Language barrier as a risk factor for obstetric anal sphincter injury - A case-control study

Racial/Ethnic Impact on Obstetric Anal Sphincter Injuries: A Multicentric Retrospective Study

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injuries (OASIs), third- and fourth-degree lacerations, represent a severe obstetric complication. Previous studies reported a higher incidence of OASIs in Asian women in non-Asian countries. This study was aimed at establishing a different OASIs prevalence among the racial/ethnic groups in Southern European centers.

METHODS

A multicenter retrospective study that included pregnant women who had vaginal singleton delivery between January 2019 and September 2022 in two Italian University hospitals, Naples and Novara, was conducted. We excluded cesarean sections, nonvertex presentation, preterm delivery, multiple pregnancies, congenital malformations, or stillbirths. Statistical analysis with an independent association of ethnicity to the risk of OASIs using clinical characteristics-adjusted multivariate logistic regression was performed.

RESULTS

A total of 3,049 pregnant women were included. 2.33% (71 patients) had an OASI. The median age was 31 years (IQR 7.00) and median gestational age was 39 weeks (IQR 1.40). Mean birth weight was 3,300 g (IQR 580.00). 1' and 5' Apgar scores were 9 and 9. The univariate logistic regression was not statistically significant. Multivariate logistic regression model adjusted for baseline clinical characteristics showed an OR 2.540 (p value 0.01) for OASIs in Asian women. Primiparous and secondiparous were protective factors for OASIs with OR 0.224 (p value < 0.001) and OR 0.209 (p value 0.01).

CONCLUSIONS

Our results confirm racial/ethnic disparities regarding OASIs, with an elevated risk for Asian women in Southern Europe. Prevention strategies and obstetric care in developed countries should be modulated to offset the risk of OASIs in this population. Additional research is needed to explain the specific mechanisms of these disparities.

Cultural and religious structures influencing the use of maternal health services in Nigeria: a focused ethnographic research

BACKGROUND

Cultural and religious structures encompass a set pattern of values, beliefs, systems and practices that define a community's behaviour and identity. These structures influence women's health-seeking behaviour and access to maternal health services, predisposing women to preventable maternal health complications. However, most maternal health policies have focused on biomedical strategies, with limited attention to women's cultural challenges around childbirth. The overall aim of this paper is to provide a thick description and understanding of cultural and religious structures in Nigeria, their meaning and how they influence women's use of maternal health services.

METHODS

Roper and Shapira's (2000) focused ethnography comprising 189 h of observation of nine women from the third trimester to deliveries. Using purposive and snowballing techniques, 21 in-depth interviews and two focus group discussions comprising 13 women, were conducted in two Nigerian primary healthcare facilities in rural and urban area of Kogi State. Data was analyzed using the steps described by Roper and Shapira.

RESULTS

Using the PEN-3 cultural model, nine themes were generated. Positive factor, such as the language of communication, existential factor, such as religion, and negative factors, such as the use of prayer houses and lack of women's autonomy, were either positive or negative enablers influencing women's use of maternal health services. Additionally, women's perceptions, such as their dependency on God and reliance on cultural norms were significant factors that influence the use of maternal health services. We also found that the use of herbal medicine was a negative enabler of women's access to facility care. At the same time, family support was also a positive and a negative nurturer that could influence how women use facility care. Finally, factors such as religion, Ibegwu, and male child syndrome were negative nurturers influencing women's contraceptive use.

CONCLUSION

Cultural and religious structures are significant factors that could promote or limit women's use of maternal health services. Further studies are needed to understand culturally focused approaches to enhance women's use of maternal health services in Nigeria.

Let this be a safe place: a qualitative study into midwifery care for forcibly displaced women in the Netherlands

BACKGROUND

Forcibly displaced women in the Netherlands face increased chances of perinatal mortality and other adverse pregnancy and childbirth outcomes compared to the resident country population, which has been linked to suboptimal care. This study was conducted to gain insights from the experiences of Dutch midwives to inform and enhance the provision of tailored and equitable care for forcibly displaced women.

