Comparison of Perinatal Data of Immigrant Women of Turkish Origin and German Women - Results of a Prospective Study in Berlin

'German Health Update Fokus (GEDA Fokus)': Study Protocol of a Multilingual Mixed-mode Interview Survey among Residents with Croatian, Italian, Polish, Syrian or Turkish Citizenship in Germany

BACKGROUND

Germany has a long history of migration. In 2020, more than every fourth person had a statistically defined, so-called 'migration background' in Germany, meaning that the person or at least one of their parents was born with a citizenship other than German. People with a history of migration are not represented proportionately to the population within public health monitoring at the Robert Koch Institute (RKI), thus impeding differentiated analyses on migration and health. In order to develop strategies to improve the inclusion of people with a history of migration in health surveys, we conducted a feasibility study in 2018. Lessons learned were implemented in the health interview survey GEDA Fokus which was conducted among people with selected citizenships representing the major migrant groups in Germany.

OBJECTIVE

The main objective of GEDA Fokus was to collect comprehensive data on the health status and social, migration-related, and structural factors among people with selected citizenships in order to enable differentiated explanations on the associations between migration-related aspects and their impact on migrant health.

METHODS

GEDA Fokus was an interview survey among people with Croatian, Italian, Polish, Syrian, or Turkish citizenship living in Germany aged 18 - 79 years, with a targeted sample size of 1,200 participants per group. The gross sample of 33,436 people was drawn out of the residents' registration offices of 99 German municipalities based on citizenship. Sequentially, multiple modes of administration were offered. The questionnaire was available for self-administration (online and paper-based); in bigger municipalities, personal or phone interviews were possible later on. Study documents and the questionnaire were bilingual, in German and the respective translation language depending on the citizenship. Data collection took place from November 2021 until May 2022.

RESULTS

Overall, 6,038 respondents participated in the survey, 49.4% were female. The median age was 39 years, and the median duration of residence in Germany was 10 years, with 19.7% of the sample being born in Germany. The overall response rate was 18.4% (AAPOR response rate 1) and was 6.8% higher in the municipalities where personal interviews were offered (19.3% vs. 12.5%). Overall, 78.2% administered the questionnaire on their own, while 21.9% took part in a personal interview. A total of 41.9% answered the questionnaire in German language only, 16.7% exclusively used the translation, and 41.4% used both languages in the bilingual version of the questionnaire.

CONCLUSIONS

Offering different modes of administration, as well as multiple study languages, enabled us to recruit a heterogeneous sample of people with a history of migration. The data collected will allow differentiated analyses of the role and interplay of migration-related and social determinants of health and their impact on the health status of people with selected citizenships.

CLINICALTRIAL

Utilisation of supplementary prenatal screening and diagnostics in Germany: cross-sectional study using data from the KUNO Kids Health Study

BACKGROUND

Appropriate health system utilisation during pregnancy is fundamental for maintaining maternal and child's health. To study the use and determinants of supplementary prenatal screening and diagnostics in Germany this study provides comprehensive data.

METHODS

We obtained data from a recently established prospective German birth cohort study, the KUNO Kids Health Study. Analyses are based on Andersen's Behavioural Model of health system use, which distinguishes between predisposing (e.g. country of birth), enabling (e.g. health insurance) and need factors (e.g. at-risk pregnancy). We examined bi- and multivariate association with the use of supplementary prenatal screening and diagnostics using logistic regression.

RESULTS

The study has a sample size of 1886 participating mothers. One fifth of the mothers investigated did not use any supplementary prenatal screening or diagnostics. Notably, the chance of using supplementary prenatal screening and diagnostics more than doubled if the pregnant woman had a private health insurance (OR 2.336; 95% CI 1.527-3.573). Higher maternal age (OR 1.038; 95% CI 1.006-1.071) and environmental tobacco smoke exposure (OR 1.465 95% CI 1.071-2.004) increased the use of supplementary prenatal screening and diagnostics. However, regarding need factors only having an at-risk-pregnancy (OR 1.688; 95% CI 1.271-2.241) showed an independent association.

CONCLUSION

The important role of the type of health insurance and the relatively small influence of need factors was surprising. Especially with respect to equity in accessing health care, this needs further attention.

Perinatal Data of Refugee Women from the Gynaecology Department of Charité University Hospital Berlin Compared with German Federal Analysis

Introduction The aim of this study was to record the perinatal data of refugee women at Charité Hospital, Berlin, and to evaluate possible differences in pre-, peri- and postnatal outcomes compared with indigenous women.

