The paradox of awareness of death in parenthood transition-A qualitative study.

In the high-income countries of Scandinavia, there is a low statistical risk of death during childbirth. However, awareness of the possibility of death seems to have prevailed. In existential psychology and philosophy, awareness of death is a universal condition in life, and facing the anxiety this awareness might invoke has the potential of being life-invigorating. In a hermeneutic analysis of Qualitative data, generated in a study on new parents' existential meaning-making, this study aimed to explore awareness of death as experienced in parenthood transition. The results found two overarching themes: Awareness of my own Finitude and Fragility of our loved ones. These were interpreted in existential philosophical and psychological theories, and concludes that awareness of death might signify an existential integration of 'self' in the new role of parenthood. Acknowledging these thoughts as healthcare professionals could support the meaning-making of parenthood transition, by normalizing their universal nature.

Continuing bonds in parents after a loss in pregnancy, or a death at or shortly after birth: A population-based study.

In this study, we describe continuing bonds and grief reactions and assess their association in 980 parents bereaved in pregnancy, at or shortly after birth. We found that most parents experienced continuing bonds. However, they differed by type of loss. Parents losing their child due to termination of pregnancy or miscarriage experienced bonds less frequently and had the least intense grief reaction. Parents losing their child postpartum experienced bonds most frequently and had the most intense grief reaction. Continuing bonds were associated with intensified grief in parents losing their child after termination or miscarriage, while this relationship was less obvious after stillbirth or postpartum death.

Carrying Death: A Qualitative Study of Women's Bodily Perceptions After Their Baby Died in Utero.

When a child dies in utero death becomes an integrated part of the mothers living body and this complex experience places a heavy existential and bodily burden on a woman experiencing stillbirth. This study uses a phenomenological approach with focus groups and individual interviews and data is discussed within a theoretical existential framework. Interviews of six women who experienced stillbirth within a range of 5 years were performed in Denmark. The participants experienced the dissonance of carrying death in their living body, expressed heightened existential considerations, a sense of transgression and of feeling trapped in an unbearable situation, and an experience of both dislocation from their body and an extreme bodily awareness. The study generates new knowledge and understanding of the how stillbirth is experienced as incomprehensible and as a violent bodily invasion of death with deep existential impact.

Parents' religious/spiritual beliefs, practices, changes and needs after pregnancy or neonatal loss-A Danish cross-sectional study.

This study describes religious/spiritual beliefs, practices, changes, and needs among parents bereaved by pregnancy or neonatal loss, and assess gender differences in religiosity/spirituality, in this population. A cross-sectional study using data from the Danish cohort Life After the Loss was conducted. Data were gathered from a questionnaire survey collected between January 2016 and December 2019. Among 713 respondents, several answered in the affirmative to items related to religious/spiritual beliefs and practices. Some experienced changes in religious/spiritual beliefs and practices, and some wished to talk to someone about these questions. Women reported higher levels of religiosity/spirituality than men.

Relatives' negotiation power in relation to older people's acute hospital admission: A qualitative interview study.

BACKGROUND: Acutely admitted older people are potentially vulnerable and dependent on relatives to negotiate and navigate on their behalf. AIM: This study aimed to explore relatives' experiences of their interactions with healthcare professionals during acute hospital admission of older people to derive themes of importance for relatives' negotiations with these professionals. METHOD: A qualitative design was applied. Relatives of acutely admitted older people at two emergency departments in Denmark were interviewed (n = 17). The qualitative content analysis was guided by Graneheim and Lundman's concepts. RESULTS: The analysis derived four themes: (a) Mandate, (b) Incentive, (c) Capability and (d) Attitude to taking action. These four sources of relatives' negotiation power can be illustrated in the MICA model. CONCLUSION: Four themes were identified as important sources of relatives' negotiation power. Since the four sources of power potentially change according to the situation, relatives' negotiation power seems to be context dependent.

Stillbirth - transitions and rituals when birth brings death: Data from a danish national cohort seen through an anthropological lens.

