Pre-pregnancy obesity among immigrant and non-immigrant women in Norway: Prevalence, trends, and subgroup variations.

INTRODUCTION: This study assessed prevalence and time trends of pre-pregnancy obesity in immigrant and non-immigrant women in Norway and explored the impact of immigrants' length of residence on pre-pregnancy obesity prevalence. MATERIAL AND METHODS: Observational data from the Medical Birth Registry of Norway and Statistics Norway for the years 2016-2021 were analyzed. Immigrants were categorized by their country of birth and further grouped into seven super regions defined by the Global Burden of Disease study. Pre-pregnancy obesity was defined as a body mass index ≥30.0 kg/m2, with exceptions for certain Asian subgroups (≥27.5 kg/m2). Statistical analysis involved linear regressions for trend analyses and log-binomial regressions for prevalence ratios (PRs). RESULTS: Among 275 609 pregnancies, 29.6% (N = 81 715) were to immigrant women. Overall, 13.6% were classified with pre-pregnancy obesity: 11.7% among immigrants and 14.4% among non-immigrants. Obesity prevalence increased in both immigrants and non-immigrants during the study period, with an average yearly increase of 0.62% (95% confidence interval [CI]: 0.55, 0.70). Obesity prevalence was especially high in women from Pakistan, Chile, Somalia, Congo, Nigeria, Ghana, Sri Lanka, and India (20.3%-26.9%). Immigrant women from "Sub-Saharan Africa" showed a strong association between longer residence length and higher obesity prevalence (≥11 years (23.1%) vs. <1 year (7.2%); adjusted PR = 2.40; 95% CI: 1.65-3.48), particularly in women from Kenya, Eritrea, and Congo. CONCLUSIONS: Prevalence of maternal pre-pregnancy obesity increased in both immigrant and non-immigrant women from 2016 to 2021. Several immigrant subgroups displayed a considerably elevated obesity prevalence, placing them at high risk for adverse obesity-related pregnancy outcomes. Particular attention should be directed towards women from "Sub-Saharan Africa", as their obesity prevalence more than doubled with longer residence.

Migrant women's experiences of community-based doula support during labor and childbirth in Sweden. A mixed methods study.

OBJECTIVE: To describe migrant women's experiences of bilingual community-based doulas (CBD) contribution to care in relation to labor and birth. METHODS: Mixed methods study combining quantitative data from 82 women who received CBD-support within a randomized controlled trial and qualitative data from semi-structured interviews with a sub-sample of 12 women from the same study arm. Descriptive analyses were used for quantitative data and content analysis for the manifest and latent content of the qualitative data. Quantitative findings were categorized according to qualitative findings. RESULTS: The women expressed how CBDs played an essential role in the response to their basic emotional, informational, and physical support needs, when no other female family member was available. Three main categories emerged from the analysis of interviews: The doulas help women feel safe and calm - providing support before, during and after childbirth; The doulas' support role fills the void left by a deeply missed family, mother or sister; and The doulas assist women in achieving autonomy through communication support and advocacy. More than half of women reported feeling involved during labor and birth (56.8%), most valued CBD positively (such as being competent, calm, secure, considerate, respectful, encouraging, supportive) (40.8%-80.3%), that CBD had interpreted (75.6%), facilitated communication with the midwife (60,3%), comforted the woman (57.7%) and reduced anxiety (48,7%). Few reported negative CBD-characteristics (1.3-9.2%). Nevertheless, 61.7% of women felt frightened sometime during labor and birth, which made it even more important to them that the doula was there. Few women (21.8%) reported that the CBD had supported her partner but expressed so in the interviews. CONCLUSION: Through an essential contribution in responding to migrant women's basic emotional, informational, and physical needs, bilingual community-based doulas have the potential to improve migrant women's experience of care during labour and birth. However, more focus on the quality of CBD-support to partners seem necessary.

Risk of Subsequent Preeclampsia by Maternal Country of Birth: A Norwegian Population-Based Study.

In this nationwide population-based study, we investigated the associations of preeclampsia in the first pregnancy with the risk of preeclampsia in the second pregnancy, by maternal country of birth using data from the Medical Birth Registry of Norway and Statistics Norway (1990-2016). The study population included 101,066 immigrant and 544,071 non-immigrant women. Maternal country of birth was categorized according to the seven super-regions of the Global Burden of Disease study (GBD). The associations between preeclampsia in the first pregnancy with preeclampsia in the second pregnancy were estimated using log-binomial regression models, using no preeclampsia in the first pregnancy as the reference. The associations were reported as adjusted risk ratios (RR) with 95% confidence intervals (CI), adjusted for chronic hypertension, year of first childbirth, and maternal age at first birth. Compared to those without preeclampsia in the first pregnancy, women with preeclampsia in the first pregnancy were associated with a considerably increased risk of preeclampsia in the second pregnancy in both immigrant (n = 250; 13.4% vs. 1.0%; adjusted RR 12.9 [95% CI: 11.2, 14.9]) and non-immigrant women (n = 2876; 14.6% vs. 1.5%; adjusted RR 9.5 [95% CI: 9.1, 10.0]). Immigrant women from Latin America and the Caribbean appeared to have the highest adjusted RR, followed by immigrant women from North Africa and the Middle East. A likelihood ratio test showed that the variation in adjusted RR across all immigrant and non-immigrant groups was statistically significant (p = 0.006). Our results suggest that the association between preeclampsia in the first pregnancy and preeclampsia in the second pregnancy might be increased in some groups of immigrant women compared with non-immigrant women in Norway.

