Comparison of Maternity Experiences of Canadian-Born and Recent and Non-Recent Immigrant Women: Findings From the Canadian Maternity Experiences Survey

Prenatal and perinatal factors associated with neonatal neurobehavioral profiles in the ECHO Program

BACKGROUND

Single-cohort studies have identified distinct neurobehavioral profiles that are associated with prenatal and neonatal factors based on the NICU Network Neurobehavioral Scale (NNNS). We examined socioeconomic, medical, and substance use variables as predictors of NNNS profiles in a multi-cohort study of preterm and term-born infants with different perinatal exposures.

METHODS

We studied 1112 infants with a neonatal NNNS exam from the Environmental influences on Child Health Outcomes (ECHO) consortium. We used latent profile analysis to characterize infant neurobehavioral profiles and generalized estimating equations to determine predictors of NNNS profiles.

RESULTS

Six distinct neonatal neurobehavioral profiles were identified, including two dysregulated profiles: a hypo-aroused profile (16%) characterized by lethargy, hypotonicity, and nonoptimal reflexes; and a hyper-aroused profile (6%) characterized by high arousal, excitability, and stress, with low regulation and poor movement quality. Infants in the hypo-aroused profile were more likely to be male, have younger mothers, and have mothers who were depressed prenatally. Infants in the hyper-aroused profile were more likely to be Hispanic/Latino and have mothers who were depressed or used tobacco prenatally.

CONCLUSIONS

We identified two dysregulated neurobehavioral profiles with distinct perinatal antecedents. Further understanding of their etiology could inform targeted interventions to promote positive developmental outcomes.

IMPACT

Prior research on predictors of neonatal neurobehavior have included single-cohort studies, which limits generalizability of findings. In a multi-cohort study of preterm and term-born infants, we found six distinct neonatal neurobehavioral profiles, with two profiles being identified as dysregulated. Hypo- and hyper-aroused neurobehavioral profiles had distinct perinatal antecedents. Understanding perinatal factors associated with dysregulated neurobehavior could help promote positive developmental outcomes.

Experiences of childbirth care among immigrant and non-immigrant women: a cross-sectional questionnaire study from a hospital in Norway

BACKGROUND

Immigrant women have higher risks for poor pregnancy outcomes and unsatisfactory birth experiences than the general population. The mechanisms behind these associations remain largely unknown, but they may result from differential care provided to immigrant women or unsatisfactory interactions with health providers. This study aimed to investigate immigrant and non-immigrant women's experiences of health care during childbirth, particularly assessing two dimensions: perceived general quality of care and attainment of health care needs during childbirth.

METHODS

This was a cross-sectional study carried out over 15 months in 2020 and 2021, and data were collected from a self-completed questionnaire. The labour and birth subscale from the Experience of Maternity Care questionnaire was used to assess the primary outcome of care experiences. A total of 680 women completed the questionnaire approximately within two days after birth (mean 2.1 days) at a hospital in Trondheim, in central Norway. The questionnaire was provided in eight languages.

RESULTS

The 680 respondents were classified as immigrants (n = 153) and non-immigrants (n = 527). Most women rated their quality of care during childbirth as high (91.5%). However, one-quarter of the women (26.6%) reported unmet health care needs during childbirth. Multiparous immigrant women were more likely than multiparous non-immigrant women to report that their health care needs were unmet during childbirth (OR: 3.31, 95% CI: 1.91-5.72, p < 0.001, aOR: 2.83, 95% CI: 1.53-5.18, p = 0.001). No other significant differences between immigrant versus non-immigrant women were found in subjective ratings of childbirth care experiences. Having a Norwegian-born partner and a high level of Norwegian language skills did not influence the immigrant women's experience of childbirth care.

CONCLUSIONS

Our findings indicate that many women feel they receive high-quality health care during childbirth, but a considerable number still report not having their health care needs met. Also, multiparous immigrant women report significantly more unmet health care needs than non-immigrants. Further research is required to assess immigrant women's childbirth experiences and for health care providers to give optimal care, which may need to be tailored to a woman's cultural background and individual expectations.

Transnational prenatal care among migrant women from low-and-middle-income countries who gave birth in Montreal, Canada

OBJECTIVES

There is little research examining transnational prenatal care (TPC) (i.e., prenatal care in more than one country) among migrant women. Using data from the Migrant-Friendly Maternity Care (MFMC) - Montreal project, we aimed to: (1) Estimate the prevalence of TPC, including TPC-arrived during pregnancy and TPC-arrived pre-pregnancy, among recently-arrived migrant women from low- and middle-income countries (LMICs) who gave birth in Montreal, Canada; (2) Describe and compare the socio-demographic, migration and health profiles and perceptions of care during pregnancy in Canada between these two groups and migrant women who received no TPC (i.e., only received prenatal care in Canada); and (3) Identify predictors of TPC-arrived pre-pregnancy vs. No-TPC.

METHODS

The MFMC study used a cross-sectional design. Data were gathered from recently-arrived (< 8 years) migrant women from LMICs via medical record review and interview-administration of the MFMC questionnaire postpartum during the period of March 2014-January 2015 in three hospitals, and February-June 2015 in one hospital. We conducted a secondary analysis (n = 2595 women); descriptive analyses (objectives 1 & 2) and multivariable logistic regression (objective 3).

RESULTS

Ten percent of women received TPC; 6% arrived during pregnancy and 4% were in Canada pre-pregnancy. The women who received TPC and arrived during pregnancy were disadvantaged compared to women in the other two groups (TPC-arrived pre-pregnancy and No-TPC women), in terms of income level, migration status, French and English language abilities, access barriers to care and healthcare coverage. However, they also had a higher proportion of economic migrants and they were generally healthier compared to No-TPC women. Predictors of TPC-arrived pre-pregnancy included: 'Not living with the father of the baby' (AOR = 4.8, 95%CI 2.4, 9.8), 'having negative perceptions of pregnancy care in Canada (general experiences)' (AOR = 1.2, 95%CI 1.1, 1.3) and younger maternal age (AOR = 1.1, 95%CI 1.0, 1.1).

CONCLUSION

Women with more capacity may self-select to migrate during pregnancy which results in TPC; these women, however, are disadvantaged upon arrival, and may need additional care. Already-migrated women may use TPC due to a need for family and social support and/or because they prefer the healthcare in their home country.

The global burden of perinatal common mental health disorders and substance use among migrant women: a systematic review and meta-analysis

BACKGROUND

There are one billion migrants globally, of whom 82 million are forced migrants. Pregnant migrants face pre-migration stressors such as conflict, transit stressors including poverty, and post-migration stressors including navigating the immigration system; these stressors can make them vulnerable to mental illness. We aimed to assess the global prevalence of and risk factors for perinatal mental health disorders or substance use among women who are migrants.

METHODS

In this systematic review and meta-analysis, we searched OVID MEDLINE, Embase, PsycINFO, CENTRAL, Global Health, Scopus, and Web of Science for studies published from database inception until July 8, 2022. Cohort, cross-sectional, and interventional studies with prevalence data for any mental illness in pregnancy or the postnatal period (ie, up to a year after delivery) or substance use in pregnancy were included. The primary outcome was the prevalence of perinatal common mental health disorders among women who are migrants, globally. Data for study quality and risk factors were also extracted. A random-effects meta-analysis was used to calculate pooled prevalence estimates, when appropriate. Sensitivity analyses were conducted according to study quality, sample representativeness, and method of outcome assessment. Risk factor data were synthesised narratively. This study is registered with PROSPERO, CRD42021226291.

FINDINGS

18 650 studies were retrieved, of which 135 studies comprising data from 621 995 participants met the inclusion criteria. 123 (91%) of 135 studies were conducted in high-income host countries. Five (4%) of 135 studies were interventional, 40 (30%) were cohort, and 90 (66%) were cross-sectional. The most common regions of origin of participants were South America, the Middle East, and north Africa. Only 26 studies presented disaggregated data for forced migrants or economic migrants. The pooled prevalence of perinatal depressive disorders was 24·2% (range 0·5-95·5%; I² 98·8%; τ² 0·01) among all women who are migrants, 32·5% (1·5-81·6; 98·7%; 0·01) among forced migrants, and 13·7% (4·7-35·1; 91·5%; 0·01) among economic migrants (p<0·001). The pooled prevalence of perinatal anxiety disorders was 19·6% (range 1·2-53·1; I² 96·8%; τ² 0·01) among all migrants. The pooled prevalence of perinatal post-traumatic stress disorder (PTSD) among all migrant women was 8·9% (range 3·2-33·3; I² 97·4%; τ² 0·18). The pooled prevalence of perinatal PTSD among forced migrants was 17·1% (range 6·5-44·3; I² 96·6%; τ² 0·32). Key risk factors for perinatal depression were being a recently arrived immigrant (ie, approximately within the past year), having poor social support, and having a poor relationship with one's partner.

