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Caesarean births among migrant women in high-income countries
Best Practice & Research Clinical Obstetrics and Gynaecology 32 (2016) 88e99
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Caesarean births among migrant women in high-income countries Lisa Merry, RN, MSc(A), PhD Candidate a, *, Siri Vangen, MD, PhD, Senior Researcher, Specialisation in Obstetrics and Gynaecology b, Rhonda Small, PhD, Professor c a
Ingram School of Nursing, McGill University, Montreal, QC, Canada Norwegian National Advisory Unit on Women's Health, Department for Women and Children's Health, Women and Children's Division, Oslo University Hospital, Oslo, Norway c Judith Lumley Centre, School of Nursing and Midwifery, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC, Australia b
Keywords: migration immigrant refugee caesarean risk factors practice guideline
High caesarean birth rates among migrant women living in highincome countries are of concern. Women from sub-Saharan Africa and South Asia consistently show overall higher rates compared with non-migrant women, whereas women from Latin America and North Africa/Middle East consistently show higher rates of emergency caesarean. Higher rates are more common with emergency caesareans than with planned caesareans. Evidence regarding risk factors among migrant women for undergoing a caesarean birth is lacking. Research suggests that pathways leading to caesarean births in migrants are complex, and they are likely to involve a combination of factors related to migrant women's physical and psychological health, their social and cultural context and the quality of their maternity care. Migration factors, including length of time in receiving country and migration classification, have an influence on delivery outcome; however, their effects appear to differ by women's country/region of origin. © 2015 Elsevier Ltd. All rights reserved.
* Corresponding author. Wilson Hall, 3506 University Street, Montreal, QC, Canada H3A 2A7. E-mail address: [email protected] (L. Merry). http://dx.doi.org/10.1016/j.bpobgyn.2015.09.002 1521-6934/© 2015 Elsevier Ltd. All rights reserved.
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Introduction Over the last two decades, caesarean birth (CB) rates have increased dramatically in most highincome countries (HICs) [1]. Although rates have remained relatively low in some countries such as Norway (16.6%), Sweden (16.3%) and the Netherlands (15.6%), current rates in the US, Canada, Australia and a number of countries in central and southern Europe have reached 25% or higher [1]. While it is debated whether an optimal CB rate should be proposed, it has been shown that at the population level, rates above 10e15% are higher than can be medically justified [2,3]. The high CB rates in HICs are considered a source of public health concern due to associated health risks. Maternal health risks include infection, wound haematoma, increased blood loss, thromboembolism, surgical injury, a lengthy recovery and higher rates of maternal death [4,5]. Complications in subsequent pregnancies include uterine rupture, stillbirth, placenta previa, placental abruption and invasive placental disease [6e8]. For newborns, there is a greater risk of respiratory problems, admission to a neonatal intensive care unit (NICU) and perinatal mortality [5]. A CB is also a costly procedure [9,10]. Costs include the material and human resources associated with performing the procedure, a longer hospital stay and hospital readmissions due to complications. Given the associated health risks and costs, and the fact that some countries with low CB rates also have low perinatal mortality rates [9,11], high CB rates have been questioned, and recommendations issued that CBs only be undertaken when medically necessary [3,12]. Worldwide, there are over 135 million international migrants living in HICs, half of whom are women [13]. ‘International migrants’ (hereafter referred to as ‘migrants’) are individuals who have moved from one country to establish themselves temporarily or permanently in another country [14]. The majority of migration is from low- and middle-income countries (LMICs) [13]. In some HICs, births to migrants represent 20% or more of all births [15e18]. Both the migrant population and the number of births among migrant women are expected to grow. CB rates of migrants living in HICs are not readily available in government reports and statistics. Based on the most recent data available from published studies [19e37], the population rates for migrants are generally well above the recommended 10e15% range, although they appear to vary according to the rates of the receiving countries. Data also suggest that rates vary for different migration subpopulations defined by migration indicators including country of birth, length of time in receiving country and migration classification (e.g., economic immigrant and refugee). A number of studies also show higher rates for certain migrant groups when compared with non-migrant women [20,23,31]. Although migrants are often healthier than non-migrants upon arrival (i.e., the ‘healthy-immigrant effect’), many migrant women, especially from LMICs, face conditions that may exacerbate health and childbearing risks including poverty, social isolation, discrimination, limited or no health insurance, barriers to accessing health care and stress related to migration and resettlement [38]. ‘Humanitarian migrants’, including refugees, those seeking asylum (i.e., those applying for refugee status at the border or from within the receiving country) and undocumented persons (i.e., those individuals with no legal status in the receiving country) may have suffered violence and trauma [38]. Risks for various diseases may also vary between different migrant subgroups depending on their country of origin, their migration trajectory and genetic predisposition. In this context, CB rates among migrant women in HICs are of concern. This review aims to provide a synthesis of what is known regarding CBs among migrants living in HICs, and it offers recommendations for clinical care to improve childbirth outcomes in migrant women. Agreed migrant indicators (i.e., country of birth, length of time in receiving country, language fluency and ethnicity) have guided the focus of the review [39], with the exception of ethnicity as it is a concept that applies both to migrants and to non-migrants, and it is often conflated with the country of birth. CB rates: migrants compared with non-migrants A systematic review and meta-analysis comparing CB rates of migrants by region/country of origin to non-migrants living in HICs was published in 2013 [40]. The search was exhaustive (to January 2012), and it had no language restrictions. The primary inclusion criterion was that studies must have examined
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migrants living in an HIC and included comparison caesarean data on non-migrant women. Migrant and non-migrant groups had to be mutually exclusive (i.e., foreign born and native born, respectively). Seventy-six studies were included in the review: Over two-thirds were conducted in Europe, 11% were conducted in Australia, 11% in the US and the remaining were done in Canada and Israel Data sources were population based in 36% of studies Seventy per cent of the data were from the 1990s or later The most studied groups were migrants from sub-Saharan Africa (33 studies), North-Africa/Middle East (32 studies), East/South-East Asia (26 studies) and Eastern Europe (26 studies) Comparisons of CB rates between migrant and non-migrant women were categorized as ‘higher’, ‘lower’ or ‘no different’ for each study. For studies comparing rates of more than one migrant group, studies were categorized as ‘higher’, ‘higher and no different’, ‘lower’, ‘lower and no different’, ‘mixed’ or ‘no different’: Overall CB rates were higher or higher and no different in 39% of studies; lower or lower and no different in 17% of studies; and mixed in 13% of studies For emergency CBs (N ¼ 21), more than half of the studies showed migrants to have higher (or higher and no different) rates For planned CBs (N ¼ 19), results were more varied: 26% showed higher (or higher and no different) rates, 37% showed lower (or lower and no different) rates, 32% showed that migrants were similar to non-migrants and 5% had mixed results Meta-analyses revealed that women from sub-Saharan Africa and South Asia were consistently at a greater risk of CBs overall as were North African/Middle-Eastern and Latin American women for emergency CBs; Vietnamese and Eastern European women showed reduced risk Review update Using the same inclusion criteria as the systematic review, electronic databases were searched to identify additional studies published between 2012 and 2015. Thirty-three studies were identified [19,20,22e25,29,31,33e35,41e62]. Twenty-two studies were conducted in Europe, four in Australia, three in Israel and two each in the US and Canada; one study was conducted in Japan Just over half included population-based data All included data from 2000 or later The migrant groups studied most were women from sub-Saharan Africa (20 studies), North Africa/ Middle East (16 studies), South/Central America and Mexico (15 studies) and Eastern Europe (14 studies) Comparing migrants with non-migrants: Overall CB rates were higher or higher and no different in 30% of studies; lower or lower and no different in 17% of studies; and mixed in 30% of studies For emergency CBs (N ¼ 13), 77% showed rates to be higher or higher and no different, and the remaining studies showed mixed results For planned CBs (N ¼ 12), 17% showed rates higher or higher and no different; 25% were lower or lower and no different; 33% were mixed results; and 25% showed no differences in CB rates Several studies showed that migrant women from sub-Saharan Africa to have a greater risk of a CB [20,23,29,35,47,49,51,55,57e59,62], and Eastern European women to have a reduced risk [23,29,34,44,52e54,58]. Results regarding migrants from other regions were insufficient and/or too heterogeneous to draw firm conclusions.
