International migration and caesarean birth: a systematic review and meta-analysis

Labor and Delivery Characteristics by Detailed Maternal Nativity Across the Black Diaspora: Place and Method of Delivery

OBJECTIVE

This study aimed to examine the associations between detailed maternal nativity (DMN) and two labor and delivery (L&D) characteristics among US-born, Latin American and Caribbean-born, and SSA-born Black women in the US. L&D characteristics included the place of delivery (i.e., hospital, birthing center, or home) and the method of delivery (i.e., vaginal or cesarean).

METHODS

Using Natality data, the authors examined the associations between detailed maternal nativity (DMN) and two L&D characteristics among US-born, Latin American and Caribbean-born, and SSA-born Black women in the USA who had a live delivery between 2016 and 2020 (N = 2,041,880). The main predictor was DMN (i.e., maternal country of birth) and the outcomes of interest were the place of delivery and the method of delivery. Associations were evaluated using multivariate multinominal and multivariate logistic regression models.

RESULTS

Findings indicated that foreign-born Black women overall had decreased odds of delivering in birthing centers or at home, except for Ghanaian-born women who had increased odds of having an unintended home delivery. All Latin American and Caribbean-born and most SSA-born women had increased odds of delivering via cesarean.

CONCLUSIONS

The findings underscore the importance of considering DMN in exploring L&D characteristics. Specifically, increased odds of cesarean delivery among Latin American and Caribbean-born women highlight a potential area for interventions. Further research is warranted to understand the underlying factors driving the observed differences and the diverse needs of the growing population of foreign-born Black women in the US, and to develop effective strategies to promote equitable and optimal birthing experiences for all.

Maternal origin matters: Country of birth as a risk factor for obstetric anal sphincter injuries

OBJECTIVE

Obstetric anal sphincter injuries (OASIS) are severe complications to vaginal births with potential long-term consequences. Maternal origin has been proposed to affect the overall risk, but the association and underlying explanation are uncertain. The objective was to assess the association between maternal country of birth and OASIS.

METHODS

A Swedish nationwide cohort study including singleton term vaginal births during 2005-2016. Data were extracted from the Swedish Medical Birth Registry and Statistics Sweden. Modified Poisson regression analyses were performed to obtain crude and adjusted risk ratios (RRs). Adjustments were made in four cumulative steps. Sub-analyses were performed to investigate the risk of OASIS associated with female genital circumcision (FGC).

RESULTS

In all, 988 804 births were included. The rate of OASIS in Swedish-born women was 3.5%. Women from East/Southeast Asia had an increased risk of OASIS (adjusted RR [aRR] 1.71, 95% confidence interval [CI] 1.60-1.83), as did women born in Sub-Saharan Africa (aRR 1.60, 95% CI 1.49-1.72). The risk remained significantly increased also after adjustment for maternal height. By contrast, women from South/Central America had a decreased risk of OASIS (aRR 0.65, 95% CI 0.56-0.76). FGC was associated with an increased risk of OASIS (aRR 3.05, 95% CI 2.60-3.58). Episiotomy appeared to have an overall protective effect (aRR 0.95, 95% CI 0.92-0.98), but not significantly more protective among women with female genital mutilation.

CONCLUSIONS

Country of birth plays an important role in the risk of OASIS. Women from East/Southeast Asia and Sub-Saharan Africa are at significantly increased risk as compared with Swedish-born women, whereas women from South/Central America are at lower risk. FGC is also a significant risk factor for OASIS.

Obstetric Outcomes of Eritrean Immigrants in Switzerland: A Comparative Study

Objectives: This study aims to compare obstetric outcomes between Eritrean and Swiss women in Switzerland, focusing on instrumental or surgical interventions and analgesia use. Methods: The study included data from 45,412 Swiss and 1,132 Eritrean women who gave birth in Swiss hospitals (2019-2022). Mixed-effects logistic regression was used to assess the effect of nationality on mode of delivery and analgesia use and multinomial mixed-effects logistic regression to assess the effect of nationality on mode of delivery in women intended for spontaneous vaginal delivery. Results: Compared with Swiss, Eritrean women had a lower rate of primary C-section (Adj. OR 0.73, 95% CI [0.60, 0.89]) but a higher risk of initially planned vaginal deliveries ending in emergency C-section (RRR 1.31, 95% CI [1.05, 1.63]). Eritrean women were less likely to receive epidural analgesia (Adj. OR 0.53, 95% CI [0.45, 0.62]) and more likely to not receive any analgesia (Adj. OR 1.73, 95% CI [1.52, 1.96]). Conclusion: This study reveals disparities in obstetric care, notably in higher emergency C-section rates and lower analgesia use among Eritrean women. For promoting equitable healthcare practices deeper understanding of obstetrics decision-making is needed.

The prevalence of preterm and low birth weight infants among migrant women in the Pearl River Delta region, China: a population-based birth cohort study

BACKGROUND

The existing literature evaluating the association between neonatal morbidity and migrant status presents contradictory results. The purpose of this study was to compare the risk of preterm birth (PTB) and low birth weight (LBW) among newborns from local and migrant women in China's Pearl River Delta (PRD) region.

METHODS

In this observational population-based study, we included all live singleton deliveries from PRD region local women and migrant women. Data were sourced from the Guangdong Medical Birth Registry Information System between Jan 1, 2014, and Dec 31, 2020. Women were categorized into three groups by maternal migrant status: local women from PRD region, migrant women from Guangdong province or from other provinces. The outcome variables that were examined included two adverse birth outcomes: PTB and LBW. The association between the risk of PTB and LBW and maternal migrant status was assessed using logistic regression.

RESULTS

During 2014-2020, 5,219,133 single live deliveries were recorded, corresponding 13.22% to local women and the rest to migrant women coming from Guangdong (53.51%) and other provinces (33.26%). PTB prevalence was highest among local women (5.79%), followed by migrant women from Guangdong (5.29%), and the lowest among migrants from other provinces (4.95%). This association did not change after including maternal age, infant sex, delivery mode, and birth season in the models. Compared to local women, migrant women from other provinces had a lower risk of LBW (4.00% vs. 4.98%, P < 0.001). The prevalence of PTB and LBW was higher among local women than migrants. The odds of delivery PTB and LBW were higher for women who were age ≥ 35. Among the three maternal migration groups, the age-LBW association displayed a typical U-shaped pattern, with those in the youngest (16-24 years) and oldest (≥ 35) age categories exhibiting the higher odds of delivering a LBW neonate. With respect to infant sex, the prevalence of PTB was significantly higher in males than females among the three maternal migration groups. An opposite trend was found for LBW, and the prevalence of LBW was higher in females among the three maternal migration groups.

CONCLUSION

The findings of this study contribute to the understanding of the epidemiology of PTB and LBW among migrant women. Our study suggests that it is the health and robust nature of migrant mothers that predisposes them to better birth outcomes. It is important to recognize that the results of this study, while supportive of the healthy migrant effect, cannot be considered definitive without some exploration of motivation for moving and changes in lifestyle postmigration.

Exploring South Asian women's perspectives and experiences of maternity care services: A qualitative evidence synthesis

BACKGROUND

The United Nations Women and other sources have highlighted the poor maternal and neonatal care experienced by South Asian women, emphasizing the need to understand the cultural factors and specific experiences that influence their health-seeking behavior. This understanding is crucial for achieving health equity and improving health outcomes for women and infants.

OBJECTIVES

This study aims to examine and synthesize qualitative evidence on the perspectives and experiences of South Asian women regarding maternity care services in destination countries.

METHODS

A systematic review was conducted using the Joanna Briggs Institute's approach. Eight databases were searched for studies capturing the qualitative views and experiences of South Asian women - Medline, EMBASE, CINAHL Plus, Global Health, Scopus, PsycInfo, British Nursing Index and the Applied Social Science Index and Abstracts. Qualitative and mixed method studies written in English are included. The methodological quality of the included studies was assessed using the JBI's QARI checklist for qualitative studies and the MMAT checklist for mixed-methods studies.

