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Comparative study between women born in France and migrant women with regard to their mode of delivery
Journal Pre-proof Comparative study between women born in France and migrant women with regard to their mode of delivery ´ Maxime Eslier, Remy Morello, Elie Azria, Michel Dreyfus
PII:
S2468-7847(19)30681-6
DOI:
https://doi.org/10.1016/j.jogoh.2019.101648
Reference:
JOGOH 101648
To appear in:
Journal of Gynecology Obstetrics and Human Reproduction
Received Date:
23 August 2019
Revised Date:
2 November 2019
Accepted Date:
6 November 2019
Please cite this article as: Eslier M, Morello R, Azria E, Dreyfus M, Comparative study between women born in France and migrant women with regard to their mode of delivery, Journal of Gynecology Obstetrics and Human Reproduction (2019), doi: https://doi.org/10.1016/j.jogoh.2019.101648
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Title Page Comparative study between women born in France and migrant women with regard to their mode of delivery
Short title: Mode of delivery between women born in France and migrants
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Maxime Eslier a*, Rémy Morello b,c, Elie Azria d,e, Michel Dreyfus a,c.
Department of Obstetrics and Gynaecology, Caen University Hospital, avenue
b Unit
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Côte-de-Nacre, 14033 Caen cedex 9, France
of Biostatistics and Clinical Research, Caen CHU, avenue Côte-de-Nacre,
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14033 Caen cedex 9, France
Caen University of Medicine, 19 rue Claude Bloch, 14000 Caen, France
d
Maternity Unit, Paris Saint Joseph Hospital, DHU Risks in Pregnancy, Paris
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c
Descartes University, Paris, France
Université de Paris, CRESS, INSERM, INRA, F-75004 Paris, France
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e
*Corresponding author: Maxime ESLIER, Department of Obstetrics/Gynecology and Reproductive Medicine Caen CHU, avenue Côte-de-Nacre, 14033 Caen cedex 9,
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France Phone number: +33689639725, Mail: [email protected]
Abstract Objective: To compare the mode of delivery between women born in France and migrants. Study Design: The study was a retrospective, observational, single-center study conducted at the university maternity unit in Caen. All women who gave birth in 2008 or 2014 were included. Women with multiple pregnancies and women whose
pregnancies ended before 22 weeks of gestational age were excluded. The preexisting characteristics at the time of pregnancy, mode of delivery and postpartum were collected from the University Hospital’s medical and administrative computer database. We first compared women born in France to those born abroad with regard to the characteristics of mode of delivery for 2008, then for 2014. Secondly, we compared migrant women between 2008 and 2014 to see if the change in the migration profile was associated with a change in the mode of delivery. Results: Of the 3,038 and 3,001 women included in 2008 and 2014 respectively, 272 and 385 women were migrants. We observed a significant decrease in the number of
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spontaneous labors (adjusted odds ratio (aOR) 0.5 [0.4-0.6]) with a significant increase in emergency cesarean sections before (aOR 2.1 [1.4-3.0]) and during labor (aOR 2.2 [1.6-3.2]) among women born in sub-Saharan Africa compared to non-
migrants. And we showed a higher risk of cesarean section prior to labor (aOR 1.2
[1.01-1.4]) and a significant decrease in cesarean section during labor (aOR 0.8 [0.7-
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0.99]) in 2014 compared to 2008.
Conclusion: We observed a significant increase in all types of Cesarean sections
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among women born abroad compared to those born in France, especially in the
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subgroup of women born in sub-Saharan Africa.
Keywords: Pregnancy, pregnant women, migrants, mode of delivery.
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Main body of text
France had 5.9 million immigrants in 2014 (1). Europe has been experiencing a migration crisis that is also a humanitarian crisis for several years. From 2004 to 2009, admissions to France remained relatively stable (2) before increasing between 2009 and 2015 (3). These migrants constitute a significant and growing proportion of
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childbearing women in high-income countries (3). According to the 2016 French National Perinatal Survey Report, 18.6% of women who gave birth in France were born outside France. The main areas of origin were Africa and Europe (4). A continuous increase in the rate of Cesarean sections has been described in
high-income countries in recent decades. In France, this rate rose from 15.5% in 1995 to 20.4% in 2016 (4). While a Cesarean birth can be a life-saving emergency, it is associated with a significantly increased risk of maternal death and severe
maternal morbidity (SMM) from thromboembolic, hemorrhagic, anesthetic and infectious complications for ongoing pregnancy and future pregnancies (5, 6). Several studies have described the increase in the rate of Cesarean sections among migrant women born in sub-Saharan Africa (SSA) compared to women from receiving countries (7, 8). No studies specifically examining the determinants of Cesarean sections in migrant women have been conducted. Identifying and understanding the mechanisms behind this increase is essential to guiding public health and healthcare organization policies. They are also crucial for designing prevention and monitoring procedures in the national context.
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In order to better understand this increased risk of Cesarean section, it is helpful to study whether the change in migration profile is associated with a change in the mode of delivery. The primary objective of this study was a description of
delivery mode according to the maternal place of birth during 2008 and 2014 in a
university maternity unit. The secondary objective was to assess whether the change
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mode of delivery among migrant women.
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in migration profile between 2008 and 2014 was associated with a change in this
Methods
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This was a retrospective, observational, single-center study conducted at the university maternity unit in Caen. All women who gave birth in 2008 or 2014 were identified and included. We chose two years six years apart in order to assess the
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significant increase in the number of migrant women delivering in this maternity unit, and changes in migration profiles. For this analysis, we restricted the study population to women who gave birth after 22 weeks of gestational age. We also excluded women with multiple pregnancies. This last category represented a very small number of people (2.9 %) which did not allow for any comparison internally and
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with the literature. Women were informed orally and gave their consent. A favorable opinion from the Northwest III ethics committee was obtained on September 28, 2016 (Reference: A16-D43-VOL.29). The sample corresponded to all women regardless of where they were born. We chose the women’s country of birth to define migrant status as recommended by the ROAM collaboration and Euro-Peristat (9). Countries of birth were grouped into 5 categories (8, 10-12): France, Europe (excluding France), North Africa, SSA, and “Other”.
