Theda Borde

Mindestindikatorensatz zur Erfassung des Migrationsstatus

ZusammenfassungNach wie vor fehlt eine Datenbasis, die Migranten und ihre gesundheitliche Situation angemessen repräsentiert. Einer der Gründe für diesen Mangel ist die unzulängliche Erfassung des Migrationsstatus in der amtlichen Statistik und in epidemiologischen Studien. Voraussetzung für eine adäquate und standardisierte Operationalisierung ist eine genaue Definition der Begriffe „Migrant“ und „Migrationshintergrund“. In unserem Beitrag diskutieren wir Konzepte zur begrifflichen Bestimmung und Erfassung ethnischer Minderheiten und Migranten und entwickeln auf dieser Grundlage einen Mindestindikatorensatz für die epidemiologische Forschung. Der vorgeschlagene Mindestindikatorensatz zur Erfassung des Migrationsstatus enthält die Merkmale Geburtsland von Vater und Mutter, Einreisejahr, Muttersprache, Deutschkenntnisse sowie den Aufenthaltsstatus. Zentraler Indikator zur Identifikation von Migranten ist das Geburtsland der Eltern und nicht – wie bislang zumeist üblich – die Staatsangehörigkeit. Die Klassifikation mittels der juristischen Kategorie Staatsangehörigkeit wird damit abgelöst durch die Klassifikation anhand des lebensbiographischen Ereignisses „Migration“. Mit der Migration gehen spezifische Lebensbedingungen und Handlungsanforderungen einher, die über mehrere Generationen für die Gesundheit von Bedeutung sein können. Ein Instrument zur Erfassung des Migrationsstatus muss dahingehend weiterentwickelt werden, dass es diese aus dem Migrationsereignis resultierenden Besonderheiten in der Lebenssituation widerspiegelt und möglichst alle Aspekte eines Migrationshintergrundes berücksichtigt.AbstractData on the health status of migrants are still scarce. One of the reasons for this is that migration status has not been well recorded in official statistics and epidemiological studies. In order to obtain an adequate and standardised operationalisation of migrant status, we first need an exact definition of the terms ”migrant“ and ”migration background“. We discuss approaches to the definition of terms and the surveying of ethnic minorities and migrants, and then develop a basic set of migration status indicators for use in epidemiological research. This set of indictors includes country of birth of the father and mother, year of immigration, mother tongue, German language skills and status of residence. The key indicator for the identification of migrants is the country of birth of the parents and not the nationality as was previously often the case. Thus, the classification based on the judicial category of nationality is replaced by a classification based on the biographical event ”migration“. Migration brings with it specific life conditions and challenges that can impact health across several generations. An instrument for surveying migrant status must be further developed both to reflect the special conditions of the life situation resulting from the migration experience and to take as full account as possible of all aspects of a migrant‘s history.

Mindestindikatorensatz zur Erfassung des Migrationsstatus - Empfehlungen für die epidemiologische Praxis

ZusammenfassungNach wie vor fehlt eine Datenbasis, die Migranten und ihre gesundheitliche Situation angemessen repräsentiert. Einer der Gründe für diesen Mangel ist die unzulängliche Erfassung des Migrationsstatus in der amtlichen Statistik und in epidemiologischen Studien. Voraussetzung für eine adäquate und standardisierte Operationalisierung ist eine genaue Definition der Begriffe „Migrant“ und „Migrationshintergrund“. In unserem Beitrag diskutieren wir Konzepte zur begrifflichen Bestimmung und Erfassung ethnischer Minderheiten und Migranten und entwickeln auf dieser Grundlage einen Mindestindikatorensatz für die epidemiologische Forschung. Der vorgeschlagene Mindestindikatorensatz zur Erfassung des Migrationsstatus enthält die Merkmale Geburtsland von Vater und Mutter, Einreisejahr, Muttersprache, Deutschkenntnisse sowie den Aufenthaltsstatus. Zentraler Indikator zur Identifikation von Migranten ist das Geburtsland der Eltern und nicht – wie bislang zumeist üblich – die Staatsangehörigkeit. Die Klassifikation mittels der juristischen Kategorie Staatsangehörigkeit wird damit abgelöst durch die Klassifikation anhand des lebensbiographischen Ereignisses „Migration“. Mit der Migration gehen spezifische Lebensbedingungen und Handlungsanforderungen einher, die über mehrere Generationen für die Gesundheit von Bedeutung sein können. Ein Instrument zur Erfassung des Migrationsstatus muss dahingehend weiterentwickelt werden, dass es diese aus dem Migrationsereignis resultierenden Besonderheiten in der Lebenssituation widerspiegelt und möglichst alle Aspekte eines Migrationshintergrundes berücksichtigt.AbstractData on the health status of migrants are still scarce. One of the reasons for this is that migration status has not been well recorded in official statistics and epidemiological studies. In order to obtain an adequate and standardised operationalisation of migrant status, we first need an exact definition of the terms ”migrant“ and ”migration background“. We discuss approaches to the definition of terms and the surveying of ethnic minorities and migrants, and then develop a basic set of migration status indicators for use in epidemiological research. This set of indictors includes country of birth of the father and mother, year of immigration, mother tongue, German language skills and status of residence. The key indicator for the identification of migrants is the country of birth of the parents and not the nationality as was previously often the case. Thus, the classification based on the judicial category of nationality is replaced by a classification based on the biographical event ”migration“. Migration brings with it specific life conditions and challenges that can impact health across several generations. An instrument for surveying migrant status must be further developed both to reflect the special conditions of the life situation resulting from the migration experience and to take as full account as possible of all aspects of a migrant‘s history.