RESULTS

Fourteen studies, including twelve qualitative and two mixed-methods studies, were identified and found to be of high methodological quality. The overarching theme that emerged was "navigating cross-cultural maternity care experiences." This theme encapsulates the challenges and complexities faced by South Asian women in destination countries, including ethnocultural and religious differences, communication and language barriers, understanding different medical systems, and the impact of migration on their maternity care experiences.

CONCLUSIONS

South Asian migrant women often have expectations that differ from the services provided in destination countries, leading to challenges in their social relationships. Communication and language barriers pose additional obstacles that can be addressed through strategies promoting better communication and culturally sensitive care. To enhance the utilization of maternity healthcare services, it is important to address these factors and provide personalized, culturally sensitive care for South Asian migrant women.

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.

Maternal multimorbidity - experiences of women seeking asylum during pregnancy and after childbirth: a qualitative study

BACKGROUND

Many women seeking asylum during pregnancy and after childbirth have ill-health but detection and assessment of all physical, psychological, and social health needs (maternal multimorbidity) are often difficult as part of routine maternity care. Healthcare providers are key for the early identification and management of vulnerable pregnant women who have additional physical, psychological, and social health needs. We sought to explore the impact of the asylum-seeking process, understanding of wellbeing, expressed health needs (in terms of maternal multimorbidity), and the experiences of maternity care of women seeking asylum during pregnancy and after childbirth in Liverpool, United Kingdom. Enabling factors and barriers to access woman-centred care were also explored.

METHODS

Key informant interviews (n = 10) and one focus group discussion (n = 4) were conducted with women attending a non-profit charitable pregnancy support group. Transcribed interviews were coded by topic and then grouped into categories. Thematic framework analysis was undertaken to identify emerging themes.

RESULTS

The asylum-seeking process negatively impacted women making them feel anxious and depressed with little control or choice over their future. Women reported feeling stressed regarding poor standard of accommodation, low income, dispersal and the uncertainty of their asylum application outcome. Wellbeing during pregnancy and after childbirth was understood to be multifactorial and women understood that their physical health needs were interlinked and negatively impacted by complex psychological and social factors. Women reported that their expectations of maternity services were often exceeded, but information giving, and the use of language interpreters needed to be improved. Women expressed the need for more psychological and social support throughout pregnancy and after childbirth.

CONCLUSIONS

A multidisciplinary team, with links and effective referral pathways to maternal mental health and social services, are necessary for women seeking asylum, to ensure a more integrated, comprehensive assessment of maternal multimorbidity and to provide maternity care in a way that meets all health needs.

UNDERSTANDING DEMOGRAPHIC AND EPIDEMIOLOGIC CHARACTERISTICS OF HOSPITALIZED IMMIGRANT FEMALE PATIENTS: A RETROSPECTIVE OBSERVATIONAL STUDY

Precise epidemiologic and demographic characteristics of immigrant women admitted to gynecology or obstetrics departments are rarely explored. The aim of this retrospective observational study was to analyze the epidemiologic and demographic characteristics of immigrant female patients hospitalized between 2012 and 2017 in one maternity hospital in south-west Slovenia. Clinical data retrieved from hospital electronic information system were used to analyze these characteristics. In the mentioned period, 605 immigrant women were hospitalized, most of them originating from countries of the former Yugoslavia (60.50%) or former Eastern Bloc (14.05%). The results show that in recent years there has been a constantly growing trend of immigrant women being admitted compared to the total number of hospitalizations. No statistical differences were established in the incidence of abortion, preterm delivery or vacuum extraction between Slovenian and immigrant women, although the analysis revealed a higher rate of cesarean section among immigrant women (χ2=26.960, p<0.01). Education level seems to be a significant predictor of the likelihood of an abortion in the group of immigrant women (B=-0.492, p=0.015), where less educated women are at a greater risk. To improve what is known about the sexual and reproductive health-related problems of immigrant women, a large-scale epidemiologic study is needed in the near future.

Migrant mothers' experiences of Caesarean section: a transcultural qualitative study

Objectives

Migrant women face an increased risk of adverse obstetrical outcome and Caesarean section. The psychological experience of Caesarean section combines physiological, social, and cultural dimensions. This qualitative study explores the subjective experiences of first-generation migrant women who gave birth by Caesarean section.

Methods

Seven qualitative, semi-directed interviews were conducted from January to March 2022 in a Paris maternity hospital, with women in their postpartum period who had had a scheduled or emergency Caesarean section and straightforward obstetrical outcomes. The presence of an interpreter-mediator was systematically offered. Thematic analysis of the interviews was carried out following the Interpretative Phenomenological Analysis (IPA) methodology.

Results

Four themes were identified in the thematic analysis relating to the women's experiences of Caesarean section: (1) The shock of the intervention combines disappointment, fear and early separation from the baby, (2) Pregnancy and delivery far from one's family aggravates the psychological suffering caused by isolation and loneliness related to migration, (3) The lack of cultural representations of Caesarean section leads to negative preconceptions and hinders mental preparation, in contrast with traditional or medicalised childbirth, and (4) The women's experiences of the medical follow-up highlights the importance of the continuity of care.

Discussion and conclusion

Caesarean section, which is a physical break, re-enacts the symbolic break (cultural, social, familial) that follows on from emigration. Improvements in care include the need for a better preparation for Caesarean section, active efforts for care continuity, and the development of early prevention interviews and groups in maternity units.

Transcultural skills for early childhood professionals

Context

Transcultural skills are especially useful for those involved in the perinatal period, when parents and babies must adapt to one another in a setting of migration a long a focus of transcultural clinical practice.

Objective

The aim of this article is to provide useful transcultural skills for any health care worker (e.g., psychologists, child psychiatrists, midwives, family doctors, pediatricians, specialized child-care attendants, and social workers) who provide care or support to families during the perinatal period. It highlights the cultural aspects requiring attention in relation to representations of pregnancy, children's needs, obstetric complications, and postnatal problems. Taking into account the impact of culture on clinical evaluation and treatment can enable professionals to distinguish what involves cultural representations of pregnancy, babies, and sometimes of disease from what is associated with interaction disorders or maternal psychopathology.

Methods

After explaining the relevance of transcultural clinical practices to provide migrant mothers with better support, we describe 9 themes useful to explore from a transcultural perspective. This choice is based on the transcultural clinical practice in our specialized department.

Results

The description of these 9 themes is intended to aid in their pragmatic application and is illustrated with short clinical vignettes for specific concepts. We describe situations that are extreme but often encountered in liaison transcultural clinical practice for maternity wards: perinatal mourning with cultural coding, mediation in refusal of care, cultural misunderstandings, situations of complex trauma and of multiple contextual vulnerabilities, and difficulties associated with acculturation.

Discussion

The transcultural levers described here make it possible to limit cultural misunderstandings and to promote the therapeutic alliance. It presupposes the professionals will concomitantly analyze their cultural countertransference and acquire both the knowledge and know-how needed to understand the elements of cultural, political, and social issues needed to develop clinical finesse.

Conclusion

This combined theoretical-clinical article is intended to be pedagogical. It provides guidelines for conducting transcultural child psychiatry/psychological interviews in the perinatal period aimed at both assessment and therapy.

