Effect of social integration on childbirth return among internal migrant pregnant women: a nationally representative study in China

In China, the number of internal migrant population had increased from 230 million in 2011 to 244 million in 2017, which occupies a large proportion of nearly 18% of the total population [1]. The rapid expanding of migrant population scale promotes economic prosperity, but also brings a number of public health issues, including problems in infectious diseases, childhood immunization, mental health, maternal healthcare etc. [2‐5] In the past decades, with the emergence of “family migration style”, more and more fertile women outmigrated with their husbands, and the number of migrant fertile women is on the rapid rise, accounting for over 30% of the total migrant population [6, 7]. Consequently, migrant maternal healthcare use is an important issue deserves attention.

From the perspective of inflow area, social integration is found to be an important factor associated with health service use among the migrants [8]. Social integration refers to the process during which migrants are incorporated into the social structure of the society in inflow areas. Although different scholars have different definitions and measurements of social integration, they all share certain dimensions: economic integration, acculturation, and identification [9‐11]. A study by Kemppainen et al. about the health utilization by immigrants in Russia found that stronger social integration predicted less frequent return for health care utilization [12]. In some countries, such as South Korea, special policies have been developed to improve social integration, so as to promote health status among migrant fertile women [13].

Pregnancy is a critical period, not only for the pregnant woman and her unborn child, but also for her whole family. Mobility during pregnancy is found to be linked to poor health outcomes of pregnant mothers and infants or unborn child [14]. Residential instability during pregnancy brings environmental change which was found to be associated with congenital anomalies [15‐17]. There are some other studies indicating that mobility during pregnancy may lead to decreased use of maternal healthcare services due to less knowledge and information, or other barriers to accessibility of health service [18, 19]. Some previous studies found that mobility during pregnancy was detrimental to healthcare provision, which was due to the failure to address the scale and traits of the migrant pregnant women and their specific demands [20, 21]. A series of policies, such as promoting the equalization of public health services^, [22‐24] were developed to enable the migrants in the inflow areas to receive the same medical and public health services as local permanent residents. In addition, the China Women’s Development Program 2011–2020 clearly states that migrant women should receive the same health care services as the women in the inflow areas [25]. Even so, previous studies have demonstrated that the migrants have poorer access to health care services in the inflow areas than that in local permanent residents [26]. As a coping style, some migrants would like to return their hometown for health care use. A previous study by Bergmark et al. showed that 46% Mexican immigrants reported they had a close friend or relative returned to Mexico from U.S. for health care use [27]. A similar study by Jiang also found that about one-fourth of the respondents have visited their home country for medical care since their migration to the US [28]. Similarly, there are also some relevant studies in China. A study by Song reported that 37.23% of 118 hospitalized migrants in Guangzhou had returned to their hometown for medical care [29]. Another study in Beijing reported that 63.16% of 114 migrant returned to their hometown for in-patient services [30]. Of the reasons for their returning hometown for health care use, preferring medical style of homeland or having social ties with homeland are the common ones that facilitate their return [31, 32].

In China, there are some studies focusing on migrants and social integration status, but mainly concentrating on the association between social integration and physical or psychological well-being of migrants [33, 34]. Few studies explored the migrants’ return for healthcare use, and also very few studies focused on the association between social integration and healthcare use among the migrants. To date, no studies have explored the association between social integration and returning their hometown for childbirth (childbirth return) among internal migrant women in China. To remedy this situation, this study aims to explore the association between social integration and childbirth return among internal migrant pregnant women. To do so, we have several specific objectives. First, we will estimate the prevalence of childbirth return among migrant pregnant women. Second, we will explore the association between the social integration and childbirth return among internal migrant pregnant women in China.

The current study finds that24.56% of the internal migrant pregnant women have childbirth return, which is lower than that among the migrant pregnant women in Beijing (59.2%) [39]. There are several possible reasons why the childbirth return rate among migrant women in Beijing is higher than that of the national average level. First, Beijing is the capital of China, and high-quality maternal healthcare service resources are intensively allocated in Beijing, which attracts a large number of pregnant women from all over the country to use maternal care, including childbirth, in Beijing [40]. This thus the accessibility to maternal care is reduced for the migrant women. Second, medical expenses in Beijing are higher than the average level in the whole country [41]. It is hard for the migrants with low income to use high-expense childbirth services in Beijing.

