Socioeconomic and migration status as predictors of emergency caesarean section: a birth cohort study.

BACKGROUND: Women with a migration background are reportedly at a higher risk of emergency caesarean section. There is evidence that this is due in part to suboptimal antenatal care use and quality of care. Despite the fact that migrant women and descendants of migrants are often at risk of socioeconomic disadvantage, there is, in comparison, scarce and incomplete evidence on the role of socioeconomic position as an independent risk factor for emergency caesarean delivery. We therefore investigate whether and how migration background and two markers of socioeconomic position affect the risk of an emergency caesarean section and whether they interact with each other. METHODS: In 2013-2016, we recruited women during the perinatal period in Bielefeld, Germany, collecting data on health and socioeconomic and migration background, as well as routine perinatal data. We studied associations between migration background (1st generation migrant, 2nd/3rd generation woman, no migration background), socioeconomic status (educational attainment and net monthly household income), and the outcome emergency caesarean section. RESULTS: Of the 881 participants, 21% (n = 185) had an emergency caesarean section. Analyses showed no association between having an emergency caesarean section and migration status or education. Women in the lowest (< 800€/month) and second lowest (between 800 and 1750€/month) income categories were more likely (aOR: 1.96, CI: 1.01-3.81; and aOR: 2.36, CI: 1.27-4.40, respectively) to undergo an emergency caesarean section than women in the higher income groups. CONCLUSIONS: Migration status and education did not explain heterogeneity in mode of birth. Having a low household income, however, increased the chances of emergency caesarean section and thereby contributed towards producing health disadvantages. Awareness of these findings and measures to correct these inequalities could help to improve the quality of obstetric care.

[Regional Deprivation in Germany: Nation-wide Analysis of its Association with Mortality Using the German Index of Multiple Deprivation (GIMD)]. / Regionale Deprivation in Deutschland: Bundesweite Analyse des Zusammenhangs mit Mortalität unter Verwendung des 'German Index of Multiple Deprivation (GIMD)'.

BACKGROUND: Deprivation indices are increasingly being used to assess the effects of contextual factors on health. In Germany, the recently developed 'German Index of Multiple Deprivation (GIMD)' integrates various dimensions of regional deprivation. We aim to assess the validity of the GIMD through a recalculation using more recent rural and urban district level data and by analysing its association with mortality at the national level. METHODS: We calculated a new version of the GIMD based on data from 2007 to 2010 for all 412 rural and urban districts in Germany. Mortality was quantified using indirectly standardised mortality ratios (SMRs). Correlation analyses and Poisson regression analyses were used to assess the association between the GIMD scores and total mortality, as well as premature mortality (< 65 years). RESULTS: Correlation analyses showed a positive association between the GIMD and both total mortality (p<0.001) and premature mortality (p<0.001). In the Poisson regression analyses, rural and urban districts in the quintile with the highest deprivation showed a significantly elevated risk of total mortality (RR: 1.29; 95% CI: 1.28-1.30) as well as premature mortality (RR: 1.50; 95% CI: 1.47-1.53), compared to the districts in the lowest quintile. CONCLUSION: The association between regional deprivation and mortality has already been shown for the federal state of Bavaria. Using more recent data, this relationship could be confirmed here for Germany as a whole. The GIMD has been shown to be able to effectively assess regional deprivation. Concerning public health policy, the significant, positive and stable association between regional deprivation and mortality indicates an increased need for health care provision particularly in the most deprived districts. Further studies should examine, for example, whether and how the allocation of districts to quintiles of regional deprivation changes over time, and how this affects mortality.

Postpartum Contraception: a Comparative Study of Berlin Women with and without Immigration Background.

