Maternal Mortality Among Migrants in Western Europe: A Meta-Analysis

Sociodemographic characteristics of maternal mortality in Japan: An analysis of national data from 2010 to 2022

OBJECTIVE

There is a paucity of studies investigating sociodemographic characteristics of maternal mortality in Japan. In this study, we investigated the sociodemographic factors associated with maternal mortality in Japan using national data.

MATERIALS AND METHODS

The Vital Statistics data in Japan (birth and mortality data) from 2010 to 2022 were used in the analysis. Region, maternal age group, maternal nationality, maternal marital status, and the main type of occupation in the household (household occupation) were used as sociodemographic variables. The maternal mortality ratio per 100,000 live births, maternal age group-specific maternal mortality ratio, and the maternal mortality ratio standardized by maternal age group were calculated by the sociodemographic characteristics.

RESULTS

A total of 12,535,198 live births and 457 maternal deaths were included in the analysis. The age-standardized maternal mortality ratio of metropolitan areas was the lowest among regions. The age-standardized maternal mortality ratio of non-Japanese mothers was approximately twice as high as that of Japanese mothers, and the ratio of unmarried mothers was approximately five times as high as that of married mothers. The age-standardized maternal mortality ratio of households with a full-time worker in a larger company and unemployed households was the lowest and highest, respectively, among household occupations, and that of unemployed households was approximately nine times as high as that of households with a full-time worker in a larger company.

CONCLUSIONS

Some sociodemographic factors, such as maternal marital status and type of household occupation, were associated with maternal mortality in Japan.

Effectiveness and cost-effectiveness of models of maternity care for women from migrant and refugee backgrounds in high-income countries: A systematic review

BACKGROUND

Different models of care may be appropriate for various groups of women during their perinatal period, depending on their risk level, location, and accessibility of healthcare practitioners and facilities. Evaluating these models' effectiveness and cost-effectiveness is critical to allocating resources and offering sustained care to women from refugee backgrounds. This systematic review aimed to synthesize evidence on the effectiveness and cost-effectiveness of maternity care models among women from migrant and refugee backgrounds living in high-income countries.

METHODS

A comprehensive search of major databases for studies published in English between 2000 and 2023 was developed to identify literature using defined keywords and inclusion criteria. Two authors independently screened the search findings and the full texts of eligible studies. The quality of the included studies was appraised, and qualitative and quantitative results were synthesised narratively and presented in tabular form. The review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Forty-seven research papers from six countries were included in the review. The review highlighted the positive impact of community and stakeholders' involvement in the implementation of models of maternity care for women from migrant and refugee backgrounds. The review summarised the models of care in terms of their effectiveness in improving perinatal health outcomes and minimising medical interventions, continuum of care in maternity services, enhancing health literacy, maternity service use and navigating the healthcare system, social support, and sense of belongingness, and addressing cultural and linguistic barriers. Notably, only one study conducted a partial economic evaluation to determine the cost-effectiveness of the model.

CONCLUSION AND IMPLICATIONS FOR PRACTICE AND RESEARCH

While the reviewed models demonstrated effectiveness in improving perinatal health outcomes, there was considerable variation in outcome measures and assessment tools across the models. Thus, reaching a consensus on prioritised perinatal outcomes and measurement tools is crucial. Researchers and policymakers should collaborate to enhance the quality and quantity of economic evaluations to support evidence-based decision-making. This includes thoroughly comparing costs and outcomes across various health models to determine the most efficient interventions. By emphasizing the importance of comprehensive economic evaluations, healthcare systems can better allocate resources, ultimately leading to more effective and efficient healthcare delivery.

Contraceptive access and use among women with migratory experience living in high-income countries: a scoping review

BACKGROUND

Women who have migrated often encounter difficulties in accessing healthcare and experience inequitable sexual and reproductive health outcomes in destination countries. These health inequities include contraceptive access and use. To better understand what influences contraceptive access and use, this scoping review set out to synthesize the evidence on contraceptive access and use and on associated interventions among women with migratory experience in high-income countries (HICs) in Europe, North America and Australasia.

METHODS

The scientific databases PubMed, Web of Science and CINAHL were searched for peer-reviewed quantitative, qualitative and mixed method articles published between January 2000 and June 2023. Articles were included if they reported on studies exploring contraceptive use to prevent pregnancies among women of reproductive age with migratory experience living in HICs. Two researchers independently screened and extracted data from the articles. Findings were categorized by patient and health system level factors according to Levesque et al.'s framework of access to health care.