Variables were then selected in relation to our primary objective. They were Preexisting characteristics at the time of pregnancy: age, the mother’s socioprofessional category in 5 classes (artisans or tradespeople or entrepreneurs, managers or higher intellectual professions, intermediate professions, employees, manual or unemployed workers), social welfare coverage in 5 categories (social security, state medical assistance (AME), universal health coverage (CMU), additional CMU or none), tobacco use during pregnancy, body mass index (BMI), notable medical history aside from pregnancy (high blood pressure, pre-existing diabetes, presence of uterine myomas), obstetrical history (parity, scarred uterus in cases of multiparity, history of
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postpartum hemorrhage, gestational diabetes, or hypertensive diseases during a previous pregnancy),
Mode of delivery and neonatal characteristics: gestational age at delivery, fetal
presentation, type of labor in 3 classes (induction of labor, emergency Cesarean section prior to labor or spontaneous labor), the mode of delivery in 4 classes
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(spontaneous vaginal delivery, instrumental vaginal delivery, Cesarean section prior
umbilical cord pH<7.10.
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to labor, Cesarean section during labor), birth weight, 5-minute Apgar score<7, and
The information was collected from the University Hospital’s medical and
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administrative computer database.
We first compared women born in France to those born abroad with regard to the characteristics of mode of delivery for 2008, then for 2014. Secondly, we
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compared migrant women between 2008 and 2014 to see if the change in the migration profile was associated with a change in the mode of delivery. Qualitative variables were expressed as a percentage, quantitative variables by their mean and standard deviation. The statistical tests used were variance analysis (ANOVA and Bonferroni post-hoc test) for quantitative variables after
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verifying the hypothesis for equality of variances (Levene test), and the Chi² test (or Fisher’s exact test if necessary) for qualitative variables. Multivariate logistic regressions were conducted according to a step-by-step procedure in relation to the mode of delivery. The threshold of significance was set at 0.05. The CHU’s Biostatistics and Clinical Research Unit conducted these statistical analysis using IBM®-SPSS® 22.0 software.
Results
Among the 3,038 and 3,001 women included in 2008 and 2014 respectively, 272 (9.0%) and 385 (12.8%) women were migrants. The characteristics of the women who gave birth in 2008 and 2014 are described in Tables 1 and 2, respectively. We observed that the maternal birth place is strongly associated with the social situation, women born in sub-Saharan Africa being the most socially deprived compared to other categories of migrant and to non-migrant women (Table 1 and 2). If we compare the mode of delivery between women born in France and those born abroad, we find a significant increase in the overall rate of Cesarean sections
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among migrant women in 2008 (p = 0.002) and 2014 (p < 0.001). Comparisons of the types of labor and the methods of delivery among women who gave birth in 2008 or 2014 are described in Table 3.
In the multivariate analysis, we observed a significant decrease in the number of spontaneous labors (adjusted odds ratio (aOR) 0.5 [0.4-0.6]) with a significant
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increase in emergency cesarean sections before (aOR 2.1 [1.4-3.0]) and during labor (aOR 2.2 [1.6-3.2]) among women born in sub-Saharan Africa compared to non-
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migrants (Table 4).
When comparing migrant women between 2008 and 2014, we found in 2014
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that they were significantly less “unemployed” with more managers and higher intellectual professions, but with more women receiving additional CMU ( p < 0.001), with a higher BMI (p = 0.046) and with a greater history of pregnancy-induced
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hypertension (p = 0.04). We found a significant increase in the rate of gestational diabetes (p = 0.01), but with less macrosomia (p = 0.03). We also observed a change in neonatal weight depending on the maternal birth place (p = 0.047). It decreased significantly among women in North Africa and SSA, in contrast to other subgroups, where it increased significantly.
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And we showed a higher risk of cesarean section prior to labor (aOR 1.2 [1.01-
1.4]) and a significant decrease in cesarean section during labor (aOR 0.8 [0.7-0.99]) in 2014 compared to 2008 (Table 4).
Discussion We observed a significant decrease in spontaneous and spontaneous vaginal labors with a significant increase in emergency cesarean sections prior to and during
labor for migrant women in 2008 and 2014, especially among those born in SSA compared to women born in France. We also noted a change in the mode of delivery between 2008 and 2014 for migrant women with a significant increase in cesarean sections prior to labor and a significant decrease in cesarean sections during labor. This study has certain limitations. It is retrospective with the risk of information bias because data are being collected using the CHU’s medical and administrative computer databases. It is also possible that there are more missing data in the records of the women born abroad than those born in France due to the language barrier and the more irregular care that could result in an under-identification of the
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variables and errors when entering data. However, it is exhaustive because we took into account all deliveries in 2008 and 2014, which rules out the risk of selection bias. Another limitation is the amount of time between the two years selected. In six years, it is possible that there may have been changes in practices, leading to potential
changes in the diagnosis and especially the management of certain pathologies. The
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low number of migrants (8.9% in 2008 and 12.8% in 2014) can lead to a lack of statistical power. Our results are difficult to extrapolate to the population of
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metropolitan France, making comparisons difficult. Our rates of migrants were well below the average rate in the 2016 National Perinatal Survey Report (18.6%), which,
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however, varied widely from maternity unit to maternity unit (4). Several studies describe the increase in the rate of cesarean section prior to and during labor among women born in SSA compared to those born in receiving
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countries (7, 8). In 2013, Merry et al.’s meta-analysis reported higher rates of cesarean section among women born in SSA compared to non-migrants (OR=2.19 (95% CI: 1.80–2.67)) (7). The same results are observed in the Saurel-Cubizolles et al. study in 2012 (8). Explanations for this increase remain limited. Among the risk factors cited are the language barrier, unfavorable socioeconomic status, poor
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maternal health, high BMI, fetopelvic disproportion, and inadequate prenatal care (7). No studies examining the determinants of cesarean sections in migrant women in particular have been conducted. In our study, we found an increase among women born in SSA compared to those born in France in the rate of cesarean section, whether an emergency cesarean section prior to labor or during labor. We can ask ourselves whether this increase is secondary to a higher BMI among migrant women, especially those born in SSA. A 2018 literature review found twice as many cesarean sections (OR = 2.01 (95% CI: 1.93-2.10)) in women with a BMI greater than 40 kg/m²
compared to those with a BMI between 18.5 and 24.9 kg/m² after adjusting for confounding factors (13). However, our figures showed a significant increase in BMI among women born in SSA compared to those born in France, both in 2008 and in 2014 (24.1 kg/m² versus 23.4 kg/m² and 25.8 kg/m² versus 24 kg/m², respectively). However, this significant increase in BMI does not reflect a clinical increase in morbid obesity. It is therefore difficult to attribute this change in the mode of delivery to this significant increase in BMI. Our secondary objective was to see whether the change in the migration profile between 2008 and 2014 influenced the mode of delivery and the perinatal
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data. Between 2008 and 2014, the proportion of migrant women increased from 9 to 12.8 %. The change in the social situation and pre-existing characteristics at the
time of pregnancy among migrant women could be explained by the establishment of a migrant camp in Calais with the increased migration flows between 2008 and 2014, mostly from Eritrea, Somalia and Syria. It could explain the increased number of
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women born in sub-Saharan Africa in our cohort. The change in the birth weights
between these two years could be the result of a significant increase in the number of
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cases of pregnancy-induced hypertension that can lead to intrauterine growth restriction delays. As for the change in the mode of delivery, it may be secondary to
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greater maternal insecurity secondary to unfavorable socioeconomic status resulting in poor maternal health, a high BMI and inadequate prenatal care (7, 14, 15). All of these factors can be made worse by the language barrier (7). Just like the Gonthier
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et al. study in 2017, the Heaman et al. meta-analysis in 2013 reported that migrant women were more likely to have inadequate prenatal care than non-migrant women. Associated factors were being under the age of 20, multiparity, not having a spouse, poor language skills, an unplanned pregnancy and a lack of health insurance (14, 15). In our study, it was not possible for us to find out the women’s prenatal care.
