Course BASIC_Graduate level learning material about the challenges of human reproductive medicine in a changing Europe

2021-1-HU01-KA220-HED-000027613 - COHRICE

SYLLABUS

Pre-pregnancy care and pregnancies related to minority ethnic groups - especially Roma ethnicities, migrants from Africa and Asia

(Basic level)

A brief overview of the Social background

According to data from the European Parliament, the Roma minority is the largest ethnic minority in Europe. Their population is estimated to be around 10-12 million, with approximately 6 million living in EU countries. However, it is difficult to determine their exact numbers.

Within a narrower geographical region, there are significant social and cultural differences among individual Roma communities. The lack of data on specific Roma communities makes it challenging to form an accurate picture of their socio-economic situation.
Despite their presence for centuries—primarily in Eastern Europe—their integration is incomplete, and significant cultural differences remain between Roma and the majority society.
For nearly 30 years, the EU has been promoting the integration of Roma communities and addressing social exclusion and negative discrimination, particularly in four key areas: education, employment, healthcare, and housing.
In terms of proportion, the largest Roma community lives in Romania. Consequently, this lecture material primarily focuses on the Romanian experience and reflects the majority perspectives of the Romanian and Hungarian universities participating in the project.

This lecture aims to equip students with knowledge that will bring them closer to specific problems that they may later face personally. Since its inception, midwifery has always had a strong social dimension. The need to assist in childbirth is almost as old as mankind, which is even more so in the case of a doctor. Our society is becoming increasingly complex, with more and more ethnic minorities. Prominent among these minorities in our region is the Roma minority, which has been living alongside various European societies for centuries, and new ethnic groups with different cultural roots are beginning to emerge, as a result of migration in recent years. In order to provide adequate reproductive care and to understand the particularities of obstetric care, it is necessary to get to know the specificities of the Roma popular culture and society. Also, migration is increasing worldwide. Migrants move to high-income countries for a variety of reasons. On the one hand, individuals migrate to improve their employment opportunities (so-called labor migration), while on the other hand, individuals are forced to migrate due to conflict, human rights violations or persecution.

While a diverse population bears important chances for economic development, inequalities in pregnancy and childbirth outcomes and disparities in access to gynecology services between migrants and non-migrants have been reported internationally with a higher maternal and infant mortality among women from minority groups and migrants in comparison to their national peers.    In order to provide adequate obstetric care and to understand the specificities of obstetric care, it is necessary to get to know the specificities of the Roma society.

What are the specificities of relevant minorities in Europe?

Although they have been present in Eastern Europe in particular for centuries, their integration is practically complete and very significant cultural differences remain between Roma and their host nations. Obviously, these cultures have influenced each other, and therefore there are large cultural differences within Roma communities even within a relatively narrow geographical region.

 What are the pressure to minority ethnic group to conform to the community culture?

 In this region, underage marriages are commonplace among well-off Roma families. They are bound by law, so to speak. Although, according to the law, sexual intercourse with a minor is a criminal offence, but only if the perpetrator is not a minor. They take advantage of this by marrying them off early. The family discusses the marriage (prearranged marriage). Sometimes so early that the girl hasn't even had her period yet. Until then, she sleeps with her mother-in-law and only moves into her husband's room after menstruation. In all cases, the daughter moves in with her mother-in-law and from that moment on she is under her mother-in-law's command. Only the mother-in-law brings her to the doctor. She cannot come alone or with her mother because they are not trusted. If there is a good relationship between the families, the girl's mother can come. Any infertility or other defects are hidden. They don't wait more than a year, they want an immediate result. The marriage must show results in a short time. If there are no children within a year or two, they are separated.

What factors affect access to reproductive health services for ethnic minorities and migrants?

Language barrier

The language barrier is one of the main obstacles to accessing care. Women described their inability to speak local language as a major source of anxiety, and they feared misinterpretation or misunderstanding. The provision of a skilled interpreter is important but sometimes few participants will use those professional interpreter services mainly due to a lack of awareness of its existence or due to the belief that costs would emerge. Mainly family members or friends served as interpreters, and most of the participants experienced the services of a family member as an interpreter as sufficient. However, some women recognized the difficulties of unskilled interpreters, especially in complicated medical situation. Family members or friends who served as interpreters are not always able to correctly translate either due to difficulties in translating the medical vocabulary or due to their personal emotions.

Lack of information

It is important to receive information to understand the health services, which are provided in the host country. Therefore, the lack of information appeared as another main barrier. Two different reasons emerged: either because participants did not understand the provided information due to language barriers or because they never received any information.

Members of vulnerable groups will consult with a gynecologist only in the case of medical problems, which is sometimes due to time or financial constraints (see financial acceptability), but often women are not aware of available preventive health services. Women who migrated from countries where prevention is less known and provided stated that it would have been helpful for them to receive information about preventive services from their health care providers. Women perceived a form of information as crucial to better understand, access and utilize reproductive health care services. Health care providers should provide them with the essential information, especially about available preventive services such as cervical cancer screening or family planning advice.