Group antenatal care compared with standard antenatal care for Somali-Swedish women: a historically controlled evaluation of the Hooyo Project.

OBJECTIVES: Comparing language-supported group antenatal care (gANC) and standard antenatal care (sANC) for Somali-born women in Sweden, measuring overall ratings of care and emotional well-being, and testing the feasibility of the outcome measures. DESIGN: A quasi-experimental trial with one intervention and one historical control group, nested in an intervention development and feasibility study. SETTING: Midwifery-led antenatal care clinic in a mid-sized Swedish town. PARTICIPANTS: Pregnant Somali-born women (<25 gestational weeks); 64 women in gANC and 81 in sANC. INTERVENTION: Language-supported gANC (2017-2019). Participants were offered seven 60-minute group sessions with other Somali-born women led by one to two midwives, in addition to 15-30 min individual appointments with their designated midwife. OUTCOMES: Primary outcomes were women's overall ratings of antenatal care and emotional well-being (Edinburgh Postnatal Depression Scale (EPDS)) in gestational week ≥35 and 2 months post partum. Secondary outcomes were specific care experiences, information received, social support, knowledge of pregnancy danger signs and obstetric outcomes. RESULTS: Recruitment and retention of participants were challenging. Of eligible women, 39.3% (n=106) declined to participate. No relevant differences regarding overall ratings of antenatal care between the groups were detected (late pregnancy OR 1.42, 95% CI 0.50 to 4.16 and 6-8 weeks post partum OR 2.71, 95% CI 0.88 to 9.41). The reduction in mean EPDS score was greater in the intervention group when adjusting for differences at baseline (mean difference -1.89; 95% CI -3.73 to -0.07). Women in gANC were happier with received pregnancy and birth information, for example, caesarean section where 94.9% (n=37) believed the information was sufficient compared with 17.5% (n=7) in standard care (p<0.001) in late pregnancy. CONCLUSIONS: This evaluation suggests potential for language-supported gANC to improve knowledge acquisition among pregnant Somali-born women with residence in Sweden ˂10 years. An adequately powered randomised trial is needed to evaluate the effectiveness of the intervention. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03879200).

Community-based bilingual doula support during labour and birth to improve migrant women's intrapartum care experiences and emotional well-being-Findings from a randomised controlled trial in Stockholm, Sweden [NCT03461640].

OBJECTIVES: To evaluate the effectiveness of community-based bilingual doula (CBD) support for improving the intrapartum care experiences and postnatal wellbeing of migrant women giving birth in Sweden. DESIGN: Randomised controlled trial. SETTING: Six antenatal care clinics and five hospitals in Stockholm, Sweden. PARTICIPANTS: 164 pregnant Somali-, Arabic-, Polish-, Russian- and Tigrinya-speaking women who could not communicate fluently in Swedish, were ≥18 years and had no contra-indications for vaginal birth. INTERVENTION: In addition to standard labour support, women were randomised to CBD support (n = 88) or no such support during labour (n = 76). Trained CBDs met with women prior to labour, provided support by telephone after labour had started, then provided emotional, physical and communication support to women throughout labour and birth in hospital, and then met again with women after the birth. PRIMARY OUTCOMES: Women's overall ratings of the intrapartum care experiences (key question from the Migrant Friendly Maternity Care Questionnaire) and postnatal wellbeing (mean value of Edinburgh Postnatal Depression Scale) at 6-8 weeks after birth. RESULTS: In total, 150 women remained to follow-up; 82 women (93.2%) randomised to receive CBD support and 68 women (89.5%) randomised to standard care (SC). Of women allocated CBD support, 60 (73.2%) received support during labour. There were no differences between the groups regarding women's intrapartum care experiences (very happy with care: CBD 80.2% (n = 65) vs SC 79.1% (n = 53); OR 1.07 CI 95% 0.48-2.40) or emotional wellbeing (EPDS mean value: CBD 4.71 (SD 4.96) vs SC 3.38 (SD 3.58); mean difference 1.33; CI 95% - 0.10-2.75). CONCLUSIONS: Community-based doula support during labour and birth for migrant women neither increased women's ratings of their care for labour and birth nor their emotional well-being 2 months postpartum compared with receiving standard care only. Further studies on the effectiveness of CBD powered to evaluate obstetric outcomes are needed. TRIAL REGISTRATION: Trial registration at ClinicalTrial.gov NCT03461640 https://www.google.com/search?client=firefox-b-d&q=NCT03461640.

