Perinatal mortality among pregnant undocumented migrants in Norway 1999-2020: A register-based population study.

BACKGROUND: Irregular legal status is a recognized health risk factor in the context of migration. However, undocumented migrants are rarely included in health surveys and register studies. Adverse perinatal outcomes are especially important because they have long-term consequences and societal risk factors are modifiable. In this study, we compare perinatal outcomes in undocumented migrants to foreign-born and Norwegian-born residents, using a population-based register. METHODS: We included women 18-49 years old giving birth to singletons as registered in the Medical Birth Registry of Norway from 1999 to 2020. Women were categorized as 'undocumented migrants' (without an identity number), 'documented migrants' (with an identity number and born abroad), and 'non-migrants' (with an identity number and born in Norway). The main outcome was perinatal mortality, i.e., death of a foetus ≥ gestational week 22, or neonate up to seven days after birth. We used log-binominal regression to estimate the association between legal status and perinatal mortality, adjusting for several maternal pre-gestational and gestational factors. Direct standardization was used to adjust for maternal region of origin. ETHICAL APPROVAL: Regional Ethical Committee (REK South East, case number 68329). RESULTS: We retrieved information on 5856 undocumented migrant women who gave birth during the study period representing 0.5% of the 1 247 537 births in Norway. Undocumented migrants had a relative risk of 6.17 (95% confidence interval 5.29 ̶7.20) of perinatal mortality compared to non-migrants and a relative risk of 4.17 (95% confidence interval 3.51 ̶4.93) compared to documented migrants. Adjusting for maternal region of origin attenuated the results slightly. CONCLUSION: Being undocumented is strongly associated with perinatal mortality in the offspring. Disparities were not explained by maternal origin or maternal health factors, indicating that social determinants of health through delays in receiving adequate care and factors negatively influencing gestational length may be of importance.

Use of emergency primary care among pregnant undocumented migrants over ten years: an observational study from Oslo, Norway.

OBJECTIVE: To compare consultations with pregnant undocumented migrants at emergency primary health care to consultations with pregnant residents of Norway. DESIGN: A cross-sectional study of consultations at several time points. SETTING: The study was conducted at the Oslo Accident and Emergency Outpatient Clinic (OAEOC), the main emergency primary care service in Oslo, Norway. SUBJECTS: Consultations with pregnant patients without a Norwegian identity number seeking care at the Department of Emergency General Practice at the OAEOC were identified through a manual search of registration lists from 2009 to 2019. The consultations were categorized by women's residency status as 'probably documented migrant', 'uncertain migrant status', or 'probably undocumented migrant'. We also extracted aggregated data for women with a Norwegian identity number (i.e. residents) presenting in consultations with pregnancy-related (ICPC-2 chapter W) conditions. MAIN OUTCOME MEASURES: Manchester Triage System urgency level at presentation, and hospitalization. RESULTS: Among 829 consultations with female patients categorized as probably undocumented migrants, we found 27.1% (225/829) with pregnant women. About half of the pregnant women (54.6% (123/225)) presented with a pregnancy-related condition. Pregnant women that were probably undocumented migrants had an increased risk of being triaged with a high level of urgency at presentation (relative risk (RR) 1.86, 95% CI 1.14-3.04) and being hospitalized (RR 1.68, 95% CI 1.21-2.34), compared to pregnant residents. CONCLUSION: Pregnant undocumented migrants were more severely sick when presenting to emergency primary care services than pregnant residents. Increased access to primary care and emergency primary care services for pregnant undocumented migrants is urgently needed.

Restricted access to primary care may increase the use of primary care facilities intended for emergency care.A considerable proportion of the consultations with undocumented migrant women at the emergency primary care services are related to pregnancy.Consultations with pregnant undocumented migrants more often contained severe pregnancy-related conditions compared to consultations with pregnant residents of Norway.Interventions to increase access to primary care for pregnant undocumented migrants are urgently needed.

