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

INTRODUCTION: Approximately 21% of Germany's inhabitants have been born abroad or are of direct descent of immigrants. A positive birth experience has an effect on a woman's mental health and her future family planning choices. While international studies showed that immigrant women are less satisfied with their birth experience, no such study has been conducted in Germany until now. METHODS: At our center of tertiary care in Berlin, with approximately 50% immigrants among patients, pregnant women of at least 18 years of age were offered participation in this study. A modified version of the Migrant Friendly Maternity Care Questionnaire (MFMCQ) designed by Gagnon et al. in German, English, French, Spanish, Arabic and Turkish was used. We compared non-immigrant women to immigrant women and women with direct descent of immigrants. For certain analysis, the latter two groups were included together under the category "migration background". RESULTS: During the study period, 184 non-immigrant, 214 immigrant women and 62 direct descendants of immigrants were included. The most frequent countries of origin were Syria (19%), Turkey (17%), and Lebanon (9%). We found a slight difference between groups regarding age (non-immigrants: mean 33 years versus women with any migration background: mean 31) as well as parity with more non-immigrants delivering their first child. No difference in the satisfaction with care was observed between immigrant and any migration background groups (p ≥ 0.093 in the two-sided Fisher's exact test). At least 75.8% of all participating women reported complete satisfaction with care during labor, birth and after birth. Interestingly, the level of German language proficiency did not influence the immigrant patient's satisfaction with care. CONCLUSION: The study results show no difference regarding overall satisfaction with care during labor and birth despite a relevant language barrier. We are for the first time providing the MFMCQ in German and Turkish. Further future analyses on the impact of patient expectations on satisfaction with care will be conducted.

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

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

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

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

[Are women with and without migration background reached equally well by health services? The example of antenatal care in Berlin]. / Werden Frauen mit und ohne Migrationshintergrund von den Gesundheitsdiensten gleich gut erreicht? : Das Beispiel Schwangerenvorsorge in Berlin.

BACKGROUND: About 20% of the population in Germany has a migration background (1st generation: immigrated themselves; 2nd generation: offspring of immigrants), which can be associated with health differentials. We assessed whether differentials in uptake of antenatal care (ANC) observed in earlier studies still persist today. METHODS: Data collection in 3 obstetric hospitals in Berlin, Germany, over a 1-year period 2011/2012. We conducted standardised interviews before delivery and linked the data to routinely collected perinatal data and to data from participants' antenatal cards. We checked for confounders using regression models. RESULTS: Of the 7100 study participants (response 89.6%), 57.9% had a migration background. First ANC attendance occurred in pregnancy weeks 3-19 in 92.1% of 1st generation immigrants vs. 97.8% of non-immigrants (mean week of first attendance: 1st generation immigrants with residence < 5 years: 13.0; 5+ years: 9.9; non-immigrants 9.7). A low ANC utilisation with ≤ 5 visits was found in 644 women (9.1%). Among the non-immigrants there were 7.1% low users, among 1st generation immigrants 11.8% (among women with no German language skills 33.0%, however). Uptake of non-medical support measures was lower among women with migration background. DISCUSSION: In our sample from Berlin, migration background had little effect on ANC uptake. Neither own migration nor low acculturation were independent risk factors for late onset or low utilisation of ANC. However, a small subgroup of women with a short duration of residence in Germany and with German language problems had a lower chance of timely onset and sufficient participation in ANC. This group needs special attention.