In addition to the information provided orally by direct contact with health or social professionals, the provision of written information material in multiple languages is essential to facilitate access and navigate through the health system. The Internet can be as a valuable source of information, especially the opportunity to search for information in their maternal language.

Financial acceptability

Among highly vulnerable groups as minorities and migrants costs is one of the most important barrier to health care. Even if they have health insurance, the costs of high deductibles or copayments are often mentioned as a barrier to visiting the doctor, which is especially the case for preventive services.

Embarrassment and other cultural issues

Embarrassment is a personal barrier explaining why women did not access especially preventive gynecology services such as cervical cancer or breast cancer screening. Most women perceived pelvic and vaginal examinations for cervical cancer screening as inconvenient and often painful. One must accept that many women grew up experiencing the female body as taboo.

Furthermore, women experienced discomfort when health care providers were not aware of their traditions and feel distress when women could not consult with a female doctor.
One important personal barrier influencing access to health services that has been outlined by previous studies is social isolation – in Roma culture a young female may have restricted access to services because she cannot walk outside the household alone.

Factors influencing patient satisfaction - Real or perceived discrimination

Members of minority groups and migrants sometimes feel that they did not receive the same attendance as local women. Real or perceived discrimination in the health sector was rarely mentioned with respect to the doctor-patient relationship; it was mainly expressed concerning reception at the registration desk prior to the clinical appointment.

Perceived inadequate provision of health services

In addition to the perceived lack of adequate culturally competent care (see embarrassment), women experienced the process of adhering to appointments for regular obstetric or gynecology visits as very difficult. In several cases, they had to wait several weeks for their appointments, and they complained of long waiting times even in the case of emergency situations.

What do we mean by pre-pregnancy counseling?

 Pre-pregnancy counseling is only available for the well-off strata. For those on the margins of society, this type of care is practically non-existent. The main reason is the lack of adequate education, they often drop out of school. The well-off are in a hurry to have children. They are impatient. They usually want results within a year. At this stage the body is often underdeveloped. In many cases, the patient is so young that they do not yet have regular menstrual cycles and are still struggling with juvenile uterine bleeding. There are relatively many with PCOS (polycystic ovary syndrome). In many cases this is the cause of primary sterility. In other cases, if PCOS persists it is untreated progressive course and secondary sterility occurs after 1-2 children are born relatively prematurely. It cannot arise that the husband is at fault for any infertility.
What do we mean by pregnancy care?

If pregnancy does occur: there is a strong need to know the sex of the newborn as soon as possible. Especially in the case of girl fetuses, there is a refusal to accept the pregnancy, because many girls in the family require greater financial sacrifice for the dowry. With the spread of NIPT-type tests, it is possible to take advantage of this. In some countries, abortion on request is allowed up to 13 weeks and is abused and selective abortion is sought.

Underage pregnancies are common in families living on the periphery of society due to family disorder and lack of education. The phenomenon of school drop-out is common. Contraception is out of the question without adequate knowledge. Although the WHO has included the right to procreation among the fundamental human rights, without adequate knowledge and conditions, contraception is not available. In other cases, early pregnancy and childbirth are the reasons for dropping out of school. In the US, too, only 1.5% of women who have given birth under the age of 18 will have completed tertiary education by the age of 30. For those living in poor social conditions, unwanted pregnancy is usually the case. Without proper education and knowledge, pregnancies are not detected in time. When it is no longer possible to terminate the pregnancy on request, the pregnancy is often excluded by the family. Prenatal care is either non-existent or more than incomplete in most cases. This carries the risk of some otherwise avoidable complications.

What do we mean by prenatal care?

 For those in good social circumstances, where they are obliged by law to have children early, prenatal care is regularly provided, but accompanied by the mother-in-law. They usually want to do everything possible to ensure a good pregnancy outcome. They often demand some kind of treatment, even if it is not due. They ask for vitamins, antibiotic treatment, etc. It is not the pregnant woman who is demanding it, but her environment. It is not uncommon to visit several doctors in succession and compare opinions. The reason for these migrations between doctors is often due to disagreements within the family.

People in poor social situations often lack prenatal care altogether. They are late in coming to the health system, usually only because of some complication related to pregnancy. Because they do not have their pregnancy followed up, the complications that do arise often reach the health system unprepared.
The care of these young pregnant women requires increased attention, as they often suffer from abnormalities both in pregnancy and during childbirth.

What maternal diseases are associated with pregnancy?

