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

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Abstract

Background

In 2011 Norway granted undocumented women the right to antenatal care and to give birth at a hospital but did not include them in the general practitioner and reimbursement schemes. As a response to limited access to health care, Non-Governmental Organizations (NGO) have been running health clinics for undocumented migrants in Norway’s two largest cities. To further facilitate universal health coverage, there is a need to investigate how pregnant undocumented women use NGO clinics and how this affects their maternal health. We therefore investigated the care received, occurrence of pregnancy-related complications and pregnancy outcomes in women receiving antenatal care at these clinics.

Methods

In this historic cohort study we included pregnant women aged 18–49 attending urban NGO clinics from 2009 to 2020 and retrieved their medical records from referral hospitals. We compared women based on region of origin using log-binominal regression to estimate relative risk of adverse pregnancy outcomes.

Results

We identified 582 pregnancies in 500 women during the study period. About half (46.5%) the women sought antenatal care after gestational week 12, and 25.7% after week 22. The women had median 1 (IQR 1–3) antenatal visit at the NGO clinics, which referred 77.7% of the women to public health care. A total of 28.4% of women were referred for induced abortion. In 205 retrieved deliveries in medical records, there was a 45.9% risk for any adverse pregnancy outcome. The risk of stillbirth was 1.0%, preterm birth 10.3%, and emergency caesarean section 19.3%.

Conclusion

Pregnant undocumented women who use NGO clinics receive substandard antenatal care and have a high risk of adverse pregnancy outcomes despite low occurrence of comorbidities. To achieve universal health coverage, increased attention should be given to the structural vulnerabilities of undocumented women and to ensure that adequate antenatal care is accessible for them.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05112-0.

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Most cited references 57

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Epidemiology and causes of preterm birth

Robert L Goldenberg, Jennifer Culhane, Jay Iams … (2008)

Summary This paper is the first in a three-part series on preterm birth, which is the leading cause of perinatal morbidity and mortality in developed countries. Infants are born preterm at less than 37 weeks' gestational age after: (1) spontaneous labour with intact membranes, (2) preterm premature rupture of the membranes (PPROM), and (3) labour induction or caesarean delivery for maternal or fetal indications. The frequency of preterm births is about 12–13% in the USA and 5–9% in many other developed countries; however, the rate of preterm birth has increased in many locations, predominantly because of increasing indicated preterm births and preterm delivery of artificially conceived multiple pregnancies. Common reasons for indicated preterm births include pre-eclampsia or eclampsia, and intrauterine growth restriction. Births that follow spontaneous preterm labour and PPROM—together called spontaneous preterm births—are regarded as a syndrome resulting from multiple causes, including infection or inflammation, vascular disease, and uterine overdistension. Risk factors for spontaneous preterm births include a previous preterm birth, black race, periodontal disease, and low maternal body-mass index. A short cervical length and a raised cervical-vaginal fetal fibronectin concentration are the strongest predictors of spontaneous preterm birth.

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Robust causal inference using directed acyclic graphs: the R package ‘dagitty’

George Ellison, Maciej Liskiewicz, Johannes Textor … (2017)

Directed acyclic graphs (DAGs), which offer systematic representations of causal relationships, have become an established framework for the analysis of causal inference in epidemiology, often being used to determine covariate adjustment sets for minimizing confounding bias. DAGitty is a popular web application for drawing and analysing DAGs. Here we introduce the R package 'dagitty', which provides access to all of the capabilities of the DAGitty web application within the R platform for statistical computing, and also offers several new functions. We describe how the R package 'dagitty' can be used to: evaluate whether a DAG is consistent with the dataset it is intended to represent; enumerate 'statistically equivalent' but causally different DAGs; and identify exposure-outcome adjustment sets that are valid for causally different but statistically equivalent DAGs. This functionality enables epidemiologists to detect causal misspecifications in DAGs and make robust inferences that remain valid for a range of different DAGs. The R package 'dagitty' is available through the comprehensive R archive network (CRAN) at [https://cran.r-project.org/web/packages/dagitty/]. The source code is available on github at [https://github.com/jtextor/dagitty]. The web application 'DAGitty' is free software, licensed under the GNU general public licence (GPL) version 2 and is available at [http://dagitty.net/].

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Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Clinical Care.