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

Aims: The aim of the study was to compare obstetrical process indicators and outcomes for German women with women of Turkish origin residing in Germany. Do women of Turkish origin attend antenatal examinations as frequently as non-immigrant women? Are high-risk pregnancies and anemia more common among immigrant women? Are the rates for epidural analgesia (PDA) and combined spinal-epidural analgesia (CSE) during delivery the same for immigrant women compared to German women? Are there identifiable differences in the mode of delivery and in perinatal outcomes? Patient Population/Methods: Data were obtained from 3 maternity clinics in Berlin for the period 2011 to 2012. The questionnaires covered socio-demographic factors and information on prenatal care as well as immigration/acculturation. The data obtained from these questionnaires was supplemented by information obtained from the official maternal record of prenatal and natal care (Mutterpass) and perinatal data recorded by the clinic. Results: The response rate was 89.6 %; the data of 1277 women of Turkish origin who had immigrated to Germany or whose family had immigrated and of 2991 non-immigrant women in Germany were included in the study. Regression analysis showed no statistically significant difference in the number of antenatal examinations between immigrant and non-immigrant women. Women of Turkish origin born in Germany had a significantly higher risk of postpartum anemia. PDA/CSE rate, arterial umbilical cord pH and 5-minute Apgar scores did not differ. The incidence of cesarean sections (elective and secondary) was significantly lower in the population of immigrant women of Turkish origin. Conclusion: Outcomes for most perinatal parameters were comparable for immigrant and non-immigrant women. These results indicate that the achieved standards of antenatal care and medical care during pregnancy are similar for Turkish immigrant women compared to non-immigrant women in maternity clinics in Berlin. The higher rates of anemia among immigrant women should be targeted by preventive measures.

The concept of "intercultural opening": the development of an assessment tool for the appraisal of its current implementation in the mental health care system.

The German concept of "intercultural opening" is an approach to facilitating migrants' access to the health care system and improving the care they receive. No data exist concerning the current status of the implementation of this approach in Germany, and the concept has never been analysed in practice. To assess the status of "intercultural opening" in the German mental health care system and to further analyse the concept, we developed a tool by combining pre-existing instruments. In order to review the preliminary tool we combined experts' knowledge by carrying out a consensusoriented, expert-based Delphi process with actual practice by piloting the instrument in each type of institution to be assessed. The assessment tool thus developed(1) is the first one to evaluate the current status of "intercultural opening" in the community mental health care system in Germany from a broad perspective. This paper is intended to present the development process of our assessment tool for demonstrating the benefits of this approach and as a model for future studies, as well as to increase transparency in relation to the current German approach to health care structures in dealing with migrants.

[A basic set of indicators for mapping migrant status. Recommendations for epidemiological practice]. / Mindestindikatorensatz zur Erfassung des Migrationsstatus. Empfehlungen für die epidemiologische Praxis.

Data on the health status of migrants are still scarce. One of the reasons for this is that migration status has not been well recorded in official statistics and epidemiological studies. In order to obtain an adequate and standardised operationalisation of migrant status, we first need an exact definition of the terms "migrant" and "migration background". We discuss approaches to the definition of terms and the surveying of ethnic minorities and migrants, and then develop a basic set of migration status indicators for use in epidemiological research. This set of indicators includes country of birth of the father and mother, year of immigration, mother tongue, German language skills and status of residence. The key indicator for the identification of migrants is the country of birth of the parents and not the nationality as was previously often the case. Thus, the classification based on the judicial category of nationality is replaced by a classification based on the biographical event "migration". Migration brings with it specific life conditions and challenges that can impact health across several generations. An instrument for surveying migrant status must be further developed both to reflect the special conditions of the life situation resulting from the migration experience and to take as full account as possible of all aspects of a migrant's history.

[Pain and ethnicity - results of a survey at three internal/gynecological first-aid stations in Berlin]. / Schmerz und Ethnizität - Ergebnisse einer Befragung an drei internistisch/gynäkologischen Rettungsstellen in Berlin.