INTERPRETATION

One in four women who are migrants and who are pregnant or post partum experience perinatal depression, one in five perinatal anxiety, and one in 11 perinatal PTSD. The burden of perinatal mental illness appears higher among women who are forced migrants compared with women who are economic migrants. To our knowledge, we have provided the first pooled estimate of perinatal depression and PTSD among women who are forced migrants. Interpreting the prevalence estimate should be observed with caution due to the very wide range found within the included studies. Additionally, 66% of studies were cross-sectional representing low quality evidence. These findings highlight the need for community-based routine perinatal mental health screening for migrant communities, and access to interventions that are culturally sensitive, particularly for forced migrants who might experience a higher burden of disease than economic migrants.

FUNDING

UK National Institute for Health Research (NIHR); March of Dimes European Preterm Birth Research Centre, Imperial College; Imperial College NIHR Biomedical Research Centre; and Nuffield Department of Population Health, University of Oxford.

Prevalence and Associated Factors of Maternal Depression and Anxiety Among African Immigrant Women in Alberta, Canada: Quantitative Cross-sectional Survey Study

BACKGROUND

Although there is a significant body of evidence on maternal mental health, an inadequate focus has been placed on African immigrant women. This is a significant limitation given the rapidly changing demographics in Canada. The prevalence of maternal depression and anxiety among African immigrant women in Alberta and Canada, as well as the associated risk factors, are not well understood and remain largely unknown.

OBJECTIVE

The purpose of this study was to investigate the prevalence and associated factors of maternal depression and anxiety among African immigrant women living in Alberta, Canada up to 2 years postpartum.

METHODS

This cross-sectional study surveyed 120 African immigrant women within 2 years of delivery in Alberta, Canada from January 2020 to December 2020. The English version of the Edinburgh Postnatal Depression Scale-10 (EPDS-10), the Generalized Anxiety Disorder-7 (GAD-7) scale, and a structured questionnaire regarding associated factors were administered to all participants. A cutoff score of 13 on the EPDS-10 was indicative of depression, while a cutoff score of 10 on the GAD-7 scale was indicative of anxiety. Multivariable logistic regression was used to determine the factors significantly associated with maternal depression and anxiety.

RESULTS

Among the 120 African immigrant women, 27.5% (33/120) met the EPDS-10 cutoff score for depression and 12.1% (14/116) met the GAD-7 cutoff score for anxiety. The majority of respondents with maternal depression were younger (18/33, 56%), had a total household income of CAD $60,000 or more (US $45,000 or more; 21/32, 66%), rented their homes (24/33, 73%), had an advanced degree (19/33, 58%), were married (26/31, 84%), were recent immigrants (19/30, 63%), had friends in the city (21/31, 68%), had a weak sense of belonging in the local community (26/31, 84%), were satisfied with their settlement process (17/28, 61%), and had access to a regular medical doctor (20/29, 69%). In addition, the majority of respondents with maternal anxiety were nonrecent immigrants (9/14, 64%), had friends in the city (8/13, 62%), had a weak sense of belonging in the local community (12/13, 92%), and had access to a regular medical doctor (7/12, 58%). The multivariable logistic regression model identified demographic and social factors significantly associated with maternal depression (maternal age, working status, presence of friends in the city, and access to a regular medical doctor) and maternal anxiety (access to a regular medical doctor and sense of belonging in the local community).

CONCLUSIONS

Social support and community belonging initiatives may improve the maternal mental health outcomes of African immigrant women. Given the complexities immigrant women face, more research is needed on a comprehensive approach for public health and preventive strategies regarding maternal mental health after migration, including increasing access to family doctors.

Effectiveness of brief alcohol interventions for pregnant women: a systematic literature review and meta-analysis

BACKGROUND

Prenatal alcohol exposure (PAE) can result in a range of adverse neonatal outcomes, including Fetal Alcohol Spectrum Disorder (FASD). This systematic review and meta-analysis sought to investigate the effectiveness of brief interventions (BIs) in eliminating or reducing 1) alcohol consumption during pregnancy; and 2) PAE-related adverse neonatal outcomes; and 3) cost-effectiveness of BIs.

METHOD

We conducted a systematic literature search for original controlled studies (randomized control trials (RCTs); quasi-experimental) in any setting, published from 1987 to 2021. The comparison group was no/minimal intervention, where a measure of alcohol consumption was reported. Studies were critically appraised using the Centre for Evidence-based Medicine Oxford critical appraisal tool for RCTs (1). The certainty in the evidence for each outcome was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) (2). Meta-analysis of continuous and binary estimates of effect-size for similar outcome measures for BIs versus control groups were pooled and reported as mean difference (MD) Hedges' g and odds ratios (ORs), respectively.

RESULTS

In total, 26 studies, all from high income countries, met inclusion criteria. Alcohol abstinence outcome available in 12 studies (n = 2620) found modest effects in favor of BIs conditions by increasing the odds of abstinence by 56% (OR = 1.56, 95% confidence interval (CI) = 1.15-2.13, I² = 46.75%; p = 0.04). BIs effects for reduction in mean drinks/week (Cohen's d = - 0.21, 95%CI = - 0.78 to 0.36; p = 0.08) and AUDIT scores (g = 0.10, 95%CI = - 0.06 to 0.26; p = 0.17) were not statistically significant. Among seven studies (n = 740) reporting neonatal outcomes, BI receipt was associated with a modest and significant reduction in preterm birth (OR = 0.67, 95% CI = 0.46-0.98, I² = 0.00%; p = 0.58). No statistically significant differences were observed for mean birthweight or lower likelihood of low birth weight (LBW). Certainty in the evidence was rated as 'low'. No eligible studies were found on cost-effectiveness of BIs.

CONCLUSION

BIs are moderately effective in increasing abstinence during pregnancy and preventing preterm birth. More studies on the effectiveness of BIs are needed from low- and middle-income countries, as well as with younger mothers and with a broader range of ethnic groups.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pertussis vaccination in Canadian pregnant women, 2018-2019

OBJECTIVE

This study was undertaken to measure the uptake of pertussis vaccination during pregnancy in Canada and to identify sociodemographic factors associated with non-vaccination.

METHODS

A total of 5091 biological mothers of children born between September 2, 2018, and March 1, 2019, were interviewed about pertussis vaccination during their pregnancy.

RESULTS

Among 4607 mothers who recalled whether they had been vaccinated for pertussis, 43% had been vaccinated and 57% had not. The main reason given by mothers for not having been vaccinated was not being aware that pertussis vaccination was recommended. Factors independently associated with non-vaccination were being born outside Canada, lower household income, living in a province or territory where pertussis vaccination was not provided free of charge, having had previous live births, and having received maternity care from a midwife.

CONCLUSION

Advice from the maternity care provider is an important driver of pertussis vaccination during pregnancy.

Determinants and Inequities in Sexual and Reproductive Health (SRH) Care Access Among Im/Migrant Women in Canada: Findings of a Comprehensive Review (2008-2018)

Given growing concerns of im/migrant women's access to sexual and reproductive health (SRH) services, we aimed to (1) describe inequities and determinants of their engagement with SRH services in Canada; and (2) understand their lived experiences of barriers and facilitators to healthcare. Using a comprehensive review methodology, we searched the quantitative and qualitative peer-reviewed literature of im/migrant women's access to SRH care in Canada from 2008 to 2018. Of 782 studies, 38 met inclusion criteria. Ontario (n = 18), British Columbia (n = 6), and Alberta (n = 6) were primary settings represented. Studies focused primarily on maternity care (n = 20) and sexual health screenings (n = 12). Determinants included health system navigation and service information; experiences with health personnel; culturally safe and language-specific care; social isolation and support; immigration-specific factors; discrimination and racialization; and gender and power relations. There is a need for research that compares experiences across diverse groups of racialized im/migrants and a broader range of SRH services to inform responsive, equity-focused programs and policies.

Becoming a Migrant Mother: An Intersectional Approach to the Narratives of Cape Verdean Women in Portugal

Becoming a mother in the context of migration configures itself as a dynamic process of identity constitution that raises questions about citizenship, belonging, and migration policies. Furthermore, it is a process that involves a new set of maternal positions and practices that are composed through possibly conflicting cultural values. Based on the occurrence of unplanned pregnancies, this study sought to analyze the dimensions crossed by this event through an intersectional perspective of the narratives of Cape Verdean immigrant women who had children in Portugal, focusing on gender, migration, race/ethnicity. In-depth interviews were conducted with nine women, born in Cape Verde and residing in Greater Lisbon, through the Biographic-Narrative Interpretative Method (BNIM), which enabled an approach to the different dimensions that intersect in life stories of becoming an immigrant mother. Thematic analysis was chosen as an analytical tool, and the framework provided by intersectionality allows us to see the multiple identities that shape the processes of becoming a migrant mother. The results brought to light themes and issues that overlap and make motherhood more complex in the context of migration, highlighting and reinforcing the conditions of inequality.

