Silke Brenne

Smoking During Pregnancy Among Turkish Immigrants in Germany—Are There Associations With Acculturation?

INTRODUCTION We analyzed the association between different acculturation measures and smoking among pregnant immigrant women from Turkey and compared smoking rates between Turkish and German women. METHODS Perinatal data from a project on the influence of migration and acculturation on pregnancy and birth in Berlin was analyzed. An acculturation index (FRAKK) and two proxy measures (German language proficiency, length of stay in Germany) were used. We performed logistic regression models and calculated age-standardized prevalence ratios (SPR). RESULTS Smoking prevalence was 19.8% among pregnant Turkish women (n = 702) and 17.8% among German women (n = 2,999). The chance of being a smoker was significantly higher among Turkish women with a length of stay of ≥20 years compared to 0-4 years (OR = 3.63, 95% CI = 1.64-8.05); with good/very good language skills compared to none/minor skills; with high levels of acculturation compared to low levels (the latter only among 18-29-year-old women). Compared to German women, Turkish women with a short length of stay, low acculturation scores and none/minor language skills had lower smoking rates. This finding inverts with long length of stay, high acculturation scores and good/very good language skills (≥20 years: SPR = 2.14, 95% CI = 1.56-2.94). CONCLUSIONS Smoking among pregnant Turkish women increases with increasing acculturation. Additionally, immigrant women with a low acculturation level are less often smokers and women with a high level are more often smokers than German women. Prevention measures have to prevent women with a low acculturation from starting to smoke and to induce those with a high acculturation to quit. As smoking and acculturation are group phenomena, it is necessary to involve immigrant communities.

Contribution of overweight and obesity to adverse pregnancy outcomes among immigrant and non-immigrant women in Berlin, Germany

BACKGROUND Maternal excessive weight and smoking are associated with an increased risk of pregnancy complications and adverse pregnancy outcomes. In Germany, immigrant women have a higher prevalence of pre-pregnancy overweight/obesity compared with autochthonous women. We compared the contribution of pre-pregnancy overweight/obesity to adverse pregnancy outcomes among immigrant and autochthonous women in Berlin/Germany. METHODS Data from 2586 immigrant women (from Turkey, Lebanon, other countries of origin) and 2676 autochthonous women delivering in three maternity hospitals of Berlin within 12 months (2011/2012) was used. Cox regression models were applied to estimate the association between overweight/obesity and smoking with the outcomes large-for-gestational-age (LGA), small-for-gestational-age (SGA), preterm birth (PTB) and extreme preterm-birth (E-PTB). Population attributive fractions (PAF) were calculated to quantify the proportion of the outcomes attributable to overweight/obesity and smoking, respectively. RESULTS Prevalence of overweight and obesity was 33.4% among autochthonous and 53.6% among Turkish women. Prevalence risk ratios of excessive weight were highest for LGA infants among immigrant and autochthonous women. The PAFs were -11.8% (SGA), +16.3% (LGA), +3.6% (PTB) and +16.5% (E-PTB) for the total study population. CONCLUSIONS Overweight/obesity is strongly associated with an increased risk of delivering an LGA infant among both immigrant and autochthonous women. Compared with autochthonous women, the contribution of excessive weight to LGA is even higher among immigrant women, in whom PAFs of overweight/obesity even exceed those of smoking for some outcomes.

Caesarean Section Frequency among Immigrants, Second- and Third-Generation Women, and Non-Immigrants: Prospective Study in Berlin/Germany

Objective The frequency of caesarean section delivery varies between countries and social groups. Among other factors, it is determined by the quality of obstetrics care. Rates of elective (planned) and emergency (in-labor) caesareans may also vary between immigrants (first generation), their offspring (second- and third-generation women), and non-immigrants because of access and language barriers. Other important points to be considered are whether caesarean section indications and the neonatal outcomes differ in babies delivered by caesarean between immigrants, their offspring, and non-immigrants. Methods A standardized interview on admission to delivery wards at three Berlin obstetric hospitals was performed in a 12-month period in 2011/2012. Questions on socio-demographic and care aspects and on migration (immigrated herself vs. second- and third-generation women vs. non-immigrant) and acculturation status were included. Data was linked with information from the expectant mothers’ antenatal records and with perinatal data routinely documented in the hospital. Regression modeling was used to adjust for age, parity and socio-economic status. Results The caesarean section rates for immigrants, second- and third-generation women, and non-immigrant women were similar. Neither indications for caesarean section delivery nor neonatal outcomes showed statistically significant differences. The only difference found was a somewhat higher rate of crash caesarean sections per 100 births among first generation immigrants compared to non-immigrants. Conclusion Unlike earlier German studies and current studies from other European countries, this study did not find an increased rate of caesarean sections among immigrants, as well as second- and third-generation women, with the possible exception of a small high-risk group. This indicates an equally high quality of perinatal care for women with and without a migration history.