Group antenatal care (gANC) for Somali-speaking women in Sweden - a process evaluation.

BACKGROUND: Language supported group antenatal care (gANC) for Somali-born women was implemented in a Swedish public ANC clinic. The women were offered seven 60-min sessions, facilitated by midwives and starting with a presentation of a selected topic, with an additional 15-min individual appointment before or after. The aim of this study was to assess the feasibility for participants and midwives of implementing The Hooyo ("mother" in Somali) gANC intervention, including implementation, mechanisms of impact and contextual factors. METHODS: A process evaluation was performed, using The Medical Research Council (MRC) guidelines for evaluating complex interventions as a framework. A range of qualitative and quantitative data sources were used including observations (n = 9), complementary, in-depth and key-informant interviews (women n = 6, midwives n = 4, interpreters and research assistants n = 3) and questionnaire data (women n = 44; midwives n = 8). RESULTS: Language-supported gANC offered more comprehensive ANC that seemed to correspond to existing needs of the participants and could address knowledge gaps related to pregnancy, birth and the Swedish health care system. The majority of women thought listening to other pregnant women was valuable (91%), felt comfortable in the group (98%) and supported by the other women (79%), and they said that gANC suited them (79%). The intervention seemed to enhance knowledge and cultural understanding among midwives, thus contributing to more women-centred care. The intervention was not successful at involving partners in ANC. CONCLUSIONS: The Hooyo gANC intervention was acceptable to the Somali women and to midwives, but did not lead to greater participation by fathers-to-be. The main mechanisms of impact were more comprehensive ANC and enhanced mutual cultural understanding. The position of women was strengthened in the groups, and the way in which the midwives expanded their understanding of the participants and their narratives was promising. To be feasible at a large scale, gANC might require further adaptations and the "othering" of women in risk groups should be avoided. TRIAL REGISTRATION: The study was registered in ClinicalTrials.gov (Identifier: NCT03879200).

The community-based bilingual doula - A new actor filling gaps in labour care for migrant women. Findings from a qualitative study of midwives' and obstetricians' experiences.

OBJECTIVES: To explore midwives' and obstetricians' views about community-based bilingual doula (CBD) support during migrant women's labour and birth and their experiences of collaborating with CBDs. STUDY DESIGN: A qualitative study with semi-structured individual interviews with 7 midwives and 4 obstetricians holding clinical positions in labour care in Stockholm, Sweden, who all had experiences of working with a CBD. Data analysis followed the framework of thematic analysis. RESULTS: The overarching theme was A new actor filling gaps in labour care - With appropriate boundary setting, CBDs can help improve care for migrant women. One year after the introduction of CBDs, the midwives and obstetricians had mainly positive experiences of CBDs who were considered to fill important gaps in maternity care for migrant women, being with the woman and simultaneously being part of the care team and this made providing high quality care easier. The CBDs' main contribution was to help migrant women navigate the maternity care system, to bridge language and cultural divides, and guarantee continuous labour and birth support. However, midwives and obstetricians sometimes experienced CBDs interfering with their professional assessments and decisions and the role of the CBD was somewhat unclear to them. CONCLUSIONS: Community-based bilingual doula support was viewed as improving migrant women's well-being during labour and birth and as increasing the possibilities for midwives and obstetricians to provide good and safe care, however, some ambivalence remained about the CBD's role and boundaries.

Placental abruption in immigrant women in Norway: A population-based study.

INTRODUCTION: Placental abruption is a serious complication in pregnancy. Its incidence varies across countries, but the information of how placental abruption varies in immigrant populations is limited. The aims of this study were to estimate the incidence of placental abruption in immigrant women compared with non-immigrants by maternal country and region of birth, reason for immigration, and length of residence. MATERIAL AND METHODS: We conducted a nationwide population-based study using data from the Medical Birth Registry of Norway and Statistics Norway (1990-2016). The study sample included 1 558 174 pregnancies, in which immigrant women accounted for 245 887 pregnancies and 1 312 287 pregnancies were to non-immigrants. Crude and adjusted odds ratios with 95% CI for placental abruption in immigrant women compared with non-immigrants were estimated by logistic regression with robust standard error estimations (accounting for within-mother clustering). Adjustment variables included year of birth, maternal age, parity, multiple pregnancies, chronic hypertension, and level of education. RESULTS: The incidence of placental abruption decreased during the study period for both immigrants (from 0.68% to 0.44%) and non-immigrants (from 0.80% to 0.34%). Immigrant women from sub-Saharan Africa had an adjusted odds ratio of 1.35 (95% CI 1.15-1.58) compared with non-immigrants for placental abruption, whereas immigrant women from Ethiopia had an adjusted odds ratio of 2.39 (95% CI 1.67-3.41). We found a small variation in placental abruption incidence by other countries or regions of birth, length of residence, and reason for immigration. CONCLUSIONS: Immigrant women from sub-Saharan Africa, especially Ethiopia, have increased odds for placental abruption when giving birth in Norway. Reason for immigration and length of residence had little impact on the incidence of placental abruption.