Research Questions: Are there differences in postpartum contraceptive use between women with and without immigration background? Do women more commonly use contraception following a high-risk pregnancy or caesarean section? What role does current breastfeeding play and, amongst immigrants, what is the effect of acculturation level on the frequency of contraceptive use? Study Population and Methods: Data collection was carried out as part of a larger study in three Berlin delivery units using standardised interviews (questionnaires covering e.g. sociodemographics, immigration history/acculturation and use of antenatal care); telephone interviews comprising 6 questions on postpartum contraception, breastfeeding and postpartum complications were conducted on a sample of the study population six months after delivery. Results: 247 women with, and 358 women without a background of immigration were included in the study (total study population n = 605, response rate 81.1 %). 68 % of 1st generation immigrants, 87 % of 2nd/3rd generation women and 73 % of women without immigration background (non-immigrants) used contraception. In the logistical regression analysis 1st generation immigrants were less likely than non-immigrants to be using contraception six months postpartum, and 1st generation immigrants with low acculturation level were significantly less likely to use contraception than 2nd/3rd generation women with low acculturation level. Conclusion: In the extended postpartum period there was no major difference in contraceptive use between immigrants in general and non-immigrants. It remains unclear whether the differing contraceptive behaviour of 1st generation immigrants is the result of less access to information, sociocultural factors or differing contraceptive requirements and further targeted, qualitative study is required.

[Are women with and without migration background reached equally well by health services? The example of antenatal care in Berlin]. / Werden Frauen mit und ohne Migrationshintergrund von den Gesundheitsdiensten gleich gut erreicht? : Das Beispiel Schwangerenvorsorge in Berlin.

BACKGROUND: About 20% of the population in Germany has a migration background (1st generation: immigrated themselves; 2nd generation: offspring of immigrants), which can be associated with health differentials. We assessed whether differentials in uptake of antenatal care (ANC) observed in earlier studies still persist today. METHODS: Data collection in 3 obstetric hospitals in Berlin, Germany, over a 1-year period 2011/2012. We conducted standardised interviews before delivery and linked the data to routinely collected perinatal data and to data from participants' antenatal cards. We checked for confounders using regression models. RESULTS: Of the 7100 study participants (response 89.6%), 57.9% had a migration background. First ANC attendance occurred in pregnancy weeks 3-19 in 92.1% of 1st generation immigrants vs. 97.8% of non-immigrants (mean week of first attendance: 1st generation immigrants with residence < 5 years: 13.0; 5+ years: 9.9; non-immigrants 9.7). A low ANC utilisation with ≤ 5 visits was found in 644 women (9.1%). Among the non-immigrants there were 7.1% low users, among 1st generation immigrants 11.8% (among women with no German language skills 33.0%, however). Uptake of non-medical support measures was lower among women with migration background. DISCUSSION: In our sample from Berlin, migration background had little effect on ANC uptake. Neither own migration nor low acculturation were independent risk factors for late onset or low utilisation of ANC. However, a small subgroup of women with a short duration of residence in Germany and with German language problems had a lower chance of timely onset and sufficient participation in ANC. This group needs special attention.

Comparison of Perinatal Data of Immigrant Women of Turkish Origin and German Women - Results of a Prospective Study in Berlin.

Aims: The aim of the study was to compare obstetrical process indicators and outcomes for German women with women of Turkish origin residing in Germany. Do women of Turkish origin attend antenatal examinations as frequently as non-immigrant women? Are high-risk pregnancies and anemia more common among immigrant women? Are the rates for epidural analgesia (PDA) and combined spinal-epidural analgesia (CSE) during delivery the same for immigrant women compared to German women? Are there identifiable differences in the mode of delivery and in perinatal outcomes? Patient Population/Methods: Data were obtained from 3 maternity clinics in Berlin for the period 2011 to 2012. The questionnaires covered socio-demographic factors and information on prenatal care as well as immigration/acculturation. The data obtained from these questionnaires was supplemented by information obtained from the official maternal record of prenatal and natal care (Mutterpass) and perinatal data recorded by the clinic. Results: The response rate was 89.6 %; the data of 1277 women of Turkish origin who had immigrated to Germany or whose family had immigrated and of 2991 non-immigrant women in Germany were included in the study. Regression analysis showed no statistically significant difference in the number of antenatal examinations between immigrant and non-immigrant women. Women of Turkish origin born in Germany had a significantly higher risk of postpartum anemia. PDA/CSE rate, arterial umbilical cord pH and 5-minute Apgar scores did not differ. The incidence of cesarean sections (elective and secondary) was significantly lower in the population of immigrant women of Turkish origin. Conclusion: Outcomes for most perinatal parameters were comparable for immigrant and non-immigrant women. These results indicate that the achieved standards of antenatal care and medical care during pregnancy are similar for Turkish immigrant women compared to non-immigrant women in maternity clinics in Berlin. The higher rates of anemia among immigrant women should be targeted by preventive measures.

