Association between maternal social deprivation and prenatal care utilization: the PreCARE cohort study

Reference values for biochemical tests during pregnancy: analysis of the PRECAREbio Cohort and correlation with precarious status

OBJECTIVE

To establish normal current values of various biochemical parameters during pregnancy in the northern area of Paris (France) in a subgroup from the PreCARE cohort and to study their changes according to the term of pregnancy, and to determine the influence of maternal precarity.

DESIGN

The PreCAREbio cohort of pregnant women was defined in the PreCARE study, a multicenter cohort study.

SETTING

Participants completed detailed questionnaires at enrolment and immediately postpartum. Data were collected prospectively. 26 biochemical parameters were longitudinally assessed.

POPULATION

All women registered to deliver or who delivered at one of the four participating university hospitals in Paris between October 2010 and November 2011 were eligible for study inclusion (n=10,419).

METHODS

We studied 26 biochemical markers during pregnancy and the influence of maternal social deprivation.

MAIN OUTCOME MEASURES

Baseline values for 26 biochemical markers and their changes according to the term of pregnancy, and the influence of maternal social deprivation on these biochemical markers.

RESULTS

386 patients with 1733 blood samples recruited in one of the four centers in the PreCARE cohort were included. Baseline concentrations (median, 2.5th and 97.5th percentile) for each marker and did not differ at the different time points. Mean concentrations of each biochemical marker did not differ between socially deprived women and non-socially deprived women.

CONCLUSIONS

We have established normal values for 26 biochemical parameters during pregnancy. We have also shown no difference in these values between socially deprived and non- socially deprived women.

Socioeconomic disparities in changes to preterm birth and stillbirth rates during the first year of the COVID-19 pandemic: a study of 21 European countries

BACKGROUND

Despite concerns about worsening pregnancy outcomes resulting from healthcare restrictions, economic difficulties and increased stress during the COVID-19 pandemic, preterm birth (PTB) rates declined in some countries in 2020, while stillbirth rates appeared stable. Like other shocks, the pandemic may have exacerbated existing socioeconomic disparities in pregnancy, but this remains to be established. Our objective was to investigate changes in PTB and stillbirth by socioeconomic status (SES) in European countries.

METHODS

The Euro-Peristat network implemented this study within the Population Health Information Research Infrastructure (PHIRI) project. A common data model was developed to collect aggregated tables from routine birth data for 2015-2020. SES was based on mother's educational level or area-level deprivation/maternal occupation if education was unavailable and harmonized into low, medium and high SES. Country-specific relative risks (RRs) of PTB and stillbirth for March to December 2020, adjusted for linear trends from 2015 to 2019, by SES group were pooled using random effects meta-analysis.

RESULTS

Twenty-one countries provided data on perinatal outcomes by SES. PTB declined by an average 4% in 2020 {pooled RR: 0.96 [95% confidence intervals (CIs): 0.94-0.97]} with similar estimates across all SES groups. Stillbirths rose by 5% [RR: 1.05 (95% CI: 0.99-1.10)], with increases of between 3 and 6% across the three SES groups, with overlapping confidence limits.

CONCLUSIONS

PTB decreases were similar regardless of SES group, while stillbirth rates rose without marked differences between groups.

Gradients in low birthweight by maternal education: A comparative perspective

Background

Longstanding research has shown strong inequalities in low birthweight by household income. However, most such research has focused on Anglophone countries, while evidence emerging from other developed countries suggest a stronger role of education rather than incomes in creating inequalities at birth. This paper compares gradients in low birthweight by maternal education, as well as explores underlying mechanisms contributing to these gradients, in France, the United States, and the United Kingdom.

Methods

Analyses are based on harmonized data from large, nationally-representative samples from France, UK and US. We use regression models and decomposition methods to explore the relative role of several possible mechanisms in producing birthweight inequalities.

Results

Inequalities in low birth weight across maternal education groups were relatively similar in the United States, the United Kingdom and France. However, the individual-level mechanisms producing such inequalities varied substantially across the three countries, with income being most important in the US, pregnancy smoking being most evident in France, and the UK occupying an intermediate position. Differences in the mechanisms producing birth health inequalities mirror differences in the policy environment in the three countries.

Conclusion

While inequalities in health appear from the earliest moments in many countries, our results suggest research on birth health inequalities, and therefore policies, is not easily generalizable across national contexts, and call for more scholarship in uncovering the "whys" of health inequalities in a variety of contexts.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Population-based study of eclampsia: Lessons learnt to improve maternity care

BACKGROUND

Among hypertensive disorders of pregnancy (HDP), eclampsia is a rare but serious event, often considered avoidable. Detailed assessment of the adequacy of care for the women who have eclampsia can help identify opportunities for improvement and for prevention of the associated adverse maternal and neonatal outcomes.

OBJECTIVE

1/ To estimate the incidence and describe the characteristics of women with eclampsia and to compare them with those of women with non-eclamptic hypertensive disorders of pregnancy (HDP)-related severe maternal morbidity (SMM) and of control women without SMM 2/ To analyse the quality of management in women who had eclampsia, at various stages of their care pathway.

METHODS

It was a planned ancillary analysis of the EPIMOMS population-based study, conducted in six French regions in 2012-2013. Among the 182,309 maternities of the source population, all women with eclampsia (n = 51), with non-eclamptic HDP-related SMM (n = 351) and a 2% representative sample of women without SMM (n = 3,651) were included. Main outcome was the quality of care for eclampsia assessed by an independent expert panel at three different stages of management: antenatal care, care for pre-eclampsia and care for eclampsia.

RESULTS

The eclampsia incidence was 2.8 per 10,000 (95%CI 2.0-4.0). Antenatal care was considered completely inadequate or substandard in 39% of women, as was pre-eclampsia care in 76%. Care for eclampsia was judged completely inadequate or substandard in 50% (21/42), mainly due to inadequate use of magnesium sulphate.

CONCLUSION

The high proportion of inadequate quality of care underlines the need for an evidence-based standardisation of care for HDP.

Association between maternal social vulnerability and cesarean delivery: A cohort study

OBJECTIVE

Although social vulnerability has been correlated to adverse obstetrical outcomes, its definition as well as its correlation to mode of delivery vary between different studies. The aim of this study is to evaluate the association between maternal social vulnerabilities and cesarean section with the inclusion of a wide range of social vulnerability characteristics.

STUDY DESIGN

The current study is a retrospective single center cohort study in a tertiary care maternity unit between January 2020 and December 2021. All women who delivered after 24 gestational weeks were included. Multiple component analysis (MCA) grouped vulnerability characteristics in three independent vulnerability axes, named after their clinical relevance as administrative, psychological, and dependency axis. Multiple logistic regression was performed, controlling for obstetrical, medical factors as well as the Robson classification.