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In view of the differences between these women in the various countries of
birth, one must wonder about the mechanisms behind them and the possibility of greater maternal morbidity. Studies conducted in high-income countries indicate that migrant women are at greater risk of unfavorable pregnancy outcomes with an increase in SMM, primarily pregnancy-related hypertensive disease (OR 1.67 [95% CI 1.43 – 1.95] (16). Migrants from SSA seem to be at higher risk for severe preeclampsia and eclampsia (10, 11, 17-20) than North African women (8, 17, 21). Concurring results are obtained in Dutch (16) and French studies where there is an
increase in SMM among women born in SSA (adjusted OR: 1.8 [1.4-2.4]), mostly concerning hypertensive complications, sepsis and severe obstetric bleeding (22). In 2017, Sauvegrain et al. highlighted the existence of differentiated care that could have an impact in terms of SMM among women born in SSA (12). The mechanisms explaining the association between the maternal birth place and the mode of delivery are complex and remain unclear. Difficulties in its understanding is partly due to the great heterogeneity of the migrant women group, both in terms of socio-economic characteristics and of maternal/perinatal risk profile. For this reason, it is also difficult to study the large group named “other”. This group includes lots of
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women with different country of birth, different social situation and different history of migration. Beside geographical origin, administrative status could also be an
important determinant of medical risk. Even if the data remain limited, asylum
seekers and refugees are only administrative categories that have been studied. It has been shown that these groups have an increased risk of SMM and SPM (23).
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While asylum seekers and refugees benefit from a status that provides them with some social protection, another category of migrants without any permit for legal
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residence in the territory is growing in number in European countries (24). The socalled “undocumented migrants”, because of the many barriers faced to interact with
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health system, including individual and institutional discrimination, and the lack of social protection are likely to be at even increased risk (25-26). It could be of great interest to study the specific impact of the legal status of migrant, particularly of
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undocumented migrant.
Conclusion
This retrospective study revealed a significant increase in all types of Cesarean
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section among women born abroad compared to those born in France, particularly in the subgroup of women born in SSA. To date, the arguments are insufficient to explain the observed differences, namely whether this is secondary to pre-existing characteristics at the time of pregnancy, an increase in SMM, or a phenomenon of differentiated care. A second study is underway to compare this maternal morbidity between different countries of birth. Disclosure of Interests
The authors report no conflicts of interest Contribution to Authorship Eslier Maxime designed, analyzed, wrote and read over the article in collaboration with Dreyfus Michel. Azria Elie read over the article. Morello Rémy conducted the statistical analysis and actively helped develop and write this study.
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Funding There was no funding for this study. Acknowledgements
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We would like to thank the CHU’s Biostatistics and Clinical Research Unit for the
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statistical analysis.
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Table Caption List Table 1. Characteristics of women who gave birth in 2008 according to maternal birth place Europe Maternal birth place (N =)
France
excluding
(2766)
France (40)
Age (years)
29.1
29.3
North Africa (84) 30.7
SubSaharan
Other
Africa
(74)
(74) 28.1
28.9
and
2.1
0
intellectual
11.5
15
Intermediate professions
30.1
20
Employees
27.2
12.5
Manual, unemployed workers
29.1
52.5
SOCIO – ECONOMIC STATUS
entrepreneurs higher
Social welfare coverage (%)
4
8.3
8
12.2
16.7
6.8
9.5
72.6
83.8
74.3
78.4
90.4
<0.001
2.5
6
8
5.4
0.002
5.0
2.4
2.7
1.4
0.09
0
0
2.4
9.5
1.4
<0.001
0
5
0
1.4
1.4
<0.001
2.6
Additional CMU
1.3
lP
re
Universal health coverage (CMU)
Tobacco use during pregnancy (%)
26.6
12.5
4.8
2.7
9.5
<0.001
Body mass index
23.4
22.6
23.9
24.1
23.6
0.006
1.3
0
0
1.4
1.4
NS
0.3
2.5
1.2
2.7
0
0.013
Uterine Myomas (%)
0.7
0
0
4.1
2.7
0.02
Parity
0.9
0.6
1.2
1.4
0.9
0.008
Primiparous (%)
45.4
55
36.9
39.2
45.9
NS
Multiparity with scarred uterus (%)
9.3
2.5
15.5
12.2
17.6
0.02
Multiparity without scarred uterus (%)
45.3
42.5
47.6
48.6
36.5
NS
Postpartum hemorrhage (%)
5.1
2.5
2.4
4.1
2.7
NS
Gestational diabetes (%)
2.1
0
7.1
5.4
2.7
0.02
Hypertensive diseases (%)
2.3
2.5
0
2.7
1.4
NS
Gestational age at delivery
36.8
36.4
37.3
37.1
36.7
NS
High blood pressure (%)
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Pre-existing diabetes (%)
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HISTORY
MEDICAL OBSTETRICAL HISTORY DELIVERY
0
89.2
96.1
None
0
87.5
Standard health insurance
State medical assistance
1.4
2.4
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professions
0
ro of
tradespeople
Managers,
0.002 <0.001
Socioprofessional category (%) Artisans,
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Fetal presentation (%) Cephalic Breech
NS 95.2
97.5
95.2
97.3
93.2
4
2.5
4.8
2.8
2.7
NEONATAL
Birth weight (grams)
3225
3192
3451
3315
3169
NS
7.8
5
4.8
9.5
6.8
NS
percentile (%)
11.7
20
20.2
14.9
9.5
0.05
5-minute Apgar score < 7 (%)
1.0
2.5
1.2
1.4
0
NS
Umbilical cord pH <7.10 (%)
0.4
2.5
0
1.4
0
NS
< 10th percentile (%) >
90th
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re
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NS, Not Significant
