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  1. a) F b) F c) F d) T e) F

Although migrants are generally at higher risk of mortality and morbidity, this is not true for all groups. Although some risk factors were shown to be elevated in some migrant groups, these factors are certainly not always present (e.g. HIV prevalence was lower in foreign women in Atlanta, United States, compared to native women). As a general statement, this hypothesis should be refuted, since many migrant groups are at higher risk of mortality and morbidity. In some migrant populations, however, the hypothesis was shown to be true. Substandard care can also be due to patient delays, for example due to a lack of knowledge about the health system in the host country.

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  2. a) F b) F c) T d) F e) F

Women from these countries did not have an increased risk compared to Dutch women. Of note: the group most vulnerable to maternal mortality and morbidity in the Netherlands were asylum seekers. Black women in the United States are indeed at the highest risk of maternal mortality, regardless of whether they are born in or outside the country. Evidence shows that care needs to be individualized in order to provide optimal care to migrant women. They may require enhanced screening for conditions such as anaemia compared to women from the host population or increased vigilance for conditions such as pre-eclampsia that may present with differently. Recommendations derived from confidential enquiries and audit require a significant political effort to come to actual health system improvements. Mere audit is meaningless without appropriate feedback and interventions.

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  3. a) T b) T c) T d) T e) T

Birthweight is affected by the infant’s sex, the duration of gestation, the altitude above sea level, maternal disease such as diabetes, maternal smoking and BMI, to name but a few.

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  4. a) T b) F c) F d) T e) F

Birthweight is affected by the infant’s sex, the duration of gestation, the altitude above sea level, maternal disease such as diabetes, maternal smoking and BMI, to name but a few. However, there is not a straightforward relationship between birthweight and infant mortality, as not all factors that are associated with lower birthweight are linked to adverse outcomes. Thus, birth weight charts consistently show a poor prediction of adverse neonatal outcome. Birthweight charts that are based on entire populations include both healthy and unhealthy pregnancies. Unhealthy pregnancies may affect the birth weight distribution in unexpected ways. Thus, such charts are ill-suited to accurately describe normal fetal growth and newborn size. Using birth weight charts from a healthy population, using a cut-off of the 10 ^th lower centile, will categorize 10% of all babies as SGA; despite that these are healthy normal babies. Conversely, babies that fall within the normal range can still be growth restricted, as they did not reach their (higher) growth potential.

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  5. a) F b) F c) F d) F e) T

Data on migrant women from Sub-Saharan Africa to the United States show that migrant women have lower preterm delivery rates compared to native-born Black women. This has partly been ascribed to a “healthy immigrant effect”. It is thus unlikely that genetic differences explain the Black-White gap in preterm delivery as, as further generations of migrant descent are exposed to inter-marriage and genetic mixing. Non-Hispanic Black women living in the US are less likely to smoke and use drugs in pregnancy compared to non-Hispanic White women. Exposures such as differentials in socio-economic position and discrimination are more likely to explain the gap. Both subtypes of preterm delivery are elevated among Black women, reflecting shared pathways between the two; however, the mechanisms for these are still poorly understood.

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  6. a) T b) T c) T d) T e) T

The last menstrual period is more likely to be erroneous or missing for women from ethnic minorities and with lower socio-economic position, many of whom are black. This can cause a bias in preterm delivery rates, which potentially could either inflate or deflate rates. Data based on ultrasound-determined gestational length is less likely to be biased and should be preferred when comparing rates. Both spontaneous and medically indicated preterm deliveries are more common among Black women compared to White women.

