Perinatal mortality among pregnant undocumented migrants in Norway 1999-2020: A register-based population study.

BACKGROUND: Irregular legal status is a recognized health risk factor in the context of migration. However, undocumented migrants are rarely included in health surveys and register studies. Adverse perinatal outcomes are especially important because they have long-term consequences and societal risk factors are modifiable. In this study, we compare perinatal outcomes in undocumented migrants to foreign-born and Norwegian-born residents, using a population-based register. METHODS: We included women 18-49 years old giving birth to singletons as registered in the Medical Birth Registry of Norway from 1999 to 2020. Women were categorized as 'undocumented migrants' (without an identity number), 'documented migrants' (with an identity number and born abroad), and 'non-migrants' (with an identity number and born in Norway). The main outcome was perinatal mortality, i.e., death of a foetus ≥ gestational week 22, or neonate up to seven days after birth. We used log-binominal regression to estimate the association between legal status and perinatal mortality, adjusting for several maternal pre-gestational and gestational factors. Direct standardization was used to adjust for maternal region of origin. ETHICAL APPROVAL: Regional Ethical Committee (REK South East, case number 68329). RESULTS: We retrieved information on 5856 undocumented migrant women who gave birth during the study period representing 0.5% of the 1 247 537 births in Norway. Undocumented migrants had a relative risk of 6.17 (95% confidence interval 5.29 ̶7.20) of perinatal mortality compared to non-migrants and a relative risk of 4.17 (95% confidence interval 3.51 ̶4.93) compared to documented migrants. Adjusting for maternal region of origin attenuated the results slightly. CONCLUSION: Being undocumented is strongly associated with perinatal mortality in the offspring. Disparities were not explained by maternal origin or maternal health factors, indicating that social determinants of health through delays in receiving adequate care and factors negatively influencing gestational length may be of importance.

Risk of obstetric anal sphincter injury associated with female genital mutilation/cutting and timing of deinfibulation.

INTRODUCTION: A greater risk of obstetric anal sphincter injury has been reported among African migrants in several host countries compared with the general population. To what degree female genital mutilation/cutting affects this risk is not clear. In infibulated women, deinfibulation prevents anal sphincter injury. Whether the timing of deinfibulation affects the risk, is unknown. This study aimed to investigate the risks of anal sphincter injury associated with female genital mutilation/cutting and timing of deinfibulation in Norway, and to compare the rates of anal sphincter injury in Somali-born women and the general population. MATERIAL AND METHODS: In a historical cohort study, nulliparous Somali-born women who had a vaginal birth in the period 1990-2014 were identified by the Medical Birth Registry of Norway and data collected from medical records. Exposures were female genital mutilation/cutting status and deinfibulation before labor, during labor or no deinfibulation. The main outcome was obstetric anal sphincter injuries. RESULTS: Rates of obstetric anal sphincter injury did not differ significantly by female genital mutilation/cutting status (type 1-2: 10.2%, type 3: 11.3%, none: 15.2% P = 0.17). The total rate of anal sphincter injury was 10.3% compared to 5.0% among nulliparous women in the general Norwegian population. Women who underwent deinfibulation during labor had a lower risk than women who underwent deinfibulation before labor (odds ratio 0.48, 95% confidence interval 0.27-0.86, P = 0.01). CONCLUSIONS: The high rate of anal sphincter injury in Somali nulliparous women was not related to type of female genital mutilation/cutting. Deinfibulation during labor protected against anal sphincter injury, whereas deinfibulation before labor was associated with a doubled risk. Deinfibulation before labor should not be routinely recommended during pregnancy.

Challenges and barriers to optimal maternity care for recently migrated women - a mixed-method study in Norway.