BACKGROUND: Many parents bereaved of a stillborn baby spend time with the child. In this time frame, different acts with the child in focus may occur. Some parents invite others to see the child too. Parents who suffer the loss of a newborn are vulnerable, and understanding acts and practices surrounding the dead newborn is important knowledge for caretakers. AIMS: This article aims to enlighten the amount of time Danish parents spend with their stillborn in hospital settings that encourage this practice. Furthermore, it aims to transcend the mere quantitative numbers through a theoretical approach that frames the analysis and discussion of possible layers of meaning imbedded in time spent with a dead newborn. STUDY DESIGN: Data from a Danish cohort of bereaved parents were collected using web-based questionnaires. These numbers were successively interpreted through an anthropological lens within the perspective of transition and ritualisation. Knowledge from existing empirical literature was also fused. RESULTS FROM THE COHORT: Danish parents spend hours or days with their stillborn child. They feel supported in this by healthcare professionals. Mainly close relatives join the parents while admitted to the hospital to see the stillborn child, followed by other family members and friends. CONCLUSION: Danish parents engage to a very high degree in contact with their dead baby. The analysis points out that 'Time' and 'Others' are needed to create a socially comprehensible status for parents and child when birth brings death. In liminal space during the transition, healthcare professionals act as ritual experts, supporting parents and their relatives to ascribe social status to the dead body of the child through ritualised acts. Instead of only thinking of this period as 'memory-making', we suggest regarding it as a time of ontological clarification as well.

Dignity in end-of-life care at hospice: An Action Research Study.

BACKGROUND: Safeguarding the dignity of patients at the end of life is a key objective in palliative care practice in Denmark. The concept of dignity and how it influences a dying persons' quality of life is thus influential in end-of-life care at hospices. However, what is meant by dignity, how dignity is understood and practiced by healthcare professionals in Danish hospices, and whether this relates to the patients' understandings and needs concerning dignity remains unanswered. AIM: The aim of this study was to explore and improve dignity in care through an action research study with patients and hospice staff at two different hospices in Denmark. This was done by exploring how patients and healthcare professionals expressed their understandings and needs concerning dignity and involving participants in the research process with the goal of improving dignity in care. METHODS: An action research method with reflection-of-praxis and action-in-praxis was applied. It was combined with methods of semi-structured individual interviews with twelve patients, five staff and nine focus-group interviews with staff. RESULTS: Three themes emerged from the analysis of data. The themes were as follows: (1) being understood, (2) contributing and (3) holistic care. Deeper analysis indicated that staff understandings of dignity mostly focused on preserving patients' autonomy, whereas patients expressed needs for relational and spiritual aspects of dignity. Staff were mostly concerned about preserving patients' autonomy when providing dignity in care, however, through the action-in-praxis they increased their awareness on their own praxis and patients' needs and understanding concerning dignity. The theoretical model on dignity presented in the study also worked as a map to guide staffs' reflections on dignity in praxis and facilitated a broader focus on supporting and caring for patients' dignity in care. We believe this study has improved dignity in care at the two hospices involved in the study.

How Giving Birth Makes Sense: A Questionnaire Study on Existential Meaning-Making Among Mothers Giving Birth Preterm or at Term.

BACKGROUND: Women's reflections on existential meaning-making in relation to giving birth may seem indistinct in maternity services and have not been thoroughly explored in secular contexts. However, research suggests that childbirth accentuates spiritual and existential considerations and needs even in secular contexts highlighting the importance of care for such needs in maternity care practices. The objectives of this study were two-fold: Firstly, to explore how first-time mothers, living in a secular context, experience their first birth in relation to existential meaning-making. Secondly, to describe the relationship between existential meaning-making reflections and gestational week at birth. METHODS: A nationwide cross-sectional study in Denmark based on the questionnaire "Faith, existence and motherhood" was conducted in 2011. Eight core items related to birth experience informed this study. The cohort was sampled from the Danish Medical Birth Registry and consisted of 913 mothers having given birth 6-18 months previously. Twenty-eight per cent had given birth preterm (PT) and 72% had given birth at full-term (FT). A total of 517 mothers responded. RESULTS: In relation to the birth of their first child, both FT and PT mothers answered, that they had existential meaning-making reflections. The consent to the 8 items ranged from 17 to 73% among FT mothers and from 19 to 58% among PT mothers. Mothers who gave birth preterm mainly identified the negative aspects of birth, whereas mothers, who gave birth at full-term, to a higher degree identified positive aspects. CONCLUSIONS: Findings suggest that not only traumatic birth events accentuate existential reflections, but that even normal childbirth to most mothers is an existential event. However, the quality of existential reflections differs when comparing normal and traumatic birth. The study points towards change in education and organization of maternity care to better care for existential needs and reflections specific to every new mother and birthing woman.