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To summarize, migrant women from Sub-Saharan Africa and South Asia consistently show an increased risk, and women from Eastern Europe and Vietnam a reduced risk, when compared to nonmigrant women. Migrant women from Latin America and North Africa/Middle-East show higher emergency caesarean rates when compared to non-migrant women. Higher emergency CB rates appear to be more of an issue rather than planned caesareans. Limitations of the research conducted to date are the heterogeneity in how migrant populations are defined (e.g., large populations grouped together as ‘foreign born’; countries/regions grouped differently across studies) and a lack of studies from North America. Only a small number of studies examined more specific migration indicators (i.e., country of origin, length of time and migration classification), and so differences within migrant populations from the same region may have been masked. Studies also have variation in which women were included (e.g., low risk), and how CBs were classified/defined (e.g., pre-labour vs. during labour; Robson classification; emergency vs. planned; all caesareans grouped together). Indications and pathways leading to high CB rates among migrants Studies show that the most common indications for CBs among migrants are repeat caesareans, failure to progress (FTP)/dystocia, fetal distress and cephalo-pelvic disproportion (CPD) [20,51,53,58,59,63e65]. It is unclear what additional factors may be driving the high rates among migrants specifically as studies comparing between migrant subpopulations defined by migration indicators are insufficient [31,44,58,66,67], and only one study examining predictors of CBs (emergency caesarean) in migrants was found [63]. Evidence to explain high caesarean rates among migrant women therefore is lacking, although a number of potential contributing factors have been identified [40]. Those most frequently cited can be grouped into six broad categories: poor maternal health [20,23,40,56,57], high body mass index (BMI) and gestational diabetes mellitus (GDM) [20,40], women's cultural attitudes and expectations regarding labour and delivery management [20,55,58,60], acculturation [44,67], genital cutting [40] and language and cultural barriers, and quality of care [20,23,25,40,51,55,57,58]. Poor maternal health It is not known whether some migrant women may have a greater medical need for a caesarean. Studies identified in the literature search did not provide any consistent evidence that migrant women require more caesareans due to placental complications, or medical conditions such as pre-eclampsia. A number of authors, however, did suggest (in discussion) that women's general health status due to other diseases, which were not measured or controlled for in analyses, for example, infectious diseases or anaemia, may have a role [20,23,40,57]. Infectious diseases including hepatitis B and C, parasitic infections and anaemia are conditions known to disproportionately afflict migrants compared with non-migrants, and migrant women of reproductive age are particularly susceptible to iron-deficiency anaemia [68]. Human immunodeficiency virus (HIV), a known indication for a caesarean, is also known to be more prevalent in migrants [68]. Humanitarian migrants or those coming from LMICs may be particularly vulnerable to exposure to diseases [69,70]. Low socio-economic status (SES), lack of insurance and reduced access to health care, including prenatal care [71], may also exacerbate poor maternal health. Gillet et al. (2014) found that migrants from low-income countries were at an increased risk of an emergency caesarean compared with non-migrant women; Kandasamy et al. (2014) found asylum-seeking/refugee women to have a greater risk of caesarean compared with Canadian-born and other migrant women [72], and Gagnon et al. (2013) found low SES and not having health insurance to be independent predictors of emergency caesarean among migrant women giving birth in Canada suggesting that the high-risk health/social profile of these women may have had some role in their risk of caesarean [22,63]. Conversely, Gagnon et al. (2013) found that refugees and asylum seekers were at a reduced risk of an emergency caesarean compared with economic and student migrants [63], and an Australian study comparing migrant women from humanitarian and nonhumanitarian source countries found the latter to have higher caesarean rates [66]. Another Canadian study showed caesarean rates by migration classification to vary based on women's country of birth [73]. The inconsistent findings and the use of more social indicators as markers of a poor health
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status make it difficult to draw conclusions. A CB associated with a ‘humanitarian’ migration classification or low SES may not be due to a high-risk health profile but rather it may be due to other reasons such as how these women were cared for and supported. BMI and GDM A greater prevalence of excess weight and obesity among certain groups of migrant women, including women from sub-Saharan Africa, and North Africa, as well as migrant women arriving from ‘humanitarian’ source countries, has been shown [23,66]. Adoption of more ‘Western’ dietary habits and sedentary lifestyles has been cited as one of the possible causes of migrants having/gaining excess weight [74]. Gagnon et al. (2013) found higher rates of obesity among migrant women who had an emergency caesarean compared with migrant women who had a planned caesarean or a vaginal birth. In multivariable analyses, however, obesity did not remain a significant factor although birth weight of >4000 g did [63]. Other research that controlled for BMI also suggests that excess weight may be a contributing factor to high CB rates for some migrants [23]. GDM has been shown to be a greater burden for migrant women compared with non-migrant women in HICs [75]. Evidence to explain higher rates of GDM among migrants is lacking, but it may be due to childhood malnutrition and/or a low social status [75]. Studies show that migrant women with GDM have high CB rates. When compared with non-migrants, results are mixed (higher, lower and no different rates) [41,45,76,77], suggesting variation in care factors and thresholds of intervention for migrant women with GDM. Women's cultural attitudes and expectations regarding labour and delivery management Culture and women's experiences before migration affect expectations of maternity care. Some women migrate from countries such as Brazil, which is known to have a very high caesarean rate and where it appears to be culturally preferred to have a caesarean [9]. Studies controlling for medical factors and showing higher caesarean rates among women from South America compared with nonmigrants provide some support for this notion [40,53,55,60]. Conversely, consistently lower rates of CB among migrants from Eastern Europe have been suggested to be due to their cultural preference for less interventionist care [40,54]. A large Norwegian study including women from 133 countries found evidence that the caesarean rate of a migrant woman's country of origin is associated with her likelihood to have a CB [33]. The premise was that the country of origin's caesarean rate (high or low) was representative of a woman's preference (or non-preference) for a CB, and this influenced the birth outcome accordingly. Although the country of origin may not be equivalent to a woman's preference, women coming from countries where caesareans are the norm may have a lower threshold for intervention. Alternatively, care providers may know which countries have high caesarean rates, and they may have a lower threshold for intervention if they believe women from these countries prefer, or are more accepting of having a CB. Caesarean rates in the country of origin, however, do not explain caesarean rates in the receiving country for all migrant women as women from sub-Saharan Africa consistently show higher rates than non-migrants, and caesarean rates in Africa are low [9]. Research on migrant women's views on CB is limited, and it suggests that some prefer a CB whereas others do not [78e81]. Acculturation ‘Acculturation’ refers to the extent to which women have adopted the attitudes, behaviours and traditions of the receiving country. The younger the age at migration and the longer a woman has resided in the receiving country, the more likely she is to integrate and to take on the lifestyle behaviours and attitudes of the receiving country. With increasing time in the receiving country or language fluency, women are more likely to adopt Western dietary habits, smoking and drinking consumption may increase and they may become more sedentary. Stress associated with resettlement may also take a toll on maternal physical and mental well-being. In contrast to those