Werden Frauen mit und ohne Migrationshintergrund von den Gesundheitsdiensten gleich gut erreicht

ZusammenfassungHintergrundRund 20 % der Bevölkerung Deutschlands hat einen Migrationshintergrund („1. Generation“: selbst migriert; „2. Generation“: deren Nachkommen), der mit gesundheitlicher Benachteiligung einhergehen kann.FragestellungBestehen die in früheren Untersuchungen beobachteten Unterschiede bei der Inanspruchnahme der Schwangerschaftsvorsorge zwischen Frauen mit und ohne Migrationshintergrund weiterhin?MethodenDatenerhebung 2011/2012 an drei Berliner Geburtskliniken anhand standardisierter Interviews, Verknüpfung der Befragungsdaten mit Perinatal- und Mutterpassdaten. Adjustierung für Störgrößen im Regressionsmodell.ErgebnisseVon den 7100 Studienteilnehmerinnen (Response 89,6 %) hatten 57,9 % einen Migrationshintergrund. 92,1 % der Migrantinnen der ersten Generation versus 97,8 % der Nicht-Migrantinnen nahmen die erste Vorsorgeuntersuchung in der Schwangerschaftswoche 3–19 in Anspruch (Mittelwerte SSW der ersten Vorsorgeuntersuchung: Migrantinnen der 1. Generation mit Aufenthaltsdauer < 5 Jahre: 13,0; > 5  Jahre: 9,9; Nicht-Migrantinnen 9,7). Eine geringe Inanspruchnahme von ≤ 5 Vorsorgeuntersuchungen fand sich bei 644 Frauen (9,1 %). Unter den Nicht-Migrantinnen sind 7,1 % „Wenignutzerinnen“, unter den Migrantinnen der ersten Generation 11,8 % (bei Frauen ohne Deutschkenntnisse jedoch 33,0 %). Nichtmedizinische Angebote werden von Frauen mit Migrationshintergrund weniger genutzt.DiskussionIn Berlin hat heute ein Migrationshintergrund kaum noch Einfluss auf die Inanspruchnahme der Schwangerenvorsorge. Weder eigene Zuwanderung noch niedriger Akkulturationsgrad sind eigenständige Risikofaktoren für geringe Nutzung oder späte Teilnahme, tendenziell aber kurze Aufenthaltsdauer. Die kleine Gruppe der „Wenignutzerinnen“ sollte differenzierter betrachtet werden, hier bestehen häufiger sprachliche Barrieren.AbstractBackgroundAbout 20 % of the population in Germany has a migration background (1st generation: immigrated themselves; 2nd generation: offspring of immigrants), which can be associated with health differentials. We assessed whether differentials in uptake of antenatal care (ANC) observed in earlier studies still persist today.MethodsData collection in 3 obstetric hospitals in Berlin, Germany, over a 1-year period 2011/2012. We conducted standardised interviews before delivery and linked the data to routinely collected perinatal data and to data from participants’ antenatal cards. We checked for confounders using regression models.ResultsOf the 7100 study participants (response 89.6 %), 57.9 % had a migration background. First ANC attendance occurred in pregnancy weeks 3–19 in 92.1 % of 1st generation immigrants vs. 97.8 % of non-immigrants (mean week of first attendance: 1st generation immigrants with residence < 5 years: 13.0; 5 + years: 9.9; non-immigrants 9.7). A low ANC utilisation with ≤ 5 visits was found in 644 women (9.1 %). Among the non-immigrants there were 7.1 % low users, among 1st generation immigrants 11.8 % (among women with no German language skills 33.0 %, however). Uptake of non-medical support measures was lower among women with migration background.DiscussionIn our sample from Berlin, migration background had little effect on ANC uptake. Neither own migration nor low acculturation were independent risk factors for late onset or low utilisation of ANC. However, a small subgroup of women with a short duration of residence in Germany and with German language problems had a lower chance of timely onset and sufficient participation in ANC. This group needs special attention.

