 So, I will introduce our speaker. Now we've got to know each other. Just before I do, just a reminder, in the public chat where you've just put where you're from, I would very much encourage questions for our speaker that I would be able to give to her at the end. So, Carolina Marland is a qualified nurse midwife and a PhD candidate at the Western Norway University of Applied Sciences. She has previously been working in Liberia, Western Africa, and now is halfway through her PhD. Her research is investigating the instance of perinatal outcomes in immigrant women giving birth in Norway over a period of time of 26 years. The immigration is increasingly global and increased knowledge about the reproductive health in immigrant women is very important. The aim of this study was to gain updated knowledge about the incidence of hypertensive disorders in immigrant women giving birth in Norway during the period of 1990 to 2016. So, I shall hand over to Carolina so that she can present just now. Welcome, Carolina. Thank you so much for that nice presentation, Marie. Yes, so my name is Carolina Marland and my research as Marie presented is about adverse perinatal outcomes in immigrant women in Norway. These are my supervisors and also my co-authors for the articles. So, what do we know about immigrants in Norway? Well, we know that first generation immigrants accounts for 14% of the total population and the immigrants comes from over 200 countries. 29% of all births in 2019 were to immigrant women. And as you can see from this picture close to 50% of the immigrants in Norway comes from other European countries. Just over one third of the immigrants comes from Asia and 14% comes from Africa. Most of the African immigrants in Norway are born in the sub-Saharan region. People immigrate for different reasons. It could be due to work, education, family reunion or establishment or the commerce refugees. Immigrant women are a heterogeneous group with different background and risks for perinatal outcomes. We often refer to reasons for immigration as for push or pull factors. People moving to something like for work or educational reasons more often have a stronger socio-economic background and better health outcomes than the ones moving away from something like refugees moving from natural disasters, war or famine, for example. We know that immigrant women have an elevated risk for hypertension, preeclampsia, gestational diabetes, preterm birth and still birth, among other things. And the possible explanation for the differences in perinatal outcomes are many. And my studies does not focus on causation as it is an epidemiological study. But from previous research, we know that differences may be due to socio-economic background, inadequate food intake, inadequate communication, both language-wise and due to cultural impediments, low health literacy, low follow-up in medical advices and medical treatments. And immigrant women may experience a low trust in the health system leading to an unsatisfactory use of the service. Increasing international immigration calls for increased knowledge about the health of immigrants. And from my study, this includes more knowledge about the reproductive health for immigrant women in Norway. Even though we do have some knowledge, there is a knowledge gap in the research. As previous epidemiological studies often lack specific information on maternal country of birth and not just race or ethnicity as it will capture just a small picture and a lot of information will get lost. There is a lack of knowledge concerning reasons for immigration. And we also have limited information about length of residence when it comes to perinatal outcomes. So the study that I'm presenting here today was published in AOGS in December 2020. In this study, we estimated the incidence of placental abruption in first-generation immigrants in Norway compared to non-immigrants in Norway by maternal country and region of birth, reason for immigration and length of residence. And placental abruption, or simply abruption, is the premature separation of placenta before birth. It is a rare diagnosis, however, it is one of the most dramatic conditions during pregnancy. And globally, abruption is one of the leading causes of maternal death, and due to hemorrhage. Abruption may be partial or complete. A partial abruption will increase the risk of fetal morbidity, whereas a complete abruption will lead to the fetal death within minutes as the fetal actually gets strangled. An abruption will also increase the risk of maternal morbidity, and in severe cases it may lead to maternal mortality. The diagnosis is clinical and based on anaemnesia, or anaemnesis and clinical findings like severe stomach pain and or vaginal bleeding. And the risk factors include the extremes of maternal age, parity, hypertension, preeclampsia and smoking during pregnancy. And this is the time trend for abruption during our study. The total incidence of abruption in our study was 0.5% for the whole study period and for the whole study population. There was a significant reduction in the incidence as you can see during the study period from 0.8% for Norwegian born women in 1919 to less than 0.4% in 2016. It's the red line. And the tendency was the same for immigrant women, however, a somewhat lower reduction from 0.7% in 2019 to 0.5% in 2016. My study is a nationwide population-based study, and we use data from the Medical Birth Register of Norway and Statistics Norway. Data was linked using the national identity number of each woman, and we included all births in Norway from 1990 and throughout 2016, which gave