Experiences of childbirth care among immigrant and non-immigrant women: a cross-sectional questionnaire study from a hospital in Norway.

BACKGROUND: Immigrant women have higher risks for poor pregnancy outcomes and unsatisfactory birth experiences than the general population. The mechanisms behind these associations remain largely unknown, but they may result from differential care provided to immigrant women or unsatisfactory interactions with health providers. This study aimed to investigate immigrant and non-immigrant women's experiences of health care during childbirth, particularly assessing two dimensions: perceived general quality of care and attainment of health care needs during childbirth. METHODS: This was a cross-sectional study carried out over 15 months in 2020 and 2021, and data were collected from a self-completed questionnaire. The labour and birth subscale from the Experience of Maternity Care questionnaire was used to assess the primary outcome of care experiences. A total of 680 women completed the questionnaire approximately within two days after birth (mean 2.1 days) at a hospital in Trondheim, in central Norway. The questionnaire was provided in eight languages. RESULTS: The 680 respondents were classified as immigrants (n = 153) and non-immigrants (n = 527). Most women rated their quality of care during childbirth as high (91.5%). However, one-quarter of the women (26.6%) reported unmet health care needs during childbirth. Multiparous immigrant women were more likely than multiparous non-immigrant women to report that their health care needs were unmet during childbirth (OR: 3.31, 95% CI: 1.91-5.72, p < 0.001, aOR: 2.83, 95% CI: 1.53-5.18, p = 0.001). No other significant differences between immigrant versus non-immigrant women were found in subjective ratings of childbirth care experiences. Having a Norwegian-born partner and a high level of Norwegian language skills did not influence the immigrant women's experience of childbirth care. CONCLUSIONS: Our findings indicate that many women feel they receive high-quality health care during childbirth, but a considerable number still report not having their health care needs met. Also, multiparous immigrant women report significantly more unmet health care needs than non-immigrants. Further research is required to assess immigrant women's childbirth experiences and for health care providers to give optimal care, which may need to be tailored to a woman's cultural background and individual expectations.

Domestic violence and perinatal outcomes - a prospective cohort study from Nepal.

BACKGROUND: Domestic violence is one of the most common forms of violence against women. Domestic violence during pregnancy is associated with adverse perinatal and maternal outcomes. We aimed to assess whether domestic violence was associated with mode of delivery, low birthweight and preterm birth in two sites in Nepal. METHODS: In this prospective cohort study we consecutively recruited 2004 pregnant women during antenatal care at two hospitals between June 2015 and September 2016. The Abuse Assessment Screen (modified) was used to assess fear and violence. Having ever experienced either fear or violence was defined as any domestic violence. Obstetric outcomes were obtained from hospital records for 1381 (69%) women, selecting singleton pregnancies only. Mode of delivery was assessed as birth by cesarean section or not. A birthweight of less than 2500 g was defined as low birthweight and preterm birth as birth before completion of 37 weeks gestation. Descriptive and multiple logistic regression analyses were performed to assess associations. RESULTS: Twenty percent of the women reported any domestic violence. Among all 1381 women, 37.6% gave birth by cesarean section. Of those women who delivered by cesarean section, 84.7% had an emergency cesarean section. Less than 10% of the babies were born prematurely and 13.5% were born with low birthweight. We found no significant association between exposure to any domestic violence during pregnancy and risk of a low birthweight baby or birth by cesarean section. However, having experienced both violence and fear was significantly associated with giving birth to a preterm infant [aOR 2.33 (95% CI;1.10-4.73)]. CONCLUSIONS: Domestic violence is common in Nepal. This is a potential risk factor for severe morbidity and mortality in newborns. We found that the risk of having a preterm baby was higher for pregnant women who experienced both fear and violence. This should be recognized by the health sector. In this study, no significant differences were found in the rate of cesarean section nor low birthweight for women who had experienced any domestic violence compared to those who did not.

Developing and validating the Nepalese Abuse Assessment Screen (N-AAS) for identifying domestic violence among pregnant women in Nepal.

This study culturally adapted and validated a Nepalese version of the Abuse Assessment Screen (AAS) tool for identifying domestic violence among pregnant women in Nepal, creating the Nepalese Abuse Assessment Screen (N-AAS). International and national topic experts reviewed the initial N-AAS version using the Delphi method, and pregnant women participated in cognitive interviews, providing feedback on the N-AAS as user experts. Subsequent pre-testing of a comprehensive questionnaire, which included the translated version of the N-AAS, occurred in two tertiary care hospitals using an electronic format known as Color-Coded Audio Computer-Assisted Self-Interview (C-ACASI). The study assessed the content validity index, compared the concurrent validity of the N-AAS with the gold standard interview, estimated the prevalence of domestic violence from two hospitals, and calculated the Kappa coefficient. The reliability of the entire questionnaire was also evaluated through a test-retest analysis, with content validity rated as "good to excellent" by topic and user experts and high test-retest reliability (91.2-98.9%), indicating consistency across questionnaires completed at two different time points, with 12% of participants reporting any form of violence. The N-AAS demonstrated ≥91.7% specificity for all forms of abuse, accurately identifying non-abuse cases. In addition, moderate to excellent sensitivity was observed for emotional abuse (52.5%) and physical abuse since marriage (50%), while sensitivity for physical abuse in the past 12 months was 100%. Thus, the N-AAS demonstrated reliable test-retest results with a good Kappa coefficient and specificity, as well as showing excellent sensitivity for detecting recent physical abuse and moderate sensitivity for detecting emotional abuse and physical abuse since marriage. Because cultural context often leads women to normalize and tolerate abuse from spouses and family members and women are thus reluctant to report abuse, the results imply that the N-AAS can serve as a valuable screening tool for domestic abuse in antenatal care settings in Nepal.