BACKGROUND: Migrant women are at increased risk for complications related to pregnancy and childbirth, possibly due to inadequate access and utilisation of healthcare. Recently migrated women are considered a vulnerable group who may experience challenges in adapting to a new country. We aimed to identify challenges and barriers recently migrated women face in accessing and utilising maternity healthcare services. METHODS: In the mixed-method MiPreg-study, we included recently migrated (≤ five years) pregnant women born in low- or middle-income countries and healthcare personnel. First, we conducted 20 in-depth interviews with migrant women at Maternal and Child Health Centres (MCHC) and seven in-depth interviews with midwives working at either the hospital or the MCHCs in Oslo. Afterwards, we triangulated our findings with 401 face-to-face questionnaires post-partum at hospitals among migrant women. The data were thematically analysed by grouping codes after careful consideration and consensus between the researchers. RESULTS: Four main themes of challenges and barriers faced by the migrant women were identified: (1) Navigating the healthcare system, (2) Language, (3) Psychosocial and structural factors, and (4) Expectations of care. Within the four themes we identified a range of individual and structural challenges, such as limited knowledge about available healthcare services, unmet needs for interpreter use, limited social support and conflicting recommendations for pregnancy-related care. The majority of migrant women (83.6%) initiated antenatal care in the first trimester. Several of the challenges were associated with vulnerabilities not directly related to maternal health. CONCLUSION: A combination of individual, structural and institutional barriers hinder recently migrated women in achieving optimal maternal healthcare. Suggested strategies to address the challenges include improved provision of information about healthcare structure to migrant women, increased use of interpreter services, appropriate psychosocial support and strengthening diversity- and intercultural competence training among healthcare personnel.

Newly Arrived Migrant Women's Experience of Maternity Health Information: A Face-to-Face Questionnaire Study in Norway.

Limited understanding of health information may contribute to an increased risk of adverse maternal outcomes among migrant women. We explored factors associated with migrant women's understanding of the information provided by maternity staff, and determined which maternal health topics the women had received insufficient coverage of. We included 401 newly migrated women (≤5 years) who gave birth in Oslo, excluding migrants born in high-income countries. Using a modified version of the Migrant Friendly Maternity Care Questionnaire, we face-to-face interviewed the women postnatally. The risk of poor understanding of the information provided by maternity staff was assessed in logistic regression models, presented as adjusted odds ratios (aORs), with 95% confidence intervals (CI). The majority of the 401 women were born in European and Central Asian regions, followed by South Asia and North Africa/the Middle East. One-third (33.4%) reported a poor understanding of the information given to them. Low Norwegian language proficiency, refugee status, no completed education, unemployment, and reported interpreter need were associated with poor understanding. Refugee status (aOR 2.23, 95% CI 1.01-4.91), as well as a reported interpreter need, were independently associated with poor understanding. Women who needed but did not get a professional interpreter were at the highest risk (aOR 2.83, 95% CI 1.59-5.02). Family planning, infant formula feeding, and postpartum mood changes were reported as the most frequent insufficiently covered topics. To achieve optimal understanding, increased awareness of the needs of a growing, linguistically diverse population, and the benefits of interpretation services in health service policies and among healthcare workers, are needed.

Satisfaction with maternity care among recent migrants: an interview questionnaire-based study.

OBJECTIVE: To examine factors associated with recently migrated women's satisfaction with maternity care in urban Oslo, Norway. DESIGN: An interview-based cross-sectional study, using a modified version of Migrant Friendly Maternity Care Questionnaire. SETTING: Face-to-face interview after birth in two maternity wards in urban Oslo, Norway, from January 2019 to February 2020. PARTICIPANTS: International migrant women, ≤5 years length of residency in Norway, giving birth in urban Oslo, excluding women born in high-income countries. PRIMARY OUTCOME: Dissatisfaction of care during pregnancy and birth, measured using a Likert scale, grouped into satisfied and dissatisfied, in relation to socio-demographic/clinical characteristics and healthcare experiences. SECONDARY OUTCOME: Negative healthcare experiences and their association with reason for migration. RESULTS: A total of 401 women answered the questionnaire (87.6% response rate). Overall satisfaction with maternal healthcare was high. However, having a Norwegian partner, higher education and high Norwegian language comprehension were associated with greater odds of being dissatisfied with care. One-third of all women did not understand the information provided by the healthcare personnel during maternity care. More women with refugee background felt treated differently because of factors such as religion, language and skin colour, than women who migrated due to family reunification. CONCLUSIONS: Although the overall satisfaction was high, for certain healthcare experiences such as understanding information, we found more negative responses. The negative healthcare experiences and factors associated with satisfaction identified in this study have implications for health system planning, education of healthcare personnel and strategies for quality improvement.