Gestational diabetes mellitus by maternal country of birth and length of residence in immigrant women in Norway.

AIMS: Immigrant women are at higher risk for gestational diabetes mellitus (GDM) than non-immigrant women. This study described the prevalence of GDM in immigrant women by maternal country of birth and examined the associations between immigrants' length of residence in Norway and GDM. METHODS: This Norwegian national population-based study included 192,892 pregnancies to immigrant and 1,116,954 pregnancies to non-immigrant women giving birth during the period 1990-2013. Associations were reported as odds ratios (ORs) with 95% confidence intervals (CIs) using logistic regression models, adjusted for year of delivery, maternal age, marital status, health region, parity, education and income. RESULTS: The prevalence and adjusted OR [CI] for GDM were substantially higher in immigrant women from Bangladesh (7.4%, OR 8.38 [5.41, 12.97]), Sri Lanka (6.3%, OR 7.60 [6.71, 8.60]), Pakistan (4.3%, OR 5.47 [4.90, 6.11]), India (4.4%, OR 5.18 [4.30, 6.24]) and Morocco (4.3%, OR 4.35 [3.63, 5.20]) compared to non-immigrants (prevalence 0.8%). Overall, GDM prevalence increased from 1.3% (OR 1.25 [1.14, 1.36]) to 3.3% (OR 2.55 [2.39, 2.71]) after 9 years of residence in immigrants compared to non-immigrant women. This association was particularly strong for women from South Asia. CONCLUSIONS: Gestational diabetes mellitus prevalence varied substantially between countries of maternal birth and was particularly high in immigrants from Asian countries. GDM appeared to increase with longer length of residence in certain immigrant groups.

Community-based bilingual doulas for migrant women in labour and birth - findings from a Swedish register-based cohort study.

BACKGROUND: Community-based bilingual doula (CBD) services have been established to respond to migrant women's needs and reduce barriers to high quality maternity care. The aim of this study was to compare birth outcomes for migrant women who received CBD support in labour with birth outcomes for (1) migrant women who experienced usual care without CBD support, and (2) Swedish-born women giving birth during the same time period and at the same hospitals. METHODS: Register study based on data retrieved from a local CBD register in Gothenburg, the Swedish Medical Birth Register and Statistics Sweden. Birth outcomes for migrant women with CBD support were compared with those of migrant women without CBD support and with Swedish-born women. Associations were investigated using multivariable logistic regression, reported as odds ratios (aORs) with 95% confidence intervals (CI), adjusted for birth year, maternal age, marital status, hypertension, diabetes, BMI, disposable income and education. RESULTS: Migrant women with CBD support (n = 880) were more likely to have risk factors for adverse pregnancy outcomes than migrant women not receiving CBD support (n = 16,789) and the Swedish-born women (n = 129,706). In migrant women, CBD support was associated with less use of pain relief in nulliparous women (epidural aOR 0.64, CI 0.50-0.81; bath aOR 0.64, CI 0.42-0.98), and in parous women with increased odds of induction of labour (aOR 1.38, CI 1.08-1.76) and longer hospital stay after birth (aOR 1.19, CI 1.03-1.37). CBD support was not associated with non-instrumental births, perineal injury or low Apgar score. Compared with Swedish-born women, migrant women with CBD used less pain relief (nulliparous women: epidural aOR 0.50, CI 0.39-0.64; nitrous oxide aOR 0.71, CI 0.54-0.92; bath aOR 0.55, CI 0.36-0.85; parous women: nitrous oxide aOR 0.68, CI 0.54-0.84) and nulliparous women with CBD support had increased odds of emergency caesarean section (aOR 1.43, CI 1.05-1.94) and longer hospital stay after birth (aOR 1.31, CI 1.04-1.64). CONCLUSIONS: CBD support appears to have potential to reduce analgesia use in migrant women with vulnerability to adverse outcomes. Further studies of effects of CBD support on mode of birth and other obstetric outcomes and women's experiences and well-being are needed.

Paternal country of origin and adverse neonatal outcomes in births to foreign-born women in Norway: A population-based cohort study.