RESULTS

In total, 7707 patients were identified. After adjustment for the aforementioned factors, a statistically significant association was shown between administrative vulnerability index and cesarean section before labor or during labor respectively (aOR 1.48 [1.23 - 1.78] and aOR 1.46 [OR 1.23 - 1.73]). In contrast, no significant correlation was found for the psychological vulnerability index (aOR 1.09 [0.86 - 1.38] and aOR 0.99 [0.78 - 1.25]) or the dependency vulnerability index (aOR 0.98 [0.76 - 1.26] and aOR 0.85 [0.64 - 1.12]).

CONCLUSIONS

The current study provides new insight into the correlation between social vulnerabilities and the risk of cesarean section. It demonstrates that administrative vulnerability is an independent risk factor of cesarean delivery. These patients should be identified and offered an adapted pregnancy monitoring in order to reduce cesarean section rates.

Deprived areas and adverse perinatal outcome: a systematic review

PURPOSE

This systematic review aimed to assess if women living in deprived areas have worse perinatal outcomes than those residing in high-income areas.

METHODS

Datasets of PubMed, ScienceDirect, CENTRAL, Embase, and Google Scholar were searched for studies comparing perinatal outcomes (preterm birth, small-for-gestational age, and stillbirth) in deprived and non-deprive areas.

RESULTS

A total of 46 studies were included. The systematic review of the literature revealed a higher risk for adverse perinatal outcomes such as preterm birth, small for gestational age, and stillbirth in deprived areas.

CONCLUSION

Deprived areas are associated with adverse perinatal outcomes. More multifactorial studies are needed to assess the weight of each factor that composes the socioeconomic gradient of health in adverse perinatal outcomes.

Maternal health-related quality of life at 1 year after a preterm birth: role of socioeconomic status at birth

BACKGROUND

Maternal problems in the postpartum period may lead to suboptimal long-term health for women and could affect mother-child attachment. Social disadvantage is a risk factor for preterm birth, which carries its own burden of health issues and stress. The main aim of this study was to investigate the role for social factors in mothers' physical and emotional health-related quality of life (HRQoL) at 1 year after a preterm birth.

METHODS

EPIPAGE-2 is a French nationwide, prospective, population-based cohort of preterm children born before 35 weeks' gestation (N=3614 women). At birth, detailed data on the family's social status were collected. At 1 year after birth, mothers completed a mailed questionnaire to report information on their HRQoL, assessed by the Medical Outcomes Study 12-item Short Form. We used multivariate linear regression models to assess the association between social factors and maternal HRQoL.

RESULTS

At 1 year after childbirth, the emotional HRQoL of mothers of preterm children was worse than their physical HRQoL, even in women without any previous signs of psychological distress at the infant's discharge from hospital. Baseline social characteristics were the most important factors influencing the physical component of HRQoL. None of the studied social factors had any clear association with the mental component of HRQoL.

CONCLUSION

Our study underlines the importance of social disadvantage during pregnancy as risk factors for poor physical HRQoL at 1 year after a preterm birth.

Impact of experiencing multiple vulnerabilities on fetal growth and complications in women with hyperglycemia in pregnancy

BACKGROUND

In women with hyperglycemia in pregnancy living in France, psychosocial deprivation is associated with both earlier and greater exposure to the condition, as well as poorer maternofetal prognosis. We explored the impact of this and two other socioeconomic vulnerability indicators-food insecurity and poor language proficiency-on adherence to prenatal care and maternal and fetal outcomes.

METHODS

In a socially deprived suburb of Paris, we selected women who delivered between 01/01/2012 and 31/12/2018 and received care (nurse, dietician, diabetologist evaluation, advice, regular follow-up to adjust insulin doses if requested) for hyperglycemia in pregnancy. We analyzed the associations between individual psychosocial deprivation, food insecurity, French language proficiency (variables assessed by individual questionnaires) and fetal growth (main outcome), as well as other core maternal and fetal outcomes.

RESULTS

Among the 1,168 women included (multiethnic cohort, 19.3% of whom were Europeans), 56%, 17.9%, and 27.5% had psychosocial deprivation, food insecurity, and poor French language proficiency, respectively. Forty-three percent were prescribed insulin therapy. Women with more than one vulnerability had more consultations for diabetes. The rates for small (SGA), appropriate (AGA), and large-for-gestational-age (LGA) infant were 11.4%, 76.5% and 12.2%, respectively. These rates were similar in women with and without psychosocial deprivation, and in those with and without food insecurity. Interestingly, women with poor French language proficiency had a higher odds ratio of delivering a small- or large-for-gestational age infant than those with good proficiency.

CONCLUSION

We found similar pregnancy outcomes for women with hyperglycemia in pregnancy living in France, irrespective of whether or not they had psychosocial deprivation or food insecurity. Optimized single-center care with specialized follow-up could contribute to reduce inequalities in maternal and fetal outcomes in women with hyperglycemia in pregnancy.

Association between social vulnerability profiles, prenatal care use and pregnancy outcomes

BACKGROUND

Evaluating social vulnerability is a challenging task. Indeed, former studies demonstrated an association between geographical social deprivation indicators, administrative indicators, and poor pregnancy outcomes.

OBJECTIVE

To evaluate the association between social vulnerability profiles, prenatal care use (PCU) and poor pregnancy outcomes (Preterm birth (PTB: <37 gestational weeks (GW)), small for gestational age (SGA), stillbirth, medical abortion, and late miscarriage).

METHODS

Retrospective single center study between January 2020 and December 2021. A total of 7643 women who delivered a singleton after 14 GW in a tertiary care maternity unit were included. Multiple component analysis (MCA) was used to assess the associations between the following social vulnerabilities: social isolation, poor or insecure housing conditions, not work-related household income, absence of standard health insurance, recent immigration, linguistic barrier, history of violence, severe dependency, psychologic vulnerability, addictions, and psychiatric disease. Hierarchical clustering on principal component (HCPC) from the MCA was used to classify patients into similar social vulnerability profiles. Associations between social vulnerability profiles and poor pregnancy outcomes were tested using multiple logistic regression or Poisson regression when appropriate.

