Sarah Fredsted Villadsen

Ethnic disparity in stillbirth and infant mortality in Denmark 1981–2003

Objective: Ethnic minorities constitute a growing part of the Danish population but little is known about ethnic disparity in early life mortality in this population. The aim of this study was to investigate ethnic disparities in stillbirth risk and infant mortality in Denmark from 1981 to 2003. Methods: From population-covering registries, all live and stillbirths of women from the five largest ethnic minority groups and of women from the (Danish) majority population (N = 1 333 452) were identified. The liveborn were followed up for vital status to the age of 1 year. Log-binomial regression was used to estimate relative risks according to ethnic group. The main outcome measure was stillbirth and infant death. Results: Compared with the majority population, the relative risks of stillbirth were 1.28 (95% CI: 1.07 to 1.53) for Turkish, 1.62 (1.25 to 2.09) for Pakistani and 2.11 (1.60 to 2.77) for Somali women. The relative risks of infant mortality were 1.41 (1.22 to 1.63), 1.88 (1.53 to 2.30) and 1.39 (1.03 to 1.89) for children born to Turkish, Pakistani and Somali mothers respectively. The fetal and infant mortality in offspring of Lebanese and Former Yugoslavian women was not different from the mortality in the Danish group. The differences found were, in general, not attributable to ethnic differences in socioeconomic position. Turkish, Pakistani and Somali children had an excess relative risk of infant death due to congenital malformations and the risk of death from perinatal causes was increased among the Pakistani offspring. Conclusion: Among the five largest ethnic minorities, the Turkish. Pakistani and Somali population had substantially higher fetal and infant mortality compared with the Danish majority population, while the Lebanese and Former Yugoslavian minorities were at the same level as the majority population. The excess risk was not attributable to socioeconomic conditions.

Cross-country variation in stillbirth and neonatal mortality in offspring of Turkish migrants in northern Europe

BACKGROUND Diverse early-life mortality outcomes have been documented in immigrant populations in northern Europe. A recent meta-analysis has suggested that national integration policy is a key factor in understanding this heterogeneous pattern. In this study, we investigated the variation of stillbirth and neonatal mortality between societies in northern Europe in one minority population, the Turkish. METHOD Data on stillbirth and neonatal deaths in 239 387 births during 1990-2005, where the mother was of Turkish origin, was drawn from birth registries or surveys in nine northern European countries. Rates were compared with births from mothers who were born in the society of residence. Logistic regression was used to calculate odds ratios adjusted for year of birth of the offspring. RESULTS The risks for stillbirth were, or tended to be, elevated for Turkish mothers in all countries compared with the native population, with the highest risk in Austria (odds ratio (OR) 1.7; 95% confidence interval (CI) 1.4-2.1) and Switzerland (OR 1.6; 1.4-1.9). For neonatal mortality the results were heterogeneous, indicating no excess risk for Turkish-born children in the Netherlands, the UK and Norway, and elevated risks in Denmark (OR 1.3; 1.0-1.6), Switzerland (OR 1.3; 1.1-1.5), Austria (OR 1.4; 1.0-1.8) and Germany (OR 1.3; CI 1.2-1.5). CONCLUSION This study suggests that preventable society-specific determinants are important for early-life mortality in Turkish migrants in Europe. An active integration policy is consistent with a favourable neonatal mortality outcome in continental Europe, but not with patterns in Scandinavia and the UK.

Antenatal Care Strengthening in Jimma, Ethiopia: A Mixed-Method Needs Assessment

Objective. We assessed how health system priorities matched user expectations and what the needs for antenatal care (ANC) strengthening were for improved maternal health in Jimma, Ethiopia. Methods. A questionnaire survey among all recent mothers in the study area was conducted to study the content of ANC and to identify the predictors of low ANC satisfaction. Further, a qualitative approach was applied to understand perceptions, practices, and policies of ANC. Results. There were no national guidelines for ANC in Ethiopia. Within the health system, the teaching of health professional students was given high priority, and that contributed to a lack of continuity and privacy. To the women, poor user-provider interaction was a serious concern hindering the trust in the health care providers. Further, the care provision was compromised by the inadequate laboratory facilities, unstructured health education, and lack of training of health professionals. Conclusions. Health system trials are needed to study the feasibility of ANC strengthening in the study area. Nationally and internationally, the leadership needs to be strengthened with supportive supervision geared towards building trust and mutual respect to protect maternal and infant health.