Material and Methods All pregnant women who gave birth in the period from 1 January 2014 to 30 September 2017 and were registered at least once in the hospital as “refugee” were included in the analysis. The data recorded from the refugee women were compared with the perinatal data of the German Federal obstetric analysis for the year 2016, which was published by the IQTIG (Institut für Qualitätssicherung und Transparenz im Gesundheitswesen [Institute for Quality Assurance and Transparency in Healthcare]).

Results The analysis comprised 907 refugee women and 928 infants (21 twin pregnancies). Pregnant refugee women were significantly younger than the pregnant women from the Federal analysis (birth before the age of 30: 66 vs. 41%, p < 0.001, RR: 1.6, 95% CI: 62.9 – 69.2). They had a history both of more pregnancies (≥ 3 pregnancies: 29.4 vs. 13.4%, p < 0.001, RR: 2.2, 95% CI: 26.4 – 32.5) and of more miscarriages (> 2 miscarriages: 9.7 vs. 5.9%, p < 0.001, RR: 1.6, 95% CI: 7.9 – 11.8) and more often had a history of suffering from psychological stress (11.1 vs. 4.1%, p < 0.001, RR: 2.70, 95% CI: 9.2 – 13.4). There were more premature births (10.3 vs. 3.0%, p < 0.001, RR: 3.36, 95% CI: 8.4 – 12.4), post-term pregnancies (8.5 vs. 0.5%, p < 0.001, RR: 15.4, 95% CI: 6.7 – 10.5), and cases of postpartum anaemia (28.7 vs. 22.0%, p < 0.001, RR: 1.30, 95% CI: 25.7 – 31.7) and puerperal endometritis (1 vs. 0.2%, p = 0.006, RR: 4.3, 95% CI: 0.5 – 1.9) compared with the Federal analysis. The neonatal outcome showed an increased rate of hypotrophy (11 vs. 7%, p < 0.001, RR: 1.6, 95% CI: 9.1 – 13.2), more stillbirths (0.7 vs. 0.2%, p = 0.006, RR: 3, 95% CI: 0.2 – 1.4) and increased congenital malformations (2.8 vs. 0.4%, p < 0.001, RR: 3, 95% CI: 0.2 – 1.4).

Conclusion Both refugee women and their infants showed significant differences. Despite the average younger age of the pregnant refugee women, the rates of premature birth and stillbirth and congenital malformations were significantly more frequent. More intensive antenatal screening with differentiated foetal organ diagnostics including psychosomatic care could contribute to early identification and prompt diagnosis. As regards the postpartum anaemia and puerperal endometritis, which occur more often in refugee women, midwife engagement and an improvement in the living situation in homes and accommodation facilities could be of great importance.

Health Care Services Utilization of Persons with Direct, Indirect and without Migration Background in Germany: A Longitudinal Study Based on the German Socio-Economic Panel (SOEP)

There is ambiguous evidence with regard to the inequalities in health care services utilization (HCSU) among migrants and non-migrants in Germany. The aim of this study was to analyze the utilization of doctors and hospitalization of persons with direct and indirect migration background as well as those without in Germany. This study was based on data of the German Socio-Economic Panel using the adult sample of the years 2013 to 2019. HCSU was measured by self-reported utilization of doctors and hospitalization. Associations between HCSU and migration background were examined using multilevel mixed-effects logistic regression and zero-truncated multilevel mixed-effects generalized linear models. The odds ratios of utilization of doctors and hospitalization for persons with direct migration background compared with persons without migration background were 0.73 (p < 0.001) and 0.79 (p = 0.002), respectively. A direct migration background was associated with a 6% lower number of doctoral visits within three months compared with no migration background (p = 0.023). Persons with direct migration background still have a lower HCSU than persons without migration background in Germany. Access to health care needs to be ensured and health policy-makers are called upon to keep focus on the issue of inequalities in HCSU between migrants and non-migrants in Germany.

[Persons with migration background in the German National Cohort (NAKO)-sociodemographic characteristics and comparisons with the German autochthonous population]

BACKGROUND

Persons with a migration background (PmM) as a population group usually differ from the autochthonous population in terms of morbidity, mortality, and use of the health care system, but they participate less frequently in health studies. The PmM group is very heterogeneous, which has hardly been taken into account in studies so far.