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  7. a) T b) T c) F d) T e) T

Overall migrant women have less favourable maternal and infant outcomes compared to White British women. In the latest confidential enquiry into maternal deaths, many deaths among Black and minority ethnic groups occurred in recently arrived migrants, refugees or asylum seekers. Analyses of infant and neonatal outcomes by maternal migrant status (UK-born vs foreign born) show persistent patterns of disadvantage over time for babies of foreign born mothers compared to babies of UK-born mothers on some outcomes. However, existing comparisons of infant outcomes for the same ethnicity with respect to maternal country of birth suggest that outcomes for foreign born mothers of some groups and their babies are better compared to those of UK – born women of the same ethnicity. Most studies comparing birth weights by maternal generational status among South Asian babies born in the UK found no significant difference between babies of UK-born and foreign born South Asian mothers. Fatal congenital anomalies are established as a leading cause of excess infant deaths among mothers of Pakistani origin compared to the general UK population. Babies born to these mothers are four times at higher risk of deaths from congenital anomalies, representing about 90 extra deaths per year in comparison to White British mothers. Both old and new studies have shown that consanguineous or first cousin unions are responsible for a significantly elevated risk of congenital abnormalities in babies of Pakistani origin.

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  8. a) T b) T c) F d) T e) F

Studies have consistently shown that migrant mothers are likely to initiate antenatal care late and get fewer antenatal visits compared to UK-born mothers. A variety of individual, contextual and structural factors have been indicated as responsible for the late and/or inadequate access and utilization of maternity services for ethnic minority women in general. Migrant mothers face language difficulties in their contact with maternity services and studies have shown the lack of adequate provision of effective language support services. While there is a statutory obligation to provide interpretation services for patients who are unable to speak English, stark inadequacies exist in the provision of these services including failure of the interpreters to attend appointments or their inability to understand medical terminology; failure from professionals in booking interpretation services; lack of interpreters for migrants speaking uncommon languages and inappropriate use of family members to interpret. In addition, difficulties between care providers and mothers due to inadequate cultural sensitivity, racism, stereotyping and/or inappropriate provider attitudes are shown to affect access as well as quality of care for migrant as well as UK-born ethnic minority mothers. Immigration status has been indicated to be one of the most important factors in determining maternity experience, with its impact on women’s rights and entitlements and in particular, the level of agency that the immigration status tend to mediate. The importance of effective communication, particularly between health care professionals and parents, is indicated to be a prerequisite for quality in maternity care by policy makers, providers and women themselves.

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  9. a) T b) T c) T d) T e) F

Country of birth, migration classification, receiving-country language fluency and length of residence in the receiving-country are all important to consider in a migrant woman’s risk for a Caesarean. These indicators have an influence on a woman’s health status, her attitudes regarding Caesarean births, her access to prenatal care, her expectations of care, and the barriers she may experience in the delivery of her care, which may all have an impact on her risk of having a Caesarean birth.

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  10. a) T b) T c) T d) F e) T

The most common indications for Caesarean births among migrants are repeat Caesareans, FTP/dystocia, fetal distress, and CPD. Efforts towards reducing the number of Caesareans should therefore mainly focus on increasing the rates of VBACs and aiming to reduce the number of primary (first) Caesareans, particularly emergency Caesareans due to FTP, abnormal fetal heart rate and CPD. The latter may be achieved by addressing attitudes regarding Caesareans (women and clinicians) and improving the quality of care during labour (e.g. by providing adequate support and by improving the accuracy in diagnosing labour complications). Litigation fears are thought to not be a driving factor underlying the high Caesarean rates in migrants.

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  11. a) F b) F c) F d) F e) F

Genital cutting is not considered an indication for Caesarean even if a woman has experienced the most severe form of cutting. Physical assessment is necessary to determine the type of cutting and whether a woman needs to be de-infibulated before the birth. An episiotomy is not always necessary but may be offered if labour is obstructed due to scarring or skin inelasticity. Re-infibulation is against the law and requests for re-infibulation should be declined. Women and their families need to be respectfully and sensitively informed as to why their requests for re-infibulation cannot be granted. Only women considered at risk based on country of origin should be asked about their cutting status. Genital cutting is practiced mainly in Africa (29 countries) and in a few countries in the Middle-East and Asia. Migrant women most affected are those who have migrated from North-Eastern Africa (e.g. Egypt, Somalia). The literature suggests that many women who have experienced genital cutting prefer a vaginal birth and fear having a Caesarean.

