Immigrants' duration of residence and adverse birth outcomes: a population-based study

Duration of residence and offspring birth weight among foreign-born mothers in Spain: a cross-sectional study

BACKGROUND

Duration of residence has been used to monitor changes in the health of a foreign-born population in a destination country. This study assesses whether the mother's duration of residence influences the relationship between maternal origin and birth weight.

METHODS

We conducted a cross-sectional study using Spanish census microdata (2011) linked to Vital Statistics (2011-15). Linear and multinomial logistic regression models were used to estimate birth weight differences between children born to foreign-born mothers by duration of residence and those born to natives. Maternal countries of origin were classified according to the Human Development Index (HDI).

RESULTS

Our findings revealed significant differences in birth weight of 109 683 births from both foreign- and native-born mothers. Overall, in descriptive statistics, compared with Spanish mothers, foreign-born mothers gave birth more frequently to high-birth weight (HBW) newborns (8.4% vs. 5.3%, respectively) and less frequently to low-birth weight (LBW) newborns (4.8% vs. 5.1%). According to the model's estimations, the risk of giving birth to HBW babies remains relatively high in foreign-born mothers. Especially, mothers from very high-HDI countries experienced changes in the RRR of HBW (1.59-1.28) and LBW (0.58-0.89) after spending over 10 years in Spain.

CONCLUSIONS

Foreign-born mothers residing in Spain are at increased risk of delivering a HBW child regardless of their duration of residence. In fact, given the long-term health consequences associated with HBW, our results highlight the need to improve prenatal care in the foreign-born population.

Underlying Causes of Ethnocultural Inequality in Pregnancy Outcomes: Role of Hospital Proximity

We evaluated the contribution of place of birth to ethnocultural inequality in pregnancy outcomes. We analyzed a cohort of 1,487,723 births between 1998 and 2019 among minority Anglophones and majority Francophones in Quebec, Canada. We estimated the association (adjusted risk ratio, RR; 95% confidence interval, CI) of language with preterm birth and stillbirth, and incorporated interaction terms to determine the contribution of place of birth and distance traveled. Compared with Francophones, minority Anglophones had a greater risk of preterm birth (RR 1.03; 95% CI 1.01-1.06) and were less likely to deliver farther from home (RR 0.95; 95% CI 0.94-0.95). Anglophones who delivered close to home had a higher risk of preterm birth (RR 1.07; 95% CI 1.04-1.11), whereas Anglophones who delivered farther had a lower risk (RR 0.69; 95% CI 0.64-0.75). Patterns were similar for stillbirth. Ethnocultural inequality in adverse birth outcomes may be influenced by place of birth.

Work as a social determinant of health in high-income countries: past, present, and future

This paper, the first in a three-part Series on work and health, provides a narrative review of research into work as a social determinant of health over the past 25 years, the key emerging challenges in this field, and the implications of these challenges for future research. By use of a conceptual framework for work as a social determinant of health, we identified six emerging challenges: (1) the influence of technology on the nature of work in high-income countries, culminating in the sudden shift to telework during the COVID-19 pandemic; (2) the intersectionality of work with gender, sexual orientation, age, race, ethnicity, migrant status, and socioeconomic status as codeterminants of health disparities; (3) the arrival in many Organisation for Economic Co-operation and Development countries of large migrant labour workforces, who are often subject to adverse working conditions and social exclusion; (4) the development of precarious employment as a feature of many national labour markets; (5) the phenomenon of working long and irregular hours with potential health consequences; and (6) the looming threat of climate change's effects on work. We conclude that profound changes in the nature and availability of work over the past few decades have led to widespread new psychosocial and physical exposures that are associated with adverse health outcomes and contribute to increasing disparities in health. These new exposures at work will require novel and creative methods of data collection for monitoring of their potential health impacts to protect the workforce, and for new research into better means of occupational health promotion and protection. There is also an urgent need for a better integration of occupational health within public health, medicine, the life sciences, and the social sciences, with the work environment explicitly conceptualised as a major social determinant of health.

Transnational prenatal care among migrant women from low-and-middle-income countries who gave birth in Montreal, Canada

OBJECTIVES

There is little research examining transnational prenatal care (TPC) (i.e., prenatal care in more than one country) among migrant women. Using data from the Migrant-Friendly Maternity Care (MFMC) - Montreal project, we aimed to: (1) Estimate the prevalence of TPC, including TPC-arrived during pregnancy and TPC-arrived pre-pregnancy, among recently-arrived migrant women from low- and middle-income countries (LMICs) who gave birth in Montreal, Canada; (2) Describe and compare the socio-demographic, migration and health profiles and perceptions of care during pregnancy in Canada between these two groups and migrant women who received no TPC (i.e., only received prenatal care in Canada); and (3) Identify predictors of TPC-arrived pre-pregnancy vs. No-TPC.

METHODS

The MFMC study used a cross-sectional design. Data were gathered from recently-arrived (< 8 years) migrant women from LMICs via medical record review and interview-administration of the MFMC questionnaire postpartum during the period of March 2014-January 2015 in three hospitals, and February-June 2015 in one hospital. We conducted a secondary analysis (n = 2595 women); descriptive analyses (objectives 1 & 2) and multivariable logistic regression (objective 3).

RESULTS

Ten percent of women received TPC; 6% arrived during pregnancy and 4% were in Canada pre-pregnancy. The women who received TPC and arrived during pregnancy were disadvantaged compared to women in the other two groups (TPC-arrived pre-pregnancy and No-TPC women), in terms of income level, migration status, French and English language abilities, access barriers to care and healthcare coverage. However, they also had a higher proportion of economic migrants and they were generally healthier compared to No-TPC women. Predictors of TPC-arrived pre-pregnancy included: 'Not living with the father of the baby' (AOR = 4.8, 95%CI 2.4, 9.8), 'having negative perceptions of pregnancy care in Canada (general experiences)' (AOR = 1.2, 95%CI 1.1, 1.3) and younger maternal age (AOR = 1.1, 95%CI 1.0, 1.1).

CONCLUSION

Women with more capacity may self-select to migrate during pregnancy which results in TPC; these women, however, are disadvantaged upon arrival, and may need additional care. Already-migrated women may use TPC due to a need for family and social support and/or because they prefer the healthcare in their home country.

Severe Maternal Morbidity and Mortality Among Immigrant and Canadian-Born Women Residing Within Low-Income Neighborhoods in Ontario, Canada

IMPORTANCE

Evidence indicates that immigrant women and women residing within low-income neighborhoods experience higher adversity during pregnancy. Little is known about the comparative risk of severe maternal morbidity or mortality (SMM-M) among immigrant vs nonimmigrant women living in low-income areas.

OBJECTIVE

To compare the risk of SMM-M between immigrant and nonimmigrant women residing exclusively within low-income neighborhoods in Ontario, Canada.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used administrative data for Ontario, Canada, from April 1, 2002, to December 31, 2019. Included were all 414 337 hospital-based singleton live births and stillbirths occurring between 20 and 42 weeks' gestation, solely among women residing in an urban neighborhood of the lowest income quintile; all women were receiving universal health care insurance. Statistical analysis was performed from December 2021 to March 2022.

EXPOSURES

Nonrefugee immigrant status vs nonimmigrant status.

MAIN OUTCOMES AND MEASURES

The primary outcome, SMM-M, was a composite outcome of potentially life-threatening complications or mortality occurring within 42 days of the index birth hospitalization. A secondary outcome was SMM severity, approximated by the number of SMM indicators (0, 1, 2 or ≥3 indicators). Relative risks (RRs), absolute risk differences (ARDs), and odds ratios (ORs) were adjusted for maternal age and parity.

RESULTS

The cohort included 148 085 births to immigrant women (mean [SD] age at index birth, 30.6 [5.2] years) and 266 252 births to nonimmigrant women (mean [SD] age at index birth, 27.9 [5.9] years). Most immigrant women originated from South Asia (52 447 [35.4%]) and the East Asia and Pacific (35 280 [23.8%]) regions. The most frequent SMM indicators were postpartum hemorrhage with red blood cell transfusion, intensive care unit admission, and puerperal sepsis. The rate of SMM-M was lower among immigrant women (2459 of 148 085 [16.6 per 1000 births]) than nonimmigrant women (4563 of 266 252 [17.1 per 1000 births]), equivalent to an adjusted RR of 0.92 (95% CI, 0.88-0.97) and an adjusted ARD of -1.5 per 1000 births (95% CI, -2.3 to -0.7). Comparing immigrant vs nonimmigrant women, the adjusted OR of having 1 SMM indicator was 0.92 (95% CI, 0.87-0.98), the adjusted OR of having 2 indicators was 0.86 (95% CI, 0.76-0.98), and the adjusted OR of having 3 or more indicators was 1.02 (95% CI, 0.87-1.19).

CONCLUSIONS AND RELEVANCE

This study suggests that, among universally insured women residing in low-income urban areas, immigrant women have a slightly lower associated risk of SMM-M than their nonimmigrant counterparts. Efforts aimed at improving pregnancy care should focus on all women residing in low-income neighborhoods.

The influence of acculturation on the risk of preterm birth and low birthweight in migrant women residing in Western Australia

BACKGROUND

The risk of preterm birth (PTB) and low birthweight (LBW) may change over time the longer that immigrants reside in their adopted countries. We aimed to study the influence of acculturation on the risk of these outcomes in Australia.

METHODS

A retrospective cohort study using linked health data for all non-Indigenous births from 2005-2013 in Western Australia was undertaken. Acculturation was assessed through age on arrival, length of residence, interpreter use and having an Australian-born partner. Adjusted odds ratios (aOR) for term-LBW and PTB (all, spontaneous, medically-indicated) were calculated using multivariable logistic regression in migrants from six ethnicities (white, Asian, Indian, African, Māori, and 'other') for different levels of acculturation, compared to the Australian-born population as the reference.

