were less likely to receive pain relief, with 16 out of 20 data points showing unadjusted ORs ranging from 0.20 (CI: 0.10-0.60) to 0.96 (CI: 0.70-1.32). Similarly, findings indicate lower odds of instrumental delivery among refugees and asylum seekers with 14 of 21 data points showing unadjusted ORs between 0.25 (CI: 0.15-0.39) and 0.78 (CI: 0.47-1.30); the remaining papers report no statistically significant difference between groups. There was no discernable trend in rates of labour induction and episiotomies across studies.

CONCLUSIONS

The studies included in this review suggest that asylum seekers and refugees are less likely to receive clinical pain relief and experience instrumental delivery than non-refugee groups in high-income countries. This review strengthens our understanding of the links between immigration status and maternity care, ultimately informing policy and practice to improve perinatal health and the provision of care for all.

Neighborhood Disadvantage and Birth Outcomes Among Refugees

OBJECTIVE

To examine the association between neighborhood socioeconomic disadvantage and birth outcomes among refugee women in Denmark, leveraging a natural experiment.

METHODS

This register-based study included 15 118 infants born to women who arrived in Denmark as refugees during 1986 to 1998, when a dispersal policy was in place that quasirandomly assigned newcomers to neighborhoods with varying degrees of socioeconomic disadvantage. Neighborhood disadvantage was measured using a composite index representing neighborhood-level income, education, unemployment, and welfare assistance. These data were linked to individual-level birth register data. Outcomes included low birth weight, preterm birth, and small-for-gestational-age infants. Associations between neighborhood disadvantage at resettlement and birth outcomes up to 20 years after resettlement were examined using multivariable regressions adjusting for characteristics of the women at resettlement.

RESULTS

Each SD of increase in neighborhood disadvantage was associated with an 18% increase in low birth weight risk (0.61 percentage points [pp], 95% confidence interval [CI]: 0.19-1.02), 15% increase in preterm birth risk (0.64 pp, 95% CI: 0.22-1.07), and 7% increase in small-for-gestational-age risk (0.78 pp, 95% CI: 0.01-1.54) 5 years after resettlement. Results did not differ after adjusting for urbanicity and conational density, but associations were attenuated after adjusting for municipality-level fixed effects, suggesting that local government characteristics may partially explain the associations.

CONCLUSIONS

Resettling in a disadvantaged neighborhood is associated with higher risk of adverse birth outcomes among refugee women. This highlights how policy decisions affecting settlement of refugees can have long-term consequences, including on the health of the next generation.

Trends and disparities in perinatal health outcomes among women from refugee backgrounds in Victoria, Australia: A population-based study

BACKGROUND

Women from refugee backgrounds generally experience poorer pregnancy-related outcomes compared to host populations.

AIM

To examine the trend and disparities in adverse perinatal outcomes among women of refugee background using population-based data from 2003 to 2017.

METHODS

A population-based cross-sectional study of 754,270 singleton births in Victoria compared mothers of refugee backgrounds with Australian-born mothers. Inferential statistics, including Pearson chi-square and binary logistic regression, were conducted. Multiple logistic regression was conducted to explore the relationship between adverse perinatal outcomes and the women's refugee status.

FINDINGS

Women of refugee background had higher odds of adverse neonatal and maternal outcomes, including stillbirth, neonatal death, low APGAR score, small for gestational age, postpartum haemorrhage, abnormal labour, perineal tear, and maternal admission to intensive care compared to Australian-born women. However, they had lower odds of neonatal admission to intensive care, pre-eclampsia, and maternal postnatal depression. The trend analysis showed limited signs of gaps closing over time in adverse perinatal outcomes.

DISCUSSION AND CONCLUSION

Refugee background was associated with unfavourable perinatal outcomes, highlighting the negative influence of refugee status on perinatal health. This evidences the need to address the unique healthcare requirements of this vulnerable population to enhance the well-being of mothers and newborns. Implementing targeted interventions and policies is crucial to meet the healthcare requirements of women of refugee backgrounds. Collaborative efforts between healthcare organisations, government agencies and non-governmental organisations are essential in establishing comprehensive support systems to assist refugee women throughout their perinatal journey.

Risk factors for maternal complications following uterine rupture: a 12-year single-center experience

PURPOSE

To determine maternal outcomes and risk factors for composite maternal morbidity following uterine rupture during pregnancy.

METHODS

A retrospective cohort study including all women diagnosed with uterine rupture during pregnancy, between 2011 and 2023, at a single-center. Patients with partial uterine rupture or dehiscence were excluded. We compared women who had composite maternal morbidity following uterine rupture to those without. Composite maternal morbidity was defined as any of the following: maternal death; hysterectomy; severe postpartum hemorrhage; disseminated intravascular coagulation; injury to adjacent organs; admission to the intensive care unit; or the need for relaparotomy. The primary outcome was risk factors associated with composite maternal morbidity following uterine rupture. The secondary outcome was the incidence of maternal and neonatal complications following uterine rupture.

RESULTS

During the study period, 147,037 women delivered. Of them, 120 were diagnosed with uterine rupture. Among these, 44 (36.7%) had composite maternal morbidity. There were no cases of maternal death and two cases of neonatal death (1.7%); packed cell transfusion was the major contributor to maternal morbidity [occurring in 36 patients (30%)]. Patients with composite maternal morbidity, compared to those without, were characterized by: increased maternal age (34.7 vs. 32.8 years, p = 0.03); lower gestational age at delivery (35 + 5 vs. 38 + 1 weeks, p = 0.01); a higher rate of unscarred uteri (22.7% vs. 2.6%, p < 0.01); and rupture occurring outside the lower uterine segment (52.3% vs. 10.5%, p < 0.01).

CONCLUSION

Uterine rupture entails increased risk for several adverse maternal outcomes, though possibly more favorable than previously described. Numerous risk factors for composite maternal morbidity following rupture exist and should be carefully assessed in these patients.

Wellbeing Outcomes and Risk and Protective Factors for Parents with Migrant and Refugee Backgrounds from the Middle East in the First 1000 Days: A Systematic Review

The First 1000 Days (the period from conception to a child's second birthday) is an important developmental period. However, little is known about experiences of parents with refugee and migrant backgrounds during this period. A systematic review was conducted according to PRISMA guidelines. Publications were identified through searches of the Embase, PsycINFO, PubMed, and Scopus databases, critically appraised, and synthesised using thematic analysis. A total of 35 papers met inclusion criteria. Depressive symptomatology was consistently higher than global averages, however maternal depression conceptualisations differed across studies. Several papers reported changes in relationship dynamics as a result of having a baby post-migration. Consistent relationships were found between social and health support and wellbeing. Conceptualisations of wellbeing may differ among migrant families. Limited understanding of health services and relationships with health providers may impede help-seeking. Several research gaps were identified, particularly in relation to the wellbeing of fathers, and of parents of children over 12 months old.

A comprehensive evaluation of pregnancy and newborn outcomes in Syrian refugees in Turkey

BACKGROUND

The research was conducted to evaluate the birth and newborn outcomes of Syrian immigrant women according to maternal age groups and Vitamin D use.

METHODS

It was conducted retrospectively using the birth records of 2,866 Syrian migrant women, who had given birth at a tertiary center between January 2016 and May 2020. Demographic features, obstetric and neonatal outcomes were analyzed according to age groups and Vitamin D use.

RESULTS

The mean age of the patients included in the study was 26.22 ± 5.90, the mean gestational age at birth was 38.06 ± 2.1 weeks, and the mean newborn birth weight was 3.151 g. The mean hemoglobin value of the patients was 11.55 ± 1.54. While most of the patients were taking iron supplements (80.59%), Vitamin D (Vit D) supplement intake was 38.31%. The mean number of antenatal follow-ups was 3.40 ± 1.65. While the most common delivery method was normal vaginal delivery (61.93%), cesarean section rates were found to be 38.07%. The need for blood transfusion was significantly lower in the group that had received Vitamin D than that in the group that had not received it (2.00% vs. 8.94% p < 0.001). The rate of preterm birth was found to be 5.74% in the group that had received Vitamin D and 9.28% in the group that had not received it, which was significantly higher (p < 0.001).

