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Lorthe E, Severo M, Hamwi S, Rodrigues T, Teixeira C, Barros H. Obstetric Interventions Among Native and Migrant Women: The (Over)use of Episiotomy in Portugal. Int J Public Health 2024; 69:1606296. [PMID: 38577390 PMCID: PMC10991787 DOI: 10.3389/ijph.2024.1606296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 02/28/2024] [Indexed: 04/06/2024] Open
Abstract
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.
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Affiliation(s)
- Elsa Lorthe
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Unit of Population Epidemiology, Department of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Milton Severo
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Departamento de Ciências de Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Sousan Hamwi
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
| | - Teresa Rodrigues
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Department of Gynecology and Obstetrics, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Cristina Teixeira
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Polytechnic Institute of Bragança, Bragança, Portugal
| | - Henrique Barros
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Departamento de Ciências de Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Villadsen SF, Johnsen H, Damsted Rasmussen T, Ekstrøm CT, Sørensen J, Azria E, Rich-Edwards J, Essén B, Christensen U, Smith Jervelund S, Nybo Andersen AM. Unlocking the mechanisms of change in the MAMAACT intervention to reduce ethnic disparity in stillbirth and newborns' health: integration of evaluation findings. FRONTIERS IN HEALTH SERVICES 2024; 4:1233069. [PMID: 38433990 PMCID: PMC10904659 DOI: 10.3389/frhs.2024.1233069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 01/17/2024] [Indexed: 03/05/2024]
Abstract
Ethnic disparities in stillbirth exist in Europe and suboptimal care due to miscommunication is one contributing cause. The MAMAACT intervention aimed to reduce ethnic disparity in stillbirth and newborns' health through improved management of pregnancy complications. The intervention encompassed training of antenatal care midwives in cultural competencies and intercultural communication combined with health education materials for the expecting parents about symptoms of pregnancy complications. The evaluation consisted of a qualitative in-depth implementation analysis and a process evaluation embedded in a cluster randomized trial including 19 of 20 maternity wards in Denmark. In this article, the findings from the different evaluation perspectives are integrated. The integration follows the principles of realist evaluation by analyzing to what extent the MAMAACT activities were generating mechanisms of change in interaction with the context. The integration analysis shows that the health education materials in the MAMAACT intervention contributed to heightened health literacy concerning pregnancy complications among pregnant women. Additionally, the training of midwives in cultural competency and intercultural communication raised awareness among midwives. Nonetheless, the exclusive emphasis on midwives and the inflexibility in care provision hindered them from changing their communication practices. To enhance the cultural competence in maternity care, it is essential to implement more comprehensive initiatives involving healthcare professionals in maternity care at all levels, from pregraduate to postgraduate. Adequate interpreter services and management support should also be ensured. Currently, the Danish antenatal care system faces challenges including inadequate information transfer between healthcare sectors, insufficient differentiation of care, and inflexibility in midwife scheduling. This results in a lack of responsiveness to the individual needs of women with immigrant backgrounds, potentially reproducing health inequities.
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Affiliation(s)
- Sarah Fredsted Villadsen
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Helle Johnsen
- Department of Midwifery and Therapeutic Sciences, University College Copenhagen, Copenhagen, Denmark
| | - Trine Damsted Rasmussen
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Claus Thorn Ekstrøm
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Janne Sørensen
- Section of Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Elie Azria
- Obstetrical Perinatal and Pediatric Epidemiology Research Team, INSERM, Paris, France
| | - Janet Rich-Edwards
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Birgitta Essén
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Ulla Christensen
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Signe Smith Jervelund
- Section of Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anne-Marie Nybo Andersen
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Radjack R, Hemmerter S, Azria E, Moro MR. [Relevance of the transcultural approach to improve the care relationship in the perinatal period]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:342-347. [PMID: 37080294 DOI: 10.1016/j.gofs.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 04/22/2023]
Abstract
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.
