Differential rates of cesarean delivery by maternal geographical origin: a cohort study in France

Robson ten group classification system for Caesarean sections across Europe: A systematic review and meta-analysis

The aim of this systemic review and meta-analysis was to examine the differences in caesarean section rates across European regions and at a country level by utilizing the Robson classification system. The study has compared caesarean rates across European regions using the Robson classification to identify the drivers of caesarean section use. This review shows significant variations in caesarean section rates across European regions, ranging from 16.9 % in Northern Europe to 43.6 % in Southern Europe. There was a higher contribution of previous CS (Robson Group 5), ranging from 51.2 to 95.0 % of CS in this group to overall rates, particularly in Southern Europe (95.0 %), raises concerns about the "domino effect" of primary caesareans. This finding emphasises the critical importance of strategies to reduce primary CS rates.

BACKGROUND

Caesarean section (CS) rates exhibit considerable global variation, reflecting diverse medical practices, cultural attitudes, and healthcare policies. While some regions maintain relatively low rates, others report significantly higher incidences of the procedure. Analysing these differences is crucial for understanding and developing targeted healthcare strategies and ensuring optimal maternal and neonatal outcomes. This review examines differences in CS rates in Europe according to the Robson 10 group classification.

METHODS

We identified articles between January 2000 to June 2023 using MEDLINE/PubMed, CINAHL, EMBASE, Global Index Medicus, Web of Science and Cochrane library. There was no restriction on patient population, except for birth in a country of the European region. We excluded all studies that were conference proceedings and studies reported in a language other than English and Swedish.

FINDINGS

The search generated a total of 1024 studies, out of which 44 were included, encompassing 6,641,615 births. The majority were from Northern (38 %) and Western Europe (33.5 %). CS rates varied markedly across Europe, ranging from 16.9 % in Northern region to 43.6 % in Southern Europe. The highest contribution to CS rates came from Robson Group 5 (previous CS), with contributions ranging from 51.2 % in Northern to 95.0 % in Southern Europe. The mode of birth for Robson Group 6 (nulliparous, breech) was predominately by CS (88.8 % in Northern to 92.5 % in Central-Eastern Europe).

INTERPRETATION

CS rates continue to vary widely across Europe, with the highest rates in Southern and the lowest in Northern Europe. Previous CS and breech presentation were prominent drivers of CS rates. Region-specific strategies are needed to address these diverse factors to minimise accelerating CS rates across Europe.

Association between maternal social vulnerability and cesarean delivery: A cohort study

OBJECTIVE

Although social vulnerability has been correlated to adverse obstetrical outcomes, its definition as well as its correlation to mode of delivery vary between different studies. The aim of this study is to evaluate the association between maternal social vulnerabilities and cesarean section with the inclusion of a wide range of social vulnerability characteristics.

STUDY DESIGN

The current study is a retrospective single center cohort study in a tertiary care maternity unit between January 2020 and December 2021. All women who delivered after 24 gestational weeks were included. Multiple component analysis (MCA) grouped vulnerability characteristics in three independent vulnerability axes, named after their clinical relevance as administrative, psychological, and dependency axis. Multiple logistic regression was performed, controlling for obstetrical, medical factors as well as the Robson classification.

RESULTS

In total, 7707 patients were identified. After adjustment for the aforementioned factors, a statistically significant association was shown between administrative vulnerability index and cesarean section before labor or during labor respectively (aOR 1.48 [1.23 - 1.78] and aOR 1.46 [OR 1.23 - 1.73]). In contrast, no significant correlation was found for the psychological vulnerability index (aOR 1.09 [0.86 - 1.38] and aOR 0.99 [0.78 - 1.25]) or the dependency vulnerability index (aOR 0.98 [0.76 - 1.26] and aOR 0.85 [0.64 - 1.12]).

CONCLUSIONS

The current study provides new insight into the correlation between social vulnerabilities and the risk of cesarean section. It demonstrates that administrative vulnerability is an independent risk factor of cesarean delivery. These patients should be identified and offered an adapted pregnancy monitoring in order to reduce cesarean section rates.