This study indicates that over 70% of the migrant pregnant women give birth in the current residence, and this percentage is still on the rise. This is a positive trend but would probably increase the burden of post-partum care for the migrant mothers and babies, especially for the healthcare practitioners in the community health centers in the inflow areas. This finding implies for the healthcare practitioners in the inflow areas to establish health records for migrant pregnant women, so as to provide continuous and timely post-partum care for the migrant mothers and babies. In addition, the primary healthcare practitioners should also carry out comprehensive health education related to the potential risk of residential instability during pregnancy and importance of the post-partum care for the mothers and babies, to further increase the percentage of childbirth in the current residence and also a better postpartum recovery among the migrant pregnant women. As a long-term countermeasure, to establish a more integrated pregnancy record system for migrant pregnant women, and then the migrant pregnant women starting care in inflow site could continue accessing care if they return to their hometown, so as to improve health outcomes whether they give childbirth in the inflow area or at their hometown.

Some previous studies found that social integration was beneficial for some health.

outcomes among migrants [33, 42, 43]. This study also demonstrates an association between social integration and childbirth return among internal migrant women in China. The social integration is found to be negatively associated with childbirth return. The higher the level of the social integration is, the less possibility the migrant fertile women have a childbirth return. This association is multifaceted, lies in the dimensions of economic integration, acculturation, and identification. This finding implies that improving the localization situation (local adaption) and also income so as to promote the social integration might be helpful for the migrant women to use maternal care in the inflow areas.

As for the dimension in the economic integration, this study finds that migrant women who do not have their own house in the inflow areas are more likely to have childbirth return. For migrant pregnant women who do not have their own house in the inflow areas, and living in renting houses with poor sanitary and environmental conditions, they are more willing to return their hometown to get better home care when giving a birth to a child. In addition, those who have a house in the inflow areas will be easier to get formal or informal maternal postpartum care, which is similar to some previous studies [44].

Acculturation and identification are both significantly associated with the childbirth return among migrant women. The results show that the shorter the migrant women stay in inflow areas, the more likely they are to have a childbirth return. According to a study by Zhou, [10] the length of the duration of stay in the inflow areas, to a certain extent, can reflect the social adaptation of the migrants. That is to say, the migrant women who stay for a longer time, may have higher degree in social adaption, and also be more likely to get social support in the inflow areas, which are useful for the migrant women to use maternal care in the inflow areas [45]. With respect to self-identity, this study finds that migrant pregnant women who are willing to live in inflow areas for a long time are less likely to have a childbirth return. Identification can comprehensively reflect the integration status of migrants to the local population [36]. The migrant women with lower identification may have poorer adaptability to the local residents. As a result, the migrant pregnant women are more likely to return their hometown for childbirth. Measures to improve the identification are helpful for the migrant women to use maternal care in the current residence. For example, early antenatal classes for migrant women would assist them acquire supports in the current residence, which would be useful to make the migrant pregnant women feel more comfortable to give birth in the current residence.

Apart from social integration status, some other factors are also found to be associated with childbirth return among migrant women. The migrant pregnant women who have a lower education level are more likely to have childbirth returns. This might be due to that higher education can enable migrant women to acquire more maternal health care knowledge, including the risk of mobility during pregnancy [46]. As shown in the study, the more family members live together in the inflow areas, the less likely the migrant women are to return their hometown for childbirth. The reason might be that the large family size in current residence, to some extent, may indicate that the migrants have gradually adapted to the local life and culture. In addition, our study finds that the migrant pregnant women who outmigrate for accompany (the women who migrate because their husband or partner), who do not establish health records in the current residence, and who are covered by any kind of social medical insurance scheme are more likely to have childbirth returns.

This study has some limitations. First, the data of the study were based on self-reported measures which might lead to recall bias. Secondly, due to the limitations of the questionnaire, we only selected some indicators of economic integration, acculturation, and identification, and some other potential factors (e.g., language) were not included, which may not comprehensively reflect social integration status of the internal migrant pregnant women. Finally, we did not use qualitative methods to explore the push and pull factors for women’s choice of childbirth place, as well as an in-depth study of the postnatal outcomes of migrant pregnant women who give birth in hometown or in inflow areas, which would be remedied in the follow-up studies.

This study finds that nearly a quarter of the migrant women return their hometown for childbirth. A significant association between social integration status and childbirth return is demonstrated among internal migrant women in China, especially lies in the dimensions of economic integration, acculturation, and identification. Migrant women with low social integration (with low income, the duration of stay in the inflow area less than 5 years, unwilling to stay for a long time) are more likely to return their hometown to give birth. This finding implies for interventions to improve the localization situation might be helpful for the migrant women to use maternal care in the inflow areas. Based on these findings, targeting promotion in social integration among migrant pregnant women, giving full consideration to their difference in culture, identification and other aspects, should be given to improve the utilization rate of maternal care in the current residence. Early antenatal classes for migrant women would assist them acquire supports in the current residence, which would be useful to make the migrant pregnant women feel more comfortable to give birth in the current residence. This study also finds some other factors, including education, family members in current residence, the reason for migration, health record, and social medical insurance, are associated with the choice of childbirth location.