Pregnancy outcomes of immigrant women living in Korea: A population-based study

Although there is a high rate of pregnant immigrant women in Korea, little is known regarding their pregnancy outcomes. The aim of this study was to evaluate the pregnancy outcomes of immigrant women in Korea. Data for all pregnant women who gave birth between January 1, 2007 and December 31, 2016 were obtained using the Health Insurance Review and Assessment Service Database. Pregnant women were divided into two groups: Korean and immigrant women. The main outcome measures were adverse pregnancy outcomes including gestational diabetes of mellitus, preeclampsia, cesarean section, placental abrnomalities, and postpartum hemorrhage. The odds of gestational diabetes mellitus, preeclampsia, cesarean section, placental previa, placental abruptio, and postpartum hemorrhage was compared between the two groups. Among 4,439,778 pregnant women who gave birth during the study period, 168,940 (3.8%) were immigrant women. The odds of gestational diabetes mellitus (adjusted OR: 1.24; 95% CI: 1.21, 1.28), and cesarean section (adjusted OR: 1.26; 95% CI: 1.25-1.28)were higher in immigrant women than in Korean women, but the odds of preeclampsia (adjusted OR: 0.84; 95% CI: 0.81-0.86) and postpartum hemorrhage (adjusted OR 0.96, 95% CI 0.94-0.97) was lower in immigrant women than in Korean women. Immigrant women had different pregnancy outcomes. Pregnancy and postpartum management that reflects these characteristics will be necessary for immigrant women.

Community-based bilingual doula support during labour and birth to improve migrant women's intrapartum care experiences and emotional well-being-Findings from a randomised controlled trial in Stockholm, Sweden [NCT03461640]

OBJECTIVES

To evaluate the effectiveness of community-based bilingual doula (CBD) support for improving the intrapartum care experiences and postnatal wellbeing of migrant women giving birth in Sweden.

DESIGN

Randomised controlled trial.

SETTING

Six antenatal care clinics and five hospitals in Stockholm, Sweden.

PARTICIPANTS

164 pregnant Somali-, Arabic-, Polish-, Russian- and Tigrinya-speaking women who could not communicate fluently in Swedish, were ≥18 years and had no contra-indications for vaginal birth.

INTERVENTION

In addition to standard labour support, women were randomised to CBD support (n = 88) or no such support during labour (n = 76). Trained CBDs met with women prior to labour, provided support by telephone after labour had started, then provided emotional, physical and communication support to women throughout labour and birth in hospital, and then met again with women after the birth.

PRIMARY OUTCOMES

Women's overall ratings of the intrapartum care experiences (key question from the Migrant Friendly Maternity Care Questionnaire) and postnatal wellbeing (mean value of Edinburgh Postnatal Depression Scale) at 6-8 weeks after birth.

RESULTS

In total, 150 women remained to follow-up; 82 women (93.2%) randomised to receive CBD support and 68 women (89.5%) randomised to standard care (SC). Of women allocated CBD support, 60 (73.2%) received support during labour. There were no differences between the groups regarding women's intrapartum care experiences (very happy with care: CBD 80.2% (n = 65) vs SC 79.1% (n = 53); OR 1.07 CI 95% 0.48-2.40) or emotional wellbeing (EPDS mean value: CBD 4.71 (SD 4.96) vs SC 3.38 (SD 3.58); mean difference 1.33; CI 95% - 0.10-2.75).

CONCLUSIONS

Community-based doula support during labour and birth for migrant women neither increased women's ratings of their care for labour and birth nor their emotional well-being 2 months postpartum compared with receiving standard care only. Further studies on the effectiveness of CBD powered to evaluate obstetric outcomes are needed.

TRIAL REGISTRATION

Trial registration at ClinicalTrial.gov NCT03461640 https://www.google.com/search?client=firefox-b-d&q=NCT03461640.

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.

Birth Tourism Is Associated with Fewer Neonatal Intensive Care Unit Admissions: A Healthy Migrant Effect?

OBJECTIVE

This work aimed to study perinatal, maternal, and neonatal characteristics of birth tourism (BT) mother-baby dyads and the rate of neonatal intensive care unit (NICU) admissions of BT infants.

STUDY DESIGN

Retrospective study at a regional perinatal center comparing BT mother-baby dyads to all dyads. BT infants admitted to the NICU were compared with a randomly selected group of infants admitted to the NICU during the same time period.

RESULTS

A total of 1,755 BT dyads were identified over 4 years. BT mothers were older (32 vs. 28 years, p < 0.0001), more likely to carry multiples (5.5 vs. 1.4%, p < 0.0001), deliver via cesarean section (40 vs. 34%, p < 0.0001), and require postpartum intensive care (0.6 vs. 0.1%, p < 0.0001). BT infants had significantly fewer NICU admissions 96 (5.5%) versus 3,213 (11.3%; p < 0.0001). There were no statistically significant differences in NICU course and outcome between BT and non-BT control infants.

CONCLUSION

Birth tourism is associated with unique determinants of health. In our study, there were fewer NICU admissions, potentially explained by the healthy migrant effect.

KEY POINTS

· Birthright citizenship attracts foreigners to give birth in the United States.. · BT is associated with unique social determinants of health.. · Fewer NICU admissions in our study are possibly explained by the healthy migrant effect..

LIVE BIRTHS OF IMMIGRANT MOTHERS IN BRAZIL: A POPULATION-BASED STUDY

Introduction

Methods

Results

Conclusion

Migration, Gestational Diabetes, and Adverse Pregnancy Outcomes: A Nationwide Study of Singleton Deliveries in Denmark

CONTEXT

It remains unclear if migrants have different odds for adverse outcomes associated with gestational diabetes mellitus (GDM).

OBJECTIVE

We investigated if the associations between GDM and adverse pregnancy outcomes are modified by country of origin and examined the odds of these outcomes according to GDM status and country of origin.

METHODS

Data were extracted from a nationwide register-based study of singleton deliveries in Denmark, 2004-2015. We used logistic regression models and tested for interaction.

RESULTS

Among the 710 413 singleton deliveries, 2.6% had GDM and 14.4% were immigrants. Country of origin modified the association between GDM and pre-eclampsia, large for gestational age (LGA), and small for gestational age (SGA) but not between GDM and planned or emergency cesarean section and preterm delivery. GDM increased the risk of pre-eclampsia among women from Denmark (OR 1.28; 95% CI, 1.18-1.39), Lebanon (OR 3.34; 95% CI, 1.35-8.26), and Morocco (OR 2.28; 95% CI, 1.16-6.88). GDM was associated with increased odds of LGA among women from most countries, particularly women from Sri Lanka (OR 4.20; 95% CI, 2.67-6.61), and was associated with reduced odds of SGA in some countries. Compared with Danish-born women with GDM, the odds of LGA were significantly lower and the odds of SGA higher among women with GDM from India, Lebanon, Pakistan, Iraq, and Somalia.

CONCLUSIONS

Our study documents that different immigrant groups have higher odds of different GDM-associated adverse pregnancy outcomes and also among countries of origin often grouped together. This highlights the importance of increased awareness to both immigrant background and GDM status in the clinical assessment.

Immigration and Adverse Pregnancy Outcomes in an Italian Free Care Hospital

Introduction

The ever-increasing wave of immigration in Italy has posed demanding challenges in the management of the new multiethnic obstetric population. The aim of this study was to compare pregnancy and perinatal outcomes between immigrants and the native population in an Italian public hospital.

Materials and Methods

Singleton pregnant women (≥ 24 weeks of gestation) who delivered during a 3-year period in an Italian free care hospital were included. Long-term (≥ 2 years of residence) immigrant patients were divided into 4 groups according to their ethnic origin: Europeans, Asians, Latin Americans, and Africans. Perinatal indicators of obstetric outcomes were collected and compared between immigrants and Italians.

Results

Of the 3556 patients included, 1092 were immigrants and 2464 Italians. The immigrant cohort experienced a higher rate of macrosomia (1.8% vs 0.6%; p = 0.001), very low birth weight (1.3% vs 0.6%; p = 0.048), very early preterm delivery (1.4% vs 0.4%; p = 0.048), and gestational diabetes mellitus (1.8% vs 0.5%; p = 003) compared with the native population. The overall rate of cesarean sections was greater among Italians (56% vs 45.8%; p < 0.001). Among ethnic groups, Europeans and Latin Americans reported a higher rate of preterm delivery (20.2% and 19%, respectively; p < 0.001). Latin Americans carried also a greater risk of fetal macrosomia (3.6%; p < 0.008), while the rate of very low birth weight was higher among Europeans and Africans (2% and 1.8%, respectively; p < 0.04).

