Equal Alternatives or Lower Standards for Immigrant Women-Analyzing Obstetric Care for Immigrant Women in Berlin Within the Framework of Cultural Health Capital.

In obstetric clinics in Berlin, Germany, more than half of the women are immigrants. The main objective of the qualitative study was to explore the staff's experiences with obstetric care for immigrants and juxtapose it with the immigrants' comments on their birth experiences. We analyze potential differences along the framework of a cultural health capital (CHC). Between May and August 2017, semi-structured interviews were carried out with 17 obstetricians and 17 midwives at four obstetric clinics in Berlin. The verbally transcribed interview material was subjected to a qualitative content analysis according to Mayring. Furthermore, a secondary data from an interview study was analyzed in the purpose of providing some insight into the practitioner study participant perspective. Between January and May 2017, in the postpartum ward at the Berlin Charité Campus Virchow Clinic, an interview study guided by the migrant-friendly maternity care questionnaire was conducted among 410 migrant and non-migrant women. For this study, the free-text comments on the pregnancy care were analyzed. The staff interviewees identified language barrier and legal status as risk factors for the late onset of obstetric care. CHC functioning potentially as alternatives to the established health care structures were voiced. Strong family ties among immigrant families bear a high potential for support. Gratefulness was voiced by the staff and immigrant patients as a source of satisfaction with care. Our study shows that obstetric care for immigrant women remains a challenge. CHC of immigrant women might partially compensate for exclusion.

[Use of emergency rooms by so-called multiple users: results of a prospective study with special consideration of the migration status]. / Inanspruchnahme von Notaufnahmen durch sog. Mehrfachnutzer/-innen: Ergebnisse einer prospektiven Studie unter besonderer Berücksichtigung des Migrationsstatus.

Objectives: Can we identify predictive factors for the group of so-called multiple users (MU; 4 and more uses of an emergency department [ED] in the past 12 months)? Are people with a migration background more likely to be classified in the MU group? Methodology: Included were consecutive patients who visited three EDs in Berlin from July 2017 to July 2018. Using a questionnaire, diseases, reasons for visiting the ED and socioeconomic factors were recorded. Comparisons between migrants (1st generation), their descendants (2nd generation) and nonmigrants were assessed using logistic regression. Results: A total of 2339 patients were included in the evaluation (repeat rate 56%), of which 901 had a migration background. Young women (<30 years), chronically ill, pregnant women, patients with severe complaints and people with (self-assessed) moderate and poor health quality as well as those without medical referral had a greater chance of multiple use of ED. Conclusion: MU burden the already increasing patient volume of ED. However, they represent a heterogeneous group of patients, among whom people with a migration background are not common. Further research is warranted to better understand the factors that lead to frequent use and to develop effective strategies to address the complex health needs of MUs.

Are Social Status and Migration Background Associated with Utilization of Non-medical Antenatal Care? Analyses from Two German Studies.

OBJECTIVE: Non-medical antenatal care (ANC) refers to a range of non-medical services available to women during pregnancy aiming at supporting women and prepare them for the birth and the postpartum period. In Germany, they include antenatal classes, breastfeeding classes and pregnancy-specific yoga or gymnastics courses. Studies suggest that various types of non-medical ANC carry benefits for both the women and their babies. Little is known about the uptake of non-medical ANC among different socioeconomic population subgroups, but one may expect lower utilization among socio-economically disadvantaged women. We analyzed factors contributing to the utilization of non-medical ANC in general and antenatal classes in particular. METHODS: Baseline data of the Bielefeld BaBi birth cohort (2013-2016) and the Berlin perinatal study (2011-2012) were analyzed. Comparing the two cohorts allowed to increase the socio-economic and migration background variance of the study population and to capture the effect of the local context on uptake of services. Multivariate logistic regression analyses were performed to study associations between the uptake of non-medical ANC and socio-economic and migration status. RESULTS: In Berlin and Bielefeld, being a first generation migrant and having lower levels of education were associated with lower non-medical ANC uptake. In Berlin, being a 2nd generation woman or having a low income was also associated with lower uptake. CONCLUSIONS FOR PRACTICE: Our study suggests that non-medical ANC remains in some part the prerogative of non-migrant, well-educated and economically privileged women. Since differences in non-medical ANC have the potential to create inequalities in terms of birth outcomes and maternal health during pregnancy and post-partum, more efforts are needed to promote the use of non-medical ANC by all population groups.

