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Maternal care and birth outcomes among ethnic minority women in Finland
– Reported, January 19, 2012
The study is based on data from the Finnish Medical Birth Register in 19992001 linked with the information of Statistics Finland on woman’s country of birth, citizenship and mother tongue. Our study data included 6,532 women of foreign origin (3.9% of all singletons) giving singleton birth in Finland during 19992001 (compared to 158,469 Finnish origin singletons).
Most women have migrated during the last fifteen years, mainly from Russia, Baltic countries, Somalia and East Europe. Migrant origin women participated substantially in prenatal care. Interventions performed or needed during pregnancy and childbirth varied between ethnic groups. Women of African and Somali origin had most health problems resulted in the highest perinatal mortality rates. Women from East Europe, the Middle East, North Africa and Somalia had a significant risk of low birth weight and small for gestational age newborns. Most premature newborns were found among women from the Middle East, North Africa and South Asia. Primiparous women from Africa, Somalia and Latin America and Caribbean had most caesarean sections while newborns of Latin American origin had more interventions after birth.
Despite good general coverage of maternal care among migrant origin women, there were clear variations in the type of treatment given to them or needed by them. African origin women had the most health problems during pregnancy and childbirth and the worst perinatal outcomes indicating the urgent need of targeted preventive and special care. These study results do not confirm either healthy migrant effect or epidemiological paradox according to which migrant origin women have considerable good birth outcomes.
The care given during pregnancy and labour is of great importance in every culture. After migration different cultures meet at childbirth, a very sensitive moment in life. Besides personal encounters, it is a situation in which parturients and their families from different parts of the world meet with western midwives, doctors and overall maternal health care with its institutional culture and practices. Because increasingly ethnically diverse migrant women resettle in industrialised countries, several social, psychological and biological factors need to be considered in caring for them during pregnancy and labour. From previous studies we know that non-western origin migrant women are more often multiparous, have more pregnancy-related risk factors, and have more infectious diseases which further may have adverse health effect to them and their newborns . One UK study reported non-white ethnicity to be one of predictors of severe obstetric morbidity .
In an ideal situation when studying the access to maternal health care and birth outcomes of ethnic minority women we have to know their health needs and health status during pregnancy, what factors may affect and have affected to their health, what kind of help seeking behaviour they have and how the service system functions for them. Help-seeking behaviour is affected at least by a person’s concepts of health and illness, health literacy, know how about the functioning of health system, economic possibilities to seek help, and past experiences of services and care . Utilisation or accessibility of care refers to the volume of service usage and service given, the site of utilisation and access and the type of services used and having access . Beside many individual/patient-related factors, access to care can be affected by a number of barriers related to ward level, supply and provision of care, such as a lack of necessary professionals and facilities, long distance to travel for the necessary care procedures , communication problems between the care giver and patient due to the missing language skills or improper attitudes, or when care givers’ referral practices differ depending on the social characteristics of the patients .
Recently, there has been an explosion of empirical evidence of ethnic disparities in medical care in regard to clinical appropriateness, to treatment site and to other clinical factors . These ethnic disparities in service delivery are not unique to medical care, since there are similar documentations in the fields of justice, child welfare , education, labour and housing . Structural, indirect and direct discrimination is recognised to cause partly these ethnic disparities in the amount and the content of public services as well as in the living conditions and opportunities. It has been indicated that when patients’ non-White ethnicity is combined with a lower social class position, the care providers’ prejudices and care giving is in increased risk of being discriminatory.
Ethnic disparities in maternity care and health outcomes seem to be persisting in those societies where ethnic minorities have existed for centuries. In the US, the perinatal outcomes (low birth weight, preterm birth and mortality) for African American newborns are still much worse than for White Americans . African Americans are also less likely to receive prenatal preventive care advice regarding smoking cessation, alcohol use and breastfeeding . Young Blacks and Hispanics have notably higher risks of adverse birth outcomes indicating less access to prenatal care of reasonable quality . In terms of the content of care it has been claimed that (White) doctors behave less affectively when interacting with ethnic minority patients compared to White non-migrants, and the ethnic minority patients have been stated to be less assertive during medical encounters .
In multicultural countries, e.g. Canada and the UK , migrant origin people use health care services less than they need, terminate their care earlier than is advantageous for the cure, and receive lower quality care than others. In a comparative European study , women who did not use maternal care as recommended were identified to be of foreign origin, teenagers, multiparous, single and with an unplanned pregnancy. Furthermore, they were more often less educated and without regular income. In the Netherlands , all non-Dutch ethnic groups were significantly later in starting antenatal care during their pregnancy compared with the ethnic Dutch group. Ethnic disparities in maternal health care have been found also in Sweden and Norway, in Italy and in Switzerland .