BACKGROUND: Migration is a risk factor for adverse neonatal outcomes. The various impacts of maternal origin have been reported previously. The aim of this study was to investigate associations between paternal origin and adverse neonatal outcomes in births to migrant and Norwegian-born women in Norway. METHODS AND FINDINGS: This nationwide population-based study included births to migrant (n = 240,759, mean age 29.6 years [±5.3 SD]) and Norwegian-born women (n = 1,232,327, mean age 29.0 years [±5.1 SD]) giving birth in Norway in 1990-2016. The main exposure was paternal origin (Norwegian-born, foreign-born, or unregistered). Neonatal outcomes were very preterm birth (22+0-31+6 gestational weeks), moderately preterm birth (32+0-36+6 gestational weeks), small for gestational age (SGA), low Apgar score (<7 at 5 minutes), and stillbirth. Associations were investigated in migrant and Norwegian-born women separately using multiple logistic regression and reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs), adjusted for year of birth, parity, maternal and paternal age, marital status, maternal education, and mother's gross income. In births to migrant women, a foreign-born father was associated with increased odds of very preterm birth (1.1% versus 0.9%, aOR 1.20; CI 1.08-1.33, p = 0.001), SGA (13.4% versus 9.5%, aOR 1.48; CI 1.43-1.53, p < 0.001), low Apgar score (1.7% versus 1.5%, aOR 1.14; CI 1.05-1.23, p = 0.001), and stillbirth (0.5% versus 0.3%, aOR 1.26; CI 1.08-1.48, p = 0.004) compared with a Norwegian-born father. In Norwegian-born women, a foreign-born father was associated with increased odds of SGA (9.3% versus 8.1%, aOR 1.13; CI 1.09-1.16, p < 0.001) and decreased odds of moderately preterm birth (4.3% versus 4.4%, aOR 0.95; CI 0.91-0.99, p = 0.015) when compared with a Norwegian-born father. In migrant women, unregistered paternal origin was associated with increased odds of very preterm birth (2.2% versus 0.9%, aOR 2.29; CI 1.97-2.66, p < 0.001), moderately preterm birth (5.6% versus 4.7%, aOR 1.15; CI 1.06-1.25, p = 0.001), SGA (13.0% versus 9.5%, aOR 1.50; CI 1.42-1.58, p < 0.001), low Apgar score (3.4% versus 1.5%, aOR 2.23; CI 1.99-2.50, p < 0.001), and stillbirth (1.5% versus 0.3%, aOR 4.87; CI 3.98-5.96, p < 0.001) compared with a Norwegian-born father. In Norwegian-born women, unregistered paternal origin was associated with increased odds of very preterm birth (4.6% versus 1.0%, aOR 4.39; CI 4.05-4.76, p < 0.001), moderately preterm birth (7.8% versus 4.4%, aOR 1.62; CI 1.53-1.71, p < 0.001), SGA (11.4% versus 8.1%, aOR 1.30; CI 1.24-1.36, p < 0.001), low Apgar score (4.6% versus 1.3%, aOR 3.51; CI 3.26-3.78, p < 0.001), and stillbirth (3.2% versus 0.4%, aOR 9.00; CI 8.15-9.93, p < 0.001) compared with births with a Norwegian-born father. The main limitations of this study were the restricted access to paternal demographics and inability to account for all lifestyle factors. CONCLUSION: We found that a foreign-born father was associated with adverse neonatal outcomes among births to migrant women, but to a lesser degree among births to nonmigrant women, when compared with a Norwegian-born father. Unregistered paternal origin was associated with higher odds of adverse neonatal outcomes in births to both migrant and nonmigrant women when compared with Norwegian-born fathers. Increased attention to paternal origin may help identify women in maternity care at risk for adverse neonatal outcomes.

Epidural analgesia for labour pain in nulliparous women in Norway in relation to maternal country of birth and migration related factors.

OBJECTIVE: To investigate associations between maternal country of birth and other migration related factors (length of residence, reason for migration, paternal origin) and epidural analgesia for labour pain in nulliparous women in Norway. DESIGN: Population-based register study including nulliparous migrant women (n = 75,922) and non-migrant women (n = 444,496) with spontaneous or induced labour. Data were retrieved from the Medical Birth Registry and Statistics Norway, 1990-2013. Odds ratios (OR) with 95% confidence intervals (CI) were estimated by logistic regression, and adjusted for maternal age, marital status, maternal education, gross income, birth year, hospital size and health region. MAIN OUTCOME: Epidural analgesia for labour pain. RESULTS: Epidural analgesia was administered to 38% of migrant women and 31% of non-migrant women. Compared with non-migrants, the odds of having epidural analgesia were lowest in women from Vietnam (adjOR 0.54; CI 0.50-0.59) and Somalia (adjOR 0.63; CI 0.58-0.68) and highest in women from Iran (adjOR 1.32; CI 1.19-1.46) and India (adjOR 1.19; CI 1.06-1.33). Refugees (adjOR 0.83; CI 0.79-0.87) and newly arrived migrants (adjOR 0.92; CI 0.89-0.94) had lower odds of epidural analgesia. Migrant women with a non-migrant partner (adjOR 1.14; CI 1.11-1.17) and those with length of residence ≥10 years (adjOR 1.06; CI 1.02-1.10) had higher odds. CONCLUSION: The use of epidural analgesia varied by maternal country of birth, reason for migration, paternal origin and length of residence. Midwives and obstetricians should pay extra attention to the provision of adequate information about pain relief options for refugees and newly arrived migrants, who had the lowest use.

