The perinatal health of immigrant women in France: a nationally representative study

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.

Implementing weight management during and after pregnancy to reduce diabetes and CVD risk in maternal and child populations

Maintaining a healthy weight during pregnancy is critical for both women's and children's health. Excessive gestational weight gain (GWG) can lead to complications such as gestational diabetes, hypertension and caesarean delivery. Insufficient GWG can cause fetal growth restriction and increase infant mortality risk. Additionally, postpartum weight retention raises risk of obesity, type 2 diabetes and other chronic diseases for both mother and child. This review seeks to identify current obstacles in weight management research during and after pregnancy and explore evidence-based strategies to overcome them. Pregnancy offers a window of opportunity for health behaviour changes as women are more receptive to education and have regular contact with health services. Staying within Institute of Medicine's recommended GWG ranges is associated with better maternal and fetal outcomes. Systematic review evidence supports structured diet and physical activity pregnancy interventions, leading to reduced GWG and fewer complications. Health economic evaluation indicates significant returns from implementation, surpassing investment costs due to decreased perinatal morbidity and adverse events. However, the most effective way to implement interventions within routine antenatal care remains unclear. Challenges increase in the postpartum period due to competing demands on women physically, mentally and socially, hindering intervention reach and retention. Flexible, technology-supported interventions are needed, requiring frameworks such as penetration-implementation-participation-effectiveness and template-for-intervention-description-and-replication for successful implementation. Greater research efforts are necessary to inform practice and investigate fidelity aspects through pragmatic implementation trials during the pregnancy and postpartum periods. Understanding the best ways to deliver interventions will empower women to maintain a healthy weight during their reproductive years.

Prevalence of smoking during pregnancy and associated social inequalities in developed countries over the 1995-2020 period: A systematic review

BACKGROUND

Smoking during pregnancy (SDP) is an important source of preventable morbidity and mortality for both mother and child.

OBJECTIVES

The aim of this study was to describe changes in the prevalence of SDP over the last 25 years in developed countries (Human Development Index >0.8 in 2020) and associated social inequalities.

DATA SOURCES

A systematic review was conducted based on a search in PubMed, Embase and PsycInfo databases and government sources.

STUDY SELECTION AND DATA EXTRACTION

Published studies between January 1995 and March 2020, for which the primary outcome was to assess the national prevalence of SDP and the secondary outcome was to describe related socio-economic data were included in the analysis. The selected articles had to be written in English, Spanish, French or Italian.

SYNTHESIS

The articles were selected after successive reading of the titles, abstracts and full-length text. An independent double reading with intervention of a third reader in case of disagreement allowed including 35 articles from 14 countries in the analysis.

RESULTS

The prevalence of SDP differed across the countries studied despite comparable levels of development. After 2015, the prevalence of SDP ranged between 4.2% in Sweden and 16.6% in France. It was associated with socio-economic factors. The prevalence of SDP slowly decreased over time, but this overall trend masked inequalities within populations. In Canada, France and the United States, the prevalence decreased more rapidly in women of higher socio-economic status, and inequalities in maternal smoking were more marked in these countries. In the other countries, inequalities tended to decrease but remained significant.

CONCLUSIONS

During pregnancy, that is a period described as a window of opportunity, smoking and social vulnerability factors need to be detected to implement targeted prevention strategies aiming at reducing related social inequalities.

Differences in birth weight between immigrants' and natives' children in Europe and Australia: a LifeCycle comparative observational cohort study

OBJECTIVE

Research on adults has identified an immigrant health advantage, known as the 'immigrant health paradox', by which migrants exhibit better health outcomes than natives. Is this health advantage transferred from parents to children in the form of higher birth weight relative to children of natives?

SETTING

Western Europe and Australia.

PARTICIPANTS

We use data from nine birth cohorts participating in the LifeCycle Project, including five studies with large samples of immigrants' children: Etude Longitudinale Française depuis l'Enfance-France (N=12 494), the Raine Study-Australia (N=2283), Born in Bradford-UK (N=4132), Amsterdam Born Children and their Development study-Netherlands (N=4030) and the Generation R study-Netherlands (N=4877). We include male and female babies born to immigrant and native parents.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome is birth weight measured in grams. Different specifications were tested: birth weight as a continuous variable including all births (DV1), the same variable but excluding babies born with over 4500 g (DV2), low birth weight as a 0-1 binary variable (1=birth weight below 2500 g) (DV3). Results using these three measures were similar, only results using DV1 are presented. Parental migration status is measured in four categories: both parents natives, both born abroad, only mother born abroad and only father born abroad.