RESULTS

The HCPC analysis revealed 5 different social vulnerability profiles. Profile 1 included the lowest rates of vulnerability and was used as a reference. After adjustment for maternal characteristics and medical factors, profiles 2 to 5 were independently associated with inadequate PCU (highest risk for profile 5, aOR = 3.14, 95%CI[2.33-4.18]), PTB (highest risk for profile 2, aOR = 4.64, 95%CI[3.80-5.66]) and SGA status (highest risk for profile 5, aOR = 1.60, 95%CI[1.20-2.10]). Profile 2 was the only profile associated with late miscarriage (adjusted incidence rate ratio (aIRR) = 7.39, 95%CI[4.17-13.19]). Profiles 2 and 4 were independently associated with stillbirth (highest association for profile 2 (aIRR = 10.9, 95%CI[6.11-19.99]) and medical abortion (highest association for profile 2 (aIRR = 12.65, 95%CI[5.96-28.49]).

CONCLUSIONS

This study unveiled 5 clinically relevant social vulnerability profiles with different risk levels of inadequate PCU and poor pregnancy outcomes. A personalized patient management according to their profile could offer better pregnancy management and reduce adverse outcomes.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Use of pregnancy personalised follow-up in case of maternal social vulnerability to reduce prematurity and neonatal morbidity

BACKGROUND

Social deprivation is a major risk factor of adverse pregnancy outcomes. Yet, there is few studies evaluating interventions aiming at reducing the impact of social vulnerability on pregnancy outcomes.

OBJECTIVE

To compare pregnancy outcomes between patients that received personalized pregnancy follow-up (PPFU) to address social vulnerability versus standard care.

METHODS

Retrospective comparative cohort in a single institution between 2020 and 2021. A total of 3958 women with social vulnerability that delivered a singleton after 14 gestational weeks were included, within which 686 patients had a PPFU. Social vulnerability was defined by the presence of at least one of the following characteristics: social isolation, poor or insecure housing conditions, no work-related household income, and absence of standard health insurance (these four variables were combined as a social deprivation index (SDI)), recent immigration (< 12 month), interpersonal violence during pregnancy, being handicaped or minor, addiction during pregnancy. Maternal characteristics and pregnancy outcomes were compared between patients that received PPFU versus standard care. The associations between poor pregnancy outcomes (premature birth before 37 gestational weeks (GW), premature birth before 34 GW, small for gestational age (SGA) and PPFU were tested using multivariate logistic regression and propensity score matching.

RESULTS

After adjustment on SDI, maternal age, parity, body mass index, maternal origin and both high medical and obstetrical risk level before pregnancy, PPFU was an independent protective factor of premature birth before 37 gestational weeks (GW) (aOR = 0.63, 95%CI[0.46-0.86]). The result was similar for premature birth before 34 GW (aOR = 0.53, 95%CI [0.34-0.79]). There was no association between PPFU and SGA (aOR = 1.06, 95%CI [0.86 - 1.30]). Propensity score adjusted (PSa) OR for PPFU using the same variables unveiled similar results, PSaOR = 0.63, 95%CI[0.46-0.86] for premature birth before 37 GW, PSaOR = 0.52, 95%CI [0.34-0.78] for premature birth before 34 GW and PSaOR = 1.07, 95%CI [0.86 - 1.33] for SGA.

CONCLUSIONS

This work suggests that PPFU improves pregnancy outcomes and emphasizes that the detection of social vulnerability during pregnancy is a major health issue.

Women and health professionals' perspectives on a conditional cash transfer programme to improve pregnancy follow-up: a qualitative analysis of the NAITRE randomised controlled study

OBJECTIVES

Women of low socioeconomic status have been described as having suboptimal prenatal care, which in turn has been associated with poor pregnancy outcomes. Many types of conditional cash transfer (CCT) programmes have been developed, including programmes to improve prenatal care or smoking cessation during pregnancy, and their effects demonstrated. However, ethical critiques have included paternalism and lack of informed choice. Our objective was to determine if women and healthcare professionals (HPs) shared these concerns.

DESIGN

Prospective qualitative research.

SETTING

We included economically disadvantaged women, as defined by health insurance data, who participated in the French NAITRE randomised trial assessing a CCT programme during prenatal follow-up to improve pregnancy outcomes. The HP worked in some maternities participating in this trial.

PARTICIPANTS

26 women, 14 who received CCT and 12 who did not, mostly unemployed (20/26), and - 7 HPs.

INTERVENTIONS

We conducted a multicentre cross-sectional qualitative study among women and HPs who participated in the NAITRE Study to assess their views on CCT. The women were interviewed after childbirth.

RESULTS

Women did not perceive CCT negatively. They did not mention feeling stigmatised. They described CCT as a significant source of aid for women with limited financial resources. HP described the CCT in less positive terms, for example, expressing concern about discussing cash transfer at their first medical consultation with women. Though they emphasised ethical concerns about the basis of the trial, they recognised the importance of evaluating CCT.

CONCLUSIONS

In France, a high-income country where prenatal follow-up is free, HPs were concerned that the CCT programme would change their relationship with patients and wondered if it was the best use of funding. However, women who received a cash incentive said they did not feel stigmatised and indicated that these payments helped them prepare for their baby's birth.

TRIAL REGISTRATION NUMBER

NCT02402855.

Update of Perinatal Human Immunodeficiency Virus Type 1 Transmission in France: Zero Transmission for 5482 Mothers on Continuous Antiretroviral Therapy From Conception and With Undetectable Viral Load at Delivery

BACKGROUND

Antiretroviral therapy (ART) is remarkably effective in preventing perinatal transmission (PT) of HIV-1. We evaluated the PT rate in a population of women with widespread access to ART before conception.

METHODS

The analysis included 14 630 women with HIV-1 who delivered from 2000 to 2017 at centers participating in the nationwide prospective multicenter French Perinatal Cohort (ANRS-EPF). PT was analyzed according to time period, timing of ART initiation, maternal plasma viral load (pVL), and gestational age at birth. No infants were breastfed, and all received neonatal prophylaxis.

RESULTS

PT decreased between 3 periods, from 1.1% in 2000-2005 (58/5123) to 0.7% in 2006-2010 (30/4600) and to 0.2% in 2011-2017 (10/4907; P < .001). Restriction of the analysis to the 6316/14 630 (43%) women on ART at conception, PT decreased from 0.42% (6/1434) in 2000-2005 to 0.03% (1/3117) in 2011-2017 (P = .007). Among women treated at conception, if maternal pVL was undetectable near delivery, no PT was observed regardless of the ART combination [95%CI 0-0.07] (0/5482). Among women who started ART during pregnancy and with undetectable pVL near delivery, PT was 0.57% [95%CI 0.37-0.83] (26/4596). Among women treated at conception but with a detectable pVL near delivery, PT was 1.08% [95%CI 0.49-2.04] (9/834). We also qualitatively described 10 cases of transmission that occurred during the 2011-2017 period.

