Prevalence of Chronic Diseases in Immigrant and Native-Born Women in Spain During Pregnancy. A Retrospective, Observational Study

    

    

    Figure 6: Multivariate model according to Maghreb origin compared with autochthonous population.
    

Discussion

We analyzed a sample of 17177 pregnant women representing the 86% of the total of pregnant women in the health region of Lleida. The highest percentage of women come from West Europe and the lower percentage from Asia and the Middle East. Besides, Eastern Europe women were the younger while the older were from West Europe.

Sub Saharan Africa women have the highest prevalence of hypertension, furthermore, the prevalence of diabetes mellitus and obesity was observed in these women together with Maghreb’s women.

The multivariate model according to country of origin compared with autochthonous population (West Europe) shows an increased risk of overweight and obesity in Sub Saharan, Maghreb, and Latin America population. Asian and the Middle East and Maghreb women had a higher risk of diabetes mellitus while being from Latin America and Eastern Europe has a protective effect for this disease. Only Sub-Saharan Africa women have increased risk of hypertension. Finally Sub-Saharan Africa, Asian and the Middle East and Maghreb had lower risk of depression compared with autochthonous population.

In our study the sub-Saharan Africa women present more comorbidity than other population, Brown et al. study, carried out in 2020 and which analyzes the risk of severe maternal morbidity among 1.280.925 delivery hospitalizations among women of different races, also confirms that deliveries among black women had a rate of maternal morbidity of 225,7 per 10.00 compared to 104,7 per 10.000 white women (OR 2,2, 95% CI 2,1-2,3). Brown et al. also demonstrates that 7% of black women had three or more comorbidities, compared to 4% of white women, 4% of Hispanic women and 3% of Asian women, this fact is also observed in our study, where African women (both sub-Saharan and Maghreb women) have a higher prevalence of obesity, hypertension, and diabetes mellitus [22].

Admon et al. [23] shows in his study that women with multiple chronic conditions have 3.8 times the rate of severe maternal morbidity and mortality compared to women without chronic conditions. In our study, Sub-Saharan women have more prevalence of comorbidities than other women and have more risk in pregnancy, almost 50% of the patients do not present any risk of pregnancy except the Sub-Saharan Africa women where only 37,9% were free of risk.

Furthermore, Metcalfe et al. developed a study in USA from 1993 to 2012, which concluded that women of minority race and ethnicity are at a higher risk of having chronic conditions during pregnancy, despite an overall increase in rates of chronic conditions among all pregnant women, with the difference in prevalence of one or more pre-existing comorbid conditions for black women (9,9%) nearly twice that of white women (5,6%) [24].

In a parallel line of research, other studies like Shah et al. one [25,26], has shown that Asian populations develop type 2 diabetes, gestational diabetes, and lower body mass index values than Europeans, which agrees with our study where being from Asia and de Middle East have a protector effect to develop diabetes mellitus. Similar results were observed in a study carried out in France [27], where they observed that women from North Africa and Turkey had a higher risk of overweight and gestational diabetes mellitus, while women from Eastern Europe and Asia had a lower risk of that; in addition, Sub-Saharan Africa had a higher risk of being overweight or obese pre pregnancy, these data are also consistent with those observed in our work.

Regarding arterial hypertension, Bastola et al. [28] carried out a study with women of Finnish origin and they conclude that the risk for any hypertensive disorders of pregnancy after adjustment for confounders was lower for women of migrant origin, with an exception for women of Sub-Saharan African origin. Knutzen et al. [29], also demonstrated the prevalence of chronic hypertension was higher in black (1,1%) and colored (1,7%) women compared to white women (0,6%). All these data are similar in our analysis, sub-Saharan African women show more risk than the rest of the groups.

Finally, Sajuan et al. [30] found racial and ethnic differences in perinatal depression, on the one hand, Asian individuals had lower risk of perinatal depression and anxiety but higher risk of moderate/severe depression during pregnancy compared to Non-Hispanic White individuals; on the other hand, Non-Hispanic Black individuals had higher risk of perinatal depression, comorbid depression/anxiety, and moderate/severe and severe depression.

They also concluded that Hispanic individuals had lower risk of depression during pregnancy and perinatal anxiety but higher risk of postpartum depression and moderate/severe and severe depression during and after pregnancy. Besides, Shakeel et al. [31], who carried out a study in Oslo, reported that women from de Middle Easterners (mainly from Iraq, Iran, and Turkey) and South Asians (mainly from Pakistan and Sri Lanka) had significantly higher risk for depression than other minorities and Western Europeans in logistic regression models, OR 2,81; 95% CI 1,29-6,15 and OR 2,72, 95% CI 1,35-5,48 respectably. The methodological differences present in these studies, in which a screening of pregnant women is carried out, compared to our study that analyses diagnostic codes may justify these differences. A lower prevalence found in our study may be attributed to a lack of addressing the mental health of patients in medical consultations.

