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Maternal Mortality Among Migrants in Western Europe: A Meta-Analysis

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Abstract

To examine whether an excess risk of maternal mortality exists among migrant women in Western Europe. We searched electronic databases for studies published 1970 through 2013 for all observational studies comparing maternal mortality between the host country and a defined migrant population. Results were derived from a random-effects meta-analysis, and statistical heterogeneity assessed by the I 2 statistic. In sub-analyses we also calculated summary estimates stratified by direct and indirect death causes. We included 13 studies with more than 42 million women and 4,995 maternal deaths. Compared with indigenous born women, the pooled risk estimate (RR) was 2.00 with 95 % confidence interval (CI) of 1.72, 2.33. Migrant women had a non-significantly higher risk of dying from direct than indirect death causes; pooled RRs of 2.65 CI 1.88, 3.74 and 1.83 CI 1.37, 2.45. This meta-analysis provides evidence that migrant women in Western European countries have an excess risk of maternal mortality.

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References

  1. Say, L., Pattinson, R. C., & Gulmezoglu, A. M. (2004). WHO systematic review of maternal morbidity and mortality: The prevalence of severe acute maternal morbidity (near miss). Reproductive Health, 1(1), 3.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Salanave, B., Bouvier-Colle, M. H., Varnoux, N., et al. (1999). Classification differences and maternal mortality: A European study. MOMS Group. MOthers’ Mortality and Severe morbidity. International Journal of Epidemiology, 28(1), 64–69.

    Article  CAS  PubMed  Google Scholar 

  3. Hogan, M. C., Foreman, K. J., Naghavi, M., et al. (2010). Maternal mortality for 181 countries, 1980–2008: A systematic analysis of progress towards Millennium Development Goal 5. Lancet, 375(9726), 1609–1623.

    Article  PubMed  Google Scholar 

  4. De Brouwere, V., Tonglet, R., & Van Lerberghe, W. (1998). Strategies for reducing maternal mortality in developing countries: What can we learn from the history of the industrialized West? Tropical Medicine & International Health, 3(10), 771–782.

    Article  Google Scholar 

  5. Tobias, M., & Jackson, G. (2001). Avoidable mortality in New Zealand, 1981–97. Australian and New Zealand Journal of Public Health, 25(1), 12–20.

    Article  CAS  PubMed  Google Scholar 

  6. Levine, R. S., Foster, J. E., Fullilove, R. E., et al. (2001). Black-white inequalities in mortality and life expectancy, 1933–1999: Implications for healthy people 2010. Public Health Reports, 116(5), 474–483.

    CAS  PubMed Central  PubMed  Google Scholar 

  7. Paxton, A., & Wardlaw, T. (2011). Are we making progress in maternal mortality? New England Journal of Medicine, 364(21), 1990–1993.

    Article  CAS  PubMed  Google Scholar 

  8. Lewis, G. (2012). Saving Mothers’ Lives: The continuing benefits for maternal health from the United Kingdom (UK) confidential enquires into maternal deaths. Seminars in Perinatology, 36(1), 19–26.

    Article  PubMed  Google Scholar 

  9. Stroup, D. F., Berlin, J. A., Morton, S. C., et al. (2000). Meta-analysis of observational studies in epidemiology: A proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group. JAMA, 283(15), 2008–2012.

    Article  CAS  PubMed  Google Scholar 

  10. Nations U. (2013). In geographical region and composition. United Nations Statistics Division. http://unstats.un.org/unsd/methods/m49/m49regin.htm Accessed 9-10-2013.

  11. WHO U, UNFPA, & The World Bank. (2007). Maternal mortality in 2005. WHO Library Cataloguing-in-Publication Data.

  12. Philibert, M., Deneux-Tharaux, C., & Bouvier-Colle, M. H. (2008). Can excess maternal mortality among women of foreign nationality be explained by suboptimal obstetric care? BJOG, 115(11), 1411–1418.

    Article  CAS  PubMed  Google Scholar 

  13. WHO. (1993). International statistical classification of diseases, and related health problems, 10th revision (ICD-10). Geneva: World Health Organization.

  14. Lewis, G., & Drife, J. (2001). Why mothers die 1997–1999: The confidential enquiries into maternal deaths in the United Kingdom. London.

  15. Lewis, G., & Drife, J. (2004). Why mothers die 2000–2002, the sixth report of the confidential enquiries into maternal deaths in the United Kingdom. London.