Comparing provision and appropriateness of health care between immigrants and non-immigrants in Germany using the example of neuraxial anaesthesia during labour: cross-sectional study

Objective Research on health services for immigrants has mostly been concerned with access barriers but rarely with appropriateness and responsiveness of care. We assessed whether appropriateness and responsiveness of care depend on migration status, using provision of neuraxial anaesthesia (NA) during labour as indicator. In relation to their migration status, we analysed whether (1) women undergoing elective or secondary/urgent secondary caesarean sections (ESCS) appropriately receive NA (instead of general anaesthesia), (2) women delivering vaginally appropriately receive NA and (3) women objecting to NA, for example, for religious reasons, may deliver vaginally without receiving NA (provider responsiveness). Design Cross-sectional study. Setting Three obstetric hospitals in Berlin, Germany. Methods Questionnaire survey covering 6391 women with migration history (first and second generations) and non-immigrant women giving birth; data linkage with routine obstetric data. We assessed the effects of migrant status, German language proficiency, religion and education on the provision of NA (primary outcome) after adjusting for other maternal and obstetric parameters. Results The chance of receiving NA for elective/ESCS was independent of migrant status after controlling for confounding variables (adjusted OR (aOR) 0.93, 95% CI 0.65 to 1.33). In vaginal deliveries, first (but not second) generation women (aOR 0.79, 95% CI 0.65 to 0.95), women with low German language skills (aOR 0.77, 95% CI 0.58 to 0.99) and women with low educational attainment (aOR 0.62, 95% CI 0.47 to 0.82) had lower chances of receiving NA; there was no evidence of overprovision among women with strong affinity to Islam (aOR 0.77, 95% CI 0.63 to 0.94). Conclusions We found evidence for underprovision of care among first-generation immigrants, among women with low German language proficiency and particularly among all women with low educational attainment, irrespective of migration status. There was no evidence for overprovision of care to immigrant women, either inappropriately (general anaesthesia for ESCS) or because of low provider responsiveness (no opt-out for NA in vaginal delivery).

A distributional approach to obtain adjusted comparisons of proportions of a population at risk

BackgroundDichotomisation of continuous data has statistical drawbacks such as loss of power but may be useful in epidemiological research to define high risk individuals.MethodsWe extend a methodology for the presentation of comparison of proportions derived from a comparison of means for a continuous outcome to reflect the relationship between a continuous outcome and covariates in a linear (mixed) model without losing statistical power. The so called “distributional method” is described and using perinatal data for illustration, results from the distributional method are compared to those of logistic regression and to quantile regression for three different outcomes.ResultsEstimates obtained using the distributional method for the comparison of proportions are consistently more precise than those obtained using logistic regression. For one of the three outcomes the estimates obtained from the distributional method and from logistic regression disagreed highlighting that the relationships between outcome and covariate differ conceptually between the two models.ConclusionWhen an outcome follows the required condition of distribution shift between exposure groups, the results of a linear regression model can be followed by the corresponding comparison of proportions at risk. This dual approach provides more precise estimates than logistic regression thus avoiding the drawback of the usual dichotomisation of continuous outcomes.

Zum Einfluss eines Migrationshintergrundes auf die Umsetzung der Stillabsicht und ein vorzeitiges Abstillen

QUESTIONS Current studies on breastfeeding behavior that adequately consider migration aspects are not available from Germany. The following research questions should be answered with the help of a prospective study: What factors influence the probability of (premature) weaning and actual breastfeeding duration? What roles do migration background (MB) and generation play? Do observed effects persist after controlling for education, parity, etc.? PATIENT COHORT AND METHODOLOGY In a one-year study in 3 Berlin maternity hospitals, women were interviewed on socio-demografic details and migration aspects on admission to the delivery room. On the 2nd / 3rd day postpartum, another standardized interview was conducted that included questions on the beginning of breastfeeding and planned breastfeeding period. Six months postpartum, a sub-cohort was interviewed by telephone or other means about the actual breastfeeding period. Nursing behavior was analyzed using multivariate regression models. A Cox regression was used to analyze actual breastfeeding duration and possible influencing factors. RESULTS The pre-partum group included 7,100 women (57.9% with a migrant background), 6,884 women were interviewed on the maternity ward, and 605 women were in the sub-cohort questioned six months postpartum. 55.9% of first-generation migrant women, 32.9% of 2nd / 3rd-generation migrant women, and 52.9% of women with no MB were still breastfeeding 6 months postpartum (p<0.001). In the adjusted regression model, women with a migrant background were more likely to start breastfeeding than women with no MB. Coxs regression analysis examined the likelihood of breastfeeding within 6 months: The adjusted model showed no effect of migration status. CONCLUSION The migration background factor has only a small influence on breastfeeding behavior. Possible differences should take the migration generation into account.