First child's impact on parental relationship: an existential perspective.

BACKGROUND: The first child's birth is for most mothers a profound experience carrying the potential to change life orientations and values. However, little is known of how becoming a mother influences the existential dimensions of life within the parental relationship for example how motherhood may change how we view our partner and what we find important. The aim of this study was to explore how becoming a mother might change the parental relationship seen from the mother's perspective with a specific focus on dimensions related to existential meaning-making. METHODS: In 2011, 499 Danish first time mothers answered a questionnaire, from which five core items related to changes in the partner relationship from the perspective of the mother, informed this study. The cohort consisted of mothers who gave birth before the 32nd week of gestation (n = 127) and mothers who gave birth at full term (n = 372). Item 1 focused on thoughts and conversations with her partner about the life change. Item 2 referred to the potential feeling of stronger ties to the partner. Item 3 related to the feeling of being connected to 'something bigger than one self' together with the partner. Item 4 focused on potential conflicts due to having a child, and item 5 referred to the experience of dreams. Possible answers ranged from 'To a high degree' to 'Not at all'. RESULTS: Most respondents found birth of the first child to have forged stronger ties to their partner and have led to both thoughts and conversations about how life together as a couple changed. At the same time, some experienced more conflicts with their partner than before giving birth, however, the majority did actually not. More than half felt their relationship linked to 'something bigger than themselves' or had had dreams on being a family. CONCLUSION: Findings suggest motherhood transition to be a significant transformer of partnership relation influencing also existential meaning-making. Having the potential to be of importance for the health and vitality of the mother, partner and child, it seems essential to scientifically and clinically address concerns related to existential meaning-making in partner relationship.

Prayer and meditation among Danish first time mothers-a questionnaire study.

BACKGROUND: Mothers' existential dimensions in the transition to motherhood have not been described thoroughly. They might experience disruption and new perspectives in existential ways and this may especially be the case in preterm birth. The aim of this study was twofold. First we investigated the existential dimension of motherhood transition in a secularized context, through practices of prayer and meditation. Second we described the relationship between time of birth (term/preterm) and the prayer/meditation practices of the mothers. METHODS: Data were gathered from a nationwide questionnaire survey among first time mothers conducted during the summer 2011. All Danish women who gave birth before the 32(nd) pregnancy week (n = 255), and double the number of mothers who gave birth at full term (n = 658) in 2010 were included (total n = 913). The questionnaire consisted of 46 overall items categorized in seven sections, which independently cover important aspects of existential meaning-making related to becoming a mother. The respondent rate was 57% (n = 517). RESULTS: Moments of praying or meditation 6-18 months post partum were reported by 65%, and mothers who responded affirmatively, practiced prayer (n = 286) more than meditation (n = 89), p < 0,001. We did not observe differences in affirmative responses to prayer or meditation between mothers of full term or preterm born children, not even after controlling for perinatal or post partum loss, mode of birth, age, status of cohabiting or education. CONCLUSIONS: In this explorative study we found specific practices of existential meaning-making through prayer and/or meditation among first time mothers, living in a very secularized context. Yet we know only little about character or importance of these practices among mothers, and hardly anything about existential meaning-making among new fathers. Hence the implications of meaning-making practices related to other dimensions of health are difficult to address in a qualified way in care for new mothers and families.

Existential meaning among first-time full-term and preterm mothers: a questionnaire study.

Research indicates that childbirth is a time when a woman might experience existential disruptions and gain new perspectives on life. The 2-fold aim of this study was to investigate whether attitudes related to existential meaning among first-time mothers intensify and whether they differ between mothers who gave birth at full term and those who gave birth preterm. All first-time mothers who gave birth in Denmark in 2010 before the 32nd week of pregnancy and twice that number of full-term mothers (randomly sampled) were invited to participate in a national cross-sectional survey. Five core items concerning meaning in life, vulnerability of life, responsibility, thoughts about life and death, and "something bigger than oneself" were analyzed to compare mothers' attitudes on existential meaning. The overall response rate was 57% (517/913). Contrary to the hypothesis, attitudes related to existential meaning intensified to the same degree among mothers of full-term and preterm infants, with no statistically significant differences in terms of age, marital status, educational level, or birth method. Danish first-time mothers' attitudes related to existential meaning measured in 5 core items were intensified and almost similar, regardless of whether they gave birth full-term or preterm.