  16. Lewis, G. (2007). The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer-2003–2005. In The seventh report on confidential enquiries into maternal deaths in the United Kingdom. London.

  17. Saucedo, M., Deneux-Tharaux, C., & Bouvier-Colle, M. H. (2012). Understanding regional differences in maternal mortality: A national case-control study in France. BJOG: An International Journal of Obstetrics and Gynaecology, 119(5), 573–581.

    Article  CAS  Google Scholar 

  18. Cantwell, R., Clutton-Brock, T., Cooper, G., et al. (2011). Saving mothers’ lives: Reviewing maternal deaths to make motherhood safer: 2006–2008. The eighth report of the confidential enquiries into maternal deaths in the United Kingdom. BJOG, 118(Suppl 1), 1–203.

    PubMed  Google Scholar 

  19. Higgins, J. P., & Thompson, S. G. (2002). Quantifying heterogeneity in a meta-analysis. Statistics in Medicine, 21(11), 1539–1558.

    Article  PubMed  Google Scholar 

  20. Chiolero, A., Santschi, V., Burnand, B., et al. (2012). Meta-analyses: With confidence or prediction intervals? European Journal of Epidemiology, 27(10), 823–825.

    Article  PubMed  Google Scholar 

  21. Egger, M., Davey Smith, G., Schneider, M., et al. (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315(7109), 629–634.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  22. Bollini, P., Wanner, P., & Pampallona, S. (2011). Trends in maternal mortality in Switzerland among Swiss and foreign nationals, 1969–2006. International Journal of Public Health, 56(5), 515–521.

    Article  PubMed  Google Scholar 

  23. Welsch, H., Krone, H. A., & Wisser, J. (2004). Maternal mortality in Bavaria between 1983 and 2000. American Journal of Obstetrics and Gynecology, 191(1), 304–308.

    Article  PubMed  Google Scholar 

  24. Murad, M. H., Montori, V. M., Walter, S. D., et al. (2009). Estimating risk difference from relative association measures in meta-analysis can infrequently pose interpretational challenges. Journal of Clinical Epidemiology, 62(8), 865–867.

    Article  PubMed  Google Scholar 

  25. Schutte, J. M., Steegers, E. A., Schuitemaker, N. W., et al. (2010). Rise in maternal mortality in the Netherlands. BJOG, 117(4), 399–406.

    Article  CAS  PubMed  Google Scholar 

  26. Luque Fernandez, M. A., Bueno Cavanillas, A., & de Mateo, S. (2010). Excess of maternal mortality in foreign nationalities in Spain, 1999–2006. European Journal of Obstetrics & Gynecology and Reproductive Biology, 149(1), 52–56.

    Article  Google Scholar 

  27. Fassler, M. Z. R., & Quack Lotscher, K. C. (2010). Maternal mortality in Switzerland 1995–2004. Swiss Medical Weekly, 140(1–2), 25–30.

    PubMed  Google Scholar 

  28. Deneux-Tharaux, C. P. M., & Bouvier-Colle, M.-H. (2009). Excess maternal mortality among foreign women in France and quality of obstetric care: A national study 1996–2001. Bulletin épidémiologique hebdomadaire, 9(3), 77–80.

    Google Scholar 

  29. Stirbu, I., Kunst, A. E., Bos, V., et al. (2006). Differences in avoidable mortality between migrants and the native Dutch in The Netherlands. BMC Public Health, 6, 78.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  30. Marmot, M. G., Adelstein, A. M., & Bulusu, L. (1984). Immigrant mortality in England and Wales 1970–1978. London: Her Majesty's Stationery Office (HMSO).

  31. van Roosmalen, J., Schuitemaker, N. W., Brand, R., et al. (2002). Substandard care in immigrant versus indigenous maternal deaths in The Netherlands. BJOG, 109(2), 212–213.

    Article  PubMed  Google Scholar 

  32. Zwart, J. J., Richters, J. M., Ory, F., et al. (2008). Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: A nationwide population-based study of 371,000 pregnancies. BJOG, 115(7), 842–850.

    Article  CAS  PubMed  Google Scholar 

  33. Lewis, G., & Drife, J. (1998). Why mothers die 1994–1996: Report on confidential enquiries into maternal deaths in the United Kingdom. London.

