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

Effect of access to antenatal care on risk of preterm birth among migrant women in Italy: A population-based cohort study

Objective

To evaluate the association between maternal migration status and preterm birth, and whether a better adherence to antenatal care during pregnancy mitigates the risk of preterm birth.

Design

Population-based cohort.

Setting

Administrative databases of the Lombardy region, Italy.

Population

First singleton births of women aged 15-55 years at 22-42 gestational weeks, between 2016 and 2021.

Methods

Assessed the risk of preterm birth (<37 weeks).

Main outcome measures

A multivariable logistic regression mediation model calculated the mediation effect of adherence to antenatal care in the association between maternal migrant status and preterm birth and the residual effect not mediated by it. Analyses were adjusted for the socio-demographic and pregnant characteristics of the women.

Results

Of 349,753 births in the cohort, Italian nationality accounted for 71 %; 28.4 % were documented migrants and 0.4 % undocumented migrants. Among them, 5.3 %, 6.4 %, and 9.3 % had a preterm birth, respectively. Using deliveries of Italian citizens as referent, migrants had a significantly increased risk of preterm birth (adjusted relative risk: 1.22, 95 % confidence interval: 1.18-1.27). Adherence to antenatal care mediated the 62 % of such risk. We have calculated that adherence to antenatal pathways set to the highest level for the whole population could lead to a 37 % reduction in preterm birth risk.

Conclusion

Part of the excess of preterm birth among documented and undocumented migrants in Italy can be explained by a lack of adherence to the antenatal care path despite equal access to National Health care. The adherence of all pregnant women to antenatal care would reduce the risk of preterm birth by about one-third.

Pregnancy outcomes of forced migrants in the Netherlands: A national registry-based study

Background

The rise of global forced migration urges healthcare systems to respond to the needs of forced migrants (FM) during pregnancy and childbirth. Yet, comprehensive data on the health outcomes of pregnant FM in destination countries remain scarce. This study aimed to describe the characteristics and maternal and perinatal outcomes of pregnancy in this specific migrant population on a national scale in the Netherlands and to explore differences from other populations.

Methods

The Dutch perinatal registry was linked to national migration data to analyze pregnancy outcomes in FM (2014-2019), using non-migrants (NM) and resident migrants (RM) as reference populations. We reported outcome rates (% [95 % CI]) for a range of primary and secondary pregnancy outcomes. Primary outcomes included perinatal mortality, small for gestational age infants (SGA), preterm birth, and emergency cesarean section (CS), for which we also calculated the crude relative risk (RR [95 % CI]) of FM compared to NM and RM. In addition, we conducted binary logistic regression analyses on primary outcomes to report adjusted odds ratios (aORs [95 % CIs]) while controlling for multiple births, maternal age and parity.

Findings

Compared to the NM group, the FM group had increased risks of perinatal mortality (RR 1.50 [95 % CI 1.20-1.88]), SGA (1.65 [1.59-1.71], and emergency CS (1.19 [1.13-1.25]). Compared to RM, FM still had elevated risks of SGA (1.17 [1.13-1.22]). In contrast, the risk of preterm birth was lower in FM than in NM (0.81 [0.76-0.86]) and RM (0.83 [0.77-0.88]). These differences were confirmed in the adjusted analysis. Differences in secondary outcomes included higher rates of late antenatal care in FM (29.4 % [28.5-30.3]) than in NM (6.7 % [6.6-6.9]) and RM (15.5 % [15.1-15.9]). Rates of planned CS were similarly elevated (14.3 % [95 % CI 13.7-14.8] versus 7.·8 % [7.7-7.8] and 9.6 % [9.5-9.7]), while FM had lower rates of postpartum hemorrhage (3.9 % [3.6-4.2]) versus 6.8 % [6.8-6.9] and 5.7 % [5.6-5.9]).

Conclusion

This first Dutch registry-based study demonstrated increased risks of multiple, though not all, adverse pregnancy outcomes in forced migrants. Our results emphasize the imperative to further unravel and address migration-related disparities, dismantle structural barriers to health among forced migrants, and improve the inclusivity of data systems. Collaborative policy, clinical practice, and research efforts are essential to ensure equitable care for every individual, regardless of migration status.