RESULTS

The least acculturated migrant women, those from non-white non-Māori ethnic backgrounds who immigrated at age ≥18 years, had an overseas-born partner, lived in Australia for < 5 years and used a paid interpreter, had 58% (aOR 1.58, 95% CI 1.15-2.18) higher the risk of term-LBW and 40% (aOR 0.60, 95% CI 0.45-0.80) lower risk of spontaneous PTB compared to the Australian-born women. The most acculturated migrant women, those from non-white non-Māori ethnic backgrounds who immigrated at age <18 years, had an Australian-born partner, lived in Australia for > 10 years and did not use an interpreter, had similar risk of term-LBW but 43% (aOR 1.43, 95% CI 1.14-1.78) higher risk of spontaneous PTB than the Australian-born women.

CONCLUSION

Acculturation is an important factor to consider when providing antenatal care to prevent PTB and LBW in migrants. Acculturation may reduce the risk of term-LBW but, conversely, may increase the risk of spontaneous PTB in migrant women residing in Western Australia. However, the effect may vary by ethnicity and warrants further investigation to fully understand the processes involved.

Medical, behavioural and social preconception and interconception risk factors among pregnancy planning and recently pregnant Canadian women

OBJECTIVES

The objective of this study is to describe the clustering of medical, behavioural and social preconception and interconception health risk factors and determine demographic factors associated with these risk clusters among Canadian women.

DESIGN

Cross-sectional data were collected via an online questionnaire assessing a range of preconception risk factors. Prevalence of each risk factor and the total number of risk factors present was calculated. Multivariable logistic regression models determined which demographic factors were associated with having greater than the mean number of risk factors. Exploratory factor analysis determined how risk factors clustered, and Spearman's r determined how demographic characteristics related to risk factors within each cluster.

SETTING

Canada.

PARTICIPANTS

Participants were recruited via advertisements on public health websites, social media, parenting webpages and referrals from ongoing studies or existing research datasets. Women were eligible to participate if they could read and understand English, were able to access a telephone or the internet, and were either planning a first pregnancy (preconception) or had ≥1 child in the past 5 years and were thus in the interconception period.

RESULTS

Most women (n=1080) were 34 or older, and were in the interconception period (98%). Most reported risks in only one of the 12 possible risk factor categories (55%), but women reported on average 4 risks each. Common risks were a history of caesarean section (33.1%), miscarriage (27.2%) and high birth weight (13.5%). Just over 40% had fair or poor eating habits, and nearly half were not getting enough physical activity. Three-quarters had a body mass index indicating overweight or obesity. Those without a postsecondary degree (OR 2.35; 95% CI 1.74 to 3.17) and single women (OR 2.22, 95% CI 1.25 to 3.96) had over twice the odds of having more risk factors. Those with two children or more had 60% lower odds of having more risk factors (OR 0.68, 95% CI 0.52 to 0.86). Low education and being born outside Canada were correlated with the greatest number of risk clusters.

CONCLUSIONS

Many of the common risk factors were behavioural and thus preventable. Understanding which groups of women are prone to certain risk behaviours provides opportunities for researchers and policy-makers to target interventions more efficiently and effectively.

Psychosocial and behavioral health indicators among immigrant and non-immigrant recent mothers

BACKGROUND

Perinatal risk factors can vary by immigration status. We examined psychosocial and behavioral perinatal health indicators according to immigration status and immigrant characteristics.

METHODS

We conducted a population-based cross-sectional study of 33,754 immigrant and 172,342 non-immigrant childbearing women residents in Manitoba, Canada, aged 15-55 years, who had a live birth and available data from the universal newborn screen completed within 2 weeks postpartum, between January 2000 and December 2017. Immigration characteristics were from the Canadian federal government immigration database. Logistic regressions models were used to obtain Odds Ratios (OR) with 95% confidence intervals (CI) for the associations between immigration characteristics and perinatal health indicators, such as social isolation, relationship distress, partner violence, depression, alcohol, smoking, substance use, and late initiation of prenatal care.

RESULTS

More immigrant women reported being socially isolated (12.3%) than non-immigrants (3.0%) (Adjusted Odds Ratio (aOR): 6.95, 95% CI: 6.57 to 7.36) but exhibited lower odds of depression, relationship distress, partner violence, smoking, alcohol, substance use, and late initiation of prenatal care. In analyses restricted to immigrants, recent immigrants (< 5 years) had higher odds of being socially isolated (aOR: 9.04, 95% CI: 7.48 to 10.94) and late initiation of prenatal care (aOR: 1.50, 95% CI: 1.07 to 2.12) compared to long-term immigrants (10 years or more) but lower odds of relationship distress, depression, alcohol, smoking and substance use. Refugee status was positively associated with relationship distress, depression, and late initiation of prenatal care. Secondary immigrants, whose last country of permanent residence differed from their country of birth, had lower odds of social isolation, relationship distress, and smoking than primary migrants. There were also differences by maternal region of birth.

CONCLUSION

Immigrant childbearing women had a higher prevalence of social isolation but a lower prevalence of other psychosocial and behavioral perinatal health indicators than non-immigrants. Health care providers may consider the observed heterogeneity in risk to tailor care approaches for immigrant subgroups at higher risk, such as refugees, recent immigrants, and those from certain world regions.

Adverse Pregnancy Outcomes and International Immigration Status: A Systematic Review and Meta-analysis

Background:

Disparities in health outcomes between immigrant and native-origin populations, particularly pregnant women, pose significant challenges to healthcare systems. The aim of this systematic-review and meta-analysis was to investigate the risk of adverse pregnancy outcomes among immigrant-women compared to native-origin women in the host country.

Methods:

PubMed (including MEDLINE), Scopus, and Web of Science were searched to retrieve studies published in English language up to September 2020. All observational studies examining the prevalence of at least one of the short-term single pregnancy outcomes for immigrants who crossed international borders compared to native-origin pregnant population were included. The meta-prop method was used for the pooled-estimation of adverse pregnancy-outcomes’ prevalence. For pool-effect estimates, the association between the immigration-status and outcomes of interest, the random-effects model was applied using the model described by DerSimonian and Laird. I² statistic was used to assess heterogeneity. The publication bias was assessed using the Harbord-test. Meta-regression was performed to explore the effect of geographical region as the heterogeneity source.

Findings:

This review involved 11 320 674 pregnant women with an immigration-background and 56 102 698 pregnant women as the native-origin population. The risk of emergency cesarean section (Pooled-OR = 1.1, 95%CI = 1.0–1.2), shoulder dystocia (Pooled-OR = 1.1, 95%CI = 1.0–1.3), gestational diabetes mellites (Pooled-OR = 1.4, 95%CI = 1.2–1.6), small for gestational age (Pooled-OR=1.3, 95%CI = 1.1–0.4), 5-min Apgar less than 7 (Pooled-OR = 1.2, 95%CI = 1.0–1.3) and oligohydramnios (Pooled-OR = 1.8, 95%CI = 1.0–3.3) in the immigrant women were significantly higher than those with the native origin background. The immigrant women had a lower risk of labor induction (Pooled-OR = 0.8, 95%CI = 0.7–0.8), pregnancy induced hypertension (Pooled-OR = 0.6, 95%CI = 0.5–0.7) preeclampsia (Pooled-OR = 0.7, 95%CI = 0.6–0.8), macrosomia (Pooled-OR = 0.8, 95%CI = 0.7–0.9) and large for gestational age (Pooled-OR = 0.8, 95%CI = 0.7–0.8). Also, the risk of total and primary cesarean section, instrumental-delivery, preterm-birth, and birth-trauma were similar in both groups. According to meta-regression analyses, the reported ORs were not influenced by the country of origin.

Conclusion:

The relationship between the immigration status and adverse perinatal outcomes indicated a heterogenous pattern, but the immigrant women were at an increased risk of some important adverse pregnancy outcomes. Population-based studies with a focus on the various aspects of this phenomena are required to explain the source of these heterogenicities.

Nativity-Related Disparities in Preterm Birth and Cardiovascular Risk in a Multiracial U.S. Cohort

INTRODUCTION

Having a preterm birth is associated with future cardiovascular risk. Non-Hispanic Black women have higher rates of preterm birth than non-Hispanic White and Hispanic women, but nativity-related disparities in preterm birth are not well understood.

METHODS

Data from 6,096 women in the Boston Birth Cohort: non-Hispanic Black (2,699), non-Hispanic White (997), or Hispanic (2,400), were analyzed in June 2021. Differences in cardiovascular risk factors were assessed. The association of preterm birth with nativity and duration of U.S. residence were investigated using multivariable logistic regression.

RESULTS

U.S.-born women in all 3 racial-ethnic groups had a higher prevalence of obesity, smoking, and severe stress than foreign-born women. Foreign-born non-Hispanic Black and Hispanic women had lower odds of preterm birth than U.S.-born counterparts (non-Hispanic Black: AOR=0.79, 95% CI=0.65, 0.97; Hispanic: AOR=0.72, 95% CI=0.56, 0.93). In all the 3 groups, foreign-born women with shorter (<10 years) duration of U.S. residence had lower odds of preterm birth than the U.S.-born women (non-Hispanic Black: AOR=0.57, 95% CI=0.43, 0.75; Hispanic: AOR=0.72, 95% CI=0.55, 0.94; non-Hispanic White: AOR=0.46, 95% CI=0.25, 0.85), whereas the odds of preterm birth in foreign-born women with ≥10 years of residence were not significantly different.