CONCLUSIONS

In a setting with free access to ART, monthly pVL assessment, infant ART prophylaxis, and in the absence of breastfeeding, suppressive ART initiated before pregnancy and continued throughout pregnancy can reduce PT of HIV to almost zero.

Social determinants of inadequate prenatal care utilization in sheltered homeless mothers in the Greater Paris area in France

Background

Sheltered homeless families suffer from deleterious living conditions such as housing instability (i.e., moving from one shelter to another) that could be an additional barrier to healthcare utilization. Few studies have specifically examined perinatal health in homeless mothers and their utilization of prenatal healthcare. This study aimed to identify social determinants such as living conditions (i.e., housing instability) associated with inadequate prenatal care utilization (PCU) in sheltered homeless mothers in the Greater Paris area in France.

Methods

The homeless children and families cross-sectional survey [ENFAMS: (Enfants et familles sans logement)] was performed on a random representative sample of homeless families living in shelters in the greater Paris area in 2013. Following French guidelines, PCU was deemed inadequate if one or more of the following criteria was met: attending fewer than 50% of recommended prenatal visits, PCU initiation after the first trimester of pregnancy, and fewer than three ultrasounds during the entire pregnancy. Families were interviewed in 17 languages by trained peer interviewers in face-to-face interviews. Structural equation modeling was used to identify factors associated with inadequate PCU and to estimate correlations between them.

Results

This study analyzed data on 121 homeless sheltered mothers who had at least one child less than one year old. They were socially disadvantaged and most were born outside France. One in five (19.3%) had inadequate PCU. Associated factors were socio-demographic characteristics (young age, primiparous), health status (dissatisfaction with self-perceived general health), and living conditions (housing instability in the second and third trimesters).

Conclusion

It is essential to reduce housing instability to help sheltered mothers to benefit from social, territorial and medical support and healthcare utilization. Housing stability for pregnant sheltered homeless mothers should be a priority to ensure better PCU and guarantee the newborn's health as much as possible.

A Comprehensive Review on Social Inequalities and Pregnancy Outcome-Identification of Relevant Pathways and Mechanisms

Scientific literature tends to support the idea that the pregnancy and health status of fetuses and newborns can be affected by maternal, parental, and contextual characteristics. In addition, a growing body of evidence reports that social determinants, measured at individual and/or aggregated level(s), play a crucial role in fetal and newborn health. Numerous studies have found social factors (including maternal age and education, marital status, pregnancy intention, and socioeconomic status) to be linked to poor birth outcomes. Several have also suggested that beyond individual and contextual social characteristics, living environment and conditions (or "neighborhood") emerge as important determinants in health inequalities, particularly for pregnant women. Using a comprehensive review, we present a conceptual framework based on the work of both the Commission on Social Determinants of Health and the World Health Organization (WHO), aimed at describing the various pathways through which social characteristics can affect both pregnancy and fetal health, with a focus on the structural social determinants (such as socioeconomic and political context) that influence social position, as well as on intermediary determinants. We also suggest that social position may influence more specific intermediary health determinants; individuals may, on the basis of their social position, experience differences in environmental exposure and vulnerability to health-compromising living conditions. Our model highlights the fact that adverse birth outcomes, which inevitably lead to health inequity, may, in turn, affect the individual social position. In order to address both the inequalities that begin in utero and the disparities observed at birth, it is important for interventions to target various unhealthy behaviors and psychosocial conditions in early pregnancy. Health policy must, then, support: (i) midwifery availability and accessibility and (ii) enhanced multidisciplinary support for deprived pregnant women.

Analysis of association between low birth weight and socioeconomic deprivation level in Japan: an ecological study using nationwide municipal data

BACKGROUND

Several international studies have indicated an association between socioeconomic deprivation levels and adverse birth outcomes. In contrast, those investigating an association between socioeconomic status and low birth weight using nationwide data are limited in Japan. In this study, we investigated an association between municipal socioeconomic deprivation level and low birth weight by an ecological study.

METHODS

Nationwide municipal-specific Vital Statistics data from 2013 to 2017 were used. We calculated the low birth weight rate and standardized incidence ratio (SIR) for low birth weight for each municipality and plotted them on a Japanese map. Furthermore, the correlation coefficient between them and the deprivation level were calculated. In addition, a spatial regression model including other municipal characteristics was used to investigate an association between low birth weight and the deprivation level.

RESULTS

Municipalities with relatively high SIR for low birth weight were dispersed across all of Japan. The correlation coefficient between the socioeconomic deprivation level and low birth weight rate was 0.196 (p-value < 0.001) among municipalities, and that between the socioeconomic deprivation level and the SIR for low birth weight was 0.260 (p-value < 0.001). In addition, the spatial regression analysis showed the deprivation level was significantly and positively associated with low birth weight.

CONCLUSIONS

The socioeconomic deprivation level and low birth weight were positively associated, and a further study using individual data is warranted to verify reasons for the association.

Disparities in the timing of antenatal care initiation and associated factors in an ethnically dense maternal cohort with high levels of area deprivation

BACKGROUND

Late access to antenatal care is a contributor to excess mortality and morbidity among ethnic minority mothers compared to White British in the UK. While individual ethnicity and socioeconomic disadvantage are linked to late antenatal care initiation, studies have seldom explored patterns of late initiation and associated factors in ethnically dense socially disadvantaged settings. This study investigated disparities in the timing of antenatal care initiation, and associated factors in an ethnically dense socially disadvantaged maternal cohort.

METHODS

A retrospective cross-sectional study using routinely collected anonymous data on all births between April 2007-March 2016 in Luton and Dunstable hospital, UK (N = 46,307). Late initiation was defined as first antenatal appointment attended at > 12 weeks of gestation and further classified into moderately late (13-19 weeks) and extremely late initiation (≥ 20 weeks). We applied logistic and multinomial models to examine associations of late initiation with maternal and sociodemographic factors.

RESULTS

Overall, one fifth of mothers (20.8%) started antenatal care at > 12 weeks of gestation. Prevalence of late initiation varied across ethnic groups, from 16.3% (White British) to 34.2% (Black African). Late initiation was strongly associated with non-White British ethnicity. Compared to White British mothers, the odds of late initiation and relative risk of extremely late initiation were highest for Black African mothers [adjusted OR = 3.37 (3.05, 3.73) for late initiation and RRR = 4.03 (3.51, 4.64) for extremely late initiation]. The odds did not increase with increasing area deprivation, but the relative risk of moderately late initiation increased in the most deprived ([RRR = 1.53 (1.37, 1.72)] and second most deprived areas [RRR = 1.23 (1.10, 1.38)]. Late initiation was associated with younger mothers and to a lesser extent, older mothers aged > 35 years. Mothers who smoked during pregnancy were at higher odds of late initiation compared to mothers who did not smoke.