Conclusion

Obstetricians should pay special attention to the potential disparities in pregnancy outcomes between immigrants and the native population. Future efforts should focus on reducing preterm delivery and glucose dysmetabolism among pregnant immigrants.

Avoiding obstetrical interventions among US-based Somali migrant women: a qualitative study

Objective: Somali refugee women are known to have poor health-seeking behavior with a higher proportion of adverse pregnancy outcomes compared to US-born women. Yet unknown is how they avoid obstetrical interventions. This study sought to identify perceived protective mechanisms used to avoid obstetric interventions as well as the underpinning factors that influence aversion to obstetrical interventions by Somali refugee women.Design: A descriptive, exploratory qualitative study purposively sampled Somali refugee women recruited via snowball technique in Franklin County, Ohio, United States. Data were collected through audio-recordings of individual interviews and focus groups conducted in English and Somali languages. The collected data were transcribed and analyzed using thematic analyses.Results: Forty Somali refugee women aged 18-42 years were recruited. Participants reported engaging in four perceived protective mechanisms to avoid obstetrical interventions during pregnancy and childbirth: (1) intentionally not seeking or misleading prenatal care, (2) changing hospitals and/or providers, (3) delayed hospital arrival during labor, and (4) refusal of care. Underpinning all four avoidance mechanisms were their significant fear of obstetrical interventions, and perceived lack of choice in their care processes as influenced by cultural and/or religious beliefs, feeling judged or undervalued by service providers, and a lack of privacy provided to them while receiving care.Conclusion: Like every woman, Somali women also have a right to choose or refuse care. If the intention is to improve access to and experiences with care for this population, building trust, addressing their fears and concerns, and respecting their culture is a critical first step. This should be well established prior to the need for critical decisions surrounding pregnancy and childbirth wherein Somali women may feel compelled to refuse necessary obstetrical care. Bridging gaps between Somali women and their providers is key to advance health equity for this vulnerable population.

Evaluating Birth Outcomes From a Community-Based Pregnancy Support Program for Refugee Women in Georgia

Refugee women face numerous and unique barriers to sexual and reproductive healthcare and can experience worse pregnancy-related outcomes compared with U.S.-born and other immigrant women. Community-based, culturally tailored programs like Embrace Refugee Birth Support may improve refugee access to healthcare and health outcomes, but empirical study is needed to evaluate programmatic benefits. This community-engaged research study is led by the Georgia Doula Access Working Group, including a partnership between academic researchers, Emory Decatur Hospital nurses, and Embrace. We analyzed hospital clinical records (N = 9,136) from 2016 to 2018 to assess pregnancy-related outcomes of Embrace participants (n = 113) and a comparison group of women from the same community and racial/ethnic backgrounds (n = 9,023). We controlled for race, language, maternal age, parity, insurance status, preeclampsia, and diabetes. Embrace participation was significantly associated with 48% lower odds of labor induction (OR = 0.52, p = 0.025) and 65% higher odds of exclusive breastfeeding intentions (OR = 1.65, p = 0.028). Embrace showed positive but non-significant trends for reduced cesarean delivery (OR = 0.83, p = 0.411), higher full-term gestational age (OR = 1.49, p = 0.329), and reduced low birthweight (OR = 0.77, p = 0.55). We conclude that community-based, culturally tailored pregnancy support programs like Embrace can meet the complex needs of refugee women. Additionally, community-engaged, cross-sector research approaches could ensure the inclusion of both community and clinical perspectives in research design, implementation, and dissemination.

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.

Association between Maternal Origin, Pre-Pregnancy Body Mass Index and Caesarean Section: A Nation-Wide Registry Study

Aims: To explore the association between maternal origin and birthplace, and caesarean section (CS) by pre-pregnancy body mass index (BMI) and length of residence. Methods: We linked records from 118,459 primiparous women in the Medical Birth Registry of Norway between 2013 and 2017 with data from the National Population Register. We categorized pre-pregnancy BMI (kg/m²) into underweight (<18.5), normal weight (18.5–24.9) and overweight/obese (≥25). Multinomial regression analysis estimated crude and adjusted relative risk ratios (RRR) with 95% confidence intervals (CI) for emergency and elective CS. Results: Compared to normal weight women from Norway, women from Sub-Saharan Africa and Southeast Asia/Pacific had a decreased risk of elective CS (aRRR = 0.57, 95% CI 0.37–0.87 and aRRR = 0.56, 0.41–0.77, respectively). Overweight/obese women from Europe/Central Asia had the highest risk of elective CS (aRRR = 1.42, 1.09–1.86). Both normal weight and overweight/obese Sub-Saharan African women had the highest risks of emergency CS (aRRR = 2.61, 2.28-2.99; 2.18, 1.81-2.63, respectively). Compared to women from high-income countries, the risk of elective CS was increasing with a longer length of residence among European/Central Asian women. Newly arrived migrants from Sub-Saharan Africa had the highest risk of emergency CS. Conclusion: Women from Sub-Saharan Africa had more than two times the risk of emergency CS compared to women originating from Norway, regardless of pre-pregnancy BMI.

Interventions to Support International Migrant Women's Reproductive Health in Western-Receiving Countries: A Systematic Review and Meta-Analysis

Purpose: The reproductive health outcomes of international migrant women differ in comparison with receiving-country-born women, depending on country of birth and immigrant status. Effective interventions to support the reproductive health of international migrant women are not well known.

Methods: We conducted a systematic review and meta-analysis of studies between 2010 and 2017 evaluating interventions directly or indirectly affecting the reproductive health (as defined by the World Health Organization) of international migrant women in Western-receiving countries.

Results: Sixteen studies representing 5080 migrants were identified. Interventions consisted of linguistically (e.g., translated brochures) or culturally adapted (e.g., cultural narratives) routine care or new interventions. Meta-analysis showed that interventions increased rates of preventive reproductive health activities, including mammography, condom use, and Pap test completion, by almost 18% (95% confidence interval 7.61–28.3) compared with usual care or interventions not adapted to migrant women.

Conclusion: Culturally and linguistically adapted care practices congruent with target populations of international migrant women are effective in improving their reproductive health outcomes, particularly their participation in preventative reproductive health activities.

Association between migration status and caesarean section delivery based on a modified Robson classification in China

Background

China has one of the highest caesarean section (C-Section) rates in the world. In recent years, China has been experiencing a massive flow of migration due to rapid urbanization. In this study, we aimed to differentiate the rates of C-Section between migrants and residents, and explore any possible factors which may moderate the association between migrant status and C-Section rates.

Methods

We conducted a retrospective cohort study in Shanghai, China. All deliveries were classified using the modified Robson Classification. The association between women’s migrant status and C-Section rates was assessed using the Poisson regression of sandwich estimation, after adjusting for possible factors.

Results

Of the 40,621 women included in the study, 66.9% were residents and 33.1% were internal migrants. The rate of C-Section in migrants was lower than that of residents in all subjects (39.9 and 47.7%) and in group 1 subjects (based on the Robson Classification) using a modified Robson Classification. There was an association between migrant status and caesarean delivery on maternal request that was statistically significant (RR = 0.664, p < 0.001), but the association was weakened after adjusting for such factors as maternal age at delivery (aRR = 0.774, p = 0.02), ethnicity (aRR = 0.753, p < 0.001), health insurance (aRR = 0.755, p < 0.001), and occupation (aRR = 0.747, p = 0.004), but had no significant changes when adjusting for health conditions (aRR = 0.668, p = 0.001) and all considering variables (aRR = 0.697, p = 0.002). In group 1 subjects, the effect of migrant status on maternal requested intrapartum C-Section was also statistically significant (RR = 0.742, p = 0.004).

Conclusion

C-Section rates are lower among migrant women than residents, especially on maternal request. The medical practitioners should further reinforce the management of elective C-Section in resident women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03708-6.

