Ethnic disparity in severe acute maternal morbidity: a nationwide cohort study in the Netherlands

Unveiling silenced narratives: a scoping review on sexual function challenges in migrant and refugee women

INTRODUCTION

Of the approximately 281 million international migrants and 35.3 million refugees around the world, almost half are women. These individuals experience significant stress due to language barriers, financial difficulties, poor living and working conditions, and discrimination. Consequently, concerns related to sexuality may receive lower priority despite their significant impact on overall well-being.

OBJECTIVES

This scoping review aims to review the sexual function of migrant and refugee women and identify any knowledge gaps in the field.

METHODS

We conducted a scoping review following the PRISMA-ScR guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews). We searched online databases-Medline, Embase, Emcare, PsycINFO, CINAHL, Scopus, Web of Science, and Cochrane-and gray literature, with no restrictions on year of publication, language, or study design. Utilizing Covidence software, 2 authors screened and extracted data from studies based on predetermined eligibility criteria. A thematic analysis was executed, and findings were reported descriptively.

RESULTS

Initially, we identified 5615 studies; after screening titles, abstracts, and full texts, we ultimately included 12 studies. The review identified a limited body of research with various unvalidated tools. Moreover, these studies yielded heterogeneous results: migrant women reported less sexual knowledge, experience, and liberal attitudes, resulting in lower rates of desire and arousal as compared with nonmigrants. Some studies showed lower sexual function in migrants, while others found no significant differences between migrants and nonmigrants. The assimilation into Western cultures may influence migrants' sexual attitudes and behaviors. Factors such as education and gender role ideology can also significantly affect sexual function among migrant populations.

CONCLUSION

This review underscores the limitations in previous sexual function research, emphasizing the need for a more inclusive approach. It also offers valuable insights for codesigning programs to address sexual dysfunction among migrant and refugee women, improving their well-being. Future research should prioritize neglected populations and create culturally sensitive interventions to reduce sexual health disparities in migrants.

Exploring barriers and strategies for improving sexual and reproductive health access for young men in Sweden: Insights from healthcare providers in youth clinics

METHODS

Youth clinics in Sweden are not reaching young men to the same extent as young women. We conducted a qualitative study to explore healthcare providers' (HCPs) perspectives on the barriers to young men's access to sexual and reproductive health (SRH) services and how youth clinics can better accommodate the needs of young men. We used thematic analysis to analyze eight interviews with nine HCPs (three men and six women).

RESULTS

We developed three themes: 1) It's about the youth clinics and those working in them-the clinics suffered from low organizational support, which affected their ability to accommodate young men's needs and were perceived as "girls' clinics". Midwifery, which is the main profession of HCPs working with SRH in the clinics, was perceived as a women's profession for women's SRH; 2) It's not all about the youth clinics-young men were perceived as lacking essential knowledge about SRH and gender norms were preventing young men from visiting youth clinics; 3) Organizational strategies for improving access-the participants discussed strategies to attract young men, including separate reception for young men, hiring more male staff, having higher age limits for young men, and digital solutions to address privacy concerns.

CONCLUSION

There is a need for societal efforts to increase young men's knowledge about SRH and improve their access to SRH services. Several strategies can be adapted by youth clinics to attract more young men but there is need for further research to design and evaluate such interventions.

Chronic Hypertension in Pregnancy: A Lens Into Cardiovascular Disease Risk and Prevention

Hypertension is a major, modifiable risk factor for cardiovascular disease (CVD) in the United States. Over the past decade, the prevalence of chronic hypertension (CHTN) during pregnancy has nearly doubled with persistent race- and place-based disparities. Blood pressure elevations are of particular concern during pregnancy given higher risk of maternal and fetal morbidity and mortality, as well as higher lifetime risk of CVD in birthing individuals with CHTN. When identified during pregnancy, CHTN can, therefore, serve as a lens into CVD risk, as well as a modifiable target to mitigate cardiovascular risk throughout the life course. Health services and public health interventions that equitably promote cardiovascular health during the peripartum period could have an important impact on preventing CHTN and reducing lifetime risk of CVD. This review will summarize the epidemiology and guidelines for the diagnosis and management of CHTN in pregnancy; describe the current evidence for associations between CHTN, adverse pregnancy outcomes, and CVD; and identify opportunities for peripartum care to equitably reduce hypertension and CVD risk throughout the life course.

Maternal mortality in the city of Berlin: consequences for perinatal healthcare

OBJECTIVES

The fifth of the United Nations' Millennium Development Goals proposed for 2000-2015 was to improve maternal health, which has only partially been achieved. Worldwide, the maternal mortality ratio is currently estimated at 216/100.000 livebirths, compared to 380/100,000 in 1990. As yet, there has been no published comprehensive analysis of maternal mortality data as it pertains to Berlin and by extension Germany. Aim of the study was to evaluate and analyze the maternal mortality rate of Berlin as a result of shortcomings in healthcare provision and identify possible solutions.

METHODS

The Institute for Quality and Transparency in the Healthcare Sector sourced external quality control from the Qualitätsbüro Berlin to provide maternal mortality data from Berlin hospitals from 2007 to 2020.

RESULTS

Nineteen maternal deaths were registered between 2007 and 2020 in total. Case analysis shows that two main events occur: thrombosis and hemorrhage at 31.6%, respectively, followed by hypertensive disorder (15.8%), and sepsis (15.8%). After detailed analysis of each case report, we determined 8/19 (42.1%) maternal deaths as being potentially preventable given slightly altered circumstances.

CONCLUSIONS

The system of registration of perinatal data in Germany does not allow for a comprehensive recording of maternal death and requires alteration to provide a more accurate picture of the phenomenon of maternal mortality; presumably, there exist twice as many unreported cases. Symptoms, risks, and primary prevention tactics of thromboembolism during pregnancy and birth should be imparted to every licensed professional in individual hospital settings, along with evidence-based simulation training for the event of obstetric or prepartum hemorrhage.

Severe Maternal Morbidity and Mortality Among Immigrant and Canadian-Born Women Residing Within Low-Income Neighborhoods in Ontario, Canada

IMPORTANCE

Evidence indicates that immigrant women and women residing within low-income neighborhoods experience higher adversity during pregnancy. Little is known about the comparative risk of severe maternal morbidity or mortality (SMM-M) among immigrant vs nonimmigrant women living in low-income areas.

OBJECTIVE

To compare the risk of SMM-M between immigrant and nonimmigrant women residing exclusively within low-income neighborhoods in Ontario, Canada.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used administrative data for Ontario, Canada, from April 1, 2002, to December 31, 2019. Included were all 414 337 hospital-based singleton live births and stillbirths occurring between 20 and 42 weeks' gestation, solely among women residing in an urban neighborhood of the lowest income quintile; all women were receiving universal health care insurance. Statistical analysis was performed from December 2021 to March 2022.

EXPOSURES

Nonrefugee immigrant status vs nonimmigrant status.

MAIN OUTCOMES AND MEASURES

The primary outcome, SMM-M, was a composite outcome of potentially life-threatening complications or mortality occurring within 42 days of the index birth hospitalization. A secondary outcome was SMM severity, approximated by the number of SMM indicators (0, 1, 2 or ≥3 indicators). Relative risks (RRs), absolute risk differences (ARDs), and odds ratios (ORs) were adjusted for maternal age and parity.

RESULTS

The cohort included 148 085 births to immigrant women (mean [SD] age at index birth, 30.6 [5.2] years) and 266 252 births to nonimmigrant women (mean [SD] age at index birth, 27.9 [5.9] years). Most immigrant women originated from South Asia (52 447 [35.4%]) and the East Asia and Pacific (35 280 [23.8%]) regions. The most frequent SMM indicators were postpartum hemorrhage with red blood cell transfusion, intensive care unit admission, and puerperal sepsis. The rate of SMM-M was lower among immigrant women (2459 of 148 085 [16.6 per 1000 births]) than nonimmigrant women (4563 of 266 252 [17.1 per 1000 births]), equivalent to an adjusted RR of 0.92 (95% CI, 0.88-0.97) and an adjusted ARD of -1.5 per 1000 births (95% CI, -2.3 to -0.7). Comparing immigrant vs nonimmigrant women, the adjusted OR of having 1 SMM indicator was 0.92 (95% CI, 0.87-0.98), the adjusted OR of having 2 indicators was 0.86 (95% CI, 0.76-0.98), and the adjusted OR of having 3 or more indicators was 1.02 (95% CI, 0.87-1.19).