Difficulties and Limitations of the Study

We must point out possible limitations. First, we have not assessed the socioeconomic data that may influence health outcomes; on the other hand, the population groups analysed have been grouped into large groups and may not be homogeneous in their composition. This fact can make correct identification as a risk group difficult.

Conclusions

The immigrant population generally presents a higher risk of diabetes, overweight/obesity, and hypertension compared to the native population; however, there are variations in risk depending on the country of origin. These data suggest that the immigrant population from these regions can benefit from medical follow-up that addresses their needs.

Future research should include data on country of origin and examine the role of premigration and postmigration factors in developing chronic diseases and its associated short- and long- term outcomes

Author Statements

Acknowledgments

The authors would like to acknowledge Dr. Miquel Butí for his valuable contribution and support to design and create the database, Joaquim Sol for his contribution to the statistics analysis, and the Gol i Gurina Foundation.

Funding

The authors declare support from PICARD 2023 subvention from Diputació de Lleida/ IDIAP Jordi Gol and Institut Catala de la Salut Lleida. The recipient is Júlia Siscart Viladegut and the grant number is 4R23/338. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors received no specific funding for this work.

Ethics Declarations

This study was approved by the ethics and clinical research committee of the “Institute for Primary Health Care Research Jordi Gol i Gurina (IDIAPJGol)” under the code 19/195-P. The study was conducted in accordance with the principles of the Declaration of Helsinki. Pseudonymized retrospective descriptive cross-sectional study according to Additional Provision 17.2.d LOPD-GDD for research purposes, without the need to obtain the consent of the data holders, there is a technical and functional distance between the research team and the performer pseudonymization, and that the data is only accessible to the research team, and technical measures have been taken to prevent such re-identification and access by third parties through the CMBD database (“Conjunt Minim de Base de Dades”) the E-CAP computerized medical history database and the Catalan Health Service database.

Competing Interests

The authors declare they have no competing interests.

Contributions

JS and LG conceptualized the study, analyzed the data, and wrote the first draft of the manuscript; MCS, MO, DP and JMJ contributed to the design of the study, data management, and manuscript development and review; BS also contributed to the design of the study, and to the creation of data bases and data analysis. All authors read and approved the final manuscript.

Ethical Aspects

This study was approved by the ethics and clinical research committee at the Institut d’Investigació IDIAP Jordi Gol under the code 19/195-P and conducted in accordance with the principles of the Declaration of Helsinki. Information was obtained from electronic medical records stored in the centralized ECAP database and extracted by the Department of Healthcare Evaluation and Research Management. Accordingly, it was not necessary to ask participants for their informed consent. The variables in the ECAP database were processed anonymously and with full confidentiality guarantees as established by national law and Regulation 2016/679 of the European Parliament and of the Council on the protection of natural persons with regard to the processing of personal data, and to the free movement of such data.