Does the Degree of Acculturation Influence Breastfeeding Intention and Start or the Frequency of Early Weaning? Results of a Prospective Observational Study

Objectives Recent breastfeeding studies from immigration countries have found that acculturation factors influence breastfeeding behaviour in women with a migration background. To date, there has been no systematic investigation for Germany. Therefore, we study whether and how the degree of acculturation within a population of migrant women influences the start, time and duration of breastfeeding. Patient Population and Methodology Pregnant women who were admitted to one of the three participating maternity clinics in Berlin for the birth of their child in the one-year study period were surveyed (including sociodemographic details, data on migration/acculturation). These women were interviewed again two or three days post partum (including start of breastfeeding, planned breastfeeding duration, reasons for not breastfeeding). In a subgroup, a telephone interview took place 6 months post partum about the actual breastfeeding duration, contraceptive behaviour post partum and availing of midwife services following delivery. Breastfeeding behaviour was analysed using multivariate regression models, among other things. Results The prepartum survey included 7100 women, 6884 women were contacted in the postnatal wards, and the subgroup six months after delivery comprised 605 women. No acculturation-related differences were found in the start of breastfeeding. In the adjusted model, a medium and higher degree of acculturation diminished the chance of planning a long breastfeeding period. More acculturated women show a greater risk of weaning within the first six months than less acculturated women. Conclusion The degree of acculturation has relevant significance for some aspects of breastfeeding behaviour in women with a migration background. This should be considered both in breastfeeding promotion programmes and in further national breastfeeding studies.

Werden Frauen mit und ohne Migrationshintergrund von den Gesundheitsdiensten gleich gut erreicht?@@@Are women with and without migration background reached equally well by health services?: Das Beispiel Schwangerenvorsorge in Berlin@@@The example of antenatal care in Berlin

ZusammenfassungHintergrundRund 20 % der Bevölkerung Deutschlands hat einen Migrationshintergrund („1. Generation“: selbst migriert; „2. Generation“: deren Nachkommen), der mit gesundheitlicher Benachteiligung einhergehen kann.FragestellungBestehen die in früheren Untersuchungen beobachteten Unterschiede bei der Inanspruchnahme der Schwangerschaftsvorsorge zwischen Frauen mit und ohne Migrationshintergrund weiterhin?MethodenDatenerhebung 2011/2012 an drei Berliner Geburtskliniken anhand standardisierter Interviews, Verknüpfung der Befragungsdaten mit Perinatal- und Mutterpassdaten. Adjustierung für Störgrößen im Regressionsmodell.ErgebnisseVon den 7100 Studienteilnehmerinnen (Response 89,6 %) hatten 57,9 % einen Migrationshintergrund. 92,1 % der Migrantinnen der ersten Generation versus 97,8 % der Nicht-Migrantinnen nahmen die erste Vorsorgeuntersuchung in der Schwangerschaftswoche 3–19 in Anspruch (Mittelwerte SSW der ersten Vorsorgeuntersuchung: Migrantinnen der 1. Generation mit Aufenthaltsdauer < 5 Jahre: 13,0; > 5  Jahre: 9,9; Nicht-Migrantinnen 9,7). Eine geringe Inanspruchnahme von ≤ 5 Vorsorgeuntersuchungen fand sich bei 644 Frauen (9,1 %). Unter den Nicht-Migrantinnen sind 7,1 % „Wenignutzerinnen“, unter den Migrantinnen der ersten Generation 11,8 % (bei Frauen ohne Deutschkenntnisse jedoch 33,0 %). Nichtmedizinische Angebote werden von Frauen mit Migrationshintergrund weniger genutzt.DiskussionIn Berlin hat heute ein Migrationshintergrund kaum noch Einfluss auf die Inanspruchnahme der Schwangerenvorsorge. Weder eigene Zuwanderung noch niedriger Akkulturationsgrad sind eigenständige Risikofaktoren für geringe Nutzung oder späte Teilnahme, tendenziell aber kurze Aufenthaltsdauer. Die kleine Gruppe der „Wenignutzerinnen“ sollte differenzierter betrachtet werden, hier bestehen häufiger sprachliche Barrieren.AbstractBackgroundAbout 20 % of the population in Germany has a migration background (1st generation: immigrated themselves; 2nd generation: offspring of immigrants), which can be associated with health differentials. We assessed whether differentials in uptake of antenatal care (ANC) observed in earlier studies still persist today.MethodsData collection in 3 obstetric hospitals in Berlin, Germany, over a 1-year period 2011/2012. We conducted standardised interviews before delivery and linked the data to routinely collected perinatal data and to data from participants’ antenatal cards. We checked for confounders using regression models.ResultsOf the 7100 study participants (response 89.6 %), 57.9 % had a migration background. First ANC attendance occurred in pregnancy weeks 3–19 in 92.1 % of 1st generation immigrants vs. 97.8 % of non-immigrants (mean week of first attendance: 1st generation immigrants with residence < 5 years: 13.0; 5 + years: 9.9; non-immigrants 9.7). A low ANC utilisation with ≤ 5 visits was found in 644 women (9.1 %). Among the non-immigrants there were 7.1 % low users, among 1st generation immigrants 11.8 % (among women with no German language skills 33.0 %, however). Uptake of non-medical support measures was lower among women with migration background.DiscussionIn our sample from Berlin, migration background had little effect on ANC uptake. Neither own migration nor low acculturation were independent risk factors for late onset or low utilisation of ANC. However, a small subgroup of women with a short duration of residence in Germany and with German language problems had a lower chance of timely onset and sufficient participation in ANC. This group needs special attention.