CONCLUSIONS

We have seen that maternal and fetal outcomes can be improved with hospital follow-up and adequate vitamin supplements in refugee pregnant women.

The unmet surgical needs of global refugee populations: A perspective review

The global refugee community, including those forced to flee due to persecution, conflict, or violence, faces significant challenges in accessing healthcare, resulting in a higher prevalence of surgical disease. These challenges have a profound impact on morbidity and mortality rates, particularly in low- and middle-income countries where many immigrants seek refuge. Limited availability of medical facilities, an inadequate surgical workforce, financial constraints and linguistic and cultural barriers all contribute to reduced access to healthcare. Limited access to competent healthcare leads to poor health outcomes, increased morbidity and mortality rates and suboptimal surgical results for refugees. To address these challenges, a multifaceted approach is necessary. This includes increased funding for healthcare initiatives, workforce recruitment and training and improved coordination between aid organisations and local healthcare systems. Strategies for managing surgical conditions in the global refugee community encompass the development of targeted public health programmes, removing legal barriers, establishing healthcare facilities to enhance surgical access and prioritising disease prevention among refugees.

Perinatal and Neonatal Outcomes of Refugee Infants in a Tertiary Hospital in Turkey

Background Worldwide, the immigration problem has been increasing due to conflicts. In recent years, Turkey accepted more than 3.8 million refugees from many countries, principally Syria. Aims In this study, we aimed to evaluate the prenatal features and neonatal outcomes of refugees and Turkish controls hospitalized in a tertiary neonatal intensive care unit in Turkey. Materials and methods This retrospective case-control study included comparative data related to populations based on whether they were refugees or not. Their perinatal and neonatal "outcomes" were compared. Results Among the 254 analyzed neonates, 127 were born to refugee mothers, and 127 controls were born to non-refugee Turkish mothers. The refugee rate in our hospitalized neonates was nine, a young mother's age (p=0.010) with a higher rate of adolescent pregnancies at OR 2.78 (95% CI 0.96-8.05) (p=0.032), and consanguineous marriage at OR 0.57 (95% CI 0.32-1.02) (p=0.031) in comparison to non-refugees. The incidence of ABO incompatibility-related hemolytic jaundice (p=0.013) was higher in the refugees. The rate of formula feeding in the first month of life was significantly higher at OR 0.49 (95% CI 0.25-0.92) (p=0.027) in neonates born to refugee mothers. Despite lower perinatal care rates in refugees at OR 7.23 (95%CI 4.12-12.69) (<0.001), preterm morbidities did not differ between refugees and non-refugee preterm infants ≤32 gestational age (p>0.05). Conclusion The importance of breast milk must be strongly encouraged to initiate and promote exclusive breastfeeding for the infants of refugees. Race is still an important risk factor for ABO incompatibility-related hemolytic jaundice. Providing high-quality healthcare is sufficient to prevent worse outcomes in refugee neonates.

Association between language barrier and inadequate prenatal care utilization among migrant women in the PreCARE prospective cohort study

BACKGROUND

Inadequate prenatal care utilization (PCU) is involved in the higher risk of adverse maternal outcomes among migrant vs. native women. Language barrier may be a risk factor for inadequate PCU. We aimed to assess the association between this barrier and inadequate PCU among migrant women.

METHODS

This analysis took place in the French multicentre prospective PreCARE cohort study, conducted in four university hospital maternity units in the northern Paris area. It included 10 419 women giving birth between 2010 and 2012. Migrants' language barrier to communication in French were categorized into three groups: migrants with no, partial or total language barrier. Inadequate PCU was assessed by the date prenatal care began, the proportion of recommended prenatal visits completed and ultrasound scans performed. The associations between these language barrier categories and inadequate PCU were tested with multivariable logistic regression models.

RESULTS

Among the 4803 migrant women included, the language barrier was partial for 785 (16.3%) and total for 181 (3.8%). Compared to migrants with no language barrier, those with partial [risk ratio (RR) 1.23, 95% confidence interval (CI) 1.13-1.33] and total (RR 1.28, 95% CI 1.10-1.50) language barrier were at higher risk of inadequate PCU. Adjustment for maternal age, parity and region of birth did not modify these associations, which were noted particularly among socially deprived women.

CONCLUSION

Migrant women with language barrier have a higher risk of inadequate PCU than those without. These findings underscore the importance of targeted efforts to bring women with language barrier to prenatal care.

Health outcomes, health services utilization, and costs consequences of medicare uninsurance among migrants in Canada: a systematic review

BACKGROUND

Medically uninsured groups, many of them migrants, reportedly delay using healthcare services due to costs and often face preventable health consequences. This systematic review sought to assess quantitative evidence on health outcomes, health services use, and health care costs among uninsured migrant populations in Canada.

METHODS

OVID MEDLINE, Embase, Global Health, EconLit, and grey literature were searched to identify relevant literature published up until March 2021. The Cochrane Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool was used to assess the quality of studies.

RESULTS

Ten studies were included. Data showed that there are differences among insured and uninsured groups in reported health outcomes and health services use. No quantitative studies on economic costs were captured.

CONCLUSIONS

Our findings indicate a need to review policies regarding accessible and affordable health care for migrants. Increasing funding to community health centers may improve service utilization and health outcomes among this population.

Evaluation of Perinatal and Neonatal Outcomes of Syrian Refugees Compared to Turkish Population: A Snapshot During the COVID-19 Pandemic

BACKGROUND

The perinatal and neonatal outcomes of Syrian refugees during the coronavirus disease 2019 (COVID-19) pandemic are unknown. Therefore, in this study, we aimed to evaluate these outcomes.

METHODS

Turkish (n = 303) and Syrian refugees (n = 303) who delivered in our hospital between June 1, 2020 and December 31, 2020 were included in the study. Demographic, perinatal, and neonatal data were obtained by retrospectively evaluating hospital records.

RESULTS

Adolescent pregnancy was more common in Syrian refugees (p < 0.001). The rates of antenatal visits, performed combined test, triple test, quadruple test, fetal anatomy ultrasound, and glucose tolerance test were lower in all refugees (p < 0.01). Furthermore, there was no difference in the mode of delivery, Hb after delivery, gestational age, birth weight, Apgar score, stillbirth, and fetal anomaly (p > 0.05 for all).

CONCLUSION

Despite poorer antenatal care during the COVID-19 pandemic, Syrian refugee pregnant women had similar perinatal and neonatal outcomes compared with the Turkish pregnant population.

What is the impact of forced displacement on health? A scoping review

While there is a broad literature analysing the effects of migration on health, important knowledge gaps persist particularly on the causal effects of forced displacement on health outcomes. We undertake a scoping review of applied epidemiological, statistical and econometric studies examining causal health impacts of forced displacement, which initially identified 1454 studies from the health and social sciences disciplines published up to May 2021. Our study makes two key contributions. First, we offer a comprehensive overview of the evidence generated, methodologies adopted and analytical challenges faced by current research examining the causal relationship between forced displacement and health. Second, we present concrete examples of how key challenges around study design and estimation approaches influence the strength of the evidence-base on the topic, using as a case study the broad domain of reproductive health. We find that, beyond the increased mortality risk that can be attributed to forced displacement, most of the available empirical evidence for a wide range of health outcomes is prone to substantial bias, making it difficult to draw firm conclusions. Our synthesis of credible studies conducted in different settings indicates that current research practice in the field could be strengthened through selection of valid control groups and application of more appropriate causal inference methods. Our findings are useful to promote the generation of further evidence on the topic that can reliably inform the design of policies to protect the health of displaced populations.