CONCLUSIONS

There is a need to intensify universal and targeted programmes/services to support mothers in ethnically dense socially disadvantaged areas to start antenatal care on time. Local variations in ethnic diversity and levels of social disadvantage are essential aspects to consider while planning services and programmes to ensure equity in maternity care provision.

Host-country language proficiency and migrant-native disparities in prenatal care utilization: A nationwide study in Portugal

BACKGROUND

Migrant-native disparities in perinatal health and care utilization are well-established, yet most evidence comes from countries without universal health coverage. Migrant-specific factors potentially contributing to such disparities are seldom examined. We investigated the association between migration and host-country language proficiency and inadequate utilization of prenatal care (PNC) in Portugal.

METHODS

We used robust Poisson regression to analyze data from 1419 migrant and 2477 native women enrolled in the Portuguese Bambino cohort study who had given birth at a Portuguese public hospital between 2017 and 2019. Migrant women's language proficiency was self-rated for understanding, speaking, reading, and writing skills. PNC utilization inadequacy was assessed using three dimensions: initiation, number of visits, and the modified Adequacy of Prenatal Care Utilization (mAPNCU) Index score.

RESULTS

Migrant women were overall more likely to initiate PNC late and have inadequate/intermediate mAPNCU scores than natives. Migrant-native disparities in the number of PNC visits were only observed among recent migrants (≤5 years in Portugal). Full, intermediate, and limited Portuguese skills were associated with increasingly higher risks of late PNC initiation (aRR 1.34 [95%CI 1.20-1.50]); (aRR 1.52 [95%CI 1.28-1.80]); (aRR 1.91 [95%CI 1.52-2.40]), inadequate number of PNC visits (aRR 1.06 [95%CI 0.93-1.22]); (aRR 1.14 [95%CI 0.97-1.34]); (aRR 1.57 [95%CI 1.19-2.07]), and inadequate/intermediate mAPNCU scores (aRR 1.18 [95%CI 1.07-1.32]); (aRR 1.30 [95%CI 1.11-1.53]); (aRR 1.69 [95%CI 1.38-2.07]) compared with native Portuguese skills, respectively.

CONCLUSIONS

Migrant-native disparities in PNC utilization are present in Portugal, despite universal health coverage. Recent migrants and women with limited language competence are the most vulnerable to inadequate PNC use.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Foot health status in pregnant women

BACKGROUND

Pregnancy is associated with physiological changes such as increased body mass index, postural changes, hormonal imbalance and changes in foot morphology. Due to an increased uterus and body mass, the centre of gravity is displaced anteriorly and superiorly as a means to produce and maintain stability and balance. An influx of relaxin mostly in the third trimester leads to ligament laxity which in turn causes the feet to become longer, flatter and broader. This structural change may remain permanent in some women. Structural changes, increased body weight and increased pressure in the lower limbs may also lead to lower limb oedema which makes it harder to find adequate fitting shoes and may be associated with causing or exacerbating foot pain in pregnant women. The purpose of this study was to determine the overall Foot Health Status (FHS) in pregnant women and also to compare the foot health status in the different trimesters.

METHODS

A quantitative approach, using a descriptive cross-sectional study design was utilized and a validated foot health status questionnaire was used. Data was analysed using a Statistical Package for Social Sciences (SPSS) version 1.04 program and presented in the form of tables.

RESULTS

All pregnant women had a poor foot health status in the area of vigour, particularly in the third trimester. In the third trimester, women's physical activity was diminished and they appeared to have greater footwear difficulties. However, it was found that despite having minimal foot pain, pregnant women maintained good foot function and good social capacity. The least amount of foot pain was felt in the second trimester.

CONCLUSION

As a woman progresses in her pregnancy, her foot health status declined in the areas of footwear, physical activity and vigour.

Social inequalities in access to care at birth and neonatal mortality: an observational study

OBJECTIVE

To look at the association of socioeconomic status (SES) with the suitability of the maternity where children are born and its association with mortality.

DESIGN

Retrospective analysis of a prospective cohort constituted using hospital discharge databases.

SETTING

France POPULATION: Live births in 2012-2014 in maternity hospitals in mainland France followed until discharge from the hospital.

MAIN OUTCOME MEASURE

Unsuitability of the maternity to newborns' needs based on birth weight and gestational age, early transfers (within 24 hours of birth) and in-hospital mortality.

RESULTS

2 149 454 births were included, among which 155 646 (7.2%) were preterm. Preterm newborns with low SES were less frequently born in level III maternities than those with high SES. They had higher odds of being born in an unsuitable maternity (OR=1.174, 95% CI 1.114 to 1.238 in the lowest SES quintile compared with the highest), and no increase in the odds of an early transfer (OR=0.966, 95% CI 0.849 to 1.099 in the lowest SES quintile compared with the highest). Overall, newborns from the lowest SES quintile had a 40% increase in their odds of dying compared with the highest (OR=1.399, 95% CI 1.235 to 1.584).

CONCLUSIONS

Newborns with the lowest SES were less likely to be born in level III maternity hospitals compared with those with the highest SES, despite having higher prematurity rates. This was associated with a significantly higher mortality in newborns with the lowest SES. Strategies must be developed to increase health equity among mothers and newborns.

Perceptions and behaviour of pregnant women in socioeconomic deprivation in rural areas. A qualitative study in France

Background

Socioeconomic deprivation (SED) is a risk factor for complications during pregnancy and childbirth, the impact of which has been studied poorly in rural areas.

Aims

To explore the perceptions and behaviour of women living in SED in a rural area with regard to their pregnancy follow‐up.

Methods

A qualitative study using semi‐structured individual interviews was carried out in a rural area in central France. To participate, the women had to have an Evaluation of Deprivation and Inequalities in Health Examination Centres deprivation score ≥ 30.17, be living in a rural area and have given birth during the month before the interview. The interviews were analysed using a thematic approach inspired by grounded theory.

Results

Seventeen women were interviewed. The difficulties of life in a rural area were linked to geographical remoteness, travel costs, lack of public services, inadequacy of nearby healthcare and social isolation. In all cases, pregnancy was an additional difficulty. The adaptive capability was related to the presence of an efficient family and social network. Most of the time, any increase in the limitations exceeded the ability to adapt and affected the medical follow‐up of the pregnancy, although follow‐up appointments were rarely abandoned altogether. Perceptions of birth preparation and parenting sessions were often limited to advice on pain management. Due to their affiliation with their rural area or their choice of lifestyle, the women complained only minimally.