OBJECTIVES

Sociodemographic characteristics of PmM in the NAKO health study (age, sex, time since migration, education) are presented. In addition, it is examined through an example whether migration background is related to the use of cancer screening for colorectal cancer (hemoccult test).

METHODS

Data of the first 101,816 persons of the NAKO were analyzed descriptively and cartographically. The migration background was assigned on the basis of the definition of the Federal Statistical Office, based on nationality, country of birth, year of entry, and country of birth of the parents.

RESULTS

Overall, the PmM proportion is 16.0%. The distribution across the 18 study centers varies considerably between 6% (Neubrandenburg) and 33% (Düsseldorf). With 153 countries of origin, most countries are represented in the NAKO. All variables show clear differences between the different regions of origin. In the hemoccult test, persons of Turkish origin (OR = 0.67) and resettlers (OR = 0.60) have a lower participation rate. PmM born in Germany do not differ in this respect from the autochthonous population (OR = 0.99).

CONCLUSION

PmM in the NAKO are a very heterogeneous group. However, due to the sample size, individual subgroups of migrants can be studied separately with respect to region of origin.

Perceived discrimination and risk of preterm birth among Turkish immigrant women in Germany

BACKGROUND

Health disparities, including adverse birth outcomes, exist between Turkish immigrants and the autochthonous population in Germany. The state of research on the risk of preterm birth (PTB, defined as <37 weeks of gestation), the leading cause of infant mortality and morbidity, among Turkish immigrant women is mixed. Perceived discrimination is discussed in the context of health disparities related to migration. We examined whether PTB risk is also increased in Turkish immigrant women in Germany and whether perceived discrimination due to origin contributes to this risk.

METHODS

We selected a sample from the German Socio-Economic Panel (SOEP) study of German autochthonous and Turkish immigrant women who recently gave birth (between 2002 and 2016) (N = 2,525, incl. n = 217 Turkish immigrant women of which n = 111 completed an item on perceived discrimination). The included variables of central interest were immigrant status, perceived discrimination, gestational age, and socioeconomic situation.

RESULTS

Logistic regression models indicated that PTB risk was significantly higher for Turkish immigrant women than autochthonous women (OR: 2.75, 95% CI [1.79-4.16]), even when adjusting for socioeconomic status. Within the subsample of Turkish immigrant women, perceived discrimination was related to a significantly higher PTB risk (OR: 4.91, 95% CI [1.76-15.06]).

CONCLUSIONS

Our study provides evidence for a higher PTB risk in Turkish immigrant women compared to autochthonous women in Germany. Perceived discrimination may contribute to this higher risk. The findings represent an important first step towards developing targeted interventions to improve pregnancy and birth outcomes in minority groups.

The influence of migration on women's satisfaction during pregnancy and birth: results of a comparative prospective study with the Migrant Friendly Maternity Care Questionnaire (MFMCQ)

INTRODUCTION

Approximately 21% of Germany's inhabitants have been born abroad or are of direct descent of immigrants. A positive birth experience has an effect on a woman's mental health and her future family planning choices. While international studies showed that immigrant women are less satisfied with their birth experience, no such study has been conducted in Germany until now.

METHODS

At our center of tertiary care in Berlin, with approximately 50% immigrants among patients, pregnant women of at least 18 years of age were offered participation in this study. A modified version of the Migrant Friendly Maternity Care Questionnaire (MFMCQ) designed by Gagnon et al. in German, English, French, Spanish, Arabic and Turkish was used. We compared non-immigrant women to immigrant women and women with direct descent of immigrants. For certain analysis, the latter two groups were included together under the category "migration background".

RESULTS

During the study period, 184 non-immigrant, 214 immigrant women and 62 direct descendants of immigrants were included. The most frequent countries of origin were Syria (19%), Turkey (17%), and Lebanon (9%). We found a slight difference between groups regarding age (non-immigrants: mean 33 years versus women with any migration background: mean 31) as well as parity with more non-immigrants delivering their first child. No difference in the satisfaction with care was observed between immigrant and any migration background groups (p ≥ 0.093 in the two-sided Fisher's exact test). At least 75.8% of all participating women reported complete satisfaction with care during labor, birth and after birth. Interestingly, the level of German language proficiency did not influence the immigrant patient's satisfaction with care.