Migrants in Finland
Finland is situated on the eastern border of Europe next to Russia creating one of the highest gaps in the standard of living. For these reasons most of the migrants in Finland are from the neighbouring areas such as Russia and the Baltic countries due to work, marriage and as returnees (having Finnish ancestors). Finland became a multicultural society only after the collapse of the Soviet Union and after the remarkable increase in non-Western refugees during the past decades. Thus, there is a small but growing ethnic minority population (determined by the country of origin) in Finland which at the moment constitutes 4% of the whole population and due to their concentration to the south 9% of the population in the City of Helsinki . Migrant origin women form very heterogeneous population from those who migrate from EU-countries voluntarily to those women who come from outside western world having left their countries by force (e.g., war, persecution). Many of those latter are separated from their families, have limited language skills, and are many times visible minorities. Thus, the health needs of these ethnic minority women vary considerable.
In this study a person with migrant origin or being ethnic minority is a person who has permanent residency in Finland and whose mother language is other than Finnish or Swedish, and her country of birth is other than Finland. Thus, a migrant origin woman could have come to the country for example as a refugee, an asylum seeker, a worker, a student, through a resettlement program or family unification, or as a result of marriage. Most of those who has migrated to Finland are young people living their productive and reproductive years . Half of the migrants to Finland are female although there are some culture-specific gender differences in their numbers, for example most Russians, Thais and Filipinos are women married with Finnish men.
Maternal care in Finland
Finnish prenatal care is free-of-charge and practically all women use it, indicating that it has good acceptance among the users. Parturients start their prenatal visits on average in the tenth week of gestation, and they have some 14 visits to a special maternity clinic and three visits to a hospital outpatient clinic during pregnancy. Maternity outpatient clinics are part of health care centres which are decentralised into local communities where they are near to those in need of care. One in five women are hospitalised during pregnancy. Practically all women gave birth in public hospitals. The delivery hospital system is centralised on three levels (university, central and local hospitals), but a well-functioning referral system exists for women who are living in catchment areas of local and central delivery hospitals.
EU citizens or everyone with a permanent residency are entitled to (almost) free health and social services. In Finland we know that adults of ethnic minority groups (except refugees) use health care services less than people with Finnish origin. One exception is young migrant-origin women aged 1529 years, who use more health care services, primarily because of their higher pregnancy and fertility rates .
The aim of this study is to analyse the access to and use of maternity care services as well as birth outcomes by ethnic minority women in health care system which main constitutional principles are equality and equity. This kind of information is lacking in Finland, but it is needed in order to improve the maternal health care system to meet better the health needs of ethnic minority parturients. Equality and equity mean that every woman despite her social or cultural background has sufficient and good quality care prenatally, during birth and after it for securing maternal and child health.
The proportion of immigrant women’s births increased slightly from 1999 to 2001 (5.4% to 5.9% of all births; 3.8% to 4.0% of singleton births). The largest migrant origin group of parturients were Russians (27.1% of all singleton births of ethnic minority women), Somalis (12.5%) and East-Europeans (9.1%). Proportionally the smallest groups were Latin American and the Caribbean (1.9%) and Chinese (2.1%)
While one out of five Finnish parturients lived in the most densely populated capital city area, this share was one out of four among migrants. The share was the lowest among women from Iran, Iraq and Afghanistan and women from the Nordic countries (many of them living in the Swedish-speaking areas in the Southern and Western parts of the country). Eighty-three percent of migrants had moved to Finland in the 1990s, i.e. ten years or less before giving birth. This reflects the fact that migration is a relatively new phenomenon in Finland, and our data mainly consists of the first generation migrant women (only 1% of the parturients were second generation).
The mean maternal age among the primiparous was similar among parturients with immigrant and Finnish background (29.9 and 29.6 years, respectively). However, the differences between ethnic minority groups were significant. Mothers from the Nordic (26.8 years) and Baltic countries (28.5 years) were the youngest, while parturients from Southeast Asia and Western countries were the oldest, on average about 31 years old, and parturients from China more than 32 years old. The proportion of parturients aged 35 years or more varied between 7% among Nordic mothers and 29% among Chinese mothers. In general, the proportion of teenage mothers was lower among immigrants than Finns (2.5% vs. 3.0%) with the exception of mothers from Nordic countries (8.0%) and the mothers from the Middle East and North Africa (3.2%).
Study showed disparities in birth outcomes among migrant origin women compared to Finns.
Our most important and alarming result was the six-fold perinatal mortality rate of African origin singleton newborns and two-fold rate for Somali origin singleton newborns. Due to small number of cases, we were not able to analyse the causes-of-death in more detail . Increased perinatal death rates among ethnic minority groups are not unique in Finland since the similar infant mortality rates have also been reported elsewhere e.g. in the Netherlands ; in Sweden, in Norway , in the UK ; in Ireland and in Italy .