us over 1.6 million births. And immigrant women accounted for 250,000 of all these births. This figure illustrates the derivation of our study sample. In order to reduce the heterogeneity within the groups, we included pregnancies to first-generation immigrant women, that is, foreign-born women with one or two foreign-born parents, and Norwegian-born women. These are the immigrants, and these are the Norwegian-born or non-immigrants. I'm so sorry. It's early in the morning. I haven't spoken much yet. And the inclusion criteria for countries, which countries to include in the study, was based on the number of births or abruptions during the study period. So, to ensure strength of the study, we included countries with 6,000 births or more during the study period. But in order not to lose countries that have a high incidence of abruption but low birth rates, we also included countries with at least 15 abruptions during the study period. The countries that did not meet the inclusion criteria were marched into a separate exposure group coded as other countries. And Norwegian-born women or non-immigrants were used as a reference group for all analysis. And for the more technical part of the methodology, we estimated crude and adjusted ratios with 95% confidence interval using binary logistic regression models. Adjustments were made for year of birth, maternal age at birth, parity, chronic hypertension, and level of education. And to account for dependency among pregnancies to the same woman, we used robust standard errors that allowed for within mother clustering. We assumed missing values to be missing at random and missing values were imputed using a multivariate normal model with 5 imputations. And we used a statistical program called STATA for all analysis. So when aggregating our data according to the seven super regions of the global burden of disease, we observed an increased risk of abruption in immigrant women born in the sub-Saharan region. While the lowest incidence was found in immigrants from Central Europe, Eastern Europe, or Central Asia. And this is one compared to non-immigrants. So as I said, immigrant women from the sub-Saharan region had the highest incidence and odds ratio, 4% abruption, and the lowest incidence was found in immigrants from Central Europe, Eastern Europe, or Central Asia. We did not find any association between length of residence or reasons for immigration and placental abruption. But it's interesting to see that refugees and women immigrating for work reasons have the same elevated risk of abruption, supporting the well-known hypothesis of the healthy immigrant where only the healthiest people will leave their country or survive the journey and reach the receiving country. And that gives us a bias in the estimates. So we included countries based on the inclusion I explained earlier. And the adjusted odds ratio for placental abruption by maternal country of births relative to non-immigrant women, illuminated a strong association for immigrant women born in Ethiopia with an odds ratio of 2.39. A higher odds ratio was also fine for Brazilian women. But as you can see, the confidence interval was wide making the result more uncertain. So to conclude, in our study we found that immigrant women from sub-Saharan Africa and especially Ethiopia had an increased incidence of placental abruption after immigration to Norway. We did not find a profound variation in placental abruption by reason of immigration or length of residence in Norway. And does this research has any clinical relevance? Yes, we think so. We think that this research is of clinical importance for doctors. Did I not change? I'm sorry. We think that this research is of clinical importance for doctors and midwives in the antenatal care who should strive to support women to achieve a healthy lifestyle and optimize of nutrition during pregnancy and to provide targeted information on early signs and symptoms of abruption for immigrant women from sub-Saharan Africa and especially Ethiopia during pregnancy. Thank you all for the attention. Thank you, Carolina. That was a wonderful presentation. I am particularly taken with the amount of work that you've put into that. And I will be inviting people to put any questions in the public chat, please. So Catherine's just thanking you. So again, thank you through. Whilst they come through, I have a couple of questions, if that's all right with you. So in the UK, we have the Embrace Report, which has shown disparities and possible systemic racism within midwifery care. I was wondering, as you were going through those slides, you were talking about disparities between European-based immigrants and those from areas such as sub-Saharan Africa. I wonder whether or not there is an aspect of systemic, possible systemic racism within Norway. And I'll be interested to hear your thoughts on that. Yes. Thank you, Marie, for that question. Well, I think the systematical or the structural racism is not that strong in Norway, as we may see in the United States or the UK, for example, or in England at least. We do have a lot of governmental hospitals and not so many private ones. But I still think that there is a possibility of so-called structural racism in Norway as well, as we do not use the interpreter services as much as we should do, I think, and maybe especially during pregnancy. I know that we use interpreters quite a lot in antenatal care and also postpartum, but not during admittance to the hospitals and not during the labor or not in labor ward. We don't use interpreters as much as we should. And I think that's a shame, actually, that