Delivery and its complications among women of Somali, Kurdish, and Russian origin, and women in the general population in Finland

Cesarean birth rates among migrants in Europe: A systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Group antenatal care compared with standard antenatal care for Somali-Swedish women: a historically controlled evaluation of the Hooyo Project

OBJECTIVES

Comparing language-supported group antenatal care (gANC) and standard antenatal care (sANC) for Somali-born women in Sweden, measuring overall ratings of care and emotional well-being, and testing the feasibility of the outcome measures.

DESIGN

A quasi-experimental trial with one intervention and one historical control group, nested in an intervention development and feasibility study.

SETTING

Midwifery-led antenatal care clinic in a mid-sized Swedish town.

PARTICIPANTS

Pregnant Somali-born women (<25 gestational weeks); 64 women in gANC and 81 in sANC.

INTERVENTION

Language-supported gANC (2017-2019). Participants were offered seven 60-minute group sessions with other Somali-born women led by one to two midwives, in addition to 15-30 min individual appointments with their designated midwife.

OUTCOMES

Primary outcomes were women's overall ratings of antenatal care and emotional well-being (Edinburgh Postnatal Depression Scale (EPDS)) in gestational week ≥35 and 2 months post partum. Secondary outcomes were specific care experiences, information received, social support, knowledge of pregnancy danger signs and obstetric outcomes.

RESULTS

Recruitment and retention of participants were challenging. Of eligible women, 39.3% (n=106) declined to participate. No relevant differences regarding overall ratings of antenatal care between the groups were detected (late pregnancy OR 1.42, 95% CI 0.50 to 4.16 and 6-8 weeks post partum OR 2.71, 95% CI 0.88 to 9.41). The reduction in mean EPDS score was greater in the intervention group when adjusting for differences at baseline (mean difference -1.89; 95% CI -3.73 to -0.07). Women in gANC were happier with received pregnancy and birth information, for example, caesarean section where 94.9% (n=37) believed the information was sufficient compared with 17.5% (n=7) in standard care (p<0.001) in late pregnancy.

CONCLUSIONS

This evaluation suggests potential for language-supported gANC to improve knowledge acquisition among pregnant Somali-born women with residence in Sweden ˂10 years. An adequately powered randomised trial is needed to evaluate the effectiveness of the intervention.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03879200).

Hormonal changes in consecutive clomiphene citrate stimulation cycles and their effect on pregnancy rates

Objective:

To determine the relationship between the cumulative effect of sequential clomiphene citrate (CC) treatments in unexplained infertile women with intercycle and intracycle serum hormone changes.

Materials and Methods:

Patients who received CC 50 mg in the first cycle (group I, n=34) as ovulation induction and those who received CC 50 mg in the second consecutive cycle (group II, n=18) were compared. Basal (cycle days 2-5) and trigger day (the day that recombinant human chorionic gonadotropin is given) levels of gonadotropin and steroid hormones were measured.

Results:

The 17OHP increase on trigger day was found to be statistically significantly higher in group II compared to the basal day (p=0.083). The testosterone (T) response on the trigger day of the patients in group II was found to be statistically significantly higher than that in group I (p=0.023). The number of selected follicles was negatively correlated with a follicle-stimulating hormone decrease and positively correlated with an estradiol increase. Endometrial thickness was positively correlated with a luteinizing hormone increase, and cycle cancelation was positively correlated with decreased estradiol.

Conclusion:

Based on this study, it was concluded that the reason for the increased efficiency rate in successive cycles of CC may be the cumulative increase in T and 17OHP levels. However, this result was found not to affect the clinical pregnancy rate.

Group antenatal care (gANC) for Somali-speaking women in Sweden - a process evaluation

BACKGROUND

Language supported group antenatal care (gANC) for Somali-born women was implemented in a Swedish public ANC clinic. The women were offered seven 60-min sessions, facilitated by midwives and starting with a presentation of a selected topic, with an additional 15-min individual appointment before or after. The aim of this study was to assess the feasibility for participants and midwives of implementing The Hooyo ("mother" in Somali) gANC intervention, including implementation, mechanisms of impact and contextual factors.

METHODS

A process evaluation was performed, using The Medical Research Council (MRC) guidelines for evaluating complex interventions as a framework. A range of qualitative and quantitative data sources were used including observations (n = 9), complementary, in-depth and key-informant interviews (women n = 6, midwives n = 4, interpreters and research assistants n = 3) and questionnaire data (women n = 44; midwives n = 8).

