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

Equal Alternatives or Lower Standards for Immigrant Women-Analyzing Obstetric Care for Immigrant Women in Berlin Within the Framework of Cultural Health Capital

In obstetric clinics in Berlin, Germany, more than half of the women are immigrants. The main objective of the qualitative study was to explore the staff's experiences with obstetric care for immigrants and juxtapose it with the immigrants' comments on their birth experiences. We analyze potential differences along the framework of a cultural health capital (CHC). Between May and August 2017, semi-structured interviews were carried out with 17 obstetricians and 17 midwives at four obstetric clinics in Berlin. The verbally transcribed interview material was subjected to a qualitative content analysis according to Mayring. Furthermore, a secondary data from an interview study was analyzed in the purpose of providing some insight into the practitioner study participant perspective. Between January and May 2017, in the postpartum ward at the Berlin Charité Campus Virchow Clinic, an interview study guided by the migrant-friendly maternity care questionnaire was conducted among 410 migrant and non-migrant women. For this study, the free-text comments on the pregnancy care were analyzed. The staff interviewees identified language barrier and legal status as risk factors for the late onset of obstetric care. CHC functioning potentially as alternatives to the established health care structures were voiced. Strong family ties among immigrant families bear a high potential for support. Gratefulness was voiced by the staff and immigrant patients as a source of satisfaction with care. Our study shows that obstetric care for immigrant women remains a challenge. CHC of immigrant women might partially compensate for exclusion.

Cultural influence on the expression of labour-associated pain

Background

Every woman expresses pain differently during birth since it depends on a multitude of predictive factors. The medical care received, companionship during birth, cultural background and language barriers of the women in labour can influence on the expression of pain. This study aims to evaluate the expression of pain during birth and its associated factors in women treated in a Spanish border town.

Methods

The study included 246 women in labour. The expression of pain during labour was evaluated using the validated ESVADOPA scale. A descriptive analysis and association study were performed between cultural identity and dimensions of the scale. Multiple linear regression models were performed to assess the association between cultural identity, origin, language barrier, and companionship during labour.

Results

The women included in the study comprised 68.7% Berbers, 71.5% Muslims and 82.1% were accompanied during labour. An association between cultural identity and greater body expression of pain (p = 0.020; Cramer’s V = 0.163) in addition to its verbal expression was found during the latent phase of labour, (p = 0.028; Cramer’s V = 0.159). During the active phase of labour, cultural identity was associated with pain expression through greater body response, verbal expression, expression of the facial muscles, anxiety, inability to relax and vegetative symptoms. The different factors studied that had a predictive value were companionship (p = 0.027) during the latent phase of labour and Berber origin (p = 0.000), language barrier (p = 0.014) and companionship (p = 0.005) during the active phase of labour. The models designed predict pain expression in the latent phase by companionship and type of companionship (β = 1.483; 95%CI = 0.459–2.506, β = 0.238; 95%CI = 0.029–0. 448, respectively), and in the active phase by background, language barrier and companionship (β = 0.728; 95%CI = 0.258–1.198, β = 0.738; 95%CI = 0.150–1.326, β = 1.888; 95%CI = 0.984–2.791, respectively).

Conclusion

Culture, origin, language barrier and companionship during labour influences the manner in which women in labour express their pain. An understanding of this may help midwives correctly interpret the signs of pain expression and be able to offer the appropriate assistance depending on a woman's particular characteristics. There is a clear need for new models of maternity care that will take the cultural and language characteristics of women in labour into consideration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05173-1.

Reasons for a Lower Rate of Epidural Anesthesia During Birth for Immigrant Women in the Eyes of Medical Staff: A Mixed-Methods Analysis