CONCLUSIONS

Foreign-born women had better cardiovascular risk profiles in all groups and lower odds of preterm birth in non-Hispanic Black and Hispanic groups. In all the 3 groups, a shorter duration of U.S. residence was associated with lower odds of preterm birth. Further studies are needed to understand the biological and social determinants underlying these nativity-related disparities and the impact of acculturation.

Immigrant ancestry and birthweight across two generations born in Sweden: an intergenerational cohort study

INTRODUCTION

Differences in birthweight are often seen between migrants and natives. However, whether migrant-native birthweight inequalities widen, narrow or remain persistent across generations when comparing the descendants of immigrants and natives remains understudied. We examined inequalities in birthweight of mothers (G2) and daughters (G3) of foreign-born grandmothers (G1) compared with those of Swedish-born grandmothers.

METHODS

We used population registers with multigenerational linkages to identify 314 415 daughters born in Sweden during the period 1989-2012 (G3), linked to 246 642 mothers (G2) born in Sweden during 1973-1996, and to their grandmothers (G1) who were Swedish or foreign-born. We classified migrants into non-western, Eastern European, the rest of Nordic and Western. We used multivariable methods to examine mean birthweight and low birthweight (<2500 g; LBW).

RESULTS

Birthweight between individuals with Swedish background (G1) and non-western groups increased from -80 g to -147 g between G2 (mothers) and G3 (daughters), respectively. Furthermore, the odds of LBW increased among the G3 non-western immigrants compared with those with Swedish grandmothers (OR: 1.38, 95% CI 1.12 to 1.69). Birthweight increased in both descendants of Swedes and non-western immigrants, but less so in the latter (83 g vs 16 g).

CONCLUSION

We observed an increase in birthweight inequalities across generations between descendants of non-western immigrants and descendants of Swedes. This finding is puzzling considering Sweden has been lauded for its humanitarian approach to migration, for being one of the most egalitarian countries in the world and providing universal access to healthcare and education.

Differences in birthweight by maternal and paternal nativity status in Canada

BACKGROUND

Parental nativity, as well as duration of residence of foreign-born parents in the host country, has been shown to be associated with size at birth. However, most studies have focused on maternal nativity status only and have not accounted for important characteristics of both parents.

OBJECTIVE

To explore whether maternal and paternal nativity and length of residence (LOR) are independently associated with birthweight for gestational age in a representative sample of infants in Canada.

METHODS

We compared mean differences in sex- and gestational age-standardised birthweight z-score by nativity status of both parents in a nationally representative sample of 130,532 singleton infants born between May 2004 and May 2006 to mothers residing in Canada. We categorised parental nativity status into four groups (both parents Canada-born, mother only foreign-born, father only foreign-born and both parents foreign-born) and parents' LOR into three (both ≤10 years, only one parent ≤10 years and both >10 years). We estimated mean differences in birthweight z-score and their 95% confidence intervals in linear regression models adjusted for parity, parents' ages, education, ethnicity and marital status of the mother.

RESULTS

Compared with babies of Canada-born couples, those of two foreign-born parents had on average smaller birthweight z-score, -0.23 (95% CI -0.28, -0.25). However, after adjustment, the mean difference in z-score was -0.02 (95% CI -0.05, 0.00). Infants born to parents who had both resided in Canada for ≤10 years had a unadjusted mean difference in z-score of -0.27 (95% CI -0.29, -0.26), compared infants whose parents were both Canada-born, but the difference became negligible (-0.02, 95% CI -0.04, 0.01) after adjustment.

CONCLUSION

The birthweight differences by parental nativity or length of residence observed in our study population could be attributed to differences in the distribution of other parental characteristics that affect birthweight.

Sexual attitudes and behaviours among Arab American young adults in the USA

While the sexual behaviours of different racial and ethnic groups have been studied extensively in the USA, Arab Americans are relatively understudied. The purpose of our study is to describe sexual attitudes and behaviours of Arab American young adults, to explore gender differences and the factors associated with five primary sexual behaviours (solo and partnered masturbation, oral, vaginal and anal sex). We conducted a cross-sectional quantitative study using a self-administered survey, which included measures of Arab ethnic identity, religiosity and sexual attitudes and behaviours. The survey was completed by 100 Arab American young adults (18-25 years old). Almost half of the sample reported being engaged in at least one of the five primary sexual behaviours in the past six months. In bivariate analysis, there were significant gender differences in sexual attitudes and all the primary sexual behaviours except for anal sex. Sexual attitudes and religiosity were significant predictors of partnered masturbation, oral and vaginal sex. Our findings challenge Arab societal assumptions that unmarried Arab American young adults do not engage in sexual behaviours, including risky behaviours, warranting further research to prevent unintended sexual health outcomes.

A Comparative Prevalence of Birth Defects between Newborns of Immigrant and Native-Born Mothers in Taiwan: Ten Years of Population-Based Data

In recent years, newborns born to immigrant mothers have accounted for about 10% of the total births in Taiwan. However, little is known about whether there are differences between newborns of immigrant and native-born mothers regarding the prevalence and the possible causes of birth defects. By combining four nationwide databases and assessing all newborns between 2005 and 2014 in Taiwan as research subjects, this study determined the prevalence of birth defects stratified into nine categories (neuronal, facial, cleft, circulatory, respiratory, digestive, urogenital, musculoskeletal and chromosomal abnormalities) in the newborns of immigrant mothers and native-born mothers. We found that the prevalence of any birth defects in newborns of immigrant mothers (ranging from 0.98 to 1.24%) was lower than that of native-born mothers (2.86%). Skeletomuscular system defects are the most common among newborns of women from the main immigrant countries (0.24–0.42%), while circulatory system defects were the most common among newborns of Taiwanese women (0.92%). The risks of all defects remained lower for newborns of immigrant mothers (AORs ranged from 0.37 to 0.47) after controlling for possible confounding variables. The higher rates of birth defects among newborns of native-born mothers may be attributed to an older maternal age at childbirth and a higher prevalence of diabetes than that of immigrant mothers. The findings from this study imply that the prevalence of birth defects between newborns of immigrant and native-born mothers is not similar, as evidenced by a decade of population-based data.

Social Vulnerability among Foreign-Born Pregnant Women and Maternal Virologic Control of HIV

OBJECTIVE

The aim of this study was to assess whether social vulnerability among foreign-born pregnant women living with HIV is associated with maternal viremia during pregnancy.

STUDY DESIGN

This retrospective cohort study included all foreign-born pregnant women living with HIV who received prenatal care in a multidisciplinary prenatal clinic between 2009 and 2018. A licensed clinical social worker evaluated all women and kept detailed clinical records on immigration status and social support. Social vulnerability was defined as both living in the United States for less than 5 years and reporting no family or friends for support. The primary outcome was evidence of viral non-suppression after achievement of initial suppression. Secondary outcomes were the proportion of women who required > 12 weeks after starting antiretroviral therapy to achieve viral suppression, median time to first viral suppression (in weeks) after initiation of antiretroviral therapy, and the proportion who missed ≥ 5 doses of antiretroviral therapy. Bivariable analyses were performed.

RESULTS

A total of 111 foreign-born women were eligible for analysis, of whom 25 (23%) were classified as socially vulnerable. Social and clinical characteristics of women diverged by social vulnerability categorization but no differences reached statistical significance. On bivariable analysis, socially-vulnerable women were at increased risk for needing > 12 weeks to achieve viral suppression (relative risk: 1.78, 95% confidence interval: 1.18-2.67), though there was no association with missing ≥ 5 doses of antiretroviral therapy or median time to viral suppression after initiation of antiretroviral therapy.

CONCLUSION

Among foreign-born, pregnant women living with HIV, markers of virologic control during pregnancy were noted to be worse among socially-vulnerable women. Insofar as maternal viremia is the predominant driver of perinatal transmission, closer clinical surveillance and support may be indicated in this population.

KEY POINTS

· 23% of foreign-born pregnant women living with HIV were identified as socially vulnerable.. · Socially-vulnerable women were at higher risk for re-emergent viremia (24 vs. 7%, RR 3.44).. · Socially-vulnerable women were at higher risk for needing >12 weeks to become aviremic (64 vs. 36%, RR: 1.7)..

Admissions and Emergency Visits by Late Preterm Singletons and Twins in the First 5 Years: A Population-Based Cohort Study

OBJECTIVE

To compare admission and emergency visits of late preterm (34^0/7-36^6/7 weeks) versus term infants (37^0/7-41^6/7 weeks) in the first 5 years.

STUDY DESIGN

This population-based cohort study included all singletons and twins born alive at 34^0/7 to 41^6/7 weeks' gestation registered in a health administrative database in Ontario, Canada, between April 1, 2002 and December 31, 2012. Admissions and emergency visits from initial postnatal discharge to 5 years were compared between late preterm and term infants adjusting for maternal and infant characteristics.

RESULTS

A total of 1,316,931 infants (75,364 late preterm infants) were included. Late preterm infants had more frequent admissions than term infants in the first 5 years in both singletons (adjusted incidence rate ratio [95% confidence interval] = 1.46 [1.42-1.49]) and twins (1.21 [1.11-1.31]). The difference in admissions between late preterm and term infants were smaller in twins than singletons and decreased with children's ages. Twins had less frequent admissions than singletons for late preterm infants, but not for term infants. The emergency visits were more frequent in late preterm than term infants in all the periods.

CONCLUSION

Admissions and emergency visits were more frequent in late preterm than term infants through the first 5 years. Admissions were less frequent in late preterm twins than singletons.