METHODS

We conducted a qualitative study using semistructured interviews with community midwives who provide care for forcibly displaced women (asylum seekers and recognized refugees) in the Netherlands. Through thematic analysis, we identified the barriers midwives encounter in providing care and explored their strategies for navigating these barriers, aiming to inform recommendations that advance equitable care provision.

RESULTS

Interviews with eleven midwives revealed barriers across three thematic levels: (1) the interactional level, where barriers related to language and interpreters, cultural differences, and building trust impeded positive interactions between midwives and forcibly displaced women; (2) the organizational level, where barriers concerning relocations of asylum seekers, delays in accessing care, and interdisciplinary collaboration impeded optimal care; and (3) the contextual level, where barriers related to women's housing conditions, the resettlement process and the mental health of forcibly displaced women impeded midwives' to respond to clients' needs. These levels of barriers culminated in a core theme of imbalance between midwives' expanded responsibilities and the limited resources and strategies available to them in care for forcibly displaced women. This imbalance forced midwives into multiple roles, increased both the practical and emotional burden on them, and undermined their ability to provide optimal, equitable care.

CONCLUSIONS

To enhance the provision of equitable pregnancy and childbirth care for forcibly displaced women in the Netherlands, it is crucial to target the imbalance between the responsibilities that midwives bear and the resources available to them. This requires dismantling barriers at the interactional, organizational and contextual level of care through targeted policy interventions. Structural determinants that perpetuate the imbalance in midwives' work and restrict their scope of influence, such as restrictive migration policies that contribute to socioeconomic marginalization and poor housing conditions, need to be addressed. Ultimately, midwives themselves require more support and education to recognize and combat injustices in pregnancy and childbirth care for forcibly displaced women.

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

Background

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

Methods

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

Findings

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

Conclusion

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Asian-White disparities in obstetric anal sphincter injury: a systematic review and meta-analysis

OBJECTIVE

Obstetrical anal sphincter injury describes a severe injury to the perineum and perianal muscles after birth. Obstetrical anal sphincter injury occurs in approximately 4.4% of vaginal births in the United States; however, racial and ethnic inequities in the incidence of obstetrical anal sphincter injury have been shown in several high-income countries. Specifically, an increased risk of obstetrical anal sphincter injury in individuals who identify as Asian vs those who identify as White has been documented among residents of the United States, Australia, Canada, Western Europe, and the Scandinavian countries. The high rates of obstetrical anal sphincter injury among the Asian diaspora in these countries are higher than obstetrical anal sphincter injury rates reported among Asian populations residing in Asia. A systematic review and meta-analysis of studies in high-income, non-Asian countries was conducted to further evaluate this relationship.

DATA SOURCES

MEDLINE, Ovid, Embase, EmCare, and the Cochrane databases were searched from inception to March 2023 for original research studies.

STUDY ELIGIBILITY CRITERIA

Observational studies using keywords and controlled vocabulary terms related to race, ethnicity and obstetrical anal sphincter injury. All observational studies, including cross-sectional, case-control, and cohort were included. 2 reviewers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Meta-analysis of Observational Studies in Epidemiology recommendations.

METHODS

Meta-analysis was performed using RevMan (version 5.4; Cochrane Collaboration, London, United Kingdom) for dichotomous data using the random effects model and the odds ratios as effect measures with 95% confidence intervals. Subgroup analysis was performed among Asian subgroups. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tools. Meta-regression was used to determine sources of between-study heterogeneity.

Results

A total of 27 studies conducted in 7 countries met the inclusion criteria encompassing 2,337,803 individuals. The pooled incidence of obstetrical anal sphincter injury was higher among Asian individuals than White individuals (pooled odds ratio, 1.64; 95% confidence interval, 1.48-1.80). Subgroup analyses showed that obstetrical anal sphincter injury rates were highest among South Asians and among population-based vs hospital-based studies. Meta-regression showed that moderate heterogeneity remained even after accounting for differences in studies by types of Asian subgroups included, study year, mode of delivery included, and study setting.