The role of acculturation in migrants' use of gynecologic emergency departments.

OBJECTIVE: To examine whether acculturation of migrant patients is a predictor of non-urgent use of gynecologic emergency departments (GEDs). METHODS: A cross-sectional study based on standardized questionnaire interviews among migrant (n=477) and non-migrant (n=246) women attending a GED in Berlin, Germany, between 2017 and 2018. Non-urgent GED use was defined by health system (e.g., no hospital admission) or patient (e.g., low subjective urgency) criteria. Acculturation was assessed by the Frankfurt Acculturation Scale. Logistic regressions were calculated with non-migrants as the reference. RESULTS: Relative to migrants, low acculturation of migrants had no significant effect on overall non-urgent GED use. However, low acculturation was a significant predictor of non-urgent use if defined only by health system criteria (adjusted odds ratio [AOR], 1.58; 95% confidence interval [CI], 1.02-2.44; P=0.041). Inversely, low acculturation had a significant negative effect on non-urgent use if defined only by patient criteria (AOR, 0.58; 95% CI, 0.38-0.90; P=0.014). CONCLUSION: Low-acculturated migrants were more prone to non-urgent GED use as defined by health system criteria, and might have a distorted perception of urgency. According to their perception, however, low-acculturated patients showed appropriate GED use for urgent complaints, indicating that they are insufficiently cared for by the healthcare system.

The influence of migration on women's use of different aspects of maternity care in the German health care system: Secondary analysis of a comparative prospective study with the Migrant Friendly Maternity Care Questionnaire (MFMCQ).

INTRODUCTION: Approximately 21% of Germany's inhabitants or their parents have been born abroad. There is evidence that immigrant women are starting antenatal care later than nonimmigrants. In Berlin, equality in health care access had improved until 2011-2012, leaving only women with Low German language proficiency and an insecure residence status particularly at risk. With the recent influx of refugees, we analyzed whether access to antenatal and postpartum care differs depending on immigration, residence status, income, and education. METHODS: At our Berlin tertiary care center, a modified version of the Migrant Friendly Maternity Care Questionnaire was administered to women who delivered in the first half of 2017. Multivariate modeling compared nonimmigrant women, immigrants, and women who are direct descendants of immigrants. RESULTS: The study included 184 nonimmigrant women, 214 immigrant women, and 62 direct descendants of immigrants. Germany is relatively good in prenatal care for immigrant women, as most are getting adequate prenatal care. However, 21% of immigrants compared with 11% of nonimmigrant women started pregnancy care after the first trimester (P = .03). Low income was a more powerful predictor than immigration status for starting prenatal care after the first trimester. Immigrant women (23%) were less informed on postpartum care availability than nonimmigrants (3%) and used less postpartum midwifery care. CONCLUSIONS: When designing health care interventions for immigrant women, not only migration-specific factors should be considered but also low income as a barrier to access to maternity care.

Comparing provision and appropriateness of health care between immigrants and non-immigrants in Germany using the example of neuraxial anaesthesia during labour: cross-sectional study.