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migrant women who bring cultural preference for caesarean, other women who come from countries where caesarean rates are low may develop greater acceptance of intervention with time, or they may even seek intervention if this is viewed as being associated with a higher social status or better care. The association between acculturation and CB risk has been studied using the length of time in the receiving country and receiving-country language fluency e although the latter is not an optimal measure for acculturation as migrants may speak the receiving-country language, but they may be very culturally divergent from the receiving-country population. Results from these studies are varied, and they suggest that different migrant subpopulations adapt differently with time and/or language fluency [31]. Greater ‘acculturation’ was associated with higher CB rates for some migrants [44] but not for others [35,58,63]. One US study showed primiparous Mexican-born migrant women with greater language ability to have less risk of a CB [67]. For multiparous women, CB rates were similar between Spanish-speaking and bilingual (English/Spanish) women. Differences by parity suggest previous birth experiences, and where they occurred may also have an influence on birth outcome. Other studies have compared the CB rates of migrant women with shorter and longer lengths of residence to non-migrant women, and they also found diverging results [35,73,82]. Although increased risk with longer lengths of time may be due to acculturation, increased risks associated with shorter lengths of time may be due to lack of familiarity with the health-care system, less support and access to care, stress related to migration and consequently a more stressful pregnancy and labour. Genital cutting Several obstetrics' organizations in HICs have reviewed the literature and developed guidelines regarding genital cutting [83e85]. Research shows that genital cutting is associated with an increased risk of a CB; however, there is inconsistent evidence as to whether a prolonged labour, which would lead to the caesarean, is associated with genital cutting in HICs. Many women who have experienced genital cutting prefer a vaginal birth, and they fear having a caesarean. In countries where genital cutting is practised, many births occur without the presence of skilled birth attendants, and women who undergo a CB die during childbirth. Migrant women attempting to avoid having a CB have been associated with an increased risk of having an emergency caesarean and perinatal death [86]. Insensitivity and improper care of women with genital cutting in general are therefore more likely the explanation of high CB rates among these women rather than the scar itself [87,88]. Language and cultural barriers and quality of care Language barriers have been frequently suggested to have a role in migrant women's risk of a CB [40]. Language barriers may lead to difficulties in accessing services, and they may lead to less effective prenatal care. During labour, women may not understand what is happening, and they may be unable to effectively communicate their preferences and support needs including pain management [89]. Care providers therefore may rely more on interventions to assess and provide assistance, and they may make decisions without being able to consider women's wishes adequately, leaving women feeling anxious and unsupported. The few studies to date that have considered the role of language fluency/ communication barriers in relation to CBs are inconclusive [35,58,63,67,89]. Variation in how language fluency has been investigated (e.g., language spoken at home) further complicates interpretation of the findings. Acculturation must also be considered (as described earlier) when considering the role of language in CB risk. What may be more important than language barriers per se is the interaction between women and care providers during pregnancy and labour. A systematic and comparative review on women's experiences of maternity care in HICs found that migrant women were less positive about their care compared with non-migrant women. Migrant women reported problems with communication and caregiver attitudes, and that they were made to feel anxious and not welcomed when they arrived at the hospital in labour [90]. No studies examining experiences of care and risk of caesarean among migrants were found. A number of studies, however, have shown that migrant women from subSaharan Africa in particular have an increased risk of caesarean after controlling for a range of
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medical factors suggesting that care and/or a low threshold for intervention may have a role [20,23,32,36,57,82,91]. As is the case with non-migrants, the role of clinician attitudes, style of practice and institutional policies regarding caesareans cannot be underestimated, and they must be considered in migrant women's risk of a CB. Other There is no evidence to show that other factors known to contribute to the high caesarean rates generally, including biological factors such as maternal age, primiparity, post-datism and maternal height, pregnancy complications related to multiple gestation and malpresentation, and defensive obstetrical practice and/or private health care, are more critical for migrant women than for nonmigrant women. Litigation fears and financial incentives are actually thought to be less of an issue among migrant women conferring protection from CB. In summary, pathways leading to CBs in migrants are complex, and they are not yet fully understood. They likely involve a combination of factors related to migrant women's physical and psychological health, their social and cultural context and the quality of their maternity care. Country of origin as well as the length of time in the receiving country and migration classification appear to be important factors that influence women's risks of undergoing a caesarean, although more research is needed to further understand these effects. Implications for practice Similar to non-migrant women, it appears that efforts towards preventing CBs should predominantly focus on aiming to reduce the primary caesarean, particularly the need for emergency caesareans due to more ‘discretionary indications’ such as FTP and distressing fetal heart rate and increasing the rates of vaginal births after a caesarean (VBACs) [92]. Reducing the primary caesarean may be achieved by addressing underlying factors related to maternal health, attitudes about childbirth and the delivery of care. Given that there is inadequate evidence concerning risk factors associated with CBs among migrant women and while a few non-randomized studies have shown promising reduction in CB in migrants using continuous support in labour from bilingual doulas [93,94], recommendations for clinical care should be primarily based on general recommendations for women, but with a ‘migration lens’ to ensure greater sensitivity to the circumstances of migrant women. Statements in HICs directed towards reducing the need for a CB [12,95e97] recommend the following:
access to prenatal care and education continuous support to be provided during labour (preferably by a doula) no interventions during labour unless medically indicated options for pharmacological as well as non-pharmacological pain management more patience for labour to progress and allowing women to push longer women to be informed and included in decisions and respect and consideration for the psychological and social aspects of labour and birth when providing care