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Affiliation(s)
- Rahmeth Radjack
- AP-HP, Maison de Solenn, Maison des adolescents de l'Hôpital Cochin, 75014 Paris, France; Université de Paris, PCPP, 92100 Boulogne-Billancourt, France; Université Paris-Saclay, UVSQ, CESP, Team DevPsy, Inserm, 94807 Villejuif, France.
| | - Stéphane Hemmerter
- Unit Director Hall ward, Department of Psychological Medicine, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Elie Azria
- Maternité du Groupe Hospitalier Paris Saint Joseph, 75014 Paris, France; UMR 1153, Équipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé); Université de Paris Cité, Paris, France
| | - Marie Rose Moro
- AP-HP, Maison de Solenn, Maison des adolescents de l'Hôpital Cochin, 75014 Paris, France; Université de Paris, PCPP, 92100 Boulogne-Billancourt, France; Université Paris-Saclay, UVSQ, CESP, Team DevPsy, Inserm, 94807 Villejuif, France
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Radjack R, Bossuroy M, Camara H, Touhami F, Ogrizek A, Rodriguez J, Robin M, Moro MR. Transcultural skills for early childhood professionals. Front Psychiatry 2023; 14:1112997. [PMID: 37151984 PMCID: PMC10160661 DOI: 10.3389/fpsyt.2023.1112997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/03/2023] [Indexed: 05/09/2023] Open
Abstract
Context Transcultural skills are especially useful for those involved in the perinatal period, when parents and babies must adapt to one another in a setting of migration a long a focus of transcultural clinical practice. Objective The aim of this article is to provide useful transcultural skills for any health care worker (e.g., psychologists, child psychiatrists, midwives, family doctors, pediatricians, specialized child-care attendants, and social workers) who provide care or support to families during the perinatal period. It highlights the cultural aspects requiring attention in relation to representations of pregnancy, children's needs, obstetric complications, and postnatal problems. Taking into account the impact of culture on clinical evaluation and treatment can enable professionals to distinguish what involves cultural representations of pregnancy, babies, and sometimes of disease from what is associated with interaction disorders or maternal psychopathology. Methods After explaining the relevance of transcultural clinical practices to provide migrant mothers with better support, we describe 9 themes useful to explore from a transcultural perspective. This choice is based on the transcultural clinical practice in our specialized department. Results The description of these 9 themes is intended to aid in their pragmatic application and is illustrated with short clinical vignettes for specific concepts. We describe situations that are extreme but often encountered in liaison transcultural clinical practice for maternity wards: perinatal mourning with cultural coding, mediation in refusal of care, cultural misunderstandings, situations of complex trauma and of multiple contextual vulnerabilities, and difficulties associated with acculturation. Discussion The transcultural levers described here make it possible to limit cultural misunderstandings and to promote the therapeutic alliance. It presupposes the professionals will concomitantly analyze their cultural countertransference and acquire both the knowledge and know-how needed to understand the elements of cultural, political, and social issues needed to develop clinical finesse. Conclusion This combined theoretical-clinical article is intended to be pedagogical. It provides guidelines for conducting transcultural child psychiatry/psychological interviews in the perinatal period aimed at both assessment and therapy.