Pregnancy Complications Among Resettled Refugees in Illinois

Newly resettled refugee populations often have significant health care needs including pregnancy complications; yet research is lacking on pregnancy complications among refugees in Illinois. This was a retrospective analysis of the 2016-2017 hospital discharge data of refugee women of childbearing age (15-44 years) in Illinois. There were 3,355 hospital encounters by refugee women in our analysis, and 19.1% (n = 640) were associated with complications mainly related to pregnancy. The majority of hospital encounters associated with complications mainly related to pregnancy occurred after the first 8 months of US arrival (85.2%) and were among women who had Medicaid insurance (90.3%), ≥ 5 hospital encounters (60.2%), and who were most commonly from Iraq (23.3%) or Burma (19.4%). Refugee women may benefit from increased awareness and education about prenatal care, support in access, and prompt referrals.

Single-Centre Retrospective Cohort Study of Demographic Characteristics and Perinatal Outcomes in Pregnant Refugee Patients in Toronto, Canada

Pregnant refugee patients are especially vulnerable to adverse perinatal outcomes. Detailed characterization of this heterogenous population will identify risk factors and thus guide contextualized initiatives for improved patient care. A retrospective cohort study of obstetrical refugee patients at a tertiary-care hospital in Toronto, Ontario. Of 196 pregnant refugees, 48% were fluent English speaking, 57% had poor social support, and 42% lived in a shelter. Eighty-seven percent started prenatal care after the first trimester, which was associated with delivery of a large-for-gestational-age infant (p = 0.043). Sixteen percent experienced family violence, which was associated with poor fetal aggregate outcomes (p = 0.03). There were significantly higher rates of pre-eclampsia and Cesarean sections in refugee versus non-refugee patients (p < 0.05). Pregnant refugees are at risk for psychosocial challenges and experience significantly worse obstetrical outcomes compared with non-refugees. Quality improvement initiatives should focus on access to early prenatal care, stable housing, and support for victims of family violence.

System-level factors influencing refugee women's access and utilization of sexual and reproductive health services: A qualitative study of providers' perspectives

Refugee women have poor outcomes and low utilization of sexual and reproductive health (SRH) services, which may be driven by access to and quality of SRH services at their resettled destinations. While healthcare providers offer valuable insights into these topics, little research has explored United States (U.S.) providers' experiences. To fill this literature gap, we investigate U.S. providers' perspectives of healthcare system-related factors influencing refugee women's access and utilization of SRH services. Between July and December 2019, we conducted in-depth, semi-structured interviews with 17 providers serving refugee women in metropolitan Atlanta in the state of Georgia (United States). We used convenience and snowball sampling for recruitment. We inquired about system-related resources, facilitators, and barriers influencing SRH services access and utilization. Two coders analyzed the data using a qualitative thematic approach. We found that transportation availability was crucial to refugee women's SRH services access. Providers noted a tension between refugee women's preferred usage of informal interpretation assistance (e.g., family and friends) and healthcare providers' desire for more formal interpretation services. Providers reported a lack of funding and human resources to offer comprehensive SRH services as well as several challenges with using a referral system for women to get SRH care in other systems. Culturally and linguistically-concordant patient navigators were successful at helping refugee women navigate the healthcare system and addressing language barriers. We discussed implications for future research and practice to improve refugee women's SRH care access and utilization. In particular, our findings underscore multilevel constraints of clinics providing SRH care to refugee women and highlight the importance of transportation services and acceptable interpretation services. While understudied, the use of patient navigators holds potential for increasing refugee women's SRH care access and utilization. Patient navigation can both effectively address language-related challenges for refugee women and help them navigate the healthcare system for SRH. Future research should explore organizational and external factors that can facilitate or hinder the implementation of patient navigators for refugee women's SRH care.

HIV prevalence ratio of international migrants compared to their native-born counterparts: A systematic review and meta-analysis

BACKGROUND

People on the move, including international migrants, may face health inequities that expose them to a higher risk for HIV than native-born populations. We conducted a systematic review to calculate the HIV prevalence ratio of international migrants compared with native-born populations.

METHODS

We searched five databases between January 2010 and March 2022. Using random-effects meta-analysis, we calculated the pooled HIV prevalence ratios (PR) by comparing the HIV prevalence of migrants with native-born populations. Our research protocol is registered in the International prospective register of systematic reviews (PROSPERO, CRD42021250867).

FINDINGS

In total, 5,121 studies were screened, and 38 were included in the final analysis: 7,121,699 migrants and more than 270 million natives were included in the analysis. The pooled PR for any foreign-born migrants was 1·70 (95% CI 1·11 - 2·61, I² =99·67%, n = 33 studies), refugees was 2·37 (95% CI 0·33-16·99, I² =99·5%, n = 5), undocumented people was 3·98 (95% CI 0·11-143·01, I² =94·6%, n = 3), whilst asylum seekers was 54·79 (95% CI 17·23-174·23, I² =90·2%, n = 2). Meta-regression revealed that population type (adjusted R-squared 11.5%), region of origin (11.3%) and migrant type (10.8%) accounted for heterogeneity more than country-income (2.4%) and study setting (2.3%).

INTERPRETATION

Although it was not possible to assess if HIV infection occurred in the country of origin or destination, the HIV prevalence ratio was higher among migrants than in native-born populations. Inclusive health policies and strategies for delivering HIV testing, prevention and treatment services for migrant populations tailored to their needs are urgently needed.

FUNDING

J.J.O. and E.P.F.C. are supported by the Australian National Health and Medical Research Council (NHMRC) Emerging Leader Fellowship (GNT1193955 and GNT1172873, respectively).

Experiences of nurses caring for involuntary migrant maternal women: a qualitative systematic review

OBJECTIVE

The objective of this review was to identify, critically appraise, and synthesize qualitative evidence on the experiences of nurses providing care within various health care delivery environments to involuntary migrant women who are experiencing pregnancy, birth, or post-birth.

INTRODUCTION

Nurses are central to providing care to populations experiencing inequities. These populations include forcibly displaced pregnant and/or mothering women who have migrated involuntarily. Most of these women are ethnically diverse and often experience poverty and low literacy. This review is focused on the experiences of nurses providing care to these women.

INCLUSION CRITERIA

This review considered qualitative, peer-reviewed studies published in academic journals. Studies and study abstracts that examined nurses' experiences of providing care to involuntary migrant maternal women were included. Women could be pregnant and/or mothering. All settings in which nurses practice were considered.

METHODS

Information sources that were systematically searched for this review included CINAHL (EBSCO), PsycINFO (EBSCO), MEDLINE (EBSCO), PubMed (NLM), Web of Science, and Google Scholar. A gray literature search in Google was also developed. Studies published in English from 2000 onward were considered. Final searches were conducted in January 2021 using language within database thesauruses, such as CINAHL headings and MeSH terms, as well as keywords related to qualitative inquires on experiences of nurses caring for involuntary migrant maternal women. An intersectionality lens was applied within all review methods. Study selection was conducted by two reviewers who screened titles and abstracts that aligned with the inclusion criteria. The review followed the JBI approach for critical appraisal, data extraction, and data synthesis.

RESULTS

Twenty-three qualitative studies were included in this review. Qualitative methodologies within these studies included case study, ethnography, interpretive descriptive, and grounded theory. Nine studies considered the sex of participating nurses, and three studies considered participant history of migration. A total of 115 findings were pooled into four categories and aggregated into the following two synthesized findings: i) Nurses integrate cultural and linguistic diversity within practice; and ii) Nurses assess for inequities resulting from forced migration on maternal women. Study quality was rated as moderate on ConQual scoring, with dependability rated as moderate and credibility rated as high.

