Physiological or pathological pregnancies are among the main reasons for seeking medical care in migrant women recently arrived in the host countries, thus significantly engaging the host national health systems. Moreover, their outcomes appear to be largely influenced by the public health policies adopted [20]. For this reason, detailed information on the topic appears to be crucial for optimal management of pregnancies in the migrant population. Our data are in line with the percentage of migrants arriving in Italy, [1], in the terms of the women’s origins: Nigeria (61; 55.5%) vs Eritrea (31; 28.2%).
This is the first study from Italy’s reception Centers quantifying differences in pregnancy outcomes between newly arrived migrant women of different origin. Among ethnic groups, data showed that Nigerian women were at a significantly higher risk for abortive outcomes: VPT, miscarriage and self-induced abortion. The aetiological factors for this observation are complex. International Organization for Migration (IOM) estimates that about 80% of Nigerian women who arrived by sea in 2016 were likely to be victims of trafficking for sexual exploitation in Italy or in other countries of the European Union. In addition, an increased number of sexual violence cases by persons outside the trafficking network were reported in Libya involving women and minors. It is undeniably true that these conditions expose them to a high rate of unwanted pregnancies [22]. Usually, women continue to follow the same preventive and reproductive patterns as found in their countries of origin. Likewise, many of the migrant women who wished to terminate an unintended pregnancy may have a direct or an indirect experience of previous self-induced abortion in their own countries [23]. According to The Society of Gynaecologists and Obstetricians of Nigeria 610,000 unsafe abortions a year are carried out in Nigeria, and the death rate is thought to be one of the highest in Africa [24].
Furthermore, the group of women undergoing self-induced abortion or VPT were mostly unmarried. This data could suggest that unmarried women could represent a particularly socially fragile population among migrants, who could be also reluctant to report a self-induced abortion (misclassified as spontaneous). On the contrary, migrant women who were married or with already at least one child, had higher delivery rates. There are some possible explanations. A steady family background may represent a relevant protective factor in Eritrean women who were more likely to carry the pregnancy to the term. In some countries, having children is the ultimate goal of marriage and symbolizes femininity [25]. Collaterally, it should be noted that given particular personal situations i.e. pregnant women, single parents with minor children as in other vulnerable conditions, an access to a range of benefits in reception procedure could be facilitated.
It is well known that the level of literacy among migrant populations is directly or indirectly related to health outcomes. Low levels of health literacy can influence access to reproductive health services even when information is presented to women in their language of origin [26]. In contrast to the statement above, the study of Ajayi et al. reveals that middle-class young women, specifically university students, were prone to unplanned pregnancy, use of unsafe emergency contraception methods and unsafe abortion [27]. It is also recognized that sexual behaviour is affected by the prevailing social rules of the country of origin, and these rules act ambivalently. Moreover, religion continues to have a strong influence on sexual beliefs and customs [25]. In our population the women who chose to undergo unsafe abortion did not result to have significantly lower educational levels, compared to women who preferred VPT. Different traditional and cultural concepts of pregnancy may explain the different approach to abortion independently of educational level.
The unmarried Nigerian women and unaccompanied girls, are among the most at risk of being victims of traffic for sexual exploitation, although it cannot be excluded that migrants from other nationalities are also affected by trafficking. These circumstance expose them to unintended pregnancies during their stay in reception facilities (or just before, along the way or in Libyan detention centers, when they often are subject to sexual violence) and thus more likely to terminate (legally or not) the pregnancy [22, 28]. Interestingly, the practice of self-practicing abortion is clearly more prevalent among the Nigerian population and is not the result of the education level.
In this report we have not explored women’s motivation in preferring self-induced abortion instead of VPT. Different cultural beliefs and obstacles to accessing VPT (beta -HCG confirmation, ultrasound to determine gestational age and paranaesthesia visit) could be the real cause rather than the lack of knowledge about Italian abortion laws (legge 104/1978).
Nigeria contributes 14% of the total maternal deaths in the world [29], 21.3% of which are attributed to septic abortion [30]. The practice of self-induced abortion is very frequent probably due to restrictive abortion law in terms of medical abortion [31], low level of awareness and knowledge of contraception and underutilisation of the emergency one [27, 32], due to moral-religious stigma involved in the purchase of contraceptives and condoms. In addition the belief that certain substances such as “concoction” (a mixture of substances with unproven efficacy, such as salt and hot water, soft drinks, a local brand of analgesic known as Alabukun, lime and potash, and lime and Alabukun) can be effective as a contraceptive, leads Nigerian women to have a low control of their fertility and therefore often opting for voluntary termination of pregnancy [27].
In Italy, the most common method among Nigerian women for self-induced abortion is the oral intake or vaginal self-application of prostaglandins used for the treatment of gastric pyrosis [14, 33] purchased on the black market online or through traffickers. The idea that self-induced abortion could be easier, faster and non-invasive with less impact on daily routine (absence from the street for the days required for intervention and convalescence, not allowed by the trafficking network) [22] may represent one of the causes of the high percentage of self-induced abortions in some settings of asylum seekers in Italy.
Our study demonstrates the need to take action in order to support migrant women’s reproductive health especially in family planning and abortion services. In ASC and ERCs the Medical service is available 24 h, seven days a week, but we acknowledge that access to information, prevention and treatment services must be improved. Health care professionals need more information on how to better take into account migrant women’s special needs such as information on family planning and reliable contraceptive methods, considering different religious and cultural customs of arriving migrants. Moreover, enhancement of psychosocial services could be the way forward to improve outcomes in reproductive health.
Our study has some important limitations that need to be considered in interpreting the results. The major limitation of this study is the small size of the population, which may be responsible for low statistical power thereby weakening our conclusions. Unfortunately, we were unable to follow-up all pregnancy outcomes, as 50.5% of pregnant women dropped-out from the study because they moved before the pregnancy outcome was known. The asylum-seeker population is subjected to frequent relocation and even tracking via personal mobile phone has proved unsuccessful, as the mobile number is often changed. The data we obtained represented only a very small percentage of the pregnant women who were lost to follow up, therefore they were not taken into account. Migrants transferred abroad according to European relocation system were not longer traceable. Nevertheless, the baseline characteristic of pregnant women lost to follow up did not differ from the study group. The authors cannot exclude information bias on self-induced/spontaneous abortions due to self-reporting. Hence, the rate of self-induced may have been under-reported among the participants. Although the study was conducted in five large reception centers in Italy, its conclusions may not be directly extensible to all asylum seekers present in Italy and Europe, being potentially influenced not only by the reception modalities and the health facilities available, but also and above all by the anthropological and cultural specificities of the people hosted.
To the best of our knowledge, this is one of the few population-based studies on pregnancy outcomes in newly arrived migrants in Europe. The findings may not be directly generalized to other settings but provide precious information about the particularly socially fragile population among migrants.