Global migration is at an all-time high with implications for perinatal health. Migrant women, especially asylum seekers and refugees, represent a particularly vulnerable group. Understanding the impact on the perinatal health of women and offspring is an important prerequisite to improving care and outcomes. The aim of this systematic review was to summarise the current evidence base on perinatal health outcomes and care among women with asylum seeker or refugee status.
The Remaining: Refugees download pdf
Gobalisation, poor living conditions, war and conflict are major factors contributing to forced migration. In 2016, the number of people displaced by conflict and persecution worldwide was estimated to be 65.6 million. Of these 2.8 million were estimated to be asylum seekers and 22.5 million refugees, which the United Nations High Commissioner for Refugees (UNHCR) suggests is the highest level ever recorded [1]. Among this population, 49% of refugees were women, a similar proportion as reported annually since 2003 [1]. The impact of migration on health is far-reaching, making migrant populations particularly vulnerable, fuelling health inequalities and resulting in serious implications for global health.
Electronic bibliographic databases were searched using PICOS criteria: Population (asylum seekers or refugees); Intervention (pregnancy); Comparator (non-asylum seekers or refugees for quantitative reviews only, no comparator group required for qualitative reviews); Outcome (defined as selected perinatal health outcomes or care); Study design (quantitative, qualitative or mixed methods systematic reviews). A search strategy for database-specific search terms and subject headings was developed with the support of an information scientist for the databases MEDLINE, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature, JBI database, PROSPERO, Cochrane Database of Systematic Reviews, Google Scholar, Science Direct, Web of Science, PubMed and ProQuest (see Additional file 2 for database search terms).
Clearly stated that women with asylum seeker or refugee status were populations within the included studies. This included reviews of migrant women where asylum seekers and refugees were part of the included population
We implemented a process of systematically extracting data which was directly relevant to women with asylum seeker and refugee status for all of the systematic reviews which combined data from multiple populations in their syntheses (e.g. migrants including asylum seekers and refugees). This involved two stages of searching for relevant data in the tables, figures and narrative in the results, discussion and conclusions sections of the included systematic reviews. First, the relevant sections of the reviews were searched for data that the authors had explicitly described as being relevant to asylum seeker or refugee populations, and these data were extracted. The second stage involved identifying whether any of the included studies in the systematic reviews were exclusively among asylum seeker or refugee populations. When studies which were exclusively among these populations were identified, data were extracted for any results which had cited these studies as part of the evidence base which informed that specific result. This second stage was only carried out if we were confident that the population of the included study were exclusively asylum seekers and/or refugees; for example, data were not extracted for studies which included migrants and refugees, as we could not be confident that the data that had informed the result originated from women who were migrants or refugees.
Evidence synthesis in systematic reviews of systematic reviews should provide a summary of existing research syntheses in tabular format with a more detailed narrative description of the systematic review characteristics and relevant quantitative and qualitative results [12]. The results have therefore been summarised in tables to describe the characteristics of the included systematic reviews, results for overall populations included in the systematic reviews and also results explicitly relevant to women with asylum seeker and refugee status. Tables are supplemented with a narrative discussion of the included systematic reviews grouped by the review themes of perinatal health outcomes and perinatal healthcare access and experiences for women who are migrants and for asylum seekers and refugees. Each theme has several data-driven sub-themes. As per reporting recommendations [12], any overlap in original research studies in the included systematic reviews is reported in the results table and narrative for the asylum seeker- and refugee-specific data. Evidence synthesis was carried out in duplicate. The first stage of synthesis was performed by JR, HB and AP to group the systematic review data into the review themes and to provide a descriptive summary of the topic-specific data. The second stage involved NH validating the review themes and performing a detailed synthesis of sub-theme data reported in the systematic reviews.
