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      Differences in pregnancy outcomes and obstetric care between asylum seeking and resident women: a cross-sectional study in a German federal state, 2010–2016

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          Abstract

          Background

          Despite large numbers of asylum seekers, there is a lack of evidence on pregnancy outcomes and obstetric care of asylum seeking women in Germany.

          Methods

          Cross-sectional study (2010–2016) using administrative data of the main referral hospital for pregnant asylum seekers of the reception center of a large federal state in South Germany. Inclusion criteria: women aged 12–50 years, admitted in relation to pregnancy, childbirth or post-partum complications. Outcomes: differences between asylum seekers and residents in the prevalence of high-risk pregnancy conditions, abortive outcomes/stillbirths, peri- and postnatal maternal complications, neonatal complications, and caesarean sections. Analysis: odds ratios (OR) and 95% confidence intervals (CI) obtained by single and multiple logistic regression analysis. Attributable fractions among the exposed ( Afe) and among the total population ( Afp) were calculated for selected outcomes.

          Results

          Of 19,864 women admitted in relation to pregnancy, childbirth or post-partum complications, 2.9% ( n = 569) were asylum seekers. Adjusted odds for high-risk pregnancy conditions (OR = 0.76, 95%CI: 0.63–0.91, p < 0.0001), caesarean sections (OR = 0.84, 95%CI 0.66–1.07, p = 0.17) and perinatal complications (OR = 0.65, 95%CI: 0.55–0.78, p < 0.0001) were lower; those for abortive outcomes/stillbirths (OR = 1.58, 95%CI: 1.11–2.20, p = 0.01) and postnatal complications (OR = 1.80, 95%CI: 0.93–3.19, p = 0.06) higher among asylum seeking women relative to residents in models adjusted for age, length of admission, and high-risk pregnancy conditions. The Afe for abortive outcomes and stillbirths among asylum seekers was 40.3% (95% CI, 16.3–56.5) and the Afp was 1.8%. The Afe for postnatal complications was 53.1% (95% CI, 7.1–74.0) and the Afp was 3.1%.

          Conclusion

          Asylum seeking women are at higher risk of abortive outcomes/stillbirths and show a tendency towards higher postnatal complications. This excess risk calls for adequate responses by health care providers and policy makers to improve outpatient postnatal care in reception centers and mitigate adverse birth outcomes among asylum seeking women. Although further research is needed, scaling-up midwivery care, improving outreach by maternity care teams, and routinely identifying and addressing mental illness by psychosocial services could be ways forward to improve outcomes in this population.

          Electronic supplementary material

          The online version of this article (10.1186/s12884-018-2053-1) contains supplementary material, which is available to authorized users.

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          Most cited references18

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          Fetal, infant, and childhood growth are predictors of coronary heart disease, diabetes, and hypertension in adult men and women.

          Many human fetuses have to adapt to a limited supply of nutrients. In doing so they permanently change their structure and metabolism. These programmed changes may be the origins of a number of diseases in later life, including coronary heart disease, hypertension, and noninsulin- dependent diabetes. We review epidemiologic studies in which the incidence of these diseases has been related to the recorded, early growth of individuals, while considering factors in the adult lifestyle, such as obesity and socioeconomic status. We discuss possible mechanisms. For hypertension these mechanisms include placentation, maternal blood pressure, fetal undernutrition; childhood growth, activation of the renin-angiotensin system, renal structure, programming of the hypothalamic-pituitary-adrenal axis, vascular structure, and sympathetic nervous activity. For noninsulin-dependent diabetes we discuss mechanisms concerning both insulin resistance and insulin deficiency. We include a review of evidence for the programming of serum cholesterol and clotting factor concentrations. We address the timing of critical windows for coronary heart disease, reviewing studies that allow assessment of the relative importance of fetal, infant, and childhood growth. We argue for a research strategy that combines clinical, animal, and epidemiological studies.
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            Stillbirths and infant deaths among migrants in industrialized countries.

            The relation of migration to infant outcomes is unclear. There are studies which show that some migrant groups have similar or even better outcomes than those from the receiving country. Equally, raised risk of adverse outcomes for other migrant groups has been reported. We sought to determine (1) if migrants in western industrialized countries have consistently higher risks of stillbirth, neonatal mortality, or infant mortality, (2) if there are migrant sub-groups at potentially higher risk, and (3) what might be the explanations for any risk differences found. Systematic review of the literature on perinatal health outcomes among migrants in western industrialized countries. Drawing on a larger systematic review of perinatal outcomes and migration, we reviewed studies including mortality outcomes (stillbirths and infant deaths). Eligible studies gave conflicting results. Half (53%) reported worse mortality outcomes, one third (35%) reported no differences and a few (13%) reported better outcomes for births to migrants compared to the receiving country population. Refugees were the most vulnerable group. For non-refugees, non-European migrants in Europe and foreign-born blacks in the United States had the highest excess mortality. In general, adjustment of background factors did not explain the increased mortality rate among migrants. Regarding causes of death, higher preterm birth rates explained the increased mortality figures among some migrant groups. The increased mortality from congenital anomalies may be related to restricted access to screening, but also to differing attitudes to screening and termination of pregnancy. Mortality risk among babies born to migrants is not consistently higher, but appears to be greatest among refugees, non-European migrants to Europe, and foreign-born blacks in the US. To understand this variation better, more information is needed about migrant background, such as length of time in receiving country and receiving country language fluency. Additional data on demographic, health care, biological, medical, and socioeconomic risk factors should be gathered and analyzed in greater detail.
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              Migration and perinatal mental health in women from low- and middle-income countries: a systematic review and meta-analysis

              Migrant women are at risk of perinatal mental disorders due to stressors experienced before, during and after migration.
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                Author and article information

                Contributors
                +49 6221 56 38581 , kayvan.bozorgmehr@med.uni-heidelberg.de
                louise.biddle@med.uni-heidelberg.de
                preussler@imbi.uni-heidelberg.de
                andreas.mueller.fk@klinikum-karlsruhe.de
                joachim.szecsenyi@med.uni-heidelberg.de
                Journal
                BMC Pregnancy Childbirth
                BMC Pregnancy Childbirth
                BMC Pregnancy and Childbirth
                BioMed Central (London )
                1471-2393
                24 October 2018
                24 October 2018
                2018
                : 18
                : 417
                Affiliations
                [1 ]ISNI 0000 0001 0328 4908, GRID grid.5253.1, Department of General Practice and Health Services Research, , University Hospital Heidelberg, ; Marsilius Arkaden, INF 130.3, 69120 Heidelberg, Germany
                [2 ]ISNI 0000 0001 0328 4908, GRID grid.5253.1, Institute for Medical Biometry and Informatics, , University Hospital Heidelberg, ; Heidelberg, Germany
                [3 ]Clinic of Gynaecology, Karlsruhe City Hospital, Karlsruhe, Germany
                Article
                2053
                10.1186/s12884-018-2053-1
                6201533
                30355297
                65c17c0b-c47d-40c3-8429-bd0e500990f0
                © The Author(s). 2018

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 14 March 2018
                : 10 October 2018
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100002347, Bundesministerium für Bildung und Forschung;
                Award ID: FKZ 01GY1611
                Award Recipient :
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2018

                Obstetrics & Gynecology
                migration,asylum seekers,health inequality,pregnancy outcome,caesarian section,stillbirth,reception center,maternity care,postnatal care,social epidemiology

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