CONCLUSIONS

Key implications are made within nursing education programming, nursing practice, and policy analysis. In the realm of nursing education, integration of migrant status as a health determinant will enhance nurses' skills in assessing migrant status and understanding how varying statuses contribute to barriers among involuntary migrant women accessing health services. Providing ongoing education to nurses centered on trauma and violence-informed practice is recommended. With regard to nursing practice, review findings revealed the need for creative solutions to overcome language barriers. Innovative approaches for nurses working across language barriers in acute and community health contexts when interpreter services are not available need further exploration and protocol integration. Examination of clinical care pathways is needed for inclusion of involuntary migrant women, and exploring assessment strategies targeting how migrant status contributes to limited health service accessibility. For policy, organizations need to build policies that promote examination of migrant status and its health impacts among involuntary migrant maternal women exposed to migration-related trauma and violence to support nurses in their care provision.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019137922.

Psychosocial and behavioral health indicators among immigrant and non-immigrant recent mothers

BACKGROUND

Perinatal risk factors can vary by immigration status. We examined psychosocial and behavioral perinatal health indicators according to immigration status and immigrant characteristics.

METHODS

We conducted a population-based cross-sectional study of 33,754 immigrant and 172,342 non-immigrant childbearing women residents in Manitoba, Canada, aged 15-55 years, who had a live birth and available data from the universal newborn screen completed within 2 weeks postpartum, between January 2000 and December 2017. Immigration characteristics were from the Canadian federal government immigration database. Logistic regressions models were used to obtain Odds Ratios (OR) with 95% confidence intervals (CI) for the associations between immigration characteristics and perinatal health indicators, such as social isolation, relationship distress, partner violence, depression, alcohol, smoking, substance use, and late initiation of prenatal care.

RESULTS

More immigrant women reported being socially isolated (12.3%) than non-immigrants (3.0%) (Adjusted Odds Ratio (aOR): 6.95, 95% CI: 6.57 to 7.36) but exhibited lower odds of depression, relationship distress, partner violence, smoking, alcohol, substance use, and late initiation of prenatal care. In analyses restricted to immigrants, recent immigrants (< 5 years) had higher odds of being socially isolated (aOR: 9.04, 95% CI: 7.48 to 10.94) and late initiation of prenatal care (aOR: 1.50, 95% CI: 1.07 to 2.12) compared to long-term immigrants (10 years or more) but lower odds of relationship distress, depression, alcohol, smoking and substance use. Refugee status was positively associated with relationship distress, depression, and late initiation of prenatal care. Secondary immigrants, whose last country of permanent residence differed from their country of birth, had lower odds of social isolation, relationship distress, and smoking than primary migrants. There were also differences by maternal region of birth.

CONCLUSION

Immigrant childbearing women had a higher prevalence of social isolation but a lower prevalence of other psychosocial and behavioral perinatal health indicators than non-immigrants. Health care providers may consider the observed heterogeneity in risk to tailor care approaches for immigrant subgroups at higher risk, such as refugees, recent immigrants, and those from certain world regions.

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.

Social Isolation, Loneliness and Health: A Descriptive Study of the Experiences of Migrant Mothers With Young Children (0–5 Years Old) at La Maison Bleue

Background

Migrant women with young children, including asylum seekers and refugees, have multiple vulnerability factors that put them at increased risk of social isolation and loneliness, which are associated with negative health outcomes. This study explored the experiences of social isolation and loneliness among migrant mothers with children aged 0–5 years as well as their perceptions on possible health impacts.

Methods

A qualitative descriptive study was conducted at La Maison Bleue, a non-profit organization providing perinatal health and social services to vulnerable women in Montreal, Canada. Recruitment and data collection occurred concurrently during the COVID-19 pandemic, between November and December 2020. Eleven women participated in individual semi-structured interviews and provided socio-demographic information. Interview data were thematically analyzed.

Results

Migrant women in this study described social isolation as the loss of family support and of their familiar social/cultural networks, and loneliness as the feelings of aloneness that stemmed from being a mother in a new country with limited support. Multiple factors contributed to women's and children's social isolation and loneliness, including migration status, socioeconomic circumstances, language barriers, and being a single mother. Women expressed that the COVID-19 pandemic exacerbated pre-existing experiences of social isolation and loneliness. Mothers' experiences affected their emotional and mental health, while for children, it reduced their social opportunities outside the home, especially if not attending childcare. However, the extent to which mothers' experiences of social isolation and loneliness influenced the health and development of their children, was less clear.

Conclusion

Migrant mothers' experiences of social isolation and loneliness are intricately linked to their status as migrants and mothers. Going forward, it is critical to better document pandemic and post-pandemic consequences of social isolation and loneliness on young children of migrant families. Supportive interventions for migrant mothers and their young children should not only target social isolation but should also consider mothers' feelings of loneliness and foster social connectedness and belongingness. To address social isolation and loneliness, interventions at the individual, community and policy levels are needed.

Severe maternal morbidity among undocumented migrant women in the PreCARE prospective cohort study

OBJECTIVE

To assess the risk of severe maternal outcomes among migrant women, considering both their legal status and birthplace; in Europe, migrant women, especially from sub-Saharan Africa, have higher risks of adverse maternal outcomes compared with non-migrants and legal status, a component of migrant condition, may be an important, and potentially actionable, risk factor.

DESIGN

Prospective cohort study.

SETTING

Four maternity units around Paris in 2010-12.

SAMPLE

A total of 9599 women with singleton pregnancies.

METHODS

Legal status was categorised in four groups: reference group of non-migrant native Frenchwomen, legal migrants with French or European citizenship, other legal migrants with non-European citizenship, and undocumented migrants. The risk of severe maternal morbidity was assessed with multivariable logistic regression models according to women's legal status and birthplace.

MAIN OUTCOME MEASURE

Binary composite criterion of severe maternal morbidity.

RESULTS

Undocumented migrants had resided for less time in France, experienced social isolation, linguistic barriers and poor housing conditions more frequently and had a pre-pregnancy medical history at lower risk than other migrants. The multivariable analysis showed that they had a higher risk of severe maternal morbidity than non-migrants (33/715 [4.6%] versus 129/4523 [2.9%]; adjusted odds ratio [aOR] 1.68, 95% CI 1.12-2.53). This increased risk was significant for undocumented women from sub-Saharan Africa (18/308 [5.8%] versus 129/4523 [2.9%]; aOR 2.26, 95% CI 1.30-3.91), and not for those born elsewhere (15/407 [3.7%] versus 129/4523 [2.9%]; aOR 1.44, 95% CI 0.82-2.53).

CONCLUSION

Undocumented migrants are the migrant subgroup at highest risk of severe maternal morbidity, whereas the prevalence of risk factors does not appear to be higher in this subgroup. This finding suggests that their interaction with maternity care services may be sub-optimal.

Characteristics of vulnerable women and their association with participation in a Canada Prenatal Nutrition Program site in Toronto, Canada

INTRODUCTION

The Canada Prenatal Nutrition Program (CPNP) supports community organizations to provide maternal-infant health services for socially/economically vulnerable women. As part of our research program exploring opportunities to provide postnatal breastfeeding support through the CPNP, we investigated the sociodemographic and psychosocial characteristics of clients enrolled in a Toronto CPNP site and explored associations with participation.

METHODS

Data were collected retrospectively from the charts of 339 women registered in one southwest Toronto CPNP site from 2013 to 2016. Multivariable regression analyses were used to assess associations between 10 maternal characteristics and three dimensions of prenatal program participation: initiation (gestational age at enrolment in weeks), intensity (number of times one-on-one supports were received) and duration (number of visits).

RESULTS

The mean (SD) age of clients was 31 (5.7) years; 80% were born outside of Canada; 29% were single; and 65% had household incomes below the Statistics Canada family size-adjusted low-income cut-offs. Income was the only characteristic associated with all dimensions of participation. Compared to clients living above the low-income cut-off, those living below the low-income cut-off enrolled in the program 2.85 weeks earlier (95% CI: -5.55 to -0.16), had 1.29 times higher number of one-on-one supports (95% CI: 1.03 to 1.61) and had 1.29 times higher number of program visits (95% CI: 1.02 to 1.63).