  34. Ibison, J. M., Swerdlow, A. J., Head, J. A., et al. (1996). Maternal mortality in England and Wales 1970–1985: An analysis by country of birth. British Journal of Obstetrics and Gynaecology, 103(10), 973–980.

    Article  CAS  PubMed  Google Scholar 

  35. Luque Fernandez, M. A., Bueno Cavanillas, A., & de Mateo, S. (2010). Excess of maternal mortality in foreign nationalities in Spain, 1999–2006. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 149(1), 52–56.

    Article  PubMed  Google Scholar 

  36. Razum, O., Jahn, A., Blettner, M., et al. (1999). Trends in maternal mortality ratio among women of German and non-German nationality in West Germany, 1980–1996. International Journal of Epidemiology, 28(5), 919–924.

    Article  CAS  PubMed  Google Scholar 

  37. Schuitemaker, N., van Roosmalen, J., Dekker, G., et al. (1998). Confidential enquiry into maternal deaths in The Netherlands 1983–1992. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 79(1), 57–62.

    Article  CAS  PubMed  Google Scholar 

  38. de Graaf, J. P., Schutte, J. M., Poeran, J. J., et al. (2012). Regional differences in Dutch maternal mortality. BJOG, 119(5), 582–588.

    Article  PubMed  Google Scholar 

  39. Deneux-Tharaux, C., Berg, C., Bouvier-Colle, M. H., et al. (2005). Underreporting of pregnancy-related mortality in the United States and Europe. Obstetrics and Gynecology, 106(4), 684–692.

    Article  PubMed  Google Scholar 

  40. Ronsmans, C., & Graham, W. J. (2006). Maternal mortality: Who, when, where, and why. Lancet, 368(9542), 1189–1200.

    Article  PubMed  Google Scholar 

  41. Hjern, A., Haglund, B., Persson, G., et al. (2001). Is there equity in access to health services for ethnic minorities in Sweden? European Journal of Public Health, 11(2), 147–152.

    Article  CAS  PubMed  Google Scholar 

  42. Atri, J., Falshaw, M., Linvingstone, A., et al. (1996). Fair shares in health care? Ethnic and socioeconomic influences on recording of preventive care in selected inner London general practices. Healthy Eastenders Project. BMJ, 312(7031), 614–617.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  43. Essen, B., Hanson, B. S., Ostergren, P. O., et al. (2000). Increased perinatal mortality among sub-Saharan immigrants in a city-population in Sweden. Acta Obstetricia et Gynecologica Scandinavica, 79(9), 737–743.

    Article  CAS  PubMed  Google Scholar 

  44. Almeida, L. M., Caldas, J., Ayres-de-Campos, D., et al. (2013). Maternal healthcare in migrants: A systematic review. Maternal and Child Health Journal, 17(8), 1346–1354.

    Article  PubMed  Google Scholar 

  45. Saastad, E., Vangen, S., & Froen, J. F. (2007). Suboptimal care in stillbirths—a retrospective audit study. Acta Obstetricia et Gynecologica Scandinavica, 86(4), 444–450. doi:10.1080/00016340701207724778247970.

    Article  PubMed  Google Scholar 

  46. Bouvier-Colle, M. H., Varnoux, N., Salanave, B., et al. (1997). Case-control study of risk factors for obstetric patients’ admission to intensive care units. European Journal of Obstetrics & Gynecology and Reproductive Biology, 74(2), 173–177.

    Article  CAS  Google Scholar 

  47. Filippi, V., Ronsmans, C., Campbell, O. M., et al. (2006). Maternal health in poor countries: The broader context and a call for action. Lancet, 368(9546), 1535–1541.

    Article  PubMed  Google Scholar 

  48. Esscher, A., Haglund, B., Hogberg, U., et al. (2012). Excess mortality in women of reproductive age from low-income countries: A Swedish national register study. European Journal of Public Health, 23(2), 274–279.

    Article  PubMed Central  PubMed  Google Scholar 

  49. Bragg, R. (2008). Maternal deaths and vulnerable migrants. Lancet, 371(9616), 879–881.

    Article  PubMed  Google Scholar 

  50. Essen, B., Johnsdotter, S., Hovelius, B., et al. (2000). Qualitative study of pregnancy and childbirth experiences in Somalian women resident in Sweden. BJOG, 107(12), 1507–1512.

    Article  CAS  PubMed  Google Scholar 

  51. Alderliesten, M. E., Vrijkotte, T. G., van der Wal, M. F., et al. (2007). Late start of antenatal care among ethnic minorities in a large cohort of pregnant women. BJOG, 114(10), 1232–1239.