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

•

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

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

•

No differences in prepartum hospitalization between migrants and country-born parturients.

Background

The 2015 refugee crisis led into a forced migration of millions of people globally. As a consequence, many countries experienced a quick change in the proportion of conflict-area born migrants. This group being stated as an especially vulnerable group for suboptimal maternal health, a timely inspection of preventive maternity care was required. This study investigated prenatal care in terms of gestation trimester at the first prenatal visit, number of check-ups prior to birth, and prepartum hospitalization in conflict-country born migrants and Finnish parturients in Finland.

Material and methods

Cross-sectional study included all pregnancies of migrants born in conflict-affected countries (n = 3 155) and country-born parturients (n = 93 600) in Finland in 2015–16. The data were obtained through Medical Birth Registry and Population Information System. Statistical analysis employed T-test, Chi-square test, and logistic regression analysis. Odds ratios with 95% Confidence Intervals (CI) were adjusted for sociodemographic and health-related background variables.

Results

Migrant parturients had a higher probability for delayed enter in prenatal care compared with Finnish-born parturients (adjusted odds ratio aOR = 3.46; 95% Confidence Interval CI 3.06, 3.91). Recommended minimum number of check-ups was participated by 95.3% of the migrant, and 96.4% of the Finnish-born group (P <0.000). Migrants’ probability for more than ten visits prior to term birth was significantly lower (aOR = 0.58; 95% CI 0.51, 0.66). No significant differences in prepartum hospitalization yielded between the groups.

Conclusions

Migrant parturients had significantly smaller number of check-ups and later entry in care compared with the country-born parturients. These findings add to earlier reported challenges in the organizing of conflict-affected country born migrants’ prenatal care in a high-income setting, in which the proportion of conflict-area born migrants has risen rapidly and unexpectedly.

Exploring ethnic minority women's experiences of maternity care during the SARS-CoV-2 pandemic: a qualitative study

OBJECTIVE

To explore the experiences of pregnancy, childbirth, antenatal and postnatal care in women belonging to ethnic minorities and to identify any specific challenges that these women faced during the SARS-CoV-2 pandemic.

DESIGN

This was a qualitative study using semistructured interviews of pregnant women or those who were 6 weeks postnatal from Black, Asian and minority ethnic backgrounds. The study included 16 women in a predominantly urban Scottish health board area.

RESULTS

The finding are presented in four themes: 'communication', 'interactions with healthcare professionals', 'racism' and 'the pandemic effect'. Each theme had relevant subthemes. 'Communication' encompassed respect, accent bias, language barrier and cultural dissonance; 'interactions with healthcare professionals': continuity of care, empathy, informed decision making and dissonance with other healthcare systems; 'racism' was deemed to be institutional, interpersonal or internalised; and 'the pandemic effect' consisted of isolation, psychological impact and barriers to access of care.

CONCLUSIONS

This study provides insight into the specific challenges faced by ethnic minority women in pregnancy, which intersect with the unique problems posed by the ongoing SARS-CoV-2 pandemic to potentially widen existing ethnic disparities in maternal outcomes and experiences of maternity care.

Cesarean Deliveries Among Immigrant and Canadian-Born Women in a Representative Community Population in Canada: A Retrospective Cohort Study

OBJECTIVE

To examine differences in the rate of cesarean delivery between Canadian-born women and immigrants to Canada and by duration of time in Canada and rate of cesarean delivery in their country-of-origin.

METHODS

We used linked data from hospitalization records and the Canadian Community Health Survey for all deliveries after 20 weeks gestation between 2002 and 2017 in Canada (excluding Québec). Odds of cesarean delivery in recent immigrants (<5 y in Canada) and non-recent immigrants (≥5 y in Canada) were compared with those of Canadian-born women using multivariable logistic regression. Immigrants were further categorized using the cesarean delivery rate in their country-of-origin as low (<10%), medium (≥10 to <35%), or high (≥35%).

RESULTS

Of the 53 505 women included, 89% were Canadian-born, 4% were recent immigrants and 7% were non-recent immigrants. Overall, 28.6% of women had a cesarean delivery. After adjusting for medical and socio-economic factors, the odds of cesarean delivery among recent immigrants (OR 1.12; 95% CI 0.95-1.34) and non-recent immigrants (OR 1.11; 95% CI 0.98-1.25) did not differ statistically from those of Canadian-born women. Recent immigrants from countries with lower caesarean delivery rates had higher odds of cesarean delivery (OR 1.34; 95% CI 1.05-1.70), whereas the odds of caesarean for recent immigrants from medium- and high-rate countries did not differ from those of Canadian-born women.

CONCLUSION

After accounting for demographic and medical factors, few differences remained in cesarean delivery rates between immigrants and Canadian-born women. Country-of-origin practices are unlikely to reflect preferences for cesarean delivery in immigrant women in Canada.

Long-distance travel for birthing among Indigenous and non-Indigenous pregnant people in Canada

BACKGROUND:

For Indigenous Peoples in Canada, birthing on or near traditional territories in the presence of family and community is of foundational cultural and social importance. We aimed to evaluate the association between Indigenous identity and distance travelled for birth in Canada.

METHODS:

We obtained data from the Maternity Experiences Survey, a national population-based sample of new Canadian people aged 15 years or older who gave birth (defined as mothers) and were interviewed in 2006–2007. We compared Indigenous with non-Indigenous Canadian-born mothers and adjusted for geographic and sociodemographic factors and medical complications of pregnancy using multivariable logistic regression. We categorized the primary outcome, distance travelled for birth, as 0 to 49, 50 to 199 or 200 km or more.

RESULTS:

We included 3100 mothers living in rural or small urban areas, weighted to represent 31 100 (1800 Indigenous and 29 300 non-Indigenous Canadian-born mothers). We found that travelling 200 km or more for birth was more common among Indigenous compared with non-Indigenous mothers (9.8% v. 2.0%, odds ratio [OR] 5.45, 95% confidence interval [CI] 3.52–8.48). In adjusted analyses, the association between Indigenous identity and travelling more than 200 km for birth was even stronger (adjusted OR 16.44, 95% CI 8.07–33.50) in rural regions; however, this was not observed in small urban regions (adjusted OR 1.04, 95% CI 0.37–2.91).

INTERPRETATION:

Indigenous people in Canada experience striking inequities in access to birth close to home compared with non-Indigenous people, primarily in rural areas and independently of medical complications of pregnancy. This suggests inequities are rooted in the geographic distribution of and proximal access to birthing facilities and providers for Indigenous people.

Variations in Relationships Between Perceived Stress and Birth Outcomes by Immigration Status

INTRODUCTION

Past research shows that stress during pregnancy predicts adverse birth outcomes. These patterns might differ based on immigration status. Our objective was to analyze differences in relationships between perceived stress during pregnancy and birth outcomes by immigration status.

METHODS

We recruited 81 pregnant women in Canada for a prospective longitudinal study of stress during pregnancy and infant development. Participants completed the Perceived Stress Questionnaire at 16-18, 24-26 and 32-34 weeks of pregnancy. Birth records were available for 73 women, including 24 non-immigrants, 18 long-term immigrants (≥ 5 years), and 31 recent immigrants (< 5 years). We used General Linear Models to test relationships between perceived stress and birthweight, birthweight for gestational age Z-scores, and gestational age, and differences based on immigration status.

RESULTS

Controlling for sociodemographic covariates, we observed interactive relationships between immigration status and perceived stress with birthweight at 16-18 (p = 0.032, partial η² = 0.11) and 24-26 weeks pregnancy (p = 0.012, partial η² = 0.15). Results were similar for birthweight for gestational age Z-scores at 16-18 weeks (p = 0.016, partial η² = 0.13) and 24-26 weeks pregnancy (p = 0.013, partial η² = 0.14). Perceived stress predicted smaller birthweight measurements among long-term immigrants. No relation was found between perceived stress, immigration status and gestational age.

DISCUSSION

Risk of adverse health outcomes, including birth outcomes, tends to increase with duration of residence among immigrants. Stress during pregnancy might represent one risk factor for adverse birth outcomes among long-term immigrant women. Promoting psychosocial health screening and care among immigrant women, and assuring continued care with acculturation, might improve both maternal and infant health outcomes.

[Motherhood in a recent immigration to Quebec context]

OBJECTIVE

Present the results of a study of the experience of maternity in the context of a recent immigration to Quebec.

METHOD

Semi-structured interviews were carried out amongst mothers from different countries, having immigrated within the last five years. L'Écuyer's (1990) developmental analysis of the content was used to analyze the results.