Female genital mutilation/cutting, timing of deinfibulation, and risk of cesarean section.

INTRODUCTION: The impact of female genital mutilation/cutting on obstetric outcomes in high-income countries is not clear. In general, women with female genital mutilation/cutting type 3 (infibulation) seem to be most at risk of adverse outcomes such as cesarean section. Deinfibulation is recommended to prevent obstetric complications. Whether the timing of this procedure affects the complication risk is not known. The aims of this study were, first, to examine the association between female genital mutilation/cutting and the risk of cesarean section in Norway, and, second, whether the timing of deinfibulation affected the cesarean section risk. MATERIAL AND METHODS: This was a historical cohort study of nulliparous Somali-born women who gave birth in Norway between 1990 and 2014. The Medical Birth Registry of Norway identified the women. Data were collected from medical records at 11 participating birth units. The exposures were female genital mutilation/cutting status and deinfibulation before pregnancy, during pregnancy, or no deinfibulation before labor onset. The main outcome was odds ratio (OR) of cesarean section. Type of cesarean section, primary indications, and neonatal outcomes were secondary outcomes. RESULTS: Women with female genital mutilation/cutting type 3 had lower risk of cesarean section compared with women with no female genital mutilation/cutting (OR 0.54, 95% CI 0.33-0.89 P = .02). Among the 1504 included women, the cesarean section rate was 28.0% and the proportion of emergency operations was 92.9%. Fetal distress was the primary indication in approximately 50% of cases, across the groups with different female genital mutilation/cutting status. Women who had no deinfibulation before labor onset had lower risk of cesarean section compared with those who underwent deinfibulation before or during pregnancy (OR 0.64, 95% CI 0.46-0.88 P = .01). CONCLUSIONS: High risk of cesarean section in Somali nulliparous women was not related to the type of female genital mutilation/cutting in the present study. Deinfibulation before labor did not protect against cesarean section. Our findings indicate that nulliparous Somali women are at high risk of intrapartum complications. Future research should focus on measures to reduce maternal morbidity and on how timing of deinfibulation affects the outcomes of vaginal births.

Induction of labor and nulliparity: A nationwide clinical practice pilot evaluation.

INTRODUCTION: Induction of labor has become an increasingly common obstetric procedure, but in nulliparous women or women with a previous cesarean section, it can pose a clinical challenge. Despite an overall expansion of medical indications for labor induction, there is little international consensus regarding the criteria for induction, or for the recommended methods among nulliparous women. In this light, we assessed variations in the practice of induction of labor among 21 birth units in a nationwide cohort of women with no prior vaginal birth. MATERIAL AND METHODS: We carried out a prospective observational pilot study of women with induced labor and no prior vaginal birth, across 21 Norwegian birth units. We registered induction indications, methods and outcomes from 1 September to 31 December 2018 using a web-based case record form. Women were grouped into "Nulliparous term cephalic", "Previous cesarean section" and "Other Robson" (Robson groups 6, 7, 8 or 10). RESULTS: More than 98% of eligible women (n=1818) were included and a wide variety of methods was used for induction of labor. In nulliparous term cephalic pregnancies, cesarean section rates ranged from 11.1% to 40.6% between birth units, whereas in the previous cesarean section group, rates ranged from 22.7% to 67.5%. The indications "large fetus" and "other fetal" indications were associated with the highest cesarean rates. Failed inductions and failure to progress in labor contributed most to the cesarean rates. Uterine rupture occurred in two women (0.11%), both in the previous cesarean section group. In neonates, 1.6% had Apgar <7 at 5 minutes, and 0.4% had an umbilical artery pH <7.00. CONCLUSIONS: Cesarean rates and applied methods for induction of labor varied widely in this nationwide cohort of women without a prior vaginal birth. Neonatal outcomes were similar to those of normal birth populations. Results could indicate the need to move towards more standardized induction protocols associated with optimal outcomes for mother and baby.

