Pregnancy outcome of migrant women and integration policy: A systematic review of the international literature
Introduction
Almost 20 million persons in Western Europe are immigrants, persons who live in a country other than the one of which they are citizens, most of them from former colonies, from Mediterranean countries, and from the countries of Central and Eastern Europe. Overall, immigrants are a disadvantaged group, living in an especially unfavourable socio-economic situation and often confronted with a discriminatory social atmosphere, which affects their health (Menke et al., 2003). Even if variability exists among ethnic groups, the reproductive health of immigrant women is often rather unsatisfactory, although one would expect that their interaction with the sophisticated health system available in Western receiving countries should produce pregnancy outcomes at least as good as those of native women. Furthermore, a number of studies documented that the differences in pregnancy outcome between immigrant and native women persisted even after adjustment for possible confounding factors, both biological and socio-economic (Balarajan, Raleigh, & Botting, 1989a). It has been posited that immigration stress, the rupture of previous social networks, low socio-economic status, poor access to health care services, and discrimination within the health system, alone or in combination, may interact to produce poorer outcomes in immigrant than in native communities (Bender, Rivera, & Madonna, 1993). Conversely, immigrants may have a health advantage because they represent the fittest segment of their community or may benefit from protective factors typical of the cultural and social background of the country of origin (Mc Glade et al., 2004).
Whatever factors are at work, pregnancy outcome of immigrant women varies considerably across European countries: for example, it is similar to that of native women in Sweden and Norway, while it is more unfavourable in the UK and Italy (Harding et al., 2004, Miceli & Di Lallo, 1996, Oldenburg et al., 1997, Stoltenberg & Magnus, 1995). These differences occur in spite of the fact that the paradigm of economic immigration is rather similar across receiving states (Bollini & Siem, 1995, Margetts et al., 2002).
Although the granting of citizenship represents the ultimate form of integration, any purely normative step towards integration of immigrants would prove insufficient in the absence of a composite social development process characterised by tolerance and equity (Spencer, 2004). In this work we consider naturalisation rate as a proxy of such a latent complex mechanism: a high naturalisation rate would be proper of a society with higher levels of sensitivity to the needs of immigrant communities (Castles & Davidson, 2000).
Receiving countries have shown different attitudes towards immigration and the health and welfare of immigrant communities (Bollini, 1995). Although it is difficult to make generalizations, countries have adopted either a “passive” attitude, in which immigrants are expected to fit in the receiving society without the support of specific policies, or an “active” attitude, where steps are taken to acknowledge cultural differences and specific needs, complemented by special forms of services. Among the active initiatives that governments adopt are policies aiming at increasing the social participation and integration of immigrant communities in the receiving societies. The effect of integration policies on the health of immigrant communities, and in particular on pregnancy outcome, may be studied using a comparative approach across several receiving countries. To explore this issue, we have reviewed all quantitative studies comparing pregnancy outcome of immigrant and native women in Europe. The main hypothesis to be tested by this study is whether the differences in pregnancy outcome that we observe across receiving countries may be associated with the varying degree of implementation of integration policies. In this perspective, a strong integration policy has to be seen as a sign of a broader social process, often latent, entrenched in the societal fabric of the host country, fostering equity and social cohesion.
Section snippets
Bibliographic search and study selection
Epidemiological studies (cross-sectional studies, case-control studies, or follow-up studies) conducted in European countries comparing pregnancy outcomes of immigrant and native women were the main source of evidence for this review. The Medline database was searched in June 2004 with the following Medical Subject Headings (MeSH) terms which were “exploded” in order to retrieve both the general concept and also all the subordinate subjects: emigration and immigration; ethnic groups; infant
Results
Of the 65 studies retained for this analysis, 47% were published between 1990 and 2004, 34% in the 1980s, and 19% in the 1970s and before. The United Kingdom, France, Sweden and Austria started publication earlier than other European countries (before the 1990s), probably due to both early immigration and heightened attention to reproductive health of immigrants.
All studies but 4 were cross-sectional. Information came most frequently from the analysis of records of single hospitals (27
Discussion
Infant and perinatal mortality, as well as other indicators of birth outcome such as low birth weight and preterm delivery, are the net effect of a number of biological and social factors that influence the health status of children, the weakest members of our societies. While indicators of reproductive health have progressively improved over the last decades, in some disadvantaged groups such improvement has been less marked than in the general population. With data assembled from over 18
Acknowledgements
We would like to thank Loes van Willigen, Camilla Stoltenberg, Salvatore Geraci, Maurizio Marceca, and Nils Sandöe for information on the ethnic health policies of their respective countries. We also wish to thank Christa Gaspoz, Rogelia Métrailler, and Fabienne Stants for their kind assistance with translation. We are grateful to the Organisation for Economic Co-operation and Development, in particular to Pauline Fron, for having kindly made available the naturalisation rates data. The study
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