Healthy People 2020 goals include the reduction in morbidity, mortality and complications in childbearing women. Healthy Migrant Theory posits that immigrants are more likely to be healthier than the general receiving population. Language acquisition is thought to be the primary marker of acculturation to the dominant society in a receiving geographic area, and effective communication in English is a marker of acculturation in the United States. In the U.S., 23% of babies are born to immigrant women, many of whom do not speak English. There are several care models for labor and delivery in the United States, and nurse midwifery and physician care models are legal in all states. There is good evidence that women who receive midwifery care have improved maternal outcomes, and that women who are not well acculturated to the dominant culture in the United States have improved neonatal outcomes. However, the maternal outcomes of women who do not communicate in English have not been well studied, nor is it known whether care during parturition by midwives when compared to physicians makes a difference in such women.
Maternal care during labor and delivery has had changes in recent years, including increased labor interventions such as induction of labor and regional anesthesia use, increased length of labor, and a maternal morbidity rate of 27%. Maternal outcomes during delivery have also had some changes, including decreased rates of episiotomy and operative vaginal deliveries. The cesarean rate in 2017 was 31.9%.
The purpose of this study was to determine whether there was a difference in maternal outcomes, defined as labor interventions and delivery methods, in English-speaking or non-English-speaking childbearing women, and when modified by nurse midwifery versus physician care models.
Methods:
This quantitative, retrospective study was conducted using analysis of labor, delivery, language, and care provider data extracted from women’s labor and delivery electronic health records. The power analysis showed that the needed sample would be 787 subjects, for a small effect size and an α = 0.01. Electronic health records of laboring patients admitted for delivery between 23 and 42 weeks’ gestation were analyzed from 2013-2016 (N=11,656) from a tertiary care center in New England. Data were analyzed using descriptive statistics and Chi squared using SPSS.
Results:
Although not all eligible women requested a translator, 16.6% of women preferred to communicate in a language other than English. Women who did not speak English were less likely to receive epidural anesthesia or second degree or periurethral lacerations, and more likely to attempt and achieve vaginal deliveries after cesarean section and to have a postpartum hemorrhage.
When the effects were evaluated further by the moderating factor of type of care provider, women who did not speak English and received care from nurse midwives were more likely to attempt and achieve vaginal deliveries after cesarean than those who received care from physicians. However, they were also more likely to receive a cesarean section than those who spoke English and received care from nurse midwives. If women did not speak English and received care from physicians, they were less likely to have labor induced, and were less likely to receive local anesthesia, episiotomies, or perineal lacerations. Further, they were less likely to have vaginal deliveries when compared to English speaking women who saw physicians.
Conclusion:
Women had improved delivery outcomes if they were unable to communicate in English when compared to English-speaking women. Healthy Migrant Theory was substantiated or not refuted in this sample by maternal delivery outcomes, although not by use of all labor interventions. All women, no matter what language used, should receive equivalent care during labor and delivery. All patients who communicate in a language that is not the dominant language should be offered translation services, and it should not be assumed that comprehension exists without a professional translator. Care should be taken that no bias or differentiation in treatment occurs between women who speak English and those who don’t during labor and delivery.