RESULTS

A total of 68 articles were included, about half (n = 32) from North America. The articles focused on the individual level rather than the health system level, including aspects such as women's contraceptive knowledge, the influence of culture and religion on accessing and using contraception, partner involvement, and differing health insurance coverage. On the health system level, the articles highlighted lack of information on contraceptive services, cultural (in)adequacy of services and communication aspects, contraceptives' side effects, as well as geographic availability and cost of services. The review further identified three articles reporting on interventions related to contraceptive counselling.

CONCLUSIONS

There is a lack of knowledge regarding how health systems impose obstacles to contraceptive services for women with migratory experience on an organizational level, as research has focused heavily on the individual level. This review's findings may serve as a foundation for further research and advances in policy and practice, specifically recommending early provision of health system related information and contraceptive education, engagement of male partners in contraceptive discourses, cultural competency training for healthcare professionals, and strengthening of interpretation services for contraceptive counselling.

Migrant women's experiences of community-based doula support during labor and childbirth in Sweden. A mixed methods study

OBJECTIVE

To describe migrant women's experiences of bilingual community-based doulas (CBD) contribution to care in relation to labor and birth.

METHODS

Mixed methods study combining quantitative data from 82 women who received CBD-support within a randomized controlled trial and qualitative data from semi-structured interviews with a sub-sample of 12 women from the same study arm. Descriptive analyses were used for quantitative data and content analysis for the manifest and latent content of the qualitative data. Quantitative findings were categorized according to qualitative findings.

RESULTS

The women expressed how CBDs played an essential role in the response to their basic emotional, informational, and physical support needs, when no other female family member was available. Three main categories emerged from the analysis of interviews: The doulas help women feel safe and calm - providing support before, during and after childbirth; The doulas' support role fills the void left by a deeply missed family, mother or sister; and The doulas assist women in achieving autonomy through communication support and advocacy. More than half of women reported feeling involved during labor and birth (56.8%), most valued CBD positively (such as being competent, calm, secure, considerate, respectful, encouraging, supportive) (40.8%-80.3%), that CBD had interpreted (75.6%), facilitated communication with the midwife (60,3%), comforted the woman (57.7%) and reduced anxiety (48,7%). Few reported negative CBD-characteristics (1.3-9.2%). Nevertheless, 61.7% of women felt frightened sometime during labor and birth, which made it even more important to them that the doula was there. Few women (21.8%) reported that the CBD had supported her partner but expressed so in the interviews.

CONCLUSION

Through an essential contribution in responding to migrant women's basic emotional, informational, and physical needs, bilingual community-based doulas have the potential to improve migrant women's experience of care during labour and birth. However, more focus on the quality of CBD-support to partners seem necessary.

A qualitative study exploring the factors influencing maternal healthcare access and utilization among Muslim refugee women resettled in the United States

Although a large number of Muslim refugees have resettled in the United States for the last decades, few studies have looked into maternal healthcare access and utilization among Muslim refugee women in the country. This qualitative study was conducted to explore the factors influencing maternal healthcare access and utilization among Muslim refugee women resettled in the United States. In-depth interviews were conducted among Afghan, Iraqi, and Syrian refugee women (n = 17) using an interview guide informed by Social Cognitive Theory and its key constructs. The interviews were recorded and transcribed verbatim, imported into MAXQDA 2020 (VERBI Software), and analyzed based on qualitative content analysis. Data analysis revealed several themes at the micro, meso, and macro-levels. Micro-level factors included women's attitudes toward hospitals and prenatal care, as well as their life skills and language proficiency. Meso-level factors, such as cultural norms and practices, social support and network, as well as health care provider characteristics, were also identified. Macro-level factors, such as the complex healthcare system and access to insurance, also appeared to influence maternal healthcare access and utilization. This study revealed the complex contextual factors that refugee populations face. Given the population's heterogeneity, a more nuanced understanding of refugee maternal health is required, as are more tailored programs for the most vulnerable groups of refugee women.