CONCLUSIONS AND RELEVANCE

This study suggests that, among universally insured women residing in low-income urban areas, immigrant women have a slightly lower associated risk of SMM-M than their nonimmigrant counterparts. Efforts aimed at improving pregnancy care should focus on all women residing in low-income neighborhoods.

Maternal characteristics associated with referral to obstetrician-led care in low-risk pregnant women in the Netherlands: A retrospective cohort study

BACKGROUND

In the Netherlands, maternity care is divided into midwife-led care (for low-risk women) and obstetrician-led care (for high-risk women). Referrals from midwife-led to obstetrician-led care have increased over the past decade. The majority of women are referred during their pregnancy or labour. Referrals are based on a continuous risk assessment of the health and characteristics of mother and child, yet referral for non-medical factors and characteristics remain unclear. This study investigated which maternal characteristics are associated with women's referral from midwife-led to obstetrician-led care.

MATERIALS AND METHODS

A retrospective cohort study in one midwife-led care practice in the Netherlands included 1096 low-risk women during January 2015-17. The primary outcomes were referral from midwife-led to obstetrician-led care in (1) the antepartum period and (2) the intrapartum period. In total, 11 maternal characteristics were identified. Logistic regression models of referral in each period were fitted and stratified by parity.

RESULTS

In the antepartum period, referral among nulliparous women was associated with an older maternal age (aOR, 1.07; 95%CI, 1.05-1.09), being underweight (0.45; 0.31-0.64), overweight (2.29; 1.91-2.74), or obese (2.65; 2.06-3.42), a preconception period >1 year (1.34; 1.07-1.66), medium education level (0.76; 0.58-1.00), deprivation (1.87; 1.54-2.26), and sexual abuse (1.44; 1.14-1.82). Among multiparous women, a referral was associated with being underweight (0.40; 0.26-0.60), obese (1.61; 1.30-1.98), a preconception period >1 year (1.71; 1.27-2.28), employment (1.38; 1.19-1.61), deprivation (1.23; 1.03-1.46), highest education level (0.63; 0.51-0.80), psychological problems (1.24; 1.06-1.44), and one or multiple consultations with an obstetrician (0.68; 0.58-0.80 and 0.64; 0.54-0.76, respectively). In the intrapartum period, referral among nulliparous women was associated with an older maternal age (1.02; 1.00-1.05), being underweight (1.67; 1.15-2.42), a preconception period >1 year (0.42; 0.31-0.57), medium or high level of education (2.09; 1.49-2.91 or 1.56; 1.10-2.22, respectively), sexual abuse (0.46; 0.33-0.63), and multiple consultations with an obstetrician (1.49; 1.15-1.94). Among multiparous women, referral was associated with an older maternal age (1.02; 1.00-1.04), being overweight (0.65; 0.51-0.83), a preconception period >1 year (0.33; 0.17-0.65), non-Dutch ethnicity (1.98; 1.61-2.45), smoking (0.75; 0.57-0.97), sexual abuse (1.49; 1.09-2.02), and one or multiple consultations with an obstetrician (1.34; 1.06-1.70 and 2.09; 1.63-2.69, respectively).

CONCLUSIONS

This exploratory study showed that several non-medical maternal characteristics of low-risk pregnant women are associated with referral from midwife-led to obstetrician-led care, and how these differ by parity and partum period.

Minoritised ethnic women's experiences of inequities and discrimination in maternity services in North-West England: a mixed-methods study

BACKGROUND

Minoritised ethnic perinatal women can experience judgemental and stigmatising care due to systemic racism. Discriminatory care contributes to increased risks of poor maternal and infant outcomes, including higher rates of mental ill-health. This study aimed to explore minoritised ethnic women's experiences of maternity services, including maternity care and mental health support, within a North-West England locality. Here we use an equity lens to report the findings that describe if and how women's personal, cultural, and spiritual needs were met, their experiences of discriminatory and prejudicial care, and to identify recommendations for service provision.

METHODS

A mixed-methods study was undertaken comprising an online survey, interviews, and community consultations. Questions explored access to and experiences of antenatal care and education; information, communication, and choice; experiences of (dis)respect and judgement; mental health needs and support; cultural/religious needs and support; and overall experiences of maternity care. Eligibility criteria were: women, 18+ years, from self-reported minoritised ethnic backgrounds, who had given birth in the previous 2 years and received maternity care in the locality. Surveys were available in seven languages and distributed via social media, mother-baby groups, and community locations. English-speaking survey participants were invited to take part in a follow-up interview. Community staff were approached to collect data on behalf of the study team. Quantitative data were analysed descriptively (n, %) and merged with qualitative data into descriptive themes.

RESULTS

Overall, 104 women provided data; most self-identified as Asian (65.0%) or Black (10.7%) and were aged between 30-34 (32.0%) or 25-29 years (23.3%). Four descriptive themes are reported: 'accessing care' details variations and barriers in accessing maternity care; 'communication needs, and resources' describes views on adaptions and resources for specific communication needs; 'meeting religious and cultural needs' outlines how various religious and cultural needs were met by maternity providers; 'discriminatory or stigmatising care' reports on experiences of pejorative and inequitable care.

CONCLUSIONS

An equity lens helped identify areas of discriminatory and inequitable care. Key recommendations include cultural safety training for staff; service-user engagement and co-production of research and resources, and appropriate facilities and recording systems to facilitate individualised, needs-based maternity care.

A Systematic Review of Severe Maternal Morbidity in High-Income Countries

With declining maternal mortality rates in high-income countries (HICs), severe maternal morbidity (SMM) is becoming an important quality measure of maternal care. However, there is no international consensus on the definition and types of SMM. This study aims to critically analyze published literature on SMM in HICs. The objectives are to compare definitions and criteria used to identify SMM and identify the main causes and risk factors contributing to SMM in HICs. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases were searched for articles published between 2010 and 2022, results were filtered, and 10 studies were critically appraised. Six of the articles discussed SMM identification criteria and proposed definition modifications. Longer hospital stays and admission to the intensive care unit (ICU) were suggested as additional criteria. Disease-based criteria were shown to be superior to organ dysfunction criteria. Seven articles detailed common types of SMM as severe hemorrhage, hypertensive disorders, and preeclampsia/eclampsia. Six articles described SMM risk factors, of which advanced maternal age and cesarean delivery were the most common. This literature review identified disease-based criteria and Canadian study criteria as promising measures of SMM. It also identified several causes and risk factors of SMM common between HICs. These findings can help physicians identify women at risk of SMM. The study is however limited to eight HICs and 10 studies. Further research should aim to investigate how these criteria compare with previous sources of criteria and discern the association of weight and race risk factors with SMM.

Confidential enquiry into maternal deaths in the Netherlands, 2006-2018

INTRODUCTION

To calculate the maternal mortality ratio (MMR) for 2006-2018 in the Netherlands and compare this with 1993-2005, and to describe women's characteristics, causes of death and improvable factors.

MATERIAL AND METHODS

We performed a nationwide, cohort study of all maternal deaths between January 1, 2006 and December 31, 2018 reported to the Audit Committee Maternal Mortality and Morbidity. Main outcome measures were the national MMR and causes of death.

