|Year : 2020 | Volume
| Issue : 1 | Page : 12-17
Comparison of delivery characteristics and early obstetric outcomes between Turkish women and Syrian refugee pregnancies
H Kiyak1, S Gezer1, C Ozdemir1, S Gunkaya1, T Karacan2, A Gedikbasi1
1 Department of Obstetric and Gynecology, Health Sciences University Istanbul, Kanuni Sultan Suleyman Teaching and Research Hospital, Istanbul, Turkey
2 Department of Obstetric and Gynecology, Health Sciences University Istanbul, Bagcilar Teaching and Research Hospital, Istanbul, Turkey
|Date of Submission||09-Jan-2019|
|Date of Acceptance||07-Sep-2019|
|Date of Web Publication||10-Jan-2020|
Dr. T Karacan
Department of Obstetric and Gynecology, Health Sciences University Istanbul, Bagcilar Teaching and Research Hospital, Istanbul
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Until September 1, 2016, Turkey hosted around 2.7 million Syrian refugees. However, data investigating the pregnancy health concerning the refugees are still limited. Aim: In the present study, we aimed to compare the delivery characteristics and short-term obstetric outcomes in Turkish women and Syrian refugees. Subjects and Methods: The study included 1556 singleton pregnancies which comprised 940 Turkish women and 616 Syrian women between January 2016 and January 2017. The groups were compared for demographic data, obstetric features, and pregnancy outcomes. Results: There were significant differences between Turkish women and the refugees in terms of preterm (18.94% vs. 11.00%, P = 0.003) and post-term delivery rates (11.49% vs. 2.91%, P < 0.001), caesarian delivery rates (33.4% vs. 23.95%, P = 0.002), newborn weights <1000 g (2.55% vs. 0.97%, P = 0.006) and >4000 g (5.32% vs. 3.24%, P = 0.006), pre-eclampsia (5.32% vs. 1.62%, P = 0.009), HELLP (1.28% vs. 0.00%, P = 0.046), and placental anomalies (1.91% vs. 0.00%, P = 0.014), respectively. Being a Turkish resident (P = 0.015) was an important risk factor for the development of unfavorable pregnancy outcomes. Moreover, maternal education of at least 12 years (P = 0.028) and receiving a regular antenatal visit at a tertiary center (P = 0.031) were preventative for the development of unfavorable pregnancy outcomes. Adverse pregnancy outcomes were less prevalent in Syrian refugees compared to that in the Turkish residents which was likely due to the contribution of maternal education and regular antenatal visits which were higher in Syrian refugees.
Conclusions: We suggest that providing adequate education particularly for women in undeveloped countries and facilitating access to the tertiary hospitals have the potential to reduce unfavorable pregnancy outcomes in immigrant women.
Keywords: Delivery characteristics, obstetric outcome, Syrian refugee
|How to cite this article:|
Kiyak H, Gezer S, Ozdemir C, Gunkaya S, Karacan T, Gedikbasi A. Comparison of delivery characteristics and early obstetric outcomes between Turkish women and Syrian refugee pregnancies. Niger J Clin Pract 2020;23:12-7
|How to cite this URL:|
Kiyak H, Gezer S, Ozdemir C, Gunkaya S, Karacan T, Gedikbasi A. Comparison of delivery characteristics and early obstetric outcomes between Turkish women and Syrian refugee pregnancies. Niger J Clin Pract [serial online] 2020 [cited 2020 Jul 16];23:12-7. Available from: http://www.njcponline.com/text.asp?2020/23/1/12/275608
| Introduction|| |
Globally, there were 244 million international migrants in 2015. Data obtained from the Office of the United Nations High Commissioner for Refugees (UNHCR) revealed that there were 65.3 million displaced people worldwide, of which 21.3 million were refugees. Turkey hosts the most Syrian refugees. Millions of people have been forced to seek asylum in Turkey, Iraq, Lebanon, Jordan, and Egypt after internal conflict started in Syria in 2011. Currently, 4.8 million Syrian refugees are registered outside Syria. Until September 1, 2016, Turkey hosted 2.7 million Syrian refugees. The Disaster and Emergency Management Authority (AFAD) of Turkey operates 26 refugee camps hosting 285 000 Syrian refugees in addition to 2.5 million living in various cities in the out-camp settlements. Data provided by Turkish public health institutions reported that 177 568 Syrian refugees gave birth between April 29, 2011, and September 30, 2016. This corresponds to approximately 3% of the total number of births in Turkey. The immigrant births correspond to approximately 20% of total births in some countries.