RESULTS

Language-supported gANC offered more comprehensive ANC that seemed to correspond to existing needs of the participants and could address knowledge gaps related to pregnancy, birth and the Swedish health care system. The majority of women thought listening to other pregnant women was valuable (91%), felt comfortable in the group (98%) and supported by the other women (79%), and they said that gANC suited them (79%). The intervention seemed to enhance knowledge and cultural understanding among midwives, thus contributing to more women-centred care. The intervention was not successful at involving partners in ANC.

CONCLUSIONS

The Hooyo gANC intervention was acceptable to the Somali women and to midwives, but did not lead to greater participation by fathers-to-be. The main mechanisms of impact were more comprehensive ANC and enhanced mutual cultural understanding. The position of women was strengthened in the groups, and the way in which the midwives expanded their understanding of the participants and their narratives was promising. To be feasible at a large scale, gANC might require further adaptations and the "othering" of women in risk groups should be avoided.

TRIAL REGISTRATION

The study was registered in ClinicalTrials.gov (Identifier: NCT03879200).

Use of pain management in childbirth among migrant women in Iceland: A population-based cohort study

BACKGROUND

Immigration is rapidly increasing in Iceland with 13.6% of the population holding foreign citizenship in 2020. Earlier findings identified inequities in childbirth care for some women in Iceland. To gain insight into the quality of intrapartum midwifery care, migrant women's use of pain management methods during birth in Iceland was explored.

METHODS

A population-based cohort study including all women with a singleton birth in Iceland between 2007 and 2018, in total 48 173 births. Logistic regression analyses with odds ratios (ORs) and 95% confidence intervals (CIs) were used to investigate the relationship between migrant backgrounds defined as holding foreign citizenship and the use of pain management during birth. The main outcome measures were use of nonpharmacological and pharmacological pain management methods.

RESULTS

Data from 6097 migrant women were included. Migrant women had higher adjusted OR (aORs) for no use of pain management (aOR = 1.23 95% CI [1.12, 1.34]), when compared to Icelandic women. Migrant women also had lower aORs for the use of acupuncture (0.73 [0.64, 0.83]), transcutaneous electrical nerve stimulation (TENS) (0.92 [0.01, 0.67]), shower/bath (0.73 [0.66, 0.82]), aromatherapy (0.59 [0.44, 0.78]), and nitrous oxide inhalation (0.89 [0.83, 0.96]). Human Development Index (HDI) scores of countries of citizenship <0.900 were associated with lower aORs for the use of various pain management methods.

CONCLUSIONS

Our results suggest that being a migrant in Iceland is an important factor that limits the use of nonpharmacological pain management, especially for migrant women with citizenship from countries with HDI score <0.900.

The Insight into Obstetric Care near the Front Line in Kharkiv

Objectives

The invasion of Russian troops into independent Ukraine has changed the humanitarian situation in the Kharkiv region. The paper is focused on the peculiarities and issues of the management of labor and delivery near the front line.

Materials and methods

Totally 2030 patients were enrolled in the study. 1410 women who delivered in the second half of 2021 were enrolled in Group I. 620 women who delivered in the first half of 2022 were observed in Group II. Some patients from Group II were used for the investigation of the comparative situation during first months of 2022. 85 women who delivered in January were included in Subgroup IIA. 94 women who have completed their pregnancies and delivered in February were observed in Subgroup IIB. 67 case histories of deliveries which occurred during March were united in Subgroup IIC.

Results

The level of anemia, uterine contractile activity in labor abnormalities, and episiotomies were surprisingly lower during wartime in March. The obtained results showed an almost similar level of obstetric complications, maternal comorbidities, and interventions during labor and delivery in all groups. The stressed environment was a possible reason for the elevation of cardiovascular disease and endocrine disorders.

Conclusion

The study did not reveal any significant changes in the structure of maternal pathologies and obstetric complications during the first months of wartime near the front line. But later the levels of cardiovascular disease and endocrine disorders were found to be elevated.

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.

Perinatal and Neonatal Outcomes in Immigrants From Conflict-Zone Countries: A Systematic Review and Meta-Analysis of Observational Studies

Objectives

There are controversies regarding the risk of adverse pregnancy outcomes among immigrants from conflict-zone countries. This systematic review and meta-analysis aimed to investigate the risk of perinatal and neonatal outcomes among immigrants from conflict-zone countries compared to native-origin women in host countries.