Female genital mutilation/cutting, timing of deinfibulation, and risk of cesarean section

INTRODUCTION

The impact of female genital mutilation/cutting on obstetric outcomes in high-income countries is not clear. In general, women with female genital mutilation/cutting type 3 (infibulation) seem to be most at risk of adverse outcomes such as cesarean section. Deinfibulation is recommended to prevent obstetric complications. Whether the timing of this procedure affects the complication risk is not known. The aims of this study were, first, to examine the association between female genital mutilation/cutting and the risk of cesarean section in Norway, and, second, whether the timing of deinfibulation affected the cesarean section risk.

MATERIAL AND METHODS

This was a historical cohort study of nulliparous Somali-born women who gave birth in Norway between 1990 and 2014. The Medical Birth Registry of Norway identified the women. Data were collected from medical records at 11 participating birth units. The exposures were female genital mutilation/cutting status and deinfibulation before pregnancy, during pregnancy, or no deinfibulation before labor onset. The main outcome was odds ratio (OR) of cesarean section. Type of cesarean section, primary indications, and neonatal outcomes were secondary outcomes.

RESULTS

Women with female genital mutilation/cutting type 3 had lower risk of cesarean section compared with women with no female genital mutilation/cutting (OR 0.54, 95% CI 0.33-0.89 P = .02). Among the 1504 included women, the cesarean section rate was 28.0% and the proportion of emergency operations was 92.9%. Fetal distress was the primary indication in approximately 50% of cases, across the groups with different female genital mutilation/cutting status. Women who had no deinfibulation before labor onset had lower risk of cesarean section compared with those who underwent deinfibulation before or during pregnancy (OR 0.64, 95% CI 0.46-0.88 P = .01).

CONCLUSIONS

High risk of cesarean section in Somali nulliparous women was not related to the type of female genital mutilation/cutting in the present study. Deinfibulation before labor did not protect against cesarean section. Our findings indicate that nulliparous Somali women are at high risk of intrapartum complications. Future research should focus on measures to reduce maternal morbidity and on how timing of deinfibulation affects the outcomes of vaginal births.

Intersections of Immigration and Sexual/Reproductive Health: An Umbrella Literature Review with a Focus on Health Equity

Identifying the opportunities and barriers of promoting and fulfilling the sexual health rights of migrants remains a challenge that requires systematic assessment. Such an assessment would include estimating the influence of acculturation processes on sexual and reproductive health, and mapping intersectional inequities that influence migrants’ sexual and reproductive health in comparison with the native population. The aim of this research was to locate, select, and critically assess/summarize scientific evidence regarding the social, cultural, and structural factors influencing migrants’ sexual and reproductive health outcomes in comparison with native population. An umbrella review of systematic reviews and/or meta-analyses, following preferred reporting items for systematic reviews and meta-analysis (PRISMA) standards was undertaken. Medline, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews were searched from their start date until June 2019. The quality of the included articles was determined using the assessment of multiple systematic reviews tool (AMSTAR 2). From the 36 selected studies, only 12 compared migrant with native populations. Overall, the findings indicated that migrants tend to underuse maternal health services and have an increased risk of poor sexual and reproductive health outcomes. Specific intersectional inequities were identified and discussed.

A Cross-Sectional Study Examining Differences in Indication for Cesarean Delivery by Race/Ethnicity

(1) Background: There are persistent racial/ethnic disparities in cesarean delivery in the United States (U.S.), yet the causes remain unknown. One factor could be provider bias. We examined medical indications for cesarean delivery that involve a greater degree of physician discretion (more subjective) versus medical indications that involve less physician discretion (more objective) to better understand factors contributing to the higher rate among Micronesian, one of the most recent migrant groups in the state, compared to White women in Hawai'i. (2) Methods: A retrospective chart review was conducted to collect data on 620 cesarean deliveries (N = 296 White and N = 324 Micronesian) at the state's largest maternity hospital. Multivariate regression models were used to examine associations between maternal and obstetric characteristics and (1) subjective indication defined as non-reassuring fetal heart tracing (NRFHT) and arrest of labor disorders, and (2) objective indication defined as all other indications (e.g., malpresentation). (3) Results: We found that Micronesian women had significantly higher odds of cesarean delivery due to a subjective indication compared to White women (aOR: 4.17; CI: 2.52-6.88; P < 0.001; N = 619) after adjusting for multiple covariates. (4) Conclusion: These findings suggest unmeasured factors, possibly provider bias, may influence cesarean delivery recommendations for Micronesian women in Hawai'i.

Mothers' experiences of perinatal care in Belgian public hospitals: exploring the social inequalities. Protocol for a cross-sectional survey

INTRODUCTION

In Europe, the social inequalities in perinatal health are usually found to be to the disadvantage of non-European immigrants and women with lower levels of education and income. Among the possible underlying mechanisms are inadequate access to healthcare services and suboptimal care. To explore this hypothesis in the Belgian context, our research will describe detailed maternal socioeconomic and migration characteristics, explore how these factors relate to each other, and how they relate to women's perinatal care trajectories and experiences of care.

METHODS

Using a modified version of the Migrant-Friendly Maternity Care Questionnaire, we will survey 900 mothers of Belgian nationality or a nationality from a North or Sub-Saharan African country, and having given birth in four maternity wards in Brussels. The questionnaire has been adapted to the study objectives and the Belgian context. Interviewers will administer the 116-item questionnaire to all women agreeing to participate and meeting inclusion criteria, within 14 days of having given birth. Clinical information will be extracted from hospital records.

ANALYSIS

We will estimate the associations of women's socioeconomic and migration characteristics with:Women's antenatal care trajectories (timing of first antenatal consultation, minimum recommended number of consultations, and problems accessing care).Obstetric practices such as episiotomies, emergency caesarean sections, and inductions.Patient experience such as feelings of discrimination, respect, and understanding of information.We will use descriptive statistics, multiple correspondence analysis, and simple and multiple logistic regressions.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the hospital Ethics Committees and from the Université libre de Bruxelles (No: P2017/055/B406201730877). Written informed consent will be sought from all participants.In addition to disseminating findings and recommendations to the scientific community through open-source journal articles and conferences, we will also address local organisations and healthcare professionals via a written report and seminars.

[Pregnant Women with Gestational Diabetes in Berlin - An Analysis of Perinatal Data Especially Regarding Immigration Background]

To date there has not been a systematic analysis of pregnant patients with an immigrant background and gestational diabetes in Germany, even though the number of these patients has been rising continuously since the 1980s.

METHODS

The case number estimate for this prospective study targeted 160 patients with gestational diabetes with and without an immigrant background. A questionnaire on socio-economic status, immigrant background, acculturation, and food intake was developed. The birth parameters and pre- and postpartum parameters were regularly documented.

RESULTS

In our study we included 198 patients with gestational diabetes, consisting of 110 patients with an immigrant background and 88 patients without an immigrant background. The number of labor inductions for the suspected diagnosis of fetal macrosomia was almost the same in both groups (immigrant background 3.6% vs. without immigrant background 4.6%, p=1.0; OR 1.73; 95% CI; 0.79-3.89, p=0.17). The study patients with an immigrant background were more likely to give birth spontaneously than via cesarean section or vaginal-operative birth. The perinatal outcome of children from our study patients with and without an immigrant background were similar.

CONCLUSION

We show that regardless of their immigrant background gestational diabetes patients have similar and homogeneous patient-centered care at our clinic.

Family planning trends among community-dwelling African refugee women

PURPOSE

From 2009 to 2019, more than 175,000 refugees were admitted into the United States from African countries. What is known about sexual and reproductive health in this population is focused on perinatal outcomes; beliefs and attitudes towards family planning and related behaviors, which can impact perinatal health, have not been explored. Understanding these beliefs and attitudes can guide future work with this population.

STUDY DESIGN

A cross-sectional, convenience survey of 100 community-dwelling African refugee women was conducted.