RESULTS

The data collected from 15 participants demonstrates that they perceive their motherly role as a great responsibility. During the postnatal phase, these women develop autonomy as mothers, but they also suffer from isolation and often only have their spouse to rely on. They experience a vast range of emotions such as happiness, anxiety, and sadness. Their level of distress depends on their representation of their maternity and immigration. To ensure their wellbeing, they keep in touch with their origins and use the professional services available.

CONCLUSION

The transition into motherhood leads to a great disruption of these women's lives. Due to social isolation, their responsibilities as mothers seem even more intense. The partner, considered an ally, thus plays an important role by their side. They struggle with trusting Quebecers, however, some services are greatly appreciated: the in-home visit of nurses, the guide From Tiny Tot to Toddler and the Info-Santé telephone service. It would be relevant to conduct more studies on the reality of immigrant fathers and to consider increasing the number of in-home nurse or midwife visits for mothers who are less socially integrated and who perceive their immigration negatively.

Trajectories of Depressive Symptoms and Perceived Stress From Pregnancy to the Postnatal Period Among Canadian Women: Impact of Employment and Immigration

Objectives. To identify trajectory patterns of maternal depressive symptoms and perceived stress from midpregnancy to 2 years postpartum and determine relationships with selected sociodemographic factors including income, education, immigration, and postpartum employment. Methods. Pregnant women (n = 3307) recruited from the general population in 4 regions in Canada provided 6 waves of data from pregnancy to 2 years postpartum. The study was conducted from 2009 to 2015. Results. We determined 5 trajectory groups distinguished by time and magnitude for both depressive symptoms and perceived stress. Immigrants living in Canada for more than 5 up to 10 years, but not more recent arrivals, were at higher risk for persistent stress and depression independent of income status. Being employed at 1 year postpartum was associated with a lower likelihood of postpartum depression and perceived stress, while mothers reporting work exhaustion were substantially more likely to experience persistent depression and stress. Conclusions. The study highlighted the heterogeneous nature of depressive symptoms and perceived stress. Targeting interventions toward women 5 to 10 years after immigration and those experiencing exhaustion from postpartum work may be particularly beneficial.

Trajectories of social support in pregnancy and early postpartum: findings from the All Our Families cohort

PURPOSE

Low social support during the perinatal period can increase the risk of postpartum depression and anxiety after giving birth but little is known about women's trajectories of social support during this time. This study will identify trajectories of social support among women from second trimester to 4-month postpartum, and the characteristics associated with different trajectories.

METHODS

Data from the All Our Families longitudinal birth cohort was used to assess women's perceived social support during their second trimester, third trimester, and at 4-month postpartum (n = 3387). Group-based trajectory modeling was used to determine the number of groups, shape of trajectories, and proportion of women with differing trajectories. Multinomial regression was used to compare probability of group membership.

RESULTS

Six distinct trajectory groups were identified, with the majority of participants belonging to groups with stable, high social support (60.6%). Only 2.7% of women had consistently low levels of social support, and 2.3% had rising levels. Membership in groups with lower levels of social support was associated with lower incomes and minority ethnicity. Women whose support improved over time may be more likely to be employed in pregnancy than those whose support remained low.

CONCLUSION

Trajectories of social support are relatively stable in pregnancy and early postpartum. Socio-demographic indicators of vulnerability predict initial levels of support, and participating in the workforce may help improve perception of support over time.

Exploring barriers to seeking health care among Kenyan Somali women with female genital mutilation: a qualitative study

Background

Female genital mutilation/cutting (FGM/C) is a cultural practice associated with health consequences, women rights and deprivation of dignity. Despite FGM/C-related health consequences, circumcised women may encounter additional challenges while seeking interventions for reproductive health problems. Experiences of women/girls while accessing health services for reproductive health problems including FGM/C-related complications in poor, remote and hard to reach areas is poorly understood. We sought to explore barriers to care seeking among Somali women with complications related to FGM/C in public health facilities in Kenya.

Methods

We drew on qualitative data collected from purposively selected women aged 15–49 years living with FGM/C, their partners, community leaders, and health providers in Nairobi and Garissa Counties. Data were collected using in-depth interviews (n = 10), key informant interviews (n = 23) and 20 focus group discussions. Data were transcribed and analyzed thematically using NVivo version 12.

Results

Barriers were grouped into four thematic categories. Structural barriers to care-seeking, notably high cost of care, distance from health facilities, and lack of a referral system. Concerns regarding perceived quality of care also presented a barrier. Women questioned health professionals’ and health facilities’ capacity to offer culturally-sensitive FGM/C-specific care, plus ensuring confidentiality and privacy. Women faced socio-cultural barriers while seeking care particularly cultural taboos against discussing matters related to sexual health with male clinicians. Additionally, fear of legal sanctions given the anti-FGM/C law deterred women with FGM/C-related complications from seeking healthcare.

Conclusion

Structural, socio-cultural, quality of service, and legal factors limit health seeking for reproductive health problems including FGM/C-related complications. Strengthening health system should consider integration of FGM/C-related interventions with existing maternal child health services for cost effectiveness, efficiency and quality care. The interventions should address health-related financial, physical and communication barriers, while ensuring culturally-sensitive and confidential care.

Gender of Provider-Barrier to Immigrant Women's Obstetrical Care: A Narrative Review

OBJECTIVE

To explore the preference for female obstetrician/gynaecologists among immigrant women, and providers' understandings of these preferences, to identify challenges and potential solutions.

METHODS

Five databases (Medline, Embase, CINAHL, Global Health, and Scopus) were searched using combinations of search terms related to immigrant, refugee, or Muslim women and obstetrics or gynaecological provider gender preference.

STUDY SELECTION

Peer reviewed, English-language articles were included if they discussed either patient or provider perspectives of women's preference for female obstetrics or gynaecological care provider among immigrant women in Western and non-western settings. After screening, 54 met inclusion criteria and were reviewed.

DATA EXTRACTION

Studies were divided first into those specifically focusing on gender of provider, and those in which it was one variable addressed. Each category was then divided into those describing immigrant women, and those conducted in a non-Western settings. The research question, study population, methods, results, and reasons given for preferences in each article were then examined and recorded.

CONCLUSION

Preference for female obstetricians/gynaecologists was demonstrated. Although many will accept a male provider, psychological stress, delays, or avoidance in seeking care may result. Providers' views were captured in only eight articles, with conflicting perspectives on responding to preferences and the health system impact.

Voices of Postpartum Women: Exploring Canadian Women's Experiences of Inpatient Postpartum Care

OBJECTIVE

To explore and understand postpartum inpatient experiences in a Canadian context.

METHODS

Inpatients at BC Women's Hospital & Health Centre were invited to complete a questionnaire during their postpartum stay. Completed responses were obtained from 178 women, representing 44% of all postpartum inpatients during the survey period.

RESULTS

Overall, women had positive experiences during their postpartum stay: 93% rated their experience as "excellent" or "very good"; 78% felt that nurses never seemed rushed or too busy to care for them; and 85% of women found the nurses to be very helpful with breastfeeding. Two-thirds of the women had concerns about going home that were related to infant feeding, feeling overwhelmed, and not knowing how to settle their baby. Other areas of improvement pertained to the hospital environment being less restful than desired. Certain groups needed additional support, such as primiparous women, women who had Caesarean deliveries, and women from certain ethnic groups.

CONCLUSION

This exploration of women's inpatient postpartum experiences in a Canadian hospital provides valuable information for improving service delivery, including assessing hospital routines, providing information/education, and improving discharge planning. Given that postpartum experiences are not uniform across demographic groups, an alternative or augmented approach to postpartum care may be warranted for some women.

Recency of migration, region of origin and women's experience of maternity care in England: Evidence from a large cross-sectional survey

Background

In the UK, changes to legislation in 2003 regarding the free movement of people in the European Union resulted in an increase in immigration from countries that joined the EU since 2004, the Accession countries.

Objective

To describe and compare the maternity experiences of recent migrant mothers to those who had been resident in the UK for longer, and to UK-born women, while taking into account their region of origin.

Design

Cross-sectional national survey.

Setting

England, 2009.

Participants

Random sample of postpartum women.

Measurements

Questionnaires asked about demographic characteristics, care during pregnancy, labour, birth and postnatally, about country of origin and, if not born in the UK, when they came to the UK. Country of origin was grouped into UK, Accession countries, and rest of the world. Recency of migration was grouped into recent arrivals (0–3 years), and earlier arrivals (4 or more years since arrival). Descriptive statistics and binary logistic regression were used to explore women's experiences of care. Stratified analyses were used to account for the strong correlation between recency of migration and region of origin.