Table 2. Characteristics of women who gave birth in 2014 according to maternal birth place Europe Maternal birth place (N =)
France
excluding
(2616)
France (67)
Age (years)
29.4
30.5
North Africa (105) 30.9
SubSaharan
Other
Africa
(85)
(128) 29.6
29.5
0.002 <0.001
Socioprofessional category (%) Artisans,
p
tradespeople
and
2.4
3
2.9
0.8
7
intellectual
13
22.4
2.9
5.5
10.6
Intermediate professions
32.4
20.9
6.7
7
9.4
Employees
25.1
16.4
18
11.7
9.4
Manual, unemployed workers
27.1
37.3
69.5
75
63.6
Standard health insurance
87.2
77.6
64.6
41.4
68.2
<0.001
Universal health coverage (CMU)
1.1
3.0
4.8
2.3
1.2
0.005
Additional CMU
11.4
14.9
24.8
42.2
25.9
<0.001
0
1.5
2.9
14.1
4.7
<0.001
0.3
3
2.9
0
0
<0.001
24.0
16.4
2.9
3.1
8.2
<0.001
24.0
23.1
24.1
25.8
23.7
0.006
0.9
0
1
1.6
1.2
NS
0.8
0
1.9
1.6
1.2
NS
SOCIO – ECONOMIC STATUS
entrepreneurs Managers,
higher
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Social welfare coverage (%)
State medical assistance
Body mass index High blood pressure (%) Pre-existing diabetes (%)
0.4
1.5
0
5.5
0
<0.001
0.8
0.8
1.1
1.0
1.0
0.02
48.2
52.2
44.8
37.5
37.6
0.04
Multiparity with scarred uterus (%)
11.2
14.9
11.4
17.2
14.1
NS
Multiparity without scarred uterus (%)
40.7
32.8
43.8
45.3
48.2
NS
Postpartum hemorrhage (%)
4.7
7.5
3.8
2.3
0
NS
Gestational diabetes (%)
2.9
1.5
6.7
3.1
5.9
NS
Hypertensive diseases (%)
2.5
4.5
3.8
7
1.2
0.03
Gestational age at delivery
36.8
36.5
36.7
36.3
37.2
NS
Parity Primiparous (%)
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OBSTETRICAL HISTORY
Uterine Myomas (%)
Fetal presentation (%)
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DELIVERY
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HISTORY
MEDICAL
Tobacco use during pregnancy (%)
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None
NS
Cephalic
95.3
94
94.3
93.8
98.8
Breech
4.1
4.5
3.9
5.4
0
Birth weight (grams)
NEONATAL
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professions
3219
3191
3250
3143
3328
NS
< 10th percentile (%)
7.7
7.5
8.6
7.8
5.9
NS
> 90th percentile (%)
11.2
9.0
12.4
13.3
9.4
NS
5-minute Apgar score < 7 (%)
1.6
0
1.9
3.1
1.2
NS
Umbilical cord pH <7.10 (%)
0.5
0
0
3.1
0
NS
NS, Not Significant
Table 3. Comparison of the mode of delivery among women who gave birth in 2008 or 2014 according to maternal birth place Europe Maternal birth place
France
excluding France
SubSaharan
Other
Africa
2766
40
84
74
74
p
Induction of labor
12.7
10
16.7
21.6
10.8
NS
Emergency Cesarean section
9.3
7.5
14.3
13.5
18.9
0.03
78.1
82.5
69
64.9
70.3
0.01
Spontaneous vaginal delivery
62
52.5
53.6
54.1
48.6
0.03
Instrumental vaginal delivery
19.1
17.5
19
17.6
20.3
NS
Cesarean section prior to labor
9
7.5
13.1
13.5
18.9
0.03
Cesarean section during labor
9.9
22.5
14.3
14.9
12.2
0.04
N Induction of labor
2616 11.7
67 13.4
105 13.3
128 16.4
85 5.9
p NS
Emergency Cesarean section
10.6
10.4
Spontaneous labor
77.7
76.1
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Spontaneous vaginal delivery
65.3
Instrumental vaginal delivery
15.3
prior to labor Spontaneous labor
prior to labor
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LABOR (%) DELIVERY (%)
Africa
13.3
21.9
10.6
0.007
73.3
61.7
83.5
0.001
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LABOR (%) DELIVERY (%)
TYPE OF MODE OF
2014
N
53.7
66.7
50
69.4
0.002
25.4
11.4
7.8
15.3
0.02
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TYPE OF MODE OF
2008
North
Cesarean section prior to labor
10.7
10.4
12.4
21.9
10.6
0.009
Cesarean section during labor
8.7
10.4
9.5
20.3
4.7
0.001
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NS, Not Significant
Table 4. Association between maternal birth place and mode of delivery among women who gave birth in 2008 or 2014 p
Adjusted OR *
IC 95%
0.1
1.1
1.0-1.4
Emergency Cesarean section prior to labor Year of delivery 2014 (Ref : 2008) Maternal birth place < 0.001
2.1
1.4-3.0
Europe excluding France
0.8
0.9
0.5-1.8
North Africa
0.1
1.4
0.9-2.2
Other
0.1
1.5
1.0-2.4
1.0
1.0
0.9-1.1
0.5
0.4-0.6
Spontaneous labor Year of delivery 2014 (Ref : 2008) Maternal birth place Sub-Saharan Africa (Ref : France)
0.9
North Africa
0.04
Other
0.9
1.0
0.7-1.7
0.7
0.5-0.98
1.0
0.7-1.4
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Europe excluding France
Cesarean section prior to labor
0.04
1.2
1.01-1.4
< 0.001
2.0
1.4-3.0
0.8
0.9
0.5-1.8
0.2
1.3
0.9-2.1
0.1
1.5
1.0-2.4
0.049
0.8
0.7-0.99
< 0.001
2.2
1.6-3.2
Europe excluding France
0.04
1,8
1.02-3.0
North Africa
0.3
1.3
0.8-2.0
Other
0.6
0.9
0.5-1.6
Year of delivery 2014 (Ref : 2008)
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Maternal birth place Sub-Saharan Africa (Ref : France) Europe excluding France
Other
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North Africa
Cesarean section during labor
Year of delivery 2014 (Ref : 2008) Maternal birth place
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MODE OF DELIVERY
< 0.001
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TYPE OF LABOR
Sub-Saharan Africa (Ref : France)
Sub-Saharan Africa (Ref : France)
* adjusted for the year of delivery when comparing the maternal birth place and adjusting for the maternal birth
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place when comparing the year of delivery
PII:
S2468-7847(19)30681-6
DOI:
https://doi.org/10.1016/j.jogoh.2019.101648
Reference:
JOGOH 101648
To appear in:
Journal of Gynecology Obstetrics and Human Reproduction
Received Date:
23 August 2019
Revised Date:
2 November 2019
Accepted Date:
6 November 2019
Please cite this article as: Eslier M, Morello R, Azria E, Dreyfus M, Comparative study between women born in France and migrant women with regard to their mode of delivery, Journal of Gynecology Obstetrics and Human Reproduction (2019), doi: https://doi.org/10.1016/j.jogoh.2019.101648
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Title Page Comparative study between women born in France and migrant women with regard to their mode of delivery
Short title: Mode of delivery between women born in France and migrants
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Maxime Eslier a*, Rémy Morello b,c, Elie Azria d,e, Michel Dreyfus a,c.