    Article  CAS  PubMed  Google Scholar 

  52. Higgins, J. P., Thompson, S. G., & Spiegelhalter, D. J. (2009). A re-evaluation of random-effects meta-analysis. Journal of the Royal Statistical Society Series A, 172(1), 137–159.

    Article  Google Scholar 

  53. Small, R., Gagnon, A., Gissler, M., et al. (2008). Somali women and their pregnancy outcomes postmigration: Data from six receiving countries. BJOG: An International Journal of Obstetrics and Gynaecology., 115(13), 1630–1640.

    Article  CAS  Google Scholar 

  54. Bollini, P., Pampallona, S., Wanner, P., et al. (2009). Pregnancy outcome of migrant women and integration policy: A systematic review of the international literature. Social Science and Medicine, 68(3), 452–461.

    Article  PubMed  Google Scholar 

  55. Hoyert, D. L. (2007). Maternal mortality and related concepts. Vital & Health Statistics 3, 33, 1–13.

    Google Scholar 

  56. Delvaux, T., Buekens, P., Godin, I., et al. (2001). Barriers to prenatal care in Europe. American Journal of Preventive Medicine, 21(1), 52–59.

    Article  CAS  PubMed  Google Scholar 

  57. Elebro, K., Roost, M., Moussa, K., et al. (2007). Misclassified maternal deaths among East African immigrants in Sweden. Reproductive Health Matters, 15(30), 153–162.

    Article  PubMed  Google Scholar 

  58. Tuncalp, O., Hindin, M. J., Souza, J. P., et al. (2012). The prevalence of maternal near miss: A systematic review. BJOG: An International Journal of Obstetrics and Gynaecology, 119(6), 653–661.

    Article  CAS  Google Scholar 

  59. Jonkers, M., Richters, A., Zwart, J., et al. (2011). Severe maternal morbidity among immigrant women in the Netherlands: Patients’ perspectives. Reproductive Health Matters, 19(37), 144–153.

    Article  PubMed  Google Scholar 

  60. Urquia, M. L., Ying, I., Glazier, R. H., et al. (2012). Serious preeclampsia among different immigrant groups. Journal of Obstetrics and Gynaecology Canada, 34(4), 348–352.

    PubMed  Google Scholar 

  61. Small, M. J., James, A. H., Kershaw, T., et al. (2012). Near-miss maternal mortality: Cardiac dysfunction as the principal cause of obstetric intensive care unit admissions. Obstetrics and Gynecology, 119(2 Pt 1), 250–255.

    Article  PubMed  Google Scholar 

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Acknowledgments

This work was funded by The Health Insurance Foundation (Grant No. 2009B071) and The Oticon Foundation.

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Authors and Affiliations

  1. Department of Epidemiology & Biostatistics, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9, 5000, Odense C, Denmark

    Grete Skøtt Pedersen

  2. Centre of Research in Childhood Health, Institute of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark

    Anders Grøntved

  3. Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark

    Laust Hvas Mortensen & Anne-Marie Nybo Andersen

  4. Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA

    Grete Skøtt Pedersen & Janet Rich-Edwards

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10995_2013_1403_MOESM2_ESM.pptx

Figure 6. Relative Risk of maternal mortality comparing migrant to non-migrant women in the first time period from 1969-1995. The summary estimates were obtained using a random-effects model. The data markers the relative risks (RRs) with 95 % confidence intervals. The size of the data markers indicates the weight of the study. The diamond data marker indicates the pooled RRs. The prediction interval is shown with lines extending from the diamond. (PPTX 68 kb)

10995_2013_1403_MOESM3_ESM.pptx

Figure 7. Relative Risk of maternal mortality comparing migrant to non-migrant women in the second time period from 1996-2008. The summary estimates were obtained using a random-effects model. The data markers the relative risks (RRs) with 95 % confidence intervals. The size of the data markers indicates the weight of the study. The diamond data marker indicates the pooled RRs. The prediction interval is shown with lines extending from the diamond. (PPTX 69 kb)

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Pedersen, G.S., Grøntved, A., Mortensen, L.H. et al. Maternal Mortality Among Migrants in Western Europe: A Meta-Analysis. Matern Child Health J 18, 1628–1638 (2014). https://doi.org/10.1007/s10995-013-1403-x

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