Birthweight of babies born to migrant mothers - What role do integration policies play?

Birthweights of babies born to migrant women are generally lower than those of babies born to native-born women. Favourable integration policies may improve migrants' living conditions and contribute to higher birthweights. We aimed to explore associations between integration policies, captured by the Migrant Integration Policy Index (MIPEX), with offspring birthweight among migrants from various world regions. In this cross-country study we pooled 31 million term birth records between 1998 and 2014 from ten high-income countries: Australia, Belgium, Canada, Denmark, Finland, Japan, Norway, Spain, Sweden and United Kingdom (Scotland). Birthweight differences in grams (g) were analysed with regression analysis for aggregate data and random effects models. Proportion of births to migrant women varied from 2% in Japan to 28% in Australia. The MIPEX score was not associated with birthweight in most migrant groups, but was positively associated among native-born (mean birthweight difference associated with a 10-unit increase in MIPEX: 105 g; 95% CI: 24, 186). Birthweight among migrants was highest in the Nordic countries and lowest in Japan and Belgium. Migrants from a given origin had heavier newborns in countries where the mean birthweight of native-born was higher and vice versa. Mean birthweight differences between migrants from the same origin and the native-born varied substantially across destinations (70 g-285 g). Birthweight among migrants does not correlate with MIPEX scores. However, birthweight of migrant groups aligned better with that of the native-born in destination counties. Further studies may clarify which broader social policies support migrant women and have impacts on perinatal outcomes.

Variations in gestational length and preterm delivery by race, ethnicity and migration.

Preterm delivery rates within industrialized countries have been reported to vary according to the parents' race, ethnicity and migrant status; however, such disparities are poorly understood. In this paper, the available evidence and potential clinical significance of racial/ethnic and migrant disparities in gestational length and preterm delivery are assessed alongside potential explanatory factors. Although measurement bias in gestational length has the potential to inflate disparities, there is a consistently higher risk of preterm birth among some racial/ethnic groups. These differences most likely reflect lasting socio-economic disadvantage and discrimination rather than genetic mechanisms. The effect of migrant status is less conclusive due to heterogeneity of populations and the healthy migrant effect; however, environmental influences in the receiving country are implicated in driving increases of overall preterm rates. When assessing preterm delivery rates across ethnic and migrant groups, the use of standardized, ultrasound-based pregnancy dating methods is crucial to minimize bias. Current evidence does not justify the provision of a different clinical care approach to minority or immigrant women solely based on their race, ethnicity or country of origin; however, these labels may serve as flags for further inquiry on individual risk factors and a detailed obstetric history.

Birth-weight charts and immigrant populations: A critical review.

There is an increasing body of literature focusing on differences in newborn size between different population subgroups defined by racial, ethnic, and immigration status. The interpretation of these differences as pathological or as merely reflecting normal variability is not straightforward and may have consequences for the provision of obstetric and neonatal care to minority populations. In this review, we critically assess some methodological issues affecting the assessment of newborn size and their potential implications for minority populations. In particular, we discuss the pros and cons of different types of newborn birth-weight (BW) charts (i.e., single local population-based references, minority-specific references, and a single international standard) to determine abnormal newborn size, with emphasis on immigrant populations. We conclude that size alone is not enough to inform clinical decisions and that all newborn size charts should be used as screening tools, not as diagnostic tools. Parental minority status may be regarded as a marker and used to further inquire about individual risk factors, particularly among immigrants who may not have a complete medical history in the new country. Finally, we outline areas for further research and recommendations for clinical practice.