'Goodbye and good luck' Midwifery care to pregnant undocumented migrants in Norway: A qualitative study.

OBJECTIVE: To explore community midwives' experiences caring for pregnant undocumented migrants seeking prenatal care in Norway. METHOD: Due to the relatively limited previous research and number of pregnant undocumented migrants we used an explorative approach through qualitative method. Ten community midwives were interviewed after snowball sampling in Oslo, the capital of Norway. The main themes emerged through a qualitative analysis of the transcripts, and meaning units were extracted. RESULTS: Midwives with no prior experience with pregnant undocumented migrants expressed uncertainty regarding the women's rights. In contrast, those midwives who had had prior experience with this group, developed their own solutions and enacted certain strategies to help them without any guidelines from their employer. All the midwives found it challenging to provide follow-up care to the undocumented migrants during pregnancy and postpartum. They also expressed concerns regarding increasing challenges creating clinical trusting relationships and restrictions and practices at public hospitals. CONCLUSIONS: To ensure adequate perinatal care, it is needed to reassure pregnant undocumented migrants free and safe care at all stages in the birth giving process. Community midwives need professional support in establishing trusting clinical relationships with pregnant undocumented migrants to reduce maternal stress and facilitate continuity in perinatal care.

Use of non-governmental maternity services and pregnancy outcomes among undocumented women: a cohort study from Norway.

BACKGROUND: In 2011 Norway granted undocumented women the right to antenatal care and to give birth at a hospital but did not include them in the general practitioner and reimbursement schemes. As a response to limited access to health care, Non-Governmental Organizations (NGO) have been running health clinics for undocumented migrants in Norway's two largest cities. To further facilitate universal health coverage, there is a need to investigate how pregnant undocumented women use NGO clinics and how this affects their maternal health. We therefore investigated the care received, occurrence of pregnancy-related complications and pregnancy outcomes in women receiving antenatal care at these clinics. METHODS: In this historic cohort study we included pregnant women aged 18-49 attending urban NGO clinics from 2009 to 2020 and retrieved their medical records from referral hospitals. We compared women based on region of origin using log-binominal regression to estimate relative risk of adverse pregnancy outcomes. RESULTS: We identified 582 pregnancies in 500 women during the study period. About half (46.5%) the women sought antenatal care after gestational week 12, and 25.7% after week 22. The women had median 1 (IQR 1-3) antenatal visit at the NGO clinics, which referred 77.7% of the women to public health care. A total of 28.4% of women were referred for induced abortion. In 205 retrieved deliveries in medical records, there was a 45.9% risk for any adverse pregnancy outcome. The risk of stillbirth was 1.0%, preterm birth 10.3%, and emergency caesarean section 19.3%. CONCLUSION: Pregnant undocumented women who use NGO clinics receive substandard antenatal care and have a high risk of adverse pregnancy outcomes despite low occurrence of comorbidities. To achieve universal health coverage, increased attention should be given to the structural vulnerabilities of undocumented women and to ensure that adequate antenatal care is accessible for them.

Infectious diseases among patients at the Health Centre for Undocumented Migrants in Oslo. / Smittsomme sykdommer blant pasienter ved Helsesenter for papirløse migranter i Oslo.

BACKGROUND: Undocumented migrants probably fall outside the scope of public infectious disease control schemes. The article aims to describe the extent of undetected highly hazardous communicable diseases among patients at the Health Centre for Undocumented Migrants in Oslo. MATERIAL AND METHOD: We reviewed the records of all patients who attended the Health Centre for the first time in 2016 or 2017, with a view to age, sex, period of stay in Norway, country category and infection test results from the period 1 January 2016-31 December 2017. RESULTS: There were four new cases of hepatitis B among 139 patients tested, and four cases of chlamydia infection among 38 patients tested. There were no new cases of active pulmonary tuberculosis, syphilis, HIV infection or hepatitis C. INTERPRETATION: There were fewer cases of highly hazardous communicable diseases than what might be expected based on the countries from which the patients originated.