RESULTS

Overall MMR was 6.2 per 100 000 live births, a decrease from 12.1 in 1993-2005 (risk ratio [RR] 0.5). Women with a non-western ethnic background had an increased MMR compared with Dutch women (MMR 6.5 vs. 5.0, RR 1.3). The MMR was increased among women with a background from Surinam/Dutch Antilles (MMR 14.7, RR 2.9). Half of all women had an uncomplicated medical history (79/161, 49.1%). Of 171 pregnancy-related deaths within 1 year postpartum, 102 (60%) had a direct and 69 (40%) an indirect cause of death. Leading causes within 42 days postpartum were cardiac disease (n = 21, 14.9%), hypertensive disorders (n = 20, 14.2%) and thrombosis (n = 19, 13.5%). Up to 1 year postpartum, the most common cause of death was cardiac disease (n = 32, 18.7%). Improvable care factors were identified in 76 (47.5%) of all deaths.

CONCLUSIONS

Maternal mortality halved in 2006-2018 compared with 1993-2005. Cardiac disease became the main cause. In almost half of all deaths, improvable factors were identified and women with a background from Surinam/Dutch Antilles had a threefold increased risk of death compared with Dutch women without a background of migration.

Implicit biases and differential perinatal care for migrant women: methodological framework and study protocol of the BiP study part 3

BACKGROUND

The mechanisms of disparities in maternal and perinatal health between migrant and native women are multiple and remain poorly understood. Access to and quality of care are likely to participate in these mechanisms, and one hypothesis is the existence of implicit biases among caregivers through which ethno-racial belonging can influence medical decisions and consequently engender healthcare disparities. Their existence and their role in the generation of non-medically justified differential care have been documented in the United States apart from perinatal care, but remain largely unexplored in Europe. In this article, we present the study protocol and theoretical framework of a study that aims to test and quantify the existence of implicit bias toward African Sub-Saharan migrant women among caregivers working in the perinatal field, and to explore the association between implicit bias and differential care.

MATERIAL AND METHODS

This study is based on an online survey to which French obstetricians, midwives, and anesthetists were invited to take part. The potential existence of implicit biases toward African Sub-Saharan migrant will be quantified through a validated tool, the Implicit Association Test. Then we will assess how implicit biases are likely to influence clinical decisions and lead to differential care using clinical vignettes designed by an experts group.

DISCUSSION

Implicit bias and differential care are concept that are tricky to capture and interpret. This research program opens up in France a field of research on certain forms of health discriminations and sheds new light on the issue of social inequalities in perinatal health.

STUDY REGISTRATION

Registration in the Open Science Framework portal: https://osf.io/djva7/?view_only=c6012ace3fe94165a65b05c2dc6aff9e.

Associations between ethnicity and admission to intensive care among women giving birth: a cohort study

OBJECTIVE

To determine the association between ethnic group and likelihood of admission to intensive care in pregnancy and the postnatal period.

DESIGN

Cohort study.

SETTING

Maternity and intensive care units in England and Wales.

POPULATION OR SAMPLE

A total of 631 851 women who had a record of a registerable birth between 1 April 2015 and 31 March 2016 in a database used for national audit.

METHODS

Logistic regression analyses of linked maternity and intensive care records, with multiple imputation to account for missing data.

MAIN OUTCOME MEASURES

Admission to intensive care in pregnancy or postnatal period to 6 weeks after birth.

RESULTS

In all, 2.24 per 1000 maternities were associated with intensive care admission. Black women were more than twice as likely as women from other ethnic groups to be admitted (odds ratio [OR] 2.21, 95% CI 1.82-2.68). This association was only partially explained by demographic, lifestyle, pregnancy and birth factors (adjusted OR 1.69, 95% CI 1.37-2.09). A higher proportion of intensive care admissions in Black women were for obstetric haemorrhage than in women from other ethnic groups.

CONCLUSIONS

Black women have an increased risk of intensive care admission that cannot be explained by demographic, health, lifestyle, pregnancy and birth factors. Clinical and policy intervention should focus on the early identification and management of severe illness, particularly obstetric haemorrhage, in Black women, in order to reduce inequalities in intensive care admission.

TWEETABLE ABSTRACT

Black women are almost twice as likely as White women to be admitted to intensive care during pregnancy and the postpartum period; this risk remains after accounting for demographic, health, lifestyle, pregnancy and birth factors.

Shaping birth: variation in the birth canal and the importance of inclusive obstetric care

Regional variation in pelvic morphology and childbirth has long occurred alongside traditional labour support and an understanding of possible normal courses of childbirth for each population. The process of migration and globalization has broken down these links, while a European model of 'normal' labour has become widespread. The description of 'normal' childbirth provided within obstetrics and midwifery textbooks, in fact, is modelled on a specific pelvic morphology that is common in European women. There is mounting evidence, however, that this model is not representative of women's diversity, especially for women of non-white ethnicities. The human birth canal is very variable in shape, both within and among human populations, and differences in pelvic shapes have been associated with differences in the mechanism of labour. Normalizing a white-centred model of female anatomy and of childbirth can disadvantage women of non-European ancestry. Because they are less likely to fit within this model, pelvic shape and labour pattern in non-white women are more likely to be considered 'abnormal', potentially leading to increased rates of labour intervention. To ensure that maternal care is inclusive and as safe as possible for all women, obstetric and midwifery training need to incorporate women's diversity. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Investigating Health Equity and Healthcare Needs among Immigrant Women Using the Association Rule Mining Method

Equitable access to healthcare services is a major concern among immigrant women. Thus, this study investigated the relationship between socioeconomic characteristics and healthcare needs among immigrant women in Taiwan. The secondary data was obtained from “Survey of Foreign and Chinese Spouses’ Living Requirements, 2008”, which was administered to 5848 immigrant women by the Ministry of the Interior, Taiwan. Additionally, descriptive statistics and significance tests were used to analyze the data, after which the association rule mining algorithm was applied to determine the relationship between socioeconomic characteristics and healthcare needs. According to the findings, the top three healthcare needs were providing medical allowances (52.53%), child health checkups (16.74%), and parental knowledge and pre- and post-natal guidance (8.31%). Based on the association analysis, the main barrier to the women’s healthcare needs was “financial pressure”. This study also found that nationality, socioeconomic status, and duration of residence were associated with such needs, while health inequality among aged immigrant women was due to economic and physical factors. Finally, the association analysis found that the women’s healthcare problems included economic, socio-cultural, and gender weakness, while “economic inequality” and “women’s health” were interrelated.

Applicability of the WHO maternal near-miss tool: A nationwide surveillance study in Suriname

BACKGROUND

Maternal near-miss (MNM) is an important maternal health quality-of-care indicator. To facilitate comparison between countries, the World Health Organization (WHO) developed the "MNM-tool". However, several low- and middle-income countries have proposed adaptations to prevent underreporting, ie, Namibian and Sub-Sahara African (SSA)-criteria. This study aims to assess MNM and associated factors in middle-income country Suriname by applying the three different MNM tools.

METHODS

A nationwide prospective population-based cohort study was conducted using the Suriname Obstetric Surveillance System (SurOSS). We included women with MNM-criteria defined by WHO-, Namibian- and SSA-tools during one year (March 2017-February 2018) and used hospital births (86% of total) as a reference group.

RESULTS

There were 9114 hospital live births in Suriname in the one-year study period. SurOSS identified 71 women with WHO-MNM (8/1000 live births, mortality-index 12%), 118 with Namibian-MNM (13/1000 live births, mortality-index 8%), and 242 with SSA-MNM (27/1000 live births, mortality-index 4%). Namibian- and SSA-tools identified all women with WHO-criteria. Blood transfusion thresholds and eclampsia explained the majority of differences in MNM prevalence. Eclampsia was not considered a WHO-MNM in 80% (n = 35/44) of cases. Nevertheless, mortality-index for MNM with hypertensive disorders was 17% and the most frequent underlying cause of maternal deaths (n = 4/10, 40%) and MNM (n = 24/71, 34%). Women of advanced age and maroon ethnicity had twice the odds of WHO-MNM (respectively adjusted odds ratio (aOR) = 2.6, 95% confidence interval (CI) = 1.4-4.8 and aOR = 2.0, 95% CI = 1.2-3.6). The stillbirths rate among women with WHO-MNM was 193/1000births, with six times higher odds than women without MNM (aOR = 6.8, 95%CI = 3.0-15.8). While the prevalence and mortality-index differ between the three MNM tools, the underlying causes of and factors associated with MNM were comparable.

