What are the health problems for migrant women and babies, and what are the risk factors?

How to identify who is at risk?

Risk factors for divergent outcomes

Some of the potential explanations and risk factors for divergent outcomes among migrants are [1,2]:

Genetic and biological factors such as consanguinity and thalassemia
Higher burden of disease in countries of origin or transit (e.g. HIV, tuberculosis, anemia)
Societal factors such as lower education and socioeconomic status, and lack of social support
Misconceptions between providers and patients through different cultural concepts and acceptability of care, or more directly through lack of professional interpretation services
Low health literacy

Healthy/protective factors for divergent outcomes [2]

Mother’s background and origin from a high-resource country with high gender-related Development Index, advanced healthcare system and lower burden of disease on a population level (www.gapminder.org).
High socio-economic status or education level of the women and, to some extent, high education level of the partner.
Knowledge of local language and solid social network/social capital.
Length of stay in the host country with more access to care and interventions for those with a longer stay.
Migration to a country with a strong integration policy (as measured by the Migrant Integration Policy Index (www.mipex.eu/key-findings).
Valid residence permit or visa.

What works to improve the maternal and newborn health of migrants?

Be aware of patient’s background and pay special attention to low socio-economic background and the great heterogenicity in this group [1].

Be aware of the higher burden of some diseases or exposures in specific migrant groups and how some may affect pregnancy outcomes
Use a systematic approach to identify migrant’s health status at antenatal care and to address the associated increased risk factors, such as tuberculosis, HIV, anemia, obesitas, with adequate screening tests and additional care.
Implement programs or support organizations that pair expecting migrant women from a similar background who have already experienced birth in the new country and are settled in the community. A cultural mediator can also provide this kind of support or pair women with peers.
Acknowledge the stress and mental-health related to the socio-economic issues associated with ill-health (such as poor living conditions, unemployment, need to support family and poverty) and refer patients to social services if needed

Provide professional translation services

Translation services such as using interpreters, cultural mediators, translating written information into migrant’s native tongue are effective tools to reduce communication barriers at the healthcare encounter.
Specifically tailored information materials in the target group’s native language about warning signs of complications in pregnancy, how to navigate the healthcare system, and provide social support during antenatal care
Provide and guarantee professional translation services in healthcare facilities for all individuals who require support. Use cultural mediators and interpreters but assure the patient of confidentiality
Use professional interpreters and not a family member or a bilingual staff member, to facilitate communication between medical staff and migrant women. Consider telephone or video sessions as a cost-effective and timely alternative when face-to-face interpreting services are not an option.

Provide a culturally sensitive and person-centered care meeting [1]

During patient contact, make an effort to educate the women about the particulars of the health system in the host country. This might require scheduling longer consultation times for women with a migration background.
Where possible and safe, try to provide individualized care that is acceptable to migrant women, rather than adhering strictly to every aspect of the protocol applied to native women.
Be aware of a different clinical presentation of conditions such as pre-eclampsia and heart disease in migrant women.
Confirm your definition of medical concepts, such as symptom severity, with those of the patient.
Do not let your own opinions about cultural mechanisms guide your clinical assessment [4].
Be aware of the other possible barriers to access obstetric care, and try to plan with the woman and those around her as to how to overcome these.
Diagnose and treat risk factors common among migrant populations such as anemia, HIV, tuberculosis, obesity.

Some specific health issues of migrant maternal and newborn health more in detail:

Stillbirths and congenital anomalies
Preterm deliveries
Caesarean births
Maternal mortality and severe morbidity

Stillbirths and congenital anomalies [5]

Migrant women are at a particularly high risk of giving birth to a stillborn child or a child having a congenital anomaly.
Optimized utilization of antenatal care and access to a migrant-friendly antenatal and perinatal care are crucial to reduce fetal mortality.
Indicators for increased risk of stillbirths and congenital anomalies vary between ethnic groups.
Improved healthcare in relation to consanguinity is needed to reduce neonatal mortality and morbidity.
Counselling to women in a consanguineous union should be offered, including education on the risks of having children with an autosomal recessive congenital anomaly, pre pregnancy counseling and antenatal diagnostics.
There seems to be an association between emotional strain and stressful live events and late stillbirths, that would partly explain the increased risk of stillbirths in migrant women, but more research in this area is needed.