What words can tell us about social determinants of mental health: A multi-method analysis of sentiment towards migration experiences and community life in Lima, Perú

To support resilience in contexts of migration, a deeper understanding of the experiences of both receiving communities and migrants is required. Research on the impacts of migration on community life is limited in contexts with high internal migration (i.e., migrating within one's country of origin). Evidence suggests that cultural similarity, community relationships, and access to resources may be protective factors that could be leveraged to support the mental health of internal migrants. The current study uses data drawn from a sample of pregnant Peruvian women (N = 251), 87 of whom reported being internal migrants and 164 of whom reported being from the locale of the study (Lima, Perú). The aim was to better understand the social experience of internal migration for both local and migrant women. Inductive thematic analysis was used to examine migration experience and perceived impact of migration on community life. Internal migrants discussed three themes relative to their experiences: motivations, adjustment, and challenges. Experiences of women in receiving communities consisted of four themes related to migration: positive, negative, neutral, and mixed perceptions. Linguistic Inquiry and Word Count (LIWC-22) software was also used to assess sentiment towards migration. Across both analytic methods, migration motivations and perceptions were multifaceted and migrants reported a wide range of challenges before, during, and after migration. Findings indicated that attitudes toward migration are broadly positive, and that there is a more positive appraisal of migration's impact on the community life for internal as opposed to international migration.

Perinatal mortality among pregnant undocumented migrants in Norway 1999-2020: A register-based population study

BACKGROUND

Irregular legal status is a recognized health risk factor in the context of migration. However, undocumented migrants are rarely included in health surveys and register studies. Adverse perinatal outcomes are especially important because they have long-term consequences and societal risk factors are modifiable. In this study, we compare perinatal outcomes in undocumented migrants to foreign-born and Norwegian-born residents, using a population-based register.

METHODS

We included women 18-49 years old giving birth to singletons as registered in the Medical Birth Registry of Norway from 1999 to 2020. Women were categorized as 'undocumented migrants' (without an identity number), 'documented migrants' (with an identity number and born abroad), and 'non-migrants' (with an identity number and born in Norway). The main outcome was perinatal mortality, i.e., death of a foetus ≥ gestational week 22, or neonate up to seven days after birth. We used log-binominal regression to estimate the association between legal status and perinatal mortality, adjusting for several maternal pre-gestational and gestational factors. Direct standardization was used to adjust for maternal region of origin.

ETHICAL APPROVAL

Regional Ethical Committee (REK South East, case number 68329).

RESULTS

We retrieved information on 5856 undocumented migrant women who gave birth during the study period representing 0.5% of the 1 247 537 births in Norway. Undocumented migrants had a relative risk of 6.17 (95% confidence interval 5.29 ̶7.20) of perinatal mortality compared to non-migrants and a relative risk of 4.17 (95% confidence interval 3.51 ̶4.93) compared to documented migrants. Adjusting for maternal region of origin attenuated the results slightly.

CONCLUSION

Being undocumented is strongly associated with perinatal mortality in the offspring. Disparities were not explained by maternal origin or maternal health factors, indicating that social determinants of health through delays in receiving adequate care and factors negatively influencing gestational length may be of importance.

Women's country of birth and failure to catch up an overdue cervical cancer cytological screening participation during pregnancy in France, an observational study based on survey sources

BACKGROUND

Cervical cancer is the fourth most common cancer among women worldwide, both for incidence and mortality. Prevention relies on screening with a Pap test to detect precancerous lesions, which can then be treated. Access to this screening is currently both improvable and inequitable. Pregnancy may be an ideal moment for women to catch up on their overdue cervical cancer screening. In the general population, women's risk of not being screened is associated with their place of birth and other social factors; this may be true as well among pregnant women. Our objective was to study the association between women's place of birth and their failure to catch up with this screening during pregnancy.

METHODS

The 2016 French National Perinatal Survey included 13,147 women who gave birth after 21 weeks of gestation. The association between their place of birth and failure to catch up on this screening (defined by the absence of a Pap test during pregnancy for women overdue for it) was adjusted for age, parity, education level, health insurance, and when they began prenatal care with logistic regression models.

RESULTS

Among the women for whom screening was then recommended, 49% were not up to date at the start of pregnancy, and of these, 53% were not caught up before delivery. After adjustment for other risk factors, maternal place of birth was not associated with a higher risk of failure to catch up with this screening during pregnancy. However, factors identified as associated with this risk included a low education level and late start of prenatal care.