RESULTS

Two patterns in children's birth weight by parental migration status emerged: higher birth weight among children of immigrants in France (+12 g, p<0.10) and Australia (+40 g, p<0.10) and lower birth weight among children of immigrants in the UK (-82 g, p<0.05) and the Netherlands (-80 g and -73 g, p<0.001) compared with natives' children. Smoking during pregnancy emerged as a mechanism explaining some of the birth weight gaps between children of immigrants and natives.

CONCLUSION

The immigrant health advantage is not universally transferred to children in the form of higher birth weight in all host countries. Further research should investigate whether this cross-national variation is due to differences in immigrant communities, social and healthcare contexts across host countries.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

[Diabetes and migration (update 2023)]

The practice recommendation is intended to supplement the existing guidelines on diabetes mellitus and provides practical recommendations for the diagnosis, therapy and care of people with diabetes mellitus who come from different linguistic and cultural back-grounds. The article deals with the demographic datas of migration in Austria and Germany; with therapeutic advice concerning drug therapy and diabetes education for patients with migration background. In this context socio-cultural spezifics are discussed. These suggestions are seen complementary to the general treatment guidelines of the Austrian Diabetes Society and German Diabetes Society. Especially for the fast months Ramadan thera are a lot of informations. The most important point is that the patient care must highly individualized and the management plan may differ for each patient.

Gestational Diabetes and International Migration

In many countries, immigrant women constitute a substantial proportion of women giving birth. With gestational diabetes being one of the most common complications in pregnancy, understanding gestational diabetes in the context of international migration becomes increasingly relevant. Here, we examine the current evidence related to international migration and gestational diabetes, including short- and long-term adverse outcomes and the experiences of immigrant women with gestational diabetes care and long-term follow-up. Existing evidence focuses on immigrants in high-income countries, and has mainly examined differences in the risk of developing gestational diabetes, or on the experiences of immigrant women diagnosed with gestational diabetes. Studies suggest that the risk of gestational diabetes may be influenced by migration and that immigrant women likely experience particular barriers to care and follow-up. Current research on perinatal outcomes is inconclusive and studies on long-term outcomes are practically absent. Future research should include data on country of origin and examine the role of premigration and postmigration factors in developing gestational diabetes and its associated short- and long-term outcomes. Understanding these factors will provide useful insights into improving the health and health care needs of migrating populations and enable inclusion of culturally appropriate health care practices, thereby improving the health of our current and future generations.

Parental migrant status and health inequalities at birth: The role of immigrant educational selectivity

Immigrants tend to exhibit better health than natives despite immigrants' more disadvantaged socioeconomic status. This paradox has often been attributed to immigrants' pre-migration selectivity. However, most empirical studies investigating the role of selectivity have focused on adult health; less attention has been paid to children's birth outcomes outside the U.S. context. Using data from the Etude Longitudinale Française depuis l'Enfance (ELFE), a nationally representative sample of over 18000 births in France in 2011, we investigate the role of immigrant parents' educational selectivity in shaping four birth outcomes: birthweight, low birthweight, prematurity, and being born small for gestational age. Results from linear and logistic regressions confirm a health advantage for children of immigrants compared to natives despite lower parental socioeconomic status, mainly among children of Middle Eastern and North African parents. Immigrant parents' positive pre-migration educational selectivity explains most of this health advantage, predominantly among children with two immigrant parents. Further, mediation analyses indicate that the effect of educational selectivity is partially mediated by parental health behaviors, particularly smoking during pregnancy. Furthermore, analyses suggest that selectivity improves birth outcomes only for children of recent arrivals, with less than five years of residence in France. The beneficial effect of selectivity declines with length of residence, suggesting that a process of "unhealthy assimilation," coupled with the cumulative exposure to health risks and disadvantaged living conditions, may lead to the erosion of the protective effect of immigrant selectivity.