CONCLUSION

The study results show no difference regarding overall satisfaction with care during labor and birth despite a relevant language barrier. We are for the first time providing the MFMCQ in German and Turkish. Further future analyses on the impact of patient expectations on satisfaction with care will be conducted.

Do social factors and country of origin contribute towards explaining a "Latina paradox" among immigrant women giving birth in Germany?

Background

The “Latina paradox” describes the unexpected association between immigrant status, which is often correlated to low socioeconomic status, and low prevalence of unfavourable birth outcomes. Social (e.g. culture, religion) and/or non-social factors related to country of origin are potentially responsible for this paradox.

Methods

Questionnaire survey of 6413 women delivering in three large obstetric hospitals in Berlin (Germany) covering socioeconomic and migration status, country of origin (Turkey, Lebanon), and acculturation. Data was linked with routine obstetric data. Logistic regressions were performed to assess the effect of acculturation, affinity to religion and country of origin on preterm birth and small-for-gestational-age (SGA).

Results

Immigrant women with a low level of acculturation (reference) were less likely to have a preterm birth than those who were highly acculturated (aOR: 1.62, 95%CI: 1.01–2.59), as were women from Turkey compared to non-immigrants (aOR: 0.49, 95%CI: 0.33–0.73). For SGA, we found no epidemiologic paradox; conversely, women from Lebanon had a higher chance (aOR: 1.72, 95%CI: 1.27–2.34) of SGA. Affinity to religion had no influence on birth outcomes.

Conclusions

There is evidence that low acculturation (but not affinity to religion) contributes towards explaining the epidemiologic paradox with regard to preterm birth, emphasising the influence of socioeconomic characteristics on birth outcomes. The influence of Turkish origin on preterm birth and Lebanese origin on SGA suggests that non-social factors relating to the country of origin are also at play in explaining birth outcome differences, and that the direction of the effect varies depending on the country of origin and the outcome.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6523-9) contains supplementary material, which is available to authorized users.

Inequalities in health care utilization among migrants and non-migrants in Germany: a systematic review

BACKGROUND

Despite the growing number of people with migrant background in Germany, a systematic review about their utilization of health care and differences to the non-migrant population is lacking. By covering various sectors of health care and migrant populations, the review aimed at giving a general overview and identifying special areas of potential intervention.

METHODS

A systematic review was conducted in PubMed database including records that were published until 1st of June 2017. Further criteria for eligibility were a publication in a peer-reviewed journal written in English or German language. The studies have to report quantitative and original data of a population residing in Germany. The appropriateness of the studies was judged by both authors. Studies were excluded if native controls were not originated from the same sample. Moreover, indicators of health care utilization have to assess individual behaviour like consultation or participation rates. 63 studies met the inclusion criteria for a qualitative synthesis of the findings.

RESULTS

The overall findings indicate a lower utilization among migrants, although the results vary in terms of health care sector, indicator of health care utilization and migrant population. For specialist care, medication use, therapist consultations and counselling, rehabilitation as well as disease prevention (early cancer detection, prevention programs for children and oral health check-ups) a lower utilization among people with migrant background was found. The lower usage was particularly shown for migrants of the 1st generation, people with two-sided migrant background, children/adolescents and women. Due to the methodological heterogeneity a meta-analysis was not feasible. As most of the studies were cross-sectional, no causal interpretations could be drawn.

CONCLUSIONS

The inequalities in utilization could not substantially be explained by differences in the socioeconomic status. Other reasons of lower utilization could be due to differences in need, preferences, information, language and formal access barriers (e.g. charges, waiting times, travel distances or lost wages). Different migrant-specific and migrant-sensitive strategies are relevant to address the problem for certain health care sectors and migrant populations.

TRIAL REGISTRATION

The review protocol was registered on PROSPERO ( CRD42014015162 ).

Comparing provision and appropriateness of health care between immigrants and non-immigrants in Germany using the example of neuraxial anaesthesia during labour: cross-sectional study

OBJECTIVE

Research on health services for immigrants has mostly been concerned with access barriers but rarely with appropriateness and responsiveness of care. We assessed whether appropriateness and responsiveness of care depend on migration status, using provision of neuraxial anaesthesia (NA) during labour as indicator. In relation to their migration status, we analysed whether (1) women undergoing elective or secondary/urgent secondary caesarean sections (ESCS) appropriately receive NA (instead of general anaesthesia), (2) women delivering vaginally appropriately receive NA and (3) women objecting to NA, for example, for religious reasons, may deliver vaginally without receiving NA (provider responsiveness).