Department of Obstetrics and Gynaecology, Caen University Hospital, avenue
b Unit
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Côte-de-Nacre, 14033 Caen cedex 9, France
of Biostatistics and Clinical Research, Caen CHU, avenue Côte-de-Nacre,
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14033 Caen cedex 9, France
Caen University of Medicine, 19 rue Claude Bloch, 14000 Caen, France
d
Maternity Unit, Paris Saint Joseph Hospital, DHU Risks in Pregnancy, Paris
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c
Descartes University, Paris, France
Université de Paris, CRESS, INSERM, INRA, F-75004 Paris, France
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e
*Corresponding author: Maxime ESLIER, Department of Obstetrics/Gynecology and Reproductive Medicine Caen CHU, avenue Côte-de-Nacre, 14033 Caen cedex 9,
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France Phone number: +33689639725, Mail: [email protected]
Abstract Objective: To compare the mode of delivery between women born in France and migrants. Study Design: The study was a retrospective, observational, single-center study conducted at the university maternity unit in Caen. All women who gave birth in 2008 or 2014 were included. Women with multiple pregnancies and women whose
pregnancies ended before 22 weeks of gestational age were excluded. The preexisting characteristics at the time of pregnancy, mode of delivery and postpartum were collected from the University Hospital’s medical and administrative computer database. We first compared women born in France to those born abroad with regard to the characteristics of mode of delivery for 2008, then for 2014. Secondly, we compared migrant women between 2008 and 2014 to see if the change in the migration profile was associated with a change in the mode of delivery. Results: Of the 3,038 and 3,001 women included in 2008 and 2014 respectively, 272 and 385 women were migrants. We observed a significant decrease in the number of
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spontaneous labors (adjusted odds ratio (aOR) 0.5 [0.4-0.6]) with a significant increase in emergency cesarean sections before (aOR 2.1 [1.4-3.0]) and during labor (aOR 2.2 [1.6-3.2]) among women born in sub-Saharan Africa compared to non-
migrants. And we showed a higher risk of cesarean section prior to labor (aOR 1.2
[1.01-1.4]) and a significant decrease in cesarean section during labor (aOR 0.8 [0.7-
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0.99]) in 2014 compared to 2008.
Conclusion: We observed a significant increase in all types of Cesarean sections
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among women born abroad compared to those born in France, especially in the
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subgroup of women born in sub-Saharan Africa.
Keywords: Pregnancy, pregnant women, migrants, mode of delivery.
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Main body of text
France had 5.9 million immigrants in 2014 (1). Europe has been experiencing a migration crisis that is also a humanitarian crisis for several years. From 2004 to 2009, admissions to France remained relatively stable (2) before increasing between 2009 and 2015 (3). These migrants constitute a significant and growing proportion of
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childbearing women in high-income countries (3). According to the 2016 French National Perinatal Survey Report, 18.6% of women who gave birth in France were born outside France. The main areas of origin were Africa and Europe (4). A continuous increase in the rate of Cesarean sections has been described in
high-income countries in recent decades. In France, this rate rose from 15.5% in 1995 to 20.4% in 2016 (4). While a Cesarean birth can be a life-saving emergency, it is associated with a significantly increased risk of maternal death and severe
maternal morbidity (SMM) from thromboembolic, hemorrhagic, anesthetic and infectious complications for ongoing pregnancy and future pregnancies (5, 6). Several studies have described the increase in the rate of Cesarean sections among migrant women born in sub-Saharan Africa (SSA) compared to women from receiving countries (7, 8). No studies specifically examining the determinants of Cesarean sections in migrant women have been conducted. Identifying and understanding the mechanisms behind this increase is essential to guiding public health and healthcare organization policies. They are also crucial for designing prevention and monitoring procedures in the national context.
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In order to better understand this increased risk of Cesarean section, it is helpful to study whether the change in migration profile is associated with a change in the mode of delivery. The primary objective of this study was a description of
delivery mode according to the maternal place of birth during 2008 and 2014 in a
university maternity unit. The secondary objective was to assess whether the change
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mode of delivery among migrant women.
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in migration profile between 2008 and 2014 was associated with a change in this
Methods
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This was a retrospective, observational, single-center study conducted at the university maternity unit in Caen. All women who gave birth in 2008 or 2014 were identified and included. We chose two years six years apart in order to assess the
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significant increase in the number of migrant women delivering in this maternity unit, and changes in migration profiles. For this analysis, we restricted the study population to women who gave birth after 22 weeks of gestational age. We also excluded women with multiple pregnancies. This last category represented a very small number of people (2.9 %) which did not allow for any comparison internally and
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with the literature. Women were informed orally and gave their consent. A favorable opinion from the Northwest III ethics committee was obtained on September 28, 2016 (Reference: A16-D43-VOL.29). The sample corresponded to all women regardless of where they were born. We chose the women’s country of birth to define migrant status as recommended by the ROAM collaboration and Euro-Peristat (9). Countries of birth were grouped into 5 categories (8, 10-12): France, Europe (excluding France), North Africa, SSA, and “Other”.
Variables were then selected in relation to our primary objective. They were Preexisting characteristics at the time of pregnancy: age, the mother’s socioprofessional category in 5 classes (artisans or tradespeople or entrepreneurs, managers or higher intellectual professions, intermediate professions, employees, manual or unemployed workers), social welfare coverage in 5 categories (social security, state medical assistance (AME), universal health coverage (CMU), additional CMU or none), tobacco use during pregnancy, body mass index (BMI), notable medical history aside from pregnancy (high blood pressure, pre-existing diabetes, presence of uterine myomas), obstetrical history (parity, scarred uterus in cases of multiparity, history of
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postpartum hemorrhage, gestational diabetes, or hypertensive diseases during a previous pregnancy),
Mode of delivery and neonatal characteristics: gestational age at delivery, fetal
presentation, type of labor in 3 classes (induction of labor, emergency Cesarean section prior to labor or spontaneous labor), the mode of delivery in 4 classes
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(spontaneous vaginal delivery, instrumental vaginal delivery, Cesarean section prior
umbilical cord pH<7.10.