Findings

Overall, 5332 women responded to the survey (a usable response rate of 54%). Seventy-nine percent of women were UK-born. Of the 21% born outside the UK, a third were born in Accession countries. All migrants reported a poorer experience of care than UK-born women. In particular, recent migrants from the Accession countries were significantly less likely to feel that they were spoken to so they could understand and treated with kindness and respect.

Conclusions

Given the rising population of non-UK-born women of childbearing age resident in the UK and the relatively high proportion from Accession countries, it is important that staff are able to communicate effectively, through interpreters if necessary.

Implications for practice

The differences in clinical practice between women's home countries and the UK should be discussed so that women's expectations of care are informed about the options available to them.

Midwifery and obstetrics: Factors influencing mothers' satisfaction with the birth experience

BACKGROUND

Satisfaction is a key component of the care experience and part of the health system "triple aim," along with improving population health and reducing per capita health care costs, the other two parts of the "triple aim." The objectives of the study were to examine birth-experience satisfaction among women in Ontario, Canada, who received care from midwives, family physicians, and obstetricians.

METHODS

We used Statistics Canada's 2006 national Maternity Experiences Survey. The sample includes 1900 Ontario women and is, with appropriate weighting, representative of an estimated population of 29 700 women who gave birth in Ontario to a singleton baby during the study period. Information was collected on respondents' satisfaction with their health care providers, demographic characteristics, and a range of pregnancy, labor, birth, and postpartum experiences. We used logistic regression analysis to assess differences in patient/client satisfaction by type of health care provider.

RESULTS

Women cared for by midwives were three times more likely to be satisfied with their care (OR 3.32 [95% CI 2.26-4.86]) when compared with obstetrician-led care. Depression symptoms, having to travel outside the respondents' community to give birth, and being born in an East Asian country were associated with lower levels of satisfaction.

CONCLUSION

Given recent health system reforms emphasizing the importance of shifting from expensive acute hospital-based care to community-based care, our findings support empirically the importance of supporting women's access to midwifery services within their communities. Findings of ethnocultural differences in satisfaction with care can inform policy makers as health systems move to provide culturally appropriate care to increasingly diverse populations.

Experiences of Chinese immigrant women following "Zuo Yue Zi" in British Columbia

AIMS AND OBJECTIVES

To describe Chinese women's experiences with "zuo yue zi" in British Columbia, Canada.

BACKGROUND

Women born in China and Taiwan are increasingly immigrating to westernised countries. Many women choose to follow traditional Chinese postpartum practices, also called "zuo yue zi." Few studies have examined women's use of traditional practices in western countries.

DESIGN

The study used a qualitative descriptive design.

METHODS

We recruited 13 mothers who were: aged 19 or older, immigrants from mainland China, Hong Kong or Taiwan in the last 5 years, and caring for infants born in the previous 6 weeks. Semistructured interviews were conducted in Mandarin, translated into English, transcribed and analysed using inductive content analysis.

RESULTS

The core theme was Chinese women's novel encounters with "zuo yue zi." The women's expectations of "zuo yue zi" were acquired through birth experiences or interactions with family and friends. The participants struggled with implementing traditional practices because social support and formal institutional structures were lacking. They modified their expectations about "zuo yue zi." Factors affecting their practices were catalysts and deterrents. Catalysts included help from Chinese family members, friends and informed healthcare providers. Deterrents included unregulated paid helpers, uninformed care providers, financial constraints and structural limitations in their new environments.

CONCLUSIONS

Chinese immigrant women struggled to modify and implement traditional practices in their adopted country when they encountered financial constraints, unregulated paid helpers and varying support from health care providers.

RELEVANCE TO CLINICAL PRACTICE

Some postpartum women following "zuo yue zi" believed that the practice would prevent chronic illness and strengthen their intrafamily relationships. Immigrant mothers require nursing support to follow traditional postpartum practices. Nurses can advocate on patients' behalf to increase care providers' knowledge about "zuo yue zi" and public awareness for necessary regulated institutional structures.

Prevalence, Incidence, and Persistence of Postpartum Depression, Anxiety, and Comorbidity among Chinese Immigrant and Nonimmigrant Women: A Longitudinal Cohort Study

OBJECTIVE

Our objectives were to examine the prevalence and incidence of postpartum depressive, anxiety, and comorbid symptoms over the first postpartum year; the persistence of these symptoms; and the prevalence stratified by immigration status.

METHOD

We conducted a longitudinal cohort study in Ontario, Canada. Participants were 571 Chinese recent immigrant, nonrecent immigrant, and Canadian-born women with live births in 2011 to 2014. Participants were assessed at 4, 12, and 52 weeks postpartum for the presence of possible and high depressive symptomatology (Edinburgh Postnatal Depression Scale [EPDS] >9 and >12, respectively), anxiety symptomatology (State-Trait Anxiety Inventory [STAI] >40), and comorbid symptomatology (EPDS >9 and STAI >40). Prevalence and incidence with 95% confidence intervals were calculated.

RESULTS

Prevalence rates were highest at 4 weeks and decreased across time, with possible depressive symptomatology most prevalent at most time points. Incidence rates at 12 and 52 weeks were generally similar. Of those with possible symptomatology at 4 weeks, 42.0% or less continued to have symptomatology at 12 weeks and 17.4% or less at 52 weeks. There were no differences in prevalence of any type of symptomatology between immigrant and Canadian-born Chinese women at 4 weeks, but at 12 and 52 weeks, most types of symptomatology were more common among recent and nonrecent immigrants.

CONCLUSION

Our findings suggest that Chinese immigrant women are a high-risk group for postpartum depressive and anxiety symptomatology. Future research should identify cultural and psychosocial factors associated with immigration that could be addressed in the system of care for postpartum immigrant women.

Mental health of South Asian youth in Peel Region, Toronto, Canada: a qualitative study of determinants, coping strategies and service access

OBJECTIVES

This qualitative study set out to understand the mental health challenges and service access barriers experienced by South Asian youth populations in the Peel Region of Toronto, Canada.

SETTING

In-depth semistructured interviews were carried out with South Asian youth living in Peel Region (Mississauga, Brampton and Caledon), a suburb of Toronto, Canada, home to over 50% of Ontario's South Asian population.

PARTICIPANTS

South Asian youth (n=10) engaged in thoughtful, candid dialogue about their mental health and service access barriers.

PRIMARY AND SECONDARY OUTCOME MEASURES

Qualitative interview themes related to mental health stressors and mental health service access barriers experienced by youth living in Peel Region were assessed using thematic analysis.

RESULTS

South Asian youth face many mental health stressors, from intergenerational and cultural conflict, academic pressure, relationship stress, financial stress and family difficulties. These stressors can contribute to mental health challenges, such as depression and anxiety and drug use, with marijuana, alcohol and cigarettes cited as the most popular substances. South Asian youth were only able to identify about a third (36%) of the mental health resources presented to them and did not feel well informed about mental health resources available in their neighbourhood.

CONCLUSIONS

They offered recommendations for improved youth support directed at parents, education system, South Asian community and mental health system. Institutions and bodies at all levels of the society have a role to play in ensuring the mental health of South Asian youth.

Systematic Review of Immigrant Women's Experiences With Perinatal Care in North America

OBJECTIVE

To understand the perinatal care experiences of pregnant immigrant women in North America.

DATA SOURCES

We searched five electronic databases: MEDLINE, PsycINFO, SocINDEX, CINAHL, and Social Work Abstracts. Two categories of search terms, pregnancy and immigrant, were used to conduct a title/abstract and subject heading search. We manually searched the reference lists of all relevant articles to identify additional articles.

STUDY SELECTION

Inclusion criteria were qualitative or mixed methods study design, focus on immigrant women's experiences of accessing perinatal care, and data collection in North America. Two reviewers were involved in a three-stage selection process: title/abstract screen, full text review, and data extraction and quality appraisal.

DATA EXTRACTION

Data on authors, date, location, methodology, sample characteristics, data collection, and themes or topics were extracted from 19 articles.

DATA SYNTHESIS

We followed the Thomas and Harden (2008) thematic synthesis methodology, which involved a three-stage data analysis approach: free line-by-line coding, organization of free codes into descriptive themes, and construction of analytical themes. We developed three meta-themes from the 19 articles included in our review: Expectations of Pregnancy as Derived From Home, Reality of Pregnancy in the Host Health Care System, and Support.

CONCLUSION

Immigration is a relevant issue in North America, and pregnancy can be an entry point into the health care system for immigrant women. We provide relevant information for health care providers, policy makers, program planners, and researchers about opportunities to explain models of health care delivery, improve communication, and facilitate social support to improve the experiences of immigrant women who interact with the health care system during pregnancy.