Various studies have shown that immigrant women in comparison to non-immigrant women of the same parity have lower rates of epidural anesthesia (EDA). Data from two studies on immigrant obstetric care in Berlin, Germany were analyzed to answer the following question: What reasons do the medical staff see for the lower rate of EDA in immigrant women? Between May and August 2017, 34 interviews with obstetricians and midwives in four obstetric clinics in Berlin were conducted on the topic of obstetric care for immigrant women. After anonymizing the more than 20 h of interview material, transcripts were coded with MaxQDa and analyzed according to the qualitative content analysis.The quantitative data is from an online survey conducted between May and October 2017, in all but one obstetric clinic in Berlin with obstetricians and midwives. Regarding the research question, 121 questionnaires could be analyzed. In the online survey, (multiple answers were possible), the top reason for a lower rate of EDA given was mostly fear on the part of the immigrant women (64%). A language barrier, which results in logistic and time constrictions, is mentioned as the second most frequent reason (50%). The explorative analysis of the interviews shows that doctors and midwives regard cultural aspects such as different expectations on the birth experience as a reason for a lower EDA rate. Furthermore, within the medical staff the impression persists that in some cases the companion decides on the behalf of the patient about the application of an EDA, which from time to time is against the wish of the immigrant woman giving birth. In the view of the medical staff, the reasons for a lower rate of EDA during birth for immigrant women were varied. On one side, this is attributed to the wishes of the respective women ("demand") but on the other side this can be attributed to the health care system ("supply"). In the case of a language barrier, the "supply" and the access of EDA for immigrant women is limited and can be then shifted to the German-speaking companion to make a decision regarding EDA ("structural deprivation of self-determination").

Parturients' Stated Preferences for Labor Analgesia: A Discrete Choice Experiment

OBJECTIVE

The objective was to investigate the extent to which treatment benefits, risks and costs affected parturients' preferences for labor analgesia.

METHODS

We recruited 248 healthy parturients prior to labor at an antenatal ward and administered a discrete choice experiment survey. Parturients were asked to choose among four hypothetical forms of labor analgesia: epidural analgesia, pethidine, Entonox and no analgesia, which were defined by: pain score, duration of second stage of labor, risks of instrumental delivery, back pain and permanent nerve injury, and out-of-pocket cost. We used mixed logit model to calculate the relative importance of each attribute (out of 100).

RESULTS

Parturients preferred receiving labor analgesia over not receiving analgesia and those who had positive past experience with epidural preferred epidural over other modalities. Out-of-pocket cost (28%), duration of second stage of labor (26%) and pain score following treatment (18%) were the most important attributes.

CONCLUSION

Out-of-pocket cost was a major concern. Parturients prioritized having lower pain and shorter labor experience over risks associated with epidural analgesia. Parturients should be presented with realistic range of risks of side-effects so that they can decide how to balance risks against benefits and costs associated with child labor.

The influence of labor epidural analgesia on maternal, uteroplacental and fetoplacental hemodynamics in normotensive parturients: a prospective observational study

BACKGROUND

Epidural analgesia provides sufficient analgesia during labor but can cause hypotension despite various prophylactic measures. We studied its effects on pre-placental, fetoplacental, and fetal hemodynamics using Doppler ultrasound. The primary endpoint was the pulsatility index of the umbilical artery at 30 min after establishing epidural analgesia. Secondary endpoints included maternal blood pressures and neonatal outcome data.

METHODS

We included healthy parturients at a cervical dilation ≥2 cm, with or without a request for epidural analgesia (n=32 per group). Ultrasound studies of the uterine arteries, umbilical artery and fetal middle cerebral artery were performed before insertion of the epidural catheter, and 30, 60 and 90 min after; the same time-points were assessed in the non-epidural control group. Maternal blood pressure was measured by a continuous non-invasive arterial pressure monitor.

RESULTS

Ultrasound studies detected no significant differences in pulsatility indices over time in any blood vessel. In contrast to the control group, maternal blood pressures were significantly lower for all measures after the onset of analgesia compared with baseline values (mean systolic pressure decreased from 132.7 ± 15.9 mmHg to 123.1 ± 14.4 mmHg at 30 min, P=0.003). The mean pH value of the umbilical arterial blood was 7.29 (±0.06) in the epidural group versus 7.31 (±0.08) in the control group (P=0.33). The median Apgar score at 5 min was 10 in both groups.

CONCLUSIONS

Pre-placental, fetoplacental and fetal hemodynamics remained stable despite a statistically significant decrease in maternal blood pressure in laboring parturients receiving epidural analgesia.

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

BACKGROUND

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

OBJECTIVE

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Qualitative data were extracted and analysed using thematic synthesis.

RESULTS

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

CONCLUSIONS

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

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).