[Data protection in rehabilitation research]. / Datenschutz in der Rehabilitationsforschung.

Data protection is regulated by legislation and has to be adhered to by scientists, too. This overview shows where aspects of data protection have to be considered in rehabilitation research. Important legal sources are the code of social law X, the German Federal Data Protection Act and the data protection acts of the German states. Specific recommendations about patient information sheet and written informed consent are given for research based on interviews with study participants. Furthermore, operations such as collecting, processing, using, storing, publishing and archiving of personal data are explained, taking into account the requirements of data protection. A practical example (URL: www.thieme-connect.de/ejournals/toc/rehabilitation) shows how to separate personal data and research data using the services of an external data custodian.

[Linkage of data of the medical service of the health insurances with data of a cancer registry]. / Abgleich von Verwaltungsdaten des Medizinischen Dienstes der Krankenversicherung mit Krebsregisterdaten.

BACKGROUND: The aim of this study was to examine whether a linkage of data sets of the Epidemiological Cancer Registry North Rhine-Westphalia (EKR-NRW) and the Medical Service of the Health Insurances (MDK WL) is feasible, which problems may occur during execution and what could be a solution strategy. METHODS: Data of the EKR-NRW were used to identify all cancer cases in the district of Munster, for which an expert opinion regarding nursing needs from the period 2004-2008 was available at the MDK WL. For this purpose factually anonymised data of the EKR-NRW and the MDK WL were linked by means of a semi-automatic probabilistic record linkage. RESULTS: Data linkage yielded 18 877 cancer cases but required great technical and temporal input. The processing of management data and the use of "routine channels" (ISDN connection), which provide the necessary safety for data transfer, but are designed for a considerably smaller amount of data, accounted for this. The interface problem (converting data from text format to a hierarchical XML format) can be solved with Excel or SAS. CONCLUSION: A record linkage with factually anonymised data from the MDK WL and the EKR-NRW is feasible. This allows, among other things, quantifying the needs for nursing care in persons with a cancer diagnosis.

Residential characteristics and radiofrequency electromagnetic field exposures from bedroom measurements in Germany.

The objectives of this study were to assess total exposure to radiofrequency electromagnetic fields (RF-EMF) in bedrooms and the contribution of different radioservices (FM radio, analogue TV and DVB-T, TETRA, GSM900 downlink, GSM1800 downlink, UMTS downlink, DECT, and wireless LAN and blue tooth) to the total exposure. Additional aims were to describe the proportion of measuring values above the detection limit of the dosimeters and to characterize the differences in exposure patterns associated with self-reported residential characteristics. Exposure to RF sources in bedrooms was measured using Antennessa(®) EME Spy 120 dosimeters in 1,348 households in Germany; 280 measures were available for each frequency band per household. Mean electrical field strengths and power flux densities were calculated. Power flux densities allow the calculation of proportions of different radioservices on total exposure. Exposure was often below the detection limit (electrical field strength: 0.05 V/m) of the dosimeter. Total exposure varied, depending on residential characteristics (urban vs. rural areas and floor of a building the measurement took place). Major sources of exposure were cordless phones (DECT standard) and wireless LAN/blue tooth contributing about 82% of total exposure (20.5 µW/m(2)). Exposure to RF-EMF is ubiquitous, but exposure levels are-if at all measurable-very low and far below the ICNIRP's exposure reference levels.