Investigating Health Equity and Healthcare Needs among Immigrant Women Using the Association Rule Mining Method

Equitable access to healthcare services is a major concern among immigrant women. Thus, this study investigated the relationship between socioeconomic characteristics and healthcare needs among immigrant women in Taiwan. The secondary data was obtained from “Survey of Foreign and Chinese Spouses’ Living Requirements, 2008”, which was administered to 5848 immigrant women by the Ministry of the Interior, Taiwan. Additionally, descriptive statistics and significance tests were used to analyze the data, after which the association rule mining algorithm was applied to determine the relationship between socioeconomic characteristics and healthcare needs. According to the findings, the top three healthcare needs were providing medical allowances (52.53%), child health checkups (16.74%), and parental knowledge and pre- and post-natal guidance (8.31%). Based on the association analysis, the main barrier to the women’s healthcare needs was “financial pressure”. This study also found that nationality, socioeconomic status, and duration of residence were associated with such needs, while health inequality among aged immigrant women was due to economic and physical factors. Finally, the association analysis found that the women’s healthcare problems included economic, socio-cultural, and gender weakness, while “economic inequality” and “women’s health” were interrelated.

Hospital Care Cost and Resource Use of Early Discharge of Healthy Late Preterm and Term Singletons: A Population-based Cohort Study and Cost Analysis

OBJECTIVE

To assess the hospital care cost and resource use associated with discharge timings after late preterm and term births.

STUDY DESIGN

This population-based cohort study and cost analysis included all healthy singleton late preterm (35-36 weeks gestational age) and term infants (37-41 weeks gestational age) born vaginally in hospitals in Ontario, Canada, from 2003 to 2012. Early, late, and very late discharge (<48, 48-71, and 72-95 hours after birth, respectively) were compared using generalized linear models. The primary outcome was the total hospital care cost (hospitalizations and emergency department visits) per infant within 28 days of birth.

RESULTS

Among 860 693 singletons (3.7% late preterm), early discharge increased significantly over 10 years for term infants (from 69% to 82%; P < .001), but not late preterm infants (from 32% to 35%; P = .75). The mean total cost within 28 days after birth was not significantly different for late preterm infants between early discharge and late discharge after adjustment. However, for term infants, the adjusted cost was higher with early discharge than late discharge (aMCD $311 [95% CI, $211-$412] per infant; $366 [95% CI, $355-$377] per mother-infant dyad). The neonatal readmission rates were higher after early than late discharge for late preterm and term infants.

CONCLUSIONS

Early discharge was not associated with cost savings for vaginally born healthy singleton late preterm infants, and instead was associated with a cost increase for term infants. Early discharge was associated with higher neonatal readmission rates. Individualized approach balancing the risk and benefit is appropriate to determine the discharge timings.

Perinatal health of refugee and asylum-seeking women in Sweden 2014-17: a register-based cohort study

Background

An increasing number of migrants have fled armed conflict, persecution and deteriorating living conditions, many of whom have also endured risky migration journeys to reach Europe. Despite this, little is known about the perinatal health of migrant women who are particularly vulnerable, such as refugees, asylum-seekers, and undocumented migrants, and their access to perinatal care in the host country.

Methods

Using the Swedish Pregnancy Register, we analyzed indicators of perinatal health and health care usage in 31 897 migrant women from the top five refugee countries of origin between 2014 and 2017. We also compared them to native-born Swedish women.

Results

Compared to Swedish-born women, migrant women from Syria, Iraq, Somali, Eritrea and Afghanistan had higher risks of poor self-rated health, gestational diabetes, stillbirth and infants with low birthweight. Within the migrant population, asylum-seekers and undocumented migrants had a higher risk of poor maternal self-rated health than refugee women with residency, with an adjusted risk ratio (RR) of 1.84 and 95% confidence interval (95% CI) of 1.72–1.97. They also had a higher risk of preterm birth (RR 1.47, 95% CI 1.21–1.79), inadequate antenatal care (RR 2.56, 95% CI 2.27–2.89) and missed postpartum care visits (RR 1.15, 95% CI 1.10–1.22).

Conclusion

Refugee, asylum-seeking and undocumented migrant women were vulnerable during pregnancy and childbirth. Living without residence permits negatively affected self-rated health, pregnancy and birth outcomes in asylum-seekers and undocumented migrants. Pregnant migrant women’s special needs should be addressed by those involved in the asylum reception process and by health care providers.

Infant mortality among Arabic-speakers in Quebec, Canada, 1989-2017

BACKGROUND

We assessed trends in infant mortality for Arabic-speakers in Quebec, Canada between 1981 and 2017.

METHODS

We computed infant mortality rates for Arabic versus French and English-speakers in Quebec over time. We used adjusted risk ratios (aRR) and 95% confidence intervals (CI) to investigate trends among Arabic-speakers according to socioeconomic status, age, and cause of death.

RESULTS

Infant mortality rates were 3.0 for Arabic-speakers and 5.1 for French and English-speakers per 1,000 live births. Infant mortality increased for Arabic-speakers between 1989-1995 and 2010-2017 (aRR 2.07; 95% CI, 1.04-4.12), but decreased for French and English-speakers (aRR 0.77; 95% CI, 0.73-0.81). The increase in infant mortality was greater for socioeconomically advantaged Arabic-speakers (aRR 2.52; 95% CI, 1.20-5.28) and early neonatal mortality (aRR 1.64; 95% CI, 0.98-2.76).

DISCUSSION

Arabic-speakers in Quebec have a lower risk of infant mortality than French and English-speakers, but increasing infant mortality among Arabic-speakers is narrowing the gap.

Variations in Relationships Between Perceived Stress and Birth Outcomes by Immigration Status

INTRODUCTION

Past research shows that stress during pregnancy predicts adverse birth outcomes. These patterns might differ based on immigration status. Our objective was to analyze differences in relationships between perceived stress during pregnancy and birth outcomes by immigration status.

METHODS

We recruited 81 pregnant women in Canada for a prospective longitudinal study of stress during pregnancy and infant development. Participants completed the Perceived Stress Questionnaire at 16-18, 24-26 and 32-34 weeks of pregnancy. Birth records were available for 73 women, including 24 non-immigrants, 18 long-term immigrants (≥ 5 years), and 31 recent immigrants (< 5 years). We used General Linear Models to test relationships between perceived stress and birthweight, birthweight for gestational age Z-scores, and gestational age, and differences based on immigration status.

RESULTS

Controlling for sociodemographic covariates, we observed interactive relationships between immigration status and perceived stress with birthweight at 16-18 (p = 0.032, partial η² = 0.11) and 24-26 weeks pregnancy (p = 0.012, partial η² = 0.15). Results were similar for birthweight for gestational age Z-scores at 16-18 weeks (p = 0.016, partial η² = 0.13) and 24-26 weeks pregnancy (p = 0.013, partial η² = 0.14). Perceived stress predicted smaller birthweight measurements among long-term immigrants. No relation was found between perceived stress, immigration status and gestational age.

DISCUSSION

Risk of adverse health outcomes, including birth outcomes, tends to increase with duration of residence among immigrants. Stress during pregnancy might represent one risk factor for adverse birth outcomes among long-term immigrant women. Promoting psychosocial health screening and care among immigrant women, and assuring continued care with acculturation, might improve both maternal and infant health outcomes.

Racial/ethnic minority segregation and low birth weight in five North American cities

Comparisons of communities across cities are rare in social epidemiology. Our prior work exploring racial/ethnic segregation and the prevalence of low birth weight (LBW) in communities from two large urban cities showed a strong relationship in Chicago and a very weak relationship in Toronto. This study extends that work by examining the association between racial/ethnic minority segregation and LBW in total of 307 communities in five North American cities: Baltimore, Boston, Chicago, Philadelphia, and Toronto. We used Pearson correlation coefficients and OLS regression models to examine potential variability in the association between racial/ethnic minority segregation and LBW, controlling for community-level unemployment. In a combined model with community-level data from all cities, a 10% increase in minority composition is associated with a 0.7% increase in LBW. While racial/ethnic minority segregation and unemployment are not associated with LBW in Toronto, these social determinants have strong and significant associations with LBW across communities in the four US cities in the analysis. Subsequent models revealed opposite effects for percentage non-Hispanic Black and percentage Hispanic. Across communities in the US cities in this analysis, there is considerable similarity in the strength of the effect of racial/ethnic segregation on LBW. Future work should incorporate communities from additional cities, looking to identify community assets and public policies that allow some minority communities to thrive, while other minority communities suffer from a high prevalence of LBW. More work is also needed on the generalizability of these patterns to other health outcomes.

Do recent immigrants have similar obstetrical care and perinatal complications as long-term residents? A retrospective exploratory cohort study in Brussels

PURPOSE

Recent immigrants (RIs) face various barriers affecting quality of care. The main research question assessed whether perinatal complications (during pregnancy, labour, delivery and neonatal period) were similar in RIs to those in long-term residents (LTRs). The secondary question assessed whether prenatal and perinatal care was similar in the two groups.

METHODS

This is a monocentric observational study, carried out in Brussels between November 2016 and March 2017 (n=1365). We surveyed 892 pregnant women during prenatal consultations and immediate postpartum period in order to identify RIs of less than 3 years (n=230, 25%) and compared them with LTRs (n=662). Sociodemographic data, baseline health status, prenatal care, obstetrical and neonatal complications were compared between these two groups. Multivariable binary logistic regression was conducted to examine the occurrence of perinatal complications (during pregnancy, labour and delivery, and neonatal period) between RIs and LTRs after adjustment for potential confounders.

RESULTS

RIs were living more frequently in precarious conditions. RIs were younger (p<0.001) and had a lower body mass index (p<0.001) than LTRs. Prenatal care was often delayed in RIs, resulting in fewer evaluations during the first trimester (p<0.001). They had a lower prevalence of gestational diabetes mellitus (p<0.05) and less complications during the pregnancy even after adjustment for confounding factors. Similar obstetrical care during labour and delivery occurred. After adjustment for confounding factors, no differences in labour and delivery complications were observed. Although RIs' newborns had a lower umbilical cord blood pH (<0.05), a lower 1 min of life Apgar score (p<0.01) and more frequently required respiratory assistance (p<0.05), no differences in the composite endpoint of neonatal complications were observed. No increase in complications in the RI group was detected whatever the considered period.