Widespread education and promotion of ‘normal childbirth’, including instituting audit and feedback systems using Robson's classification [98] within institutions, have also been recommended [92,99]. Barriers including limited or no health insurance impeding access to prenatal care need to be addressed to ensure all migrant women receive prenatal care. Interpreters and translated materials should be used to ensure effective screening, treatment, education and health promotion [93,94,100]. Care providers should also consider migrant women's limited access to resources and stress related to migration and resettlement, especially among more vulnerable migrants (i.e., humanitarian and/or recently arrived women), which are also likely to impact migrant women's overall physical health and
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well-being. Greater attention to promoting proper nutrition and exercise, appropriate weight gain and maintaining overall good health is imperative, and it can be further emphasized during prenatal care visits and prenatal education classes [12]. Consideration should be given to women's SES, living environment and access to food stores, and cultural traditions regarding nutritional habits and activities during pregnancy. Supportive care during labour should be optimized by considering women's preferences, ensuring that information is adequately exchanged using interpretation/translation support as needed, and by providing additional information and emotional support for more vulnerable migrants [93,94,101]. Regarding genital cutting, clinicians should refer to practice guidelines for their country for detailed recommendations [83e85]. Genital cutting should not be considered an indication for caesarean. All women considered at risk (based on their country of origin) should be sensitively asked about their ‘cutting status’. Physical assessment should be done prenatally to determine the type and need for deinfibulation before delivery. Documentation of assessments should be detailed including diagrams to avoid repeat examinations. Episiotomy should be offered if labour is obstructed due to scarring or skin inelasticity. Reinfibulation is against the law in most HICs [102], and it should not be performed. Non-judgemental care and respect for privacy are crucial.
Summary High CB rates among migrant women living in HICs are of concern. Women from sub-Saharan Africa and South Asia consistently show overall higher rates, whereas women from Latin America and North Africa/Middle East show consistently higher rates of emergency caesareans compared with nonmigrants. Disparities (i.e., higher rates) in emergency caesareans seem to be more of an issue than in planned caesareans. Evidence regarding risk factors for caesarean is lacking although studies suggest that both medical and non-medical factors are involved. Migration factors, including length of residence and migration classification, have an influence on the mode of birth outcome; however, their effects appear to differ by women's country/region of origin.
Conflict of interest None to declare.
Practice points Access to prenatal care is essential with language barriers sensitively and adequately addressed to ensure effective care, support and health promotion Promotion of healthy weight gain and exercise during pregnancy should consider women's eating and lifestyle traditions, SES and access to healthy foods Available support during labour should be discussed during pregnancy care, and measures taken to ensure that migrant women have adequate support with communication in labour, including the possibility of a bilingual labour companion or support person (doula) if needed Professional interpreters should be accessed early in labour to ensure good communication about preferences during labour Genital cutting is not an indication for a caesarean, and appropriate care to promote vaginal birth should be provided based on the type of cutting Education and encouraging normal childbirth’ (including VBACs) across all migrant populations is needed (cultural attitudes need to be considered in this process) Clinical audits and using Robson's classification could reveal important information about indications and decision-making for caesareans among migrants
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Research agenda Further research is needed to elucidate the following: indications and risk factors (including pathways) for CB among migrants, using Robson's classification, and investigated where possible, by individual countries of birth the role of migration factors such as receiving-country language fluency, length of time in the receiving country and migration classification on the mode of birth the influence of care factors, including psychosocial support, especially during labour for the mode of birth outcome and migrant women's views and experiences of CBs
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Caesarean section by immigrants' length of residence in Norway: a populationbased study. Eur J Public Health 2014. http://dx.doi.org/10.1093/eurpub/cku135. [32] Merten S, Wyss C, Ackermann-Liebrich U. Caesarean sections and breastfeeding initiation among migrants in Switzerland. Int J Public Health 2007;52:210e22. [33] Grytten J, Skau I, Sørensen R. Do mothers decide? The impact of preferences in healthcare. J Hum Resour 2013;48: 142e68. n Busto J. Stillbirth incidence in Spain: a comparison of native and recent immigrant [34] Fuster V, Zuluaga Arias P, Roma mother. Demogr Res 2014;31:889e912. *[35] Essex H, Green J, Baston H, et al. Which women are at an increased risk of a caesarean section or an instrumental vaginal birth in the UK: an exploration within the Millennium Cohort Study. Br JObstet Gynaecol 2013;120:732e43. [36] Roman H, Blondel B, Breart G, et al. Do risk factors for elective cesarean section differ from those of cesarean section during labor in low risk pregnancies? 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The migration process as a stress factor in pregnant immigrant women in Spain. J Transcult Nurs 2013;24:348e54. [43] Michaan N, Gil Y, Amzalag S, et al. Perinatal outcome, social and financial Impact of African refugees delivered in a tertiary hospital in Tel-Aviv, Israel (scientific abstract). Reprod Sci 2012;19:370A. [44] Oberaigner P-DW, Leitner MH, Oberaigner MK, et al. Migrants and obstetrics in Austriadapplying a new questionnaire shows differences in obstetric care and outcome. Wien Klin Wochenschr 2013;125:34e40. rez-Ferre N, Ferna ndez D, Torrejo n MJ, et al. Effect of lifestyle on the risk of gestational diabetes and obstetric [45] Pe outcomes in immigrant Hispanic women living in Spain. J Diabetes 2012;4:432e8. [46] Andrioti D, Apostolakis I, Planiteros G, et al. Migrants' newborns characteristics in a neonatal intensive care unit (NICU) in Greece. Int J Caring Sci 2012;5:162e70. A, Río I, Martinez E, et al. 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Immigrants present improved obstetric and neonatal outcomes compared to native women. A northern Greek population analysis. J Immigr Minor Health 2013;15:249e54. [53] Bernis C, Varea C, Bogin B, et al. Labor management and mode of delivery among migrant and Spanish women: does the variability reflect differences in obstetric decisions according to ethnic origin? Matern Child Health J 2013;17: 918e27. [54] Gorman D, Katikireddi S, Morris C, et al. Ethnic variation in maternity care: a comparison of Polish and Scottish women delivering in Scotland 2004e2009. Public Health 2014;128:262e7. *[55] Janevic T, Loftfield E, Savitz D, et al. Disparities in cesarean delivery by ethnicity and nativity in New York City. Matern Child Health J 2014;18:250e7. [56] Almeida LM, Santos CC, Caldas JP, et al. Obstetric care in a migrant population with free access to health care. Int J Gynecol Obstet 2014;126:244e7. [57] Bakken KS, Skjeldal OH, Stray-Pedersen B. Higher risk for adverse obstetric outcomes among immigrants of African and Asian descent: a comparison study at a low-risk maternity hospital in Norway. Birth 2015;42:132e40. *[58] David M, Borde T, Brenne S, et al. Caesarean section frequency among immigrants, second-and third-generation women, and non-immigrants: prospective study in Berlin/Germany. PLoS One 2015. http://dx.doi.org/10.1371/journal. pone.0127489.