Preterm deliveries [6]

Higher rates of preterm delivery have been associated to ethnicity, and to a lesser extent to migrant status. These differences are identified at population level, however in clinical practice it is very challenging to identify which individuals within the group are at risk.
The mechanisms behind these higher rates are not well understood but research points toward socio-economic disadvantage and discrimination rather than genetic factors.
A standardized method of early pregnancy dating is necessary to avoid misclassifications of gestational length [2].

Caesarean births [7]

Migrant women generally have higher rates of C-sections

High rates of emergency C-sections are especially reported in migrant women, which could indicate a lack of quality of care. If migrant women have a higher burden of disease it should be identified at antenatal care and result in planned C-sections. High rates of emergency sections are an indication of “too few or too late” planned interventions.
On the other hand, too many C-sections can also be problematic as unnecessary sections carry risks for the women. The WHO estimates that at population level, there are no more reductions in adverse effects beyond 10% of caesarean section rates, and also that “the effects of caesarean section rates on other outcomes, such as maternal and perinatal morbidity, paediatric outcomes and psychological or social well-being are still unclear”
Factors leading to a C-section decision are multiple and complex, and include both physical and psychological health of the mother, as well as social and cultural context and quality of care.
The woman (and her partner) should be appropriately informed and included in the decision about caesarian births. Inform the women from low-income countries about the reasons for caesarean section, and the safety of this procedure in Europe.
Provide continuous support during labor, including an intercultural mediator and pain management.

References:

[1] Copenhagen: WHO Regional Office for Europe. (2018). Improving the health care of pregnant refugee and migrant women and newborn children. (Technical guidance on refugee and migrant health). Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0003/388362/tc-mother-eng.pdf?ua=1

[2] Keygnaert, I., World Health Organization. Regional Office for Europe, & Health Evidence Network. (2016). What is the evidence on the reduction of inequalities in accessibility and quality of maternal health care delivery for migrants? A review of the existing evidence in the WHO European Region. World Health Organisation Regional Office for Europe.

[3] van den Akker, T., & van Roosmalen, J. (2016). Maternal mortality and severe morbidity in a migration perspective. Best Practice & Research Clinical Obstetrics & Gynaecology, 32, 26–38. https://doi.org/10.1016/J.BPOBGYN.2015.08.016

[4] Binder, P. (2012). The Maternal Migration Effect: Exploring Maternal Healthcare in Diaspora Using Qualitative Proxies for Medical Anthropology. Retrieved from http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-182870

[5] Nybo Andersen, A. M., Gundlund, A., & Villadsen, S. F. (2016). Stillbirth and congenital anomalies in migrants in Europe. Best Practice and Research: Clinical Obstetrics and Gynaecology, 32, 50–59. https://doi.org/10.1016/j.bpobgyn.2015.09.004

[6] Sørbye, I. K., Wanigaratne, S., & Urquia, M. L. (2016). Variations in gestational length and preterm delivery by race, ethnicity and migration. Best Practice and Research: Clinical Obstetrics and Gynaecology, 32, 60–68. https://doi.org/10.1016/j.bpobgyn.2015.08.017

[7] Esscher, A. (2014). Maternal Mortality in Sweden: Classification, Country of Birth, and Quality of Care. Uppsala http://uu.diva-portal.org/smash/get/diva2:690761/FULLTEXT01.pdf

[8] Byrskog, U. (2015). ’Moving On’and Transitional Bridges: Studies on migration, violence and wellbeing in encounters with Somali-born women and the maternity health care in. Retrieved from http://www.diva-portal.org/smash/record.jsf?pid=diva2:845757

from http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-182870

[7] Esscher, A. (2014). Maternal Mortality in Sweden: Classification, Country of Birth, and Quality of Care. Uppsala http://uu.diva-portal.org/smash/get/diva2:690761/FULLTEXT01.pdf