CONCLUSION

RIs had less optimal prenatal care but this did not result in more obstetrical and perinatal complications.

Access to and interventions to improve maternity care services for immigrant women: a narrative synthesis systematic review

Background

In 2016, over one-quarter of births in the UK (28.2%) were to foreign-born women. Maternal and perinatal mortality are disproportionately higher among some immigrants depending on country of origin, indicating the presence of deficits in their care pathways and birth outcomes.

Objectives

Our objective was to undertake a systematic review and narrative synthesis of empirical research that focused on access and interventions to improve maternity care for immigrant women, including qualitative, quantitative and mixed-methods studies.

Review methods

An information scientist designed the literature database search strategies (limited to retrieve literature published from 1990 to 2018). All retrieved citations (45,954) were independently screened by two or more team members using a screening tool. We searched grey literature reported in related databases and websites. We contacted stakeholders with subject expertise. In this review we define an immigrant as a person who relocates to the destination country for a minimum of 1 year, with the goal of permanent residence.

Results

We identified 40 studies for inclusion. Immigrant women tended to book and access antenatal care later than the recommended first 10 weeks of pregnancy. Primary factors included limited English-language skills, lack of awareness of availability of the services, lack of understanding of the purpose of antenatal appointments, immigration status and income barriers. Immigrant women had mixed perceptions regarding how health-care professionals (HCPs) had delivered maternity care services. Those with positive perceptions felt that HCPs were caring, confidential and openly communicative. Those with negative views perceived HCPs as rude, discriminatory or insensitive to their cultural and social needs; these women therefore avoided accessing maternity care. We found very few interventions that had focused on improving maternity care for these women and the effectiveness of these interventions has not been rigorously evaluated.

Limitations

Our review findings are limited by the available research evidence related to our review questions. There may be many aspects of immigrant women’s experiences that we have not addressed. For example, few studies exist for perinatal mental health in immigrant women from Eastern European countries (in the review period). Many studies included both immigrant and non-immigrant women.

Conclusions

Available evidence suggests that the experiences of immigrant women in accessing and using maternity care services in the UK are mixed; however, women largely had poor experiences. Contributing factors included a lack of language support, cultural insensitivity, discrimination and poor relationships between immigrant women and HCPs. Furthermore, a lack of knowledge of legal entitlements and guidelines on the provision of welfare support and maternity care to immigrants compounds this.

Future work

Studies are required on the development of interventions and rigorous scientific evaluation of these interventions. Development and evaluation of online antenatal education resources in multiple languages. Development and appraisal of education packages for HCPs focused on the provision of culturally safe practice for the UK’s diverse population. The NHS in the UK has a hugely diverse workforce with a vast untapped linguistic resource; strategies could be developed to harness this resource.

Study registration

This study is registered as PROSPERO CRD42015023605.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 14. See the NIHR Journals Library website for further project information.

Perinatal health among foreign versus native-born mothers in Canada: variations across outcomes and cohorts

BACKGROUND

To examine perinatal health differences between foreign-born and native-born mothers in Canada across multiple outcomes and two cohorts 10 years apart.

METHODS

Using 94 896 and 131 271 births in the 1996 and 2006 Canadian Census-Birth Cohort, respectively, we estimated risk ratios and risk differences of preterm birth (PTB), small-for-gestational age (SGA), large-for-gestational age (LGA), stillbirth and infant mortality between foreign-born and Canadian-born mothers.

RESULTS

In the 1996 cohort, we observed no important differences in adverse outcomes between foreign-born and native-born mothers. In the 2006 cohort, however, foreign-born mothers had lower risks of PTB, LGA, stillbirth, and infant mortality and a higher risk of SGA on both the relative and absolute scales. Lowered risk of PTB among foreign-born mothers in the 2006 cohort was also observed within Caucasian, East Asian, Southeast Asian and South Asian mothers. Favourable outcomes associated with foreign-born status in the 2006 cohort were negatively graded by duration of residence in Canada among immigrant mothers.

CONCLUSIONS

Differences in perinatal health by maternal foreign-born status varied across cohorts and a more pronounced 'healthy migrant' effect was observed among more recent migrants. The native-born mothers' perinatal health over time and a more restrictive/selective immigration policy in recent years would explain our results.

Association of Acculturation With Adverse Pregnancy Outcomes

OBJECTIVE

To evaluate the relationship between acculturation and adverse pregnancy outcomes, and whether these relationships differ across racial or ethnic groups.

METHODS

This is a planned secondary analysis of the nuMoM2b study (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be), a prospective observational cohort study of 10,038 pregnant women at eight academic health care centers in the United States. Nulliparous pregnant women with singleton gestations were recruited between 6 0/7 and 13 6/7 weeks of gestation from October 2010-September 2013. Acculturation was defined by birthplace (United States vs non-United States), language used during study visits (English or Spanish), and self-rated English proficiency. The adverse pregnancy outcomes of interest were preterm birth (less than 37 weeks of gestation, both iatrogenic and spontaneous), preeclampsia or eclampsia, gestational hypertension, gestational diabetes, stillbirth, small for gestational age, and large for gestational age. Multivariable regression modeling was performed, as was an interaction analysis focusing on the relationship between acculturation and adverse pregnancy outcomes by maternal race or ethnicity.

RESULTS

Of the 10,006 women eligible for this analysis, 8,100 (80.9%) were classified as more acculturated (eg, born in the United States with high English proficiency), and 1,906 (19.1%) were classified as having less acculturation (eg, born or not born in the United States with low proficiency in English or use of Spanish as the preferred language during study visits). In multivariable logistic regression modeling, more acculturation was significantly associated with higher frequency of preterm birth (odds ratio [OR] 1.46, adjusted odds ratio [aOR] 1.50, 95% CI 1.16-1.95); spontaneous preterm birth (OR 1.54, aOR 1.62, 95% CI 1.14-2.24); preeclampsia or eclampsia (OR 1.39, aOR 1.31, 95% CI 1.03-1.67); preeclampsia without severe features (OR 1.44, aOR 1.43, 95% CI 1.03-2.01); and gestational hypertension (OR 1.68, aOR 1.48, 95% CI 1.22-1.79). These associations did not differ by self-described race or ethnicity.

CONCLUSION

In a large cohort of nulliparous women, more acculturation, regardless of self-described race or ethnicity, was associated with increased odds of several adverse pregnancy outcomes.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT01322529.

Offspring birthweight and placental weight in immigrant women from conflict-zone countries; does length of residence in the host country matter? A population study in Norway

INTRODUCTION

We aimed to estimate differences in offspring birthweight and placental weight between Norwegian women and immigrants in Norway from countries with armed conflicts. We also studied whether length of residence in Norway was associated with offspring birthweight and placental weight.

MATERIAL AND METHODS

We included in our study all singleton births in Norway at gestational week 28 or beyond during the years 1999-2014, to mothers who were born in Somalia, Afghanistan, Iraq (total immigrants n = 18 817), or Norway (n = 668 439). Data were obtained from The Medical Birth Registry of Norway and the Central Person Registry of Norway. We estimated the differences between Norwegian and immigrant women in mean offspring birthweight and mean placental weight by applying linear regression analyses. Adjustments were made for maternal age, parity, year of delivery, gestational age at delivery, preeclampsia, and diabetes.

RESULTS

The immigrant women had 206 g (95% CI 199 to 213 g) lower mean offspring birthweight and 16 g (95% CI 14 to 18 g) lower mean placental weight than Norwegian women. Immigrant women with ≥5 years of residence in Norway had higher offspring birthweight (40 g) and higher placental weight (17 g) than immigrant women with <5 years of residence.

CONCLUSIONS

Immigrant mothers from Somalia, Afghanistan, and Iraq gave birth to infants and placentas with lower weight than Norwegian women. However, the difference between Norwegian women and immigrant women was reduced by length of residence in Norway.

Association between sleep duration and hypertension of migrant workers in China: a national cross-sectional surveillance study

OBJECTIVES

To examine the relationship between sleep duration and hypertension of migrant workers aged 18-59 years in China.

DESIGN

Population-based cross-sectional study using a complex survey sampling design.

PARTICIPANTS

There were 43 655 subjects in our analysis, after excluding people with missing information for key exposure and outcome variables and abnormal values for sleep duration (≤2 or ≥17 hours).

PRIMARY OUTCOME MEASURE

Hypertension was defined as systolic blood pressure (BP) ≥140 mm Hg and/or diastolic BP ≥90 mm Hg, or self-reported history of hypertension diagnosis in hospitals at the township (community) level or above and use of hypertensive medicine in the last 2 weeks.

RESULTS

Of 43 655 subjects, 15.6% (95% CI 15.1% to 16.1%) of migrant workers had hypertension. The prevalence of hypertension decreased with the increased sleep duration, both in males and females. Logistic regression models, using 7-8 hours sleep/day as the reference, showed a greater odds for hypertension among men and women who reported <6 hours of sleep after adjusting for sociodemographic characteristics, behavioural risk factors, body mass index, diabetes, stroke and myocardial infarction (men: OR 1.26; 95% CI 1.03 to 1.54, women: OR 1.55; 95% CI 1.13 to 2.06, p_interaction=0.096). Further stratified by age and migration time, it revealed that among adults less than 45 years old, those sleeping 9 or more hours had adjusted odds for hypertension of 0.82 (95% CI 0.72 to 0.93, p_interaction=0.020),while there was no evidence of an association between sleep duration and hypertension among adults aged 45-59 years. Among adults whose migration time was less than 4.5 years, those sleeping 9 or more hours had adjusted odds for hypertension of 0.80 (95% CI 0.68 to 0.94, p_interaction=0.097).