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  12. a) F b) F c) F d) F e) T

Migrant women from Sub-Saharan Africa have an increased risk for Caesarean compared to non-migrant women even after controlling for a range of medical factors suggesting that non-medical factors are involved in driving the high rates in this population (HIV or other medical factors are therefore not likely the key factors). Higher Caesarean rates are more common with emergency Caesareans than planned Caesareans when comparing migrant to non-migrant women. No studies examining experiences of care and risk for Caesarean among migrants were found. Further research is needed to determine the influence of care factors, especially during labour, on mode of birth outcome. Studies do not provide any consistent evidence that migrant women require more Caesareans due to placental complications or medical conditions such as pre-eclampsia. Pathways leading to Caesarean births in migrants are complex and not yet fully understood, however research suggests they likely involve a combination of factors related to migrant women’s physical and psychological health, their social and cultural context and the quality of their maternity care. Research on migrant women’s views and experiences of Caesarean births is limited and further research is needed.

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  13. a) F b) F c) T d) F e) F

In order to provide a good level of healthcare for devout Muslims, research and practice must be aware that Islamic edicts are under constant reconstruction and re-negotiation by individual Muslims. This does not exclude that some Muslim women prefer female physicians, that pre-marital sex sometimes is discouraged, or that Islam’s discouragement of third-party donation can restrict some Muslim couples’ reproductive possibilities. However, it would be misleading to suggest that this is the case for all devout Muslims. Instead, it is important to acknowledge that individuals’ relationship to Islamic advices are characterized by flexibility, fluidity, and heterogeneity; thus requiring professionals to manage people individually.

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  14. a) T b) F c) F d) F e) F

Both cultural competence models and person-centered care approaches have been influential contributions aiming to improve healthcare provision in the care of Muslim patients. Although revealing some theoretical differences, both cultural sensitiveness and person-centered care models urge for improved healthcare delivery through providers’ increased familiarity about Islamic practices and sexual and reproductive health matters. However, though these models have shown to increase providers’ knowledge base, there is no evidence that the acquired awareness leads to improved patient health and reduced healthcare disparities. More research is needed to refine and better conceptualize these two models in reproductive healthcare of Muslim patients.

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  15. a) T b) F c) T d) T e) T

Migrant-related policies and laws help control migrants from having a negative impact on locals and at the same time protect migrants. However it does not fully protect migrants as the policies and laws require various agencies to ensure effective enforcement. These policies are important to ensure migrants have proper access to their sexual and reproductive health and rights (SRHR). Different countries will have different sets of migrant-related policies and laws.

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  16. a) T b) T c) T d) F e) T

Among the efforts to enable migrants to receive proper sexual and reproductive health and rights are the need to increase public awareness on the plight of migrants, increase access to health care among migrants in terms of cost and quality of service, having migrant-related laws and policies that would enable migrants to exercise their SRHR and the government to be more committed and takes actions in upholding the SRHR of migrants. Increasing the frequency of mandatory health screening among migrants is discriminatory and biased against low-skilled migrant workers and subjects them to various violations of their SRHR.

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  17. a) T b) F c) T d) T e) F

The general trend is that non-Western migrant women are less likely to initiate ANC timely and totally and have fewer visits during pregnancy compared to non-migrant women. It has been found that lack of knowledge on how to navigate the health system, challenges due to language barriers and inadequate use of professional interpreters, as well as indirect discrimination including lack of culturally sensitive health care providers all hinder use of ANC for pregnant migrant women.

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  18. a) F b) T c) T d) T e) T

Disparities in quality of pregnancy and delivery care are documented for non-western migrants in Europe, North America, and Australia. Suboptimal care occurs more often in migrants and is one of many explanations for the increased risk of poor reproductive outcomes. Low use of interpreters, poor cross-cultural communication, and mutual broken trust between providers and women has been shown to reduce the quality of care for migrant women. Further, delay in receiving appropriate care has been shown and linked to increased risk of perinatal and maternal death.

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  19. a) T b) T c) F d) T e) T

When developing health promoting interventions it is important to combine evidence based knowledge about causes and effects with involvement of the people who know the realty of the setting. Evidence based insight is needed to ensure effectiveness of the intervention, however if an intervention does not fit the needs, perceptions and context of the providers who have to implement it and the target group (migrant women) it will not be implemented with success. In research regarding health of migrant women, inclusion of migrant women themselves could be seen as ethically important.