In our study the increased prenatal death rates could be associated to the increased risk of low birth weight (LBW) and risk for the small for gestational age (SGA) for Somali origin newborns (LBW 4.5%, P < 0.05; SGA 4.7%, P < 0.001), but not for African origin newborns. Also newborns of South Asian and of Middle East and North Africa origin had increased risks of prematurity and low birth weight which did not end to such fatal outcomes like among African and Somali mothers. Gestational age varies by ethnic background , but such information is unavailable for the Nordic countries, neither these have been used in clinical practice in Finland. Ethnic-specific perinatal health indicators should be developed and utilised both in clinical practise and in investigating the connection of these different perinatal outcomes in more detail.
Both African and Somali origin primiparous women had the highest caesarean section rates compared to any other group. During their pregnancy African origin parturients had hospital care due to vaginal bleeding or hypertension more often than others. After delivery newborns of African origin were given more antibiotics indicating more infectious diseases in the birth, and during pregnancy. During pregnancy Somali origin newborns were diagnosed to have more asphyxia and Somali origin parturients to have more than others insulin treatment for diabetes. After birth Somali origin newborns had more intubations showing an increased need for special treatment. According to our data multiparous African and Somali origin women had more visits to the hospital outpatient clinics during their pregnancies than any other ethnic group. This indicates that they should have got all needed care and treatment to avoid at least some part of these perinatal deaths. Many of these African but especially Somali origin parturients were multiparous (14% and 31% respectively) and thus they were expected to be familiar with the Finnish maternity care system, knowing its practices and functioning and therefore being able to find help when ever needed, as well as, to be familiar with their pregnancy and childbirth related experiences and health needs.
Single motherhood, infavourable maternal age, and lower socio-economic position are shown to be important risk factors of higher infant mortality . In our data, African and Somali origin mothers who experienced perinatal mortality were more often unmarried (18.4%) and older (mean 31.7 years) compared to those with surviving newborns in their groups (12.8% and 29.1 years). Our data was too small to study this in more detail, and it did not include variables related to socioeconomic position. In the Netherlands, ethnic infant mortality rate differs also according to generational status and age at immigration of the mother which is related to acculturation and selective migration. Unfortunately, in our data we are not able to study this issue, since we have only information on first generation migrants and we lacked information on woman’s age at migration.
Perinatal deaths among ethnic minority population are partly preventable by improving the efficacy of care given during pregnancy and child birth, since suboptimal care factors has been given as one possible explanation for the higher mortality rates . Studies in Norway , in the Netherlands , and in Sweden have reported the following care-related problems among migrants: late start of antenatal care, insufficient attendance in antenatal care, a delayed notification by the caregiver about obstetrical problems (e.g. rupturing of membranes, decrease in foetal movements), failure for care givers to act on non-reassuring foetal status or incorrect assessment of labour progression, unidentified or inadequate management of intrauterine growth restriction or decreased foetal movements, inadequate medication, misinterpretation of cardiotomography, and inadequate communication or interpersonal miscommunication with care providers. Also mother’s delay in seeking health care and her refusing caesarean sections have been given as a factors related to suboptimal care.
European comparative perinatal death audit study explicitly stated that non-western women constituted a risk group for sub-optimal care factors in infant deaths. This study concluded that suboptimal factors possibly contributed to the fatal outcome in 46% of cases. The most common suboptimal factors were care givers’ failure to detect severe intrauterine growth retardation (IUGR 10% of all cases) and smoking in combination with severe IUGR and/or placental abruption (12%). In Finland, however, the suboptimal care factors in perinatal deaths were found to be minor compared to other countries. Care providers’ cultural and medical competence when caring for non-western migrant mothers is at the stake. In the long run, ethnic health disparities in maternal, foetal and infant health may be preventable by reducing ethnic inequalities in socio-economic positions. It is also alarming according to one Dutch study that migrant origin women themselves are in a more than three-fold risk of death from maternity related conditions than their Dutch counterparts.
What can western care providers learn from migrant origin women’s maternal care experiences? In one Canadian study , Somali pregnant women felt that their needs were not always adequately met by care providers, with women reporting unhappiness with both clinical practice and the quality of maternal care they received. In the UK , Somali women reported that they were denied information in prenatal care due to punitive attitudes and prejudiced views among health professionals toward them. In the US , Somali women considered their childbirth experience positive in general, but they reported racial stereotyping, apprehension of caesarean births, and concern about the competence of medical interpreters as negative aspects of maternal care. Women wanted more information about events in the delivery room, pain medications, prenatal visits, interpreters, and roles of hospital staff. In another US study , Somali women were well informed on healthy prenatal practices and compliant in following them. They were generally pleased with the care that they received and accepted most of the diagnostic and therapeutic interventions, but they preferred practitioner who was informed about female circumcision and conservative in the decision to perform section deliveries because many of them are afraid of section . In our study African and Somali origin mothers having the worst birth outcomes- were the visible ethnic minority groups of which Somalis are said to be situated in the lowest level of Finnish ethnic hierarchy according to public opinion . Interview or ethnographic study is needed to investigate specifically migrant origin women’s discrimination experiences in maternity care.