Quality control for exposure assessment in epidemiological studies.

In the framework of an epidemiological study, dosemeters were used for the assessment of radio frequency electromagnetic field exposure. To check the correct dosemeter's performance in terms of consistency of recorded field values over the entire study period, a quality control strategy was developed. In this paper, the concept of quality control and its results is described. From the 20 dosemeters used, 19 were very stable and reproducible, with deviations of a maximum of +/-1 dB compared with their initial state. One device was found to be faulty and its measurement data had to be excluded from the analysis. As a result of continuous quality control procedures, the confidence in the measurements obtained during the field work was strengthened significantly.

Mobile phone base stations and adverse health effects: phase 2 of a cross-sectional study with measured radio frequency electromagnetic fields.

OBJECTIVE: The aim of the cross-sectional study was to test the hypothesis that exposure to continuous low-level radio frequency electromagnetic fields (RF-EMFs) emitted from mobile phone base stations was related to various health disturbances. METHODS: For the investigation people living mainly in urban regions were selected from a nationwide study in 2006. In total, 3526 persons responded to a questionnaire (response rate 85%). For the exposure assessment a dosimeter measuring different RF-EMF frequencies was used. Participants answered a postal questionnaire on how mobile phone base stations affected their health and they gave information on sleep disturbances, headaches, health complaints and mental and physical health using standardised health questionnaires. Information on stress was also collected. Multiple linear regression models were used with health outcomes as dependent variables (n = 1326). RESULTS: For the five health scores used, no differences in their medians were observed for exposed versus non-exposed participants. People who attributed adverse health effects to mobile phone base stations reported significantly more sleep disturbances and health complaints, but they did not report more headaches or less mental and physical health. Individuals concerned about mobile phone base stations did not have different well-being scores compared with those who were not concerned. CONCLUSIONS: In this large population-based study, measured RF-EMFs emitted from mobile phone base stations were not associated with adverse health effects.

Mobile phone base stations and adverse health effects: phase 1 of a population-based, cross-sectional study in Germany.

OBJECTIVE: The aim of this first phase of a cross-sectional study from Germany was to investigate whether proximity of residence to mobile phone base stations as well as risk perception is associated with health complaints. METHODS: The researchers conducted a population-based, multi-phase, cross-sectional study within the context of a large panel survey regularly carried out by a private research institute in Germany. In the initial phase, reported on in this paper, 30,047 persons from a total of 51,444 who took part in the nationwide survey also answered questions on how mobile phone base stations affected their health. A list of 38 health complaints was used. A multiple linear regression model was used to identify predictors of health complaints including proximity of residence to mobile phone base stations and risk perception. RESULTS: Of the 30,047 participants (response rate 58.6%), 18.7% of participants were concerned about adverse health effects of mobile phone base stations, while an additional 10.3% attributed their personal adverse health effects to the exposure from them. Participants who were concerned about or attributed adverse health effects to mobile phone base stations and those living in the vicinity of a mobile phone base station (500 m) reported slightly more health complaints than others. CONCLUSIONS: A substantial proportion of the German population is concerned about adverse health effects caused by exposure from mobile phone base stations. The observed slightly higher prevalence of health complaints near base stations can not however be fully explained by attributions or concerns.

Applicability of an exposure model for the determination of emissions from mobile phone base stations.