Conclusion

Obstetrical anal sphincter injury is more frequent among Asian versus white birthing individuals in multiple high-income, non-Asian countries. Qualitative and quantitative research to elucidate underlying causal mechanisms responsible for this relationship are warranted.

Community midwives' perspectives on perinatal care for asylum seekers and refugees in the Netherlands: A survey study

BACKGROUND

The rise of forced migration worldwide compels birth care systems and professionals to respond to the needs of women giving birth in these vulnerable situations. However, little is known about the perspective of midwifery professionals on providing perinatal care for forcibly displaced women. This study aimed to identify challenges and target areas for improvement of community midwifery care for asylum seekers (AS) and refugees with a residence permit (RRP) in the Netherlands.

METHODS

For this cross-sectional study, data were collected through a survey aimed at community care midwives who currently work or who have worked with AS and RRP. We evaluated challenges identified through an inductive thematic analysis of respondents' responses to open-ended questions. Quantitative data from close-ended questions were analyzed descriptively and included aspects related to the quality and organization of perinatal care for these groups.

RESULTS

Respondents generally considered care for AS and RRP to be of lower quality, or at best, equal quality compared to care for the Dutch population, while the workload for midwives caring for these groups was considered higher. The challenges identified were categorized into five main themes, including: 1) interdisciplinary collaboration; 2) communication with clients; 3) continuity of care; 4) psychosocial care; and 5) vulnerabilities among AS and RRP.

CONCLUSIONS

Findings suggest that there is considerable opportunity for improvement in perinatal care for AS and RRP, while also providing direction for future research and interventions. Several concerns raised, especially the availability of professional interpreters and relocations of AS during pregnancy, require urgent consideration at legislative, policy, and practice levels.

High Incidence of Obstetric Anal Sphincter Injuries among Immigrant Women of Asian Ethnicity

(1) Background: Obstetric anal sphincter injuries (OASI) may complicate vaginal deliveries. The aim of the present study was to explore the incidence and clinical characteristics of OASI among Asian women living in a Western country compared to local Caucasian women. (2) Methods: A retrospective cohort study of 380 women diagnosed with OASI, following singleton vaginal deliveries, during a 10-year period (January 2011 to December 2020). Exclusion criteria: age < 18 years, stillbirth, and breech presentation. Demographic, clinical, and obstetrical data were obtained, and a comparison between Asian and Caucasian women was performed. (3) Results: There were 35 cases of OASI among 997 women of Asian ethnicity compared to 345 cases of OASI among 86,250 Caucasian women (3.5% vs. 0.4%, respectively, p < 0.001). Asian women endured a significantly higher rate of fourth-degree OASI (17.1%) even though they bore smaller newborns (3318 g vs. 3501 g, p = 0.004), and birth weights rarely exceeded 3800 g (2.8% vs. 25.8%, p < 0.001). Asian ethnicity was also associated with a significantly higher risk for blood transfusion following OASI and a lower tendency for postpartum follow up. (4) Conclusions: Immigrant women of Asian ethnicity had a nine-fold higher rate of OASI, much higher than previously reported. Furthermore, Asian women had higher rates of fourth-degree OASI.

Risk of obstetric anal sphincter injury associated with female genital mutilation/cutting and timing of deinfibulation

INTRODUCTION

A greater risk of obstetric anal sphincter injury has been reported among African migrants in several host countries compared with the general population. To what degree female genital mutilation/cutting affects this risk is not clear. In infibulated women, deinfibulation prevents anal sphincter injury. Whether the timing of deinfibulation affects the risk, is unknown. This study aimed to investigate the risks of anal sphincter injury associated with female genital mutilation/cutting and timing of deinfibulation in Norway, and to compare the rates of anal sphincter injury in Somali-born women and the general population.

MATERIAL AND METHODS

In a historical cohort study, nulliparous Somali-born women who had a vaginal birth in the period 1990-2014 were identified by the Medical Birth Registry of Norway and data collected from medical records. Exposures were female genital mutilation/cutting status and deinfibulation before labor, during labor or no deinfibulation. The main outcome was obstetric anal sphincter injuries.