CONCLUSION

Our findings show that this CPNP site serves vulnerable women, with few differences in participation based on maternal characteristics. This evidence can guide service provision and monitoring decisions at this program site. Further research is needed to explore new program delivery models to enhance perinatal services for vulnerable women.

Perinatal Data of Refugee Women from the Gynaecology Department of Charité University Hospital Berlin Compared with German Federal Analysis

Introduction The aim of this study was to record the perinatal data of refugee women at Charité Hospital, Berlin, and to evaluate possible differences in pre-, peri- and postnatal outcomes compared with indigenous women.

Material and Methods All pregnant women who gave birth in the period from 1 January 2014 to 30 September 2017 and were registered at least once in the hospital as “refugee” were included in the analysis. The data recorded from the refugee women were compared with the perinatal data of the German Federal obstetric analysis for the year 2016, which was published by the IQTIG (Institut für Qualitätssicherung und Transparenz im Gesundheitswesen [Institute for Quality Assurance and Transparency in Healthcare]).

Results The analysis comprised 907 refugee women and 928 infants (21 twin pregnancies). Pregnant refugee women were significantly younger than the pregnant women from the Federal analysis (birth before the age of 30: 66 vs. 41%, p < 0.001, RR: 1.6, 95% CI: 62.9 – 69.2). They had a history both of more pregnancies (≥ 3 pregnancies: 29.4 vs. 13.4%, p < 0.001, RR: 2.2, 95% CI: 26.4 – 32.5) and of more miscarriages (> 2 miscarriages: 9.7 vs. 5.9%, p < 0.001, RR: 1.6, 95% CI: 7.9 – 11.8) and more often had a history of suffering from psychological stress (11.1 vs. 4.1%, p < 0.001, RR: 2.70, 95% CI: 9.2 – 13.4). There were more premature births (10.3 vs. 3.0%, p < 0.001, RR: 3.36, 95% CI: 8.4 – 12.4), post-term pregnancies (8.5 vs. 0.5%, p < 0.001, RR: 15.4, 95% CI: 6.7 – 10.5), and cases of postpartum anaemia (28.7 vs. 22.0%, p < 0.001, RR: 1.30, 95% CI: 25.7 – 31.7) and puerperal endometritis (1 vs. 0.2%, p = 0.006, RR: 4.3, 95% CI: 0.5 – 1.9) compared with the Federal analysis. The neonatal outcome showed an increased rate of hypotrophy (11 vs. 7%, p < 0.001, RR: 1.6, 95% CI: 9.1 – 13.2), more stillbirths (0.7 vs. 0.2%, p = 0.006, RR: 3, 95% CI: 0.2 – 1.4) and increased congenital malformations (2.8 vs. 0.4%, p < 0.001, RR: 3, 95% CI: 0.2 – 1.4).

Conclusion Both refugee women and their infants showed significant differences. Despite the average younger age of the pregnant refugee women, the rates of premature birth and stillbirth and congenital malformations were significantly more frequent. More intensive antenatal screening with differentiated foetal organ diagnostics including psychosomatic care could contribute to early identification and prompt diagnosis. As regards the postpartum anaemia and puerperal endometritis, which occur more often in refugee women, midwife engagement and an improvement in the living situation in homes and accommodation facilities could be of great importance.

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.

Perinatal Outcomes Among Venezuelan Immigrants in Colombia: A Cross-Sectional Study

In the last decade, Venezuela suffers a humanitarian crisis, leading to massive emigration. One of the most vulnerable migrants´ groups is pregnant women. We analyzed the perinatal outcomes of Venezuelan migrants in Colombia and identified if migration was associated with perinatal outcomes. Birth data were obtained from the 2017 Colombian national birth registry (1085 births in migrants and 654,829 in Colombians). Logistic and linear regression models were used to identify the association between the demographic, obstetric and neonatal characteristics with premature birth (PB), low birth weight (LBW), 1-min, and 5-min Apgar score. Venezuelan were more likely to have newborns with LBW, lower Apgar scores at 1-min and 5-min in comparison to Colombians. Furthermore, a difference was observed in the low health insurance coverage and antenatal care visits among Venezuelan in comparison to natives. Access to health care services for the migrants is desirable for the improvement of perinatal health conditions.

Antenatal care and perinatal outcomes of asylum seeking women and their infants

OBJECTIVES

Asylum seekers have been highlighted as a particularly vulnerable group of expectant mothers due to complex medical and psychosocial needs, as well as the difficulties they may face in accessing care. Our aim was to examine if there were differences in the antenatal care and perinatal outcomes for asylum seeking women when compared to age- and ethnicity-matched controls delivering at the same hospital.

METHODS

Two age- and ethnicity-matched non-asylum seeking controls were identified for each asylum-seeking woman. Electronic patient records were analysed to determine the amount of antenatal care received and neonatal outcomes.

RESULTS

Thirty-four asylum-seeking women were identified who had term born infants. The median number of antenatal care episodes at the delivering hospital was significantly fewer amongst asylum-seeking women compared to controls (three vs. nine, p<0.0001). The median number of antenatal ultrasound examinations at the delivering hospital amongst asylum-seeking women was one (IQR 1-2), compared to three (IQR 3-4) in the controls (p<0.0001). The postnatal length of stay was significantly longer for infants of asylum-seeking women (median three vs. two days, p=0.002). Thirty-seven percent of asylum seeking women but none of the controls required assistance from social services. There was a significant correlation between antenatal and postnatal costs for asylum seeking women (r=0.373, p=0.042), but not for controls (r=0.171, p=0.181).

CONCLUSIONS

The increased postnatal length of stay in the infants of asylum seeking mothers may reflect their mother's reduced antenatal care and hence insufficient discharge planning for mothers and infants with increased social needs.

Addressing Obstetric Health Disparities among Refugee Populations: Training the Next Generation of Culturally Humble OB/GYN Medical Providers

Issue: The burden of increasing obstetric morbidity and mortality in the United States disproportionately affects marginalized and vulnerable populations, including refugees. Many factors have been attributed to this disparity in birth outcomes, such as linguistic, cultural, and health system limitations. However, refugee health disparities have received little attention in the U.S., especially as it relates to the training of healthcare providers. Evidence: Poor obstetric outcomes among refugee communities have been historically attributed to delayed initiation of prenatal care, failure to detect co-morbidities, as well as higher rates of Cesarean sections in comparison to host-country mothers. These inequities are often linked to poor communication due to cultural misunderstandings, which ultimately leads to mistrust and reduced utilization of healthcare services. In 2017, a Midwest academic hospital, refugee community, and health system came together to form the Congolese Health Partnership (CHP). The CHP was formed to improve access to quality healthcare for expecting Congolese mothers and their families experiencing poor quality of obstetric care. Discussions that arose from this partnership identified issues of mistrust in healthcare providers within the community, worry about misjudgment and overuse of C-sections, and a lack of understanding about health insurance during pregnancy and childbirth. Therefore, it is apparent that understanding the contextual nuances that play a role in these poor outcomes among refugee communities in the U.S. is critical in order to narrow the healthcare gap. Implications: Since pregnancy and its surrounding events are intricately tied to the ways in which different societies define culture, we argue for a focus on culture when training future healthcare providers to work with refugees in the U.S. Specifically, we focus on the necessity of cultural humility, rather than cultural competence, when caring for obstetric patients from diverse backgrounds. Cultural humility forces providers to think about power imbalances that exist between a patient and provider when cultural differences exist. We describe specific barriers to care among Congolese refugees living in eastern Iowa and explore ways to utilize community-provider partnership and cultural humility training to address obstetric morbidity. Finally, we propose ways to incorporate cultural humility training among OB/GYN residents to address community-identified barriers to improve overall health outcomes locally with implications for refugee communities across the U.S.