Obstetric Interventions Among Native and Migrant Women: The (Over)use of Episiotomy in Portugal

Objective: Episiotomy, defined as the incision of the perineum to enlarge the vaginal opening during childbirth, is one of the most commonly performed surgical interventions in the world. We aimed to determine if migrant status is associated with episiotomy, and if individual characteristics mediate this association. Methods: We analyzed data from the Bambino study, a national, prospective cohort of migrant and native women giving birth at a public hospital in mainland Portugal between 2017 and 2019. We included all women with vaginal delivery. The association between migrant status and episiotomy was assessed using multivariable multilevel random-effect logistic regression models. We used path analysis to quantify the direct, indirect and total effects of migrant status on episiotomy. Results: Among 3,583 women with spontaneous delivery, migrant parturients had decreased odds of episiotomy, especially those born in Africa, compared to native Portuguese women. Conversely, with instrumental delivery, migrant women had higher odds of episiotomy. Disparities in episiotomy were largely explained by maternity units' factors, and little by maternal and fetal characteristics. Conclusion: Our results suggest non-medically justified differential episiotomy use during childbirth and highlight the importance of developing evidence-based recommendations for episiotomy use in a country with a high frequency of medical interventions during delivery.

Migrant women's experiences of an individual language-assisted information and support visit to the labor ward before giving birth - A qualitative study from Sweden

BACKGROUND

Migrant women are less likely to receive an individualized maternal care where they feel safe, informed and supported but few measures have been undertaken to meet their needs. In Södertälje municipality in Sweden, community-based antenatal care midwives identify migrant women and offer them and their partners language-assisted information and support through an individual two-hour-visit to the labor ward. The aim of the present study was to explore migrant women's experiences of antenatal care including receiving language-assisted information and support during pregnancy through a two-hour INFOR-visit to the labor ward.

METHODS

Semi-structured interviews were conducted with 10 non-Swedish speaking migrant women, using an interpreter. Interview analysis was conducted using reflexive thematic analysis.

RESULTS

The individualized support, including thorough information given with language support available, sufficient time for questions and discussion, and a caring approach - did appear to inform and reassure the women. Overall, they felt that they were seen and treated as individuals during both pregnancy and birth and that their specific needs were listened to and met by the health care providers. Having professional interpreters was seen as essential for receiving the right information, something achieved at the individual visit.

CONCLUSIONS

The findings from this study provide evidence that a two-hour-visit to the labor ward during pregnancy has potential to empower migrant women during pregnancy and birth and to improve their experiences of maternity care. The two-hour-visit is a relatively simple intervention with the potential of not only improving migrant women's experiences of pregnancy and birth, but also their medical outcomes.

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.

Women's health in migrant populations: a qualitative study in France

BACKGROUND

In 2019, there are 6.5 million migrants living in France. Numerous quantitative studies show inequalities in access and quality of care, in particular in women's health. This study aimed to explore migrant women's experience of gynaecological care.

METHODS

We conducted 17 semi-structured in-depth interviews with migrant women in Toulouse (France). We used a Grounded Theory approach to perform the analysis.

RESULTS

Although migrant women were generally satisfied with the gynaecological care received, they also reported dysfunctions. Positive elements were the French health insurance system, the human qualities of the healthcare providers and the performance of the health system. Although reassuring, the structured framework was perceived to have little flexibility. This was sometimes felt as oppressive, paternalistic or discriminatory. These obstacles, amplified by the women's lifestyle instability and precariousness, the language barrier and the difficulty to understand a totally new healthcare system, made women's health care and, especially, preventive care, a difficult-to-achieve and low-priority objective for the women.

CONCLUSIONS

Migrant women's overall satisfaction with the healthcare system contrasted with the known health inequalities in these populations. This is a good example of the concept of acculturation. Healthcare professionals need to make an introspective effort to prevent the emergence of stereotypes and of discriminatory and paternalistic behaviours. A better understanding and respect of the other person's culture is an indispensable condition for intercultural medicine, and thus for reducing the health inequalities that migrant women experience.

Quality of maternal and newborn care around the time of childbirth for migrant versus nonmigrant women during the COVID-19 pandemic: Results of the IMAgiNE EURO study in 11 countries of the WHO European region

OBJECTIVE

To describe the perception of quality of maternal and newborn care (QMNC) around the time of childbirth among migrant and nonmigrant women in Europe.

METHODS

Women who gave birth at a health facility in 11 countries of the WHO European Region from March 2020 to July 2021 were invited to answer an online questionnaire including demographics and childbirth experience. Data were analyzed and compared for 1781 migrant and 20 653 nonmigrant women.