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9
Caesarean births among migrant women in high-income countries Lisa Merry, RN, MSc(A), PhD Candidate a, *, Siri Vangen, MD, PhD, Senior Researcher, Specialisation in Obstetrics and Gynaecology b, Rhonda Small, PhD, Professor c a
Ingram School of Nursing, McGill University, Montreal, QC, Canada Norwegian National Advisory Unit on Women's Health, Department for Women and Children's Health, Women and Children's Division, Oslo University Hospital, Oslo, Norway c Judith Lumley Centre, School of Nursing and Midwifery, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC, Australia b
Keywords: migration immigrant refugee caesarean risk factors practice guideline
High caesarean birth rates among migrant women living in highincome countries are of concern. Women from sub-Saharan Africa and South Asia consistently show overall higher rates compared with non-migrant women, whereas women from Latin America and North Africa/Middle East consistently show higher rates of emergency caesarean. Higher rates are more common with emergency caesareans than with planned caesareans. Evidence regarding risk factors among migrant women for undergoing a caesarean birth is lacking. Research suggests that pathways leading to caesarean births in migrants are complex, and they are likely to involve a combination of factors related to migrant women's physical and psychological health, their social and cultural context and the quality of their maternity care. Migration factors, including length of time in receiving country and migration classification, have an influence on delivery outcome; however, their effects appear to differ by women's country/region of origin. © 2015 Elsevier Ltd. All rights reserved.
* Corresponding author. Wilson Hall, 3506 University Street, Montreal, QC, Canada H3A 2A7. E-mail address: [email protected] (L. Merry). http://dx.doi.org/10.1016/j.bpobgyn.2015.09.002 1521-6934/© 2015 Elsevier Ltd. All rights reserved.
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Introduction Over the last two decades, caesarean birth (CB) rates have increased dramatically in most highincome countries (HICs) [1]. Although rates have remained relatively low in some countries such as Norway (16.6%), Sweden (16.3%) and the Netherlands (15.6%), current rates in the US, Canada, Australia and a number of countries in central and southern Europe have reached 25% or higher [1]. While it is debated whether an optimal CB rate should be proposed, it has been shown that at the population level, rates above 10e15% are higher than can be medically justified [2,3]. The high CB rates in HICs are considered a source of public health concern due to associated health risks. Maternal health risks include infection, wound haematoma, increased blood loss, thromboembolism, surgical injury, a lengthy recovery and higher rates of maternal death [4,5]. Complications in subsequent pregnancies include uterine rupture, stillbirth, placenta previa, placental abruption and invasive placental disease [6e8]. For newborns, there is a greater risk of respiratory problems, admission to a neonatal intensive care unit (NICU) and perinatal mortality [5]. A CB is also a costly procedure [9,10]. Costs include the material and human resources associated with performing the procedure, a longer hospital stay and hospital readmissions due to complications. Given the associated health risks and costs, and the fact that some countries with low CB rates also have low perinatal mortality rates [9,11], high CB rates have been questioned, and recommendations issued that CBs only be undertaken when medically necessary [3,12]. Worldwide, there are over 135 million international migrants living in HICs, half of whom are women [13]. ‘International migrants’ (hereafter referred to as ‘migrants’) are individuals who have moved from one country to establish themselves temporarily or permanently in another country [14]. The majority of migration is from low- and middle-income countries (LMICs) [13]. In some HICs, births to migrants represent 20% or more of all births [15e18]. Both the migrant population and the number of births among migrant women are expected to grow. CB rates of migrants living in HICs are not readily available in government reports and statistics. Based on the most recent data available from published studies [19e37], the population rates for migrants are generally well above the recommended 10e15% range, although they appear to vary according to the rates of the receiving countries. Data also suggest that rates vary for different migration subpopulations defined by migration indicators including country of birth, length of time in receiving country and migration classification (e.g., economic immigrant and refugee). A number of studies also show higher rates for certain migrant groups when compared with non-migrant women [20,23,31]. Although migrants are often healthier than non-migrants upon arrival (i.e., the ‘healthy-immigrant effect’), many migrant women, especially from LMICs, face conditions that may exacerbate health and childbearing risks including poverty, social isolation, discrimination, limited or no health insurance, barriers to accessing health care and stress related to migration and resettlement [38]. ‘Humanitarian migrants’, including refugees, those seeking asylum (i.e., those applying for refugee status at the border or from within the receiving country) and undocumented persons (i.e., those individuals with no legal status in the receiving country) may have suffered violence and trauma [38]. Risks for various diseases may also vary between different migrant subgroups depending on their country of origin, their migration trajectory and genetic predisposition. In this context, CB rates among migrant women in HICs are of concern. This review aims to provide a synthesis of what is known regarding CBs among migrants living in HICs, and it offers recommendations for clinical care to improve childbirth outcomes in migrant women. Agreed migrant indicators (i.e., country of birth, length of time in receiving country, language fluency and ethnicity) have guided the focus of the review [39], with the exception of ethnicity as it is a concept that applies both to migrants and to non-migrants, and it is often conflated with the country of birth. CB rates: migrants compared with non-migrants A systematic review and meta-analysis comparing CB rates of migrants by region/country of origin to non-migrants living in HICs was published in 2013 [40]. The search was exhaustive (to January 2012), and it had no language restrictions. The primary inclusion criterion was that studies must have examined
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migrants living in an HIC and included comparison caesarean data on non-migrant women. Migrant and non-migrant groups had to be mutually exclusive (i.e., foreign born and native born, respectively). Seventy-six studies were included in the review: Over two-thirds were conducted in Europe, 11% were conducted in Australia, 11% in the US and the remaining were done in Canada and Israel Data sources were population based in 36% of studies Seventy per cent of the data were from the 1990s or later The most studied groups were migrants from sub-Saharan Africa (33 studies), North-Africa/Middle East (32 studies), East/South-East Asia (26 studies) and Eastern Europe (26 studies) Comparisons of CB rates between migrant and non-migrant women were categorized as ‘higher’, ‘lower’ or ‘no different’ for each study. For studies comparing rates of more than one migrant group, studies were categorized as ‘higher’, ‘higher and no different’, ‘lower’, ‘lower and no different’, ‘mixed’ or ‘no different’: Overall CB rates were higher or higher and no different in 39% of studies; lower or lower and no different in 17% of studies; and mixed in 13% of