Country of first birth and neonatal outcomes in migrant and Norwegian-born parous women in Norway: a population-based study.

BACKGROUND: This study compares subsequent birth outcomes in migrant women who had already had a child before arriving in Norway with those in migrant women whose first birth occurred in Norway. The aim of this study was to investigate the associations between country of first birth and adverse neonatal outcomes (very preterm birth, moderately preterm birth, post-term birth, small for gestational age, large for gestational age, low Apgar score, stillbirth and neonatal death) in parous migrant and Norwegian-born women. METHODS: National population-based study including second and subsequent singleton births in Norway from 1990 to 2016. Data were retrieved from the Medical Birth Registry of Norway and Statistics Norway. Neonatal outcomes were compared between births to: 1) migrant women with a first birth before immigration to Norway (n = 30,062) versus those with a first birth after immigration (n = 66,006), and 2) Norwegian-born women with a first birth outside Norway (n = 6205) versus those with a first birth in Norway (n = 514,799). Associations were estimated as crude and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) using multiple logistic regression. RESULTS: Migrant women with a first birth before immigrating to Norway had increased odds of adverse outcomes in subsequent births relative to those with a first birth after immigration: very preterm birth (22-31 gestational weeks; aOR = 1.27; CI 1.09-1.48), moderately preterm birth (32-36 gestational weeks; aOR = 1.10; CI 1.02-1.18), post-term birth (≥42 gestational weeks; aOR = 1.19; CI 1.11-1.27), low Apgar score (< 7 at 5 min; aOR = 1.27; CI 1.16-1.39) and stillbirth (aOR = 1.29; CI 1.05-1.58). Similar results were found in the sample of births to Norwegian-born women. CONCLUSIONS: The increased odds of adverse neonatal outcomes for migrant and Norwegian-born women who had their first births outside Norway should serve as a reminder of the importance of taking a careful obstetric history in these parous women to ensure appropriate care for their subsequent pregnancies and births in Norway.

Community-based doula support for migrant women during labour and birth: study protocol for a randomised controlled trial in Stockholm, Sweden (NCT03461640).

INTRODUCTION: Migrant women consistently rate their care during labour and birth more negatively than non-migrant women, due to communication difficulties, lack of familiarity with how care is provided, and discrimination and prejudicial staff attitudes. They also report being left alone, feeling fearful, unsafe and unsupported, and have poorer birth outcomes than non-migrant women. Community-based doulas (CBDs) are bilingual women from migrant communities who are trained in childbirth and labour support, and who facilitate communication between woman-partner-staff during childbirth. This study protocol describes the design, rationale and methods of a randomised controlled trial that aims to evaluate the effectiveness of CBD support for improving the intrapartum care experiences and postnatal well-being of migrant women giving birth in Sweden. METHODS AND ANALYSIS: A randomised controlled trial. From six antenatal care clinics in Stockholm, Sweden, we aim to recruit 200 pregnant Somali, Arabic, Polish, Russian and Tigrinya-speaking women who cannot communicate fluently in Swedish, are 18 years or older and with no contraindications for vaginal birth. In addition to standard labour support, women are randomised to CBD support (n=100) or no such support during labour (n=100). Trained CBDs meet with women once or twice before the birth, provide emotional, physical and communication support to women throughout labour and birth in hospital, and then meet with women once or twice after the birth. Women's ratings of the intrapartum care experiences and postnatal well-being are assessed at 6-8 weeks after the birth using selected questions from the Migrant Friendly Maternity Care Questionnaire and by the Edinburgh Postnatal Depression Scale. The intervention group will be compared with the control group using intention-to-treat analyses. ORs and 95% CIs will be estimated and adjustments made if key participant characteristics differ between trial arms. ETHICS AND DISSEMINATION: The study was approved by the Regional Ethical Review Board in Stockholm (approval number: 2018/12 - 31/2). TRIAL REGISTRATION NUMBER: NCT03461640; Pre-results.

Preconception Folic Acid Supplement Use in Immigrant Women (1999-2016).