Conclusion

Women often minimize any limitations and implement adaptive techniques that make identification by social and medical services more difficult.

Patient or Public Contribution

Eighteen women in SED were contacted by Childhood Medical Protection, midwives and general practitioners practising in rural areas. One woman declined participation and seventeen were interviewed.

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

OBJECTIVE

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

DESIGN

Prospective cohort study.

SETTING

Four maternity units around Paris in 2010-12.

SAMPLE

A total of 9599 women with singleton pregnancies.

METHODS

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

MAIN OUTCOME MEASURE

Binary composite criterion of severe maternal morbidity.

RESULTS

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

CONCLUSION

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

Barriers and facilitators of maternal healthcare utilisation in the perinatal period among women with social disadvantage: A theory-guided systematic review

BACKGROUND

Women with social disadvantage have poorer perinatal outcomes compared to women in advantaged social positions, which may be linked to poorer healthcare utilisation. Disadvantaged groups may experience a greater diversity of barriers (e.g., feeling embarrassed about pregnancy, lack of transportation) or barriers judged to be particularly difficult (e.g., embarrassment about pregnancy). They may also experience barriers more frequently (e.g., depression). Using Levesque et al.'s (2013) framework of healthcare access, our review identifies the barriers and facilitators that affect maternal healthcare utilisation in the perinatal period among women with social disadvantage in high-income nations.

OBJECTIVES

Our review searches for the barriers and facilitators affecting maternal healthcare utilisation in the perinatal period, from pregnancy to the first year postpartum, among women with social disadvantage (Prospero registration CRD42020151506).

DESIGN

We conducted a theory-guided systematic review. PubMed, Embase, MEDLINE, PsycINFO, and Social Science Citation Index databases were searched for publications between 1999 and 2018.

FINDINGS

37 articles out of 12'972 were included in the qualitative synthesis. 19 domains of barriers and facilitators were extracted. Domains on the provider side includes 'information regarding available treatments' and 'trustful relationships.' On the user-side, domains include 'awareness of pregnancy' and 'unplanned/unwanted pregnancy' KEY CONCLUSIONS: Provider- and user-side characteristics interact to affect access. User-side characteristics that pose a barrier can be offset by provider-side characteristics that lower barriers to access.

IMPLICATIONS FOR PRACTICE

User-side characteristics (e.g., lack of awareness of pregnancy) play an important role in the initial steps toward access. Among women with social disadvantage, reducing barriers may require active outreach on the part of providers.

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

•

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

•

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

•

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.

Relationship Between Maternal Economic Vulnerability and Childhood Neurodevelopment at 2 and 5 Years of Life

OBJECTIVE

To assess the relationship between economic vulnerability during pregnancy and childhood neurodevelopment.

METHODS

This is a secondary analysis of two parallel multicenter, randomized, controlled trials of administration of levothyroxine to pregnant individuals with subclinical hypothyroidism or hypothyroxinemia in the United States. All participants who delivered a live, nonanomalous neonate and completed the WPPSI-III (Weschler Preschool & Primary Scale of Intelligence) at 5 years of life and the Bayley-III (Bayley Scales of Infant Development) test at 2 years were included. The primary outcome is WPPSI-III score. Secondary outcome included Bayley-III subtest scores. Multivariable analyses were used to assess the relationships between economic vulnerability during the index pregnancy-defined as a household income less than 200% of the estimated federal poverty level, part-time or no employment, and use of government insurance-and the prespecified outcomes. Tests of interaction were performed to assess whether the magnitude of association differed according to whether participants were married or completed more than a high school education. A sensitivity analysis was performed to limit the income criteria for economic vulnerability to household income of less than 100% of the estimated federal poverty level.

RESULTS

Of 955 participants who met inclusion criteria, 406 (42.5%) were considered economically vulnerable. In bivariate analysis, the WPPSI-III score and Bayley-III subtest scores were significantly lower among children of the economically vulnerable. For the WPPSI-III, Bayley-III cognitive subtest, and Bayley-III language subtest scores, the associations between economic vulnerability and lower childhood neurodevelopmental scores were primarily seen only among those who were married or completed more than a high school education (P for interaction<.05). A similar pattern was noted when restricting the income criteria for economic vulnerability to less than 100% of the federal poverty level.

CONCLUSION

Economic vulnerability during pregnancy is associated with an increased risk of adverse neurodevelopmental outcomes in their children at 2 and 5 years of life, particularly among those who are married or completed more than a high school education.

Variance estimators for weighted and stratified linear dose-response function estimators using generalized propensity score

Propensity score methods are widely used in observational studies for evaluating marginal treatment effects. The generalized propensity score (GPS) is an extension of the propensity score framework, historically developed in the case of binary exposures, for use with quantitative or continuous exposures. In this paper, we proposed variance estimators for treatment effect estimators on continuous outcomes. Dose-response functions (DRFs) were estimated through weighting on the inverse of the GPS, or using stratification. Variance estimators were evaluated using Monte Carlo simulations. Despite the use of stabilized weights, the variability of the weighted estimator of the DRF was particularly high, and none of the variance estimators (a bootstrap-based estimator, a closed-form estimator especially developed to take into account the estimation step of the GPS, and a sandwich estimator) were able to adequately capture this variability, resulting in coverages below the nominal value, particularly when the proportion of the variation in the quantitative exposure explained by the covariates was large. The stratified estimator was more stable, and variance estimators (a bootstrap-based estimator, a pooled linearized estimator, and a pooled model-based estimator) more efficient at capturing the empirical variability of the parameters of the DRF. The pooled variance estimators tended to overestimate the variance, whereas the bootstrap estimator, which intrinsically takes into account the estimation step of the GPS, resulted in correct variance estimations and coverage rates. These methods were applied to a real data set with the aim of assessing the effect of maternal body mass index on newborn birth weight.

Social Vulnerability among Foreign-Born Pregnant Women and Maternal Virologic Control of HIV

OBJECTIVE

The aim of this study was to assess whether social vulnerability among foreign-born pregnant women living with HIV is associated with maternal viremia during pregnancy.

STUDY DESIGN

This retrospective cohort study included all foreign-born pregnant women living with HIV who received prenatal care in a multidisciplinary prenatal clinic between 2009 and 2018. A licensed clinical social worker evaluated all women and kept detailed clinical records on immigration status and social support. Social vulnerability was defined as both living in the United States for less than 5 years and reporting no family or friends for support. The primary outcome was evidence of viral non-suppression after achievement of initial suppression. Secondary outcomes were the proportion of women who required > 12 weeks after starting antiretroviral therapy to achieve viral suppression, median time to first viral suppression (in weeks) after initiation of antiretroviral therapy, and the proportion who missed ≥ 5 doses of antiretroviral therapy. Bivariable analyses were performed.