Morbidity, Self-Perceived Health and Mortality Among non-Western Immigrants and Their Descendants in Denmark in a Life Phase Perspective

To enable preventive policies to address health inequity across ethnic groups, this review overviews the current knowledge on morbidity, self-perceived health and mortality among non-Western immigrants and their descendants in Denmark. A systematic search in PUBMED, SCOPUS, Embase and Cochrane as well as in national databases was undertaken. The final number of publications included was 45. Adult immigrants had higher morbidity, but lower mortality compared to ethnic Danes. Immigrant children had higher mortality and morbidity compared to ethnic Danes. Immigrants’ health is critical to reach the political goals of integration. Despite non-Western immigrants’ higher morbidity than ethnic Danes, no national strategy targeting immigrants’ health has been implemented. Future research should include elderly immigrants and children, preferably employing a life-course perspective to enhance understanding of parallel processes of societal adaptation and health.

Stillbirth and congenital anomalies in migrants in Europe

The risk of giving birth to a stillborn child or a child with severe congenital anomaly is higher for women who have immigrated to Europe as compared to the majority population in the receiving country. The literature, however, reveals great differences between migrant groups, even within migrants from low-income countries, although there is no clear pattern regarding refugee or non-refugee status. This heterogeneity argues against a particular migration-related explanation. There are social disparities in stillbirth risk worldwide, and it has been suggested that the demonstrated ethnic disparity is a result of the socioeconomic disadvantage most migrants face. Consanguinity has been considered as another cause for the increased stillbirth risk and the high risk of congenital anomaly observed in many migrant groups. Utilization and quality of care during pregnancy and childbirth is the third major aspect. All three factors seem to contribute to stillbirth risk, and they should be considered in clinical practice and public health.

A Register‐Based Study of Diseases With an Autosomal Recessive Origin in Small Children in Denmark According to Maternal Country of Origin

BACKGROUND Compared with children born of Danish mothers, the mortality of children, born and living in Denmark, is significantly increased in those with a mother from Afghanistan, Iraq, Pakistan, Somalia, and Turkey. Consanguinity has been suggested to account for part of this disparity. Since information on consanguinity is lacking, this suggestion is difficult to test. With an indirect approach, we addressed this question by comparing the risk of diseases with autosomal recessive inheritance in children born in Denmark of Danish-born women and of women born in these five countries, respectively. METHODS All children born in Denmark (1994-2010) were followed until 5 years of age or end-of-study period for the risk of hospitalisation with diseases of autosomal recessive aetiology, and therefore considered consanguinity-related. Diagnoses of autosomal recessive diseases were identified using two different methods: a literature review of consanguinity-associated diseases and a search in the Online Catalogue of Human Genes and Genetic Disorders. Risks were also calculated for diseases with known non-autosomal recessive aetiology (considered non-consanguinity-related). We estimated adjusted hazard ratios for the diseases in children of foreign-born women compared with children of Danish-born women. RESULTS Compared with offspring of Danish-born women, the risk of a consanguinity-related disease was significantly increased in children of foreign-born women, although the absolute risk was low. The risk of non-consanguinity-related diseases did not differ between the groups compared. CONCLUSIONS The findings support the hypothesis that consanguinity accounts for some, however a minor part, of the disparity in child mortality among migrants in Denmark.

