Elevated stress during pregnancy in women of Turkish origin: Results from a prospective cohort study

Abstract Background Ethnic health disparities exist in the context of pregnancy and childbirth, suggesting that women of Turkish origin (i.e., they or their parents born in Turkey) in Germany have higher risks for some adverse maternal health and child developmental outcomes. Stress is believed to be a relevant pathway by which migration may be associated with these risks. In this study, we tested associations of Turkish origin with stress biology and psychological stress experiences during pregnancy. Methods 140 pregnant women (33 of Turkish/26 of other origin) participated in a prospective cohort study that was carried out in Bielefeld and Berlin (Spallek et al., 2020). Inflammatory markers CRP and IL-6 from venous blood samples and diurnal cortisol profiles from salivary cortisol samples were derived and participants completed the Perceived Stress Scale (PSS) and Center for Epidemiologic Studies Depression Scale (CESD) at two study visits during pregnancy (T1: 20-25 weeks of gestation, T2: 30-35 weeks of gestation). Multilevel models were conducted to account for the nested data structure due to repeated measurements. Results Compared to non-migrant women, women of Turkish origin had significantly higher inflammatory levels (b = 0.28, SE = 0.14, p=.052) (Spallek et al., 2021), a blunted cortisol awakening response (b=-0.21, CI=-0.38–0.03, p<.05), a flatter diurnal cortisol slope (b = 0.02, CI = 0.00-0.04, p<.05), and higher PSS (b = 0.46, SE = 0.13, p< .001) and CESD scores (b = 0.29, SE = 0.08, p<.001) during pregnancy after adjusting for socioeconomic factors. Conclusions The results of our study suggest higher stress at the biological and psychological level in pregnant women of Turkish origin. Stress is a risk factor for pregnancy complications and poor birth and child developmental outcomes. To reduce such unequally distributed risks, interventions for stress reduction are needed that are tailored to women of Turkish origin. Key messages • Women of Turkish origin in Germany have elevated psychological and biological stress levels during pregnancy compared to non-migrant women. • This finding underscores the need for targeted interventions to reduce stress in this high-risk group.


Background:
The importance of resilience factors in the positive adaptation of refugee youth is widely recognised. However, their actual mechanism of impact remains under-researched. The aim of this study was therefore to explore protective and promotive resilience mechanisms on both negative and positive mental health outcomes. Promotive resilience is seen as a direct main effect and protective resilience as a moderating effect.

Methods:
Cross-sectional study with 160 Syrian youth aged 13-24 years, who recently resettled in Norway. A multi-dimensional measure for resilience was used to explore the potential impact of resilience factors on pathways between potentially traumatic events from war and flight (PTE), post-migration stress, mental distress and health-related quality of life (HRQoL). Analyses included regression, moderation and moderated mediation using the PROCESS macro for SPSS.

Results:
A direct main effect of resilience factors (promotive resilience mechanism) was found for HRQoL and general mental distress, but not for post-traumatic stress disorder (PTSD). No moderating effects of resilience factors (protective resilience mechanism) were found. Post-migration stressors mediated the effects of PTE, and this indirect effect was present at all levels of resilience. Relational and environmental level resilience factors and combined amounts had more impact than individual level factors.

Conclusions:
Despite high risk exposure and mental distress, resilience was also high. The direct main effect of resilience factors and less impact on PTSD, suggests universal resilience building interventions may be beneficial, compared to exclusively targeting groups with high symptom levels. These interventions should target relational and environmental resilience factors as well as individual coping techniques. Additionally, reducing current stress and symptoms could increase the efficacy of resilience factors already present.

Background:
Ethnic health disparities exist in the context of pregnancy and childbirth, suggesting that women of Turkish origin (i.e., they or their parents born in Turkey) in Germany have higher risks for some adverse maternal health and child developmental outcomes. Stress is believed to be a relevant pathway by which migration may be associated with these risks. In this study, we tested associations of Turkish origin with stress biology and psychological stress experiences during pregnancy. Methods: 140 pregnant women (33 of Turkish/26 of other origin) participated in a prospective cohort study that was carried out in Bielefeld and Berlin (Spallek et al., 2020). Inflammatory markers CRP and IL-6 from venous blood samples and diurnal cortisol profiles from salivary cortisol samples were derived and participants completed the Perceived Stress Scale (PSS) and Center for Epidemiologic Studies Depression Scale (CESD) at two study visits during pregnancy (T1: 20-25 weeks of gestation, T2: 30-35 weeks of gestation). Multilevel models were conducted to account for the nested data structure due to repeated measurements. Results: Compared to non-migrant women, women of Turkish origin had significantly higher inflammatory levels (b = 0.28, SE = 0.14, p = .052) (Spallek et al., 2021), a blunted cortisol awakening response (b = -0.21, CI = -0.38-0.03, p<.05), a flatter diurnal cortisol slope (b = 0.02, CI = 0.00-0.04, p<.05), and higher PSS (b = 0.46, SE = 0.13, p< .001) and CESD scores (b = 0.29, SE = 0.08, p<.001) during pregnancy after adjusting for socioeconomic factors.

Conclusions:
The results of our study suggest higher stress at the biological and psychological level in pregnant women of Turkish origin. Stress is a risk factor for pregnancy complications and poor birth and child developmental outcomes. To reduce such unequally distributed risks, interventions for stress reduction are needed that are tailored to women of Turkish origin. Key messages: Women of Turkish origin in Germany have elevated psychological and biological stress levels during pregnancy compared to non-migrant women. This finding underscores the need for targeted interventions to reduce stress in this high-risk group. For many affected by ongoing coloniality, research is not neutral or objective, but is part of the colonial violence inflicted through disciplines as diverse as medicine and ethnography. Against this background, choosing Community-based Participatory Research (CBPR) as research strategy for researching racism in health care can be seen as a way of challenging existing epistemologies of ignorance by embracing diversity of knowledge production. 'Community Perspectives on Racism in Health Care' is a participatory research project carried out in the frame of the National Discrimination and Racism Monitor which aims to improve the involvement of people affected by racial injustice in the research process, collect data on and generate theory about healthcare-related racism. It is conducted by DeZIM-Institut in collaboration with different racialized communities. Community members were trained as peer researchers and supported to conduct CBPR-projects. Two CBPR-projects were conducted: 1) digital focus groups with people marked as Muslims 2) digital focus groups with Black people. 'Racial' health disparities were identified on three levels: differential access to health care, differential care within the system and differences in exposures. The theory was built inductively, while drawing on existing theoretical concepts from the disciplines of public health, postcolonial and decolonial studies. Racialized people used the opportunity to be trained as peer researchers. They conducted CBPR projects tailored to the needs of their communities and conceptualized racism in the broader context of health care. Suggestions were made for improving health care services. Including those most impacted by racial injustice as peer researchers enables us to widen the ''we'' who constitute the researchers and to harvest the wisdom of situated knowledges. However ongoing challenges have been faced raising the question of the (im)possibilities of democratic knowledge production in German academia.

Key messages:
Including those most impacted by racial injustice as peer researchers enables us to harvest the wisdom of situated knowledges.
Ongoing challenges have been faced by trying to establish democratic knowledge production in German academia.