Obstetric Interventions Among Native and Migrant Women: The (Over)use of Episiotomy in Portugal

Objective: Episiotomy, defined as the incision of the perineum to enlarge the vaginal opening during childbirth, is one of the most commonly performed surgical interventions in the world. We aimed to determine if migrant status is associated with episiotomy, and if individual characteristics mediate this association. Methods: We analyzed data from the Bambino study, a national, prospective cohort of migrant and native women giving birth at a public hospital in mainland Portugal between 2017 and 2019. We included all women with vaginal delivery. The association between migrant status and episiotomy was assessed using multivariable multilevel random-effect logistic regression models. We used path analysis to quantify the direct, indirect and total effects of migrant status on episiotomy. Results: Among 3,583 women with spontaneous delivery, migrant parturients had decreased odds of episiotomy, especially those born in Africa, compared to native Portuguese women. Conversely, with instrumental delivery, migrant women had higher odds of episiotomy. Disparities in episiotomy were largely explained by maternity units' factors, and little by maternal and fetal characteristics. Conclusion: Our results suggest non-medically justified differential episiotomy use during childbirth and highlight the importance of developing evidence-based recommendations for episiotomy use in a country with a high frequency of medical interventions during delivery.

Cesarean birth rates among migrants in Europe: A systematic review

BACKGROUND

Cesarean birth (CB) rates have increased over recent years with concerns over differences between these rates in migrant communities compared with the rates among women in their receiving country. This review aimed at summarizing the available literature regarding the incidence of CB among migrants in Europe.

METHODS

A systematic search of four electronic databases was carried out, including CINAHL, MEDLINE, Scopus, and Maternity and Infant Care. Identified studies were screened and their quality assessed. Meta-analysis was undertaken using Rev Man 5.4 where sufficient data were available. Otherwise, data were synthesized narratively.

RESULTS

From the 435 records identified in searches, 21 papers were included. Analysis shows that overall CB rates were significantly lower for Syrian refugee women compared with women in their receiving country (Turkey) and higher for Iranian migrants than women in their host country. Emergency CB rates were significantly higher for migrant women from "Sub Saharan Africa" and the "South East Asia, Asia and Pacific" region than rates in the receiving country. Statistical significance was not found between other populations.

CONCLUSIONS

This review highlights differences between CB rates in certain migrant groups in comparison with women native to their host country, which merits further investigation for potential explanations. We also identified a need to standardize definitions and population groupings to enable more meaningful analysis. This review also highlights a substantial lack of data on CB rates between different population groups that could negatively impact the provision of care.

[Relevance of the transcultural approach to improve the care relationship in the perinatal period]

The international literature review highlights higher neonatal morbimortality in migrant patients and their babies. The explanatory hypotheses include late pregnancy follow-up with difficulty accessing care, language barriers, and different cultural representation in pregnancy support. On the one hand, we propose to explain the cultural factors that can impact the caring relationship during the perinatal period. On the other hand, we set out tools for anthropological and psychological understanding to enhance the sharing of cultural representations around pregnancy follow-up, the needs of a baby, and obstetrical or postnatal complications. The request for a specialised transcultural opinion needs to be more systematic; the transcultural posture is adaptable to each care professional. This requires the professional to address explicitly the impact of culture in care and consider their own cultural distance. Specialised advice is recommended in certain situations of cumulative vulnerability (complex trauma, perinatal depression with cultural coding of symptoms), blockage or refusal of care for cultural reasons and to avoid cultural misunderstandings. We detail two modalities: mediation and a discussion group around cultural issues set up in the maternity ward. The institutional work we propose within the multidisciplinary team in the maternity ward also allows the acquisition of transcultural competencies.

Migrant mothers' experiences of Caesarean section: a transcultural qualitative study

Objectives

Migrant women face an increased risk of adverse obstetrical outcome and Caesarean section. The psychological experience of Caesarean section combines physiological, social, and cultural dimensions. This qualitative study explores the subjective experiences of first-generation migrant women who gave birth by Caesarean section.