CONCLUSION

The association between sleep duration and hypertension varies by age. Short sleep duration (<6 hours) is associated with an increased prevalence of hypertension in both genders.

Adverse perinatal outcomes in immigrants: A ten-year population-based observational study and assessment of growth charts

BACKGROUND

Maternity populations are becoming increasingly multiethnic. Conflicting findings exist regarding the risk of adverse perinatal outcomes among immigrant mothers from different world regions and which growth charts are most appropriate for identifying the risk of adverse outcomes.

OBJECTIVE

To evaluate whether infant mortality and morbidity, and the categorisation of infants as small for gestational age or large for gestational age (SGA or LGA) vary by maternal country of birth, and to assess whether the choice of growth chart alters the risk of adverse outcomes in infants categorised as SGA and LGA.

METHODS

A population cohort of 601 299 singleton infants born in Australia to immigrant mothers was compared with 1.7 million infants born to Australian-born mothers, 2004-2013. Infants were categorised as SGA and LGA according to a descriptive Australian population-based birthweight chart (Australia-2012 reference) and the prescriptive INTERGROWTH-21st growth standard. Propensity score reweighting was used for the analysis.

RESULTS

Compared to Australian-born infants, infants of mothers from Africa, Philippines, India, other Asia countries, and the Middle East had between 15.4% and 48.1% elevated risk for stillbirth, preterm delivery, or low Apgar score. The association between SGA and LGA and perinatal mortality varied markedly by growth chart and country of birth. Notably, SGA infants from African-born mothers had a relative risk of perinatal mortality of 6.1 (95% CI 4.3, 6.7) and 17.3 (95% CI 12.0, 25.0) by the descriptive and prescriptive charts, respectively. LGA infants born to Australian-born mothers were associated with a 10% elevated risk of perinatal mortality by the descriptive chart compared to a 15% risk reduction by the prescriptive chart.

CONCLUSIONS

Country-of-birth-specific variations are becoming increasingly important for providing ethnically appropriate and safe maternity care. Our findings highlight significant variations in risk of adverse perinatal outcomes in immigrant subgroups, and demonstrate how the choice of growth chart alters the quantification of risk associated with being born SGA or LGA.

Influence of time since naturalisation on socioeconomic status and low birth weight among immigrants in Belgium. A population-based study

Background

Increasingly studies show that immigrants have different perinatal health outcomes compared to native-born women. Nevertheless, we lack a detailed examination of the combined effects of maternal immigrant trajectory and socioeconomic status on perinatal outcomes. Our objective was to analyze the influence of time since naturalization on low birth weight and maternal socioeconomic status in Belgium.

Methods

The data came from the linkage between the Brussels birth and death registers, the national register of migrant trajectories and the social security register for the years 2004–2010. We used logistic regression to estimate the odds ratios of the associations between low birth weight (LBW) and time since naturalization, by nationality groups, taking into account socioeconomic status (SES), parity and maternal age.

Results

Data relate to all singleton births to Belgian, Maghrebi, Sub-Saharan African and Turkish women (n = 76 312). The results show an U-shaped of LBW according to time since naturalization for all migrant groups. LBW declines for women naturalized since less than one year and increases significantly thereafter (p<0.0001). In parallel, we observe an increase of SES among all migrant groups. Compared to Belgians, we found a lower risk of LBW among women from Maghreb (p<0.0001) and this protection is maintained even after 10 years since naturalization. In contrast, the risk of LBW for Sub-Saharan African and Turkish mothers is lower than for Belgians after one year of naturalization but similar to that of Belgians after 10 years of naturalization.

Conclusion

Our results show that, despite an improvement of their SES, LBW increases among Maghrebi, Sub-Saharan African and Turkish women with time since naturalization. Mothers from Maghreb have lower rates of LBW compared to Belgians and maintain their protection even after more than 10 years of having acquired the Belgian nationality. Additional studies need to be carried out in order to gain a better understanding of the association between migration trajectories, SES and perinatal health of immigrants.

Geospatial analyses of adverse birth outcomes in Southwestern Ontario: Examining the impact of environmental factors

BACKGROUND

A growing body of research has examined the association between exposure to environmental factors during pregnancy and adverse birth outcomes; however, many studies do not control for potential covariates and findings vary considerably.

OBJECTIVE

To test the relative influence of environmental factors including exposure to air pollution, major roads, highways, industry, parks, greenspaces, and food retailers on low birth weight (LBW) and preterm birth (PTB) in Southwestern Ontario (SWO), Canada, while accounting for medical (e.g., previous preterm birth, gestational diabetes), behavioral (e.g., alcohol, smoking), demographic (e.g., maternal age, body mass index), and neighborhood-level socioeconomic (e.g., household income, education) factors.

METHODS

This retrospective cohort study consisted of a large sample of pregnant women from SWO who gave birth to singleton newborns between February 2009 and February 2014 at London Health Sciences Centre. Data on maternal postal codes were entered into a Geographic Information System to map the distribution of maternal residences and determine selected characteristics of their neighborhood environments (i.e., socioeconomic, built, natural). These variables were developed based on postal codes where the mothers lived prior to giving birth. Logistic regression was used to assess the relative effects of the physical environment, socioeconomic status, clinical history, and behavioral risk factors on mothers having a LBW or PTB infant.

RESULTS

Out of 25,263 live births, 5.7% were LBW and 7.5% were PTB. Exposure to sulfur dioxide was a top predictor of both LBW and PTB. For every one-unit increase in sulfur dioxide, the odds of a LBW and PTB were 3.4 (95% CI: 2.2, 5.2) and 2.0 (95% CI: 1.4, 3.0) times higher, after controlling for other variables in the model, respectively (p < 0.001). Previous PTB was also highly associated with both birth outcomes.

CONCLUSIONS

Health care providers should be informed about the hazards of air pollution to developing fetuses so that recommendations can be made to their pregnant patients about limiting exposure when air quality is poor.

Do social factors and country of origin contribute towards explaining a "Latina paradox" among immigrant women giving birth in Germany?

Background

The “Latina paradox” describes the unexpected association between immigrant status, which is often correlated to low socioeconomic status, and low prevalence of unfavourable birth outcomes. Social (e.g. culture, religion) and/or non-social factors related to country of origin are potentially responsible for this paradox.

Methods

Questionnaire survey of 6413 women delivering in three large obstetric hospitals in Berlin (Germany) covering socioeconomic and migration status, country of origin (Turkey, Lebanon), and acculturation. Data was linked with routine obstetric data. Logistic regressions were performed to assess the effect of acculturation, affinity to religion and country of origin on preterm birth and small-for-gestational-age (SGA).

Results

Immigrant women with a low level of acculturation (reference) were less likely to have a preterm birth than those who were highly acculturated (aOR: 1.62, 95%CI: 1.01–2.59), as were women from Turkey compared to non-immigrants (aOR: 0.49, 95%CI: 0.33–0.73). For SGA, we found no epidemiologic paradox; conversely, women from Lebanon had a higher chance (aOR: 1.72, 95%CI: 1.27–2.34) of SGA. Affinity to religion had no influence on birth outcomes.

Conclusions

There is evidence that low acculturation (but not affinity to religion) contributes towards explaining the epidemiologic paradox with regard to preterm birth, emphasising the influence of socioeconomic characteristics on birth outcomes. The influence of Turkish origin on preterm birth and Lebanese origin on SGA suggests that non-social factors relating to the country of origin are also at play in explaining birth outcome differences, and that the direction of the effect varies depending on the country of origin and the outcome.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6523-9) contains supplementary material, which is available to authorized users.

Stillbirth in relation to maternal country of birth and other migration related factors: a population-based study in Norway

BACKGROUND

Migrant women's overall increased risk of adverse pregnancy outcomes is well known. The aim of this study was to investigate possible associations between stillbirth and maternal country of birth and other migration related factors (paternal origin, reason for immigration, length of residence and birthplace of firstborn child) in migrant women in Norway.

METHODS

Nationwide population-based study including births to primiparous and multiparous migrant women (n = 198,520) and non-migrant women (n = 1,156,444) in Norway between 1990 and 2013. Data from the Medical Birth Registry of Norway and Statistics Norway. Associations were investigated by multiple logistic regression and reported as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Primiparous women from Sri-Lanka and Pakistan, and multiparous women from Pakistan, Somalia, the Philippines and Former Yugoslavia had higher odds of stillbirth when compared to non-migrant women (adjusted OR ranged from 1.58 to 1.79 in primiparous and 1.50 to 1.71 in multiparous women). Primiparous migrant women whose babies were registered with Norwegian-born fathers had decreased odds of stillbirth compared to migrant women whose babies were registered with foreign-born fathers (aOR = 0.73; CI 0.58-0.93). Primiparous women migrating for work or education had decreased odds of stillbirth compared to Nordic migrants (aOR = 0.58; CI 0.39-0.88). Multiparous migrant women who had given birth to their first child before arriving in Norway had higher odds of stillbirth in later births in Norway compared with multiparous migrant women who had their first child after arrival (aOR = 1.28; CI 1.06-1.55). Stillbirth was not associated with length of residence in Norway.

CONCLUSIONS

This study identifies sub-groups of migrant women who are at an increased risk of stillbirth, and highlights the need to improve care for them. More attention should be paid to women from certain countries, multiparous women who had their first baby before arrival and primiparous women whose babies have foreign-born fathers.