Recruitment of ethnic minorities for public health research: An interpretive synthesis of experiences from six interlinked Danish studies:

Aims: This paper examines the importance of recruitment site in relation to the recruitment of ethnic minorities into health research. It presents a synthesis of experiences drawn from six interlinked Danish studies which applied different methods and used healthcare facilities and educational settings as sites for recruitment. Methods: Inspired by interpretive reviewing, data on recruitment methods from the different studies were synthesized with a focus on the various levels of recruitment success achieved. This involved an iterative process of comparison, analysis and discussion of experiences among the researchers involved. Results: Success in recruitment seemed to depend partly on recruitment site. Using healthcare facilities as the recruitment site and healthcare professionals as gatekeepers was less efficient than using schools and employees from educational institutions. Successful study designs also depended on the possibility of singling out specific locations with a high proportion of the relevant ethnic minority target population. Conclusions: The findings, though based on a small number of cases, indicate that health professionals and healthcare institutions, despite their interest in high-quality health research into all population groups, fail to facilitate research access to some of the most disadvantaged groups, who need to be included in order to understand the mechanisms behind health disparities. This happens despite the genuine wish of many healthcare professionals to help facilitate such research. In this way, the findings indirectly emphasize the specific challenge of accessing more vulnerable and sick groups in research studies.

Care during pregnancy and childbirth for migrant women: How do we advance? Development of intervention studies--the case of the MAMAACT intervention in Denmark.

The increased risk of adverse pregnancy and childbirth outcomes demonstrated for many non-Western migrants in Europe, Australia and North America may be due to inadequate use and suboptimal quality of care. It is indicated that a poor user-provider interaction leads to inequity of pregnancy and delivery care. This review demonstrated that there is no evidence of best practice antenatal care for migrant women. Health system interventions for improved maternal and child health among migrants should be based on thorough needs assessments, contextual understanding and involvement of the target group and health-care providers. We present the Danish MAMAACT study as a strategic perspective on how to move forward, and we describe methodological steps in intervention development. Based on a mixed method needs assessment, the MAMAACT study aimed to enhance the communication between migrant women and midwives during antenatal care regarding warning signs of pregnancy and how to access acute care.

Antenatal care strengthening for improved health behaviours in Jimma, Ethiopia, 2009–2011: An effectiveness study

INTRODUCTION health systems in low-income settings are not sufficiently reaching the poor, and global disparities in reproductive health persist. The frequency and quality of health education during antenatal care is often low. Further studies are needed on how to improve the performance of health systems in low income settings to improve maternal and child health. OBJECTIVES to assess the effectiveness of a participatory antenatal care intervention on health behaviours and to illuminate how the different socioeconomic groups responded to the intervention in Jimma, Ethiopia. SETTING, INTERVENTION AND MEASUREMENTS: an intervention was designed participatorily and comprised trainings, supervisions, equipment, health education material, and adaption of guidelines. It was implemented at public facilities. Household surveys, before (2008) and after (2010) intervention, were conducted amongst all women who had given birth within the previous 12 months. The effect of the intervention was assessed by comparing the change in health behaviours (number of antenatal visits, health facility delivery, breast feeding, preventive infant health check, and infant immunisation) from before to after the intervention period at intervention sites, relative to control sites, using logistic mixed effect regression. RESULTS on the basis of 1357 women included before and 2262 after the intervention, there were positive effects of the intervention on breast feeding practices (OR 3.0, 95% CI: 1.4; 3.6) and preventive infant health check (OR 2.4, 95% CI: 1.5; 3.5). There was no effect on infant immunisation coverage and negative effect on number of antenatal visits. The effect on various outcomes was modified by maternal education, and results indicate increased health facility delivery (OR 2.4, 95% CI: 0.8; 6.9) and breast feeding practices (OR 18.2, 95% CI: 5.2;63.6) among women with no education. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE the facility based intervention improved some, but not all health behaviours. The improvements indicated amongst the most disadvantaged antenatal care attendants in breast feeding and health facility delivery are encouraging and underline the need to scale up priority of antenatal care in the effort to reduce maternal and child health inequity.