Methods

Seven qualitative, semi-directed interviews were conducted from January to March 2022 in a Paris maternity hospital, with women in their postpartum period who had had a scheduled or emergency Caesarean section and straightforward obstetrical outcomes. The presence of an interpreter-mediator was systematically offered. Thematic analysis of the interviews was carried out following the Interpretative Phenomenological Analysis (IPA) methodology.

Results

Four themes were identified in the thematic analysis relating to the women's experiences of Caesarean section: (1) The shock of the intervention combines disappointment, fear and early separation from the baby, (2) Pregnancy and delivery far from one's family aggravates the psychological suffering caused by isolation and loneliness related to migration, (3) The lack of cultural representations of Caesarean section leads to negative preconceptions and hinders mental preparation, in contrast with traditional or medicalised childbirth, and (4) The women's experiences of the medical follow-up highlights the importance of the continuity of care.

Discussion and conclusion

Caesarean section, which is a physical break, re-enacts the symbolic break (cultural, social, familial) that follows on from emigration. Improvements in care include the need for a better preparation for Caesarean section, active efforts for care continuity, and the development of early prevention interviews and groups in maternity units.

Use of labour neuraxial analgesia according to maternal immigration status: a national cross-sectional retrospective population-based study in France

BACKGROUND

Disparities in neuraxial analgesia use for childbirth by maternal origin have been reported in high-resource countries. We explored the association between maternal immigrant status (characterised separately by geographic continental origin and Human Development Index [HDI] of maternal country of birth) and neuraxial analgesia use. We hypothesised that immigrant women from low-resource countries may have more limited access to neuraxial analgesia than native French women.

METHODS

The study population, extracted from the 2016 National Perinatal Survey, a cross-sectional study of a representative sample of births in France, included only women who initially wished to deliver with neuraxial analgesia. We used multivariable multilevel logistic regression to explore the association between immigrant status and both use of neuraxial analgesia and its timely administration.

RESULTS

Among the 6070 women included, 88.1% gave birth with neuraxial analgesia and 15.8% were immigrants. There was no difference in neuraxial analgesia use between native French women and either immigrant women by geographic continental region of origin, or immigrants from countries with low HDI. However, immigrants from countries with very high HDI were more likely to give birth with neuraxial analgesia (adjusted odds ratio [aOR]=2.6; 95% confidence interval (CI), 1.2-5.8; P=0.018) and its timeliness <60 min after admission (aOR=1.8; 95% CI, 1.2-2.7; P=0.005) compared with native French women.

CONCLUSIONS

In France, immigrant women from low-resource countries have similar access to labour neuraxial analgesia to native French women. Our results suggest differential neuraxial analgesia use in favour of immigrant women from very high HDI countries compared with native women.

Caesarean delivery in a migration context: the role of prior delivery in the host country

Migrant women in industrialised countries experience high caesarean section (CS) rates but little is known about the effect of a previous delivery in the host country. This study set out to investigate this effect among migrant women in France, using data from the DSAFHIR study on healthcare access of migrant women living in emergency housing hotels, collected in the Paris Metropolitan area in 2017. Respondents reported life-long history of deliveries. We focused on deliveries occurring in France in 2000–2017: 370 deliveries reported by 242 respondents. We conducted chi-square tests and multivariate logistic regressions, adjusting for the clustering of deliveries among respondents by computing standard errors allowing for intragroup correlation. Mode of delivery was associated with duration of residence among multiparous women with no prior CS, with a higher CS rate with shorter duration of residence (16% vs. 7%, p = 0.04). In this group, a previous delivery in France was associated with a lower CS rate (5% vs. 16%, p = 0.008). In multivariate analysis, compared with women with previous birth in France, women giving birth in France for the first time had a higher risk of CS, regardless of duration of residence (aOR = 4.0, 95% CI = 1.3–12.1 for respondents with short duration of residence, aOR = 4.7, 95% CI = 1.2–18.0 for respondents with longer duration of residence). Efforts directed at decreasing the CS rate among migrant women should target women giving birth in the host country for the first time.