RESULTS

Migrant women who experienced labor perceived slightly more difficulties in attending routine antenatal visits (41.2% vs 39.4%; P = 0.001), more barriers in accessing facilities (32.9% vs 29.9%; P = 0.001), lack of timely care (14.7% vs 13.0%; P = 0.025), inadequate room comfort and equipment (9.2% vs 8.5%; P = 0.004), inadequate number of women per room (9.4% vs 8.6%; P = 0.039), being prevented from staying with their baby as they wished (7.8% vs 6.9%; P = 0.011), or suffering abuse (14.5% vs 12.7%; P = 0.022) compared with nonmigrant women. For women who had a prelabor cesarean, migrant women were more likely not to receive pain relief after birth (16.8% vs.13.5%; P = 0.039) and less likely to provide informal payment (1.8% vs 4.4%; P = 0.005) compared with nonmigrant women. Overall, the QMNC index was not significantly different for migrant compared with nonmigrant women.

CONCLUSION

Gaps in overall QMNC were reported by both migrant and nonmigrant women, with improvements to healthcare necessary for all.

Military provision of maternal care in humanitarian and disaster relief operations

With three-quarters of the 80 million people in need of humanitarian assistance being women or children in 2014, maternal care makes up a significant burden of medical care in humanitarian assistance and disaster relief operations. Due to lack of infrastructure and up to 80% of these displaced people being located in developing countries, mothers are often extremely vulnerable to disease, abuse and malnutrition. This can lead to late presentations of severe disease and birthing complications that would usually be easily manageable, but are far more complex due to the physical condition of the mother and lack of available resources. The British Armed Forces are often involved in humanitarian assistance and disaster relief either intentionally or due to the nature of the operations they carry out. However, it is not always possible to predict the requirement of maternal care. This humanitarian special edition article focuses on the factors impacting the maternal patient in a humanitarian environment, also looking at common pathologies and ways of managing these in a Role 1 facility. This is a paper commissioned as a part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

Experiences of armed conflicts and forced migration among women from countries in the Middle East, Balkans, and Africa: a systematic review of qualitative studies

Background

A significant proportion of the global population is displaced, many being women. Qualitative studies can generate in-depth findings that will contribute to an understanding of their experiences, but there is a need for further synthetization efforts. The aim was to provide a comprehensive perspective about adult women’s experiences of armed conflicts and forced migration, focusing on women in or from countries in the Middle East, Balkans, or Africa.

Methods

Systematic review of English reports presenting empirical qualitative studies published in scientific journals 1980 or later, utilizing searches performed in September 2021 within three databases combined with manual screening. Of the 3 800 records screened in total, 26 were included. Methodological details and quality were appraised using pre-specified extraction and appraisal tools. The findings within the included reports were analyzed with thematic analysis.

Results

Most reports utilized interviews, including in total 494 participants, and were appraised as having insignificant methodological limitations. The first theme concerns changed living conditions, involving reduced safety, insufficient access to resources meeting basic needs, forced migration as a last resort, and some positive effects. The second theme concerns the experienced health-related consequences, involving psychological distress, risks during pregnancy and childbirth, exposure to violence and discrimination as a woman, as well as a lack of adequate healthcare services and social support. The third theme concerns the resources and strategies that enhance resilience, involving social support and family life, as well as utilization of internal resources and strategies.

Conclusion

When experiencing armed conflicts and forced migration, women face significant challenges related to changed living conditions and are exposed to health-related consequences. Consistently, women are targets of severe structural and personal violence, while lacking access to even the most basic healthcare services. Despite facing considerable hardships, these women display extraordinary resilience and endurance by finding strength through social support and internal resources. Synthesized qualitative research illustrates that women value social support, including peer support, which is a promising intervention that needs to be evaluated in future experimental studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-022-00481-x.

Language-supported labor ward visits for pregnant migrant women: Staff experiences in a Swedish hospital

INTRODUCTION

METHODS

RESULTS

CONCLUSIONS

Nationwide longitudinal population-based study on mortality in Italy by immigrant status