RESULTS

The following research questions guided analysis: What are African refugee women's family planning attitudes (pregnancy intention, desired timing, perceived fecundity)? What are African refugee women's family planning behaviors (use vs. non-use of methods, type of methods used)? and What socio-demographic factors and family planning attitudes are related to family panning behaviors (use or non-use of methods)? Almost 49% of participants reported ever using a method of family planning and 35% reported current use. Reasons for non-use included desire for more children (28.8%), infrequent intercourse (22.0%), and fear of side effects (16.9%). Nearly two thirds expressed a desire for a future pregnancy (63.4%), but the majority reported wanting to become pregnant in two or more years (25.7%) or "when God wants" (24.8%). No significant relationship was found between family planning method use and future pregnancy intention, desired timing of future pregnancy, perceived fecundity, marital status, religious affiliation, number of years in the US. Having had any formal schooling decreased the likelihood of using a family planning method.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Low family planning method use rates among African refugee women are not completely explained by desires for future pregnancy, perceived fecundity, marital status, or other sociodemographic factors. Concern for future fertility and fear of side effects were identified as potentially modifiable reasons appropriate for community based culturally congruent educational interventions on family planning use.

Secular changes in body height predict global rates of caesarean section

The massive global variation in caesarean-section (C-section) rate is usually attributed to socio-economic, medical and cultural heterogeneity. Here, we show that a third of the global variance in current national C-section rate can be explained by the trends of adult body height from the 1970s to the 1990s. In many countries, living conditions have continually improved during the last century, which has led to an increase in both fetal and adult average body size. As the fetus is one generation ahead of the mother, the fetus is likely to experience better environmental conditions during development than the mother did, causing a disproportionately large fetus and an increased risk of obstructed labour. A structural equation model revealed that socio-economic development and access to healthcare affect C-section rate via multiple causal pathways, but the strongest direct effect on C-section rate was body height change. These results indicate that the historical trajectory of socio-economic development affects-via its influence on pre- and postnatal growth-the intergenerational relationship between maternal and fetal dimensions and thus the difficulty of labour. This sheds new light on historic and prehistoric transitions of childbirth and questions the World Health Organization (WHO) suggestion for a global 'ideal' C-section rate.

Socioeconomic and migration status as predictors of emergency caesarean section: a birth cohort study

BACKGROUND

Women with a migration background are reportedly at a higher risk of emergency caesarean section. There is evidence that this is due in part to suboptimal antenatal care use and quality of care. Despite the fact that migrant women and descendants of migrants are often at risk of socioeconomic disadvantage, there is, in comparison, scarce and incomplete evidence on the role of socioeconomic position as an independent risk factor for emergency caesarean delivery. We therefore investigate whether and how migration background and two markers of socioeconomic position affect the risk of an emergency caesarean section and whether they interact with each other.

METHODS

In 2013-2016, we recruited women during the perinatal period in Bielefeld, Germany, collecting data on health and socioeconomic and migration background, as well as routine perinatal data. We studied associations between migration background (1st generation migrant, 2nd/3rd generation woman, no migration background), socioeconomic status (educational attainment and net monthly household income), and the outcome emergency caesarean section.

RESULTS

Of the 881 participants, 21% (n = 185) had an emergency caesarean section. Analyses showed no association between having an emergency caesarean section and migration status or education. Women in the lowest (< 800€/month) and second lowest (between 800 and 1750€/month) income categories were more likely (aOR: 1.96, CI: 1.01-3.81; and aOR: 2.36, CI: 1.27-4.40, respectively) to undergo an emergency caesarean section than women in the higher income groups.

CONCLUSIONS

Migration status and education did not explain heterogeneity in mode of birth. Having a low household income, however, increased the chances of emergency caesarean section and thereby contributed towards producing health disadvantages. Awareness of these findings and measures to correct these inequalities could help to improve the quality of obstetric care.

Differences in caesarean delivery and neonatal outcomes among women of migrant origin in Finland: A population-based study

BACKGROUND

In Finland, limited information is available on neonatal disparities among women of migrant origin.

OBJECTIVE

This study investigated differences in caesarean delivery and neonatal outcomes between women of migrant origin and Finnish women in Finland.

METHODS

The study was based on nationwide data from the Medical Birth Register of Finland. Our study included information on the most recent singleton birth of women delivering between January 2004 and December 2014 (N = 382 233). Women were classified into nine regional categories based on their country of origin. Generalized linear models were used to describe associations between country of origin and pregnancy outcomes adjusted for maternal age, socio-economic status, pre-pregnancy body mass index, parity, marital status, smoking during pregnancy, and delivery year. Finnish women were the reference group.

RESULTS

Among the study population, almost 92% of women were of Finnish origin; the remaining 8% were of migrant origin. Among the migrant women, those of Russian/former USSR origin were the largest group (n = 11 994); the smallest group was women of Latin American/Caribbean origin (n = 739). Compared with Finnish women, women of sub-Saharan African, South Asian, and East Asian origin were at greater risk of emergency caesarean delivery, preterm birth, low birthweight, and lower five-minute Apgar scores for newborns. Latin American/Caribbean-origin women were at increased risk of both elective and emergency caesarean delivery and lower five-minute Apgar scores compared with Finnish women. Women of Russian/former USSR origin overall had a lower risk of caesarean delivery and poor neonatal outcomes compared with Finnish women.

CONCLUSIONS

We identified sub-Saharan African, South Asian, and East Asian women as higher-risk groups, and women from Russia/former USSR as a lower-risk group, for emergency caesarean delivery and poor neonatal outcome compared with Finnish women. More research is needed to identify the reasons for these differences by country of origin in Finland.

Comparative study between women born in France and migrant women with regard to their mode of delivery

OBJECTIVE

To compare the mode of delivery between women born in France and migrants.

STUDY DESIGN

The study was a retrospective, observational, single-center study conducted at the university maternity unit in Caen. All women who gave birth in 2008 or 2014 were included. Women with multiple pregnancies and women whose pregnancies ended before 22 weeks of gestational age were excluded. The pre-existing characteristics at the time of pregnancy, mode of delivery and postpartum were collected from the University Hospital's medical and administrative computer database. We first compared women born in France to those born abroad with regard to the characteristics of mode of delivery for 2008, then for 2014. Secondly, we compared migrant women between 2008 and 2014 to see if the change in the migration profile was associated with a change in the mode of delivery.

RESULTS

Of the 3038 and 3001 women included in 2008 and 2014 respectively, 272 and 385 women were migrants. We observed a significant decrease in the number of spontaneous labors (adjusted odds ratio (aOR) 0.5 [0.4-0.6]) with a significant increase in emergency cesarean sections before (aOR 2.1 [1.4-3.0]) and during labor (aOR 2.2 [1.6-3.2]) among women born in sub-Saharan Africa compared to non-migrants. And we showed a higher risk of cesarean section prior to labor (aOR 1.2 [1.01-1.4]) and a significant decrease in cesarean section during labor (aOR 0.8 [0.7-0.99]) in 2014 compared to 2008.

CONCLUSION

We observed a significant increase in all types of Cesarean sections among women born abroad compared to those born in France, especially in the subgroup of women born in sub-Saharan Africa.

Differential rates of cesarean delivery by maternal geographical origin: a cohort study in France

BACKGROUND

In many Western countries, higher rates of cesarean have been described among migrant women compared to natives of receiving countries. We aimed to estimate this difference comparing women originating from France and Sub-Saharan Africa (SSA), identify the clinical situations explaining most of this difference and assess whether maternal origin was independently associated with cesarean risk.

METHODS

The PreCARE prospective multicenter cohort study was conducted in 2010-2012 in the north Paris area. Our sample was restricted to 1500 women originating from Sub-Saharan Africa and 2206 from France. Profiles of cesarean section by maternal origin were described by the Robson classification. Independent associations between maternal origin and 1) cesarean before labor versus trial of labor, then 2) intrapartum cesarean versus vaginal delivery were assessed by logistic regression models to adjust for other maternal and pregnancy characteristics.