CONCLUSIONS

The MNM ratio in Suriname is comparable to other countries in the region. The WHO-tool underestimates the prevalence of MNM (high mortality-index), while the adapted tools may overestimate MNM and compromise global comparability. Contextualized MNM-criteria per obstetric transition stage may improve comparability and reduce underreporting. While MNM studies facilitate international comparison, audit will remain necessary to identify shortfalls in quality-of-care and improve maternal outcomes.

[Severe maternal morbidity in public hospitals in Ribeirão Preto, São Paulo State, Brazil]

This study analyzed the occurrence of severe maternal morbidity, the most frequent diagnostic criteria, and the quality of obstetric care in public hospitals in Ribeirão Preto, São Paulo State, Brazil. A quantitative surveillance survey of severe maternal morbidity used World Health Organization (WHO) criteria for potentially life-threatening conditions and maternal near miss. Cases were identified from August 1, 2015, to February 2, 2016. The sample included 259 women with severe maternal morbidity (potentially life-threatening conditions/maternal near miss) during the gestational and postpartum cycle, hospitalized for childbirth in the four public institutions providing obstetric care in the city. The descriptive analysis was based on absolute and relative rates of diagnostic criteria for potentially life-threatening conditions and maternal near miss, besides description of the women in the sample (sociodemographic characteristics, obstetric history, and prenatal and childbirth care). Quality of care indicators set by the WHO based on morbimortality were also calculated. There were 3,497 deliveries, 3,502 live births in all the hospitals in the city, two maternal deaths, and 19 maternal near miss. Maternal near miss ratio was 5.4 cases per 1,000 live births, and the maternal mortality ratio was 57.1 deaths per 100,000 live birth. The mortality rate among cases with severe maternal outcome (maternal near miss plus maternal death) was 9.5%. The study revealed important potentially life-threatening conditions and maternal near miss rates. The occurrence of deaths from hemorrhagic causes highlights the need to improve the quality of obstetric care. The findings can potentially help improve local policy for obstetric care.

Pregnancy outcomes in asylum seekers in the North of the Netherlands: a retrospective documentary analysis

BACKGROUND

With more than 20,000 asylum seekers arriving every year, healthcare for this population has become an important issue. Pregnant asylum seekers seem to be at risk of poor pregnancy outcomes. This study aimed to assess the difference in pregnancy outcomes between asylum seekers and the local Dutch population and to identify potential substandard factors of care.

METHODS

Using a retrospective study design we compared pregnancy outcomes of asylum-seeking and Dutch women who gave birth in a northern region of the Netherlands between January 2012 and December 2016. The following data were compared: perinatal mortality, maternal mortality, gestational age at delivery, preterm delivery, birth weight, small for gestational age children, APGAR score, intrauterine foetal death, mode of delivery and the need for pain medication. Cases of perinatal mortality in asylum seekers were reviewed for potential substandard factors.

RESULTS

A total of 344 Asylum-seeking women and 2323 Dutch women were included. Asylum seekers had a higher rate of perinatal mortality (3.2% vs. 0.6%, p = 0.000) including a higher rate of intrauterine foetal death (2.3% vs. 0.2%, p = 0.000), higher gestational age at birth (39 + 4 vs. 38 + 6 weeks, p = 0.000), labour was less often induced (36.9 vs. 43.8, p = 0.016), postnatal hospitalization was longer (2.24 vs. 1.72 days p = 0.006) and they received more opioid analgesics (27.3% vs. 22%, p = 0.029). Babies born from asylum-seeking women had lower birth weights (3265 vs. 3385 g, p = 0.000) and were more often small for gestational age (13.9% vs. 8.4%, p = 0.002). Multivariate analysis showed that the increased risk of perinatal mortality in asylum-seeking women was independent of parity, birth weight and gestational age at birth. Review of the perinatal mortality cases in asylum seekers revealed possible substandard factors, such as late initiation of antenatal care, missed appointments because of transportation problems, not recognising alarm symptoms, not knowing who to contact and transfer to other locations during pregnancy.

CONCLUSION

Pregnant asylum seekers have an increased risk of adverse pregnancy outcomes. More research is needed to identify which specific risk factors are involved in poor perinatal outcomes in asylum seekers and to identify strategies to improve perinatal care for this group of vulnerable women.

Childbirth outcomes and ethnic disparities in Suriname: a nationwide registry-based study in a middle-income country

Background

Our study aims to evaluate the current perinatal registry, analyze national childbirth outcomes and study ethnic disparities in middle-income country Suriname, South America.

Methods

A nationwide birth registry study was conducted in Suriname. Data were collected for 2016 and 2017 from the childbirth books of all five hospital maternity wards, covering 86% of all births in the country. Multinomial regression analyses were used to assess ethnic disparities in outcomes of maternal deaths, stillbirths, teenage pregnancy, cesarean delivery, low birth weight and preterm birth with Hindustani women as reference group.

Results

18.290 women gave birth to 18.118 (98%) live born children in the five hospitals. Hospital-based maternal mortality ratio was 112 per 100.000 live births. Hospital-based late stillbirth rate was 16 per 1000 births. Stillbirth rate was highest among Maroon (African-descendent) women (25 per 1000 births, aOR 2.0 (95%CI 1.3–2.8) and lowest among Javanese women (6 stillbirths per 1000 births, aOR 0.5, 95%CI 0.2–1.2). Preterm birth and low birthweight occurred in 14 and 15% of all births. Teenage pregnancy accounted for 14% of all births and was higher in Maroon women (18%) compared to Hindustani women (10%, aOR 2.1, 95%CI 1.8–2.4). The national cesarean section rate was 24% and was lower in Maroon (17%) than in Hindustani (32%) women (aOR 0.5 (95%CI 0.5–0.6)). Cesarean section rates varied between the hospitals from 17 to 36%.

Conclusion

This is the first nationwide comprehensive overview of maternal and perinatal health in a middle income country. Disaggregated perinatal health data in Suriname shows substantial inequities in outcomes by ethnicity which need to be targetted by health professionals, researchers and policy makers.

Human Development Index of the maternal country of origin and its relationship with maternal near miss: A systematic review of the literature

Background

The reduction in maternal mortality worldwide has increased the interest in studying more frequent severe events such as maternal near miss. The Human Development Index is a sociodemographic country-specific variable that includes key human development indicators such as living a long and healthy life, acquiring knowledge, and enjoying a decent standard of living, allowing differentiation between countries. In a globalised environment, it is necessary to study whether the Human Development Index of each patient's country of origin can be associated with the maternal near-miss rate and thus classify the risk of maternal morbidity and mortality.

Methods

A systematic review of the literature published between 2008 and 2019 was conducted, including all articles that reported data about maternal near miss in their sample of pregnant women, in addition to describing the study countries of their sample population. The Human Development Index of the study country, the maternal near-miss rate, the maternal mortality rate, and other maternal-perinatal variables related to morbidity and mortality were used.

Results

After the systematic review, eighty two articles from over thirty countries were included, for a total of 3,699,697 live births, 37,191 near miss cases, and 4029 mortality cases. A statistically significant (p <0.05) inversely proportional relationship was observed between the Human Development Index of the study country and the maternal near-miss and mortality rates. The most common cause of maternal near miss was haemorrhage, with an overall rate of 38.5%, followed by hypertensive disorders of pregnancy (34.2%), sepsis (7.5%), and other undefined causes (20.9%).

Conclusions

The Human Development Index of the maternal country of origin is a sociodemographic variable allowing differentiation and classification of the risk of maternal mortality and near miss in pregnant women. The most common cause of maternal near miss published in the literature was haemorrhage.

