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Maternity without borders: examining disparities in healthcare and perinatal outcomes. A survey of women having given birth in Brussels and an analysis of Belgian population data

par Schönborn, Claudia
Président du jury Racapé, Judith
Promoteur Castetbon, Katia
Co-Promoteur De Spiegelaere, Myriam
Publication Non publié, 2024-08-28

Thèse de doctorat

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Résumé :

Access to antenatal care is considered a given in high-income countries, where virtually all women are guaranteed skilled birth attendants and emergency care in the case of complications. However, significant perinatal health disparities persist based on women's migration history.Considering the importance of building equity from the early life stages, it seems necessary to identify the underlying causes of these inequalities and, at health system’s level, to determine whether access barriers or inadequate perinatal care disproportionately affect the populations most at risk of adverse outcomes.In this context, this doctoral thesis aimed to investigate women's utilisation and experiences of perinatal healthcare services in Brussels, focusing on the effect of maternal birthplace and socioeconomic factors. Additionally, the thesis aimed to analyse the impact of legal status on perinatal health outcomes such as mortality and prematurity.The study involved adapting the Migrant Friendly Maternity Care Questionnaire for use in a multi-centre survey in Brussels. Face-to-face interviews were conducted with approximately 900 postnatal mothers, including immigrants from North Africa and Sub-Saharan Africa, as well as women born in Belgium. Antenatal care timing, frequency, and patient experiences were compared across maternal birth regions, while socioeconomic and migration-related predictors were identified. Furthermore, using Belgian population data spanning seven years, the association between maternal registration in the National Population Registry (as a proxy for legal status) and pregnancy outcomes was assessed.Overall, the results indicated adequate care in terms of initiation, frequency of consultations, and self-reported access, and positive experiences for both immigrants and non-immigrants. However, disparities in healthcare use and experiences were highlighted from a migration-related perspective (e.g. women born in Sub-Saharan Africa more likely to initiate antenatal care later) but also, from a socioeconomic perspective. Specific socioeconomic determinants, such as unstable housing situation, unemployment, lack of health insurance, single motherhood, and language barriers, were identified as independent risk factors for inadequate perinatal care. Additionally, the absence of maternal legal residency at the time of birth was associated with increased rates of prematurity and low birthweight, independent of other socioeconomic factors. Moreover, immigrants lacking legal status had higher risks of perinatal mortality compared to legally residing immigrants from the same region, which were linked to their greater socioeconomic vulnerability. These results suggest that among the immigrant populations, those living in the most precarious situations experience an excess burden in terms of contact with perinatal healthcare and, ultimately, pregnancy outcomes.The discussion explores interpretations and implications of the results, focusing on understanding why particular immigrant and socioeconomically vulnerable groups fare worse. We consider that while perinatal healthcare in Brussels appears adequate for most, improvements are needed to address the needs of the most vulnerable minorities. The findings underline the multifactorial nature of social inequalities in perinatal health and call for actions within and beyond of the healthcare sector.