Caesarean section by immigrants' length of residence in Norway: a population-based study.

BACKGROUND: Immigrants to Europe account for a significant proportion of births in a context of rising caesarean rates. We examined the risk of planned and emergency caesarean section (CS) by immigrants' length of residence in Norway, and compared the results with those of non-immigrants. METHODS: We linked population-based birth registry data to immigration data for first deliveries among 23 147 immigrants from 10 countries and 385 306 non-immigrants between 1990-2009. Countries were grouped as having low CS levels (<16%; Iraq, Pakistan, Poland, Turkey, Yugoslavia, Vietnam) or high CS levels (>22%; the Philippines, Somalia, Sri Lanka, Thailand). Associations between length of residence and planned/emergency CS were estimated as relative risks (RR) with 95% confidence intervals (CI) in multivariable models. RESULTS: In the immigrant group with low CS levels, planned, but not emergency, CS was independently associated with longer length of residence. Compared with recent immigrants (<1 year), the risk of planned CS was 70% greater among immigrants with residency of 2-5 years (RR 1.70, CI: 1.19-2.42), and twice as high in those with residency of ≥ 6 years. (RR 2.01, CI: 1.28-3.17). Compared with non-immigrants, immigrants in the low group with residency <2 years had lower risk of planned CS, while those with residency >2 years had greater risk of emergency CS. In the high group, the risk of planned CS was similar to non-immigrants, while emergency CS was 51-75% higher irrespective of length of residency. CONCLUSION: Efforts to improve immigrants' labour outcomes should target subgroups with sustained high emergency caesarean risk.

Preterm subtypes by immigrants' length of residence in Norway: a population-based study.

BACKGROUND: The reduction of the preterm delivery (PTD) rate is a maternal and child health target. Elevated rates have been found among several immigrant groups, but few studies have distinguished between PTD according to the mode of birth start. In addition, migrants' birth outcomes have further been shown to be affected by the time in residence; however, the association to PTD subtypes has not previously been assessed. In this study we examined if the risk of spontaneous and non-spontaneous, or iatrogenic, PTD among immigrants in Norway varied according to the length of residence and the country of birth, and compared with the risks among the majority population. METHODS: We linked population-based birth and immigration data for 40 709 singletons born to immigrant women from Iraq, Pakistan, the Philippines, Somalia, Sri Lanka and Vietnam and 868 832 singletons born to non-immigrant women from 1990-2009. Associations between the length of residence and subtypes of PTD were estimated as relative risks (RRs) with 95% confidence intervals (CIs) from multivariable models. RESULTS: In total, 48 191 preterm births occurred. Both spontaneous and non-spontaneous PTD rates were higher among immigrants (4.8% and 2.0%) than among non-immigrants (3.6% and 1.6%). Only non-spontaneous PTD was associated with longer lengths of residence (p trend <0.001). Recent immigrants (<5 years of residence) and non-immigrants had a similar risk of non-spontaneous PTD, whereas immigrants with lengths of residence of 5-9 years, 10-14 years and ≥ 15 years had adjusted RRs of 1.18 [95% CI 1.03,1.35], 1.43 [95% CI 1.20,1.71] and 1.66 [95% CI 1.41,1.96]. The association was reduced after further adjustments for maternal and infant morbidity. Conversely, the risk of spontaneous PTD among immigrants was not mitigated by length of residence, but varied with country of birth according to the duration of pregnancy in term births. CONCLUSIONS: Non-spontaneous PTD increased with the length of residence whereas spontaneous PTD remained elevated regardless of the length of residence. Policies to improve birth outcomes in ethnically mixed populations should address the modifiable causes of PTD rather than aiming to reduce absolute PTD rates.

Stillbirth and infant death among generations of Pakistani immigrant descent: a population-based study.