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to labor, Cesarean section during labor), birth weight, 5-minute Apgar score<7, and
The information was collected from the University Hospital’s medical and
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administrative computer database.
We first compared women born in France to those born abroad with regard to the characteristics of mode of delivery for 2008, then for 2014. Secondly, we
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compared migrant women between 2008 and 2014 to see if the change in the migration profile was associated with a change in the mode of delivery. Qualitative variables were expressed as a percentage, quantitative variables by their mean and standard deviation. The statistical tests used were variance analysis (ANOVA and Bonferroni post-hoc test) for quantitative variables after
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verifying the hypothesis for equality of variances (Levene test), and the Chi² test (or Fisher’s exact test if necessary) for qualitative variables. Multivariate logistic regressions were conducted according to a step-by-step procedure in relation to the mode of delivery. The threshold of significance was set at 0.05. The CHU’s Biostatistics and Clinical Research Unit conducted these statistical analysis using IBM®-SPSS® 22.0 software.
Results
Among the 3,038 and 3,001 women included in 2008 and 2014 respectively, 272 (9.0%) and 385 (12.8%) women were migrants. The characteristics of the women who gave birth in 2008 and 2014 are described in Tables 1 and 2, respectively. We observed that the maternal birth place is strongly associated with the social situation, women born in sub-Saharan Africa being the most socially deprived compared to other categories of migrant and to non-migrant women (Table 1 and 2). If we compare the mode of delivery between women born in France and those born abroad, we find a significant increase in the overall rate of Cesarean sections
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among migrant women in 2008 (p = 0.002) and 2014 (p < 0.001). Comparisons of the types of labor and the methods of delivery among women who gave birth in 2008 or 2014 are described in Table 3.
In the multivariate analysis, we observed a significant decrease in the number of spontaneous labors (adjusted odds ratio (aOR) 0.5 [0.4-0.6]) with a significant
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increase in emergency cesarean sections before (aOR 2.1 [1.4-3.0]) and during labor (aOR 2.2 [1.6-3.2]) among women born in sub-Saharan Africa compared to non-
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migrants (Table 4).
When comparing migrant women between 2008 and 2014, we found in 2014
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that they were significantly less “unemployed” with more managers and higher intellectual professions, but with more women receiving additional CMU ( p < 0.001), with a higher BMI (p = 0.046) and with a greater history of pregnancy-induced
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hypertension (p = 0.04). We found a significant increase in the rate of gestational diabetes (p = 0.01), but with less macrosomia (p = 0.03). We also observed a change in neonatal weight depending on the maternal birth place (p = 0.047). It decreased significantly among women in North Africa and SSA, in contrast to other subgroups, where it increased significantly.
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And we showed a higher risk of cesarean section prior to labor (aOR 1.2 [1.01-
1.4]) and a significant decrease in cesarean section during labor (aOR 0.8 [0.7-0.99]) in 2014 compared to 2008 (Table 4).
Discussion We observed a significant decrease in spontaneous and spontaneous vaginal labors with a significant increase in emergency cesarean sections prior to and during
labor for migrant women in 2008 and 2014, especially among those born in SSA compared to women born in France. We also noted a change in the mode of delivery between 2008 and 2014 for migrant women with a significant increase in cesarean sections prior to labor and a significant decrease in cesarean sections during labor. This study has certain limitations. It is retrospective with the risk of information bias because data are being collected using the CHU’s medical and administrative computer databases. It is also possible that there are more missing data in the records of the women born abroad than those born in France due to the language barrier and the more irregular care that could result in an under-identification of the
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variables and errors when entering data. However, it is exhaustive because we took into account all deliveries in 2008 and 2014, which rules out the risk of selection bias. Another limitation is the amount of time between the two years selected. In six years, it is possible that there may have been changes in practices, leading to potential
changes in the diagnosis and especially the management of certain pathologies. The
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low number of migrants (8.9% in 2008 and 12.8% in 2014) can lead to a lack of statistical power. Our results are difficult to extrapolate to the population of
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metropolitan France, making comparisons difficult. Our rates of migrants were well below the average rate in the 2016 National Perinatal Survey Report (18.6%), which,
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however, varied widely from maternity unit to maternity unit (4). Several studies describe the increase in the rate of cesarean section prior to and during labor among women born in SSA compared to those born in receiving
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countries (7, 8). In 2013, Merry et al.’s meta-analysis reported higher rates of cesarean section among women born in SSA compared to non-migrants (OR=2.19 (95% CI: 1.80–2.67)) (7). The same results are observed in the Saurel-Cubizolles et al. study in 2012 (8). Explanations for this increase remain limited. Among the risk factors cited are the language barrier, unfavorable socioeconomic status, poor
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maternal health, high BMI, fetopelvic disproportion, and inadequate prenatal care (7). No studies examining the determinants of cesarean sections in migrant women in particular have been conducted. In our study, we found an increase among women born in SSA compared to those born in France in the rate of cesarean section, whether an emergency cesarean section prior to labor or during labor. We can ask ourselves whether this increase is secondary to a higher BMI among migrant women, especially those born in SSA. A 2018 literature review found twice as many cesarean sections (OR = 2.01 (95% CI: 1.93-2.10)) in women with a BMI greater than 40 kg/m²
compared to those with a BMI between 18.5 and 24.9 kg/m² after adjusting for confounding factors (13). However, our figures showed a significant increase in BMI among women born in SSA compared to those born in France, both in 2008 and in 2014 (24.1 kg/m² versus 23.4 kg/m² and 25.8 kg/m² versus 24 kg/m², respectively). However, this significant increase in BMI does not reflect a clinical increase in morbid obesity. It is therefore difficult to attribute this change in the mode of delivery to this significant increase in BMI. Our secondary objective was to see whether the change in the migration profile between 2008 and 2014 influenced the mode of delivery and the perinatal
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data. Between 2008 and 2014, the proportion of migrant women increased from 9 to 12.8 %. The change in the social situation and pre-existing characteristics at the
time of pregnancy among migrant women could be explained by the establishment of a migrant camp in Calais with the increased migration flows between 2008 and 2014, mostly from Eritrea, Somalia and Syria. It could explain the increased number of
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women born in sub-Saharan Africa in our cohort. The change in the birth weights
between these two years could be the result of a significant increase in the number of
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cases of pregnancy-induced hypertension that can lead to intrauterine growth restriction delays. As for the change in the mode of delivery, it may be secondary to
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greater maternal insecurity secondary to unfavorable socioeconomic status resulting in poor maternal health, a high BMI and inadequate prenatal care (7, 14, 15). All of these factors can be made worse by the language barrier (7). Just like the Gonthier
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et al. study in 2017, the Heaman et al. meta-analysis in 2013 reported that migrant women were more likely to have inadequate prenatal care than non-migrant women. Associated factors were being under the age of 20, multiparity, not having a spouse, poor language skills, an unplanned pregnancy and a lack of health insurance (14, 15). In our study, it was not possible for us to find out the women’s prenatal care.