RESULTS

Rates of cesarean for women originating from France and SSA were 17 and 31%. The Robson 5A category "unique uterine scar, single cephalic ≥37 weeks" was the main contributor to this difference. Within this category, SSA origin was associated with cesarean before labor after adjustment for medical risk factors (adjusted odds ratio [aOR] = 2.30 [1.12-4.71]) but no more significant when adjusting on social deprivation (aOR = 1.45 [0.63-3.31]). SSA origin was associated with cesarean during labor after adjustment for both medical and social factors (aOR = 2.95 [1.35-6.44]).

CONCLUSIONS

The wide difference in cesarean rates between SSA and French native women is mainly explained by the Robson 5A category. Within this group, medical factors alone do not explain the increased risk of cesarean in SSA women.

Emergency cesarean section among women in Robson groups one and three: A comparison study of immigrant and Norwegian women giving birth in a low-risk maternity hospital in Norway

Researchers have shown that some immigrant groups have an increased risk of emergency cesarean section. The authors' aim was to examine the differences in emergency cesarean section rates among immigrant women in Norway with low obstetric risks by using the Robson classification system. We performed secondary analysis on a Norwegian cohort study, where 10,125 women were classified in Robson groups one and three. Women from East, Southeast, and Central Asia, and from Africa had a higher risk of emergency cesarean section. The Robson classification system was a useful tool in comparing cesarean section rates between immigrant groups and host country populations.

Ethnic differences in the risk of caesarean section: a Danish population-based register study 2004-2015

BACKGROUND

Studies have shown differences in the risk of caesarean section (CS) between ethnic minority groups. This could be a marker of unequal health care. The aim of this study was to investigate differences in the risk of CS between immigrants of various origins in Denmark, where all health care is free and easy to access, and Danish-born women. A further aim was to determine the possible influence of known risk factors for CS.

METHODS

The design was a population-based register study using national Danish registers and included all live- and stillborn singleton deliveries by primiparous women in Denmark from 2004 to 2015. The total study population consisted of 298,086 births, including 25,198 births to women from the 19 largest immigrant groups in Denmark. Multinomial logistic regression analysis was used to estimate relative risk ratios (RRR) of emergency and planned CS, using vaginal delivery (VD) as reference, in immigrant women compared to Danish-born women. A number of known risk factors were included separately.

RESULTS

Women from Turkey, the Philippines, Thailand, Somalia, Vietnam, Iran and Afghanistan had a statistically significant elevated risk ratio of emergency CS vs. VD compared to Danish-born women; adjusted RRR's ranging 1.15-2.19. The risk ratio of planned CS vs. VD was lower among the majority of immigrant groups, however higher among women from Poland, Thailand and Iran, when compared to Danish-born women. None of the studied explanatory variables affected the risk ratio of planned CS vs. VD, whereas maternal height contributed with varying strength to the risk ratio of emergency CS vs. VD for all immigrant groups.

CONCLUSION

Substantial variations in CS risks by maternal country of birth were documented. Some of the disparities in emergency CS seem to be explained by maternal height.

Reproductive Health Outcomes in African Refugee Women: A Comparative Study

Background: African refugee women in the United States are at risk of poor reproductive health outcomes; however, examination of reproductive health outcomes in this population remains inadequate. We compared: (1) prepregnancy health and prenatal behavior; (2) prenatal history and prenatal care utilization; and (3) labor and birth outcomes between African refugee women and U.S.-born Black and White women. Methods: A secondary data analysis of enhanced electronic birth certificate data was used. Univariate comparisons using chi-squared tests for dichotomous variables and analysis of variance and/or Kruskal-Wallis tests for continuous variables were conducted for Refugee versus Black versus White women. A p-value <0.05 was considered statistically significant. Results: From 2007 to 2016, 789 African refugee, 17,487 Black, and 59,615 White women in our population gave birth. African refugees experienced more favorable health outcomes than U.S.-born groups on variables examined. Compared to U.S.-born women, African refugee women had fewer prepregnancy health risks (p < 0.001), fewer preterm births (p < 0.001), fewer low birth weight infants (p < 0.001), and higher rates of vaginal deliveries (p < 0.001). These favorable outcomes occurred despite later initiation of prenatal care (p < 0.001) and lower scores of prenatal care adequacy among refugee women compared to U.S.-born groups (p < 0.001). Conclusions: The healthy immigrant effect appears to extend to reproductive health outcomes in our studied population of African refugee women. However, based on our data, targeted, culturally-congruent education surrounding family planning and prenatal care is recommended. Insight from reproductive health care experiences of African refugee women can provide understanding of the protective factors contributing to the healthy immigrant effect in reproductive health outcomes, and knowledge gained can be utilized to improve outcomes in other at-risk groups.

Length of residence and caesarean section in migrant women in Sweden: a population-based study

Background

Prior studies have reported substantial differences in caesarean rates between migrant and non-migrant women. In this study we investigate whether the association between maternal country of birth and caesarean section is modified by length of residence in Sweden.

Methods

Population-based register study. A total of 106 760 migrant and 473 881 Swedish-born women having singleton, first births were studied using multinomial multiple regression models to estimate odds ratios (OR) and 95% confidence intervals for mode of birth. Random effect meta-analyses were conducted to assess true heterogeneity between categories of length of residence.

Results

Longer duration of residence was associated with an increased overall risk of both unplanned and planned caesarean section among migrant women. This pattern was more pronounced among countries grouped as having higher prevalence (compared to Swedes) of unplanned: OR≤1=1.41 (1.32-1.50); OR>1-<6=1.49 (1.42-1.57); OR6-<10=1.61 (1.50-1.72); OR≥10=1.71 (1.64-1.79) and planned caesarean section [OR≤1=1.14 (0.95-1.36); OR>1-<6=1.30 (1.13-1.51); OR6-<10=1.97 (1.64-2.37]; OR≥10=1.82 (1.67-1.98)]. The results were robust to social, obstetric and health adjustments. There were some country-of-origin-specific findings.

Conclusions

The fact that the risk of unplanned and planned caesarean section tended to increase with length of residence, even with adjustment for social, obstetric and health factors, suggests that receiving country-specific factors are playing an important role in caesarean section.

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

INTRODUCTION

Limited information is available on delivery and its complications among migrant women in Finland. We compared mode of delivery, delivery complications, and use of pain medication during delivery between migrant women of Somali, Kurdish, and Russian origin and women in the general population in Finland.

METHODS

The women were of Russian (n = 318), Somali (n = 583), and Kurdish (n = 373) origin and 243 women from the general population (reference group) who had given birth in Finland between 2004 and 2014. The data were obtained from the National Medical Birth Register and the Hospital Discharge Register. The most recent birth of each woman was included in the analyses. The main statistical methods were logistic regression analyses adjusting for age, parity, body mass index, gestational age, and smoking during pregnancy.

RESULTS

Vaginal delivery was the most common mode of delivery among all study groups (79%-89%). The prevalence of any delivery complications varied between 15% and 19% among all study groups. When adjusted for confounders, Russian women had lower odds (OR 0.49; CI 0.29-0.82) of having a cesarean delivery, whereas Somali and Kurdish women did not differ from the reference group. Somali women had an increased risk of any delivery complications (OR 1.62; CI 1.03-2.55) compared with the reference group. No differences were observed in the use of pain medication between the groups.

CONCLUSION

Delivery complications were more common among migrant Somali women than among women in the general Finnish population. Somali women represent a high-risk group calling for special attention and care.