Teenage pregnancies, especially those in poor social conditions, are more likely to be affected by anaemia during pregnancy. This anaemia leads to a reduction in the mother's immune system and an increased susceptibility to infections. In these cases, there is a higher incidence of postnatal complications if the pregnancy is terminated by caesarean section, and a poorer tendency to wound healing after surgery. The fetal consequences of iron deficiency anaemia are more frequent premature births and, in severe cases, fetal growth retardation.

However, in juvenile pregnancies, preeclampsia and consequent intrauterine fetal retardation are more common. In preeclampsia, the necessary increase in uteroplacental perfusion is not achieved, resulting in impaired fetal weight gain due to placental insufficiency. However, ethnic characteristics are also associated with the development of fetal retardation, as in our country the Roma ethnic group has a lower birth weight.

What are the particular characteristics of childbirth the minority ethnic groups?

They don't insist on a caesarean section, as long as everything goes well. People in good social circumstances are usually disciplined at delivery, while those on the periphery of society who have not been to antenatal care at all often lose their heads and behave aggressively. They are completely desperate in a new environment that is so alien to them. Those who have never even seen a doctor's surgery are obviously unable to adapt to the hospital stones.

Why is important the childbirth guidance?

When you are admitted to the maternity ward, a detailed obstetric examination and anamnesis is very important, because you need to be prepared for any surprises. Often this is the first contact between the doctor and the birth mother. Good communication skills on the part of the doctor are very important to gain the patient's trust. A detailed obstetric examination is important because it is often only at this time that any serious complications become apparent in the absence of prenatal care.

Which are the abnormalities during labor and delivery?

The smooth progress of labor requires adequate uterine activity. In very young first-time mothers, genital hypoplasia is common, resulting in primary pain weakness. In this case, the contractions are weak, irregular, infrequent and ineffective from the onset of labor. The underdeveloped body associated with young maternal age and a narrow pelvis, which may be the cause of a spatial imbalance, may result in secondary pain weakness. In such cases, the contractions may be of adequate intensity and frequency at the beginning of labor, but they become weaker and more irregular later in labor. Both primary and secondary labor pains are associated with prolonged labor and obstructed labor. The complications of prolonged labor can harm both mother and fetus. Often this pain weakness, which does not respond to treatment, is an indication for obstetric surgery.

Unmarried marital status, lower educational attainment, often poor social situation and late initiation of antenatal care all affect the pregnancy and the pregnancy, with an increased incidence of prematurity and intrauterine growth retardation.

In addition, the underdeveloped body associated with young maternal age, associated uterine hypoplasia or a possible uterine malformation also play a role in the pathogenesis of preterm birth.

The underdeveloped body, or more precisely the underdeveloped bony pelvis, is responsible for the occurrence of spatial disproportion in these women. The difference in the size of the pelvis and the skull clearly rules out the possibility of vaginal delivery. In addition to the narrow pelvis, there are also abnormalities of positioning, posture and alignment, which, together with the narrow pelvis, also lead to abnormalities.

In these cases, when the imbalance makes vaginal delivery impossible, a caesarean section is the solution.
According to data from the National Institute of Statistics, almost 20,000 underage girls become mothers in Romania every year, which puts the country at the top of the European Union in terms of the number of mothers of girls.

In the last ten years (2011-2020), there have been 17143 births at the Tîrgu- Mureș County Emergency Hospital, 900 of which were to mothers under 18 years of age, representing an incidence of 5.24%.

Within this, further dividing the underage mothers into groups, we found that the age group 12-13 years represents 4.55%, the age group 14-15 years represents 38.22%, while the age group 16-17 years represents 57.22%.

In terms of their origin, the vast majority of these teenage mothers, 82.77%, are of rural origin and from poor social situations.

The inadequate social background is also reflected in their lack of schooling, as 95.77% of these girl mothers are uneducated.

Most of the underage mothers grew up in families where their mothers also gave birth as minors, in most cases to many children. This is also reflected in the statistics of our clinic, of these underage mothers, primipara occurred in 83.11%, secundipara in 14.77% and tercipara in 2.11%.

Which are the particularities of puerperium?

In those with increased anaemia, attention should be paid to the management of anaemia.

It is now rare, however, that a previously undetected congenital cardiac malformation in a young mother who has been in contact with health care in the context of childbirth may decompensate in the puerperium.

Pre-eclampsia pregnant women sometimes have eclampsia in the first days of puerperium, even in cases where it did not occur during pregnancy.

Very often they leave the hospital without the doctors' consent, leaving the newborn in the hospital. In most cases, this is not because they are not prepared to take on the care of the child, but simply because they do not have the patience to stay in hospital in cases where the care of the child will take a long time.  If the child is premature and has to spend a lot of time in hospital, the mother often leaves because there is no one else at home to look after the other children. When the newborn baby reaches the stage where it can be discharged and is brought home to the mother, with very few exceptions, it is taken over and cared for properly.

 

 

 

Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union or the Foundation for the Development of the Education System. Neither the European Union nor entity providing the grant can be held responsible for them.