Trial registration

PROSPERO ID: CRD 42019133464

Gestation, equality and freedom: ectogenesis as a political perspective

The benefits of full ectogenesis, that is, the gestation of human fetuses outside the maternal womb, for women ground many contemporary authors' arguments on the ethical desirability of this practice. In this paper, I present and assess two sets of arguments advanced in favour of ectogenesis: arguments stressing ectogenesis' equality-promoting potential and arguments stressing its freedom-promoting potential. I argue that although successfully grounding a positive case for ectogenesis, these arguments have limitations in terms of their reach and scope. Concerning their limited reach, I contend that ectogenesis will likely benefit a small subset of women and, arguably, not the group who most need to achieve equality and freedom. Concerning their limited scope, I contend that these defences do not pay sufficient attention to the context in which ectogenesis would be developed and that, as a result, they risk leaving the status quo unchanged. After providing examples of these limitations, I move to my proposal concerning the role of ectogenesis in promoting women's equality and freedom. This proposal builds on Silvia Federici's, Mariarosa Dalla Costa's and Selma James' readings of the international feminist campaign 'Wages for Housework'. It maintains that the political perspective and provocation that ectogenesis can advance should be considered and defended.

Magnitude of maternal near misses and the role of delays in Ethiopia: a hospital based cross-sectional study

OBJECTIVES

This study was aimed to assess the magnitude of maternal near misses and the role of delays including other risk factors. A Hospital based cross sectional study was conducted at three referral hospitals of Amhara region on 572 mothers who came to obtain obstetrics care services from February 01 to July 30, 2018.

RESULTS

The magnitude of maternal near miss was 26.6% (95% CI 23, 30). With regards to delays, 83 (14.5%), 226 (39.5%), and 154 (26.9%) of women delayed in the decision to seek care, in reaching care, and in receiving care respectively. Women who had no antenatal care [AOR = 3.16; CI (1.96, 5.10)], who stayed in hospital 7 days or more [AOR = 2.20; CI (1.33, 3.63)] and those who had delay in reaching health facility [AOR = 1.99; CI (1.10, 3.61)] were more likely to be near miss. While, women whose husband was able to read and write [AOR = 0.29; CI (0.09, 0.96)] and those with monthly household income between 2001 and 3000 ETB [AOR = 0.35; CI (0.18, 0.70)] were 71% and 65% less likely to be near misses respectively. Promoting antenatal care and increasing maternal health care access could have significant impact in reducing maternal near misses.

The impact of migration background on maternal near miss

PURPOSE

(1) To evaluate the association between immigration background and the occurrence of maternal near miss (MNM). (2) To identify medical co-factors, health-care utilization, and health-care disparities as explanations of a possibly higher risk of MNM among immigrants.

METHODS

We compared perinatal outcomes between immigrant women (first- or second-generation) versus non-immigrant women, delivering at three maternity hospitals in Berlin, Germany, 2011-2012. Near-miss events were defined as: HELLP syndrome, eclampsia, the occurrence or threat of uterine rupture, postpartum hemorrhage (PPH) > 1000 ml, sepsis, peripartal hysterectomy, cardiovascular complications, lung embolism. Logistic regression analyses were performed to determine the associations of immigration status, acculturation, and language competency with near-miss events, and of near-miss events with the perinatal outcomes.

RESULTS

The databank included 2647 first-generation immigrants, 889 second-generation immigrants, and 3231 women without an immigration background (total N = 6767). Near-miss events occurred in 141 women. The likelihood of near-miss events was lower among multiparous women (OR 0.6; 95% CI 0.42-0.87; p = 0.01). No other factors had a statistically significant influence. Near-miss events are associated with an elevated likelihood for an unfavorable perinatal condition: the ORs ranged from 2.15 for an arterial umbilical cord pH value < 7.1-2.47 for premature delivery.

CONCLUSIONS

Immigration status does not change the risk of near-miss events. Besides parity, no medical or socio-demographic factors were identified that were associated with an elevated likelihood for the occurrence of severe peripartal complications.

A global view of severe maternal morbidity: moving beyond maternal mortality

BACKGROUND

Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs).

SEVERE MATERNAL MORBIDITY IN HIGH-INCOME COUNTRIES

Since the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify "high risk" status, delays in diagnosis, and delays in treatment.

SEVERE MATERNAL MORBIDITY IN LOW AND MIDDLE INCOME COUNTRIES

The highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity.

EFFECTS OF SMM ON DELIVERY OUTCOMES AND INFANTS

Severe maternal morbidity not only puts the woman's life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn.

CONCLUSION

Increasing global maternal morbidity is a failure to achieve broad public health goals of improved women's and infants' health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.

The midwife-woman relationship in a South Wales community: Experiences of midwives and migrant Pakistani women in early pregnancy

BACKGROUND

In 2015, 27.5% of births in England and Wales were to mothers born outside of the UK. Compared to their White British peers, minority ethnic and migrant women are at a significantly higher risk of maternal and perinatal mortality, along with lower maternity care satisfaction. Existing literature highlights the importance of midwife-woman relationships in care satisfaction and pregnancy outcomes; however, little research has explored midwife-woman relationships for migrant and minority ethnic women in the UK.

METHODS

A focused ethnography was conducted in South Wales, UK, including semi-structured interviews with 9 migrant Pakistani participants and 11 practising midwives, fieldwork in the local migrant Pakistani community and local maternity services, observations of antenatal appointments, and reviews of relevant media. Thematic data analysis was undertaken concurrently with data collection.

FINDINGS

The midwife-woman relationship was important for participants' experiences of care. Numerous social and ecological factors influenced this relationship, including family relationships, culture and religion, differing health-care systems, authoritative knowledge and communication of information. Marked differences were seen between midwives and women in the perceived importance of these factors.

CONCLUSIONS

Findings provide new theoretical insights into the complex factors contributing to the health-care expectations of pregnant migrant Pakistani women in the UK. These findings may be used to create meaningful dialogue between women and midwives, encourage women's involvement in decisions about their health care and facilitate future midwifery education and research. Conclusions are relevant to a broad international audience, as achieving better outcomes for migrant and ethnic minority communities is of global concern.

Global disparities in maternal morbidity and mortality

The disparity in maternal mortality for African American women remains one of the greatest public health inequities in the United States (US). To better understand approaches toward amelioration of these differences, we examine settings with similar disparities in maternal mortality and "near misses" based on race/ethnicity. This global analysis of disparities in maternal mortality/morbidity will focus on middle- and high-income countries (based on World Bank definitions) with multiethnic populations. Many countries with similar histories of slavery and forced migration demonstrate disparities in health outcomes based on social determinants such as race/ethnicity. We highlight comparisons in the Americas between the US and Brazil-two countries with the largest populations of African descent brought to the Americas primarily through the transatlantic slave trade. We also address the need to capture race/ethnicity/country of origin in a meaningful way in order to facilitate transnational comparisons and potential translatable solutions. Race, class, and gender-based inequities are pervasive, global themes. This approach is human rights-based and consistent with the UN Millennium Development Goals (MDG) and post 2015-sustainable development goals' aim to place women's health the context of health equity/women's rights. Solutions to these issues of inequity in maternal mortality are nation-specific and global.

Severe Maternal Morbidity Associated With Maternal Birthplace: A Population-Based Register Study

OBJECTIVE

This study sought to quantify the risk of severe maternal morbidity (SMM) according to maternal country of birth in Canada.

METHODS

The study analyzed 1 252 543 in-hospital deliveries of Ontario residents discharged between April 1, 2002, and March 31, 2012. The main outcome measure was a composite indicator of SMM used for surveillance. The top 10 most common component conditions were also evaluated. Maternal country of birth and other immigration characteristics were obtained through linkage with official immigration records. We used modified Poisson regression with generalized estimating equations to assess associations according to maternal country of birth.