CONCLUSION

About half of women overdue for cervical cancer screening did not catch up with it during their pregnancy. Professionals should pay special attention to women with lower education levels and late initiation of prenatal care, who constitute a group at high risk of not catching up on this screening during pregnancy.

[Maternal mortality among socially vulnerable women in France 2016-2018]

Social vulnerability is a known factor in perinatal medical risk, both for the foetus and the mother. As part of the French confidential enquiry into maternal deaths, the introduction in 2015 of specific items relating to social status has made it possible to recreate this composite variable. Over the period 2016-2018, one woman in three who died was in a situation of social vulnerability. Of these 79 deaths, 32 (41%) were related to direct obstetric causes, 26 (33%) to indirect obstetric causes, 12 (15%) to suicides and 8 (10%) of unknown cause. Care was considered sub-optimal in 73% of cases, compared with 64% in the group of maternal deaths with no identified social vulnerability. 43 deaths were judged to be probably (n=12) or possibly (n=31) avoidable, 25 were not avoidable, and 11 were not sufficiently documented for this assessment; i.e. a proportion of 63% of probable or possible avoidability, a higher proportion compared with the 56% of avoidability among women with no identified social vulnerability. In 1/3 of maternal deaths, a lack of interaction between the woman and the healthcare system was involved in the chain of events leading to death, i.e. 2 times more than in the case of socially non-vulnerable women. Improving the interaction of women in socially vulnerable situations with the hospital system and the institutional and voluntary networks providing care, support and assistance is a priority. A specific, responsive medical and social organisation could contribute to this.

The effect of limited access to antenatal care on pregnancy experiences and outcomes among undocumented migrant women in Europe: a systematic review

Women who are undocumented migrants in Europe encounter a variety of challenges while trying to access health services, including restricted access to antenatal care (ANC) despite the importance of ANC to the well-being of mothers and their infants. This study's aim was to examine the effect that limited access to antenatal care has on the pregnancy experiences and outcomes of undocumented migrant (UM) women in Europe. Systematic searches were done on PubMed, Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL Plus, and BioMed Central. From the search results, only primary research articles that reported on the pregnancy outcomes and experiences of undocumented migrants were selected. A meta-analysis was not possible because this review included information from both qualitative and quantitative studies. The data that was taken from the included publications was organised, analysed, using the Microsoft Excel programme, and then meta-synthesised. Twelve papers from seven different European nations-Belgium, France, Sweden, Denmark, Norway, Finland, and England-were included in this systematic review. Eight of the studies aimed to explore the access to and utilization of ANC by undocumented migrant women and the related pregnancy outcomes. Two of the included studies examined the pregnancy experiences of UMs and two examined the perinatal risks associated with living as a migrant with no legal status. Although heterogeneous in their specific findings most of the studies showed undocumented immigrants are more likely to experience unfavourable pregnancy outcomes and experience greater anxiety and worries due to a variety of factors than documented migrants and registered citizens. This review's conclusions demonstrate the pressing need for policy modifications and healthcare reforms in Europe to address the problems associated with undocumented migrants' restricted access to antenatal care. It also highlights the urgent need for structural changes that will give this vulnerable population's health and well-being a higher priority. It is not just an issue of health equality but also a humanitarian obligation to address the many obstacles and difficulties undocumented migrant women endure during pregnancy.

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

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

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.

Is conservative management of placenta accreta spectrum disorders practical in the United States?

This commentary discusses the issues related to conservative management (also called leaving the placenta in situ or intentional retention of the placenta) of placenta accreta spectrum disorders. Considerations related to placenta accreta spectrum disorder management in the United States are compared with France, where conservative management is a well-accepted management option. The history of placenta accreta spectrum disorder treatment is reviewed, finding that since 1937, the most common treatment in the United States been cesarean-hysterectomy without placental removal. Although definitive studies have yet to be conducted, a growing body of evidence suggests that conservative management is able to reduce maternal morbidity, compared with cesarean-hysterectomy. International and national guidelines from several countries are examined. Comparisons between the United States and France that are addressed in the commentary include population and geography, structure of the healthcare system, physician training and acceptability, and patient acceptability. Considering the differences between the countries, conservative management is feasible in the United States. Different options for placenta accreta spectrum disorder management should be rigorously researched in multicenter international collaborations. Conservative management should be considered as an option for women with placenta accreta spectrum disorders in the United States, especially for those desiring fertility preservation.