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In view of the differences between these women in the various countries of
birth, one must wonder about the mechanisms behind them and the possibility of greater maternal morbidity. Studies conducted in high-income countries indicate that migrant women are at greater risk of unfavorable pregnancy outcomes with an increase in SMM, primarily pregnancy-related hypertensive disease (OR 1.67 [95% CI 1.43 – 1.95] (16). Migrants from SSA seem to be at higher risk for severe preeclampsia and eclampsia (10, 11, 17-20) than North African women (8, 17, 21). Concurring results are obtained in Dutch (16) and French studies where there is an
increase in SMM among women born in SSA (adjusted OR: 1.8 [1.4-2.4]), mostly concerning hypertensive complications, sepsis and severe obstetric bleeding (22). In 2017, Sauvegrain et al. highlighted the existence of differentiated care that could have an impact in terms of SMM among women born in SSA (12). The mechanisms explaining the association between the maternal birth place and the mode of delivery are complex and remain unclear. Difficulties in its understanding is partly due to the great heterogeneity of the migrant women group, both in terms of socio-economic characteristics and of maternal/perinatal risk profile. For this reason, it is also difficult to study the large group named “other”. This group includes lots of
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women with different country of birth, different social situation and different history of migration. Beside geographical origin, administrative status could also be an
important determinant of medical risk. Even if the data remain limited, asylum
seekers and refugees are only administrative categories that have been studied. It has been shown that these groups have an increased risk of SMM and SPM (23).
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While asylum seekers and refugees benefit from a status that provides them with some social protection, another category of migrants without any permit for legal
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residence in the territory is growing in number in European countries (24). The socalled “undocumented migrants”, because of the many barriers faced to interact with
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health system, including individual and institutional discrimination, and the lack of social protection are likely to be at even increased risk (25-26). It could be of great interest to study the specific impact of the legal status of migrant, particularly of
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undocumented migrant.
Conclusion
This retrospective study revealed a significant increase in all types of Cesarean
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section among women born abroad compared to those born in France, particularly in the subgroup of women born in SSA. To date, the arguments are insufficient to explain the observed differences, namely whether this is secondary to pre-existing characteristics at the time of pregnancy, an increase in SMM, or a phenomenon of differentiated care. A second study is underway to compare this maternal morbidity between different countries of birth. Disclosure of Interests
The authors report no conflicts of interest Contribution to Authorship Eslier Maxime designed, analyzed, wrote and read over the article in collaboration with Dreyfus Michel. Azria Elie read over the article. Morello Rémy conducted the statistical analysis and actively helped develop and write this study.
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Funding There was no funding for this study. Acknowledgements
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We would like to thank the CHU’s Biostatistics and Clinical Research Unit for the
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statistical analysis.
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Table Caption List Table 1. Characteristics of women who gave birth in 2008 according to maternal birth place Europe Maternal birth place (N =)
France
excluding
(2766)
France (40)
Age (years)
29.1
29.3
North Africa (84) 30.7
SubSaharan
Other
Africa
(74)
(74) 28.1
28.9
and
2.1
0
intellectual
11.5
15
Intermediate professions
30.1
20
Employees
27.2
12.5
Manual, unemployed workers
29.1
52.5
SOCIO – ECONOMIC STATUS
entrepreneurs higher
Social welfare coverage (%)
4
8.3
8
12.2
16.7
6.8
9.5
72.6
83.8
74.3
78.4
90.4
<0.001
2.5
6
8
5.4
0.002
5.0
2.4
2.7
1.4
0.09
0
0
2.4
9.5
1.4
<0.001
0
5
0
1.4
1.4
<0.001
2.6
Additional CMU
1.3
lP
re
Universal health coverage (CMU)
Tobacco use during pregnancy (%)
26.6
12.5
4.8
2.7
9.5
<0.001
Body mass index
23.4
22.6
23.9
24.1
23.6
0.006
1.3
0
0
1.4
1.4
NS
0.3
2.5
1.2
2.7
0
0.013
Uterine Myomas (%)
0.7
0
0
4.1
2.7
0.02
Parity
0.9
0.6
1.2
1.4
0.9
0.008
Primiparous (%)
45.4
55
36.9
39.2
45.9
NS
Multiparity with scarred uterus (%)
9.3
2.5
15.5
12.2
17.6
0.02
Multiparity without scarred uterus (%)
45.3
42.5
47.6
48.6
36.5
NS
Postpartum hemorrhage (%)
5.1
2.5
2.4
4.1
2.7
NS
Gestational diabetes (%)
2.1
0
7.1
5.4
2.7
0.02
Hypertensive diseases (%)