RESULTS

Overall, immigrant women (N = 335 544) did not differ from Canadian-born women (n = 916 999) in SMM rates (12.1 vs. 12.0 cases per 1000 deliveries, respectively). However, SMM varied substantially according to maternal region of birth, from 9.2 cases per 1000 deliveries among immigrants from Western countries to 23.0 cases per 1000 deliveries among immigrants from Sub-Saharan Africa. Even larger variations were found when immigrants were categorized by their specific countries of birth. The top 10 contributing conditions to SMM among Canadian-born women were also the main contributors among immigrant subgroups. The notable exception was HIV infection, the top contributor among immigrants from Sub-Saharan Africa, whose rate of HIV infection was 43 times that of Canadian-born women (95% CI 34.39-55.23). After excluding HIV cases, disparities in SMM were largely reduced among Sub-Saharan African women but did not disappear.

CONCLUSION

There is large heterogeneity in SMM and its component conditions among Canadian immigrants depending on country of origin.

Burden of severe maternal morbidity and association with adverse birth outcomes in sub-Saharan Africa and south Asia: protocol for a prospective cohort study

Objectives

The AMANHI morbidity study aims to quantify and describe severe maternal morbidities and assess their associations with adverse maternal, fetal and newborn outcomes in predominantly rural areas of nine sites in eight South Asian and sub–Saharan African countries.

Methods

AMANHI takes advantage of on–going population–based cohort studies covering approximately 2 million women of reproductive age with 1– to 3–monthly pregnancy surveillance to enrol pregnant women. Morbidity information is collected at five follow–up home visits – three during the antenatal period at 24–28 weeks, 32–36 weeks and 37+ weeks of pregnancy and two during the postpartum period at 1–6 days and after 42–60 days after birth. Structured–questionnaires are used to collect self–reported maternal morbidities including hemorrhage, hypertensive disorders, infections, difficulty in labor and obstetric fistula, as well as care–seeking for these morbidities and outcomes for mothers and babies. Additionally, structured questionnaires are used to interview birth attendants who attended women’s deliveries. All protocols were harmonised across the sites including training, implementation and operationalising definitions for maternal morbidities.

Importance of the AMANHI morbidity study

Availability of reliable data to synthesize evidence for policy direction, interventions and programmes, remains a crucial step for prioritization and ensuring equitable delivery of maternal health interventions especially in high burden areas. AMANHI is one of the first large harmonized population–based cohort studies being conducted in several rural centres in South Asia and sub–Saharan Africa, and is expected to make substantial contributions to global knowledge on maternal morbidity burden and its implications.

Afghan migrants face more suboptimal care than natives: a maternal near-miss audit study at university hospitals in Tehran, Iran

BACKGROUND

Women from low-income settings have higher risk of maternal near miss (MNM) and suboptimal care than natives in high-income countries. Iran is the second largest host country for Afghan refugees in the world. Our aim was to investigate whether care quality for MNM differed between Iranians and Afghans and identify potential preventable attributes of MNM.

METHODS

An MNM audit study was conducted from 2012 to 2014 at three university hospitals in Tehran. Auditors evaluated the quality of care by reviewing the hospital records of 76 MNM cases (54 Iranians, 22 Afghans) and considering additional input from interviews with patients and professionals. Main outcomes were frequency of suboptimal care and the preventable attributes of MNM. Crude and adjusted odds ratios with confidence intervals for the independent predictors were examined.

RESULTS

Afghan MNM faced suboptimal care more frequently than Iranians after adjusting for educational level, family income, and insurance status. Above two-thirds (71%, 54/76) of MNM cases were potentially avoidable. Preventable factors were mostly provider-related (85%, 46/54), but patient- (31%, 17/54) and health system-related factors (26%, 14/54) were also important. Delayed recognition, misdiagnosis, inappropriate care plan, delays in care-seeking, and costly care services were the main potentially preventable attributes of MNM.

CONCLUSIONS

Afghan mothers faced inequality in obstetric care. Suboptimal care was provided in a majority of preventable near-miss events. Improving obstetric practice and targeting migrants' specific needs during pregnancy may avert near-miss outcomes.

Burden of severe maternal morbidity and association with adverse birth outcomes in sub-Saharan Africa and south Asia: protocol for a prospective cohort study

OBJECTIVES

The AMANHI morbidity study aims to quantify and describe severe maternal morbidities and assess their associations with adverse maternal, fetal and newborn outcomes in predominantly rural areas of nine sites in eight South Asian and sub-Saharan African countries.

METHODS

AMANHI takes advantage of on-going population-based cohort studies covering approximately 2 million women of reproductive age with 1- to 3-monthly pregnancy surveillance to enrol pregnant women. Morbidity information is collected at five follow-up home visits - three during the antenatal period at 24-28 weeks, 32-36 weeks and 37+ weeks of pregnancy and two during the postpartum period at 1-6 days and after 42-60 days after birth. Structured-questionnaires are used to collect self-reported maternal morbidities including hemorrhage, hypertensive disorders, infections, difficulty in labor and obstetric fistula, as well as care-seeking for these morbidities and outcomes for mothers and babies. Additionally, structured questionnaires are used to interview birth attendants who attended women's deliveries. All protocols were harmonised across the sites including training, implementation and operationalising definitions for maternal morbidities.

IMPORTANCE OF THE AMANHI MORBIDITY STUDY

Availability of reliable data to synthesize evidence for policy direction, interventions and programmes, remains a crucial step for prioritization and ensuring equitable delivery of maternal health interventions especially in high burden areas. AMANHI is one of the first large harmonized population-based cohort studies being conducted in several rural centres in South Asia and sub-Saharan Africa, and is expected to make substantial contributions to global knowledge on maternal morbidity burden and its implications.

Functional status of women with and without severe maternal morbidity: A prospective cohort study

BACKGROUND

Little is known regarding the impact on maternal functional status in women who have survived severe obstetric complications.

OBJECTIVE

To compare the maternal functional status score between women with and without severe morbidity at one month and six months postpartum in Kelantan, Malaysia.

METHODS

A prospective cohort study design was applied at two tertiary referral hospitals over a six-month period. The study population included all postpartum women who gave birth in 2014. Postpartum women with severe maternal morbidity and without severe maternal morbidity were selected as the exposed and non-exposed group, respectively. Functional ability based on the Inventory of Functional Status after Childbirth was used as the main outcome measure. Repeated measure analysis of variance was performed.

RESULTS

A total of 145 and 187 women with and without severe maternal morbidity, respectively, were measured. There were significant differences in Inventory of Functional Status after Childbirth score changes (P<0.001) between women with and without severe maternal morbidity at one month and at six months. Functional ability score of women with severe maternal morbidity was lower at one month postpartum (P=0.001). The most affected domain was infant care (P=0.002).

CONCLUSIONS

Healthcare providers are recommended to assess the short-term functional ability of severe morbid mother in addition to existing routine physical examination. Provision of physical support from spouse and family of the high risk mothers particularly on infant care during their early postpartum period is crucial to optimise health and minimise the negative health outcomes.

Contribution of HIV to Maternal Morbidity Among Refugee Women in Canada

OBJECTIVES

We compared severe maternal morbidity (SMM) and SMM subtypes, including HIV, of refugee women with those of nonrefugee immigrant and nonimmigrant women.

METHODS

We linked 1,154,421 Ontario hospital deliveries (2002-2011) to immigration records (1985-2010) to determine the incidence of an SMM composite indicator and its subtypes. We determined SMM incidence according to immigration periods, which were characterized by lifting restrictions for all HIV-positive immigrants (in 1991) and refugees who may place "excessive demand" on government services (in 2002).

RESULTS

Refugees had a higher risk of SMM (17.1 per 1000 deliveries) than did immigrants (12.1 per 1000) and nonimmigrants (12.4 per 1000). Among SMM subtypes, refugees had a much higher risk of HIV than did immigrants (risk ratio [RR] = 7.94; 95% confidence interval [CI] = 5.64, 11.18) and nonimmigrants (RR = 17.37; 95% CI = 12.83, 23.53). SMM disparities were greatest after the 2002 policy came into effect. After exclusion of HIV cases, SMM disparities disappeared.

CONCLUSIONS

An apparent higher risk of SMM among refugee women in Ontario, Canada is explained by their high prevalence of HIV, which increased over time parallel to admission policy changes favoring humanitarian protection.