Twenty-two of the included systematic reviews either explicitly reported results relevant to women with asylum seeker or refugee status, or they cited studies where the participants were exclusively women with asylum seeker or refugee status [5,6,7,8,9,10,11, 14, 16, 18,19,20, 23, 27,28,29,30,31,32,33,34, 36]. In total, the reviews cited 54 studies, although there was some overlap in the original studies relevant to asylum seekers and refugees included in the systematic reviews and used to inform the analyses (Additional file 5); data from 43 unique studies were cited by these 22 systematic reviews. Eight systematic reviews use primary data that view asylum seekers and refugees as separate sub-groups [5, 6, 16, 18, 19, 23, 30, 36]. Five systematic reviews [7, 9,10,11, 34, 36] combine asylum seekers and refugees as a sub-group of the migrant population. Seven systematic reviews [8, 20, 27,28,29, 32, 33] use primary data solely involving refugees. Two systematic reviews [14, 31] use primary data looking at asylum seekers only. Seven systematic reviews [17, 21, 22, 24,25,26, 35] do not distinguish asylum seekers and refugees from other types of immigrants in their analysis.
Fourteen systematic reviews reported perinatal health outcomes for asylum seeker and refugee populations [5,6,7, 14, 16, 18,19,20, 23, 27,28,29,30, 36]. Perinatal health results are presented for perinatal mental health, offspring mortality, mode of delivery, birth weight, preterm birth and additional morbidities. Perinatal mental health was reported most frequently by the systematic reviews. No data specific to asylum seekers or refugees were reported for maternal mortality or congenital anomaly outcomes.
Three systematic reviews reported risk factors for the development of perinatal mental health disorders specifically relevant to asylum seekers and refugees [6, 18, 19]. Fellmeth et al. [6] reported data from Matthey et al. [45] which showed statistically significant associations between anxiety and the number of premigration traumatic events experienced or witnessed, but no association with anxiety or post-traumatic stress disorder and history of living in a refugee camp prior to resettlement. Collins et al. [18] and De Maio [19] presented data from Stewart et al. [37] which found that refugees and asylum seekers had significantly lower social support than women in the host country of Canada (p
Two systematic reviews [14, 29] reported data for low birth weight (LBW) and intrauterine growth retardation using data from five original studies [40, 49, 59,60,61]. Villalonga-Olives et al. [29] reported no difference in LBW between refugee populations in Ireland or undocumented Latina migrants in the USA and women in the host countries (data from Kelaher and Jessop [61] and Lalchandani et al. [49]). However, Somali refugees in Belgium, Canada, Finland, Norway and Sweden had lower rates of LBW compared with women in the host countries (data from Small et al. [59]). Hadgkiss and Renzaho [14] reported prevalence of intrauterine growth restriction to be one of the most prevalent outcomes amongst women who were seeking asylum, 7% of the population (data from Kurth et al. [40]; no comparison data were reported for women in the host countries).
Two systematic reviews [14, 27] reported preterm birth amongst women who were refugees using data from two original studies [40, 54]. Hadgkiss and Renzaho [14] reported premature labour to be one of the most prevalent outcomes in women seeking asylum at 15% of the population (data from Kurth et al. [40]), and Gissler et al. [27] reported that women who were displaced from the former Yugoslavia had higher preterm rates than women in the host country (data from Nedic et al. [54]).
Two systematic reviews [14, 30] reported additional maternal morbidities and data from six original studies [40,41,42, 55, 56, 62]. The additional morbidity outcomes reported for women with asylum seeker and refugee status (eclampsia, obstetric haemorrhage and maternal infections) are similar to those reported for migrant women (placental dysfunction, postpartum haemorrhage and maternal infection). There were additional data reported explicitly for women with asylum seeker and refugee status that were not reported for migrant women (including asylum seekers and refugees) showing increased risk of severe acute maternal morbidity (SAMM), gestational diabetes, anaemia and uterine rupture. There was a lack of data explicitly for women with asylum seeker and refugee status and offspring infection and admission to special care units. Hadgkiss and Renzaho [14] reported that asylum seekers faced a range of complex obstetric issues including bleeding, gestational diabetes, anaemia, 4.5 times higher incidence of SAMM than the general obstetric population (31.0 vs 6.8 per 1000 births), uterine rupture (15 vs 8.4%) and eclampsia (27.5 vs 9.1%); but lower incidence of obstetric haemorrhage (42.5 vs 63.3%) (data from Kurth et al. [40], Goosen et al. [55], Rogstad and Dale [56], Van Hanegem et al. [62]). Baalam et al. [30] reported poor health amongst women with asylum seeker and refugee status which caused complications for the women and the newborn babies, including infected wounds, HIV and hepatitis (data from Kennedy and Murphy-Lawless [41] and McLeish [42]). 2ff7e9595c
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