The childbirth experiences of Syrian refugee mothers living in Turkey: a qualitative study

Objective:The study aims to examine the childbirth experiences of Syrian refugee mothers living in Turkey.Methods: This qualitative study was conducted with 12 mothers who had a vaginal birth and were assisted by midwives. The data were collected using an in-depth interview form and analyzed with the thematic analysis technique.Results: The childbirth experiences of the mothers were grouped under two main headings as negative and positive experiences. "Negative childbirth experiences" were divided into 4 main themes as "negative emotions experienced during childbirth, lack of effective communication due to the language barrier, difficulties experienced related to hospital policies and dissatisfaction with midwives". "Positive birth experiences", were categorized under three main themes as "satisfaction with the midwife, finding the country safe to give birth, and mother' s positive attitude towards birth process". The mothers were satisfied with "the attitudes and behaviors of the midwives and their professional practices", and the positive attitude of mothers towards birth in religious and cultural terms contributed to the positive birth perception.Conclusion: Refugee mothers were found to have both positive and negative childbirth experiences. Individualized, empathic communication-based, culturally sensitive and evidence-based care may contribute to the positive childbirth experiences of refugee women.

Antenatal Care Utilization and Obstetric and Newborn Outcomes Among Pregnant Refugees Attending a Specialized Refugee Clinic

The objective of the study is to characterize the antenatal care utilization and obstetric and newborn outcomes among refugee women at a specialized refugee clinic and determine whether these outcomes varied between refugees (government-assisted or privately-sponsored) and asylum seekers. This retrospective cohort study included women receiving antenatal care at a specialized refugee clinic between 2011 and 2016. Time from arrival to first clinic visit, Adequacy of Prenatal Care Utilization Index, and obstetric and newborn outcomes were examined, stratified by refugee category. Amongst 179 women, median time from arrival to first clinic visit was longer for asylum seekers (2.8 months, IQR 12.9) compared to government-assisted and privately-sponsored refugees (0.4 months, IQR 0.7, and 1.6 months, IQR 3.2, respectively; p < 0.01). A larger proportion of asylum seeking women received inadequate antenatal care. No difference was found in obstetric and newborn outcomes. Differences in antenatal care utilization between refugee categories suggest that barriers may remain for asylum seekers; however, obstetric and newborn outcomes were comparable amongst refugee categories.

Pregnancy complications among refugee women: A systematic review

INTRODUCTION

Pregnancy is a time of increased vulnerability for women. Women of refugee background may be further challenged in pregnancy due to a complex series of physical, psychological and social factors. Previous studies show ambiguous results, with some showing increased the risk of prenatal complications in refugees compared with their native counterparts, whereas other studies report the opposite. With the current steep rise in the number of refugees and displaced persons worldwide, research is important to understand whether pregnancy disparities between this population and their native counterparts exist, and the causes. This systematic literature review aims to find out whether refugee women have a higher prevalence of adverse pregnancy outcomes and prenatal infections compared with native women.

MATERIAL AND METHODS

We conducted a literature search in the databases PubMed and Embase, supplemented with screening of reference lists and citations for relevant literature. We included studies published in English reporting risk of preeclampsia, spontaneous abortion and stillbirths, preterm birth, preterm prelabor rupture of membranes (PPROM) and adverse prenatal infectious diseases in women of refugee status. PROSPERO registration CRD42020205628.

RESULTS

We identified 19 articles eligible for inclusion: 12 were cross-sectional, six were cohort studies and one was a case-control study. The most frequently reported outcome in the literature was preterm birth (reported in 16 of the studies) and preeclampsia (reported in 11 of the studies). Refugees had increased risk of stillbirth (reported relative risk ranging from 1.20 to 2.24) and spontaneous abortion (reported relative risk ranging from 1.56 to 1.58), when compared with native women and a decreased risk of preeclampsia (reported relative risk ranging from 0.65 to 0.81).

CONCLUSIONS

The small number of articles eligible for inclusion in the review highlights the lack of research and knowledge on refugee health during pregnancy. Further research is required to understand and reduce disparities in pregnancy outcomes between refugee and non-refugee women.

Experiences of nurses caring for maternal immigrant and refugee women: a qualitative systematic review protocol

OBJECTIVE

This review will focus on studies inquiring into nurses working across diverse health care settings and their experiences of caring for immigrant and refugee women who are pregnant or mothering. Within this review, diverse terminologies used to conceptualize "nurse," immigrant," and "refugee" will also be captured.

INTRODUCTION

Immigrant and refugee women who are pregnant or mothering experience poorer health than non-displaced women. Nurses are pivotal in providing care to this population. Understanding nursing experiences can reveal structural barriers and facilitators to equitable care provision.

INCLUSION CRITERIA

Peer-reviewed, qualitative studies that include nurses working across diverse health care settings and providing care to involuntary immigrant and refugee maternal women will be considered. Studies where nurses are described as being educated within a basic and generalized nursing program and have been authorized by a regulatory organization to practice nursing in their country will be included.

METHODS

Key information sources searched include CINAHL, PsycINFO, MEDLINE, Google Scholar, Web of Science, and PubMed. Search terms will be adapted for each information source. Study selection includes screening titles and abstracts by two independent reviewers against the inclusion criteria. These reviewers will then critically appraise for methodological quality and begin data extraction to understand experiences of nurses and diverse understandings of "nurse," "immigrant," and "refugee." Synthesis includes assembling and categorizing findings on the basis of meaning similarity. A set of statements will be generated representing this synthesis.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019137922.

Association between Migrant Women's Legal Status and Prenatal Care Utilization in the PreCARE Cohort

Barriers to access to prenatal care may partially explain the higher risk of adverse pregnancy outcomes among migrants compared with native-born women in Europe. Our aim was to assess the association between women's legal status and inadequate prenatal care utilization (PCU) in France, where access to healthcare is supposed to be universal. The study population was extracted from the PreCARE prospective cohort (N = 10,419). The associations between women's legal status and a composite outcome variable of inadequate PCU were assessed with multivariate logistic regressions. The proportion of women born in sub-Saharan Africa (SSA) was higher among the undocumented than that of other migrants. All groups of migrant women had a higher risk of inadequate PCU (31.6% for legal migrants with European nationalities, 40.3% for other legal migrants, and 52.0% for undocumented migrants) than French-born women (26.4%). The adjusted odds ratio (aOR) for inadequate PCU for undocumented migrants compared with that for French-born women was 2.58 (95% confidence interval 2.16-3.07) overall, and this association was similar for migrant women born in SSA (aOR 2.95, 2.28-3.82) and those born elsewhere (aOR 2.37, 1.89-2.97). Regardless of the maternal place of birth, undocumented migrant status is associated with a higher risk of inadequate PCU.

A lifespan developmental science perspective on trauma experiences in refugee situations

Developmental science theory and empirical research on refugee situations requires an updated approach to the study of trauma as a multi-systemic and multilevel phenomenon. We present a theoretical framework that integrates developmental science approaches to highlight critical threats to development in situations of violent displacement. Given the complexities of displacement (causes, trajectories, and living circumstances once displaced), this theoretical model highlights the utility of an approach that recognizes the person-age-context fit in which displaced individuals live their lives and how both trauma and ongoing major disruption to daily life affects outcomes. In so doing, we aim to broaden understanding for future trauma and intervention research as well as practice with those who experience potentially traumatic events and severe disruption to their social ecology at different points in the lifespan.

Antenatal and perinatal outcomes of refugees in high income countries

OBJECTIVES

The World Health Organisation (WHO) has highlighted a marked trend for worse pregnancy-related indicators in migrants, such as maternal and neonatal morbidity and mortality, poor mental health and suboptimal care. The aim of this study was to determine whether such adverse outcomes occurred in refugees who moved to high income countries by comparing their antenatal and perinatal outcomes to those of non-immigrant women.

METHODS

A literature search was undertaken. Embase and Medline databases were searched using Ovid. Search terms included "refugee", "pregnan*" or "neonat*", and "outcome".