Methods

A systematic search on the databases of PubMed/MEDLINE, Scopus, and Web of Science was carried out to retrieve studies on perinatal and neonatal outcomes among immigrants from Somalia, Iraq, Afghanistan, Yemen, Syria, Nigeria, Sudan, Ethiopia, Eritrea, Kosovo, Ukraine, and Pakistan. Only peer-reviewed articles published in the English language were included in the data analysis and research synthesis. The odds ratio and forest plots were constructed for assessing the outcomes of interests using the DerSimonian and Laird, and the inverse variance methods. The random-effects model and the Harbord test were used to account for heterogeneity between studies and assess publication bias, respectively. Further sensitivity analysis helped with the verification of the reliability and stability of our review results.

Results

The search process led to the identification of 40 eligible studies involving 215,718 pregnant women, with an immigration background from the conflict zone, and 12,806,469 women of native origin. The adverse neonatal outcomes of the risk of small for gestational age (Pooled OR = 1.8, 95% CI = 1.6, 2.1), a 5-min Apgar score <7 (Pooled OR = 1.4, 95% CI = 1.0, 2.1), stillbirth (Pooled OR = 1.9, 95% CI = 1.2, 3.0), and perinatal mortality (Pooled OR = 2, 95% CI = 1.6, 2.5) were significantly higher in the immigrant women compared to the women of native-origin. The risk of maternal outcomes, including the cesarean section (C-S) and emergency C-S, instrumental delivery, preeclampsia, and gestational diabetes was similar in both groups.

Conclusion

Although the risk of some adverse maternal outcomes was comparable in the groups, the immigrant women from conflict-zone countries had a higher risk of neonatal mortality and morbidity, including SGA, a 5-min Apgar score <7, stillbirth, and perinatal mortality compared to the native-origin population. Our review results show the need for the optimization of health care and further investigation of long-term adverse pregnancy outcomes among immigrant women.

Prenatal care adequacy of migrants born in conflict-affected countries and country-born parturients in Finland

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Migrants from conflict-affected areas had a 3.5-fold risk for delayed prenatal care.

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Less prenatal visits prior to term birth compared with country-born parturients.

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No differences in prepartum hospitalization between migrants and country-born parturients.

Background

The 2015 refugee crisis led into a forced migration of millions of people globally. As a consequence, many countries experienced a quick change in the proportion of conflict-area born migrants. This group being stated as an especially vulnerable group for suboptimal maternal health, a timely inspection of preventive maternity care was required. This study investigated prenatal care in terms of gestation trimester at the first prenatal visit, number of check-ups prior to birth, and prepartum hospitalization in conflict-country born migrants and Finnish parturients in Finland.

Material and methods

Cross-sectional study included all pregnancies of migrants born in conflict-affected countries (n = 3 155) and country-born parturients (n = 93 600) in Finland in 2015–16. The data were obtained through Medical Birth Registry and Population Information System. Statistical analysis employed T-test, Chi-square test, and logistic regression analysis. Odds ratios with 95% Confidence Intervals (CI) were adjusted for sociodemographic and health-related background variables.

Results

Migrant parturients had a higher probability for delayed enter in prenatal care compared with Finnish-born parturients (adjusted odds ratio aOR = 3.46; 95% Confidence Interval CI 3.06, 3.91). Recommended minimum number of check-ups was participated by 95.3% of the migrant, and 96.4% of the Finnish-born group (P <0.000). Migrants’ probability for more than ten visits prior to term birth was significantly lower (aOR = 0.58; 95% CI 0.51, 0.66). No significant differences in prepartum hospitalization yielded between the groups.

Conclusions

Migrant parturients had significantly smaller number of check-ups and later entry in care compared with the country-born parturients. These findings add to earlier reported challenges in the organizing of conflict-affected country born migrants’ prenatal care in a high-income setting, in which the proportion of conflict-area born migrants has risen rapidly and unexpectedly.

Maternal Smoking During Pregnancy and Offspring Head Growth in Comparison to Height and Weight Growth Up to 6 Years of Age: A Longitudinal Study

Background

Maternal smoking during pregnancy causes fetal growth retardation. Thereafter, it has been associated with excessive childhood weight gain and decreased linear growth in the offspring. However, it is not known whether head circumference (HC), the surrogate of brain size in childhood, is altered after intrauterine tobacco exposure. We assessed the association of maternal smoking during pregnancy with offspring HC growth up to age 6 years in comparison with length/height growth and weight gain.

Methods

We combined data from Medical Birth Register and longitudinal growth data from primary care of 43,632 children (born 2004–2017). Linear mixed effects models were used for modeling, adjusting for potential perinatal and socioeconomic confounders.

