Association between migration and severe maternal outcomes in high-income countries: Systematic review and meta-analysis.

BACKGROUND: Literature focusing on migration and maternal health inequalities is inconclusive, possibly because of the heterogeneous definitions and settings studied. We aimed to synthesize the literature comparing the risks of severe maternal outcomes in high-income countries between migrant and native-born women, overall and by host country and region of birth. METHODS AND FINDINGS: Systematic literature review and meta-analysis using the Medline/PubMed, Embase, and Cochrane Library databases for the period from January 1, 1990 to April 18, 2023. We included observational studies comparing the risk of maternal mortality or all-cause or cause-specific severe maternal morbidity in high-income countries between migrant women, defined by birth outside the host country, and native-born women; used the Newcastle-Ottawa scale tool to assess risk of bias; and performed random-effects meta-analyses. Subgroup analyses were planned by host country and region of birth. The initial 2,290 unique references produced 35 studies published as 39 reports covering Europe, Australia, the United States of America, and Canada. In Europe, migrant women had a higher risk of maternal mortality than native-born women (pooled risk ratio [RR], 1.34; 95% confidence interval [CI], 1.14, 1.58; p < 0.001), but not in the USA or Australia. Some subgroups of migrant women, including those born in sub-Saharan Africa (pooled RR, 2.91; 95% CI, 2.03, 4.15; p < 0.001), Latin America and the Caribbean (pooled RR, 2.77; 95% CI, 1.43, 5.35; p = 0.002), and Asia (pooled RR, 1.57, 95% CI, 1.09, 2.26; p = 0.01) were at higher risk of maternal mortality than native-born women, but not those born in Europe or in the Middle East and North Africa. Although they were studied less often and with heterogeneous definitions of outcomes, patterns for all-cause severe maternal morbidity and maternal intensive care unit admission were similar. We were unable to take into account other social factors that might interact with migrant status to determine maternal health because many of these data were unavailable. CONCLUSIONS: In this systematic review of the existing literature applying a single definition of "migrant" women, we found that the differential risk of severe maternal outcomes in migrant versus native-born women in high-income countries varied by host country and region of origin. These data highlight the need to further explore the mechanisms underlying these inequities. TRIAL REGISTRATION: PROSPERO CRD42021224193.

Association between language barrier and inadequate prenatal care utilization among migrant women in the PreCARE prospective cohort study.

BACKGROUND: Inadequate prenatal care utilization (PCU) is involved in the higher risk of adverse maternal outcomes among migrant vs. native women. Language barrier may be a risk factor for inadequate PCU. We aimed to assess the association between this barrier and inadequate PCU among migrant women. METHODS: This analysis took place in the French multicentre prospective PreCARE cohort study, conducted in four university hospital maternity units in the northern Paris area. It included 10 419 women giving birth between 2010 and 2012. Migrants' language barrier to communication in French were categorized into three groups: migrants with no, partial or total language barrier. Inadequate PCU was assessed by the date prenatal care began, the proportion of recommended prenatal visits completed and ultrasound scans performed. The associations between these language barrier categories and inadequate PCU were tested with multivariable logistic regression models. RESULTS: Among the 4803 migrant women included, the language barrier was partial for 785 (16.3%) and total for 181 (3.8%). Compared to migrants with no language barrier, those with partial [risk ratio (RR) 1.23, 95% confidence interval (CI) 1.13-1.33] and total (RR 1.28, 95% CI 1.10-1.50) language barrier were at higher risk of inadequate PCU. Adjustment for maternal age, parity and region of birth did not modify these associations, which were noted particularly among socially deprived women. CONCLUSION: Migrant women with language barrier have a higher risk of inadequate PCU than those without. These findings underscore the importance of targeted efforts to bring women with language barrier to prenatal care.

Impact of the absence of hospital staff obstetricians on method of delivery, severe maternal and perinatal morbidity in a type 2 maternity ward.