RESULTS

The search yielded 194 papers, 23 were included in the final analysis. All the papers included were either retrospective cohort or cross-sectional studies. The refugees studied originated from a wide variety of source countries, including Eritrea, Somalia, Afghanistan, Iraq, and Syria. Refugee women were more likely to be socially disadvantaged, but less likely to smoke or take illegal drugs during pregnancy. Refugee women were more likely to have poor, late, or no attendance at antenatal care. Miscarriages and stillbirth were more common amongst refugee women than non-refugees. Perinatal mortality was higher among refugees.

CONCLUSIONS

Despite better health care services in high income countries, refugee mothers still had worse outcomes. This may be explained by their late or lack of attendance to antenatal care.

A study of low birth weight prevalence and risk factors among newborns in a public-hospital at Kilis, Turkey

Background

Low birth weight (LBW) is an important indicator of reproductive health and general health status of population.

Objectives

The present study was aimed to estimate the prevalence of low birth weight (LBW), and to investigate the associations between some risk factors and LBW in Syrian refugee and Turkish population in Kilis, Turkey.

Methods

The population of this study constituted of a total of 4379 infants born in Kilis State Hospital in 2016 using a retrospective cross-sectional study design. The data were collected from birth records. The data were analyzed using SPSS version 16.0. Binary logistic regression analysis was performed to identify predictors of low birth weight. Factors with a p-value < 0.05 were deemed to be statistically significant.

Results

The prevalence of LBW was 6.7% in all groups. Significant relationships were found between young maternal age, Syrian refugee mother, female infants, cesarean delivery and LBW.

Conclusion

The prevalence of low birth weight in the study area was comparatively lower than that of countrywide figure. Maternal related variables like, maternal age, mother's nationality, and mode of birth (vaginal, cesarean) take after up as well as new-born related variables like gender of the neonate were significantly related with low birth weight.

Surgical Needs of Internally Displaced Persons in Kerenik, West Darfur, Sudan

BACKGROUND

The burden of surgical disease in refugee and internally displaced person (IDP) populations has not been well defined. Populations fleeing conflict are mobile, limiting the effectiveness of traditional sampling methods. We employed novel sampling and survey techniques to conduct a population-based surgical needs assessment amongst IDPs in Kerenik, West Darfur, Sudan, over 4 weeks in 2008.

METHODS

Satellite imagery was used to identify man-made structures. Ground teams were guided by GPS to randomly selected households. A newly created surgical needs survey was administered by surgeons to household members. One randomly selected individual answered demographic and medical history questions pertaining to themselves and first-degree blood relatives. All household members were offered a physical examination looking for surgical disease.

FINDINGS

There were 780 study participants; 82% were IDPs. A history since displacement of surgical and potentially surgical conditions was reported in 38% of respondents and by 73% of respondents in first-degree blood relatives. Surgical histories included trauma (gunshots, stabbings, assaults) (5% respondents; 27% relatives), burns (6% respondents; 14% relatives), and obstetrical problems (5% female respondents; 11% relatives). 1485 individuals agreed to physical examinations. Untreated surgical and potentially surgical disease was identified in 25% of participants.

INTERPRETATION

We identified and characterized a high burden of surgical and potentially surgical disease in an IDP population in West Darfur. Our study is unique in its direct assessment of a traumatized, mobile, vulnerable population. Health officials and agencies charged with the care of IDP and refugee populations should be aware of the high prevalence of surgical and potentially surgical conditions in these communities. This study adds to the growing body of evidence that investment in surgical resources may address a significant portion of the overall burden of disease in marginalized populations.

Perinatal outcomes of African refugees after their integration into the Israeli health care system

OBJECTIVE

Evaluate whether the incorporation of the refugees into the Israeli medical system resulted in improvements in perinatal outcomes, namely a reduction in the number of preterm deliveries and a decrease in NICU admissions.

METHODS

Retrospective cohort study. Electronic medical records of all African immigrants who delivered in our tertiary referral center between January 2018 and September 2019 were reviewed. African patients' demographics, maternal and perinatal outcomes were compared to those of native Israeli population. In addition, the results were compared to the cohort from our previous study from 2010.

RESULTS

A total of 20,796 deliveries took place at our labor and delivery department during the study period. Of these, 3% of all deliveries were of African refugees. Total rates of preterm deliveries <37 weeks was similar between groups, while rate of premature deliveries <34 week was higher among refugees. Rates of extreme prematurity <28 weeks were also similar between groups. Rate of meconium stained amniotic fluid, neonatal weight <2000 g as well as NICU admissions were significantly higher among refugees.

CONCLUSION

Though perinatal results have not substantially improved with the incorporation of a refugee population into a healthcare system, some progression has indeed been achieved in some perinatal parameters.

Pregnancy outcomes in asylum seekers in the North of the Netherlands: a retrospective documentary analysis

BACKGROUND

With more than 20,000 asylum seekers arriving every year, healthcare for this population has become an important issue. Pregnant asylum seekers seem to be at risk of poor pregnancy outcomes. This study aimed to assess the difference in pregnancy outcomes between asylum seekers and the local Dutch population and to identify potential substandard factors of care.

METHODS

Using a retrospective study design we compared pregnancy outcomes of asylum-seeking and Dutch women who gave birth in a northern region of the Netherlands between January 2012 and December 2016. The following data were compared: perinatal mortality, maternal mortality, gestational age at delivery, preterm delivery, birth weight, small for gestational age children, APGAR score, intrauterine foetal death, mode of delivery and the need for pain medication. Cases of perinatal mortality in asylum seekers were reviewed for potential substandard factors.

RESULTS

A total of 344 Asylum-seeking women and 2323 Dutch women were included. Asylum seekers had a higher rate of perinatal mortality (3.2% vs. 0.6%, p = 0.000) including a higher rate of intrauterine foetal death (2.3% vs. 0.2%, p = 0.000), higher gestational age at birth (39 + 4 vs. 38 + 6 weeks, p = 0.000), labour was less often induced (36.9 vs. 43.8, p = 0.016), postnatal hospitalization was longer (2.24 vs. 1.72 days p = 0.006) and they received more opioid analgesics (27.3% vs. 22%, p = 0.029). Babies born from asylum-seeking women had lower birth weights (3265 vs. 3385 g, p = 0.000) and were more often small for gestational age (13.9% vs. 8.4%, p = 0.002). Multivariate analysis showed that the increased risk of perinatal mortality in asylum-seeking women was independent of parity, birth weight and gestational age at birth. Review of the perinatal mortality cases in asylum seekers revealed possible substandard factors, such as late initiation of antenatal care, missed appointments because of transportation problems, not recognising alarm symptoms, not knowing who to contact and transfer to other locations during pregnancy.

CONCLUSION

Pregnant asylum seekers have an increased risk of adverse pregnancy outcomes. More research is needed to identify which specific risk factors are involved in poor perinatal outcomes in asylum seekers and to identify strategies to improve perinatal care for this group of vulnerable women.

Retrospective Evaluation of Perinatal and Early Neonatal Outcomes in Infants of Migrant Mothers: A Case-Controlled Study

Objective:

To investigate the incidence of perinatal features and neonatal morbidities in migrant mothers in comparison with native Turkish mothers.

Method:

A retrospective analysis was conducted using the medical records of 89 infants born to Syrian immigrants and 89 infants born to native Turkish mothers who were consecutively admitted to the neonatal intensive care unit of our hospital between 2015 and 2019. Statistical analyses were used to compare demographic data and perinatal and neonatal outcomes between the two groups.

Results:

Compared to Turkish mothers, Syrian mothers were significantly younger and adolescent pregnancy rate was significantly higher (p<0.01). The rates of multiple pregnancy, consanguineous marriage, and prolonged premature membrane rupture were also significantly higher in Syrian mothers (p<0.05). The incidence rates of congenital anomalies, respiratory distress syndrome, transient tachypnea of newborn pneumonia/bronchiolitis, sepsis, jaundice, and feeding problems were the same for infants born to Syrian and Turkish mothers (p>0.05). In addition, the two groups did not differ with respect to gestational week at birth, birth weight, sex, types of delivery, Apgar score, duration of hospital stay, and incidence of infant mortality (p>0.05).