QUESTION: How high is the pain pressure in everyday life of German vs. not German patients, with which troubles do they come to the emergency room, how intense is their pain, how long is it lasting, how many pain areas are named? GROUP OF PATIENTS/METHODS: The study "Utilization of clinical emergency rooms by German patients and migrants" was carried out at first-aid stations of three Berlin hospitals in municipal districts with a high share of foreigners in the population in the form of standardized interviews on following topics: roads to have access to the emergency room, perception and interpretation of pain/troubles, expectations from the first-aid station, further medical care, chronical diseases, self-help measures, social data, migration aspects. RESULTS: An everyday life pressure because of headache and rheumatic pains was named significant more often by migrants of Turkish extraction than by the German women asked. In the age-group 50-65 years the migrants chose significant higher scale values to characterize their pain intensity. Migrants named all in all clearly more pain areas than German patients. The share of patients with pain persisting more than three days was 36.1 % in German women, 45.5 % in migrants of Turkish origin, 45.8 % in women of other ethnicity. CONCLUSIONS: Pain interpretation as well as pain expression are socio-culturally conditioned. Differences between migrants and native patients should lead to take more into consideration the concrete life situation and specific strain in the patients' treatment.

[What Turkish-speaking women expect in a German hospital and how satisfied they are with health care during their stay in a gynaecological hospital in Berlin - a comparative approach]. / Erwartungen und Zufriedenheit deutscher und türkischsprachiger Patientinnen im Krankenhaus - eine vergleichende Befragung in einer Berliner Frauenklinik.

Although cultural diversity in German metropolises is rapidly increasing, immigrant patients are rarely included in clinical studies. Specific needs of these patients are hardly known. In a comparative study, 320 German and 262 Turkish immigrant women, respectively, were interviewed via bilingual questionnaires to assess their expectations from and their satisfaction with provided health care services. While no significant differences could be found between basic expectations concerning anticipated health care standards between the two study groups, women of Turkish origin were markedly less satisfied with provided health care services. High expectations of immigrant patients towards information during their stay, communication with doctors and nurses and psychosocial services were only insufficiently met. The results indicate that specific health-relevant factors, such as social and educational status, knowledge of German language and health knowledge together with structural deficiencies of a health care service that is not prepared to correspond properly to patients of different social and cultural backgrounds, have a negative impact on patient satisfaction for migrant women.

[Female menopause--comparison of knowledge and opinion in German and Turkish-born women]. / Die Wechseljahre der Frau--Kenntnisse und Meinungen deutscher und türkischstämmiger Frauen im Vergleich.

320 German and 262 Turkish immigrant patients of the gynaecological units of the Virchow Women's Clinic in Berlin were questioned, to compare their knowledge and opinion on menopause and possible cultural influence factors. The results showed that 70% of the migrant vs. 90% of the German women regarded menopause as a normal phase in a women's life and more Turkish than German women (35% vs. 7%) associated complaints with menopause. However the immigrant women knew noticeably less about health risks related to menopause (10% vs. 50%).

Knowledge among German and Turkish women about specifically female bodily functions, contraception, preventative medical examinations and menopause.

The legally binding consent of a patient to surgical operations of certain diagnostic measures during hospitalisation is actually guaranteed only in cases where the medical information is oriented to the individual level of understanding of the patient. The real extent of actual knowledge about health relevant aspects is not always known. Immigrant women constitute a large portion of the patients in big German cities. In most clinics the difficulties in communication caused by persistent language barriers are not presently being solved in a satisfactory manner. In light of this situation, it seemed necessary to ascertain the knowledge of German and Turkish women with respect to specifically female bodily functions, contraception, preventative medical examinations and menopause. The study included a total of 320 German and 262 Turkish patients of both gynaecological units at the Virchow Women's Clinic in Berlin during the 1 1/2-year inquiry period (1997/98). The questionnaire we used was laid out in multiple choice format, whereby each question was provided with a list of possible answers (level of significance p < 0.05). Only a small portion of the general female populace (approximately 13% of the study population, 22% of German patients) is well-to-very-well informed about 'specific female bodily functions, anatomy, preventative health care and contraception', and this proportion is even smaller among Turkish female patients (3% of Turkish women surveyed). While the understanding demonstrated by immigrants who possessed strong writing skills in German is nearly as great as that of the German group, the proportion of patients who demonstrated less sophisticated understanding was still twice as high with 32.5% as compared to that of the German group (15%). According to the opinion of approximately one-third of the Turkish immigrants (German women 8.2%) surveyed, there are no (increased) health risks associated with menopause.