BACKGROUND: The presence of locum obstetricians in the delivery room raises concerns of increased maternal or perinatal morbidities. OBJECTIVES: To examine the method of delivery, maternal and perinatal morbidities depending on whether the delivery doctor is a member of hospital staff or a locum doctor. MATERIALS AND METHODS: The study took place in a type 2 maternity ward marked by the departure of all hospital staff obstetricians in 2018. We compared the characteristics of the deliveries carried out in 2017 by a team of hospital staff obstetricians to those carried out by locums in 2019. The same was done for severe maternal and perinatal morbidities. The only exclusion criteria were medical terminations of pregnancy and births before 22 weeks of gestation. RESULTS: A total of 1,323 deliveries in 2017, and 1,463 in 2019 were included. We found no significant difference in the overall rate of Caesarean sections between 2017 (19.6%) and 2019 (20.5%). However, we noted a significant increase in forceps-assisted deliveries (8.5% in 2017 versus 21.4% in 2019) (p<0.001). Regarding severe maternal morbidity, we found no significant difference in 2019 (3.2%) compared to 2017 (2.7%). Severe perinatal morbidity was not significantly different (4.3% morbidity in 2017 versus 5.1% in 2019). CONCLUSION: The presence of locum obstetricians does not appear to impact either the method of delivery or maternal and perinatal morbidities.

Towards an evolution in ambulatory surgery for orbital floor repair? Our experience over a period of 11 years.

INTRODUCTION: Orbital floor fracture repair is a complex surgery with intra-orbital hematoma being the most feared complication as it can lead to visual loss if not treated in good time. This is why currently patients are monitored for almost 48 hours as inpatients. The purpose of this study was to find out if orbital floor repair surgery could be safely undertaken as a day case by reviewing the experience of the last 11 years at the Caen University Hospital. MATERIALS AND METHODS: A retrospective, monocentric study was conducted at the Caen University Hospital. All patients undergoing orbital floor reconstruction in a trauma setting from January 2008 to December 2019 were included. RESULTS: Of the 130 included patients, none presented a post-operative complication such as intra-orbital hematoma. 3 patients had their surgery performed as a day case. DISCUSSION: In the literature, more and more surgeons are proposing orbital floor fracture repair to be undertaken as day case. Indeed, the theoretical risk of intra-orbital hematoma is greater within the first 6 hours after surgery and can persist up to 10 days postoperatively. Provided patients meet the classic criteria for outpatient surgery, and are provided with a precise post-operative care protocol. Under these conditions, orbital floor fractures may be repair in ambulatory surgery.

Severe maternal morbidity among undocumented migrant women in the PreCARE prospective cohort study.

OBJECTIVE: To assess the risk of severe maternal outcomes among migrant women, considering both their legal status and birthplace; in Europe, migrant women, especially from sub-Saharan Africa, have higher risks of adverse maternal outcomes compared with non-migrants and legal status, a component of migrant condition, may be an important, and potentially actionable, risk factor. DESIGN: Prospective cohort study. SETTING: Four maternity units around Paris in 2010-12. SAMPLE: A total of 9599 women with singleton pregnancies. METHODS: Legal status was categorised in four groups: reference group of non-migrant native Frenchwomen, legal migrants with French or European citizenship, other legal migrants with non-European citizenship, and undocumented migrants. The risk of severe maternal morbidity was assessed with multivariable logistic regression models according to women's legal status and birthplace. MAIN OUTCOME MEASURE: Binary composite criterion of severe maternal morbidity. RESULTS: Undocumented migrants had resided for less time in France, experienced social isolation, linguistic barriers and poor housing conditions more frequently and had a pre-pregnancy medical history at lower risk than other migrants. The multivariable analysis showed that they had a higher risk of severe maternal morbidity than non-migrants (33/715 [4.6%] versus 129/4523 [2.9%]; adjusted odds ratio [aOR] 1.68, 95% CI 1.12-2.53). This increased risk was significant for undocumented women from sub-Saharan Africa (18/308 [5.8%] versus 129/4523 [2.9%]; aOR 2.26, 95% CI 1.30-3.91), and not for those born elsewhere (15/407 [3.7%] versus 129/4523 [2.9%]; aOR 1.44, 95% CI 0.82-2.53). CONCLUSION: Undocumented migrants are the migrant subgroup at highest risk of severe maternal morbidity, whereas the prevalence of risk factors does not appear to be higher in this subgroup. This finding suggests that their interaction with maternity care services may be sub-optimal. TWEETABLE ABSTRACT: Undocumented migrants, especially those born in sub-Saharan Africa, have the highest risk of Severe Maternal Morbidity.

Association between Migrant Women's Legal Status and Prenatal Care Utilization in the PreCARE Cohort.