DESIGN

Cross-sectional study.

SETTING

Three obstetric hospitals in Berlin, Germany.

METHODS

Questionnaire survey covering 6391 women with migration history (first and second generations) and non-immigrant women giving birth; data linkage with routine obstetric data. We assessed the effects of migrant status, German language proficiency, religion and education on the provision of NA (primary outcome) after adjusting for other maternal and obstetric parameters.

RESULTS

The chance of receiving NA for elective/ESCS was independent of migrant status after controlling for confounding variables (adjusted OR (aOR) 0.93, 95% CI 0.65 to 1.33). In vaginal deliveries, first (but not second) generation women (aOR 0.79, 95% CI 0.65 to 0.95), women with low German language skills (aOR 0.77, 95% CI 0.58 to 0.99) and women with low educational attainment (aOR 0.62, 95% CI 0.47 to 0.82) had lower chances of receiving NA; there was no evidence of overprovision among women with strong affinity to Islam (aOR 0.77, 95% CI 0.63 to 0.94).

CONCLUSIONS

We found evidence for underprovision of care among first-generation immigrants, among women with low German language proficiency and particularly among all women with low educational attainment, irrespective of migration status. There was no evidence for overprovision of care to immigrant women, either inappropriately (general anaesthesia for ESCS) or because of low provider responsiveness (no opt-out for NA in vaginal delivery).

[Migration: A neglected dimension of inequalities in health?]

Over the past 70 years, several million people have immigrated into Germany-from different countries of origin and for different reasons. The categories used by society to label immigrants ("guest workers", "persons with a migration background") have changed over time. This change has occurred in parallel with changes in the societal attitude towards immigrants and in their legal position. There is unequivocal evidence that the forms that migration takes, in addition to the societal responses towards immigrants, have an effect on their health. The spectrum of migration to Germany is likely to remain fluent because of the continuing process of globalization; also, societal responses to migration will change over time. Thus, migration will continue to pose challenges to society and to health. Only through continuous attentiveness will it be possible to identify, and then avoid or reduce, health disadvantages faced by persons with a migration background.

A Retrospective Perinatal Data Analysis of Immigrant and German Women from Representative Birth Cohorts at the Virchow Hospital, Berlin

Introduction: The aim of this study was to define and characterise differences in the level of obstetric care provided to immigrant and German women. Materials and Methods: An analysis of the Virchow Hospital's birth registers was conducted for the years 1974, 1984 and 1994. The study population of 5445 patients was grouped according to ancestry/family origin on the basis of a name analysis, and subsequently also according to parity (primiparous or multiparous). On name analysis 2741 women were defined as German, 1598 were grouped as women of Turkish origin and 810 as immigrants of other origin. χ² tests and Fisher's exact test were used for significance testing (significance level p < 0.05), and a logistic regression analysis was performed. Results: Rates of caesarean section, episiotomy, higher grade perineal tears and severe postpartum haemorrhage did not differ between the groups. There were however significant differences in the use of uterine stimulants, analgesics in labour and both local and regional anaesthesia, with women of Turkish origin and other immigrants receiving anaesthesia less, but oxytocin more often. Rooming-in was more common among German primipara and multipara from 1984 onwards. Discussion: This retrospective analysis of three historical birth cohorts showed significant differences in perinatal care between German and immigrant women, presumably reflecting deficits in care. It seems remarkable that this trend has not changed over a time span of three decades despite a continuous increase in immigration and acculturation. A "research paradox", however, remains: Despite these increasing rates, there are no current or older, prospective or systematic studies of obstetric care in immigrants.