Exploration of low-phosphate diet management of patients receiving renal dialysis: An interpretive description.

BACKGROUND: Patients with dialysis-dependent kidney failure and treated for hyperphosphatemia receive a combination of dietary advice, phosphate binders and prolonged dialysis. However, research focusing on the challenges patients meet in everyday life addressing diet and medication is sparse. OBJECTIVE: The objective of this study is to explore the everyday challenges patients meet when following treatment for hyperphosphatemia. DESIGN: Interpretive description was the methodological approach. Semistructured in-depth interviews were employed to study the challenges patients experienced. Data were analysed using Braun and Clarke's reflexive thematic analysis. PARTICIPANTS: Patients (n = 14) receiving haemodialysis and treated for hyperphosphatemia from two hospitals in Southern Denmark. FINDINGS: The analysis resulted in one over-arching theme; separation in social gatherings and two subthemes; a new social code, and my food and their food. Participants experienced difficulty integrating diet and medication in daily life, especially at social gatherings. They felt separated from others when special menus were provided for them or struggled when choosing between high and low phosphate-containing food. A new awareness of self and others arose, especially their position among families and friends, and how they presented themselves and their social identity to others. Likewise, a new social code manifested itself, which was difficult to accept. Most participants experienced that diet and medication were accompanied by a moral responsibility of whether to accept prepared food with high phosphorus content or not, which affected commensality. CONCLUSION: Patients were often nonadherent to hyperphosphatemia treatment at social gatherings. Hyperphosphatemia treatment led to new social identities with new social codes, which patients found difficult to accept.

Existential communication in maternity care - Mixed method evaluation of a postgraduate short course.

OBJECTIVE: The birth of a child is a significant life event, possibly accompanied by thoughts and feelings of existential turmoil, which some parents need to share. Maternity care professionals may be unprepared for this, as very few educational initiatives exist with a focus on existential communication. We evaluated the curriculum and delivery of a course in existential communication for midwives. The evaluation was based on participants' experiences of self-reported self-efficacy and self-reflection before and after participation. METHODS: A parallel mixed methods design with pre- and post-course questionnaires and field observations. Quantitative data were evaluated using Mann-Whitney analyses, and open-ended questions and field observations were thematised for further analysis. RESULTS: Seventy-three maternity care professionals participated in the course. Of these, 69 (95%) completed a pre-course questionnaire, and 71 (97%) a post-course questionnaire. The quantitative data found a significant difference in various participant measures such as increase in self-efficacy in existential communication and understanding of existential communication. Qualitative data from the questionnaires and field observations led to six different themes including topics such as the need for reflection with peers and the presence of existential within maternity care. CONCLUSIONS: The course evaluation suggested an increase in participants' awareness of existential aspects of maternity care and improved self-reflection and existential awareness.

Relatives' negotiations with healthcare professionals during older people's admission in an emergency department: An ethnographic study.

BACKGROUND: Relatives are recognised as important for older patients' care and treatment. Variations in relatives' opportunities to negotiate the quality and continuity of older people's care and treatment can potentially lead to inequality in older people's access to care and treatment. AIM: This study aimed to examine relatives' opportunities and strategies for negotiation with health care professionals (HCPs) during the admission of older people to emergency departments in Denmark. MATERIALS AND METHODS: We planned a qualitative ethnographical study employing a hermeneutic approach. Observations focused on social situations and interactions between relatives and HCPs. The analysis was guided by qualitative content analysis. RESULTS: The analysis derived one main theme, attitude to action, containing three subthemes: frustration obtaining access, presenting the case and a powerful relationship. Being active appeared to be essential to achieving possibilities for negotiation with HCPs. DISCUSSION: Inspired by Bourdieu, habitus, doxical values and institutional logics of relatives seem to affect their opportunities to negotiate with HCPs during older people's admission to an emergency department. CONCLUSION: Active and proactive relatives seem to have better opportunities to negotiate with HCPs during older people's acute hospital admission than reactive, passive and hesitant relatives. The logic of public management and the medical profession seem to dominate and influence doxa in the EDs and put special demands on the relatives. This imbalance constitutes a risk of inequality in older people's access to health.