Barriers to access to prenatal care may partially explain the higher risk of adverse pregnancy outcomes among migrants compared with native-born women in Europe. Our aim was to assess the association between women's legal status and inadequate prenatal care utilization (PCU) in France, where access to healthcare is supposed to be universal. The study population was extracted from the PreCARE prospective cohort (N = 10,419). The associations between women's legal status and a composite outcome variable of inadequate PCU were assessed with multivariate logistic regressions. The proportion of women born in sub-Saharan Africa (SSA) was higher among the undocumented than that of other migrants. All groups of migrant women had a higher risk of inadequate PCU (31.6% for legal migrants with European nationalities, 40.3% for other legal migrants, and 52.0% for undocumented migrants) than French-born women (26.4%). The adjusted odds ratio (aOR) for inadequate PCU for undocumented migrants compared with that for French-born women was 2.58 (95% confidence interval 2.16-3.07) overall, and this association was similar for migrant women born in SSA (aOR 2.95, 2.28-3.82) and those born elsewhere (aOR 2.37, 1.89-2.97). Regardless of the maternal place of birth, undocumented migrant status is associated with a higher risk of inadequate PCU.

Comparative study of changes in maternal and perinatal morbidity inequalities among migrant and native women over time, between 2008 and 2014 in France.

BACKGROUND: An increased risk of severe maternal morbidity and mortality has been described in migrant women, particularly in those born in sub-Saharan Africa. The mechanisms in question are poorly identified and rarely studied specifically. OBJECTIVE: To compare changes in maternal and perinatal morbidity inequalities among migrant and native women over time, between 2008 and 2014. MATERIAL AND METHOD: A retrospective, single-centre study carried out at the Maternity Unit of the University of Caen Hospital in France. All women who gave birth in 2008 or 2014 were included. Twin pregnancies and delivery before reaching 22 weeks of pregnancy were excluded. Pre-pregnancy characteristics and maternal and perinatal morbidities were collected from the university hospital's medical and administrative database. We compared the maternal and perinatal morbidity in 2008 and 2014 of women born in France to the morbidity of women born abroad. Secondly, we compared these migrant women between 2008 and 2014 to see if changes in the characteristics of migrant women were associated with a change in the type of maternal and perinatal complications. RESULTS: Of the 3,038 and 3,001 women included in 2008 and 2014, respectively, 272 (9.0 %) and 385 (12.8 %) women were migrants. Compared to women born in France, we found two times more severe postpartum hemorrhages in women born in sub-Saharan Africa (aOR = 2.1[1.1-3.9]) and a significant increase in the risk of gestational diabetes in women born in North Africa (aOR = 1.9[1.2-2.9]). We found a significant increase in the risk of severe postpartum hemorrhage (aOR = 2.1[1.5-3.0]) and gestational diabetes (aOR = 3.0[2.5-3.7]) in 2014 compared to 2008. We did not find a significant difference in perinatal morbidity between 2008 and 2014. CONCLUSION: We noted a significant increase in the risk of severe postpartum hemorrhage in women born in sub-Saharan Africa and gestational diabetes in women born in North Africa compared to those born in France, and these risks increase in 2014 relative to 2008.

Comparative study between women born in France and migrant women with regard to their mode of delivery.

OBJECTIVE: To compare the mode of delivery between women born in France and migrants. STUDY DESIGN: The study was a retrospective, observational, single-center study conducted at the university maternity unit in Caen. All women who gave birth in 2008 or 2014 were included. Women with multiple pregnancies and women whose pregnancies ended before 22 weeks of gestational age were excluded. The pre-existing characteristics at the time of pregnancy, mode of delivery and postpartum were collected from the University Hospital's medical and administrative computer database. We first compared women born in France to those born abroad with regard to the characteristics of mode of delivery for 2008, then for 2014. Secondly, we compared migrant women between 2008 and 2014 to see if the change in the migration profile was associated with a change in the mode of delivery. RESULTS: Of the 3038 and 3001 women included in 2008 and 2014 respectively, 272 and 385 women were migrants. We observed a significant decrease in the number of spontaneous labors (adjusted odds ratio (aOR) 0.5 [0.4-0.6]) with a significant increase in emergency cesarean sections before (aOR 2.1 [1.4-3.0]) and during labor (aOR 2.2 [1.6-3.2]) among women born in sub-Saharan Africa compared to non-migrants. And we showed a higher risk of cesarean section prior to labor (aOR 1.2 [1.01-1.4]) and a significant decrease in cesarean section during labor (aOR 0.8 [0.7-0.99]) in 2014 compared to 2008. CONCLUSION: We observed a significant increase in all types of Cesarean sections among women born abroad compared to those born in France, especially in the subgroup of women born in sub-Saharan Africa.