RESULTS

Rates of obstetric anal sphincter injury did not differ significantly by female genital mutilation/cutting status (type 1-2: 10.2%, type 3: 11.3%, none: 15.2% P = 0.17). The total rate of anal sphincter injury was 10.3% compared to 5.0% among nulliparous women in the general Norwegian population. Women who underwent deinfibulation during labor had a lower risk than women who underwent deinfibulation before labor (odds ratio 0.48, 95% confidence interval 0.27-0.86, P = 0.01).

CONCLUSIONS

The high rate of anal sphincter injury in Somali nulliparous women was not related to type of female genital mutilation/cutting. Deinfibulation during labor protected against anal sphincter injury, whereas deinfibulation before labor was associated with a doubled risk. Deinfibulation before labor should not be routinely recommended during pregnancy.

[Screening and healthcare for pregnant women with psycho-social vulnerability : A French national study]

INTRODUCTION

Psycho-social vulnerabilities are a medical risk factor for both fetus and mother. Association between socioeconomic status and prenatal follow-up has been well established and inadequate follow-up is associated with higher morbidity and mortality in women in unfavorable situations.

OBJECTIVE

The objective is to identify screening strategies and to describe existing systems for pregnant women in psycho-social vulnerability in French maternity hospitals.

MATERIAL AND METHODES

This is a national survey conducted by questionnaire in all French maternities.

RESULTS

Screening by means of targeted questions is carried out by 96.7% of maternity units. Early prenatal interviews are offered systematically by 64% of maternity units and access to them is still difficult for women in vulnerable situations. In order to organize care pathways, 28.7% of maternities have a structured unit within their establishment and 81% state that they have mobilizable caregivers. Multidisciplinary meetings for the coordination of the various stakeholders are held by 85.8% of maternity units. Collaboration with networks and associations is emphasized.

CONCLUSION

A large proportion of maternities seek to identify women in situation of psycho-social vulnerabilities and to organize care paths. However, the resources implemented still appear insufficient for many maternity units. Each maternity hospital has resources and is developing initiatives to deal with the difficulties of care.

Obstetric anal sphincter injury by maternal origin and length of residence: a nationwide cohort study

OBJECTIVE

To estimate the association between maternal origin and obstetric anal sphincter injury (OASI), and assess if associations differed by length of residence.

DESIGN

Population-based cohort study.

SETTING

The Medical Birth Registry of Norway.

POPULATION

Primiparous women with vaginal livebirth of a singleton cephalic fetus between 2008 and 2017 (n = 188 658).

METHODS

Multivariable logistic regression models estimated adjusted odds ratios (aORs) for OASI with 95% CI by maternal region of origin and birthplace. We stratified models on length of residence and paternal birthplace.

MAIN OUTCOME MEASURES

OASI.

RESULTS

Overall, 6373 cases of OASI were identified (3.4% of total cohort). Women from South Asia were most likely to experience OASI (6.2%; aOR 2.24, 95% CI 1.87-2.69), followed by those from Southeast Asia, East Asia & the Pacific (5.7%; 1.59, 1.37-1.83) and Sub-Saharan Africa (5.2%; 1.85, 1.55-2.20), compared with women originating from Norway. Among women born in the same region, those with short length of residence in Norway (0-4 years), showed the highest odds of OASI. Migrant women across most regions of origin had the lowest risk of OASI if they had a Norwegian partner.

CONCLUSIONS

Primiparous women from Asian regions and Sub-Saharan Africa had up to two-fold risk of OASI, compared with women originating from Norway. Migrants with short residence and those with a foreign-born partner had higher risk of OASI, implying that some of the risk differential is due to sociocultural factors. Some migrants, especially new arrivals, may benefit from special attention during labour to reduce morbidity and achieve equitable outcomes.

TWEETABLE ABSTRACT

Anal sphincter injury during birth is more common among Asian and Sub-Saharan migrants and particularly among recent arrivals.