we're not allowing every woman to have the same right to express herself or to understand the information given in a proper way from a qualified interpreter. So I think the answer is that the structural racism is not that strong, as you might see in other countries, but I still think that we do have quite a long way to go still to gain equality in antenatal or in maternity care in Norway as well. Thank you, Carolina. And I expect that the evidence that you have gathered will help in some way towards supporting that work, so thank you for that work. We do have some questions within the TAP box, so Gaxu asks, have you found any relation between placental abruption and pre-existing medical conditions within the cohorts? Well, thank you, Gaxu, for that question. We did not look for any relation between abruption and pre-existing medical conditions, but we do know that we have quite a lot of risk factors, like chronic hypertension and preeclampsia during pregnancy. Diabetes might be a risk factor, so we do know that we have some medical conditions that are more of a risk factor for placental abruption in pregnancy. Is that an answer to your question? Thank you. We have another question from Joanne, who is interested to see how many prenatal visits the different groups had and if that was part of your research. Yes, thank you, Joanne. That's very interesting. It was not a part of my research, but we did discuss it within the research group. I think that's very important. Unfortunately, it's not that well registered in the medical birth register of Norway, but it should be recorded properly, and it is very interesting. We know from previous research that especially women from sub-Saharan Africa and Somalia, more specific, do have less consultants during antenatal care or during pregnancy than non-immigrants compared to other immigrant groups as well. We know that the total group of immigrants, and especially women from Somalia, usually come later to first antenatal care visits, either to the doctor or to the midwife. And we know that that may delay the any medical treatment or detection of risk factors that may actually prevent an abruption or at least give her enough information to contact the labor ward early enough to hopefully save the baby. So yes, I think it's very important to know the number of visits during pregnancy for these women. Thank you. Catherine has the question of, do you have any thoughts about continuity of care in order to reduce complications like abruption? Well, thank you, Catherine, for that question. I think there is little research on the continues of care in Norway, because we don't actually use it that much. We know from other countries and other studies that it's preventive for a lot of different outcomes, most definitely. I would say for placental abruption, it's probably not preventive, but still it can help with the outcomes and making the outcomes less severe. As we know, as midwives, during an abruption, the baby, if you have a complete abruption, the baby will actually die within four or five minutes. So you need to come quickly to the hospital and you need to make a C-section and get the baby out as quick as possible. If you don't have that information as a woman or if you don't know what to look for and signs and symptoms, you may come late. A continuous carer could probably help with that and inform you in a correct way so that you are actually contacting the antenatal or the labour ward quick enough. So I think the answer is that for placental abruption itself, it would probably not be preventive for the outcome, most definitely. Thank you, Carolina. Linda has asked in many countries, antenatal care is not commonplace. So are there specific advertisements to the women that are coming in as immigrants that antenatal care is actually available to them? Yes, thank you, Linda. That's a very good question. I think if you're pregnant when arriving, at least in Norway, if you're pregnant when arriving, you will have the antenatal care follow-up done properly because you will be in what you call, when you just arrive, you will come to a place where someone will actually take care of your medical concerns and you will probably get help to get to antenatal care as well. Whereas women who had just settled down in Norway, maybe not have been there for such a long time or in other countries as well, are left to themselves in another way. So I think the biggest risks for immigrants are not when they're just arrived but when they're just settled for themselves in a country because then you're left to yourself and then you have to try to figure out how to get the medical treatment that you need and where to look for it and it could be a jungle to understand the codes and to find your way through the system. Thank you, Carolina. Margaret has a question of is there any relationship with domestic violence within the cohort or is this not recorded? Yes, thank you, Margaret. It's not recorded in our study but we know that domestic violence is quite common in some subgroups of immigrant women and we know that domestic violence is a threat to placental abruption. Again, we're discussing this in the research group but there are no, it's not well recorded, domestic violence is not well recorded. It may be the woman that doesn't want to record it, it might be that it's not actually known to anyone else than the woman that it's kept a secret within the family which is most often the case. So I think it would be really interesting to look into domestic violence a little bit closer but it's a sensible topic to get into and I think it's quite difficult to do