Neighborhood Income and Cesarean Section Rates at a Tertiary Care Center in Canada

Background: With rising rates of cesarean sections (CSs) in Canada and worldwide, nonclinical factors for CS warrant consideration. Objective: To determine the association between a primigravid woman's neighborhood income and rates of CSs. Materials and Methods: A retrospective cohort study was conducted at an Ontario tertiary care center from January 2003 to December 2013. Rates of CSs were determined using data collected from the Discharge Abstract Database. Women with singleton live births were included. The main exposure variable was the neighborhood income quintile. A multivariable model was used to adjust for covariates and provide an estimate of the independent effect of neighborhood income on the CS rate. Results: The study cohort comprised 32,714 women. Compared with the lowest quintile, women in the highest quintile had increased rates of CSs (relative risk, RR 1.06, 95% confidence interval, CI [1.02-1.11]). Following adjustment for important confounders, there was no longer an association between the neighborhood income and CS rate (adjusted RR 1.00, 95% CI [0.99-1.01]). Women in the highest quintile were more likely to have greater maternal age (p < 0.01). Conclusions: Although differences in CS rates are seen by the neighborhood income quintile, they appear to be mediated through a combination of maternal age and other clinical factors. Neighborhood income does not appear to be an independent predictor of CS.

Advanced cervical dilatation as a predictor for low emergency cesarean delivery: a comparison between migrant and non-migrant Primiparae - secondary analysis in Berlin, Germany

Background

Cesarean rates are higher in women admitted to labor ward during early stages rather than at later stages of labor. In a study in Germany, crude cesarean rates among Turkish and Lebanese immigrant women were low compared to non-immigrant women. We evaluated whether these immigrant women were admitted during later stages of labor, and if so, whether this explains their lower cesarean rates.

Methods

We enrolled 1413 nulliparous women with vertex pregnancies, singleton birth, and 37+ week of gestation, excluding elective cesarean deliveries, in three Berlin obstetric hospitals. We applied binary logistic regression to adjust for social and obstetric factors; and standardized coefficients to rank predictors derived from the regression model.

Results

At the time of admission to labor ward, a smaller proportion of Turkish migrant women was in the active phase of labor (cervical dilation: 4+ cm), compared to women of Lebanese origin and non-immigrant women. Rates of cesarean deliveries were lower in women of Turkish and Lebanese origin (15.8 and 13.9%) than in non-immigrant women (23.9%). In the logistic regression analysis, more advanced cervical dilatation was inversely associated with the outcome cesarean delivery (OR: 0.76, 95%CI: 0.70–0.82). In addition, higher maternal age (OR: 1.06, 95%CI: 1.04–1.09), application of oxytocic agents (OR: 0.55, 95%CI: 0.42–0.72), and obesity (OR: 2.25, 95%CI: 1.51–3.34) were associated with the outcome. Ranking of predictors indicate that cervical dilatation is the most relevant predictor derived from the regression model.

Conclusions

Advanced cervical dilatation at the time of admission to labor ward does not explain lower emergency cesarean delivery rates in Turkish and Lebanese migrant women, despite the fact that this is the strongest among the predictors for emergency cesarean delivery identified in this study.

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.

Comparison of the pregnancy results between adolescent Syrian refugees and local adolescent Turkish citizens who gave birth in our clinic

Adolescence is the transition period from childhood to adulthood; the World Health Organization has defined it as the ages between 10 and 19. Approximately 11% of all births in the world are by adolescent mothers. Pregnant adolescent refugees who have been forced to emigrate due to civil wars raging on in their native countries often face difficult social life conditions, have little or no access to hospitals, and experience language barriers and poor nutritional status have been found to experience poor maternal and obstetric outcomes. These include an increase in cesarean births, premature births, intrauterine growth retardation, and low-birth-weight infant rates. The purpose of the article was to share with you the comparative results of the adolescent pregnancies among the immigrants and among the local adolescents who gave birth between January 2016 and July 2017 in Kocaeli Derince Training and Research Hospital Gynecology Clinic in Kocaeli, Turkey. Its materials and method is a comparative study planned retrospectively between 67 adolescent Syrian refugees and 188 adolescent Turkish locals who gave birth between January 2016 and July 2017. The demographic data, obstetric outcomes, hospitalization durations, and neonatal outcomes of the patients were compared between the groups. Results, no statistically significant difference was found between pregnancy numbers, normal birth rates, cesarean sections and interventional birth rates, nullipara-multipara birth rates, or premature birth rates (<37 weeks) of the pregnant Turkish adolescents and pregnant immigrant adolescents (p > .05). The number of days these patients were hospitalized was found to be lower among Syrian immigrants than among the Turkish locals and statistically significant (p = .045 and p < .05, respectively). In addition, an analysis of the birth rates of low-birth-weight infants revealed that said rates were higher among the Syrian refugees than the Turkish local and statistically borderline significant (p = .049, p < .05, respectively). Between January 2016 and July 2017, a total of 8,570 live births were performed in our clinic. In our study of the 255 patients under the age of 19 who gave live births, 188 were Turkish and 67 were Syrian refugees. The average age of Turkish mothers under 19 was found to be 17.30 ± 1.01 years and the average age of immigrant mothers was found to be 17.27 ± 0.82 years. In conclusion, adolescent pregnancies are more common among Syrian refugees. Adolescent pregnancies are at risk for obstetric and neonatal outcomes. Therefore, studies should be done to prevent these pregnancies.

Perinatal Outcome in Women with a Vietnamese Migration Background - Retrospective Comparative Data Analysis of 3000 Deliveries

Introduction

Perinatal data of women with a Vietnamese migration background have not been systematically studied in Germany to date. Numerous details of important maternal and child outcomes were compared and analysed. The studyʼs primary parameters were the frequency of and indication for c-section.

Methodology

The perinatal data from a Berlin hospital were analysed retrospectively. The women (Vietnamese migration background vs. autochthonous) were grouped using name analysis. Datasets of 3002 women giving birth, including 999 women with a Vietnamese migration background, were included. The associations between primary or secondary cesarean delivery and different child outcomes depending on the migration background (exposure) were studied using logistical regression analysis.

Results

Women with a Vietnamese migration background have a lower c-section rate of 8.0% for primary and 12.6% for secondary c-section than women without a migration background (11.1% primary and 16.4% secondary c-section respectively). Regression analysis shows that the odds that women with a Vietnamese migration background will have a primary (OR 0.75; p = 0.0884) or secondary c-section (OR 0.82; p = 0.1137) are not significantly lower. A Vietnamese migration background was associated with higher odds for an episiotomy but not for a grade 3 – 4 perineal tear. A Vietnamese migration background does not have a significant influence on poor 5-min Apgar scores ≤ 7 and low umbilical cord arterial pH values ≤ 7.10. Newborns of mothers with a Vietnamese migration background have higher odds of a relatively higher birth weight (> 3110 g).

Summary

There was no evidence that women with a Vietnamese migration background are delivered more often by caesarean section. There were also no differences as regards important child outcome data from women in the comparator group. Overall, the results do not provide any evidence for poorer quality of care of women with a Vietnamese migration background in Berlin despite the cultural and communication barriers in the reality of care provision.

Comparing Pregnancy Outcomes of Immigrants from Ethiopia and the Former Soviet Union to Israel, to those of Native-Born Israelis

To compare pregnancy outcomes of immigrants from Former-Soviet-Union (FSUI) and Ethiopia (EI) to those of Jewish-native-born Israelis (JNB), in context of universal health insurance. Birth outcomes of all singletons born in Soroka-University Medical-Center (1998-2011) of EI (n = 1,667) and FSUI (n = 12,920) were compared with those of JNB (n = 63,405). Low birthweight rate was significantly higher among EI (11.0 %) and slightly lower (7.0 %) among FSUI, compared to JNB (7.5 %). Preterm-delivery rates were similar to those of JNB. Both immigrant groups had significantly (p < 0.001) higher rates of perinatal mortality (PM) than JNB (21/1000 in EI, and 11/1000 in FSUI, compared to 9/1000). Using multivariable GEE models both immigrant groups had significantly increased risk for PM; however, EI had twice as much FSUI origin (OR 2.3, 95 % CI 1.6-3.4, and OR 1.3, 95 % CI 1.1-1.6, respectively). Universal health care insurance does not eliminate excess PM in immigrants, nor the gaps between immigrant groups.

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 .