title: Suboptimal care and maternal mortality among foreign-born women in Sweden: maternal death audit with application of the 'migration three delays' model.
abstract: BACKGROUND
  Several European countries report differences in risk of maternal mortality between immigrants from low- and middle-income countries and host country women. The present study identified suboptimal factors related to care-seeking, accessibility, and quality of care for maternal deaths that occurred in Sweden from 1988-2010.
  
  
  METHODS
  A subset of maternal death records (n = 75) among foreign-born women from low- and middle-income countries and Swedish-born women were audited using structured implicit review. One case of foreign-born maternal death was matched with two native born Swedish cases of maternal death. An assessment protocol was developed that applied both the 'migration three delays' framework and a modified version of the Confidential Enquiry from the United Kingdom. The main outcomes were major and minor suboptimal factors associated with maternal death in this high-income, low-maternal mortality context.
  
  
  RESULTS
  Major and minor suboptimal factors were associated with a majority of maternal deaths and significantly more often to foreign-born women (p = 0.01). The main delays to care-seeking were non-compliance among foreign-born women and communication barriers, such as incongruent language and suboptimal interpreter system or usage. Inadequate care occurred more often among the foreign-born (p = 0.04), whereas delays in consultation/referral and miscommunication between health care providers where equally common between the two groups.
  
  
  CONCLUSIONS
  Suboptimal care factors, major and minor, were present in more than 2/3 of maternal deaths in this high-income setting. Those related to migration were associated to miscommunication, lack of professional interpreters, and limited knowledge about rare diseases and pregnancy complications. Increased insight into a migration perspective is advocated for maternity clinicians who provide care to foreign-born women.
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, SE-751 85 Uppsala, Sweden. annika.esscher@kbh.uu.se.
authors.forename: Annika
authors.initials: A
authors.lastname: Esscher
authors.forename: Pauline
authors.initials: P
authors.lastname: Binder-Finnema
authors.forename: Birgit
authors.initials: B
authors.lastname: Bødker
authors.forename: Ulf
authors.initials: U
authors.lastname: Högberg
authors.forename: Ajlana
authors.initials: A
authors.lastname: Mulic-Lutvica
authors.forename: Birgitta
authors.initials: B
authors.lastname: Essén
mesh_terms: D000328:Adult; D003644:Death Certificates; D054242:Emigrants and Immigrants; D005260:Female; D006801:Humans; D063130:Maternal Death / Q000706:statistics & numerical data*; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008428:Maternal Mortality / Q000639:trends; D008875:Middle Aged; D015233:Models, Statistical; D011247:Pregnancy; D011248:Pregnancy Complications / Q000208:ethnology*; D012189:Retrospective Studies; D012307:Risk Factors; D012959:Socioeconomic Factors; D013548:Sweden / Q000453:epidemiology; D055815:Young Adult
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