Obstetric outcomes of immigrants in a low-risk maternity ward in Norway
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AbstractBackground: A greater number of individuals are on the move today compared with any other time in human history. The health status of migrants and ethnic minority groups has often been demonstrated to be lower than the average population. Studies have also indicated that immigrants are at increased risks of adverse obstetric outcomes. At the lowrisk maternity ward in Baerum Hospital, Norway, 40% of women who give birth are immigrants, and 63% of this group originate from non-Western countries. Aim: The overall aim of this thesis was to examine the association between country of origin and adverse obstetric outcomes in women who give birth at the low-risk maternity ward in Baerum Hospital. We aimed to determine whether immigrant women had increased risk of adverse obstetric outcomes relative to Norwegians (papers I and III). We also aimed to establish whether originating from countries considered conflict-zones influenced obstetric outcomes (paper II). Finally, we aimed to determine whether there were differences in the obstetric outcomes between first- and second-generation immigrants (paper IV). Material and methods: The study comprised a population-based observational study with a prospective, cohort design. The study population included women who gave birth at Baerum Hospital in Norway between January 1, 2006 and December 31, 2010 (papers IIII) and January 1, 2006 and December 31, 2013 (paper IV). The maternity ward lacks a children’s section (i.e., it has no neonatal intensive care unit) and is referred to as a lowrisk maternity ward. The women who give birth in this ward comprise a particularly lowrisk group, which includes women at more than 35 weeks of gestation, who expect a healthy baby. Data were extracted from information recorded during pregnancy, birth and the early postpartum period and were provided by the Medical Birth Registry of Norway. In addition, Statistics Norway provided information regarding maternal and paternal country of birth, country of origin, immigrant category, and age at immigration, which were obtained from the Population Database, and data regarding maternal education from the National Education Database. The main exposure variables were country of origin/birth. In papers I and III, women were assigned to one of seven groups according to the country of origin: Norway; Eastern Europe; Latin America and the Caribbean; East, Southeast, and Central Asia; South and Western Asia; Africa; and Western Europe, North America, Australia, and New Zealand, which also included Nordic countries. In paper II, ethnic Norwegians and women from Somalia, Iraq, Afghanistan, and Kosovo, which are considered conflict-zones, were included. Paper IV included women of Pakistani origin, who were divided into first- and second-generation immigrants according to the country of birth. We examined differences in the proportions of participants with specific background characteristics and obstetric outcomes using bivariate analyses. Differences in the risk of adverse obstetric outcomes were estimated using multiple regression analysis. The association between country of origin/birth and risk of obstetric outcomes was assessed in reference to ethnic Norwegians, and the analyses controlled for several confounding variables. Results: Paper I: Relative to ethnic Norwegians, women from East, Southeast, and Central Asia were at increased risk of operative vaginal delivery, postpartum bleeding, and low Apgar scores. African women were at increased risk of postterm birth, meconium-stained liquor, episiotomy, operative vaginal delivery, emergency cesarean section, postpartum bleeding, low Apgar scores, and a low birth weight. Women from South and Western Asia were at increased risk of a low birth weight. Paper II: Women from Somalia exhibited the greatest risk of adverse obstetric outcomes and had increased odds ratios for emergency cesarean section, postterm birth, meconiumstained liquor, and a small for gestational age infant. They also had a reduced odds ratio for the use of epidural analgesia and a large for gestational age infant. Women from Iraq and Afghanistan differed in the median gestational age and mean birth weight and had an increased odds ratio for infants regarded as small for gestational age. Women from Kosovo did not differ from ethnic Norwegians in any obstetric outcomes assessed. Paper III: Seven hundred sixty-nine infants were treated for neonatal jaundice. Relative to infants born to ethnic Norwegians, infants born to mothers from East, Southeast, and Central Asia and African mothers were at an increased and decreased risk, respectively, of neonatal jaundice. A substantial number of jaundiced infants of African origin were transferred to neonatal intensive care units relative to jaundiced Norwegian infants. Paper IV: Relative to the first-generation Pakistani immigrants, the second-generation reported more health issues prior to pregnancy and an increased proportion experienced preterm birth (week 350 to 366) relative to Norwegians. An increased number of newborns of first-generation immigrants were transferred to neonatal intensive care units relative to Norwegian newborns. Conclusions and clinical implications: The results of this study suggest that even in a pregnant population that gives birth in a low-risk maternity ward, the obstetric outcomes of immigrants are significantly different from ethnic Norwegians. We introduced a theory that women of African origin, particularly from Somalia, are exposed to stressful pregnancies. The combined results of adverse obstetric outcomes give the impression of a fetus in distress with suboptimal conditions during pregnancy. To reduce stress and suboptimal conditions for these women, antenatal care must adapt to accommodate their needs. This adaption involves a substantial investment in the development of wellfunctioning interpreting services and strengthening midwifery services to facilitate a more individualized approach to high quality antenatal care.
List of papers
|I Bakken KS, Skjeldal OH, Stray-Pedersen B. Higher risk for adverse obstetric outcomes among immigrants of African and Asian descent: A comparison study at a low-risk maternity hospital in Norway. Birth. 2015; 42(2): 132-140. The paper is not available in DUO due to publisher restrictions. The published version is available at: https://doi.org/10.1111/birt.12165|
|II Bakken KS, Skjeldal OH, Stray-Pedersen B. Immigrants from conflict-zone countries: a comparison study of obstetric outcomes in a low-risk maternity hospital in Norway. BMC Pregnancy and Childbirth. 2015; 15:163. The paper is available in DUO: http://urn.nb.no/URN:NBN:no-51350|
|III Bakken KS, Skjeldal OH, Stray-Pedersen B. Neonatal jaundice and the immigrant population: A comparison study at a low-risk maternity ward in Norway. Nordic Journal of Nursing Research. 2015; 35:165-171, first published online 2 June 2015. The paper is not available in DUO due to publisher restrictions. The published version is available at: https://doi.org/10.1177/0107408315590566|
|IV Bakken KS, Skjeldal OH, Stray-Pedersen B. Obstetric outcomes of first- and second-generation Pakistani immigrants: a comparison study at a low risk maternity ward in Norway. Journal of Immigrant and Minority Health. 2015; published online 26 December 2015. The paper is not available in DUO due to publisher restrictions. The published version is available at: https://doi.org/10.1007/s10903-015-0329-3|