OBJECTIVE: To examine the risk of stillbirth and infant death among offspring of Pakistani-born and Norwegian-born women of Pakistani immigrant descent. DESIGN: Population-based study linking the Medical Birth Registry of Norway to immigration data from Statistics Norway. SETTING: Norway. POPULATION: Births to women of Pakistani immigrant descent classified as Pakistani-born (n = 8814) or Norwegian-born (n = 1801), and to the host population of Norwegian descent (n = 712 430) from 1995 to 2010. METHODS: The relative risk of stillbirth and infant death by country of descent and birth was estimated by odds ratios with 95% confidence intervals (95% CI) using logistic regression. MAIN OUTCOME MEASURES: Stillbirth and infant death. RESULTS: Risk of stillbirth was highest in the Pakistani-born group (7.4/1000, 95% CI 5.7-9.4) followed by the Norwegian-born group (5.0/1000, 95% CI 1.7-8.3) and finally the host population (3.5/1000, 95% CI 3.3-3.6). Relative to the host population, risk of stillbirth was higher in both Pakistani-born (odds ratios 2.8, 95% CI 2.2-3.6) and Norwegian-born (odds ratios 2.2, 95% CI 1.1-4.2) groups, after adjustment for year of birth, age, parity and residence. For infant death, absolute risks were 6.9/1000 (95% CI 5.2-8.8), 5.6/1000 (95% CI 2.7-10.2), and 2.9/1000 (95% CI 2.7-3.0), with adjusted odds ratios of 2.8 (95% CI 2.1-3.7) and 2.4 (95% CI 1.3-4.6), respectively. CONCLUSIONS: An elevated risk of stillbirth and infant death persists across generations of Pakistani immigrant descent living in Norway. While translating into few excess deaths, the elevated risks should be taken into account by obstetric and pediatric care providers.

Caesarean section among referred and self-referred birthing women: a cohort study from a tertiary hospital, northeastern Tanzania.

BACKGROUND: The inequity in emergency obstetric care access in Tanzania is unsatisfactory. Despite an existing national obstetric referral system, many birthing women bypass referring facilities and go directly to higher-level care centres. We wanted to compare Caesarean section (CS) rates among women formally referred to a tertiary care centre versus self-referred women, and to assess the effect of referral status on adverse outcomes after CS. METHODS: We used data from 21,011 deliveries, drawn from the birth registry of a tertiary hospital in northeastern Tanzania, during 2000-07. Referral status was categorized as self-referred if the woman had bypassed or not accessed referral, or formally-referred if referred by a health worker. Because CS indications were insufficiently registered, we applied the Ten-Group Classification System to determine the CS rate by obstetric group and referral status. Associations between referral status and adverse outcomes after CS delivery were analysed using multiple regression models. Outcome measures were CS, maternal death, obstetric haemorrhage ≥ 750 mL, postpartum stay > 9 days, neonatal death, Apgar score < 7 at 5 min and neonatal ward transfer. RESULTS: Referral status contributed substantially to the CS rate, which was 55.0% in formally-referred and 26.9% in self-referred birthing women. In both groups, term nulliparous singleton cephalic pregnancies and women with previous scar(s) constituted two thirds of CS deliveries. Low Apgar score (adjusted OR 1.42, 95% CI 1.09-1.86) and neonatal ward transfer (adjusted OR 1.18, 95% CI 1.04-1.35) were significantly associated with formal referral. Early neonatal death rates after CS were 1.6% in babies of formally-referred versus 1.2% in babies of self-referred birthing women, a non-significant difference after adjusting for confounding factors (adjusted OR 1.37, 95% CI 0.87-2.16). Absolute neonatal death rates were > 2% after CS in breech, multiple gestation and preterm deliveries in both referral groups. CONCLUSIONS: Women referred for delivery had higher CS rates and poorer neonatal outcomes, suggesting that the formal referral system successfully identifies high-risk birth, although low volume suggests underutilization. High absolute rates of post-CS adverse outcomes among breech, multiple gestation and preterm deliveries suggest the need to target self-referred birthing women for earlier professional intrapartum care.