Association between Maternal Origin, Pre-Pregnancy Body Mass Index and Caesarean Section: A Nation-Wide Registry Study

Aims: To explore the association between maternal origin and birthplace, and caesarean section (CS) by pre-pregnancy body mass index (BMI) and length of residence. Methods: We linked records from 118,459 primiparous women in the Medical Birth Registry of Norway between 2013 and 2017 with data from the National Population Register. We categorized pre-pregnancy BMI (kg/m²) into underweight (<18.5), normal weight (18.5–24.9) and overweight/obese (≥25). Multinomial regression analysis estimated crude and adjusted relative risk ratios (RRR) with 95% confidence intervals (CI) for emergency and elective CS. Results: Compared to normal weight women from Norway, women from Sub-Saharan Africa and Southeast Asia/Pacific had a decreased risk of elective CS (aRRR = 0.57, 95% CI 0.37–0.87 and aRRR = 0.56, 0.41–0.77, respectively). Overweight/obese women from Europe/Central Asia had the highest risk of elective CS (aRRR = 1.42, 1.09–1.86). Both normal weight and overweight/obese Sub-Saharan African women had the highest risks of emergency CS (aRRR = 2.61, 2.28-2.99; 2.18, 1.81-2.63, respectively). Compared to women from high-income countries, the risk of elective CS was increasing with a longer length of residence among European/Central Asian women. Newly arrived migrants from Sub-Saharan Africa had the highest risk of emergency CS. Conclusion: Women from Sub-Saharan Africa had more than two times the risk of emergency CS compared to women originating from Norway, regardless of pre-pregnancy BMI.

Social and ethnic disparities in stillbirth and infant death in Denmark, 2005-2016

Ethnic disparity in stillbirth and infant death has been demonstrated in Europe. As the relation between migration and health change over time, this population based register study investigated the recent figures and explored if potential differences could be explained by the well-known educational and income inequalities in stillbirth and infant death using a novel approach. Stillbirth and infant mortality varied considerably according to country of origin, with only immigrants from China, Norway, and Poland having an overall lower risk than Danish women. Women of Pakistani, Turkish, and Somali origin had a particularly high risk of both outcomes. Women from recent high conflict areas displayed a pattern with increased stillbirth risk. An observed excess risks across generations was found, which is disturbing and rule out factors related to language barriers or newness. Differences in educational level and household income explained only part of the observed inequalities. Strengthening of the maternity care system to better understand and meet the needs of immigrant women seems needed to mitigate the disparities.

A Cross-Sectional Study Examining Differences in Indication for Cesarean Delivery by Race/Ethnicity

(1) Background: There are persistent racial/ethnic disparities in cesarean delivery in the United States (U.S.), yet the causes remain unknown. One factor could be provider bias. We examined medical indications for cesarean delivery that involve a greater degree of physician discretion (more subjective) versus medical indications that involve less physician discretion (more objective) to better understand factors contributing to the higher rate among Micronesian, one of the most recent migrant groups in the state, compared to White women in Hawai'i. (2) Methods: A retrospective chart review was conducted to collect data on 620 cesarean deliveries (N = 296 White and N = 324 Micronesian) at the state's largest maternity hospital. Multivariate regression models were used to examine associations between maternal and obstetric characteristics and (1) subjective indication defined as non-reassuring fetal heart tracing (NRFHT) and arrest of labor disorders, and (2) objective indication defined as all other indications (e.g., malpresentation). (3) Results: We found that Micronesian women had significantly higher odds of cesarean delivery due to a subjective indication compared to White women (aOR: 4.17; CI: 2.52-6.88; P < 0.001; N = 619) after adjusting for multiple covariates. (4) Conclusion: These findings suggest unmeasured factors, possibly provider bias, may influence cesarean delivery recommendations for Micronesian women in Hawai'i.