Conclusion:

The immigrant status negatively affects perinatal and neonatal outcomes. However, the incidence rates of infant mortality and neonatal morbidity did not differ between infants born to Syrian and those born to Turkish mothers. This may be due to the recent improvements in the of overall health status of migrant women or of those migrants living in Turkey being able to have access to increased prenatal and postnatal period policies of mother-child health services which have been successfully implemented.

Common Diagnoses among Refugee Populations: Linked Results with Statewide Hospital Discharge Database

BACKGROUND

According to the U.S. State Department's Refugee Processing Center and the U.S. Census Bureau, in the fiscal year 2016, among all states in the United States, Nebraska resettled the highest number of refugees per capita.

OBJECTIVES

The objectives of this study were to determine the most common reasons for refugees utilizing hospital services in Nebraska between January 2011 and September 2015, and to examine whether refugee patients had increased risks for adverse health conditions compared to non-refugee patients.

METHODS

Statewide linkage was performed between Nebraska Medicaid Program's immigration data, and 2011-2015 Nebraska hospital discharge data inpatient and outpatient files. The linkage produced 3017, 5460, and 775 cases for emergency department visits, outpatient clinic visits, and inpatient care for the refugee sample, respectively.

FINDINGS

Refugee patients were at increased risk for a number of diagnoses or medical conditions, including pregnancy complications, abdominal pain, upper respiratory infections, viral infections, mood disorders, disorders of teeth and jaw, deficiency and anemia, urinary system disorders, headache, nausea and vomiting, limb fractures, spondylosis, essential hypertension, and uncomplicated diabetes mellitus.

CONCLUSIONS

The findings suggest a greater emphasis on preventive healthcare, especially in areas of maternal health and perinatal outcomes, psychological counseling, screening for infectious diseases, nutrition and healthy eating, and oral health. Additionally, culturally appropriate measures to address prevention, health screening, and treatments should be adopted by health providers who care for refugees.

Perinatal health outcomes and care among asylum seekers and refugees: a systematic review of systematic reviews

BACKGROUND

Global migration is at an all-time high with implications for perinatal health. Migrant women, especially asylum seekers and refugees, represent a particularly vulnerable group. Understanding the impact on the perinatal health of women and offspring is an important prerequisite to improving care and outcomes. The aim of this systematic review was to summarise the current evidence base on perinatal health outcomes and care among women with asylum seeker or refugee status.

METHODS

Twelve electronic database, reference list and citation searches (1 January 2007-July 2017) were carried out between June and July 2017. Quantitative and qualitative systematic reviews, published in the English language, were included if they reported perinatal health outcomes or care and clearly stated that they included asylum seekers or refugees. Screening for eligibility, data extraction, quality appraisal and evidence synthesis were carried out in duplicate. The results were summarised narratively.

RESULTS

Among 3415 records screened, 29 systematic reviews met the inclusion criteria. Only one exclusively focussed on asylum seekers; the remaining reviews grouped asylum seekers and refugees with wider migrant populations. Perinatal outcomes were predominantly worse among migrant women, particularly mental health, maternal mortality, preterm birth and congenital anomalies. Access and use of care was obstructed by structural, organisational, social, personal and cultural barriers. Migrant women's experiences of care included negative communication, discrimination, poor relationships with health professionals, cultural clashes and negative experiences of clinical intervention. Additional data for asylum seekers and refugees demonstrated complex obstetric issues, sexual assault, offspring mortality, unwanted pregnancy, poverty, social isolation and experiences of racism, prejudice and stereotyping within perinatal healthcare.

CONCLUSIONS

This review identified adverse pregnancy outcomes among asylum seeker and refugee women, representing a double burden of inequality for one of the most globally vulnerable groups of women. Improvements in the provision of perinatal healthcare could reduce inequalities in adverse outcomes and improve women's experiences of care. Strategies to overcome barriers to accessing care require immediate attention. The systematic review evidence base is limited by combining heterogeneous migrant, asylum seeker and refugee populations, inconsistent use of definitions and limited data on some perinatal outcomes and risk factors. Future research needs to overcome these limitations to improve data quality and address inequalities.

SYSTEMATIC REGISTRATION

Systematic review registration number: PROSPERO CRD42017073315 .

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.

Do Syrian refugees have increased risk for worser pregnancy outcomes? Results of a tertiary center in İstanbul

Objective:

To compare obstetric and perinatal outcomes of Syrian refugee pregnants and Turkish counterparts who gave birth at a tertiary center in İstanbul.

Materials and Methods:

A retrospective study including the birth records of 704 Syrian refugees and 744 Turkish pregnant women between January 2016 and May 2017 were analyzed. Demographic data, obstetric and neonatal outcomes were compared. The primary aims of this study were to evaluate the pregnancy outcomes and cesarean rates between the groups. The secondary outcomes were the use of antenatal vitamin supplementation, hemoglobin-hematocrit values, and maternal complications.

Results:

Our results showed that the use of folic acid and iron supplementation rates during pregnancy were similar between the groups (folic acid supplementation 8.1% vs 6.5%, p=0.264; iron supplementation 20.7% vs 19.6%, p=0.125; respectively for Turkish women and Syrian refugees). Cesarean rates were significantly higher for Turkish patients than in Syrian refugees (42.7% vs 32.7%; p<0.05). Gestational age at delivery was significantly higher among Turkish women when compared with Syrian refugees (37.7±2.3 vs 36.4±2.3 weeks, p<0.05), but there was no significant difference regarding the birtweights’ of the newborns (3134 g vs 3066 g for Turkish women and Syrian refugees, respectively, p=0.105). Although obstetric complications were seen more often in Syrian refugees, it did not reach statistical difference (9.7% vs 8.1%, respectively, p=0.285).

Conclusion:

Syrian refugees use antenatal vitamin supplementations at similar rates to Turkish citizens and obstetric and perinatal outcomes are similar between the groups.

Gestational diabetes care and outcomes for refugee women: a population-based cohort study

AIM

To determine the prevalence of adverse clinical outcomes, the rates of healthcare utilization, and the incidence of post-partum Type 2 diabetes in refugees with gestational diabetes (GDM), compared with other immigrants and non-immigrants.

METHODS

A population-based cohort study was conducted using healthcare databases in Ontario, Canada. Over 40 000 women with GDM having singleton live births between 2002 and 2014 were identified. We identified GDM adverse outcomes such as macrosomia, pre-eclampsia and respiratory distress syndrome. Antenatal and newborn healthcare utilization were ascertained. Women were then followed for diagnosis of diabetes post-partum.

RESULTS

Both refugees and other immigrants had a lower rate than non-immigrants of many adverse GDM outcomes, including pre-eclampsia [relative risk (RR) 0.65, 95% confidence interval (95% CI) 0.44-0.95 and 0.61, 95% CI 0.52-0.72, respectively], preterm birth (RR 0.87, 95% CI 0.75-0.995 and 0.85, 95% CI 0.80-0.91, respectively), and respiratory distress syndrome (RR 0.83, 95% CI 0.70-0.97 and 0.78, 95% CI 0.72-0.84, respectively). However, refugees were less likely to attend well-baby care in time for the first routine vaccination (RR 0.92, 95% CI 0.88-0.95). Incidence of post-partum diabetes was high in all groups, but refugee women were at increased risk (hazard ratio 1.23, 95% CI 1.11-1.37).

CONCLUSIONS

Despite different circumstances leading to migration, refugees have a similar 'healthy immigrant effect' to other immigrants, with respect to adverse GDM outcomes. However, newborns of refugees were less likely to have well-baby care, and refugee women were also at especially high risk of developing diabetes post-partum. These are both important public health issues.