Improving Safety Among Pregnant Women Reporting Domestic Violence in Nepal-A Pilot Study.

Introduction: Domestic violence (DV) during pregnancy is associated with poor health outcomes for both the mother and newborn, and sometimes death. In a low-income country like Nepal, women have few options to leave abusive situations. Therefore, there is a need for interventions to improve their safety. The aim of our study was to explore the use of safety measures before and after an educational intervention among women who have reported DV during pregnancy. Materials and methods: Of 1010 pregnant women screened consecutively for DV using the Abuse Assessment Screen (AAS) during routine antenatal care, 181 women reported domestic violence. All 1010 participating pregnant women were taught 15 safety measures using a locally developed flipchart. We obtained contact with 80 of the 181 eligible women postpartum, of whom 62 completed the follow-up assessment. We explored and described the use of safety measures at baseline and follow-up, using a standardized instrument called the Safety Behavior Checklist. Results: At follow-up, less than half of the women (n = 30, or 48.3%) reported any form of DV. Of the women who reported DV at follow-up, significantly more reported the experience of both violence and fear at baseline (21.9%, p = 0.01) compared with the women who did not report DV at follow-up (3.3%, p = 0.01). Women reporting DV at baseline and follow-up used more safety measures at baseline (56) and follow-up (80) compared with women reporting DV at baseline only (36 and 46). Women reporting DV at baseline and follow-up used more safety measures for the first time at follow-up, 57 new measures compared with the 28 new measures used by women reporting DV at baseline only. Conclusions: The use of a flipchart teaching session on safety measures within antenatal care may increase the number of safety measures women use to protect themselves during pregnancy and decrease the risks of adverse health effects of DV.

Exposure to domestic violence influences pregnant women's preparedness for childbirth in Nepal: A cross-sectional study.

OBJECTIVE: This study aimed to evaluate if domestic violence affected women's ability to prepare for childbirth. Birth preparedness and complication readiness (BP/CR) includes saving money, arranging transportation, identifying a skilled birth attendant, a health facility, and a blood donor before childbirth. During data collection, Nepal experienced two earthquakes and therefore it was possible to examine associations between domestic violence, women's BP/CR and effects of the earthquakes. METHODS: Women who were between 12 and 28 weeks of gestation participated in a descriptive cross-sectional study at a hospital antenatal clinic in Nepal, where they completed a structured questionnaire on sociodemographic characteristics, obstetric history, experiences of domestic violence, and BP/CR. The 5-item Abuse Assessment Screen was used to assess prevalence of domestic violence, and a questionnaire on safe motherhood obtained from Jhpiego was used to assess BP/CR status. The participants self-completed the questionnaire on a tablet computer. Those who reported at least three out of five BP/CR activities were considered prepared for childbirth. RESULTS: A total of 1011 women participated in the study: 433 pre-earthquakes and 578 post-earthquakes. With respect to BP/CR, 78% had identified a health facility for childbirth and 65% had saved money prior to childbirth. Less than 50% had identified a birth attendant to assist with the delivery, transportation to a health facility, or arranged for a potential blood donor. Prior to the earthquakes, 38% were unprepared; by contrast, almost 62% were not prepared after the earthquakes. A significant association was found between exposure to violence and not being prepared for childbirth (AOR = 2.3, 95% CI: 1.4-3.9). The women with increased odds of not being prepared for childbirth were illiterate (AOR = 9.9, 95% CI:5.7-17), young (AOR = 3.4, 95% CI:1.6-7.2), from the most oppressed social classes (AOR = 3.0, 95% CI:1.2-7.6), were married to illiterate husbands (AOR = 2.5, 95% CI:1.2-5.2), had attended fewer than four antenatal visits (AOR = 2.0, 95% CI: 1.4-2.6), had low incomes (AOR = 1.7, 95% CI:1.1-2.9) or lived in rural settings (AOR = 1.5, 95% confidence interval CI:1.2-2.1). CONCLUSION: The paper identifies vulnerable women who require extra care from the health system, and draws attention to the need for interventions to reduce the harmful effects of domestic violence on women's preparations for childbirth.