OBJECTIVE: Research on health services for immigrants has mostly been concerned with access barriers but rarely with appropriateness and responsiveness of care. We assessed whether appropriateness and responsiveness of care depend on migration status, using provision of neuraxial anaesthesia (NA) during labour as indicator. In relation to their migration status, we analysed whether (1) women undergoing elective or secondary/urgent secondary caesarean sections (ESCS) appropriately receive NA (instead of general anaesthesia), (2) women delivering vaginally appropriately receive NA and (3) women objecting to NA, for example, for religious reasons, may deliver vaginally without receiving NA (provider responsiveness). DESIGN: Cross-sectional study. SETTING: Three obstetric hospitals in Berlin, Germany. METHODS: Questionnaire survey covering 6391 women with migration history (first and second generations) and non-immigrant women giving birth; data linkage with routine obstetric data. We assessed the effects of migrant status, German language proficiency, religion and education on the provision of NA (primary outcome) after adjusting for other maternal and obstetric parameters. RESULTS: The chance of receiving NA for elective/ESCS was independent of migrant status after controlling for confounding variables (adjusted OR (aOR) 0.93, 95% CI 0.65 to 1.33). In vaginal deliveries, first (but not second) generation women (aOR 0.79, 95% CI 0.65 to 0.95), women with low German language skills (aOR 0.77, 95% CI 0.58 to 0.99) and women with low educational attainment (aOR 0.62, 95% CI 0.47 to 0.82) had lower chances of receiving NA; there was no evidence of overprovision among women with strong affinity to Islam (aOR 0.77, 95% CI 0.63 to 0.94). CONCLUSIONS: We found evidence for underprovision of care among first-generation immigrants, among women with low German language proficiency and particularly among all women with low educational attainment, irrespective of migration status. There was no evidence for overprovision of care to immigrant women, either inappropriately (general anaesthesia for ESCS) or because of low provider responsiveness (no opt-out for NA in vaginal delivery).

Real-time, ray casting-based scatter dose estimation for c-arm x-ray system.

OBJECTIVES: Dosimetric control of staff exposure during interventional procedures under fluoroscopy is of high relevance. In this paper, a novel ray casting approximation of radiation transport is presented and the potential and limitation vs. a full Monte Carlo transport and dose measurements are discussed. METHOD: The x-ray source of a Siemens Axiom Artix C-arm is modeled by a virtual source model using single Gaussian-shaped source. A Geant4-based Monte Carlo simulation determines the radiation transport from the source to compute scatter from the patient, the table, the ceiling and the floor. A phase space around these scatterers stores all photon information. Only those photons are traced that hit a surface of phantom that represents medical staff in the treatment room, no indirect scattering is considered; and a complete dose deposition on the surface is calculated. To evaluate the accuracy of the approximation, both experimental measurements using Thermoluminescent dosimeters (TLDs) and a Geant4-based Monte Carlo simulation of dose depositing for different tube angulations of the C-arm from cranial-caudal angle 0° and from LAO (Left Anterior Oblique) 0°-90° are realized. Since the measurements were performed on both sides of the table, using the symmetry of the setup, RAO (Right Anterior Oblique) measurements were not necessary. RESULTS: The Geant4-Monte Carlo simulation agreed within 3% with the measured data, which is within the accuracy of measurement and simulation. The ray casting approximation has been compared to TLD measurements and the achieved percentage difference was -7% for data from tube angulations 45°-90° and -29% from tube angulations 0°-45° on the side of the x-ray source, whereas on the opposite side of the x-ray source, the difference was -83.8% and -75%, respectively. Ray casting approximation for only LAO 90° was compared to a Monte Carlo simulation, where the percentage differences were between 0.5-3% on the side of the x-ray source where the highest dose usually detected was mainly from primary scattering (photons), whereas percentage differences between 2.8-20% are found on the side opposite to the x-ray source, where the lowest doses were detected. Dose calculation time of our approach was 0.85 seconds. CONCLUSION: The proposed approach yields a fast scatter dose estimation where we could run the Monte Carlo simulation only once for each x-ray tube angulation to get the Phase Space Files (PSF) for being used later by our ray casting approach to calculate the dose from only photons which will hit an movable elliptical cylinder shaped phantom and getting an output file for the positions of those hits to be used for visualizing the scatter dose propagation on the phantom surface. With dose calculation times of less than one second, we are saving much time compared to using a Monte Carlo simulation instead. With our approach, larger deviations occur only in regions with very low doses, whereas it provides a high precision in high-dose regions.

[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.

Menopausal symptoms in an intercultural context: a comparison between German women, Chinese women and migrant Chinese women using the Menopause Rating Scale (MRS II).