Early onset of type 2 diabetes among visible minority and immigrant populations in Canada

OBJECTIVES

Type 2 diabetes is a chronic condition that affects nearly over three million Canadians, including immigrants. The timing of the first onset of diabetes has been linked to several other severe diseases. Yet, there is a dearth of empirical studies that examine the timing of the first onset of diabetes among Canadians, in general, and among immigrants and ethnic minority populations within Canada, in particular.

DESIGN

Applying event history techniques to the 2013 Canadian Community and Health Survey, we address this research void by examining factors that contribute to the first onset of diabetes among immigrant and visible minority populations in Canada (N = 8905). Given the gendered patterns in the epidemiology of diseases and the differences in risk factors for men and women, gender-specific models were estimated.

RESULTS

Results showed that South Asian, Black and Filipino women developed diabetes earlier, compared to women from the UK. Similarly, South Asian, Chinese, Filipino, Black, South East Asian and Arab men developed diabetes earlier than men from the UK. A significant and important finding of this analysis was that the risks of developing diabetes vanished completely for Black and Filipino women, after accounting for lifestyle factors. For South Asian women, however, there was significant attenuation in their risks after accounting for lifestyle factors. The findings were strikingly different for immigrant men. Specifically, their risks of developing diabetes increased after accounting for lifestyle factors.

CONCLUSIONS

These results suggest the development of gender-specific and lifestyle interventions, targeted at specific immigrant groups with increased risks of developing diabetes earlier in the life course.

Postpartum depression risk factors among recent refugee, asylum-seeking, non-refugee immigrant, and Canadian-born women: results from a prospective cohort study

PURPOSE

The objective was to examine and compare risk factors for postpartum depression among: (1) recent (≤5 years) migrant and Canadian-born women, and (2) refugee, asylum-seeking, and non-refugee immigrant women.

METHODS

A sample of 1536 women (1024 migrant and 512 Canadian-born) were recruited from 12 hospitals. Women completed questionnaires at 1-2 and 16 weeks postpartum including questions on socio-demographics, biomedical history, health services, and migration and resettlement factors. Bivariate analyses and multivariate logistic regression were performed to examine and compare risk factors for postpartum depressive symptoms at 16 weeks postpartum.

RESULTS

Recent migrant women had significantly higher rates (6%) of depressive symptoms at 16 weeks postpartum than Canadian-born women (2.9%). Asylum-seekers had the highest rate (14.3%), followed by refugee (11.5%) and non-refugee immigrant women (5.1%). Migrant women at greatest risk to develop depressive symptoms were those who experienced abuse, had pain post-birth, worried about family members left behind, had food insecurity, and had reduced access to healthcare (limited insurance and/or no regular care-provider). Conversely, those with higher levels of social support and who felt they belonged to a community had a lower risk of developing depressive symptoms.

CONCLUSION

All childbearing recent migrant women should be considered at risk for postpartum depression. To prevent and support migrant women suffering postpartum depressive symptoms, barriers to healthcare need to be addressed and interventions should include assessments and support/programmes for abuse/violence, lack of social support, food insecurity, and stress/poor mental health. Treatment of pain during the postpartum period is also critical.

Scoping Review on Maternal Health among Immigrant and Refugee Women in Canada: Prenatal, Intrapartum, and Postnatal Care

The last fifteen years have seen a dramatic increase in both the childbearing age and diversity of women migrating to Canada. The resulting health impact underscores the need to explore access to health services and the related maternal health outcome. This article reports on the results of a scoping review focused on migrant maternal health within the context of accessible and effective health services during pregnancy and following delivery. One hundred and twenty-six articles published between 2000 and 2016 that met our inclusion criteria and related to this group of migrant women, with pregnancy/motherhood status, who were living in Canada, were identified. This review points at complex health outcomes among immigrant and refugee women that occur within the compelling gaps in our knowledge of maternal health during all phases of maternity. Throughout the prenatal, intrapartum, and postnatal periods of maternity, barriers to accessing healthcare services were found to disadvantage immigrant and refugee women putting them at risk for challenging maternal health outcomes. Interactions between the uptake of health information and factors related to the process of immigrant settlement were identified as major barriers. Availability of appropriate services in a country that provides universal healthcare is discussed.

A Population-Based Study of Postpartum Mental Health Service Use by Immigrant Women in Ontario, Canada

OBJECTIVE

Postpartum mental disorders are twice as common among immigrant women compared to nonimmigrant women in developed countries. Immigrant women may experience barriers to access and use of postpartum mental health services, but little is known about their service use on a population level. We described postpartum mental health service use of immigrant mothers living in Ontario, Canada, comparing to a referent group of mothers who were either born in Canada or had lived in Ontario or another Canadian province since 1985.

METHOD

Among all women in Ontario, Canada, delivering a live infant from 2008 to 2012 (n = 450,622), we described mental health service use within 1 year postpartum, including mental health physician visits, psychiatric emergency department visits, and psychiatric hospitalization. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) comparing immigrant women to the referent group were adjusted for maternal age, parity, income, rurality, mental health services in prior 2 years, and maternal and newborn health.

RESULTS

Immigrant women (n = 123,231; 27%) were less likely to use mental health services than women in the referent group (14.1% vs. 21.4%; aOR, 0.59; 95% CI, 0.58 to 0.61), including for physician-based (13.9% vs. 21.1%; aOR, 0.59; 95% CI, 0.58 to 0.61) and emergency department (0.6% vs. 1.3%; aOR, 0.63; 95% CI, 0.57 to 0.68) services. Hospitalization risk was lower among immigrants (0.20% vs. 0.33%) but became similar after covariate adjustment (aOR, 0.92; 95% CI, 0.79 to 1.06).

CONCLUSIONS

Underuse of postpartum mental health services may be contributing to the high burden of postpartum mental disorders among immigrant women.

Expectations and satisfaction with antenatal care among pregnant women with a focus on vulnerable groups: a descriptive study in Ghent

Background

Previous studies demonstrate that people’s satisfaction with healthcare influences their further use of that healthcare system. Satisfied patients are more likely to take part in the decision making process and to complete treatment. One of the important determinants of satisfaction is the fulfillment of expectations. This study aims to analyse both expectations and satisfaction with antenatal care among pregnant women, with a particular focus on vulnerable groups.

Methods

A quantitative descriptive study was conducted in 155 women seeking antenatal care at the University Hospital of Ghent (Belgium), of whom 139 completed the questionnaire. The statistical program SPSS-21 was used for data analysis.

Results

Women had high expectations relating to continuity of care and women-centered care, while expectations regarding availability of other services and complete care were low. We observed significantly lower expectations among women without higher education, with low income, younger than 26 years and women who reported intimate partner violence. General satisfaction with antenatal care was high. Women were satisfied with their relationship with the healthcare worker, however ; they evaluated the information received during the consultation and the organizational aspects of antenatal care as less satisfactory.

Conclusions

In order to improve satisfaction with antenatal care, organizational aspects of antenatal care (e.g. reducing waiting times and increasing accessibility) need to be improved. In addition, women would appreciate a better provision of information during consultation. More research is needed for an in-depth understanding of the determinants of satisfaction and the relationship with low socio economic status (SES).

Electronic supplementary material

The online version of this article (doi:10.1186/s12905-015-0266-2) contains supplementary material, which is available to authorized users.

Prevalence of postpartum depression among immigrant women: A systematic review and meta-analysis

The aims of this systematic review and meta-analysis were threefold: to estimate the prevalence of postpartum depressive symptoms in immigrant women, compare this prevalence to non-immigrant women, and determine risk factors for postpartum depressive symptoms in immigrant women. Literature searches were conducted in PubMed, Embase, PsycINFO, Web of Science, Scopus, ResearchGate and Google Scholar databases from 1950 until October 2014. Twenty-four studies met the inclusion criteria of which 22 (12 cross-sectional and 10 prospective cohort) contributed data for meta-analyses. Heterogeneity and publication bias were assessed. The prevalence of postpartum depressive symptoms in immigrant women was 20% (95% confidence interval [CI] 17-23%, 18 studies, N = 13,749 women). Immigrant women were twice more likely to experience depressive symptoms in the postpartum period than non-immigrant women (pooled unadjusted odds ratio [OR] = 2.10 [95% CI 1.62-2.73, 15 studies, N = 50,519 women] and adjusted OR = 2.18 [95% CI 1.60-2.96, 7 studies, N = 35,557 women]). There was, however, evidence of publication bias with the pooled adjusted OR reduced to 1.63 (95% CI 1.22-2.17) after adjustment for bias. Risk factors associated with postpartum depressive symptoms among immigrant women included shorter length of residence in the destination country, lower levels of social support, poorer marital adjustment, and perceived insufficient household income. This study suggests that postpartum depression is a common condition among immigrant women. Moreover, immigrant women are at higher risk of postpartum depression than non-immigrant women. Further prospective studies on the risk factors of postpartum depression among immigrant women verified by a clinical diagnosis are needed.