Maternal mortality and severe morbidity in a migration perspective

Among migrants in high-income countries, maternal mortality and severe morbidity generally occur more frequently as compared to host populations. There is marked variation between groups of migrants and host countries, with much elevated risks in some groups and no elevated risk at all in others. Those without a legal resident permit are most vulnerable. A reason for these elevated risks could be a different risk profile in migrants, but risk factors are unevenly distributed and not always present. Another reason is substandard care, which is identified more frequently in migrants, and comprises patient delays, for example, due to a lack of knowledge about the health system in the host country, and health worker delays, often compounded by communication barriers. Improvements in family planning and antenatal services are needed, and audits and confidential enquiries should be extended to include maternal morbidity and ethnic background. This requires scientific and political efforts.

Contributory Factors for Severe Maternal Morbidity

Maternal morbidity is a concept of increasing interest in maternal health. This review aims to assess the contributory factors for severe maternal morbidity over the past one decade worldwide. A comprehensive electronic search was conducted. The search was restricted to articles written in the English language published from 2004 to 2013. Qualitative studies were excluded. A total of 24 full articles were retrieved of which 9 cohort, 7 case–control, 3 cross-sectional studies, and 5 unmentioned designs were included. The contributory factors were divided into 3 components: ( a) sociodemographic characteristics, ( b) medical and gynecological history, and ( c) past and present obstetric performance. This review informs emerging knowledge regarding contributory factors for severe maternal morbidity and has implications for education, clinical practice and intervention. It enables a better understanding of the problem and serves as a foundation for the development of an effective preventive strategy for maternal morbidity and mortality.

Severe Adverse Maternal Outcomes among Women in Midwife-Led versus Obstetrician-Led Care at the Onset of Labour in the Netherlands: A Nationwide Cohort Study

Objective

To test the hypothesis that it is possible to select a group of low risk women who can start labour in midwife-led care without having increased rates of severe adverse maternal outcomes compared to women who start labour in secondary care.

Design and Methods

We conducted a nationwide cohort study in the Netherlands, using data from 223 739 women with a singleton pregnancy between 37 and 42 weeks gestation without a previous caesarean section, with spontaneous onset of labour and a child in cephalic presentation. Information on all cases of severe acute maternal morbidity collected by the national study into ethnic determinants of maternal morbidity in the Netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, was merged with data from the Netherlands Perinatal Registry of all births occurring during the same period.

Our primary outcome was severe acute maternal morbidity (SAMM, i.e. admission to an intensive care unit, uterine rupture, eclampsia or severe HELLP, major obstetric haemorrhage, and other serious events). Secondary outcomes were postpartum haemorrhage and manual removal of placenta.

Results

Nulliparous and parous women who started labour in midwife-led care had lower rates of SAMM, postpartum haemorrhage and manual removal of placenta compared to women who started labour in secondary care. For SAMM the adjusted odds ratio’s and 95% confidence intervals were for nulliparous women: 0.57 (0.45 to 0.71) and for parous women 0.47 (0.36 to 0.62).

Conclusions

Our results suggest that it is possible to identify a group of women at low risk of obstetric complications who may benefit from midwife-led care. Women can be reassured that we found no evidence that midwife-led care at the onset of labour is unsafe for women in a maternity care system with a well developed risk selection and referral system.

Severe maternal morbidity associated with maternal birthplace in three high-immigration settings

Background: Maternal mortality and morbidity vary substantially worldwide. It is unknown if these geographic differences translate into disparities in severe maternal morbidity among immigrants from various world regions. We assessed disparities in severe maternal morbidity between immigrant women from various world regions giving birth in three high-immigration countries. Methods: We used population-based delivery data from Victoria; Australia and Ontario, Canada and national data from Denmark, in the most recent 10-year period ending in 2010 available to each participating centre. Each centre provided aggregate data according to standardized definitions of the outcome, maternal regions of birth and covariates for pooled analyses. We used random effects and stratified logistic regression to obtain odds ratios (ORs) with 95% confidence intervals (95% CIs), adjusted for maternal age, parity and comparability scores. Results: We retrieved 2,322,907 deliveries in all three receiving countries, of which 479,986 (21%) were to immigrant women. Compared with non-immigrants, only Sub-Saharan African women were consistently at higher risk of severe maternal morbidity in all three receiving countries (pooled adjusted OR: 1.67; 95% CI: 1.43, 1.95). In contrast, both Western and Eastern European immigrants had lower odds (OR: 0.82; 95% CI: 0.70, 0.96 and OR: 0.64; 95% CI: 0.49, 0.83, respectively). The most common diagnosis was severe pre-eclampsia followed by uterine rupture, which was more common among Sub-Saharan Africans in all three settings. Conclusions: Immigrant women from Sub-Saharan Africa have higher rates of severe maternal morbidity. Other immigrant groups had similar or lower rates than the majority locally born populations.

Immigration and Continuing Inequalities in Maternity Outcomes: Time to Reexplore the Client–Provider Relationship?

The United Kingdom has seen a substantial rise in immigration over the past 10 years. This new population has a high percentage of women of childbearing age (Office for National Statistics, 2012b), consequently placing an increased demand on U.K. maternity services. Previous research suggests lower satisfaction and worse maternity outcomes for migrant and minority ethnic women both in the United Kingdom and abroad. Most papers exploring ethnic health inequalities have centered on causal factors such as differences in socioeconomic status and host country language ability. Health care policies to tackle inequalities in the United Kingdom, based on these assumptions, have had limited success. Consequently, alternative causal factors need to be explored. This article discusses ethnic inequalities in maternity outcomes in the United Kingdom and proposes that research exploring the client–provider relationship in migrant women’s maternity care could provide important new insights.

The East Timorese: a high-risk ethnic minority in UK obstetrics: a cohort study

OBJECTIVE

To observe the incidence of antenatal risk-factors and adverse maternal outcome in women of East Timorese origin within a UK population.

METHODS

This retrospective cohort study assessed a sample of women of East Timorese Origin (N = 42) attending UK maternity services from 01/2011 to 09/2012 compared to a control group of a standard UK maternity population (N = 7210). Data on the rate of pregnancy related risk-factors and complications were obtained from a computerized patient note database (NIMATS).

RESULTS

The East Timorese were at significant risk antenatally of anaemia (OR 19.5 (95% CI 10.2-37.2) (p < 0.001)), gestational diabetes (OR 10.6 (95% CI 4.6-24.4) (p < 0.001)) and hypertension in pregnancy (OR 4.6 (95% CI 1.4-15.3) (p < 0.01)) as well as late booking for care (OR 19.5 (95% CI 10.2-37.2) p < 0.001). In terms of post-partum complications there was a significant risk of admission to the intensive-care unit (OR 20.0 (95% CI 4.5-89.0) p < 0.001) and of postpartum hemorrhage (OR 15.9 (95% CI 7.7-33.0) p < 0.001). In 72 documented occasions an interpreter could not be obtained.

CONCLUSIONS

Women from East Timor are a high-risk ethnic minority who, with added risk-factors of late booking and difficulty in obtaining interpreters are at greater risk of complications in pregnancy and the puerperium.

Pregnancy, parturition and preeclampsia in women of African ancestry

Maternal and associated neonatal mortality rates in sub-Saharan Africa remain unacceptably high. In Mulago Hospital (Kampala, Uganda), 2 major causes of maternal death are preeclampsia and obstructed labor and their complications, conditions occurring at the extremes of the birthweight spectrum, a situation encapsulated as the obstetric dilemma. We have questioned whether the prevalence of these disorders occurs more frequently in indigenous African women and those with African ancestry elsewhere in the world by reviewing available literature. We conclude that these women are at greater risk of preeclampsia than other racial groups. At least part of this susceptibility seems independent of socioeconomic status and likely is due to biological or genetic factors. Evidence for a genetic contribution to preeclampsia is discussed. We go on to propose that the obstetric dilemma in humans is responsible for this situation and discuss how parturition and birthweight are subject to stabilizing selection. Other data we present also suggest that there are particularly strong evolutionary selective pressures operating during pregnancy and delivery in Africans. There is much greater genetic diversity and less linkage disequilibrium in Africa, and the genes responsible for regulating birthweight and placentation may therefore be easier to define than in non-African cohorts. Inclusion of African women into research on preeclampsia is an essential component in tackling this major disparity of maternal health.