References

1. United Nations Department of Economic and Social Affairs. Internal Migrants Stock [Internet]. Nueva York: UN DESA. 2019.
2. Portal de inmigración. Observatorio Permanente de la Inmigración. Estadísticas. 2019.
3. Catalonia welcomed more immigrants than ever in 2019, Catalan News. CAN/Barcelona. 2020.
4. SanSantiago Mda C, Figueiredo MH. Immigrant women’s perspective on prenatal and postpartum care: systematic review. J Immigr Minor Health. 2015; 17: 276-84.
5. Almeida LM, Caldas J, Ayres-de-Campos D, Salcedo-Barrientos D, Dias S. Maternal healthcare in migrants: a systematic review. Matern Child Health J. 2013; 17: 1346-54.
6. Chu DM, Aagaard J, Levitt R, Whitham M, Mastrobattista J, Rac M, Eppes C, Gandhi M, Belfort MA, Aagaard KM. Cohort Analysis of Immigrant Rhetoric on Timely and Regular Access of Prenatal Care. Obstet Gynecol. 2019; 133: 117-128.
7. Gimeno-Feliu LA, Pastor-Sanz M, Poblador-Plou B, Calderón-Larrañaga A, Díaz E, Prados-Torres A. Multimorbidity and chronic diseases among undocumented migrants: evidence to contradict the myths. Int J Equity Health. 2020; 19: 113.
8. Llácer A, Zunzunegui MV, del Amo J, Mazarrasa L, Bolumar F. The contribution of a gender perspective to the understanding of migrants’ health. J Epidemiol Community Health. 2007; 61: ii4-10.
9. Malmusi D, Borrell C, Benach J. Migration-related health inequalities: showing the complex interactions between gender, social class and place of origin. Soc Sci Med. 2010; 71: 1610-9.
10. Nielsen SS, Krasnik A. Poorer self-perceived health among migrants and ethnic minorities versus the majority population in Europe: a systematic review. Int J Public Health. 2010; 55: 357-371.
11. Toselli S, Gualdi-Russo E, Marzouk D, Sundquist J, Sundquist K. Psychosocial health among immigrants in central and southern Europe. Eur J Public Health. 2014; 24: 26-30.
12. Nuñez L. Migration, gender and health. Handbook on gender and health. 2016; 251-267.
13. Spitzer D. Engendered movements: migration, gender and health in a globalized world. Handbook on gender and health. 223-234.
14. Behboudi-Gandevani S, Bidhendi-Yarandi R, Panahi MH, Mardani A, Prinds C, Vaismoradi M. Perinatal and Neonatal Outcomes in Immigrants From Conflict-Zone Countries: A Systematic Review and Meta-Analysis of Observational Studies. Front PublicHealth. 2022; 10: 766943.
15. Behboudi-Gandevani S, Bidhendi-Yarandi R, Panahi MH, Mardani A, GåreKymre I, Paal P, Vaismoradi M. A Systematic Review and Meta-Analysis of the Risk of Stillbirth, Perinatal and Neonatal Mortality in Immigrant Women. Int J Public Health. 2022; 67: 1604479.
16. Gieles NC, Tankink JB, van Midde M, Düker J, van der Lans P, Wessels CM, Bloemenkamp KWM, Bonsel G, van den Akker T, Goosen S, Rijken MJ, Browne JL. Maternal and perinatal outcomes of asylum seekers and undocumented migrants in Europe: a systematic review. Eur J Public Health. 2019; 29: 714-723.
17. Orós M, Siscart J, Perejón D, Serna MC, Godoy P, Salinas-Roca B. Ethnic Disparities and Obesity Risk Factors in Pregnant Women: A Retrospective Observational Cohort Study. Nutrients. 2023; 15: 926.
18. Siscart J, Orós M, Serna MC, Perejón D, Galván L, Ortega M. Adherence to treatment for hypothyroidism in pregnancy and relationship with thyrotropin control: a retrospective observational cohort study. BMC Pregnancy Childbirth. 2022; 22: 168.
19. Siscart J, Perejón D, Serna MC, Oros M, Godoy P, Sole E. Prevalence, risk factors, and consequences of hypothyroidism among pregnant women in the health region of Lleida: A cohort study. PLoS One. 2023; 18: e0278426.
20. Orós M, Perejón D, Serna MC, Siscart J, Leon J, Ortega M, Salinas-Roca B. Prevalence and risk factors of gestational diabetes in the health region of Lleida: a retrospective observational cohort study. J Endocrinol Invest. 2023; 46: 2639-2646.
21. Orós M, Lorenzo M, Serna MC, Siscart J, Perejón D, Salinas-Roca B. Obesity in Pregnancy as a Risk Factor in Maternal and Child Health-A Retrospective Cohort Study. Metabolites. 2024; 14: 56.
22. Brown CC, Adams CE, George KE, Moore JE. Associations Between Comorbidities and Severe Maternal Morbidity. Obstet Gynecol. 2020; 136: 892-901.
23. Admon LK, Winkelman TNA, Zivin K, Terplan M, Mhyre JM, Dalton VK. Racial and Ethnic Disparities in the Incidence of Severe Maternal Morbidity in the United States, 2012- 2015. Obstet Gynecol. 2018 ; 132: 1158-1166.
24. Metcalfe A, Wick J, Ronksley P. Racial disparities in comorbidity and severe maternal morbidity/mortality in the United States: an analysis of temporal trends. Acta Obstet Gynecol Scand. 2018; 97: 89-96.
25. Shah A, Stotland NE, Cheng YW, Ramos GA, Caughey AB. The association between body mass index and gestational diabetes mellitus varies by race/ethnicity. Am J Perinatol. 2011; 28: 515-20.
26. WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004; 363: 157- 63.
27. El-Khoury Lesueur F, Sutter-Dallay AL, Panico L, Azria E, Van der Waerden J, Regnault Vauvillier N, Charles MA, Melchior M. The perinatal health of immigrant women in France: a nationally representative study. Int J Public Health. 2018; 63: 1027-1036.
28. Bastola K, Koponen P, Skogberg N, Gissler M, Kinnunen TI. Hypertensive disorders of pregnancy among women of migrant origin in Finland: A population-based study. Acta Obstet Gynecol Scand. 2022; 101: 127-134.
29. Knutzen VK, Davey DA. Hypertension in pregnancy and perinatal mortality. S Afr Med J. 1977; 51: 675-9.
30. Sujan AC, Nance N, Quesenberry C, Ridout K, Bhalala M, Avalos LA. Racial and ethnic differences in perinatal depression and anxiety. J Affect Disord. 2023; 334: 297-301.
31. Shakeel N, Eberhard-Gran M, Sletner L, Slinning K, Martinsen EW, Holme I, Jenum AK. A prospective cohort study of depression in pregnancy, prevalence and risk factors in a multi-ethnic population. BMC Pregnancy Childbirth. 2015; 15: 5.