This study examines how preconception folic acid supplement use varied in immigrant women compared with non-immigrant women. We analyzed national population-based data from Norway from 1999-2016, including 1,055,886 pregnancies, of which 202,234 and 7,965 were to 1st and 2nd generation immigrant women, respectively. Folic acid supplement use was examined in relation to generational immigrant category, maternal country of birth, and length of residence. Folic acid supplement use was lower overall in 1st and 2nd generation immigrant women (21% and 26%, respectively) compared with Norwegian-born women (29%). The lowest use among 1st generation immigrant women was seen in those from Eritrea, Ethiopia, Morocco, and Somalia (around 10%). The highest use was seen in immigrant women from the United States, the Netherlands, Denmark, and Iceland (>30%). Folic acid supplement use increased with increasing length of residence in immigrant women from most countries, but the overall prevalence was lower compared with Norwegian-born women even after 20 years of residence (adjusted odds ratio: 0.63; 95% confidence interval: 0.60-0.67). This study suggests that immigrant women from a number of countries are less likely to use preconception folic acid supplements than non-immigrant women, even many years after settlement.

Rationale, development and feasibility of group antenatal care for immigrant women in Sweden: a study protocol for the Hooyo Project.

INTRODUCTION: Somali-born women comprise a large group of immigrant women of childbearing age in Sweden, with increased risks for perinatal morbidity and mortality and poor experiences of care, despite the goal of providing equitable healthcare for the entire population. Rethinking how care is provided may help to improve outcomes. OVERALL AIM: To develop and test the acceptability, feasibility and immediate impacts of group antenatal care for Somali-born immigrant women, in an effort to improve experiences of antenatal care, knowledge about childbearing and the Swedish healthcare system, emotional well-being and ultimately, pregnancy outcomes. This protocol describes the rationale, planning and development of the study. METHODS AND ANALYSIS: An intervention development and feasibility study. Phase I includes needs assessment and development of contextual understanding using focus group discussions. In phase II, the intervention and evaluation tools, based on core values for quality care and person-centred care, are developed. Phase III includes the historically controlled evaluation in which relevant outcome measures are compared for women receiving individual care (2016-2018) and women receiving group antenatal care (2018-2019): care satisfaction (Migrant Friendly Maternity Care Questionnaire), emotional well-being (Edinburgh Postnatal Depression Scale), social support, childbirth fear, knowledge of Swedish maternity care, delivery outcomes. Phase IV includes the process evaluation, investigate process, feasibility and mechanisms of impact using field notes, observations, interviews and questionnaires. All phases are conducted in collaboration with a stakeholder reference group. ETHICS AND DISSEMINATION: The study is approved by the Regional Ethical Review Board, Stockholm, Sweden. Participants receive information about the study and their right to decline/withdraw without consequences. Consent is given prior to enrolment. Findings will be disseminated at antenatal care units, national/international conferences, through publications in peer-reviewed journals, seminars involving stakeholders, practitioners, community and via the project website. Participating women will receive a summary of results in their language.

Antenatal care for Somali-born women in Sweden: Perspectives from mothers, fathers and midwives.

OBJECTIVE: To explore Somali-born parents' experiences of antenatal care in Sweden, antenatal care midwives' experiences of caring for Somali-born parents, and their respective ideas about group antenatal care for Somali-born parents. DESIGN: Eight focus group discussions with 2-8 participants in each were conducted, three with Somali-born mothers, two with fathers and three with antenatal care midwives. The transcribed text was analysed using Attride-Stirling's tool "Thematic networks". SETTING: Two towns in mid-Sweden and a suburb of the capital city of Sweden. PARTICIPANTS: Mothers (n = 16), fathers (n = 13) and midwives (n = 7) were recruited using purposeful sampling. FINDINGS: Somali-born mothers and fathers in Sweden were content with many aspects of antenatal care, but they also faced barriers. Challenges in the midwife-parent encounter related to tailoring of care to individual needs, dealing with stereotypes, addressing varied levels of health literacy, overcoming communication barriers and enabling partner involvement. Health system challenges related to accessibility of care, limited resources, and the need for clear, but flexible routines and supportive structures for parent education. Midwives confirmed these challenges and tried to address them but sometimes lacked the support, resources and tools to do so. Mothers, fathers and midwives thought that language-supported group antenatal care might help to improve communication, provide mutual support and enable better dialogue, but they were concerned that group care should still allow privacy when needed and not stereotype families according to their country of birth. KEY CONCLUSIONS: ANC interventions targeting inequalities between migrants and non-migrants may benefit from embracing a person-centred approach, as a means to counteract stereotypes, misunderstandings and prejudice. Group antenatal care has the potential to provide a platform for person-centred care and has other potential benefits in providing high-quality antenatal care for sub-groups that tend to receive less or poor quality care. Further research on how to address stereotypes and implicit bias in maternity care in the Swedish context is needed.

Stillbirth in relation to maternal country of birth and other migration related factors: a population-based study in Norway.