Mothers' experiences of perinatal care in Belgian public hospitals: exploring the social inequalities. Protocol for a cross-sectional survey

INTRODUCTION

In Europe, the social inequalities in perinatal health are usually found to be to the disadvantage of non-European immigrants and women with lower levels of education and income. Among the possible underlying mechanisms are inadequate access to healthcare services and suboptimal care. To explore this hypothesis in the Belgian context, our research will describe detailed maternal socioeconomic and migration characteristics, explore how these factors relate to each other, and how they relate to women's perinatal care trajectories and experiences of care.

METHODS

Using a modified version of the Migrant-Friendly Maternity Care Questionnaire, we will survey 900 mothers of Belgian nationality or a nationality from a North or Sub-Saharan African country, and having given birth in four maternity wards in Brussels. The questionnaire has been adapted to the study objectives and the Belgian context. Interviewers will administer the 116-item questionnaire to all women agreeing to participate and meeting inclusion criteria, within 14 days of having given birth. Clinical information will be extracted from hospital records.

ANALYSIS

We will estimate the associations of women's socioeconomic and migration characteristics with:Women's antenatal care trajectories (timing of first antenatal consultation, minimum recommended number of consultations, and problems accessing care).Obstetric practices such as episiotomies, emergency caesarean sections, and inductions.Patient experience such as feelings of discrimination, respect, and understanding of information.We will use descriptive statistics, multiple correspondence analysis, and simple and multiple logistic regressions.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the hospital Ethics Committees and from the Université libre de Bruxelles (No: P2017/055/B406201730877). Written informed consent will be sought from all participants.In addition to disseminating findings and recommendations to the scientific community through open-source journal articles and conferences, we will also address local organisations and healthcare professionals via a written report and seminars.

ehealth literacy and health literacy among immigrants and their descendants compared with women of Danish origin: a cross-sectional study using a multidimensional approach among pregnant women

OBJECTIVE

To explore ehealth literacy, ability to actively engage with healthcare providers and health system navigation among pregnant immigrant women and their descendants compared with women of Danish origin.

DESIGN AND SETTING

A cross-sectional survey at antenatal clinics in 2016, Denmark.

PARTICIPANTS

Pregnant women attending antenatal care (n=405).

OUTCOME MEASURES

The eHealth Literacy Questionnaire (eHLQ) and two domains from the Health Literacy Questionnaire (HLQ): ability to actively engage with healthcare providers and health system navigation. Range of response options for eHLQ (1-4) and HLQ (1-5). With mixed-effect linear regressions, eHLQ and HLQ among immigrants and their descendants compared with women of Danish origin were assessed.

RESULTS

The response rate was 75%. The overall trend was lower ehealth literacy and HLQ domains among immigrants and their descendants compared with women of Danish origin. For ehealth literacy, the results suggest that challenges related more to digital abilities than motivation, trust and access to technology. The mean ability to engage with digital services was 3.20 (SD 0.44) for women of Danish origin. Non-Western descendants (-0.14, 95% CI -0.31 to 0.02), non-Western (-0.20, 95% CI -0.34 to -0.06) and Western (-0.22, 95% CI -0.39 to -0.06) immigrants had lower adjusted means of this outcome. No differences in motivation to engage with digital services were found for descendants (-0.00, 95% CI -0.17 to 0.17), non-Western (0.03, 95% CI -0.11 to 0.18) or Western (-0.06, 95% CI -0.23 to 0.10) immigrants compared with the mean of the reference (2.85, SD 0.45). Lower ability to engage with healthcare providers was found for non-Western born immigrants (-0.15, CI 95% -0.30 to -0.01) compared with the mean of women with Danish origin (4.15, SD 0.47).

CONCLUSION

Generally, descendant and immigrant women had lower levels of ehealth literacy and health literacy than women of Danish origin. These differences are potentially antecedents of adverse birth outcomes and could inform structural efforts to mitigate health inequalities.