it during pregnancy but it would be very interesting to see what domestic violence might do for the perinatal outcomes and not just immigrant women, Norwegian women as well but yeah, it would be very interesting. Thank you, Margaret says thanks too. Gaxu has another question, in Norway is antenatal care free of charge to all immigrant women? Yes Gaxu, thank you for that question. In Norway the antenatal care is free for all women, Norwegian women and immigrant women so you don't pay anything either you decide yourself or according to your medical history if you go to a doctor or a midwife and most Norwegians and most immigrants go to both a doctor and a midwife during pregnancy and it's all free of charge so it's going to the labour ward, it's no costs at all. That's wonderful, I have a question myself too if that's okay. I was wondering about the possible link with FGM because I was curious about the sub-Saharan region cohort coming through and how that might impact how the abruptions are being picked up or subsequently treated. Do you have any thoughts to share about that? Yes, thank you Marie. I think FGM of female genital mutilation is, we know that it's very common in sub-Saharan Africa and in Ethiopia in particular. We didn't record it in our study because it's not recorded in the medical birth register of Norway but we do have a lot of previous research on female genital mutilation. I think the procedure itself may be a risk factor for abruptions later. I don't think it's a risk factor B and mutilized is a risk factor for abruption but I think during the procedure you may harm the anatomy or you may leave scars. You may wish to stop the bleeding and we know that it's quite common in Ethiopia to use herbs and using herbs maybe inside uterus or inside the vagina during the cut may actually, we don't know but you can speculate that this may actually leave either scars or some damaged tissue that actually may cause or at least be a risk factor for abruption in later pregnancies. So yes, I think there is probably a connection even if we don't have it in our study. I think there is an association in some kind of way for either it may be female genital mutilation or previous illegal abortions for example which may be more or less of the same and I think that could definitely be a risk factor for abruptions in later pregnancies. Thank you, Karolina. So that's a possible area for future research. Yes, that would be wonderful to be able to support women in that way. Kari has a question about the time period that abruptions occur in pregnancy. I wonder whether or not you could maybe comment on that. Yes, thank you, Kari. It's recorded after the 20th gestational week in the medical birth register and we see that it's more common in the third trimester of pregnancy than earlier in pregnancies or earlier in the pregnancy. So yes, at the end in the third trimester it's more common than earlier. Thank you. I was wondering whether or not you could maybe talk a little bit about the theory of the healthy immigrants. You were saying that it would only be the healthy who made it to Norway and I was wondering about if you could maybe talk about that a wee bit further. Yes, most definitely. Thank you, Marie. Well, the healthy immigrant theory or the theory of the healthy immigrants leaves us a bias actually when we're doing research on immigrants concerning the group of immigrants are not actually that representative to the rest of the region. So we can't actually generalize our data saying that all women from Ethiopia do have a higher risk of placental abruption than Norwegian women, for example. Because we know that the women immigrating more often have a stronger health than the women that are left in Ethiopia because you don't go for the journey to another country if you're not healthy enough or you will not survive the journey if you're not healthy enough. So we think that or we know that we actually do get biases and can only generalize our data to the immigrant population in this country because we don't know the situation of the population within the country. It could be worse, but it could also be better. We don't actually know. And we also have a bias called the Salmon Bias in Norway where we know that immigrants quite often refer to as Norwegians in Spain as well. If you get sick or if you get pregnant, you want to go to your home country if you're able to to seek medical advice and medical help or to give birth to your baby because that's a system you know instead of staying in a country where you don't know the system you maybe don't know the language and you don't have any family around you. So again, we will select the population, the immigrant population to a more healthy immigrant population within the country than outside of the country. And that's the theory of the healthy immigrant says that the immigrants are actually more healthy than the receiving population or the receiving country population. And that's based on those theories that you actually get a selective population of immigrants in a receiving country. Is that an answer? That was a perfect answer. Thank you, Karina, that really does explain it. I'm just checking if there's any last questions before we wrap up. But I for one, I'm really looking forward to the PhD being written up and being able to read it and hear what you come, what conclusions you come to towards the end. And I'm very, very much delighted to have facilitated your session, Karina. I feel very fortunate indeed to have you here. And thank you for all the questions that people have put forward. It's been a very interesting session.