OBJECTIVE: What are the differences between the occurrence of menopausal symptoms in German women, migrant Chinese women in Germany and Chinese women in their native country? Can these potential discrepancies be explained by sociocultural differences? What are the differences in menopausal symptoms in connection with the consumption of soya? PATIENT STUDY GROUP AND METHODS: Cross-sectional study 2005-2008. Survey of three groups of women aged between 45 and 60 years (native German women in Berlin, migrant Chinese women in several German cities, Chinese women in Beijing) with an evaluated set of questionnaires surveying socio-demographic data, use of hormone therapy, migration/acculturation, MRS II and other areas. RESULTS: A total of 2,109 questionnaires were sent out and a 41 % response rate was achieved, although this varied greatly across the three individual study groups. The results of the MRS II factor analysis were almost identical for German women and migrant Chinese women, but there were some differences in content compared to the Chinese study group. Chinese women surveyed in Beijing reported severe symptoms significantly less frequently in all three symptom groups (factors) of MRS II than the German women and the migrant Chinese women, but the values from the German women and migrant Chinese women surveyed are relatively similar. In all three study groups there are no significant differences in the stated severity of the symptoms, regardless of whether soya is consumed frequently or less frequently. CONCLUSION: The question whether the differences found are solely cultural or migration-related must be examined in further studies. The special experiences and situation in life of migrant women should be taken into particular account by attending physicians during the care and treatment of women in this phase of life.

Assessment of regional ventilation distribution: comparison of vibration response imaging (VRI) with electrical impedance tomography (EIT).

BACKGROUND: Vibration response imaging (VRI) is a bedside technology to monitor ventilation by detecting lung sound vibrations. It is currently unknown whether VRI is able to accurately monitor the local distribution of ventilation within the lungs. We therefore compared VRI to electrical impedance tomography (EIT), an established technique used for the assessment of regional ventilation. METHODOLOGY/PRINCIPAL FINDINGS: Simultaneous EIT and VRI measurements were performed in the healthy and injured lungs (ALI; induced by saline lavage) at different PEEP levels (0, 5, 10, 15 mbar) in nine piglets. Vibration energy amplitude (VEA) by VRI, and amplitudes of relative impedance changes (rel.ΔZ) by EIT, were evaluated in seven regions of interest (ROIs). To assess the distribution of tidal volume (VT) by VRI and EIT, absolute values were normalized to the VT obtained by simultaneous spirometry measurements. Redistribution of ventilation by ALI and PEEP was detected by VRI and EIT. The linear correlation between pooled VT by VEA and rel.ΔZ was R(2) = 0.96. Bland-Altman analysis showed a bias of -1.07±24.71 ml and limits of agreement of -49.05 to +47.36 ml. Within the different ROIs, correlations of VT-distribution by EIT and VRI ranged between R(2) values of 0.29 and 0.96. ALI and PEEP did not alter the agreement of VT between VRI and EIT. CONCLUSIONS/SIGNIFICANCE: Measurements of regional ventilation distribution by VRI are comparable to those obtained by EIT.

Doctor's perception of doctor-patient relationships in emergency departments: What roles do gender and ethnicity play?

BACKGROUND: Emergency departments continuously provide medical treatment on a walk-in basis. Several studies investigated the patient's perception of the doctor-patient relationship, but few have asked doctors about their views. Furthermore, the influence of the patient's ethnicity and gender on the doctor's perception remains largely unanswered. METHODS: Based on data collated in three gynaecology (GYN)/internal medicine (INT) emergency departments in Berlin, Germany, we evaluated the impact of the patient's gender and ethnicity on the doctors' satisfaction with the course of the treatment they provided. Information was gathered from 2.429 short questionnaires completed by doctors and the medical records of the corresponding patients. RESULTS: The patient's ethnicity had a significant impact on the doctors' satisfaction with the doctor-patient relationship. Logistic regression analysis showed that the odds ratio (OR) for physician satisfaction was significantly lower for patients of Turkish origin (OR = 2.6 INT and 5.5 GYN) than for those of German origin. The main reasons stated were problems with communication and a perceived lack of urgency for emergency treatment. The odds ratios for dissatisfaction due to a lack of language skills were 4.48 (INT) and 6.22 (GYN), and those due to perceived lack of urgency for emergency treatment were 0.75 (INT) and 0.63 (GYN). Sex differences caused minor variation. CONCLUSION: The results show that good communication despite language barriers is crucial in providing medical care that is satisfactory to both patient and doctors, especially in emergency situations. Therefore the use of professional interpreters for improved communication and the training of medical staff for improved intercultural competence are essential for the provision of adequate health care in a multicultural setting.

