Inclusiveness of Access Policies to Maternity Care for Migrant Women Across Europe: A Policy Review.

INTRODUCTION: Despite the interconnectedness of the European Union, there are significant variations in pregnant women's legal status as migrants and therefore their ability to access maternity care. Limited access to maternity care can lead to higher morbidity and mortality rates in migrant women and their babies. This study aimed to investigate and compare maternal health access policies and the context in which they operate across European countries for women who have migrated and are not considered citizens of the host country. METHODS: The study adopted a mixed-methods research design exploring policies on migrant women's access to maternity care across the migration regimes. Data were extracted from legal documents and research reports to construct a new typology to identify the inclusiveness of policies determining access to maternity care for migrant women. RESULTS: This study found inconsistency in the categorisation of migrants across countries and significant disparities in access to maternity care for migrant women within and between European countries. A lack of connection between access policies and migration regimes, along with a lack of fit between policies and public support for migration suggests a low level of path dependency and leaves space for policy innovation. DISCUSSION: Inequities and inconsistencies in policies across European countries affect non-citizen migrant women's access to maternity care. These policies act to reproduce structural inequalities which compromise the health of vulnerable women and newborns in reception countries. There is an urgent need to address this inequity, which discriminates against these already marginalised women.

Giving birth in rural Arctic Greenland results from an Eastern Greenlandic birth cohort.

Eastern Greenland is one of the most remote areas in the world. Approximately 3,500 people lives in two small towns and five villages. There is limited information on birth outcomes in Eastern Greenland. A cohort of all birthing women from Eastern Greenland from 2000 to 2017 was established and pregnancy, birth, and neonatal outcomes were described. A total of 1,344 women and 1,355 children were included in the cohort where 14.5% of the women were 18 years or younger, and 36.2% were single parents. Most women, 84.8% gave birth in East Greenland and 92.9%, experienced a vaginal, non-instrumental birth. The overall caesarean section rate was 6.5%. The rate of premature births was 10.1% and 2.2% of the children were born with malformations. The rate of premature births was high, preventive initiatives such as midwifery-led continuity of care including a stronger focus on the pregnant woman's social and mental life situation may be recommended. Organisation of maternity services in East Greenland may benefit from a strong focus on public health, culture, and setting specific challenges, including the birth traditions of the society.

How much synthetic oxytocin is infused during labour? A review and analysis of regimens used in 12 countries.

OBJECTIVE: To compare synthetic oxytocin infusion regimens used during labour, calculate the International Units (IU) escalation rate and total amount of IU infused over eight hours. DESIGN: Observational study. SETTING: Twelve countries, eleven European and South Africa. SAMPLE: National, regional or institutional-level regimens on oxytocin for induction and augmentation labour. METHODS: Data on oxytocin IU dose, infusion fluid amount, start dose, escalation rate and maximum dose were collected. Values for each regimen were converted to IU in 1000ml diluent. One IU corresponded to 1.67µg for doses provided in grams/micrograms. IU hourly dose increase rates were based on escalation frequency. Cumulative doses and total IU amount infused were calculated by adding the dose administered for each previous hour. Main Outcome Measures Oxytocin IU dose infused. RESULTS: Data were obtained on 21 regimens used in 12 countries. Details on the start dose, escalation interval, escalation rate and maximum dose infused were available from 16 regimens. Starting rates varied from 0.06 IU/hour to 0.90 IU/hour, and the maximum dose rate varied from 0.90 IU/hour to 3.60 IU/hour. The total amount of IU oxytocin infused, estimated over eight hours, ranged from 2.38 IU to 27.00 IU, a variation of 24.62 IU and an 11-fold difference. CONCLUSION: Current variations in oxytocin regimens for induction and augmentation of labour are inexplicable. It is crucial that the appropriate minimum infusion regimen is administered because synthetic oxytocin is a potentially harmful medication with serious consequences for women and babies when inappropriately used. Estimating the total amount of oxytocin IU received by labouring women, alongside the institution's mode of birth and neonatal outcomes, may deepen our understanding and be the way forward to identifying the optimal infusion regimen.

Women on the move: A search for preferred birth services.