Mainly language problems, cultural differences, and geographic factors decrease the access to health services, thus negatively affecting their treatment. Refugees have psychologic or physical trauma, and they are socio-culturally disadvantaged. All these factors may negatively affect pregnancy outcomes. Insufficiency in pregnancy health care of immigrants and related maternal and neonatal morbidity has been demonstrated in previous reports.,,
In the present study, we aimed to compare the delivery characteristics and short-term obstetric outcomes in Turkish women and Syrian refugees.
| Subjects and Methods|| |
This is a retrospective cohort study performed in a total of 1556 singleton pregnancies delivered in Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey, between January 2016 and January 2017. Kanuni Sultan Suleyman Training and Research Hospital is a tertiary referral hospital in which 15,000 women give birth per year. The Syrian refugees included in this study lived in urban areas. The study was approved by the local ethics committee. Posthoc power calculations based on our pilot study with 60 patients revealed that (Low birth weight in refugee group: 12% in Turkish participants: 9%, effect size 0.50, alpha error: 0.05 power: 0.95) at least 80 patients were required in each group for an adequate sample size (G*Power: Universität Düsseldorf). Turkish women (n = 940) and Syrian women (n = 616) were compared for demographic data, obstetric history, delivery route, indications for caesarian section, fetal weight, Apgar scores, preterm delivery, preterm rupture of membranes, stillbirth, fetal anomalies, placental anomalies, intrauterine growth restriction, oligohydramnios, pre-eclampsia, eclampsia, HELLP, cholestasis, prepartum hemoglobin/hematocrit levels, and blood transfusion requirement.
Pregnancy dates were calculated using the last menstrual period or the first-trimester ultrasonography. If both were unobtainable these patients were excluded.
The Number Cruncher Statistical System (NCSS) 2007 Statistical Software (Utah, USA) was used for statistical analysis. Mean and standard deviation were used in the analysis of descriptive variables. The independent samples t- test was used to compare numeric variables. Categorical variables were calculated using the Chi-square test and Fischer's exact tests. P < 0.05 was considered as statistically significant.
| Results|| |
Around 616 Syrian refugees were compared with 940 Turkish patients. [Table 1] shows the demographic data of the Syrian and Turkish women. The length of stay in Turkey was 3.8 ± 1.4 years among the Syrian refugees. The Syrian patients were significantly younger than the Turkish patients (P < 0.01) and the rate of adolescent pregnancies was significantly higher among Syrian refugees compared to that of the Turkish citizens (P < 0.01). Compulsory basic education of 12 years was completed by 33% of the Turkish participants and by 43% of the Syrian refugees (P < 0.01). Gravida (P < 0.01) and abortion (P < 0.01) numbers were higher in Turkish patients than in Syrian patients but no difference was seen in parity between the two groups. Although the proportion of patients having regular antenatal visits was similar in both groups, rate of participants receiving a regular visit at a tertiary hospital was significantly higher among Syrian refugees compared to that of the Turkish residents (P < 0.01).
Delivery characteristics are shown in [Table 2]. The mean gestational week was higher in Turkish patients than in the Syrian patients (P < 0.01). The Turkish patients had significantly higher preterm (P < 0.01) and post-term delivery rates (P < 0.01) than Syrian patients. There were no differences between newborn weights, except < 1000 g and > 4000 g. Newborn weights < 1000 g (P < 0.01) and > 4000 g (P < 0.01) were significantly higher in the Turkish group. The rate of low birth weight newborns was similar in the two groups (P = 0.29). There was no difference between first and fifth min Apgar scores and between stillbirth and fetal anomaly rates. The caesarian delivery rate was higher among the Turkish patients (P < 0.01).
Cesarean indications shown in [Table 3]. were not significantly different between the two groups. In addition, obstetric conditions are shown in [Table 4]. There was no difference in the hemoglobin levels and blood transfusion requirements after delivery but hematocrit levels were higher in Turkish patients than in the Syrian patients (P = 0.04). Pre-eclampsia (P < 0.01), HELLP (P = 0.04), and placental anomalies (P = 0.01) were higher among Turkish patients. There was no difference between rates of preterm rupture of membranes, intrauterine growth restriction, oligohydramnios, and cholestasis.