Results

At birth, maternal smoking during pregnancy was associated with a mean deficit of 0.19 standard deviation score (SDS) (95% CI: −0.25, −0.12) in HC, −0.38 SDS (95% CI: −0.43, −0.32) in length, and −0.08 SDS (95% CI:−0.14, −0.02) in weight-for-length. HC in smokers’ children failed to catch up to that of non-smokers’ children. Height of smokers’ infants reached that of non-smokers’ infants by 12 months but declined thereafter. Weight-for-height of smokers’ infants exceeded the level of non-smokers’ infants at 3 months and remained significantly elevated thereafter. HC in the offspring of mothers who quit smoking in the first trimester was not deficient, but their weight-for-height was elevated.

Conclusion

HC of smokers’ children is still deficient at age 6 years. Since most of the head growth occurs during the first 2 years of life, the defect may be permanent. In smokers’ children, weight gain was excessive up to 6 years and height was deficient at 6 years consistent with previous literature. Efforts should be made to encourage pregnant women to quit smoking in the beginning of the pregnancy.

Challenges in migrant women's maternity care in a high-income country: A population-based cohort study of maternal and perinatal outcomes

INTRODUCTION

This study aims to explore maternal and perinatal outcomes of migrant women in Iceland.

MATERIAL AND METHODS

This prospective population-based cohort study included women who gave birth to a singleton in Iceland between 1997 and 2018, comprising a total of 92 403 births. Migrant women were defined as women with citizenship other than Icelandic, including refugees and asylum seekers, and categorized into three groups, based on their country of citizenship Human Development Index score. The effect of country of citizenship was estimated. The main outcome measures were onset of labor, augmentation, epidural, perineum support, episiotomy, mode of birth, obstetric anal sphincter injury, postpartum hemorrhage, preterm birth, a 5-minute Apgar <7, neonatal intensive care unit admission and perinatal mortality. Odds ratios (ORs) and 95% confidence intervals (CIs) for maternal and perinatal outcomes were calculated using logistic regression models.

RESULTS

A total of 8158 migrant women gave birth during the study period: 4401 primiparous and 3757 multiparous. Overall, migrant women had higher adjusted ORs (aORs) for episiotomy (primiparas: aOR 1.43, 95% CI 1.26-1.61; multiparas: 1.39, 95% CI 1.21-1.60) and instrumental births (primiparas: 1.14, 95% CI 1.02-1.27, multiparas: 1.41, 95% CI 1.16-1.72) and lower aORs of induction of labor (primiparas: 0.88, 95% CI 0.79-0.98; multiparas: 0.74, 95% CI 0.66-0.83), compared with Icelandic women. Migrant women from countries with a high Human Development Index score (≥0.900) had similar or better outcomes compared with Icelandic women, whereas migrant women from countries with a lower Human Development Index score than that of Iceland (<0.900) had additionally increased odds of maternal and perinatal complications and interventions, such as emergency cesarean and postpartum hemorrhage.

CONCLUSIONS

Women's citizenship and country of citizenship Human Development Index scores are significantly associated with a range of maternal and perinatal complications and interventions, such as episiotomy and instrumental birth. The results indicate the need for further exploration of whether Icelandic perinatal healthcare services meet the care needs of migrant women.

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.

The lived experience among Somali women of giving birth in Sweden: an interpretive phenomenological study

Background

The health care-seeking behaviour among Somali women is different from Swedish women’s behaviour, and this may have consequences for birth giving. The aim of the study was to identify and describe Somali women’s lived experience of birth giving in Sweden.

Methods

Qualitative individual interviews were conducted in Swedish with seven Somali women. The sample was purposeful, and the snowball sampling method was used. The interviews were digitally recorded and transcribed verbatim. Data were analysed using interpretative phenomenological analysis.

Results

Four themes emerged during the analysis which revealed the Somali women’s lived experiences of giving birth in Sweden. a) Being recognised and confirmed as a woman. Somali women consider it important to be confirmed as a woman by the surrounding and professionals during pregnancy and birth giving. b) Communication is important for the women’s independence. There is a need to provide a structure for how this information is given and adaptation regarding content and format .c) Something naturally becomes unknown and complicated. Somali women come from a different culture, which affects their lived experiences of pregnancy and birth giving. There is a need for improved and clearer information for these Somali women regarding pregnancy and birth giving in another culture- the Swedish context d) Professional and competent taking care of. The women appreciate if they are treated with competency and professionalism; they do not want to be discriminated. The women feel confidence in health care when they meet competent and professional health care professionals.

Conclusions

The findings in the study indicate that reproductive health care for Somali women should be improved with regard to cultural differences and lived experiences, as this affects their experience of pregnancy and childbirth in Sweden. There is a need for both knowledge and understanding in order to provide good quality care for these Somali women, especially those who have been genitally mutilated.