Sexual health is dead in my body: participatory assessment of sexual health determinants by refugees, asylum seekers and undocumented migrants in Belgium and The Netherlands

Background

Although migrants constitute an important proportion of the European population, little is known about migrant sexual health. Existing research mainly focuses on migrants’ sexual health risks and accessibility issues while recommendations on adequate sexual health promotion are rarely provided. Hence, this paper explores how refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands define sexual health, search for sexual health information and perceive sexual health determinants.

Methods

Applying Community-based Participatory Research as the overarching research approach, we conducted 223 in-depth interviews with refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands. The Framework Analysis Technique was used to analyse qualitative data. We checked the extensiveness of the qualitative data and analysed the quantitative socio-demographic data with SPSS.

Results

Our results indicate that gender and age do not appear to be decisive determinants. However, incorporated cultural norms and education attainment are important to consider in desirable sexual health promotion in refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands. Furthermore, our results demonstrate that these migrants have a predominant internal health locus of control. Yet, most of them feel that this personal attitude is hugely challenged by the Belgian and Dutch asylum system and migration laws which force them into a structural dependent situation inducing sexual ill-health.

Conclusion

Refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands are at risk of sexual ill-health. Incorporated cultural norms and attained education are important determinants to address in desirable sexual health promotion. Yet, as their legal status demonstrates to be the key determinant, the prime concern is to alter organizational and societal factors linked to the Belgian and Dutch asylum system. Refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands should be granted the same opportunity as Belgian and Dutch citizens have, to become equally in control of their sexual health and sexuality.

Ethnic variations in severe maternal morbidity in the UK- a case control study

BACKGROUND

Previous studies showed a higher risk of maternal morbidity amongst black and other minority ethnic (BME) groups, but were unable to investigate whether this excess risk was concentrated within specific BME groups in the UK. Our aim was to analyse the specific risks and to investigate reasons for any disparity.

METHODS

Unmatched case-control analysis using data from the United Kingdom Obstetric Surveillance System (UKOSS), February 2005-January 2013. Cases were 1,753 women who experienced severe morbidity during the peripartum period. Controls were 3,310 women who delivered immediately before the cases in the same hospital. Multivariable logistic regression modelling was used to adjust for known confounders and to understand their effects.

RESULTS

Compared with white European women, the odds of severe maternal morbidity were 83% higher among black African women (adjusted odds ratio (aOR) = 1.83; 95% Confidence Interval (CI) = 1.39-2.40), 80% higher among black Caribbean (aOR = 1.80; 95% CI = 1.14-2.82), 74% higher in Bangladeshi (aOR = 1.74; 95% CI = 1.05-2.88), 56% higher in other non-whites (non-Asian) (aOR = 1.56; 95% CI = 1.05-2.33) and 43% higher among Pakistani women (aOR = 1.43; 95% CI = 1.07-1.92). There was no evidence of substantial confounding. Anaemia in current pregnancy, previous pregnancy problems, inadequate utilisation of antenatal care, pre-existing medical conditions, parity>3, and being younger and older were independent risk factors but, the odds of severe maternal morbidity did not differ by socioeconomic status, between smokers and non-smokers or by BMI.

DISCUSSION

This national study demonstrates an increased risk of severe maternal morbidity among women of ethnic minority backgrounds which could not be explained by known risk factors for severe maternal morbidity.

Born in another country: women's experience of labour and birth in Queensland, Australia

BACKGROUND

Women born outside Australia make up more than a fifth of the Queensland birthing population and like migrants in other parts of the world face the challenges of cultural dislocation and possible language barriers. Recognising that labour and birth are major life events the aim was to investigate the experiences of these women in comparison to native-born English speaking women.

METHODS

Secondary analysis of data from a population based survey of women who had recently birthed in Queensland. Self-reported clinical outcomes and quality of interpersonal care of 481 women born outside Australia who spoke a language other than English at home were compared with those of 5569 Australian born women speaking only English.

RESULTS

After adjustment for demographic factors and type of birthing facility, women born in another country were less likely to be induced, but more likely to have constant electronic fetal monitoring (EFM), to give birth lying on their back or side, and to have an episiotomy. Most women felt that they were treated as an individual and with kindness and respect. However, women born outside Australia were less likely to report being looked after 'very well' during labour and birth and to be more critical of some aspects of care.

CONCLUSION

In comparing the labour and birth experiences of women born outside the country who spoke another language with native-born English speaking women, the present study presents a largely positive picture. However, there were some marked differences in both clinical and interpersonal aspects of care.

Overweight and severe acute maternal morbidity in a low-risk pregnant population in the Netherlands

Objective

To investigate the association between overweight and severe acute maternal morbidity (SAMM) in a low-risk pregnant population.

Design

Nationwide case-control study.

Setting

The Netherlands, august 2004 to august 2006.

Population

1567 cases from initially primary care and 2994 women from primary care practices as controls, out of 371 012 women delivering in the Netherlands during the study period

Methods

Cases were women with SAMM obtained from a nationwide prospective study. All women in this cohort who initially had low-risk pregnancies were compared with low-risk women without SAMM to calculate odd ratios (ORs) to develop SAMM by body mass index (BMI) category. We divided body mass index in three overweight categories and calculated the ORs (95% CI) of total SAMM and per specific endpoint by logistic regression, with normal weight as reference. We adjusted for age, parity and socio-economic status.

Main Outcome Measures

SAMM, defined as Intensive Care Unit (ICU)-admission, Uterine Rupture, Eclampsia or Major Obstetric Haemorrhage (MOH)

Results

SAMM was reported in 1567 cases which started as low-risk pregnancies. BMI was available in 1097 (70.0%) cases and 2994 control subjects were included. Analysis showed a dose response relation for overweight (aOR, 1.3; 95% CI, 1.0-1.5), obese (aOR, 1.4; 95% CI, 1.1-1.9) and morbidly obese (aOR, 2.1; 95% CI, 1.3-3.2) women to develop SAMM compared to normal weight. Sub analysis showed the same dose response relation for ICU-admission, Uterine Rupture and Eclampsia. We found no association for MOH.

Conclusion

Overweight without pre-existent co-morbidity is an important risk-indicator for developing SAMM. This risk increases with an increasing body mass index.

Increased risk of severe maternal morbidity (near-miss) among immigrant women in Sweden: a population register-based study

OBJECTIVE

To determine if immigrant women from low-, middle- and high-income countries have an increased risk of severe maternal morbidity (near-miss) when they deliver in Sweden.

DESIGN

Population register-based study.

SETTING

Nationwide study including all singleton deliveries (≥28 weeks of gestation) between 1998 and 2007.

POPULATION

Women with a near-miss event; all women with a singleton delivery ≥28 weeks of gestation during the same period acted as reference group.

METHODS

Near-miss was defined by a combined clinical and management approach with use of International Classification of Diseases, 10th revision codes for severe maternal morbidity. A woman's country of origin was designated as low-, middle- or high-income according to the World Bank Classification of 2009. Unconditional logistic regression models were used in the analysis.

MAIN OUTCOME MEASURES

Maternal near-miss frequencies per 1000 deliveries and odds ratios with 95% confidence intervals.

RESULTS

There were 914 474 deliveries during the study period and 2655 near-misses (2.9 per 1000 deliveries). In comparison to Swedish-born women, those from low-income countries had an increased risk of near-miss (odds ratio 2.3, 95% confidence interval 1.9-2.8) that was significant in all morbidity groups except for cardiovascular diseases and sepsis. Women from middle- and high-income countries showed no increased risk of near-miss.

CONCLUSIONS

Women from low-income countries have an increased risk of maternal near-miss morbidity compared with women born in Sweden. Although the rate is low it should alert healthcare providers.