Differences in the Frequency of Use of Epidural Analgesia between Immigrant Women of Turkish Origin and Non-Immigrant Women in Germany - Explanatory Approaches and Conclusions of a Qualitative Study

Introduction: The starting point of this study was the considerably lower rate of epidural analgesia use among women of Turkish origin in Germany compared to non-immigrant women in the German Research Foundation (DFG)-funded study entitled "Perinatal Health and Migration Berlin". The study aimed to identify possible differences in the women's attitudes towards epidural analgesia. Methods: Exploratory study with semi-structured interviews, interviews lasting 17 minutes on average were conducted with 19 women of Turkish origin and 11 non-immigrant women at a Berlin hospital. The interviews were subjected to a qualitative content analysis. Results: Immigrant women of Turkish origin in Germany more frequently ascribe meaning to the pain associated with vaginal delivery. They more frequently categorically reject the use of epidural analgesia, 1) for fear of long-term complications such as paralysis and back pain and 2) based on the view that vaginal delivery with epidural analgesia is not natural. Information on epidural analgesia is frequently obtained from a variety of sources from their social setting, in particular, by word of mouth. The women in both groups stated that they would take the decision to use epidural analgesia independent of their partner's opinion. Discussion: The differences in epidural analgesia use rates observed correspond to the women's attitudes. For the immigrant women of Turkish origin in Germany, the attitude towards using epidural analgesia is based in part on misinformation. In order to enable the women to make an informed decision, epidural analgesia could receive a stronger focus during childbirth courses.

Social and health epidemiology of immigrants in Germany: past, present and future

Germany has experienced different forms of immigration for many decades. At the end of and after the Second World War, refugees, displaced persons and German resettlers constituted the largest immigrant group. In the 1950s, labor migration started, followed by family reunification. There has been a constant migration of refugees and asylum seekers reaching peaks in the early 1990s as well as today. Epidemiological research has increasingly considered the health, and the access to health care, of immigrants and people with migration background. In this narrative review we discuss the current knowledge on health of immigrants in Germany. The paper is based on a selective literature research with a focus on studies using representative data from the health reporting system.

Our review shows that immigrants in Germany do not suffer from different diseases than non-immigrants, but they differ in their risk for certain diseases, in the resources to cope with theses risk and regarding access to treatment. We also identified the need for differentiation within the immigrant population, considering among others social and legal status, country of origin and duration of stay. Though most of the studies acknowledge the need for differentiation, the lack of data currently rules out analyses accounting for the existing diversity and thus a full understanding of health inequalities related to migration to Germany.

A distributional approach to obtain adjusted comparisons of proportions of a population at risk

BACKGROUND

Dichotomisation of continuous data has statistical drawbacks such as loss of power but may be useful in epidemiological research to define high risk individuals.

METHODS

We extend a methodology for the presentation of comparison of proportions derived from a comparison of means for a continuous outcome to reflect the relationship between a continuous outcome and covariates in a linear (mixed) model without losing statistical power. The so called "distributional method" is described and using perinatal data for illustration, results from the distributional method are compared to those of logistic regression and to quantile regression for three different outcomes.

RESULTS

Estimates obtained using the distributional method for the comparison of proportions are consistently more precise than those obtained using logistic regression. For one of the three outcomes the estimates obtained from the distributional method and from logistic regression disagreed highlighting that the relationships between outcome and covariate differ conceptually between the two models.

CONCLUSION

When an outcome follows the required condition of distribution shift between exposure groups, the results of a linear regression model can be followed by the corresponding comparison of proportions at risk. This dual approach provides more precise estimates than logistic regression thus avoiding the drawback of the usual dichotomisation of continuous outcomes.

Postpartum Contraception: a Comparative Study of Berlin Women with and without Immigration Background

Research Questions: Are there differences in postpartum contraceptive use between women with and without immigration background? Do women more commonly use contraception following a high-risk pregnancy or caesarean section? What role does current breastfeeding play and, amongst immigrants, what is the effect of acculturation level on the frequency of contraceptive use? Study Population and Methods: Data collection was carried out as part of a larger study in three Berlin delivery units using standardised interviews (questionnaires covering e.g. sociodemographics, immigration history/acculturation and use of antenatal care); telephone interviews comprising 6 questions on postpartum contraception, breastfeeding and postpartum complications were conducted on a sample of the study population six months after delivery. Results: 247 women with, and 358 women without a background of immigration were included in the study (total study population n = 605, response rate 81.1 %). 68 % of 1st generation immigrants, 87 % of 2nd/3rd generation women and 73 % of women without immigration background (non-immigrants) used contraception. In the logistical regression analysis 1st generation immigrants were less likely than non-immigrants to be using contraception six months postpartum, and 1st generation immigrants with low acculturation level were significantly less likely to use contraception than 2nd/3rd generation women with low acculturation level. Conclusion: In the extended postpartum period there was no major difference in contraceptive use between immigrants in general and non-immigrants. It remains unclear whether the differing contraceptive behaviour of 1st generation immigrants is the result of less access to information, sociocultural factors or differing contraceptive requirements and further targeted, qualitative study is required.