Logistic regression analysis performed to identify the risk factors associated with the combination of unfavorable outcomes, including C-section delivery, pre and post-term births, pre-eclampsia, abruption placenta, HELLP, demonstrated that being a Turkish resident (OR: 2.527, 95% CI: 1.195-5.345, P = 0.01) was an important risk factor for development of unfavorable pregnancy outcomes. Moreover, maternal education of at least 12 years (OR: 0.833, 95% CI: 0.775-0.895, P = 0.03) and receiving regular antenatal visit at a tertiary center (OR: 0.907, 95% CI: 0.830-0.991, P = 0.03) were preventative for the development of unfavorable pregnancy outcomes [Table 5].
|Table 5: Risk factors associated with the combination of unfavorable outcomes including C-section delivery, pre and post-term births, pre-eclampsia, abruption placenta, HELLP|
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| Discussion|| |
There has been an ongoing civil war in Syria since 2011, and it is hard to say that problems will be resolved in a short period. Migration of huge numbers of people, being a refugee, and war conditions have the greatest negative effects on pregnant women. The required convenience to provide health services for Syrian refugees was increased by measures taken by the Turkish Ministry of Health.
Health services are provided both for those living in refugee camps and those living outside camps. Pregnancies of Syrian women are categorized in high-risk groups because these people have lower incomes and poor living conditions. Language problems and cultural differences prevent access to required reproductive health care. In addition, the communication problems of refugee women may be associated with maternal deaths and providing translators for refugees may reduce the number of poor pregnancy outcomes. The Turkish government gave permission for Syrian refugee physicians to serve in refugee camps which prevented the possible delay to access primary health services due to language difficulties. Compared to Turkish women, Syrian refugee women were younger and adolescent pregnancies were more common among Syrian refugees in this study. Supporting the existing evidence derived from previous studies on Syrian refugees settling in Turkey, we consider that cultural differences are the leading factors contributing to maternal age.,
Preterm and post-term births were higher in Turkish women compared with the Syrian women. According to a study conducted in the United States of America (USA), post-term births were found higher in Somalian-born women compared with US-born women. Literature findings are more contradictory for preterm births. A recent meta-analysis of 23 studies including over 20,000,000 subjects demonstrated that migrant women were at a greater risk of fetal-infant mortality and preterm births as compared with the general population.
In the present study, no difference was detected among the two groups regarding low birth weights (<2500 g). However, newborns below 1000 g were more prevalent among the Turkish residents when compared with that of the Syrian refugees. Nevertheless, few numbers of newborns below 1000 g in the two groups, makes it complicated to reach a clear conclusion whether being an immigrant is an advantage for newborn weights although current scientific evidence indicates being immigrants as a disadvantage for the newborn weight. Low birth weight and small for gestational age (SGA) infants were more frequent in India-born women in a study conducted in Canada. Similarly, a study conducted on Mexican immigrants revealed that the rate of low birth weight infants was significantly higher than newcomers who have lived in US for 5 years or less.
The hosting country may also affect pregnancy outcomes. A study compared pregnant refugee women regarding source countries (humanitarian and nonhumanitarian source countries) instead of comparing with them pregnant women of the hosting country, and less perinatal care, more post-term pregnancies, stillbirths, and birth outside the hospital were detected in humanitarian source countries. A population-based study conducted in Norway showed that Somalian pregnant women had the worst outcomes regarding emergency cesareans, post-term births, meconium-stained liquor, SGA infants; whereas Iraqi and Afghan-origin women had significantly worse outcomes regarding SGA infants.