2.3
2.5
0
2.7
1.4
NS
Gestational age at delivery
36.8
36.4
37.3
37.1
36.7
NS
High blood pressure (%)
ur na
Pre-existing diabetes (%)
Jo
HISTORY
MEDICAL OBSTETRICAL HISTORY DELIVERY
0
89.2
96.1
None
0
87.5
Standard health insurance
State medical assistance
1.4
2.4
-p
professions
0
ro of
tradespeople
Managers,
0.002 <0.001
Socioprofessional category (%) Artisans,
p
Fetal presentation (%) Cephalic Breech
NS 95.2
97.5
95.2
97.3
93.2
4
2.5
4.8
2.8
2.7
NEONATAL
Birth weight (grams)
3225
3192
3451
3315
3169
NS
7.8
5
4.8
9.5
6.8
NS
percentile (%)
11.7
20
20.2
14.9
9.5
0.05
5-minute Apgar score < 7 (%)
1.0
2.5
1.2
1.4
0
NS
Umbilical cord pH <7.10 (%)
0.4
2.5
0
1.4
0
NS
< 10th percentile (%) >
90th
Jo
ur na
lP
re
-p
ro of
NS, Not Significant
Table 2. Characteristics of women who gave birth in 2014 according to maternal birth place Europe Maternal birth place (N =)
France
excluding
(2616)
France (67)
Age (years)
29.4
30.5
North Africa (105) 30.9
SubSaharan
Other
Africa
(85)
(128) 29.6
29.5
0.002 <0.001
Socioprofessional category (%) Artisans,
p
tradespeople
and
2.4
3
2.9
0.8
7
intellectual
13
22.4
2.9
5.5
10.6
Intermediate professions
32.4
20.9
6.7
7
9.4
Employees
25.1
16.4
18
11.7
9.4
Manual, unemployed workers
27.1
37.3
69.5
75
63.6
Standard health insurance
87.2
77.6
64.6
41.4
68.2
<0.001
Universal health coverage (CMU)
1.1
3.0
4.8
2.3
1.2
0.005
Additional CMU
11.4
14.9
24.8
42.2
25.9
<0.001
0
1.5
2.9
14.1
4.7
<0.001
0.3
3
2.9
0
0
<0.001
24.0
16.4
2.9
3.1
8.2
<0.001
24.0
23.1
24.1
25.8
23.7
0.006
0.9
0
1
1.6
1.2
NS
0.8
0
1.9
1.6
1.2
NS
SOCIO – ECONOMIC STATUS
entrepreneurs Managers,
higher
-p
Social welfare coverage (%)
State medical assistance
Body mass index High blood pressure (%) Pre-existing diabetes (%)
0.4
1.5
0
5.5
0
<0.001
0.8
0.8
1.1
1.0
1.0
0.02
48.2
52.2
44.8
37.5
37.6
0.04
Multiparity with scarred uterus (%)
11.2
14.9
11.4
17.2
14.1
NS
Multiparity without scarred uterus (%)
40.7
32.8
43.8
45.3
48.2
NS
Postpartum hemorrhage (%)
4.7
7.5
3.8
2.3
0
NS
Gestational diabetes (%)
2.9
1.5
6.7
3.1
5.9
NS
Hypertensive diseases (%)
2.5
4.5
3.8
7
1.2
0.03
Gestational age at delivery
36.8
36.5
36.7
36.3
37.2
NS
Parity Primiparous (%)
ur na
OBSTETRICAL HISTORY
Uterine Myomas (%)
Fetal presentation (%)
Jo
DELIVERY
lP
HISTORY
MEDICAL
Tobacco use during pregnancy (%)
re
None
NS
Cephalic
95.3
94
94.3
93.8
98.8
Breech
4.1
4.5
3.9
5.4
0
Birth weight (grams)
NEONATAL
ro of
professions
3219
3191
3250
3143
3328
NS
< 10th percentile (%)
7.7
7.5
8.6
7.8
5.9
NS
> 90th percentile (%)
11.2
9.0
12.4
13.3
9.4
NS
5-minute Apgar score < 7 (%)
1.6
0
1.9
3.1
1.2
NS
Umbilical cord pH <7.10 (%)
0.5
0
0
3.1
0
NS
NS, Not Significant
Table 3. Comparison of the mode of delivery among women who gave birth in 2008 or 2014 according to maternal birth place Europe Maternal birth place
France
excluding France
SubSaharan
Other
Africa
2766
40
84
74
74
p
Induction of labor
12.7
10
16.7
21.6
10.8
NS
Emergency Cesarean section
9.3
7.5
14.3
13.5
18.9
0.03
78.1
82.5
69
64.9
70.3
0.01
Spontaneous vaginal delivery
62
52.5
53.6
54.1
48.6
0.03
Instrumental vaginal delivery
19.1
17.5
19
17.6
20.3
NS
Cesarean section prior to labor
9
7.5
13.1
13.5
18.9
0.03
Cesarean section during labor
9.9
22.5
14.3
14.9
12.2
0.04
N Induction of labor
2616 11.7
67 13.4
105 13.3
128 16.4
85 5.9
p NS
Emergency Cesarean section
10.6
10.4
Spontaneous labor
77.7
76.1
-p
Spontaneous vaginal delivery
65.3
Instrumental vaginal delivery
15.3
prior to labor Spontaneous labor
prior to labor
ro of
LABOR (%) DELIVERY (%)
Africa
13.3
21.9
10.6
0.007
73.3
61.7
83.5
0.001
re
LABOR (%) DELIVERY (%)
TYPE OF MODE OF
2014
N
53.7
66.7
50
69.4
0.002
25.4
11.4
7.8
15.3
0.02
lP
TYPE OF MODE OF
2008
North
Cesarean section prior to labor
10.7
10.4
12.4
21.9
10.6
0.009
Cesarean section during labor
8.7
10.4
9.5
20.3
4.7
0.001
Jo
ur na
NS, Not Significant
Table 4. Association between maternal birth place and mode of delivery among women who gave birth in 2008 or 2014 p
Adjusted OR *
IC 95%
0.1
1.1
1.0-1.4
Emergency Cesarean section prior to labor Year of delivery 2014 (Ref : 2008) Maternal birth place < 0.001
2.1
1.4-3.0
Europe excluding France
0.8
0.9
0.5-1.8
North Africa
0.1
1.4
0.9-2.2
Other
0.1
1.5
1.0-2.4
1.0
1.0
0.9-1.1
0.5
0.4-0.6
Spontaneous labor Year of delivery 2014 (Ref : 2008) Maternal birth place Sub-Saharan Africa (Ref : France)
0.9
North Africa
0.04
Other
0.9
1.0
0.7-1.7
0.7
0.5-0.98
1.0
0.7-1.4
-p
Europe excluding France
Cesarean section prior to labor
0.04
1.2
1.01-1.4
< 0.001
2.0
1.4-3.0
0.8
0.9
0.5-1.8
0.2
1.3
0.9-2.1
0.1
1.5
1.0-2.4
0.049
0.8
0.7-0.99
< 0.001
2.2
1.6-3.2
Europe excluding France
0.04
1,8
1.02-3.0
North Africa
0.3
1.3
0.8-2.0
Other
0.6
0.9
0.5-1.6
Year of delivery 2014 (Ref : 2008)
re
Maternal birth place Sub-Saharan Africa (Ref : France) Europe excluding France
Other
lP
North Africa
Cesarean section during labor
Year of delivery 2014 (Ref : 2008) Maternal birth place
ur na
MODE OF DELIVERY
< 0.001
ro of
TYPE OF LABOR
Sub-Saharan Africa (Ref : France)
Sub-Saharan Africa (Ref : France)
* adjusted for the year of delivery when comparing the maternal birth place and adjusting for the maternal birth
Jo
place when comparing the year of delivery