Existential aspects of parenthood transition seen from the health professionals' perspective - an interview and theatre workshop study.

OBJECTIVES: A sense of existential vulnerability is embedded in parenthood transition. It is linked to meaning in life, relationship changes, awareness of death, and sometimes a transcendent belief. Nevertheless, in most maternity service guidelines, the existential aspects of life are not an explicit focus. Therefore, this study aimed to explore how health professionals in maternity services experience and understand existential aspects of parenthood transition among new parents. STUDY DESIGN: Data were generated through a user-involving two-phase process inspired by action research consisting of three focus group interviews with health professionals (n = 10) and, subsequently, a theatre workshop for parents, health professionals, and researchers (n = 40). Between the two phases, case narratives were constructed using information from the interviews and, in collaboration with a dramatist, dramatized and then played out at a workshop by professional actors. We used thematic analysis for all data. RESULTS: We identified five themes in the data material: 1. Death and fragility in maternity care, 2. Existential aspects in camouflage, 3. Existential and spiritual aspects of being professional in maternity care, 4. Talking about existential aspects of care, 5. Equipped for providing existential care? CONCLUSIONS: Existential aspects were often recognized during birth, specially in traumatic situations or discerned in the physical and non-verbal relational energy between the birthing woman and midwife or partner. Less often, existential aspects were recognized during pregnancy and the post-partum period.

Stimulating existential communication - first steps towards enhancing health professionals' reflective skills through blended learning.

Introduction: Talking about existential issues with patients is often experienced as challenging for healthcare professionals. This paper describes our first steps towards developing existential communication training with particular attention to reflective learning methods. Blended learning was chosen to support reflection and an easier transition to classroom conversations, and through Participatory Action Research (PAR), patients were involved in developing the curriculum. Method: To develop the most valuable and relevant communication training, patients, relatives, healthcare professionals and researchers were involved in a PAR process including 1) three theatre workshops and 2) collaborative meetings to develop the blended learning curriculum and reflection videos. The evaluation of the communication training was based on semi-structured interviews with the healthcare professionals participating in the blended learning communication training. Discussion and innovation: The results indicate that a blended learning format involving a high degree of reflection is valuable for developing skills related to existential communication. Engaging patients in the process may be essential to develop a training curriculum for healthcare professionals that accommodates the patient's needs. Conclusion: Future communication training on existential communication may benefit from adopting a blended learning format, including reflective learning methods and the involvement of patients in curriculum development.

Prayer and meditation practices in the early COVID-19 pandemic: A nationwide survey among Danish pregnant women. The COVIDPregDK study.

BACKGROUND: The emergence of the COVID-19 pandemic and the derived changes in maternity care have created stress and anxiety among pregnant women in different parts of the world. In times of stress and crisis, spirituality, including spiritual and religious practices, may increase. OBJECTIVE: To describe if the COVID-19 pandemic influenced pregnant women's considerations and practises of existential meaning-making and to investigate such considerations and practices during the early pandemic in a large nationwide sample. METHODS: We used survey data from a nationwide cross-sectional study sent to all registered pregnant women in Denmark during April and May 2020. We used questions from four core items on prayer and meditation practices. RESULTS: A total of 30,995 women were invited, of whom 16,380 participated (53%). Among respondents, we found that 44% considered themselves believers, 29% confirmed a specific form of prayer, and 18% confirmed a specific form of meditation. In addition, most respondents (88%) reported that the COVID-19 pandemic had not influenced their responses. CONCLUSION: In a nationwide Danish cohort of pregnant women, existential meaning-making considerations and practices were not changed due to the COVID-19 pandemic. Nearly one in two study participants described themselves as believers, and many practised prayer and/or meditation.

Prevalence of preterm birth in Scandinavian countries: a systematic review and meta-analysis.