Applicability of a model to estimate radiofrequency electromagnetic field (RF-EMF) strength in households from mobile phone base stations was evaluated with technical data of mobile phone base stations available from the German Net Agency, and dosimetric measurements, performed in an epidemiological study. Estimated exposure and exposure measured with dosemeters in 1322 participating households were compared. For that purpose, the upper 10th percentiles of both outcomes were defined as the 'higher exposed' groups. To assess the agreement of the defined 'higher' exposed groups, kappa coefficient, sensitivity and specificity were calculated. The present results show only a weak agreement of calculations and measurements (kappa values between -0.03 and 0.28, sensitivity between 7.1 and 34.6). Only in some of the sub-analyses, a higher agreement was found, e.g. when measured instead of interpolated geo-coordinates were used to calculate the distance between households and base stations, which is one important parameter in modelling exposure. During the development of the exposure model, more precise input data were available for its internal validation, which yielded kappa values between 0.41 and 0.68 and sensitivity between 55 and 76 for different types of housing areas. Contrary to this, the calculation of exposure-on the basis of the available imprecise data from the epidemiological study-is associated with a relatively high degree of uncertainty. Thus, the model can only be applied in epidemiological studies, when the uncertainty of the input data is considerably reduced. Otherwise, the use of dosemeters to determine the exposure from RF-EMF in epidemiological studies is recommended.

[Changes in the perception of risk factors for stroke in the German population between 1995-1996 and 2000-2001. Results of two representative EMNID surveys]. / Veränderungen in der Wahrnehmung der Risikofaktoren für einen Schlaganfall in der deutschen Bevölkerung zwischen 1995/1996 und 2000/2001. Ergebnisse zweier repräsentativer EMNID-Befragungen.

BACKGROUND AND OBJECTIVE: Stroke is one of the leading causes for death and disability worldwide. A better understanding of the perception of modifiable stroke risk factors in the population is the first step to initiate effective prevention strategies on population level. Changes over 5 years in the risk perception in the general population were investigated by two representative surveys in Germany. METHODS: Nationwide programs to screen voluntary participants for stroke risk were undertaken in 1995-1996 and 2000-2001 by the German Stroke Foundation, in cooperation with the health insurance company BARMER and the Sanofi-Synthelabo Company. As part of these programmes two surveys were performed by TNS-EMNID to collect data on population knowledge. A representative sample of the German population was selected and asked to categorize their perception of stroke risk for common vascular risk factors. RESULTS: A total of 8193 participants were interviewed (4081 in 1995-1996 and 4112 in 2000-2001); 43.5% were (3) 50 years of age and 52.5% were female. Hypertension was rated by 68.3% to be in the highest risk category for stroke, followed by smoking (52.3%), hypercholesterolemia (48.0%), overweight (48.0%), excessive alcohol consumption (32.9%) and diabetes (26.6%). The proportion of participants who graded these factors to be important for stroke occurrence was persistently higher in 2000-2001 than in 1995-1996. CONCLUSION: Perception of modifiable risk factors for stroke increased over a 5-year time period in two representative surveys in Germany. The importance of diabetes mellitus as a risk factor for stroke is especially underestimated in the general population.

Can a decline in the population means of cardiovascular risk factors reduce the number of people at risk?

OBJECTIVE: To prove the possibility of shifting distribution of cardiovascular risk factors for a whole population over time and thereby to influence the prevalence of the corresponding disease states, according to the theory stated by Geoffrey Rose in 1985. DESIGN: Examination of standardised data from the German Cardiovascular Prevention Study (GCP), a seven year long, population-based, multicentre intervention trial, concerned with decreasing risk factors for cardiovascular disease. SETTING AND SUBJECTS: three cross sectional surveys of a population 25 to 69 years old in six study regions, and three nationwide cross sectional surveys in the former West Germany in 1984, 1988 and 1991. MAIN OUTCOME MEASURES: The relation between the population mean for systolic and diastolic blood pressure, total serum cholesterol, body mass index, and alcohol intake, and the prevalence of the corresponding disease states, as are systolic (> or =140 and > or =160 mm Hg) and diastolic hypertension (> or =90 and > or =95 mm Hg), hypercholesterolaemia (> or =250 and > or =300 mg/dl), overweight (body mass index > or =30 kg/m2), and heavy drinking (weekly alcohol intake > or =300 g/week). Results are expressed as linear regression equations and Pearson correlation coefficients. RESULTS: The correlation between the mean population values and prevalence of disease was close for blood pressures and body mass index. The Pearson coefficients, corrected for the influence of values increased above borderlines, were 0.86 and 0.81 respectively for systolic blood pressure, 0.88 and 0.91 for diastolic blood pressure, 0.28 and 0.52 for cholesterol, and 0.86 for the body mass index. The coefficient for alcohol intake was 0.55. CONCLUSIONS: It seems possible to shift the risk distribution of a population for some physiological parameters over time with the effect of changing the disease prevalence. This strategy can be used successfully for specific preventive measures, as was strongly advocated by Geoffrey Rose.