A systematic analysis of the mortality of immigrant residents throughout Italy has never been carried out. The present study aimed to evaluate differences in mortality by immigrant status. A longitudinal study of the Italian resident population (native and immigrants) recorded in the 2011 National Institute of Statistics Census was conducted. This cohort was followed up from 2012 to 2018 until death, emigration, or end of the study period. The exposure variable was the immigrant status, measured through citizenship, dichotomized into Italian and immigrant. The main outcome was overall and cause-specific mortality. Age-standardized mortality ratios (SMRs) were calculated. The SMRs among immigrants were half that of Italians, both for men (SMR 0.52) and women (SMR 0.51), with the lowest SMRs observed for subjects from North Africa and Oceania. For some causes of death, mortality was higher among immigrants: tuberculosis in both men (SMR 4.58) and women (SMR 4.72), and cervical cancer (SMR 1.58), complications of pregnancy, childbirth, and puerperium (SMR 1.36), and homicide (SMR 2.13) for women. A multivariable quasi-Poisson regression analysis, adjusted for age and macro area of residence in Italy, confirmed a lower all-cause mortality for immigrants compared to Italians, both for men (RR 0.46) and women (RR 0.44). Although immigration to Italy is no longer a recent phenomenon, and the presence of immigrants is acquiring structural characteristics, our study confirms their health advantage, with a lower mortality than that of Italians for almost all causes of death and for all areas of origin.

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.

Severe hypovitaminosis D in pregnant refugees arriving in Europe: neonatal outcomes and importance of prenatal intervention

Adequate vitamin D levels are particularly important in pregnant women for both maternal and neonatal health. Prior studies have shown a significantly high prevalence of vitamin D deficiency (VDD) among refugees. However, no study has addressed the prevalence of VDD in pregnant refugees and its effects on neonatal health. In this study, we examined the prevalence of VDD in refugee pregnant women living in Greece and compared our results with Greek pregnant inhabitants. VDD was frequent in both groups but was significantly more common in refugees (92.2 vs 67.3% of Greek women, P = 0.003) with 70.6% of refugees having severe hypovitaminosis D (<10 ng/mL). As a result, most newborns had VDD, which affected refugee newborns to a greater extent. Our results suggest a need to screen newcomer children and pregnant women for VDD in all host countries around the world. Such a screen will appropriately guide early and effective interventions with the goal to prevent adverse neonatal and maternal outcomes.

[Maternal Mortality, Frequency, causes, women's profile and preventability of deaths in France, 2013-2015]

OBJECTIVE

To describe, for the 2013-2015 period, the frequency, causes, risk factors, adequacy of care and preventability of maternal deaths in France.

METHOD

Data from the National Confidential Enquiry into Maternal Deaths for 2013-2015.

RESULTS

For the period 2013-2015, 262 maternal deaths occurred in France, one every four days, i.e a maternal mortality ratio of 10.8 per 100,000 live births (95 % CI 9.5-12.1), stable compared to 2010-2012. Compared to women aged 25-29, the risk is multiplied by 1.9 for women aged 30-34, by 3 for women aged 35-39 and by 4 for women aged 40 and over. Obese women are twice as frequent among maternal deaths (24 %) than in the general population of parturients (11 %). There are territorial disparities - the maternal mortality ratio in the French overseas departments is 4 times higher than in metropolitan France -, and social disparities - the mortality of migrant women remains higher than that of women born in France, particularly for women born in sub-Saharan Africa whose risk is 2.5 times higher than that native women. A striking result of the 2013-2015 period is the preponderance of suicides and cardiovascular diseases, the two leading causes of maternal mortality, each responsible for approximately one death per month. These two etiologies are not only the most frequent, but also among those with the highest proportion of preventable deaths, 91.3 % and 65.7 % respectively. Another important result is the continued decrease in mortality from obstetric haemorrhage, halved in 15 years, particularly the decrease n hemorrhages due to uterine atony. Overall, 57.8 % of maternal deaths are considered probably or possibly preventable and in 66 % of cases, the care provided was not optimal.

CONCLUSION

While the overall maternal mortality ratio remains stable overall, and territorial and social inequalities unchanged, the profile of the causes of maternal mortality is changing. Some developments are a success, such as the continued decrease in maternal mortality due to haemorrhage, the result of the general mobilisation of health actors on this issue. Others point to new priorities for mobilisation, in particular on the mental and cardiovascular health of women during pregnancy or in the year following childbirth. In order to go further in understanding the mechanisms involved, and to identify precise avenues for prevention, it is necessary to analyse in detail the stories of each maternal death in order to identify the opportunities for improvement repeatedly found in the series of deaths. This is what the following articles in this issue propose, with an analysis by cause of death.

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.