Paradoxically, better pregnancy outcomes were detected in the refugee population in our study. Refugees are expected to have poorer living conditions and less access to primary health and pregnancy care compared with the control residents. The definition of the healthy immigrant effect tries to explain this paradox. The healthy immigrant effect, which can positively affect birth outcomes, is dependent on various variables such as country of origin, health policies in the hosting country, integration policies, and the period lived in a hosting country. Better pregnancy outcomes in refugees compared with native residents could be due to selective migration, which means unhealthy people could not migrate but healthy people were able to move to other countries. Psychosocial factors may affect adverse pregnancy outcomes such as SGA in refugees, and these risks can be decreased by lengthening the stay in the hosting country and by having social support opportunities. The incidence of post-traumatic stress disorder increased in asylum seekers and refugees. In addition, both physiologic and psychological stress may have adverse effects on pregnancy outcomes. Lifestyle changes, adaptation to a sedentary life, and diet changes due to longer periods of stay in a hosting country may decrease this protective effect over time.
No difference was detected regarding the newborn Apgar scores, stillbirths, and fetal anomalies. A poorer neonatal death rate was found in refugees compared with natives in a study conducted in Turkey. The stillbirth rate was found higher in refugee women in some other studies.
However, cesarean birth rates were higher in the Turkish population, no difference was detected regarding cesarean indications between the two groups. In addition, no significant difference was detected between the first cesarean and repeat cesarean rates. Thirty-three studies were analyzed in a meta-analysis published in 2016, and the overall CS rates were found to be higher in 30% of studies, lower in 17%, and mixed in 30%. Sub-Saharan African immigrants had higher cesarean risk and East European immigrants had lower cesarean risks in the same study. The underlying causes of increase in cesarean rates in immigrant groups could be due to poor living conditions, cultural, and language differences.,,
Although hematocrit levels were found lower in the Syrian group, hemoglobin levels were similar. Refugees and immigrants were found more anemic in similar studies.,, In their study, Bakken found that Somalian, Afghan, and Iraqi refugees were more anemic than the ethnic Norwegians. While pre-eclampsia, HELLP syndrome, and placental anomalies were higher in the Turkish group, no difference was detected between PPROM, IUGR, oligohydramnios, and cholestasis rates. The higher rate of pre-eclampsia and HELLP observed in Turkish residents compared to that of the Syrian refugees may be somewhat explained with less antenatal visits at a tertiary center in Turkish residents. Although access to a tertiary center has not been limited for both refugees and Turkish residents by government policies, it appears that majority of the Turkish residents preferred an antenatal follow-up at a primary care center most probably due to easy access, shorter wait time, and familiar approach of the primary care physicians and staff instead of a tertiary center which provides a comprehensive antenatal diagnosis for complex perinatal conditions including pre-eclampsia and HELLP at the expense of complicated access, longer waiting time, and communicating with a group of more ceremonial staff. Moreover, the education level of the Syrian refugees was more favorable than the education level of the Turkish participants which could somewhat be explained by the location of the Turkish residents which was a lower-income urban area and a substantial amount of children living in this area were leaving school to start working, at early stages of their lives. Thus, we consider that the higher education level noted in Syrian refugees compared to that of the Turkish participants might also have influenced their choice for antenatal follow-up at a tertiary center.
The limitations of our study are that the study sample was small and it was a retrospective study. More comprehensive community-based studies are required on this subject. Turkey has accepted the highest number of Syrian refugees who have been giving birth in Turkey. We did not identify the expected poor obstetric outcomes in our study. Refugees have been living for a relatively long period in Turkey, hence they have no difficulty in accessing health care services and free health services are provided for these people.
| Conclusion|| |
Results of the present study demonstrate that adverse pregnancy outcomes are less prevalent in Syrian refugees compared to that of the Turkish resident which is likely due to the contribution of maternal education and regular antenatal visits which were higher in Syrian refugees. We suggest that providing adequate education particularly for women in under developed countries and facilitating access to the tertiary hospitals, have the potential to reduce the unfavorable pregnancy outcomes in immigrant women.
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Declaration of patient consent
Informed consent was obtained from all individual participants included in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
İçduygu A, Millet E. Syrian refugees in Turkey: Insecure lives in and environment of pseudo-integration. Istituto affari internazionali; Koç University, Istanbul 2016.
Demirci H, Topak NY, Ocakoglu G, Gomleksiz MK, Ustunyurt E, Turker AU. Birth characteristics of Syrian refugees and Turkish citizens in Turkey in 2015. Int J Gynecol Obstet 2017;137:63-6.
Betts A, Loescher G, Milner J. The United Nations High Commissioner for Refugees (UNHCR): The Politics and Practice of Refugee Protection. Routledge Taylor&Francis Group, London and New York; 2013.