RESULTS

A total of 111 foreign-born women were eligible for analysis, of whom 25 (23%) were classified as socially vulnerable. Social and clinical characteristics of women diverged by social vulnerability categorization but no differences reached statistical significance. On bivariable analysis, socially-vulnerable women were at increased risk for needing > 12 weeks to achieve viral suppression (relative risk: 1.78, 95% confidence interval: 1.18-2.67), though there was no association with missing ≥ 5 doses of antiretroviral therapy or median time to viral suppression after initiation of antiretroviral therapy.

CONCLUSION

Among foreign-born, pregnant women living with HIV, markers of virologic control during pregnancy were noted to be worse among socially-vulnerable women. Insofar as maternal viremia is the predominant driver of perinatal transmission, closer clinical surveillance and support may be indicated in this population.

KEY POINTS

· 23% of foreign-born pregnant women living with HIV were identified as socially vulnerable.. · Socially-vulnerable women were at higher risk for re-emergent viremia (24 vs. 7%, RR 3.44).. · Socially-vulnerable women were at higher risk for needing >12 weeks to become aviremic (64 vs. 36%, RR: 1.7)..

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

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

The role of neighbourhood socioeconomic status in large for gestational age

OBJECTIVE

To determine whether neighbourhood socioeconomic status (SES) was associated with large for gestational age (LGA) while considering key sociodemographic and clinical confounding factors.

SETTING AND PATIENT

All singleton infants whose parents were living in the city of Marseilles, France, between 2013 and 2016.

METHOD

Population-based study based on new-born hospital birth admission charts from the French National Uniform Hospital Discharge Data Set Database. LGA infants were compared to appropriate-for-gestational-age (AGA) infants. Multiple generalized logistic model analysis was used to examine factors associated with LGA.

RESULTS

A total of 43,309 singleton infants were included, and 4,747 (11%) were born LGA. LGA infants were more likely to have metabolic and respiratory diseases and to be admitted to the neonatal intensive care unit. Multiparity, advanced maternal age, obesity and diabetes were associated with an increased risk of LGA. Lower neighbourhood SES was associated with LGA (aOR = 1.24, 95% CI: 1.14; 1.36; p<0.0001) independent of age, diabetes, obesity, maternal smoking and multiparity. The strength of this association increased with maternal age, reaching an aOR of 1.50 (95% CI: 1.26; 1.78; p<0.0001) for women > 35 years old.

CONCLUSION

Neighbourhood SES could be considered an important factor for clinicians to better identify mothers at risk of having LGA births in addition to well-known risk factors such as maternal diabetes, obesity and age. The intensification of the association between SES and LGA with increasing maternal age suggests that neighbourhood disadvantage may act on LGA cumulatively over time.

Maternal obesity and severe pre-eclampsia among immigrant women: a mediation analysis

We investigated the extent to which pre-pregnancy obesity mediates the association between maternal place of birth and severe pre-eclampsia in the PreCARE cohort of pregnant women in Paris (n = 9,579). Adjusted path analysis logistic regression models were used to assess the role of pre-pregnancy obesity as a mediator in the association between maternal place of birth and the development of severe pre-eclampsia. We calculated 1. adjusted odds ratios and 95% confidence intervals for the total exposure-outcome association and for the direct and indirect/obesity-mediated components 2. the indirect/obesity-mediated effect. Ninety-five (0.99%) women developed severe pre-eclampsia, 47.6% were non-European immigrants, 16.3% were born in Sub-Saharan Africa, and 12.6% were obese (BMI > = 30 kg/m2). Women experiencing severe pre-eclampsia were more likely to be from Sub-Saharan Africa (p = 0.023) and be obese (p = 0.048). Mothers from Sub-Saharan Africa had an increased risk of severe pre-eclampsia compared to European-born mothers (aOR 2.53, 95% CI 1.39-4.58) and the obesity-mediated indirect effect was 18% of the total risk (aOR 1.18, 95%CI 1.03-1.35). In conclusion, Sub-Saharan African immigrant women have a two-fold higher risk of developing severe pre-eclampsia as compared to European-born women, one-fifth of which is mediated by pre-pregnancy obesity. Our results quantify the potential benefit of decreasing obesity among at-risk women.

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.

Social Vulnerability in Congenital Syphilis Case Mothers: Qualitative Assessment of Cases in Indiana, 2014 to 2016

BACKGROUND

Congenital syphilis occurs when a pregnant woman with syphilis is not diagnosed or treated and the infection is passed in utero, causing severe infant morbidity and mortality. Congenital syphilis is easily prevented if women receive timely and adequate prenatal care. Cases of congenital syphilis are considered indicators of problems in the safety net. However, maternal social and behavioral factors can impede women's care, even when providers follow guidelines.

METHODS

We reviewed case interviews and maternal records for 23 congenital syphilis cases reported to the Centers for Disease Control and Prevention from Indiana between 2014 and 2016. We used qualitative methods to analyze narrative notes from maternal interviews to learn more about factors that potentially contributed to congenital syphilis cases.

RESULTS

All providers followed Centers for Disease Control and Prevention and state recommendations for screening and treatment for pregnant women with syphilis. Twenty-one of 23 women had health insurance. The number of prenatal care visits women had was suboptimal; more than one third of women had no prenatal care. Nearly one third of women's only risk factor was sex with a primary male sex partner. The majority of women suffered social vulnerabilities, including homelessness, substance abuse, and incarceration.

CONCLUSIONS

Despite provider adherence to guidelines and health insurance availability, some pregnant women with syphilis are unlikely to receive timely diagnosis and treatment. Pregnant women at high risk for syphilis may need additional social and material support to prevent a congenital syphilis case. Additional efforts are needed to reach the male partners of vulnerable females with syphilis.

Associations between maternal obesity and severe maternal morbidity: Findings from the French EPIMOMS population-based study

BACKGROUND

Maternal obesity is increasing. There is growing evidence of its effect on severe maternal morbidity. We assessed prepregnancy obesity as an independent risk factor for severe maternal morbidity by timing and cause.