[Are women with and without migration background reached equally well by health services? The example of antenatal care in Berlin].

ZusammenfassungHintergrundRund 20 % der Bevölkerung Deutschlands hat einen Migrationshintergrund („1. Generation“: selbst migriert; „2. Generation“: deren Nachkommen), der mit gesundheitlicher Benachteiligung einhergehen kann.FragestellungBestehen die in früheren Untersuchungen beobachteten Unterschiede bei der Inanspruchnahme der Schwangerschaftsvorsorge zwischen Frauen mit und ohne Migrationshintergrund weiterhin?MethodenDatenerhebung 2011/2012 an drei Berliner Geburtskliniken anhand standardisierter Interviews, Verknüpfung der Befragungsdaten mit Perinatal- und Mutterpassdaten. Adjustierung für Störgrößen im Regressionsmodell.ErgebnisseVon den 7100 Studienteilnehmerinnen (Response 89,6 %) hatten 57,9 % einen Migrationshintergrund. 92,1 % der Migrantinnen der ersten Generation versus 97,8 % der Nicht-Migrantinnen nahmen die erste Vorsorgeuntersuchung in der Schwangerschaftswoche 3–19 in Anspruch (Mittelwerte SSW der ersten Vorsorgeuntersuchung: Migrantinnen der 1. Generation mit Aufenthaltsdauer < 5 Jahre: 13,0; > 5  Jahre: 9,9; Nicht-Migrantinnen 9,7). Eine geringe Inanspruchnahme von ≤ 5 Vorsorgeuntersuchungen fand sich bei 644 Frauen (9,1 %). Unter den Nicht-Migrantinnen sind 7,1 % „Wenignutzerinnen“, unter den Migrantinnen der ersten Generation 11,8 % (bei Frauen ohne Deutschkenntnisse jedoch 33,0 %). Nichtmedizinische Angebote werden von Frauen mit Migrationshintergrund weniger genutzt.DiskussionIn Berlin hat heute ein Migrationshintergrund kaum noch Einfluss auf die Inanspruchnahme der Schwangerenvorsorge. Weder eigene Zuwanderung noch niedriger Akkulturationsgrad sind eigenständige Risikofaktoren für geringe Nutzung oder späte Teilnahme, tendenziell aber kurze Aufenthaltsdauer. Die kleine Gruppe der „Wenignutzerinnen“ sollte differenzierter betrachtet werden, hier bestehen häufiger sprachliche Barrieren.AbstractBackgroundAbout 20 % of the population in Germany has a migration background (1st generation: immigrated themselves; 2nd generation: offspring of immigrants), which can be associated with health differentials. We assessed whether differentials in uptake of antenatal care (ANC) observed in earlier studies still persist today.MethodsData collection in 3 obstetric hospitals in Berlin, Germany, over a 1-year period 2011/2012. We conducted standardised interviews before delivery and linked the data to routinely collected perinatal data and to data from participants’ antenatal cards. We checked for confounders using regression models.ResultsOf the 7100 study participants (response 89.6 %), 57.9 % had a migration background. First ANC attendance occurred in pregnancy weeks 3–19 in 92.1 % of 1st generation immigrants vs. 97.8 % of non-immigrants (mean week of first attendance: 1st generation immigrants with residence < 5 years: 13.0; 5 + years: 9.9; non-immigrants 9.7). A low ANC utilisation with ≤ 5 visits was found in 644 women (9.1 %). Among the non-immigrants there were 7.1 % low users, among 1st generation immigrants 11.8 % (among women with no German language skills 33.0 %, however). Uptake of non-medical support measures was lower among women with migration background.DiscussionIn our sample from Berlin, migration background had little effect on ANC uptake. Neither own migration nor low acculturation were independent risk factors for late onset or low utilisation of ANC. However, a small subgroup of women with a short duration of residence in Germany and with German language problems had a lower chance of timely onset and sufficient participation in ANC. This group needs special attention.