Emergency outpatient services in the city of Berlin: Factors for appropriate use and predictors for hospital admission.

OBJECTIVES: To determine the proportion of patients making inappropriate use of medical care at hospital emergency rooms. To identify the factors that influence appropriateness of use and the probability of subsequent hospital admission. METHODS: Data were collected from 815 patients at three gynaecological/internal medicine emergency clinics in Berlin, Germany using multiple data sources: (i) standardized interviews covered service use history, psychosocial variables, migration history and sociodemographics; (ii) medical data were retrieved from patients' medical records, including case histories, diagnoses and therapies; (iii) emergency room physicians were asked to evaluate patients' language comprehension, physician-patient relationship and treatment urgency. Statistical analyses included chi tests, correlational and logistic regression analyses. RESULTS: According to a self-constructed index measuring appropriateness of emergency service use, about half of the patients' visits would have to be classified as inappropriate. Age, chronic illness and the time of day of the emergency service attendance were significantly associated with appropriateness of use. The probability of a hospital admission following the emergency treatment increased with patients' age and the physician's evaluation of treatment urgency. Remarkably, and contrary to the results of international studies, the patient's ethnicity played no significant role with respect to the appropriateness of use of emergency outpatient services or the likelihood of subsequent hospital admission.

Perinatal outcome in Berlin (Germany) among immigrants from Turkey.

PURPOSE: Are there differences regarding important perinatal outcome-parameters in Berlin relating to ethnicity? PATIENTS AND METHODS: A database was available covering 152,193 single deliveries in all hospitals in Berlin/Germany in the period 1993-1999, including 132,555 German women and 19,638 women of other ethnicities. Comparisons were made between a total of four pairs of sub-groups matched in terms of parity and social status (significance level P < 0.01). RESULTS: Pregnant migrants come for their first antenatal check-up significantly later, thus delaying the initiation of necessary diagnostic or therapeutic measures. Migrants show higher rates of prepartal and also postpartal anemia than the German women. In all sub-groups the German women had a significantly higher frequency of planned cesarean sections. Migrants were significantly less likely to receive an epidural anesthesia during delivery. It is also noticeable that the rate of congenital malformations of neonates is significantly higher in the migrant collectives. CONCLUSIONS: Important perinatal quality parameters such as infant and maternal mortality and rates of premature delivery have largely converged between German and Turkish migrant mothers. The differences found (e.g., rates of planned cesarean section, epidural anesthesia, or anemia) could be interpreted as indications of persistent differences in quality of care for migrants.

Turkish and German patients' recall of diagnosis and therapy before and following informed consent.

OBJECTIVE: Adequate patient knowledge is essential for good compliance, effective doctor-patient communications and is the basis for informed consent. The purpose of the study was to examine differences in recall of informed consent procedures between patients with different ethnicity and to identify potential explanatory factors. DESIGN: We analyzed 579 patients, attending and released from a gynecology department in Berlin, Germany, between March 1997 and October 1998. To assess actual understanding of disclosure information, Turkish and German patients' perceptions were compared with documented data of their diagnoses and therapy. RESULTS: Overall, patients correctly identified 69% of their diagnosis and 76% of their therapy. On discharge overall patients' recall decreased significantly. Whereas German patients' knowledge increased, Turkish patients showed significant decreases in diagnosis and therapy recall. CONCLUSION: The results reflect socio-demographic differences between ethnic groups and indicate deficiency of the informed consent process for patients belonging to an ethnic minority.