BACKGROUND: Women and midwives travel long distances, or abroad, to receive or provide birth services. Travel for birth services is not represented in the existing literature, despite the wide scale research available on medical travel. AIM: We explored the perspectives of women who were seeking better services outside their places of residence and midwives who travel to provide these services. METHOD: We followed a qualitative descriptive approach. We conducted 13 qualitative interviews with women from various European countries, four travelling midwives and one activist. Principles of thematic analysis were used. FINDINGS: Deciding whether to travel is the result of a long-term process, influenced by various push and pull factors. Travelling women and midwives share values; they trust the capacity of women to give birth; they value respect and equality in communication; they search for trusting relationships and friendly environments without unnecessary treatments. Trust and distrust on interpersonal and institutional levels influence women's decisions and frame narratives about their experiences. CONCLUSION: To a great extent, travelling women and midwives share the values embedded in the midwifery model of care. Women and midwives are willing to take matters into their own hands to achieve their expected birth experiences.

Women's experiences of self-reporting health online prior to their first midwifery visit: A qualitative study.

BACKGROUND: Information and communication technologies are increasingly used in health care to meet demands of efficiency, safety and patient-centered care. At a large Danish regional hospital, women report their physical, mental health and personal needs prior to their first antenatal visit. Little is known about the process of self-reporting health, and how this information is managed during the client-professional meeting. AIM: To explore women's experiences of self-reporting their health status and personal needs online prior to the first midwifery visit, and how this information may affect the meeting between the woman and the midwife. METHOD: Fifteen semi-structured interviews with pregnant women and 62h of observation of the first midwifery visit were carried out. Conventional content analysis was used to analyse data. FINDINGS: Three main categories were identified; 'Reporting personal health', 'Reducing and generating risk', and 'Bridges and gaps'. Compared to reporting physical health information, more advanced levels of health literacy might be needed to self-assess mental health and personal needs. Self-reporting health can induce feelings of being normal but also increase perceptions of pregnancy-related risk and concerns of being judged by the midwife. Although women want to have their self-reported information addressed, they also have a need for the midwife's expert knowledge and advice, and of not being perceived as a demanding client. CONCLUSION: Self-reported health prior to the first midwifery visit appears to have both intended and unintended effects. During the midwifery visit, women find themselves navigating between competing needs in relation to use of their self-reported information.

Quality assessment of patient leaflets on misoprostol-induced labour: does written information adhere to international standards for patient involvement and informed consent?

OBJECTIVES: The need for thorough patient information is increasing as maternity care becomes more medicalised. The aim was to assess the quality of written patient information on labour induction. In most Danish hospitals, misoprostol is the first-choice drug for induction in low-risk pregnancies. Misoprostol has been associated with adverse side effects and severe outcomes for mother and child and is not registered for obstetric use in Denmark. SETTING: Secondary care hospitals in Denmark. DATA: Patient information leaflets from all hospitals that used misoprostol as an induction agent by June 2015 (N=13). DESIGN: Patient leaflets were evaluated according to a validated scoring tool (International Patient Decision Aid Standards instrument, IPDAS), core elements in the Danish Health Act, and items regarding off-label use and non-registered medication. Two of the authors scored all leaflets independently. OUTCOME MEASURES: Women's involvement in decision-making, information on benefits and harms associated with the treatment, other justifiable treatment options, and non-registered treatment. RESULTS: Generally, the hospitals scored low on the IPDAS checklist. No hospitals encouraged women to consider their preferences. Information on side effects and adverse outcomes was poorly covered and varied substantially between hospitals. Few hospitals informed about precautions regarding outpatient inductions, and none informed about the lack of evidence on the safety of this procedure. None informed that misoprostol is not registered for induction or explained the meaning of off-label use or use of non-registered medication. Elements such as interprofessional consensus, long-term experience, and health authorities' approval were used to add credibility to the use of misoprostol. CONCLUSIONS: Central criteria for patient involvement and informed consent were not met, and the patient leaflets did not inform according to current evidence on misoprostol-induced labour. Our findings indicate that patients receive very different, sometimes contradictory, information with potential ethical implications. Concerns should be given to outpatient inductions, where precise written information is of particular importance.