Contribution of overweight and obesity to adverse pregnancy outcomes among immigrant and non-immigrant women in Berlin, Germany

BACKGROUND

Maternal excessive weight and smoking are associated with an increased risk of pregnancy complications and adverse pregnancy outcomes. In Germany, immigrant women have a higher prevalence of pre-pregnancy overweight/obesity compared with autochthonous women. We compared the contribution of pre-pregnancy overweight/obesity to adverse pregnancy outcomes among immigrant and autochthonous women in Berlin/Germany.

METHODS

Data from 2586 immigrant women (from Turkey, Lebanon, other countries of origin) and 2676 autochthonous women delivering in three maternity hospitals of Berlin within 12 months (2011/2012) was used. Cox regression models were applied to estimate the association between overweight/obesity and smoking with the outcomes large-for-gestational-age (LGA), small-for-gestational-age (SGA), preterm birth (PTB) and extreme preterm-birth (E-PTB). Population attributive fractions (PAF) were calculated to quantify the proportion of the outcomes attributable to overweight/obesity and smoking, respectively.

RESULTS

Prevalence of overweight and obesity was 33.4% among autochthonous and 53.6% among Turkish women. Prevalence risk ratios of excessive weight were highest for LGA infants among immigrant and autochthonous women. The PAFs were -11.8% (SGA), +16.3% (LGA), +3.6% (PTB) and +16.5% (E-PTB) for the total study population.

CONCLUSIONS

Overweight/obesity is strongly associated with an increased risk of delivering an LGA infant among both immigrant and autochthonous women. Compared with autochthonous women, the contribution of excessive weight to LGA is even higher among immigrant women, in whom PAFs of overweight/obesity even exceed those of smoking for some outcomes.

Smoking during pregnancy among Turkish immigrants in Germany-are there associations with acculturation?

INTRODUCTION

We analyzed the association between different acculturation measures and smoking among pregnant immigrant women from Turkey and compared smoking rates between Turkish and German women.

METHODS

Perinatal data from a project on the influence of migration and acculturation on pregnancy and birth in Berlin was analyzed. An acculturation index (FRAKK) and two proxy measures (German language proficiency, length of stay in Germany) were used. We performed logistic regression models and calculated age-standardized prevalence ratios (SPR).

RESULTS

Smoking prevalence was 19.8% among pregnant Turkish women (n = 702) and 17.8% among German women (n = 2,999). The chance of being a smoker was significantly higher among Turkish women with a length of stay of ≥20 years compared to 0-4 years (OR = 3.63, 95% CI = 1.64-8.05); with good/very good language skills compared to none/minor skills; with high levels of acculturation compared to low levels (the latter only among 18-29-year-old women). Compared to German women, Turkish women with a short length of stay, low acculturation scores and none/minor language skills had lower smoking rates. This finding inverts with long length of stay, high acculturation scores and good/very good language skills (≥20 years: SPR = 2.14, 95% CI = 1.56-2.94).

CONCLUSIONS

Smoking among pregnant Turkish women increases with increasing acculturation. Additionally, immigrant women with a low acculturation level are less often smokers and women with a high level are more often smokers than German women. Prevention measures have to prevent women with a low acculturation from starting to smoke and to induce those with a high acculturation to quit. As smoking and acculturation are group phenomena, it is necessary to involve immigrant communities.

Reviewing the topic of migration and health as a new national health target for Germany

OBJECTIVES

To review migration and health as a potential new national health target for Germany.

METHODS

The theme was evaluated along 13 standardized criteria preset by the Health Targets Network. For each of the criteria an expert opinion based on an extensive (but nonsystematic) review of literature is presented.

RESULTS

Migrants differ in many health-related aspects from the majority population in Germany. Despite having some health advantages, their health status, on average, is lower than that of non-migrants. They also experience barriers in health care and cannot participate in the society on equal terms with the majority population. Different measures to improve the health situation of migrants are available, but their current implementation in the health system is limited in several ways. Present data on the health of migrants is inadequate and limits migrant-sensitive health reporting.

CONCLUSION

The evaluation of potential health targets based on standardized criteria is a valuable tool for health policy formulation. The present documentation can assist other countries in evaluating migration and health as a national health target. It may also contribute to similar activities at the European level.