Stillbirth in relation to maternal country of birth and other migration related factors: a population-based study in Norway

Background

Migrant women’s overall increased risk of adverse pregnancy outcomes is well known. The aim of this study was to investigate possible associations between stillbirth and maternal country of birth and other migration related factors (paternal origin, reason for immigration, length of residence and birthplace of firstborn child) in migrant women in Norway.

Methods

Nationwide population-based study including births to primiparous and multiparous migrant women (n = 198,520) and non-migrant women (n = 1,156,444) in Norway between 1990 and 2013. Data from the Medical Birth Registry of Norway and Statistics Norway. Associations were investigated by multiple logistic regression and reported as odds ratios (ORs) with 95% confidence intervals (CIs).

Results

Primiparous women from Sri-Lanka and Pakistan, and multiparous women from Pakistan, Somalia, the Philippines and Former Yugoslavia had higher odds of stillbirth when compared to non-migrant women (adjusted OR ranged from 1.58 to 1.79 in primiparous and 1.50 to 1.71 in multiparous women). Primiparous migrant women whose babies were registered with Norwegian-born fathers had decreased odds of stillbirth compared to migrant women whose babies were registered with foreign-born fathers (aOR = 0.73; CI 0.58–0.93). Primiparous women migrating for work or education had decreased odds of stillbirth compared to Nordic migrants (aOR = 0.58; CI 0.39–0.88). Multiparous migrant women who had given birth to their first child before arriving in Norway had higher odds of stillbirth in later births in Norway compared with multiparous migrant women who had their first child after arrival (aOR = 1.28; CI 1.06–1.55). Stillbirth was not associated with length of residence in Norway.

Conclusions

This study identifies sub-groups of migrant women who are at an increased risk of stillbirth, and highlights the need to improve care for them. More attention should be paid to women from certain countries, multiparous women who had their first baby before arrival and primiparous women whose babies have foreign-born fathers.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2140-3) contains supplementary material, which is available to authorized users.

Factors associated with pregnant adolescents' access to sexual and reproductive health services in New York City

OBJECTIVE

This longitudinal study examined access to, and factors associated with, receipt of sexual and reproductive health services deemed essential by the World Health Organization among pregnant adolescents in New York City.

METHODS

Participants included 649 pregnant adolescents, ages 14-21 who were enrolled in a clustered randomized controlled trial from 2008 to 2012. Data were collected via medical record abstraction and structured surveys during the second and third trimesters of pregnancy and 12-months postpartum. We used multivariable logistic regression to test associations between measures of social and economic vulnerability (age, race/ethnicity, immigration status, food and housing security, relationship status, perceived discrimination) and access to core sexual and reproductive health services (perinatal care, contraception, HIV testing, sexual health knowledge).

RESULTS

Only 4% of participants received all four core aspects of sexual and reproductive health assessed. Adolescents <18 years old had lower odds of contraception use (OR = 0.46, CI 0.27-0.78), having had an HIV test (OR = 0.35, CI 0.16-0.78), and high sexual health knowledge (OR = 0. 59, CI 0.37-0.95), compared to those ≥18 years. Black women were significantly more likely to have high sexual health knowledge compared to other women (OR = 1.84, CI 1.05, 3.22). Immigrants had higher odds of adequate perinatal care (OR = 1.60, CI 1.09-2.36) and contraception use (OR = 1.64, CI 1.07-2.53), but lower likelihood of high sexual health knowledge (OR = 0.52, CI 0.34-0.81), compared to US-born counterparts. Food insecurity was associated with lower likelihood of comprehensive perinatal care (OR = 0.63, CI 0.45-0.90).

CONCLUSIONS

Access to sexual and reproductive health services in New York City is poor among vulnerable adolescents. Health practice and policy should assure access to fundamental sexual and reproductive health services among vulnerable populations in the United States.

Evaluating the effect of income support policies on social health inequalities (SHIs) at birth in Montreal and Brussels using a contextualised comparative approach and model family method: a study protocol

INTRODUCTION

Assessing the effects of social policies on social health inequalities (SHIs) is a complex issue. Variations in social policy between countries or regions provide natural experiments in policy implementation to perform comparative research. Comparisons are most enlightening when: the object of the evaluation is well defined (types of policies, population groups); the context of policy is analysed (history, implementation); the impact of policy on household poverty is outlined in detail; the influence of various factors (other than poverty) on SHI is taken into consideration.

METHODS AND ANALYSIS

This study aims to understand how income support policies (ISPs) in Brussels and Montreal influence the poverty level of households receiving social assistance, and how they are associated with SHI at birth. Two cases studies will be carried out from a comparative perspective. The analysis includes four stages : (1) The model family method will be used to compare ISPs and their impact on disposable income and poverty of households receiving social assistance in both regions. (2) Statistical analysis of administrative databases will enable the description and comparison of SHI in adverse pregnancy outcomes across the two regions. (3) Analysis of databases and documents will allow for description of various factors which are likely to interact with poverty and influence SHI at birth. (4) Based on the Diderichsen model, results from the previous stages will be used to formulate hypotheses about the mechanisms by which ISPs contribute to increasing or reducing SHI at birth in both regions.

ETHICS AND DISSEMINATION

This research was approved by the Human Research Ethics Committee for Health research of Université de Montréal. In Belgium, the access to linked databases was approved by the Commission for the Protection of Privacy. Databases de-identified according to Belgian and Canadian legislation will be used. Results will be disseminated in scientific publications and will be shared with policy makers and field actors through collaborations with local organisations in Brussels and Montreal.

Comparing Pregnancy Outcomes of Immigrants from Ethiopia and the Former Soviet Union to Israel, to those of Native-Born Israelis

To compare pregnancy outcomes of immigrants from Former-Soviet-Union (FSUI) and Ethiopia (EI) to those of Jewish-native-born Israelis (JNB), in context of universal health insurance. Birth outcomes of all singletons born in Soroka-University Medical-Center (1998-2011) of EI (n = 1,667) and FSUI (n = 12,920) were compared with those of JNB (n = 63,405). Low birthweight rate was significantly higher among EI (11.0 %) and slightly lower (7.0 %) among FSUI, compared to JNB (7.5 %). Preterm-delivery rates were similar to those of JNB. Both immigrant groups had significantly (p < 0.001) higher rates of perinatal mortality (PM) than JNB (21/1000 in EI, and 11/1000 in FSUI, compared to 9/1000). Using multivariable GEE models both immigrant groups had significantly increased risk for PM; however, EI had twice as much FSUI origin (OR 2.3, 95 % CI 1.6-3.4, and OR 1.3, 95 % CI 1.1-1.6, respectively). Universal health care insurance does not eliminate excess PM in immigrants, nor the gaps between immigrant groups.

Immigrant women's food choices in pregnancy: perspectives from women of Chinese origin in Canada

OBJECTIVE

Following migration, pregnant immigrant women may encounter social, cultural, and economic challenges that negatively affect their food choices and subsequent health outcomes. Culturally appropriate health care is crucial during the perinatal period to ensure the health of immigrant mothers and their children. This project aims to explore and understand how the health beliefs and practices of Chinese immigrant women affect their food choices during the perinatal period.

DESIGN

This qualitative study used the methodology of focused ethnography. Women participated in one semi-structured interview, followed by a second photo-assisted, semi-structured interview which incorporated photographs taken by the women themselves.

RESULTS

The food choices and health behaviors of immigrant women were influenced by their general health beliefs, cultural knowledge concerning particular types of foods, traditional Chinese medical beliefs, social advice and information, and socio-economic factors.

CONCLUSION

The provision of culturally appropriate health care is crucial during the perinatal period, as it is not only a vulnerable life stage for women and their children but also a sensitive period of interaction with the Canadian health-care system. Understanding these intersecting factors can help to ensure culturally appropriate care and optimized health outcomes for Chinese immigrant women during the perinatal period.

Effect of maternal country of birth on breastfeeding practices: results from Portuguese GXXI birth cohort

Background

Maternal country of birth has been associated with perinatal health outcomes but less is known regarding breastfeeding practices in contemporary European settings. This study investigated effect of maternal country of birth on breastfeeding initiation and duration by comparing native Portuguese and migrant mothers.

Methods

We analyzed data of 7065 children of the Generation XXI (GXXI) birth cohort recruited at birth (2005–06) and followed-up 4 years later. Logistic regression was used to assess the effect of maternal country of birth on breastfeeding initiation. Kaplan-Meier estimate was used to compare breastfeeding duration by maternal country of birth and length of residence by migrant mothers in Portugal.

Results

Breastfeeding initiation and the type of breastfeeding practice were similar for native Portuguese and migrant mothers. The migrants had significantly higher median duration in months of any breastfeeding (Odds Ratio [OR] 6.0, 95% Confidence Interval [CI] 5.4,6.6) and exclusive breastfeeding (OR 4.0, 95% CI 3.8,4.2) than native Portuguese mothers (OR 4.0, 95% CI 3.8,4.2 and OR 3.0, 95% CI 2.9,3.0). Migrant mothers who resided in Portugal for either ≤5 years (OR 5.0, 95% CI 3.9,6.1 and OR 4.0, 95% CI 3.8,4.2) or >  5 years (OR 6.0, 95% CI 5.5,6.5 and OR 4.0, 95% CI 3.7,4.3) years had similar duration of any breastfeeding or exclusive breastfeeding, in both cases higher than the native Portuguese mothers. No significant differences were found when world regions were compared.

Conclusions

Maternal country of birth does not influence breastfeeding initiation and type of feeding practice. However, migrant mothers have longer breastfeeding duration of either exclusive or any breastfeeding, which was not changed by length of residence in Portugal.

Electronic supplementary material

The online version of this article (10.1186/s13006-018-0157-x) contains supplementary material, which is available to authorized users.