Human Development Index of the maternal country of origin and its relationship with maternal near miss: A systematic review of the literature

Background

The reduction in maternal mortality worldwide has increased the interest in studying more frequent severe events such as maternal near miss. The Human Development Index is a sociodemographic country-specific variable that includes key human development indicators such as living a long and healthy life, acquiring knowledge, and enjoying a decent standard of living, allowing differentiation between countries. In a globalised environment, it is necessary to study whether the Human Development Index of each patient's country of origin can be associated with the maternal near-miss rate and thus classify the risk of maternal morbidity and mortality.

Methods

A systematic review of the literature published between 2008 and 2019 was conducted, including all articles that reported data about maternal near miss in their sample of pregnant women, in addition to describing the study countries of their sample population. The Human Development Index of the study country, the maternal near-miss rate, the maternal mortality rate, and other maternal-perinatal variables related to morbidity and mortality were used.

Results

After the systematic review, eighty two articles from over thirty countries were included, for a total of 3,699,697 live births, 37,191 near miss cases, and 4029 mortality cases. A statistically significant (p <0.05) inversely proportional relationship was observed between the Human Development Index of the study country and the maternal near-miss and mortality rates. The most common cause of maternal near miss was haemorrhage, with an overall rate of 38.5%, followed by hypertensive disorders of pregnancy (34.2%), sepsis (7.5%), and other undefined causes (20.9%).

Conclusions

The Human Development Index of the maternal country of origin is a sociodemographic variable allowing differentiation and classification of the risk of maternal mortality and near miss in pregnant women. The most common cause of maternal near miss published in the literature was haemorrhage.

Trial registration

PROSPERO ID: CRD 42019133464

Involvement in maternal care by migrants and ethnic minorities: a narrative review

BACKGROUND

Guidelines for improving the quality of maternal health services emphasise women's involvement in care. However, evidence about migrant and ethnic minorities' preferences for participation in maternal care remains unsystematised. Understanding these populations' experiences with and preferred forms of involvement in care provision is crucial for imbuing policies and guidelines with sensitivity to diversity and for implementing people-centred care. This paper presents a narrative synthesis of empirical studies of involvement in maternal health care by migrants and ethnic minorities based on four key dimensions: information, communication, expression of preferences and decision-making.

METHODS

Studies indexed in PubMed and Scopus published until December 2019 were searched. Original quantitative, qualitative and mixed methods studies written in English and reporting on migrant and ethnic minority involvement in maternal care were included. Backward reference tracking was carried out. Three researchers conducted full-text review of selected publications.

RESULTS

In total, 22 studies met the inclusion criteria. The majority of studies were comparative and addressed only one or two dimensions of involvement, with an emphasis on the information and communication dimensions. Compared to natives, migrants and ethnic minorities were more likely to (1) lack access to adequate information as a result of health care staff's limited time, knowledge and misconceptions about women's needs and preferences; (2) report suboptimal communication with care staff caused by language barriers and inadequate interpreting services; (3) be offered fewer opportunities to express preferences and to have preferences be taken less into account; and (4) be less involved in decisions about their care due to difficulties in understanding information, socio-cultural beliefs and previous experiences with care provision less attuned with playing an active role in decision-making and care staff detracting attitudes.

CONCLUSION

Constraints to adequate and inclusive involvement in maternal care can hinder access to quality care and result in severe negative health outcomes for migrant and ethnic minority women. More research is needed into how to tailor the dimensions of involvement to migrant and ethnic minorities' needs and preferences, followed by provision of the resources necessary for effective implementation (e.g. sufficient time for consultations, optimal interpreter systems, health care staff training).

Migrant women's experiences of pregnancy, childbirth and maternity care in European countries: A systematic review

BACKGROUND

Across Europe there are increasing numbers of migrant women who are of childbearing age. Migrant women are at risk of poorer pregnancy outcomes. Models of maternity care need to be designed to meet the needs of all women in society to ensure equitable access to services and to address health inequalities.

OBJECTIVE

To provide up-to-date systematic evidence on migrant women's experiences of pregnancy, childbirth and maternity care in their destination European country.

SEARCH STRATEGY

CINAHL, MEDLINE, PubMed, PsycINFO and Scopus were searched for peer-reviewed articles published between 2007 and 2017.

SELECTION CRITERIA

Qualitative and mixed-methods studies with a relevant qualitative component were considered for inclusion if they explored any aspect of migrant women's experiences of maternity care in Europe.

DATA COLLECTION AND ANALYSIS

Qualitative data were extracted and analysed using thematic synthesis.