[The second stage of the Nursing Insurance Act and its effects on the institutional care within welfare for the elderly]. / Auswirkungen der 2. Stufe des Pflegeversicherungsgesetzes auf die Versorgung im stationären Bereich der Altenhilfe.

OBJECTIVE: The intention of the recently introduced compulsory nursing care insurance in Germany has been to support patients as well as relatives, and to reduce the burden on the social insurance system in financing professional services. In this study we examine the consequences of the 2nd stage of this legislation upon the care in old people's homes. METHODS: The investigation covered 5 institutions comprising two components: 1) Analysis of the records kept by the administration (N = 369), and 2) analysis of the volume of nursing care in a sample of N = 121 (including basic care as well as psychosocial support) provided by the staff over a period of 14 days. RESULTS: The required volume of basic nursing care (SGB XI) determines the classification of patients according to their need for nursing. Although by law the amount of nursing in stage 0 should be none, nevertheless 20 minutes of basic care in average are provided each day here. In stages II and III the observed nursing-time exceeded the allowed values slightly. In stage III realized nursing was far below the legal provision, although the private co-payments were highest. CONCLUSION: The agreement between nursing providers and nursing insurance aiming at comprehensive care, under the given circumstances cannot be executed satisfactorily. This is true especially for stage III patients in old people's homes.

[The effect of diagnosis-related groups on hospital care]. / Der Einfluss von Fallpauschalen auf die stationäre Versorgung.

OBJECTIVE: The implementation of Diagnosis Related Groups (DRG's) is intended to lead to a shortening of hospital days. DRG's therefore may endanger the quality of hospital care or cause a transfer of services from inward to ambulatory care. In this study the consequences of two selected DRG's are examined: operations of patients with varicosis and with hernia. METHODS: A retrospective comparison of 875 patient files in 6 hospitals in Northrhine-Westphalia (NRW) and a follow-up questionnaire to the patients themselves (N = 510). RESULTS: Between 1995 and 1997 average hospital days have been reduced by 2 days (varicosis) and 1 day (hernia) respectively. However, the standard stay according to an expert commission of the MOH is still exceeded. The shortening of inward care leads to an increase of ambulatory care. Also the patients indicate a worse subjective health status at discharge although this does not carry through the ambulatory phase. CONCLUSION: For the two DRG's examined the reduction of hospital services due to shorter inward periods is mostly compensated during ambulatory care. An additional shortening of hospital days, however, is likely to lead to negative effects on the health status of patients.

[Epidemiologic evidence in the treatment of cardiovascular risk factors in Germany]. / Zur epidemiologischen Evidenz der Behandlung kardiovaskulärer Risikofaktoren in Deutschland.

Up to now, approaches neither in primary nor in secondary prevention led to a relevant decline in prevalences of hypertension and hypercholesterolemia. On the contrary, prevalence of hypercholesterolemia increased from 38 to 40% (p < 0.001) while the hypertension prevalence stagnated (at nearly 20%) in the 30 to 69 years old population in West Germany between 1984/85 and 1991/92. The potential of medical advice is not sufficiently used, the compliance of patients regarding medical recommendations to change health behavior is limited. Subsequently the scientific consensus with regard to benefits from normalization of hypertension and hypercholesterolemia does not become effective at the population level. Evidence based medicine needs more efficient evaluation of continued medical education and quality assurance.