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Affiliation(s)
- Rahmeth Radjack
- Maison de Solenn, Department of Adolescent Psychiatry, Cochin Hospital, AP-HP, Paris University, Paris, France
- Department of Child and Adolescent Psychiatry, University of Paris, Paris, France
- CESP-UVSQ, DevPsy, INSERM, Université Paris-Saclay, Villejuif, France
- *Correspondence: Rahmeth Radjack,
| | - Muriel Bossuroy
- Unité Transversale de Psychogénèse et Psychopathologie, Sorbonne Paris Nord University, UTRPP, Villetaneuse, France
| | - Hawa Camara
- Maison de Solenn, Department of Adolescent Psychiatry, Cochin Hospital, AP-HP, Paris University, Paris, France
- Department of Child and Adolescent Psychiatry, University of Paris, Paris, France
- CESP-UVSQ, DevPsy, INSERM, Université Paris-Saclay, Villejuif, France
| | - Fatima Touhami
- Maison de Solenn, Department of Adolescent Psychiatry, Cochin Hospital, AP-HP, Paris University, Paris, France
- Department of Child and Adolescent Psychiatry, University of Paris, Paris, France
- CESP-UVSQ, DevPsy, INSERM, Université Paris-Saclay, Villejuif, France
| | - Anaïs Ogrizek
- Maison de Solenn, Department of Adolescent Psychiatry, Cochin Hospital, AP-HP, Paris University, Paris, France
- Department of Child and Adolescent Psychiatry, University of Paris, Paris, France
- Department of Adult and Child Psychiatry, University Hospital of Martinique, Fort-de-France, France
| | - Juliette Rodriguez
- Maison de Solenn, Department of Adolescent Psychiatry, Cochin Hospital, AP-HP, Paris University, Paris, France
- Department of Child and Adolescent Psychiatry, University of Paris, Paris, France
- CESP-UVSQ, DevPsy, INSERM, Université Paris-Saclay, Villejuif, France
| | - Marion Robin
- Department of Child and Adolescent Psychiatry, University of Paris, Paris, France
- CESP-UVSQ, DevPsy, INSERM, Université Paris-Saclay, Villejuif, France
- Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France
| | - Marie Rose Moro
- Maison de Solenn, Department of Adolescent Psychiatry, Cochin Hospital, AP-HP, Paris University, Paris, France
- Department of Child and Adolescent Psychiatry, University of Paris, Paris, France
- CESP-UVSQ, DevPsy, INSERM, Université Paris-Saclay, Villejuif, France
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How Do We Address and Treat the Trauma of a 16-Year-Old Girl, Unaccompanied Minor, and Her Rape-Born Son? A Case Report. Healthcare (Basel) 2022; 10:healthcare10102036. [PMID: 36292484 PMCID: PMC9602657 DOI: 10.3390/healthcare10102036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/09/2022] [Accepted: 10/11/2022] [Indexed: 11/04/2022] Open
Abstract
Background: The child psychiatry unit of the Cochin Hospital in Paris is specialized in a transcultural clinical approach and treatment of psychotraumatism. The clinical demands addressed to the service often combine several levels of vulnerability: recent migration, repeated and intentional traumas, isolation and breach in family bonds sometimes precarious living conditions. Mastering how to approach trauma content adapting to the person’s temporality while taking into account the individual, family and collective dimensions, is a key driver to the clinical intervention (of our approach). Objective and method: We describe a paradigmatic clinical situation articulating its multidimensional complexity: the case of Céline, a 16-year-old Mozambique teenager, unaccompanied minor (UM), who arrived in France three years ago with her 4-year-old child born out of rape. They are both cared for by Paris Child Welfare Bureau. The authors used the CARE guidelines for a rigorous approach to clinical case writing. Results and discussion: In the clinical discussion, we highlight the pertinence of transcultural abilities for the treatment of a complex PTSD (post-traumatic stress disorder). We describe the measures taken to adapt the clinical interview framework to the mother’s psychic temporality, while negotiating what can be said in attendance of the child. The idea of tranquility is primordial—whether she decides to tell or not tell the child. Removing the pressure to have to tell is an element of treatment. Conclusion: Working through a progressive narrative construction, the therapeutical process allowed for the restoration of multiple levels of continuity between times prior to the trauma and following it, as well as prior to migration and following it, to create a continuum from adolescence to adulthood. Restoring narrativity favors the process of becoming a mother and the one of negotiating this new identity. The therapeutic axes also focused on improving the well-being of the UM-mother and preventing the impacts of transgenerational trauma transmission to the child. For women with similar experiences, sharing their emotions and their stories with us makes their choice about telling their child legitimate and comfortable, regardless of the decision they make.
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