studies For emergency CBs (N ¼ 21), more than half of the studies showed migrants to have higher (or higher and no different) rates For planned CBs (N ¼ 19), results were more varied: 26% showed higher (or higher and no different) rates, 37% showed lower (or lower and no different) rates, 32% showed that migrants were similar to non-migrants and 5% had mixed results Meta-analyses revealed that women from sub-Saharan Africa and South Asia were consistently at a greater risk of CBs overall as were North African/Middle-Eastern and Latin American women for emergency CBs; Vietnamese and Eastern European women showed reduced risk Review update Using the same inclusion criteria as the systematic review, electronic databases were searched to identify additional studies published between 2012 and 2015. Thirty-three studies were identified [19,20,22e25,29,31,33e35,41e62]. Twenty-two studies were conducted in Europe, four in Australia, three in Israel and two each in the US and Canada; one study was conducted in Japan Just over half included population-based data All included data from 2000 or later The migrant groups studied most were women from sub-Saharan Africa (20 studies), North Africa/ Middle East (16 studies), South/Central America and Mexico (15 studies) and Eastern Europe (14 studies) Comparing migrants with non-migrants: Overall CB rates were higher or higher and no different in 30% of studies; lower or lower and no different in 17% of studies; and mixed in 30% of studies For emergency CBs (N ¼ 13), 77% showed rates to be higher or higher and no different, and the remaining studies showed mixed results For planned CBs (N ¼ 12), 17% showed rates higher or higher and no different; 25% were lower or lower and no different; 33% were mixed results; and 25% showed no differences in CB rates Several studies showed that migrant women from sub-Saharan Africa to have a greater risk of a CB [20,23,29,35,47,49,51,55,57e59,62], and Eastern European women to have a reduced risk [23,29,34,44,52e54,58]. Results regarding migrants from other regions were insufficient and/or too heterogeneous to draw firm conclusions.
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To summarize, migrant women from Sub-Saharan Africa and South Asia consistently show an increased risk, and women from Eastern Europe and Vietnam a reduced risk, when compared to nonmigrant women. Migrant women from Latin America and North Africa/Middle-East show higher emergency caesarean rates when compared to non-migrant women. Higher emergency CB rates appear to be more of an issue rather than planned caesareans. Limitations of the research conducted to date are the heterogeneity in how migrant populations are defined (e.g., large populations grouped together as ‘foreign born’; countries/regions grouped differently across studies) and a lack of studies from North America. Only a small number of studies examined more specific migration indicators (i.e., country of origin, length of time and migration classification), and so differences within migrant populations from the same region may have been masked. Studies also have variation in which women were included (e.g., low risk), and how CBs were classified/defined (e.g., pre-labour vs. during labour; Robson classification; emergency vs. planned; all caesareans grouped together). Indications and pathways leading to high CB rates among migrants Studies show that the most common indications for CBs among migrants are repeat caesareans, failure to progress (FTP)/dystocia, fetal distress and cephalo-pelvic disproportion (CPD) [20,51,53,58,59,63e65]. It is unclear what additional factors may be driving the high rates among migrants specifically as studies comparing between migrant subpopulations defined by migration indicators are insufficient [31,44,58,66,67], and only one study examining predictors of CBs (emergency caesarean) in migrants was found [63]. Evidence to explain high caesarean rates among migrant women therefore is lacking, although a number of potential contributing factors have been identified [40]. Those most frequently cited can be grouped into six broad categories: poor maternal health [20,23,40,56,57], high body mass index (BMI) and gestational diabetes mellitus (GDM) [20,40], women's cultural attitudes and expectations regarding labour and delivery management [20,55,58,60], acculturation [44,67], genital cutting [40] and language and cultural barriers, and quality of care [20,23,25,40,51,55,57,58]. Poor maternal health It is not known whether some migrant women may have a greater medical need for a caesarean. Studies identified in the literature search did not provide any consistent evidence that migrant women require more caesareans due to placental complications, or medical conditions such as pre-eclampsia. A number of authors, however, did suggest (in discussion) that women's general health status due to other diseases, which were not measured or controlled for in analyses, for example, infectious diseases or anaemia, may have a role [20,23,40,57]. Infectious diseases including hepatitis B and C, parasitic infections and anaemia are conditions known to disproportionately afflict migrants compared with non-migrants, and migrant women of reproductive age are particularly susceptible to iron-deficiency anaemia [68]. Human immunodeficiency virus (HIV), a known indication for a caesarean, is also known to be more prevalent in migrants [68]. Humanitarian migrants or those coming from LMICs may be particularly vulnerable to exposure to diseases [69,70]. Low socio-economic status (SES), lack of insurance and reduced access to health care, including prenatal care [71], may also exacerbate poor maternal health. Gillet et al. (2014) found that migrants from low-income countries were at an increased risk of an emergency caesarean compared with non-migrant women; Kandasamy et al. (2014) found asylum-seeking/refugee women to have a greater risk of caesarean compared with Canadian-born and other migrant women [72], and Gagnon et al. (2013) found low SES and not having health insurance to be independent predictors of emergency caesarean among migrant women giving birth in Canada suggesting that the high-risk health/social profile of these women may have had some role in their risk of caesarean [22,63]. Conversely, Gagnon et al. (2013) found that refugees and asylum seekers were at a reduced risk of an emergency caesarean compared with economic and student migrants [63], and an Australian study comparing migrant women from humanitarian and nonhumanitarian source countries found the latter to have higher caesarean rates [66]. Another Canadian study showed caesarean rates by migration classification to vary based on women's country of birth [73]. The inconsistent findings and the use of more social indicators as markers of a poor health