A basic set of indicators for mapping migrant status. Recommendations for epidemiological practice

ZusammenfassungNach wie vor fehlt eine Datenbasis, die Migranten und ihre gesundheitliche Situation angemessen repräsentiert. Einer der Gründe für diesen Mangel ist die unzulängliche Erfassung des Migrationsstatus in der amtlichen Statistik und in epidemiologischen Studien. Voraussetzung für eine adäquate und standardisierte Operationalisierung ist eine genaue Definition der Begriffe „Migrant“ und „Migrationshintergrund“. In unserem Beitrag diskutieren wir Konzepte zur begrifflichen Bestimmung und Erfassung ethnischer Minderheiten und Migranten und entwickeln auf dieser Grundlage einen Mindestindikatorensatz für die epidemiologische Forschung. Der vorgeschlagene Mindestindikatorensatz zur Erfassung des Migrationsstatus enthält die Merkmale Geburtsland von Vater und Mutter, Einreisejahr, Muttersprache, Deutschkenntnisse sowie den Aufenthaltsstatus. Zentraler Indikator zur Identifikation von Migranten ist das Geburtsland der Eltern und nicht – wie bislang zumeist üblich – die Staatsangehörigkeit. Die Klassifikation mittels der juristischen Kategorie Staatsangehörigkeit wird damit abgelöst durch die Klassifikation anhand des lebensbiographischen Ereignisses „Migration“. Mit der Migration gehen spezifische Lebensbedingungen und Handlungsanforderungen einher, die über mehrere Generationen für die Gesundheit von Bedeutung sein können. Ein Instrument zur Erfassung des Migrationsstatus muss dahingehend weiterentwickelt werden, dass es diese aus dem Migrationsereignis resultierenden Besonderheiten in der Lebenssituation widerspiegelt und möglichst alle Aspekte eines Migrationshintergrundes berücksichtigt.AbstractData on the health status of migrants are still scarce. One of the reasons for this is that migration status has not been well recorded in official statistics and epidemiological studies. In order to obtain an adequate and standardised operationalisation of migrant status, we first need an exact definition of the terms ”migrant“ and ”migration background“. We discuss approaches to the definition of terms and the surveying of ethnic minorities and migrants, and then develop a basic set of migration status indicators for use in epidemiological research. This set of indictors includes country of birth of the father and mother, year of immigration, mother tongue, German language skills and status of residence. The key indicator for the identification of migrants is the country of birth of the parents and not the nationality as was previously often the case. Thus, the classification based on the judicial category of nationality is replaced by a classification based on the biographical event ”migration“. Migration brings with it specific life conditions and challenges that can impact health across several generations. An instrument for surveying migrant status must be further developed both to reflect the special conditions of the life situation resulting from the migration experience and to take as full account as possible of all aspects of a migrant‘s history.

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.

Do immigration and acculturation have an impact on hyperemesis gravidarum? Results of a study in Berlin/Germany

Question: How large is the number of immigrant women being treated for hyperemesis gravidarum (HG) among the in-patients in a University hospital in Germany? Does migration have an impact on the psychosocial state of HG patients? Does acculturation have an impact on psychosocial distress in HG patients? Methods: The following methods were used: retrospective evaluation of all in-patients with HG from 1/1997 to 11/2009, inquiry of a consecutively surveyed group (from 2007 to 2009) of HG in-patients with a questionnaire set: socio-demographic data, questionnaire on psychic distress (SCL-90-R) questionnaire on migration/acculturation, and comparison of German patients and patients with immigration backgrounds as well as among immigrant groups. Results: During the 13-year study period, there were 4.5 times more immigrants treated for HG than native German patients. Compared to the age standardized resident population, the number of women with immigration backgrounds is over-proportionally high. The HG patients scored high in the SCL-90-R scale “somatization” without showing a higher level of psychic distress than the native patients. Conclusions: Experience of migration is an etiological cofactor for HG. The grade of acculturation does not have a significant influence on the psychic well-being of HG patients.

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.

Migrantinnen in der Geburtshilfe - psychosomatische Aspekte im Zusammenhang mit dem Akkulturationsprozess

Psychosomatic aspects and processes of acculturation in migrants that indicate transcultural change can be observed in obstetrics. Such Turkish men increasingly accompany their partners during birth in the delivery room. The analysis of perinatal data shows a harmonization for important perinatal quality parameters like infant and maternal mortality and the rate of preterm delivery between migrant and German women. However differences in the utilization and in the quality of care have been observed internationally (e. g. for migrants: later utilization of pregnancy checkups, higher rate of anaemia, less planned and higher rates of in-patient treatment of hyperemesis gravidarum). Specific risks of migration and psychosocial as well as the potentials of transcultural change more consideration.

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).