Caesarean births among migrant women in high-income countries

High caesarean birth rates among migrant women living in high-income countries are of concern. Women from sub-Saharan Africa and South Asia consistently show overall higher rates compared with non-migrant women, whereas women from Latin America and North Africa/Middle East consistently show higher rates of emergency caesarean. Higher rates are more common with emergency caesareans than with planned caesareans. Evidence regarding risk factors among migrant women for undergoing a caesarean birth is lacking. Research suggests that pathways leading to caesarean births in migrants are complex, and they are likely to involve a combination of factors related to migrant women's physical and psychological health, their social and cultural context and the quality of their maternity care. Migration factors, including length of time in receiving country and migration classification, have an influence on delivery outcome; however, their effects appear to differ by women's country/region of origin.

Body image in adolescent pregnancy

STUDY OBJECTIVES

To review the existing literature on body image in adolescent pregnancy and explore concepts about the relationship between the two.

DESIGN

A systematic review.

SETTING

Peer-reviewed articles were identified through MEDLINE (1946-present) and PsycINFO (1806-November 2013), conducted in any setting.

PARTICIPANTS

Pregnant and postpartum adolescents ages 13-19 y.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

The outcome measures used in the studies reviewed varied: themes from focus groups, diary entry analysis, Pregnancy and weight gain attitude scale, Edinburgh postnatal depression scale, Parenting stress index, Eating disorder inventory, Tennessee self concept scale.

RESULTS

The search yielded a total of 149 studies, of which 6 were relevant to the specific topic and age group. The very limited research shows a dichotomy in body image perception during pregnancy in adolescence; some studies show an increase in body image disturbance and dissatisfaction during pregnancy in adolescents, and other studies reviewed found that the majority of pregnant adolescents had positive body image and positive attitudes towards weight gain. A bidirectional link between depression and negative body image in adolescent pregnancy is suggested.

CONCLUSIONS

The current research exploring the relationshp between body image and pregnancy in adolescence is limited, both in quality and quantity. Future research is needed to evaluate longitudinal models that will better inform about potential risk factors for body dissatisfaction during pregnancy in adolescence, including the possible role of depression.

Immigrant women's experiences of maternity-care services in Canada: a systematic review using a narrative synthesis

BACKGROUND

Canada's diverse society and its statutory commitment to multiculturalism means that a synthesis of knowledge related to the healthcare experiences of immigrants is essential to realise the health potential for future Canadians. Although concerns about the maternity experiences of immigrants in Canada are relatively new, recent national guidelines explicitly call for the tailoring of services to user needs. We therefore assessed the experiences of immigrant women accessing maternity-care services in Canada. In particular, we investigated the experiences of immigrant women in Canada in accessing and navigating maternity and related healthcare services from conception to 6 months postpartum in Canada. Our focus was on (a) the accessibility and acceptability of maternity-care services for immigrant women and (b) the effects of the perceptions and experiences of these women on their birth and postnatal outcomes.

METHODS

We conducted a systematic review using a systematic search and narrative synthesis of peer-reviewed and non-peer-reviewed reports of empirical research, with the aim of providing stakeholders with perspectives on maternity-care services as experienced by immigrant women. We partnered with key stakeholders ('integrated knowledge users') to ensure the relevancy of topics and to tailor recommendations for effective translation into future policy, practice and programming. Two search phases and a three-stage selection process for published and grey literature were conducted prior to appraisal of literature quality and narrative synthesis of the findings.

RESULTS

Our knowledge synthesis of maternity care among immigrants to Canada provided a coherent evidence base for (a) eliciting a better understanding of the factors that generate disparities in accessibility, acceptability and outcomes during maternity care; and (b) improving culturally based competency in maternity care. Our synthesis also identified pertinent issues in multiple sectors that should be addressed to configure maternity services and programs appropriately.

CONCLUSIONS

Although immigrant women in Canada are generally given the opportunity to obtain necessary services, they face many barriers in accessing and utilising these services. These barriers include lack of information about or awareness of the services, insufficient supports to access these services and discordant expectations between the women and their service providers.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42012002185 .

Survey of women's experiences of care in a new freestanding midwifery unit in an inner city area of London, England. 1: Methods and women's overall ratings of care

OBJECTIVE

to describe and compare women's choices and experiences of maternity care before and after the opening of the Barkantine Birth Centre, a new freestanding midwifery unit in an inner city area.

DESIGN

telephone surveys undertaken in late pregnancy and about six weeks after birth in two separate time periods, Phase 1 before the birth centre opened and Phase 2 after it had opened.

SETTING

Tower Hamlets, a deprived inner city borough in east London, England, 2007-2010.

PARTICIPANTS

620 women who were resident in Tower Hamlets and who satisfied the Barts and the London NHS Trust's eligibility criteria for using the birth centre. Of these, 259 women were recruited to Phase 1 and 361 to Phase 2.

MEASUREMENTS AND FINDINGS

women who satisfied the criteria for birth centre care and who booked antenatally for care at the birth centre were significantly more likely to rate their care as good or very good overall than corresponding women who also satisfied these criteria but booked initially at the hospital. Women who started labour care in spontaneous labour at the birth centre were significantly more likely to be cared for by a midwife they had already met, have one to one care in labour and have the same midwife with them throughout their labour. They were also significantly more likely to report that the staff were kind and understanding, that they were treated with respect and dignity and that their privacy was respected.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

this survey in an inner city area showed that women who chose the freestanding midwifery unit care had positive experiences to report. Taken together with the findings of the Birthplace Programme, it adds further weight to the evidence in support of freestanding midwifery unit care for women without obstetric complications.

A collaborative outreach clinic for pregnant youth and adolescent mothers: Description of a pilot clinic and its patients

OBJECTIVE

To describe the pregnant youth and adolescent parents seen at an adolescent health outreach clinic in an urban community setting during a two-year pilot project.

METHODS

A retrospective chart review of all adolescents who presented at the monthly half-day clinics from January 2008 through January 2010 (n=36) was performed. Measures extracted from charts included demographic information, reason for referral, social history, mental health history and outcome of assessment.

RESULTS

All participants were female (mean age 17 years). Forty-two percent were pregnant at initial assessment, while the remainder had one or two children, or a recent pregnancy loss. Sixty-one percent had no primary care physician. The primary reason for referral was mental health concerns, most commonly depression. Almost one-half of patients relied on social assistance and almost one-third were living in shelters. At the time of first visit, 42% of patients were not attending school; the highest level of school completed for most patients was grade 8. The majority had a history of mental health issues and previous drug and/or alcohol use.

CONCLUSIONS

Adolescents presenting to the clinic had a history of disadvantage in terms of income, educational attainment, living arrangements and mental health background, and are in need of various health services including primary care practitioners. These findings will help to inform future program development for these vulnerable youth, and have implications for practitioners caring for this population.

Immigrant and non-immigrant women's experiences of maternity care: a systematic and comparative review of studies in five countries

BACKGROUND

Understanding immigrant women's experiences of maternity care is critical if receiving country care systems are to respond appropriately to increasing global migration. This systematic review aimed to compare what we know about immigrant and non-immigrant women's experiences of maternity care.

METHODS

Medline, CINAHL, Health Star, Embase and PsychInfo were searched for the period 1989-2012. First, we retrieved population-based studies of women's experiences of maternity care (n = 12). For countries with identified population studies, studies focused specifically on immigrant women's experiences of care were also retrieved (n = 22). For all included studies, we extracted available data on experiences of care and undertook a descriptive comparison.

RESULTS

What immigrant and non-immigrant women want from maternity care proved similar: safe, high quality, attentive and individualised care, with adequate information and support. Immigrant women were less positive about their care than non-immigrant women. Communication problems and lack of familiarity with care systems impacted negatively on immigrant women's experiences, as did perceptions of discrimination and care which was not kind or respectful.

CONCLUSION

Few differences were found in what immigrant and non-immigrant women want from maternity care. The challenge for health systems is to address the barriers immigrant women face by improving communication, increasing women's understanding of care provision and reducing discrimination.

Korean immigrant women's lived experience of childbirth in the United States

OBJECTIVE

To understand Korean immigrant women's common experiences and practices of utilizing health care services in the United States during childbirth.

DESIGN

A qualitative interpretive phenomenological research design.

SETTING

Recruitment was conducted through advertisement on the MissyUSA.com website, which is the largest online community for married Korean women who live in North America.

PARTICIPANTS

A purposive sample of 15 Korean immigrant women who experienced childbirth in the United States within the past 5 years was recruited.

METHODS

Data were collected using semistructured telephone interviews and were analyzed using the Heideggerian hermeneutical methodology.