Ekmekci PE. Syrian refugees, health and migration legislation in Turkey. J Immigr Minor Healt 2017;19:1434-41.
Merry L, Semenic S, Gyorkos TW, Fraser W, Small R, Gagnon AJ. International migration as a determinant of emergency caesarean. Women Birth 2016;29:e89-98.
Betancourt GS, Colarossi L, Perez A. Factors associated with sexual and reproductive health care by Mexican immigrant women in New York City: A mixed method study. J Immigr Minor Healt 2013;15:326-33.
Maria da Conceição FS, Figueiredo MH. Immigrant women's perspective on prenatal and postpartum care: Systematic review. J Immigr Minor Health 2015;17:276-84.
Degni F, Suominen S, Essén B, El Ansari W, Vehviläinen-Julkunen K. Communication and cultural issues in providing reproductive health care to immigrant women: Health care providers' experiences in meeting Somali women living in Finland. J Immigr Minor Healt 2012;14:330-43.
Erenel H, Mathyk BA, Sal V, Ayhan I, Karatas S, Bebek AK. Clinical characteristics and pregnancy outcomes of Syrian refugees: A case–control study in a tertiary care hospital in Istanbul, Turkey. Arch Gynecol Obstet 2017;295:45-50.
Güngör ES, Seval O, İlhan G, Verit FF. Do syrian refugees have increased risk for worser pregnancy outcomes? Results of a tertiary center in Istanbul. Turk J Obstet Gynecol 2018;15:23.
Johnson EB, Reed SD, Hitti J, Batra M. Increased risk of adverse pregnancy outcome among Somali immigrants in Washington state. Am J Obstet Gynecol 2005;193:475-82.
Higginbottom GM, Morgan M, Alexandre M, Chiu Y, Forgeron J, Kocay D, et al
. Immigrant women's experiences of maternity-care services in Canada: A systematic review using a narrative synthesis. Syst Rev 2015;4:13.
Guendelman S, English PB. Effect of United States residence on birth outcomes among Mexican immigrants: An exploratory study. Am J Epidemiol 1995;142(Suppl 9):S30-8.
Gibson-Helm ME, Teede HJ, Cheng IH, Block AA, Knight M, East CE, et al
. Maternal health and pregnancy outcomes comparing migrant women born in humanitarian and nonhumanitarian source countries: A retrospective, observational study. Birth 2015;42:116-24.
Bakken KS, Skjeldal OH, Stray-Pedersen B. Immigrants from conflict-zone countries: An observational comparison study of obstetric outcomes in a low-risk maternity ward in Norway. BMC Pregnancy Childbirth 2015;15:163.
Gissler M, Alexander S, MacFarlane A, Small R, Stray-Pedersen B, Zeitlin J, et al
. Stillbirths and infant deaths among migrants in industrialized countries. Acta Obstet Gynecol Scand 2009;88:134-48.
Merry L, Vangen S, Small R. Caesarean births among migrant women in high-income countries. Best Pract Res Clin Obstet Gynaecol 2016;32:88-99.
Rio I, Castello A, Barona C, Jane M, Mas R, Rebagliato M, et al
. Caesarean section rates in immigrant and native women in Spain: The importance of geographical origin and type of hospital for delivery. Eur J Public Health 2010;20:524-9.
Trinh LTT, Assareh H, Achat H, Chua S, Guevarra V. Caesarean section among immigrants with different obstetrical risks. Int J Nurs Pract 2018;24:e12638.
Verga ME, Widmeier-Pasche V, Beck-Popovic M, Pauchard JY, Gehri M. Iron deficiency in infancy: Is an immigrant more at risk? Swiss Med Wkly 2014;144:w14065.
David M, Borde T, Brenne S, Ramsauer B, Henrich W, Breckenkamp J, et al
. Comparison of perinatal data of immigrant women of Turkish origin and German women–results of a prospective study in Berlin. Geburtshilfe Frauenheilkd 2014;74:441-8.
Philibert M, Deneux-Tharaux C, Bouvier-Colle MH. Can excess maternal mortality among women of foreign nationality be explained by suboptimal obstetric care? BJOG 2008;115:1411-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]