METHODS

We designed a case-control analysis within the EPIMOMS prospective population-based study conducted in six French regions in 2012-2013 (182 309 women who delivered at ≥22 weeks). Cases were all women who experienced severe maternal morbidity during pregnancy to 42 days postpartum as per a multicriteria definition derived by national expert consensus (n = 2540, severe maternal morbidity prevalence 1.4%). Controls were randomly selected from the same health centres (n = 3651). The association between obesity and severe maternal morbidity was assessed from fitting multivariable logistic regression models: overall, by timing (antepartum and intrapartum/ postpartum), and by cause.

RESULTS

Prepregnancy obesity was associated with overall severe maternal morbidity (adjusted odds ratio [OR] 1.34, 95% confidence interval [CI] 1.14, 1.59) and antepartum severe maternal morbidity (OR 2.07, 95% CI 1.61, 2.65), but not with intra/postpartum severe maternal morbidity (OR 1.15, 95% CI 0.96, 1.38). Among antepartum severe maternal morbidity, severe hypertensive disorders were most strongly associated with obesity (OR 2.50, 95% CI 1.85, 3.40) but the risk of antepartum severe maternal morbidity due to other causes was also increased among obese women (OR 1.64, 95% CI 1.13, 2.37). Obesity was not associated with severe postpartum haemorrhage (OR 1.12, 95% CI 0.92, 1.37).

CONCLUSION

Obesity is associated with an increased risk of antepartum, but not intra/ postpartum, severe maternal morbidity.

The impact of a patient's social status on the cost of vaginal deliveries: an observational study in a French university hospital

INTRODUCTION

We aimed to assess the association between a patient's social status and the cost of stay for a single uncomplicated vaginal delivery. Currently, few data have been reported.

MATERIAL AND METHODS

We conducted an observational study with data retrieved from the medical and administrative databases of a university hospital in North-West France. We included all patients admitted in 2014 and classified in either Diagnosis-Related Group (DRG) « Single uncomplicated vaginal deliveries in a primiparous patient » or DRG « Single uncomplicated vaginal deliveries in a multiparous patient ». Criteria defining poor social status were: a specific healthcare benefit in relation to low income or for foreign undocumented patients, and/or a consultation with a social worker during the hospital stay except if no social problem was diagnosed. We compared the cost of stay between patients with poor social status and patients with good social status using a multivariate median regression stratified on parity, and adjusted for age, gestational age and neonatal hospitalization.

RESULTS

Among 686 primiparous patients, 21% had poor social status, which was associated with an increase in the median cost of stay (+€475; 95% CI [+334 to +616]), mostly explained by a 1-day increase in the median length of stay.Among 899 multiparous patients, 29% had poor social status, which was not associated with the cost of stay.

DISCUSSION

Social status had an impact on the cost of vaginal deliveries in primiparous patients. Our findings suggest a need to redefine the DRG classification according to patients' social status.

A systematic review on the use of healthcare services by undocumented migrants in Europe

Background

Undocumented migrants face particular challenges in accessing healthcare services in many European countries. The aim of this study was to systematically review the academic literature on the utilization of healthcare services by undocumented migrants in Europe.

Methods

The databases Embase, Medline, Global Health and Cinahl Plus were searched systematically to identify quantitative, qualitative and mixed methods studies published in 2007–2017.

Results

A total of 908 articles were retrieved. Deletion of duplicates left 531. After screening titles, abstracts and full texts according to pre-defined inclusion and exclusion criteria, 29 articles were included in the review. Overall, quantitative studies showed an underutilization of different types of healthcare services by undocumented migrants. Qualitative studies reported that, even when care was received, it was often inadequate or insufficient, and that many undocumented migrants were unfamiliar with their entitlements and faced barriers in utilizing healthcare services.

Conclusions

Although it is difficult to generalize findings from the included studies due to methodological differences, they provide further evidence that undocumented migrants in Europe face particular problems in utilizing healthcare services.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2838-y) contains supplementary material, which is available to authorized users.

NAITRE study on the impact of conditional cash transfer on poor pregnancy outcomes in underprivileged women: protocol for a nationwide pragmatic cluster-randomised superiority clinical trial in France

INTRODUCTION

Prenatal care is recommended during pregnancy to improve neonatal and maternal outcomes. Women of lower socioeconomic status (SES) are less compliant to recommended prenatal care and suffer a higher risk of adverse perinatal outcomes. Several attempts to encourage optimal pregnancy follow-up have shown controversial results, particularly in high-income countries. Few studies have assessed financial incentives to encourage prenatal care, and none reported materno-fetal events as the primary outcome. Our study aims to determine whether financial incentives could improve pregnancy outcomes in women with low SES in a high-income country.

METHODS AND ANALYSIS

This pragmatic cluster-randomised clinical trial includes pregnant women with the following criteria: (1) age above 18 years, (2) first pregnancy visit before 26 weeks of gestation and (3) belonging to a socioeconomically disadvantaged group. The intervention consists in offering financial incentives conditional on attending scheduled pregnancy follow-up consultations. Clusters are 2-month periods with random turnover across centres. A composite outcome of maternal and neonatal morbidity and mortality is the primary endpoint. Secondary endpoints include maternal or neonatal outcomes assessed separately, qualitative assessment of the perception of the intervention and cost-effectiveness analysis for which children will be followed to the end of their first year through the French health insurance database. The study started in June 2016, and based on an expected decrease in the primary endpoint from 18% to 14% in the intervention group, we plan to include 2000 women in each group.

ETHICS AND DISSEMINATION

Ethics approval was first gained on 28 September 2014. An independent data security and monitoring committee has been established. Results of the main trial and each of the secondary analyses will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT02402855; pre-results.

[Observational study of a social device for women in precarious situations during pregnancy and post-partum]

OBJECTIVES

To assess the impact of the Regional experimental accompanying nutrition and breast-feeding for pregnant women (PRENAP) 75 social device on the duration of postpartum hospitalization and breast-feeding for pregnant women in precarious situation.

METHODS

A retrospective observational study took place between November 2013 and May 2015 in a type III Parisian maternity. Comparison of sociodemographic, perinatal and postpartum characteristics of women in precarious situations (no stable housing and no social care or universal medical coverage or state medical aid) was done according to whether they were included in the system PRENAP or not.

RESULTS

Over the study period, 344 (4.6%) women in precarious situations gave birth in this maternity. Among these women, the women included in the PRENAP system were more frequently in a very unfavorable social situation than those who were not included. The inclusion in the PRENAP device did not reduce the hospitalization in post-partum. Breast-feeding was chosen more frequently by the women included in the PRENAP device.

CONCLUSION

The PRENAP device seems to favor the use of breast-feeding, but is not associated with a diminution of the hospitalization time in post-partum. This social device, which seems to be beneficial in terms of social and medical support for women in precarious situations, deserves to be evaluated prospectively.