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status make it difficult to draw conclusions. A CB associated with a ‘humanitarian’ migration classification or low SES may not be due to a high-risk health profile but rather it may be due to other reasons such as how these women were cared for and supported. BMI and GDM A greater prevalence of excess weight and obesity among certain groups of migrant women, including women from sub-Saharan Africa, and North Africa, as well as migrant women arriving from ‘humanitarian’ source countries, has been shown [23,66]. Adoption of more ‘Western’ dietary habits and sedentary lifestyles has been cited as one of the possible causes of migrants having/gaining excess weight [74]. Gagnon et al. (2013) found higher rates of obesity among migrant women who had an emergency caesarean compared with migrant women who had a planned caesarean or a vaginal birth. In multivariable analyses, however, obesity did not remain a significant factor although birth weight of >4000 g did [63]. Other research that controlled for BMI also suggests that excess weight may be a contributing factor to high CB rates for some migrants [23]. GDM has been shown to be a greater burden for migrant women compared with non-migrant women in HICs [75]. Evidence to explain higher rates of GDM among migrants is lacking, but it may be due to childhood malnutrition and/or a low social status [75]. Studies show that migrant women with GDM have high CB rates. When compared with non-migrants, results are mixed (higher, lower and no different rates) [41,45,76,77], suggesting variation in care factors and thresholds of intervention for migrant women with GDM. Women's cultural attitudes and expectations regarding labour and delivery management Culture and women's experiences before migration affect expectations of maternity care. Some women migrate from countries such as Brazil, which is known to have a very high caesarean rate and where it appears to be culturally preferred to have a caesarean [9]. Studies controlling for medical factors and showing higher caesarean rates among women from South America compared with nonmigrants provide some support for this notion [40,53,55,60]. Conversely, consistently lower rates of CB among migrants from Eastern Europe have been suggested to be due to their cultural preference for less interventionist care [40,54]. A large Norwegian study including women from 133 countries found evidence that the caesarean rate of a migrant woman's country of origin is associated with her likelihood to have a CB [33]. The premise was that the country of origin's caesarean rate (high or low) was representative of a woman's preference (or non-preference) for a CB, and this influenced the birth outcome accordingly. Although the country of origin may not be equivalent to a woman's preference, women coming from countries where caesareans are the norm may have a lower threshold for intervention. Alternatively, care providers may know which countries have high caesarean rates, and they may have a lower threshold for intervention if they believe women from these countries prefer, or are more accepting of having a CB. Caesarean rates in the country of origin, however, do not explain caesarean rates in the receiving country for all migrant women as women from sub-Saharan Africa consistently show higher rates than non-migrants, and caesarean rates in Africa are low [9]. Research on migrant women's views on CB is limited, and it suggests that some prefer a CB whereas others do not [78e81]. Acculturation ‘Acculturation’ refers to the extent to which women have adopted the attitudes, behaviours and traditions of the receiving country. The younger the age at migration and the longer a woman has resided in the receiving country, the more likely she is to integrate and to take on the lifestyle behaviours and attitudes of the receiving country. With increasing time in the receiving country or language fluency, women are more likely to adopt Western dietary habits, smoking and drinking consumption may increase and they may become more sedentary. Stress associated with resettlement may also take a toll on maternal physical and mental well-being. In contrast to those
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migrant women who bring cultural preference for caesarean, other women who come from countries where caesarean rates are low may develop greater acceptance of intervention with time, or they may even seek intervention if this is viewed as being associated with a higher social status or better care. The association between acculturation and CB risk has been studied using the length of time in the receiving country and receiving-country language fluency e although the latter is not an optimal measure for acculturation as migrants may speak the receiving-country language, but they may be very culturally divergent from the receiving-country population. Results from these studies are varied, and they suggest that different migrant subpopulations adapt differently with time and/or language fluency [31]. Greater ‘acculturation’ was associated with higher CB rates for some migrants [44] but not for others [35,58,63]. One US study showed primiparous Mexican-born migrant women with greater language ability to have less risk of a CB [67]. For multiparous women, CB rates were similar between Spanish-speaking and bilingual (English/Spanish) women. Differences by parity suggest previous birth experiences, and where they occurred may also have an influence on birth outcome. Other studies have compared the CB rates of migrant women with shorter and longer lengths of residence to non-migrant women, and they also found diverging results [35,73,82]. Although increased risk with longer lengths of time may be due to acculturation, increased risks associated with shorter lengths of time may be due to lack of familiarity with the health-care system, less support and access to care, stress related to migration and consequently a more stressful pregnancy and labour. Genital cutting Several obstetrics' organizations in HICs have reviewed the literature and developed guidelines regarding genital cutting [83e85]. Research shows that genital cutting is associated with an increased risk of a CB; however, there is inconsistent evidence as to whether a prolonged labour, which would lead to the caesarean, is associated with genital cutting in HICs. Many women who have experienced genital cutting prefer a vaginal birth, and they fear having a caesarean. In countries where genital cutting is practised, many births occur without the presence of skilled birth attendants, and women who undergo a CB die during childbirth. Migrant women attempting to avoid having a CB have been associated with an increased risk of having an emergency caesarean and perinatal death [86]. Insensitivity and improper care of women with genital cutting in general are therefore more likely the explanation of high CB rates among these women rather than the scar itself [87,88]. Language and cultural barriers and quality of care Language barriers have been frequently suggested to have a role in migrant women's risk of a CB [40]. Language barriers may lead to difficulties in accessing services, and they may lead to less effective prenatal care. During labour, women may not understand what is happening, and they may be unable to effectively communicate their preferences and support needs including pain management [89]. Care providers therefore may rely more on interventions to assess and provide assistance, and they may make decisions without being able to consider women's wishes adequately, leaving women feeling anxious and unsupported. The few studies to date that have considered the role of language fluency/ communication barriers in relation to CBs are inconclusive [35,58,63,67,89]. Variation in how language fluency has been investigated (e.g., language spoken at home) further complicates interpretation of the findings. Acculturation must also be considered (as described earlier) when considering the role of language in CB risk. What may be more important than language barriers per se is the interaction between women and care providers during pregnancy and labour. A systematic and comparative review on women's experiences of maternity care in HICs found that migrant women were less positive about their care compared with non-migrant women. Migrant women reported problems with communication and caregiver attitudes, and that they were made to feel anxious and not welcomed when they arrived at the hospital in labour [90]. No studies examining experiences of care and risk of caesarean among migrants were found. A number of studies, however, have shown that migrant women from subSaharan Africa in particular have an increased risk of caesarean after controlling for a range of