RESULTS

The search identified 7472 articles, of which 51 were eligible and included. Studies were conducted in 14 European countries and focused on women described as migrants, refugees or asylum seekers. Four overarching themes emerged: 'Finding the way-the experience of navigating the system in a new place', 'We don't understand each other', 'The way you treat me matters', and 'My needs go beyond being pregnant'.

CONCLUSIONS

Migrant women need culturally-competent healthcare providers who provide equitable, high quality and trauma-informed maternity care, undergirded by interdisciplinary and cross-agency team-working and continuity of care. New models of maternity care are needed which go beyond clinical care and address migrant women's unique socioeconomic and psychosocial needs.

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.

Maternal mortality in Spain and its association with country of origin: cross-sectional study during the period 1999-2015

Background

The available literature suggests that there are significant differences in maternal mortality according to maternal origin in high income countries. The objective of this study was to quantify the risk of maternal death by maternal origin and region of Spain where the birth occurred and to identify the most important causes of maternal death in our country.

Methods

An ecological cross-sectional study was conducted that included all deliveries that resulted in maternal survival and cases of maternal death during 1999–2015 in Spain. A descriptive analysis of the maternal mortality rate by maternal origin, region and year of birth was performed. The risk of maternal death was calculated using univariate and multivariate logistic regression analysis, with adjustment for the variables included in the descriptive analysis.

Results

There were 272 maternal deaths during this period, most of which were due to haemorrhage (63 cases, 23.16%).Women whose continent of origin was South America had the highest adjusted risk of maternal death, with an OR of 3.92 (95% CI 2.75–5.58). The region of Spain with the highest risk of maternal death was Ceuta, with an OR of 12.11 (95% CI 2.02–72.68).

Conclusions

This study shows that there are inequalities in maternal mortality according to maternal origin and region where labour occurred. These findings highlight the need to establish strategies at the national and European levels to analyse the most relevant causes and risk factors associated with maternal mortality in order to reduce it and pay closer attention in identifying and carefully managing pregnant women from this at risk 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 .

Severe Maternal Morbidity Associated With Maternal Birthplace: A Population-Based Register Study

OBJECTIVE

This study sought to quantify the risk of severe maternal morbidity (SMM) according to maternal country of birth in Canada.

METHODS

The study analyzed 1 252 543 in-hospital deliveries of Ontario residents discharged between April 1, 2002, and March 31, 2012. The main outcome measure was a composite indicator of SMM used for surveillance. The top 10 most common component conditions were also evaluated. Maternal country of birth and other immigration characteristics were obtained through linkage with official immigration records. We used modified Poisson regression with generalized estimating equations to assess associations according to maternal country of birth.

RESULTS

Overall, immigrant women (N = 335 544) did not differ from Canadian-born women (n = 916 999) in SMM rates (12.1 vs. 12.0 cases per 1000 deliveries, respectively). However, SMM varied substantially according to maternal region of birth, from 9.2 cases per 1000 deliveries among immigrants from Western countries to 23.0 cases per 1000 deliveries among immigrants from Sub-Saharan Africa. Even larger variations were found when immigrants were categorized by their specific countries of birth. The top 10 contributing conditions to SMM among Canadian-born women were also the main contributors among immigrant subgroups. The notable exception was HIV infection, the top contributor among immigrants from Sub-Saharan Africa, whose rate of HIV infection was 43 times that of Canadian-born women (95% CI 34.39-55.23). After excluding HIV cases, disparities in SMM were largely reduced among Sub-Saharan African women but did not disappear.

CONCLUSION

There is large heterogeneity in SMM and its component conditions among Canadian immigrants depending on country of origin.

Maternal mortality and severe morbidity in a migration perspective

Among migrants in high-income countries, maternal mortality and severe morbidity generally occur more frequently as compared to host populations. There is marked variation between groups of migrants and host countries, with much elevated risks in some groups and no elevated risk at all in others. Those without a legal resident permit are most vulnerable. A reason for these elevated risks could be a different risk profile in migrants, but risk factors are unevenly distributed and not always present. Another reason is substandard care, which is identified more frequently in migrants, and comprises patient delays, for example, due to a lack of knowledge about the health system in the host country, and health worker delays, often compounded by communication barriers. Improvements in family planning and antenatal services are needed, and audits and confidential enquiries should be extended to include maternal morbidity and ethnic background. This requires scientific and political efforts.