Philippe Bourgois, Seth M Holmes, Kim Sue … (2017)

The authors propose reinvigorating and extending the traditional social history beyond its narrow range of risk behaviors to enable clinicians to address negative health outcomes imposed by social determinants of health. In this Perspective, they outline a novel, practical medical vulnerability assessment questionnaire that operationalizes for clinical practice the social science concept of "structural vulnerability." A structural vulnerability assessment tool designed to highlight the pathways through which specific local hierarchies and broader sets of power relationships exacerbate individual patients' health problems is presented to help clinicians identify patients likely to benefit from additional multidisciplinary health and social services. To illustrate how the tool could be implemented in time- and resource-limited settings (e.g., emergency department), the authors contrast two cases of structurally vulnerable patients with differing outcomes. Operationalizing structural vulnerability in clinical practice and introducing it in medical education can help health care practitioners think more clearly, critically, and practically about the ways social structures make people sick. Use of the assessment tool could promote "structural competency," a potential new medical education priority, to improve understanding of how social conditions and practical logistics undermine the capacities of patients to access health care, adhere to treatment, and modify lifestyles successfully. Adoption of a structural vulnerability framework in health care could also justify the mobilization of resources inside and outside clinical settings to improve a patient's immediate access to care and long-term health outcomes. Ultimately, the concept may orient health care providers toward policy leadership to reduce health disparities and foster health equity.

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Author and article information

Contributors

Frode Eick: frode.eick@medisin.uio.no

Journal

Journal ID (nlm-ta): BMC Pregnancy Childbirth

Journal ID (iso-abbrev): BMC Pregnancy Childbirth

Title: BMC Pregnancy and Childbirth

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2393

Publication date (Electronic): 24 October 2022

Publication date PMC-release: 24 October 2022

Publication date Collection: 2022

Volume: 22

Electronic Location Identifier: 789

Affiliations

[1 ]GRID grid.5510.1, ISNI 0000 0004 1936 8921, Department of Community Medicine and Global Health, , Institute of Health and Society, University of Oslo, ; Postboks 1130 Blindern, 0318 Oslo, Norway

[2 ]GRID grid.5510.1, ISNI 0000 0004 1936 8921, Department of General Practice, , Institute of Health and Society, University of Oslo, ; Oslo, Norway

[3 ]GRID grid.55325.34, ISNI 0000 0004 0389 8485, Department of Obstetrics, Division of Obstetrics and Gynaecology, , Oslo University Hospital, ; Oslo, Norway

[4 ]GRID grid.5510.1, ISNI 0000 0004 1936 8921, Faculty of Medicine, , University of Oslo, ; Oslo, Norway

[5 ]GRID grid.7914.b, ISNI 0000 0004 1936 7443, Faculty of Medicine, , University of Bergen, ; Bergen, Norway

[6 ]GRID grid.411279.8, ISNI 0000 0000 9637 455X, Division of Gynaecology and Obstetrics, , Akershus University Hospital, ; Oslo, Norway

[7 ]GRID grid.7914.b, ISNI 0000 0004 1936 7443, Department of Obstetrics and Gynaecology, Haukeland University Hospital, and Department of clinical medicine, , University of Bergen, ; Bergen, Norway

[8 ]GRID grid.463529.f, ISNI 0000 0004 0610 6148, Faculty of Health Studies, , VID specialized university, ; Oslo, Norway

Article

Publisher ID: 5112

DOI: 10.1186/s12884-022-05112-0

PMC ID: 9589618

PubMed ID: 36280826

SO-VID: 8cffc0fb-08a1-454e-a403-90057db32086

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 24 May 2022

Date accepted : 10 October 2022

Funding

Funded by: FundRef http://dx.doi.org/10.13039/100009471, EkstraStiftelsen Helse og Rehabilitering (Stiftelsen Dam);

Award ID: 2021/FO347363

Custom metadata

ScienceOpen disciplines: Obstetrics & Gynecology

Keywords: undocumented migrants,pregnancy,non-governmental organizations,antenatal care,structural vulnerability

Data availability:

ScienceOpen disciplines: Obstetrics & Gynecology

Keywords: undocumented migrants, pregnancy, non-governmental organizations, antenatal care, structural vulnerability

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

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Background

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Supplementary Information

Related collections

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Most cited references 57

Epidemiology and causes of preterm birth

Robust causal inference using directed acyclic graphs: the R package ‘dagitty’

Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Clinical Care.

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