Infant mortality among native-born children of immigrants in France, 2008-17: results from a socio-demographic panel survey

BACKGROUND

Within Europe, France stands out as a major country that lacks recent and reliable evidence on how infant mortality levels vary among the native-born children of immigrants compared with the native-born children of two parents born in France.

METHODS

We used a nationally representative socio-demographic panel consisting of 296 400 births and 980 infant deaths for the period 2008-17. Children of immigrants were defined as being born to at least one parent born abroad and their infant mortality was compared with that of children born to two parents born in France. We first calculated infant mortality rates per 1000 live births. Then, using multi-level logit models, we calculated odds ratios of infant mortality in a series of models adjusting progressively for parental origins (M1), core demographic factors (M2), father's socio-professional category (M3) and area-level urbanicity and deprivation score (M4).

RESULTS

We documented a substantial amount of excess infant mortality among those children born to at least one parent from Eastern Europe, Northern Africa, Western Africa, Other Sub-Saharan Africa and the Americas, with variation among specific origin countries belonging to these groups. In most of these cases, the excess infant mortality levels persisted after adjusting for all individual-level and area-level factors.

CONCLUSIONS

Our findings, which can directly inform national public health policy, reaffirm the persistence of longstanding inequality in infant mortality according to parental origins in France and add to a growing body of evidence documenting excess infant mortality among the children of immigrants in Europe.

Body mass index and gestational weight gain in migrant women by birth regions compared with Swedish-born women: A registry linkage study of 0.5 million pregnancies

Introduction

Women migrating to high-income countries may have increased risks of adverse pregnancy outcomes as compared with native-born women. However, little is known whether migrant women are more likely to have unhealthy body mass index (BMI) or gestational weight gain (GWG), which is of importance considering the well-established links between unhealthy BMI and GWG with adverse pregnancy outcomes. Hence, the aim of the study was to examine the prevalence and estimate odds ratios (ORs) of underweight and obesity in the first trimester as well as inadequate and excessive GWG across birth regions in migrant (first-generation) and Swedish-born women in a population-based sample of pregnant women in Sweden.

Methods

This population-based study included 535 609 pregnancies from the Swedish Pregnancy Register between the years 2010–2018. This register has a coverage of approximately 90% and includes data on body weight, height, birth country and educational attainment. BMI in the first trimester of pregnancy was classified as underweight, normal weight, overweight and obesity whereas GWG was classified as inadequate, adequate and excessive according to the recommendations from the National Academy of Medicine, USA. BMI and GWG were examined according to 7 birth regions and the 100 individual birth countries. Adjusted ORs of underweight, obesity as well as inadequate or excessive GWG by birth regions were estimated using multinomial logistic regression.

Results

There were large disparities in unhealthy BMI and GWG across birth regions. For instance, women born in North Africa and Middle East and Sub-Saharan Africa had 1.40 (95% CI 1.35–1.44) and 2.13 (95% CI 2.03–2.23) higher odds of obesity compared with women born in Sweden. However, women born in Sub-Saharan Africa had also considerably higher odds of underweight (OR, 2.93 [95% CI 2.70–3.18]) and inadequate GWG (OR, 1.97 [95% CI 1.87–2.07]). The limitations of the study include the lack of a validated measure of acculturation and that the study only had data on first-generation migration.

Conclusions

The large differences across the 7 regions and 100 countries highlights the importance of considering birth region and country-specific risks of unhealthy BMI and GWG in first-generation migrant women. Furthermore, inadequate GWG was common among pregnant first-generation migrant women, especially in women born in Sub-Saharan Africa, which demonstrates the need to promote adequate GWG, not only the avoidance of excessive GWG. Thus, our findings also indicate that additional support and interventions may be needed for first-generation migrant women from certain birth regions and countries in order to tackle the observed disparities in unhealthy BMI and GWG. Although further studies are needed, our results are useful for identifying groups of women at increased risk of unhealthy BMI and weight gain during pregnancy.

Gestational diabetes mellitus among Sub-Saharan African and Surinamese women in the Netherlands

AIM

We assessed the association between ethnicity and the risk of gestational diabetes mellitus (GDM) in the Netherlands.

METHODS

A cohort of 7815 women with known GDM status and ethnicity, including women of Sub-Saharan African ethnicity who are currently not identified as high-risk in guidelines. We compared GDM rates among participants of ethnicity to those of ethnic Dutch participants. We employed multivariable regression to correct for possible confounders, including maternal age, pre-pregnancy body mass index (BMI), and education. GDM prevalence and odds ratios based on ethnicity were the main outcome measures.