RESULTS

During childbirth in the United States, participants faced multifaceted barriers in unfamiliar sociocultural contexts yet maintained their own cultural heritages. They navigated the unfamiliar health care system and developed their own strategies to overcome barriers to health care access. Korean immigrant women actively sought health information on the Internet and through social networking during childbirth.

CONCLUSIONS

Korean immigrant women selectively accepted new cultural beliefs with some modifications from their own cultural contexts and developed their own distinct birth cultures. Understanding a particular culture and respecting women's traditions, beliefs, and practices about their childbirth could help nurses to provide culturally sensitive care.

Navigating maternity health care: a survey of the Canadian prairie newcomer experience

Background

Immigration to Canada has significantly increased in recent years, particularly in the Prairie Provinces. There is evidence that pregnant newcomer women often encounter challenges when attempting to navigate the health system. Our aim was to explore newcomer women’s experiences in Canada regarding pregnancy, delivery and postpartum care and to assess the degree to which Canada provides equitable access to pregnancy and delivery services.

Methods

Data were obtained from the Canadian Maternity Experiences Survey. Women (N = 6,241) participated in structured computer-assisted telephone interviews. Women from Alberta, Saskatchewan and Manitoba were included in this analysis. A total of 140 newcomers (arriving in Canada after 1996) and 1137 Canadian-born women met inclusion criteria.

Results

Newcomers were more likely to be university graduates, but had lower incomes than Canadian-born women. No differences were found in newcomer ability to access acceptable prenatal care, although fewer received information regarding emotional and physical changes during pregnancy. Rates of C-sections were higher for newcomers than Canadian-born women (36.1% vs. 24.7%, p = 0.02). Newcomers were also more likely to be placed in stirrups for birth and have an assisted birth.

Conclusion

Although newcomers residing in Prairie Provinces receive adequate maternity care, improvements are needed with respect to provision of information related to postpartum depression and informed choice around the need for C-sections.

"I have to do what I believe": Sudanese women's beliefs and resistance to hegemonic practices at home and during experiences of maternity care in Canada

Background

Evidence suggests that immigrant women having different ethnocultural backgrounds than those dominant in the host country have difficulty during their access to and reception of maternity care services, but little knowledge exists on how factors such as ethnic group and cultural beliefs intersect and influence health care access and outcomes. Amongst immigrant populations in Canada, refugee women are one of the most vulnerable groups and pregnant women with immediate needs for health care services may be at higher risk of health problems. This paper describes findings from the qualitative dimension of a mixed-methodological study.

Methods

A focused ethnographic approach was conducted in 2010 with Sudanese women living in an urban Canadian city. Focus group interviews were conducted to map out the experiences of these women in maternity care, particularly with respect to the challenges faced when attempting to use health care services.

Results

Twelve women (mean age 36.6 yrs) having experience using maternity services in Canada within the past two years participated. The findings revealed that there are many beliefs that impact upon behaviours and perceptions during the perinatal period. Traditionally, the women mostly avoid anything that they believe could harm themselves or their babies. Pregnancy and delivery were strongly believed to be natural events without need for special attention or intervention. Furthermore, the sub-Saharan culture supports the dominance of the family by males and the ideology of patriarchy. Pregnancy and birth are events reflecting a certain empowerment for women, and the women tend to exert control in ways that may or may not be respected by their husbands. Individual choices are often made to foster self and outward-perceptions of managing one’s affairs with strength.

Conclusion

In today’s multicultural society there is a strong need to avert misunderstandings, and perhaps harm, through facilitating cultural awareness and competency of care rather than misinterpretations of resistance to care.

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

Background

Perinatal health disparities including disparities in caesarean births have been observed between migrant and non-migrant women and some literature suggests that non-medical factors may be implicated. A systematic review was conducted to determine if migrants in Western industrialized countries consistently have different rates of caesarean than receiving-country-born women and to identify the reasons that explain these differences.

Methods

Reports were identified by searching 12 literature databases (from inception to January 2012; no language limits) and the web, by bibliographic citation hand-searches and through key informants. Studies that compared caesarean rates between international migrants and non-migrants living in industrialized countries and that did not have a ‘fatal flaw’ according to the US Preventative Services Task Force criteria were included. Studies were summarized, analyzed descriptively and where possible, meta-analyzed.

Results

Seventy-six studies met inclusion criteria. Caesarean rates between migrants and non-migrants differed in 69% of studies. Meta-analyses revealed consistently higher overall caesarean rates for Sub-Saharan African, Somali and South Asian women; higher emergency rates for North African/West Asian and Latin American women; and lower overall rates for Eastern European and Vietnamese women. Evidence to explain the consistently different rates was limited. Frequently postulated risk factors for caesarean included: language/communication barriers, low SES, poor maternal health, GDM/high BMI, feto-pelvic disproportion, and inadequate prenatal care. Suggested protective factors included: a healthy immigrant effect, preference for a vaginal birth, a healthier lifestyle, younger mothers and the use of fewer interventions during childbirth.

Conclusion

Certain groups of international migrants consistently have different caesarean rates than receiving-country-born women. There is insufficient evidence to explain the observed differences.

Risk factors and health profiles of recent migrant women who experienced violence associated with pregnancy

BACKGROUND

Violence associated with pregnancy is a major public health concern, but little is known about it in recent migrant women. This study looked at (1) risk factors for violence associated with pregnancy among newly arrived migrant women in Canada and (2) if those who experienced violence associated with pregnancy had a different health profile or use of healthcare services for themselves or their infants during pregnancy and up to 4 months postpartum compared to other childbearing migrant women.

METHODS

Pregnant migrant women in Canada <5 years were recruited in 12 hospitals in 3 large cities between 2006 and 2009 and followed to 4 months postpartum. Data were collected on maternal background, migration history, violence associated with pregnancy, maternal and infant physical and mental health, and services used.

RESULTS

Of a total of 774 pregnant migrant women, 59 (7.6%) women reported violence associated with pregnancy. Migrant women who experienced violence, compared to those who did not, were at increased risk of violence if they lived without a partner, were asylum seekers, migrated <2 years ago, or had less than high school education. Women who reported violence were less likely to have up-to-date vaccinations, take folic acid before pregnancy, more likely to commence prenatal care after 3 months gestation and to not use contraceptives after birth. They were also more likely to have a history of miscarriage and report more postpartum pain and increased bleeding. They were also more likely to have inadequate social support and report more depression, anxiety, somatization, and posttraumatic stress disorder (PTSD) on standardized tests. No differences were found in the health status of the infants of women who experienced violence compared to those who did not.

CONCLUSIONS

Clinicians should sensitively ask recent migrant women (asylum seekers, refugees, and nonrefugee immigrants) about violence associated with pregnancy and appropriately assess, treat, and refer them.

Immigrant women's experiences of maternity-care services in Canada: a protocol for systematic review using a narrative synthesis

BACKGROUND

Canada's diverse society and statutory commitment to multiculturalism means that the synthesis of knowledge related to the health care experiences of immigrants is essential to realize the health potential for future Canadians. Although concerns about the maternity experiences of immigrants in Canada are relatively new, recent national guidelines explicitly call for tailoring of services to user needs. We are therefore assessing the experiences of immigrant women in Canada accessing maternity-care services. We are focusing on: 1) accessibility and acceptability (as an important dimension of access) to maternity-care services as perceived and experienced by immigrant women, and 2) the birth and postnatal outcomes of these women.

METHODS

The aim of this study is to use a narrative synthesis, incorporating both a systematic review using narrative synthesis of reports of empirical research (qualitative, quantitative, and mixed-method designs), and a literature review of non-empirically based reports, both of which include 'grey' literature. The study aims to provide stakeholders with perspectives on maternity-care services as experienced by immigrant women. To achieve this, we are using integrated knowledge translation, partnering with key stakeholders to ensure topic relevancy and to tailor recommendations for effective translation into future policy and practice/programming. Two search phases and a three-stage selection process are being conducted (database search retrieved 1487 hits excluding duplicates) to provide evidence to contribute jointly to both the narrative synthesis and the non-empirical literature review. The narrative synthesis will be informed by the previous framework published in 2006 by Popay et al., using identified tools for each of its four elements. The non-empirical literature review will build upon the narrative-synthesis findings and/or identify omissions or gaps in the empirical research literature. The integrated knowledge translation plan will ensure that key messages are delivered in an audience-specific manner to optimize their effect on policy and practice change throughout the health service, and the public health, immigration and community sectors.

DISCUSSION

Narrative-synthesis methods of systematic review facilitate understanding and acknowledgement of the broader influences of theoretical and contextual variables, such as race, gender, socioeconomic status, and geographical location. They also enable understanding of the shaping of differences between reported outcomes and study designs related to childbearing populations, and the development and implementation of maternity services and health interventions across diverse settings.

PROSPERO REGISTRATION

Number 2185.