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medical factors suggesting that care and/or a low threshold for intervention may have a role [20,23,32,36,57,82,91]. As is the case with non-migrants, the role of clinician attitudes, style of practice and institutional policies regarding caesareans cannot be underestimated, and they must be considered in migrant women's risk of a CB. Other There is no evidence to show that other factors known to contribute to the high caesarean rates generally, including biological factors such as maternal age, primiparity, post-datism and maternal height, pregnancy complications related to multiple gestation and malpresentation, and defensive obstetrical practice and/or private health care, are more critical for migrant women than for nonmigrant women. Litigation fears and financial incentives are actually thought to be less of an issue among migrant women conferring protection from CB. In summary, pathways leading to CBs in migrants are complex, and they are not yet fully understood. They likely involve a combination of factors related to migrant women's physical and psychological health, their social and cultural context and the quality of their maternity care. Country of origin as well as the length of time in the receiving country and migration classification appear to be important factors that influence women's risks of undergoing a caesarean, although more research is needed to further understand these effects. Implications for practice Similar to non-migrant women, it appears that efforts towards preventing CBs should predominantly focus on aiming to reduce the primary caesarean, particularly the need for emergency caesareans due to more ‘discretionary indications’ such as FTP and distressing fetal heart rate and increasing the rates of vaginal births after a caesarean (VBACs) [92]. Reducing the primary caesarean may be achieved by addressing underlying factors related to maternal health, attitudes about childbirth and the delivery of care. Given that there is inadequate evidence concerning risk factors associated with CBs among migrant women and while a few non-randomized studies have shown promising reduction in CB in migrants using continuous support in labour from bilingual doulas [93,94], recommendations for clinical care should be primarily based on general recommendations for women, but with a ‘migration lens’ to ensure greater sensitivity to the circumstances of migrant women. Statements in HICs directed towards reducing the need for a CB [12,95e97] recommend the following:
access to prenatal care and education continuous support to be provided during labour (preferably by a doula) no interventions during labour unless medically indicated options for pharmacological as well as non-pharmacological pain management more patience for labour to progress and allowing women to push longer women to be informed and included in decisions and respect and consideration for the psychological and social aspects of labour and birth when providing care
Widespread education and promotion of ‘normal childbirth’, including instituting audit and feedback systems using Robson's classification [98] within institutions, have also been recommended [92,99]. Barriers including limited or no health insurance impeding access to prenatal care need to be addressed to ensure all migrant women receive prenatal care. Interpreters and translated materials should be used to ensure effective screening, treatment, education and health promotion [93,94,100]. Care providers should also consider migrant women's limited access to resources and stress related to migration and resettlement, especially among more vulnerable migrants (i.e., humanitarian and/or recently arrived women), which are also likely to impact migrant women's overall physical health and
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well-being. Greater attention to promoting proper nutrition and exercise, appropriate weight gain and maintaining overall good health is imperative, and it can be further emphasized during prenatal care visits and prenatal education classes [12]. Consideration should be given to women's SES, living environment and access to food stores, and cultural traditions regarding nutritional habits and activities during pregnancy. Supportive care during labour should be optimized by considering women's preferences, ensuring that information is adequately exchanged using interpretation/translation support as needed, and by providing additional information and emotional support for more vulnerable migrants [93,94,101]. Regarding genital cutting, clinicians should refer to practice guidelines for their country for detailed recommendations [83e85]. Genital cutting should not be considered an indication for caesarean. All women considered at risk (based on their country of origin) should be sensitively asked about their ‘cutting status’. Physical assessment should be done prenatally to determine the type and need for deinfibulation before delivery. Documentation of assessments should be detailed including diagrams to avoid repeat examinations. Episiotomy should be offered if labour is obstructed due to scarring or skin inelasticity. Reinfibulation is against the law in most HICs [102], and it should not be performed. Non-judgemental care and respect for privacy are crucial.
Summary High CB rates among migrant women living in HICs are of concern. Women from sub-Saharan Africa and South Asia consistently show overall higher rates, whereas women from Latin America and North Africa/Middle East show consistently higher rates of emergency caesareans compared with nonmigrants. Disparities (i.e., higher rates) in emergency caesareans seem to be more of an issue than in planned caesareans. Evidence regarding risk factors for caesarean is lacking although studies suggest that both medical and non-medical factors are involved. Migration factors, including length of residence and migration classification, have an influence on the mode of birth outcome; however, their effects appear to differ by women's country/region of origin.
Conflict of interest None to declare.
Practice points Access to prenatal care is essential with language barriers sensitively and adequately addressed to ensure effective care, support and health promotion Promotion of healthy weight gain and exercise during pregnancy should consider women's eating and lifestyle traditions, SES and access to healthy foods Available support during labour should be discussed during pregnancy care, and measures taken to ensure that migrant women have adequate support with communication in labour, including the possibility of a bilingual labour companion or support person (doula) if needed Professional interpreters should be accessed early in labour to ensure good communication about preferences during labour Genital cutting is not an indication for a caesarean, and appropriate care to promote vaginal birth should be provided based on the type of cutting Education and encouraging normal childbirth’ (including VBACs) across all migrant populations is needed (cultural attitudes need to be considered in this process) Clinical audits and using Robson's classification could reveal important information about indications and decision-making for caesareans among migrants
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Research agenda Further research is needed to elucidate the following: indications and risk factors (including pathways) for CB among migrants, using Robson's classification, and investigated where possible, by individual countries of birth the role of migration factors such as receiving-country language fluency, length of time in the receiving country and migration classification on the mode of birth the influence of care factors, including psychosocial support, especially during labour for the mode of birth outcome and migrant women's views and experiences of CBs
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