OBJECTIVES: As welfare societies, Scandinavian countries share characteristics of equality related to healthcare access, gender, and social services. However, cultural and lifestyle variations create country-specific health differences. This meta-analysis assessed the prevalence of preterm birth (PTB) and its categories in Scandinavian countries. METHODS: A systematic search in key databases of literature published between 1990 and 2021 identified studies of the prevalence of PTB and its categories. Following the use of the Freeman-Tukey double arcsine transformation, a meta-analysis of weighted data was performed using the random-effects model and meta-prop method. RESULTS: We identified 109 observational studies that involved 86,420,188 live births. The overall pooled prevalence (PP) of PTB was 5.3% (PP = 5.3%, 95% confidence interval [CI] 5.1%, 5.5%). The highest prevalence was in Norway (PP = 6.2%, 95% CI 5.3%, 7.0%), followed by Sweden (PP = 5.3%, 95% CI 5.1%, 5.4%), Denmark (PP = 5.2%, 95% CI 4.9%, 5.3%), and Iceland (PP = 5.0%, 95% CI 4.4%, 5.7%). Finland had the lowest PTB rate (PP = 4.9%, 95% CI 4.7%, 5.1%). CONCLUSIONS: The overall PP of PTB was 5.3%, with small variations among countries (4.9%-6.2%). The highest and lowest PPs of PTB were in Norway and Finland, respectively.

Existential aspects as an inevitable part of salutogenesis in maternity care - A discussion paper.

BACKGROUND: Poor mental health is considered a major health challenge globally, not least for young people, who will form families within forthcoming years. Research related to childbirth and parenthood transition has focused on how to promote good mental health by preventing mental illness. AIM: We discuss how a salutogenetic approach to mental health in parenthood transition is beneficial, and specifically how the component of meaningfulness in Sense of Coherence (SoC), could be investigated to optimize good mental health during parenthood transition. DISCUSSION: In more recent understandings of meaningfulness, ideas from existential philosophy and psychology have been included. We discuss how, from an existential psychological perspective, open and explorative questioning of life conditions and dilemmas may help to regain one's footing and get in touch with one's driving force - meaningfulness. Such questioning implies that someone, a professional or a friend, actively and relationally helps explore existential aspects of life. CONCLUSION: We believe that investigating and asking research questions pointing at optimizing a salutogenetic perspective, specifically focusing on the component of meaningfulness and its embedded existential aspects of life, could lead to new knowledge on how to promote good mental health in maternity care.

Perinatal and Neonatal Outcomes in Immigrants From Conflict-Zone Countries: A Systematic Review and Meta-Analysis of Observational Studies.

Objectives: There are controversies regarding the risk of adverse pregnancy outcomes among immigrants from conflict-zone countries. This systematic review and meta-analysis aimed to investigate the risk of perinatal and neonatal outcomes among immigrants from conflict-zone countries compared to native-origin women in host countries. Methods: A systematic search on the databases of PubMed/MEDLINE, Scopus, and Web of Science was carried out to retrieve studies on perinatal and neonatal outcomes among immigrants from Somalia, Iraq, Afghanistan, Yemen, Syria, Nigeria, Sudan, Ethiopia, Eritrea, Kosovo, Ukraine, and Pakistan. Only peer-reviewed articles published in the English language were included in the data analysis and research synthesis. The odds ratio and forest plots were constructed for assessing the outcomes of interests using the DerSimonian and Laird, and the inverse variance methods. The random-effects model and the Harbord test were used to account for heterogeneity between studies and assess publication bias, respectively. Further sensitivity analysis helped with the verification of the reliability and stability of our review results. Results: The search process led to the identification of 40 eligible studies involving 215,718 pregnant women, with an immigration background from the conflict zone, and 12,806,469 women of native origin. The adverse neonatal outcomes of the risk of small for gestational age (Pooled OR = 1.8, 95% CI = 1.6, 2.1), a 5-min Apgar score <7 (Pooled OR = 1.4, 95% CI = 1.0, 2.1), stillbirth (Pooled OR = 1.9, 95% CI = 1.2, 3.0), and perinatal mortality (Pooled OR = 2, 95% CI = 1.6, 2.5) were significantly higher in the immigrant women compared to the women of native-origin. The risk of maternal outcomes, including the cesarean section (C-S) and emergency C-S, instrumental delivery, preeclampsia, and gestational diabetes was similar in both groups. Conclusion: Although the risk of some adverse maternal outcomes was comparable in the groups, the immigrant women from conflict-zone countries had a higher risk of neonatal mortality and morbidity, including SGA, a 5-min Apgar score <7, stillbirth, and perinatal mortality compared to the native-origin population. Our review results show the need for the optimization of health care and further investigation of long-term adverse pregnancy outcomes among immigrant women.