RESULTS

The prevalence rates of GDM according to ethnicity were: Dutch 0.6%, South-Asian Surinamese 6.9%, African-Surinamese 3.5%, Antillean 1.0%, Turkish 1.0%, Moroccan 1.4%, Ghanaian 6.8%, Sub-Saharan African 3.5%, other Western 0.5% and other non-Western 2.8%. After adjustment for age, pre-pregnancy BMI, and education duration, compared with the reference Dutch-ethnicity population, adjusted odds ratios (aOR) for GDM were statistically significantly higher in South-Asian Surinamese (aOR 10.9; 95% Confidence Interval (CI), 4.7-25.0), African-Surinamese (4.3; 2.0-9.2), Ghanaian (6.5; 3.0-14.5), Sub-Saharan African (5.7; 2.0-16.0), and other non-Western women (4.5; 2.2-9.0). GDM was not significantly increased among Antillean (1.4; 0.2-10.3), Turkish (1.4; 0.4-4.2), Moroccan (1.8; 0.8-4.0), and other Western women (0.8; 0.3-2.2).

CONCLUSIONS

This study shows for the first time in the Netherlands that women of Ghanaian or other Sub-Saharan African ethnicity have an increased risk of developing GDM than the Dutch. This calls for adaptation of the Dutch guidelines of screening high-risk groups for GDM and more awareness amongst obstetric caregivers.

Risk and adverse outcomes of gestational diabetes in migrants: A population cohort study

AIMS

To evaluate the risk of gestational diabetes (GDM) and of neonatal/maternal complications (macrosomia, large for gestational age (LGA), cesarean sections, preterm deliveries, neonatal distress and fetal malformations) among women coming from High Migration Pressure Countries (HMPC), compared to native (Italian) mothers.

METHODS

Risks of GDM and related neonatal/maternal complications were evaluated in a cohort of 581,073 Italian compared with 105,111 HMPC women of age 15-45 yr, resident in Tuscany, Italy along years 2012-2017, delivering 122,652 singleton live births (18,596 from HMPC mothers).

RESULTS

HMPC women, compared to Italian ones, were at higher risk of GDM (OR: 1.586; 1.509-1.666;p < 0.0001), peaking for women originating from South Asia (OR:3.0.49; 2.618-3.553;p < 0.0001). GDM was associated with increased risk of preterm delivery and cesarean sections, while migrants, regardless of GDM, were burdened by a higher risk of all considered complications. The rise in all these risks, including macrosomia or LGA however, disappeared, after addition of interaction term GDM × HMPC ethnicity.

CONCLUSION

Compared to Italian mothers, HMPC women had higher risk of GDM and of all considered adverse events. The addiction of the interaction term GDM × HMPC ethnicity in the predictive model, however reversed the rise in risk of all HMPC associated adverse outcomes.

The maternal health behaviours of non-Irish nationals during pregnancy and the effect of time living in Ireland

OBJECTIVES

Maternal health behaviours (MHBs) can influence pregnancy outcomes. Despite efforts internationally to encourage positive MHBs, women often fail to comply with pregnancy guidelines. International studies show differences in MHBs between nationalities and an effect of time spent in the host country. There is limited Irish data in this area, with no previous research relating to the effect of time in Ireland.

STUDY DESIGN

This study is a cross-sectional analysis of the Growing Up in Ireland infant cohort, a nationally representative longitudinal study.

METHODS

Examination of the MHBs of non-Irish nationals during pregnancy and the effect of time in Ireland on the said behaviours.

RESULTS

An association was found between time spent in Ireland and increased alcohol consumption prevalence. Those living in Ireland for ≤5 years were 60.8% less likely to consume alcohol during pregnancy (0.000) and 29.3% less likely to take folic acid before conception (0.021). Those who smoked during pregnancy were 98.6% more likely to consume alcohol (0.000) and those who consumed alcohol were 95.2% more likely to smoke during pregnancy (0.000).

CONCLUSIONS

The results demonstrate differences in MHBs and the influence of time living in Ireland. These findings are of relevance for policy and intervention planning to optimise pregnancy outcomes among non-nationals.