BACKGROUND: Migrant women's overall increased risk of adverse pregnancy outcomes is well known. The aim of this study was to investigate possible associations between stillbirth and maternal country of birth and other migration related factors (paternal origin, reason for immigration, length of residence and birthplace of firstborn child) in migrant women in Norway. METHODS: Nationwide population-based study including births to primiparous and multiparous migrant women (n = 198,520) and non-migrant women (n = 1,156,444) in Norway between 1990 and 2013. Data from the Medical Birth Registry of Norway and Statistics Norway. Associations were investigated by multiple logistic regression and reported as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Primiparous women from Sri-Lanka and Pakistan, and multiparous women from Pakistan, Somalia, the Philippines and Former Yugoslavia had higher odds of stillbirth when compared to non-migrant women (adjusted OR ranged from 1.58 to 1.79 in primiparous and 1.50 to 1.71 in multiparous women). Primiparous migrant women whose babies were registered with Norwegian-born fathers had decreased odds of stillbirth compared to migrant women whose babies were registered with foreign-born fathers (aOR = 0.73; CI 0.58-0.93). Primiparous women migrating for work or education had decreased odds of stillbirth compared to Nordic migrants (aOR = 0.58; CI 0.39-0.88). Multiparous migrant women who had given birth to their first child before arriving in Norway had higher odds of stillbirth in later births in Norway compared with multiparous migrant women who had their first child after arrival (aOR = 1.28; CI 1.06-1.55). Stillbirth was not associated with length of residence in Norway. CONCLUSIONS: This study identifies sub-groups of migrant women who are at an increased risk of stillbirth, and highlights the need to improve care for them. More attention should be paid to women from certain countries, multiparous women who had their first baby before arrival and primiparous women whose babies have foreign-born fathers.

Preeclampsia by maternal reasons for immigration: a population-based study.

BACKGROUND: To investigate whether the occurrence of preeclampsia varied by maternal reasons for immigration. METHODS: We included 1,287,270 singleton pregnancies (163,508 to immigrant women) in Norway during 1990-2013. Individual data were obtained through record linkage between the Medical Birth Registry of Norway and Statistics Norway. Analyses were performed for preeclampsia overall and in combination with preterm birth < 37 and < 34 weeks of gestation, referred to as preterm and very preterm preeclampsia. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using logistic regression with robust standard errors, adjusted for relevant covariates, including maternal income and education. RESULTS: Preeclampsia was reported in 3.5% of Norwegian women and 2.5% of immigrants. Compared with Norwegian women, the adjusted OR for preeclampsia was lowest in labour immigrants (adjusted OR 0.55 [95% CI 0.49-0.62]), followed by family immigrants (0.62 [0.59-0.65]), immigrant students (0.75 [0.65-0.86]), refugees (0.81 [0.75-0.88]), and immigrants from other Nordic countries (0.87 [0.80-0.94]). Compared with Norwegian women, labour immigrants also had lower adjusted odds of preterm and very preterm preeclampsia, whereas refugees had increased adjusted odds of preterm and very preterm preeclampsia (< 37 weeks: 1.18 [1.02-1.36], and < 34 weeks: 1.41 [1.15-1.72]). CONCLUSIONS: The occurrence of preeclampsia was lower overall in immigrants than in non-immigrants, but associations varied by maternal reasons for immigration. Maternity caregivers should pay increased attention to pregnant women with refugee backgrounds due to their excess odds of preterm preeclampsia.

Length of residence and caesarean section in migrant women in Sweden: a population-based study.

Background: Prior studies have reported substantial differences in caesarean rates between migrant and non-migrant women. In this study we investigate whether the association between maternal country of birth and caesarean section is modified by length of residence in Sweden. Methods: Population-based register study. A total of 106 760 migrant and 473 881 Swedish-born women having singleton, first births were studied using multinomial multiple regression models to estimate odds ratios (OR) and 95% confidence intervals for mode of birth. Random effect meta-analyses were conducted to assess true heterogeneity between categories of length of residence. Results: Longer duration of residence was associated with an increased overall risk of both unplanned and planned caesarean section among migrant women. This pattern was more pronounced among countries grouped as having higher prevalence (compared to Swedes) of unplanned: OR≤1=1.41 (1.32-1.50); OR>1-<6=1.49 (1.42-1.57); OR6-<10=1.61 (1.50-1.72); OR≥10=1.71 (1.64-1.79) and planned caesarean section [OR≤1=1.14 (0.95-1.36); OR>1-<6=1.30 (1.13-1.51); OR6-<10=1.97 (1.64-2.37]; OR≥10=1.82 (1.67-1.98)]. The results were robust to social, obstetric and health adjustments. There were some country-of-origin-specific findings. Conclusions: The fact that the risk of unplanned and planned caesarean section tended to increase with length of residence, even with adjustment for social, obstetric and health factors, suggests that receiving country-specific factors are playing an important role in caesarean section.