The parturient’s concept about good maternal care is quite similar all over the world despite woman’s ethnicity, i.e. respectful, safe and understandable care. Ethnic minority women do have some special preconditions for a good care depending on her socioeconomic background, on education and on her migration history (reason for migration, from where she has migrated, with whom to which country, at what age and how long time ago). In the US Somali women recognised that a good healthcare practise is characterised by effective verbal and nonverbal communication, feeling valued and understood, availability of female interpreters and clinicians and sensitivity to privacy for gynaecologic concerns. Access to healthcare services and investment in community-based programs to improve women’s health literacy were stated to be the prerequisite to good health care system by Somali study subjects. In Australia Vietnamese, Turkish and Filipino women appreciated safe, kind, supportive, and respectful care. They expressed less satisfaction with care during labour and birth compared to Australian origin women and communication problems were named to be one reason for being unsatisfied with care. In the same vein, in Denmark , Turkish immigrant parturients said that communication problems were a risk to good quality care which often resulted in mutual misunderstandings between care provider and patient. The lack of continuity of the care was an additional strain for these women. The difficulties in communication are potentially dangerous, increasing the risk of delayed care or the risk of missing obstetrical care and intervention. In theory, migrant origin patients in Finland have legal right for official interpreter in medical encounters. There is no information about how much they are used and how well interpretation function for all those involved in medical encounter.
In our study the good news is that there was small variation in the use of and access to inpatient and outpatient prenatal care by woman’s ethnicity. One explanation for this is that pregnant woman is required to visit to maternity clinic the first time before 16 gestational weeks in order to get maternity benefits. But still, migrant origin women seem to accept maternity care well since they visited in the clinic almost as frequently as Finns. Thus, the lesser use of maternity care does not explain these ethnic differences in birth outcomes.
But the content of care during labour seem to vary according to mother’s ethnicity, since we know from previous studies elsewhere in Europe that there are considerable variations in care procedures given to and needed by migrant origin women during labour. Caesarean section rates are considerable higher for some ethnic minority groups . These findings are in accordance with our study, where the most caesarean sections were performed on primiparous women of African origin (41%), followed by women of Latin American and Caribbean origin (31%) and Somali origin (29%), while only 13% of Nordic and East European origin women had caesarean sections. Only mothers of Latin America had the risk of repeated caesarean section, reflecting the high section rates in their countries of origin. They also had slightly more often pre-eclampsia during their recent birth which may partly explain their higher numbers of sections. In vaginal births Latin American and Caribbean origin women received pain relief more often than others. Additionally their newborns got considerable more often different interventions after birth (intensive ward care, respiratory and intubations) compared to others. To study the cultural meanings of pain in childbirth, qualitative studies are needed to investigate these women’s birth and care experiences.
The reproductive health of ethnic minority women is at least three dimensional affected by the woman’s social position determined by her ethnicity, class position of her household and her gender both in her country of origin as well as in the new host country. All these categories are hierarchical (and in interaction with each other). Additionally, women of non-Western origin may be at risk of discrimination and deprivation based on gender, class and ethnicity in the Western countries. All these factors can potentially and adversely affect their health and utilization of services. Woman’s time of residence in new home country and the level of acculturation may modify the effects of these hierarchies to her health in general and during pregnancy in particular.
We used population-based nationwide register data to study parturients in various ethnic minority groups. This information about woman’s ethnicity must not be included in the routine register due to strict ban to register ethnic origin. Therefore, we had to link population register data from another organisation. This caused extra delays and costs for the study. In this register based study we did not have information directly from women’s health needs and their realisation during pregnancy, which will affect to the utilisation of care and to the access to care, but we were able to study how the diagnosed risks during pregnancy and birth outcomes are related to given and received care procedures and visits to maternity care among different groups of ethnic minority women.
Because there are serious differences in birth outcomes and in the care procedures given to and used by ethnic minority women during pregnancy and childbirth, maternity care practises should be re-examined carefully to see whether they systematically vary by mother’s ethnicity and by non clinical factors. Empowering of migrant background women and organizing supplement training for public health nurses, midwives and doctors are needed to build together maternity care that is culturally sensitive and respond better to the health needs of different pregnant women and their newborns. Furthermore, to enhance best possible and long lasting health and wellbeing of all mothers and their newborns, some migrant origin women groups are in need of particular type of help and support also after delivery because many of them have less advantageous social position in the West.
Credits: Maili Malin and Mika Gissler
National Institute for Health and Welfare, Mannerheimintie 166, 00300 Helsinki, Finland
More information at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2674879/
– WF Team