Divergent Patterns of Mitochondrial and Nuclear Ancestry Are Associated with the Risk for Preterm Birth

OBJECTIVE

To examine linkages between mitochondrial genetics and preterm birth by assessing the risk for preterm birth associated with the inheritance of nuclear haplotypes that are ancestrally distinct from mitochondrial haplogroup.

STUDY DESIGN

Genome-wide genotyping studies of cohorts of preterm and term individuals were evaluated. We determined the mitochondrial haplogroup and nuclear ancestry for individuals and developed a scoring for the degree to which mitochondrial ancestry is divergent from nuclear ancestry.

RESULTS

Infants with higher degrees of divergent mitochondrial ancestry were at increased risk for preterm birth (0.124 for preterm vs 0.105 for term infants; P< .05). This finding was validated in 1 of 2 replication cohorts. We also observed that greater degrees of divergent ancestry correlated with earlier delivery within the primary study population, but this finding was not replicated in secondary cohorts born preterm.

CONCLUSIONS

Individuals with divergent patterns of mitochondrial and nuclear ancestry are at increased risk for preterm birth. These findings may in part explain the higher rates of preterm birth in African Americans and in individuals with a matrilineal family history of preterm birth.

Obstetric care quality indicators and outcomes based on the degree of acculturation of immigrants-results from a cross-sectional study in Berlin

HYPOTHESIS

Acculturation is a complex, multidimensional process involving the integration of the traditional norms, values, and lifestyles of a new cultural environment. It is, however, unclear what impact the degree of acculturation has on obstetric outcomes.

METHODS

Data collection was performed in 2011 and 2012 at three obstetric tertiary centers in Berlin, Germany. Standardized interviews (20-30 min.) were performed with support of evaluated questionnaires. The primary collected data were then linked to the perinatal data recorded at the individual clinics provided from the obstetric centers which correspond with the routinely centralized data collected for quality assurance throughout Germany. The questionnaire included questions on sociodemographic, health care, and migrant-related aspects. Migrant women and women with a migration background were assessed using the Frankfurt Acculturation Scale, a one-dimensional measurement tool to assess the degree of acculturation (15 items on language and media usage as well as integration into social networks).

RESULTS

In summary, 7100 women were available for the survey (response rate of 89.6%) of which 3765 (53%) had a migration background. The probability of low acculturation is significantly (p < 0.001) associated with a lower level of German knowledge, a shorter period of residence, and lower education. Pregnant women with a low acculturation also had a significantly greater chance of having the first booking visit after 9 weeks of pregnancy and fewer ultrasound examinations during pregnancy. There is no significant difference depending on the degree of acculturation for the frequency of elective and emergency cesarean sections. The results of the logistic regression analyses for the examination of possible relationships between the degree of acculturation and obstetric parameters show no significant differences for prematurity, 5 min.-Apgar values > 7, arterial umbilical cord pH values > 7.00 and admissions to the neonatal unit.

CONCLUSIONS

In Berlin, among migrant women a low degree of acculturation may have an unfavorable effect on the utilization of pregnancy care provision. However, there were no relevant differences in obstetric outcome parameters in relation to the degree of acculturation within the migrant population of Berlin.

Salmon Bias and Preterm Birth Among Western Immigrants in China

Introduction Immigrants from Western industrialized countries are rarely found in immigrant studies. Our primary objective was to calculate the rate of cesarean delivery, 5-min Apgar score <7, and preterm birth among Chinese and Western women. Our secondary objective was to examine whether there are significant differences in terms of risk factors between Western immigrants who chose to deliver in their country of citizenship compared to those who chose to deliver in China. Methods Single-center retrospective cohort study in Shanghai, China. Multivariate logistic regression models used delivery outcome, and place of delivery (China vs. country of citizenship) as outcome variables. Results Preterm birth occurred at a rate of 3.82% among Chinese citizens, 4.12% among Chinese-born Western citizens, and 6.54% among non-Chinese-born Western citizens. After adjustment, preterm birth <37 weeks was more frequent among non-Chinese-born Western citizens compared with Chinese citizens, with an odds ratio of 1.82 (Confidence Interval 1.20-2.78), p = 0.005. Variables statistically associated with giving birth in China were maternal age ≥35 years and being Chinese-born Western, as well as the absence of medical or obstetrical conditions. Discussion Western immigrants have overall good obstetrical outcomes in China, and this could be partly explained by selective immigration, but also by the Salmon bias, as women with risk factors tend to return to their country of citizenship for the delivery. However, the preterm birth rate was higher among Western women than in their Chinese counterparts, and further research is needed.

Are immigrants healthier than native-born Canadians? A systematic review of the healthy immigrant effect in Canada

OBJECTIVES

Immigrants are typically healthier than the native-born population in the receiving country and also tend to be healthier than non-migrants in the countries of origin. This foreign-born health advantage has been referred to as the healthy immigrant effect (HIE). We examined evidence for the HIE in Canada.

DESIGN

We employed a systematic search of the literature on immigration and health and identified 78 eligible studies. We used a narrative method to synthesize the HIE across different stages of the life-course and different health outcomes within each stage. We also examined the empirical evidence for positive selection and duration effects - two common explanations of migrants' health advantage and deterioration, respectively.

RESULTS

We find that the HIE appears to be strongest during adulthood but less so during childhood/adolescence and late life. A foreign-born health advantage is also more robust for mortality but less so for morbidity. The HIE is also stronger for more recent immigrants but further research is needed to determine the critical threshold for when migrants' advantage disappears. Positive selection as an explanation for the HIE remains underdeveloped.

CONCLUSIONS

There is an absence of a uniform foreign-born health advantage across different life-course stages and health outcomes in Canada. Nonetheless, it remains the case that the HIE characterizes the majority of contemporary migrants since Canada's foreign-born population consists mostly of core working age adults.

Emergency Department as a First Contact for Mental Health Problems in Children and Youth

OBJECTIVE

To characterize youth who use the emergency department (ED) as a "first contact" for mental health (MH) problems.

METHOD

This was a population-based cross-sectional cohort study using linked health and demographic administrative datasets of youth 10 to 24 years of age with an incident MH ED visit from April 1, 2010, to March 31, 2014, in Ontario, Canada. We modeled the association of demographic, clinical, and health service use characteristics with having no prior outpatient MH care in the preceding 2-year period ("first contact") using modified Poisson models.

RESULTS

Among 118,851 youth with an incident mental health ED visit, 14.0% were admitted. More than half (53.5%) had no prior outpatient MH care, and this was associated with younger age (14-17 versus 22-24 years old: risk ratio [RR] = 1.09, 95% CI = 1.07-1.10), rural residence (RR = 1.16, 95% CI = 1.14-1.18), lowest versus highest income quintile (RR = 1.04, 95% CI = 1.03-1.06), and refugee immigrants (RR = 1.17, 95% CI = 1.13-1.21) and other immigrants (RR = 1.10, 95% CI = 1.08-1.13) versus nonimmigrants. The 5.1% of the cohort without a usual provider of primary care had the highest risk of first contact (RR = 1.78, 95% CI = 1.77-1.80). A history of low-acuity ED use and individuals whose primary care physicians were in the lowest tertile for mental health visit volumes were associated with higher risk.

CONCLUSION

More than half of youth requiring ED care had not previously sought outpatient MH care. Associations with multiple markers of primary care access characteristics suggest that timely primary care could prevent some of these visits.

Applying Precision Public Health to Prevent Preterm Birth

Preterm birth (PTB) is one of the major health-care challenges of our time. Being born too early is associated with major risks to the child with potential for serious consequences in terms of life-long disability and health-care costs. Discovering how to prevent PTB needs to be one of our greatest priorities. Recent advances have provided hope that a percentage of cases known to be related to risk factors may be amenable to prevention; but the majority of cases remain of unknown cause, and there is little chance of prevention. Applying the principle of precision public health may offer opportunities previously unavailable. Presented in this article are ideas that may improve our abilities in the fields of studying the effects of migration and of populations in transition, public health programs, tobacco control, routine measurement of length of the cervix in mid-pregnancy by ultrasound imaging, prevention of non-medically indicated late PTB, identification of pregnant women for whom treatment of vaginal infection may be of benefit, and screening by genetics and other “omics.” Opening new research in these fields, and viewing these clinical problems through a prism of precision public health, may produce benefits that will affect the lives of large numbers of people.

Overdose Risk in Young Children of Women Prescribed Opioids

BACKGROUND AND OBJECTIVE

Over the past 20 years, the prescribing of opioids has increased dramatically in North America, with parallel increases in opioid addiction, overdose, and associated deaths. We examined whether young children of women prescribed opioids were at increased risk of opioid overdose.

METHODS

We conducted a population-based, nested case control study in Ontario, Canada, between 2002 and 2015. We identified children aged ≤10 years, whose mothers received publicly funded prescriptions for an opioid or a nonsteroidal antiinflammatory drug (comparator analgesic) in the preceding year. Cases were children who presented to hospital for or died of opioid overdose. Each case was matched with 4 controls with no opioid overdose. The primary outcome was the risk of opioid overdose.

RESULTS

We identified 103 children who presented to the hospital with opioid overdose and matched them with 412 controls. Half of the children with opioid overdose were <2 years old. Compared with controls, children with an opioid overdose were far more likely to have a mother who received a prescription opioid (unadjusted odds ratio, 2.41; 95% confidence interval, 1.68-3.45) and who was prescribed antidepressants. The most commonly implicated overdose opioids were codeine (53.4%), oxycodone (32.0%), and methadone (15.5%).

CONCLUSIONS

Young children of mothers prescribed opioids are at a markedly increased risk of overdose. Physicians, pharmacists, and parents should take measures to mitigate the risk of opioid-related harm to children, such as prescribing smaller quantities, emphasizing the importance of secure medication storage, and the prompt disposal of unused opioids.