1 M M igration to igration to western western industrialized industrialized countries and countries and perinatal health: perinatal health: A systematic review A systematic review Many, many thanks to Hilary Elkins (in New York) Many, many thanks to Hilary Elkins (in New York) & & Diane Habbouche (in Montreal) for diligently Diane Habbouche (in Montreal) for diligently searching, locating, photocopying, scanning, and searching, locating, photocopying, scanning, and ultimately providing all the literature in an ultimately providing all the literature in an electronic format that has made up this review. electronic format that has made up this review. Anita J Gagnon, Jennifer Zeitlin, Anita J Gagnon, Jennifer Zeitlin, Meg Zimbeck, and the ROAM Meg Zimbeck, and the ROAM collaboration collaboration
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MMigration to western igration to western industrialized countries industrialized countries and perinatal health:and perinatal health:A systematic review A systematic review
Many, many thanks to Hilary Elkins (in New York) & Many, many thanks to Hilary Elkins (in New York) & Diane Habbouche (in Montreal) for diligently searching, Diane Habbouche (in Montreal) for diligently searching,
locating, photocopying, scanning, and ultimately locating, photocopying, scanning, and ultimately providing all the literature in an electronic format that has providing all the literature in an electronic format that has
made up this review.made up this review.
Anita J Gagnon, Jennifer Zeitlin, Meg Anita J Gagnon, Jennifer Zeitlin, Meg Zimbeck, and the ROAM collaborationZimbeck, and the ROAM collaboration
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What is ROAM?What is ROAM? ((RReproductive eproductive OOutcomes utcomes AAnd nd MMigration: igration: an international research collaboration)an international research collaboration)
• Sophie Alexander, Université libre de Bruxelles (Belgium)
• Béatrice Blondel, INSERM (France)• Simone Buitendijk, TNO Institute –
Prevention and Care (Netherlands)• Marie Desmeules, Public Health
Agency of Canada• Dominico DiLallo, Agency for
Public Health – Rome (Italy)• Anita Gagnon (co-leader), McGill
University/MUHC, (Canada)• Mika Gissler, STAKES (Finland)• Richard Glazier, Inst. For Clinical
Evaluative Sciences (Canada)• Maureen Heaman, University of
Manitoba (Canada)• Dineke Korfker, TNO Institute –
Prevention and Care (Netherlands)
• Alison Macfarlane, City University of London (UK)
• Edward Ng, Statistics Canada• Carolyn Roth, Keele University
(UK) • Rhonda Small (co-leader),
LaTrobe University (Australia)• Donna Stewart, Univ. Hlth
Netwk of Toronto/U of T (Canada)
• Babill Stray-Pederson, University of Oslo (Norway)
• Marcelo Urquia, Inst. For Clinical Evaluative Sciences (Canada)
• Siri Vangen, Dept Ob/Gyn of The National Hospital of Norway
• Jennifer Zeitlin, INSERM and EURO-PERISTAT (France)
• Canadian Institutes of Health Research (CIHR), International Opportunities Program
• Start-up support: Immigration et métropoles (Center of Excellence in Immigration Studies - Montreal)
• Career support to AJG: Le fonds de la recherche en santé du Québec (FRSQ)
• Visiting scientist scholarship to AJG: l'Institut national de la santé et de la recherche médicale (INSERM, France)
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Why is migrant perinatal health Why is migrant perinatal health important?important?
• Important volume of women giving birth that are migrants
• Perinatal health of migrant women inconsistently reported although often thought to be worse than receiving country women
• Health care policies/ delivery need to be responsive to migration
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History…History…
• In August 2005 in Siena, Italy at a joint meeting involving EPEN and Euro-PERISTAT, ROAM was officially created– Common themes identified by the group at
that time included the need to1. Examine definitions/ standardization of
migration-related terms 2. Explore acceptability of these terms
– Thus:• the review being presented here &• the Delphi process (previously presented) were
undertaken
– Done in conjunction with Euro-PERISTAT
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Research questionResearch question
• Do migrant women in ‘western industrialized countries’ have consistently poorer perinatal health outcomes than receiving-country women?
• Absence of confirmation/strong likelihood of international cross-border movement (i.e., migration)
• Non ‘western industrialized’ receiving country• Outcome not directly related to Euro-
PERISTAT /CPSS indicators or to outcome differences specific to pregnant migrants such as infectious disease risk/ occurrence, smoking/drugs/alcohol use
(NB: No language exclusions were applied)
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Methods: MeasurementMethods: Measurement
Country of birth/ foreign-born:Ethnicity:
Nationality:
“Foreigner”:
Language:
Refugee:
Immigrant status:
= any label which required data on country of birth to define
= term (undefined) used by authors; included ethnicity, ethnic group, ethnic mix, race
= term (usually undefined) used by authors; included national origin, citizen, citizenship, ‘extra-community’ (i.e., extra-EU)
= term used by authors; included undefined ‘immigrant’, unclear if country of birth used to define term
= any label which required data on language to define it
= term used by authors; also included leaving home unwillingly, having been to resettlement camps
= as categorized by author; may include labels “undocumented”, “illegal”, “irregular”
Migration labels were grouped into the following general categories (based on frequency of occurrence in the literature)
Geographic coverage of publications within receiving countries
(n=129)
33%
24%
43%
Nat'l
Reg'l
Loc'l
2222
Migration labels used in the literature
0
20
40
60
80
100
120
COB/foreign-born
ethnicity nationality foreigner language refugee immigrantstatus
Num
ber o
f pub
licat
ions
(may
be >
1 lab
el in
1 pu
bl)
2323
Results:Results:Perinatal outcomes of Perinatal outcomes of migrants vs. receiving-migrants vs. receiving-
country borncountry born(unadjusted)(unadjusted)
2424
28%
31%3%
38% # Worse
# Better
# Mixed
# No Diff
Preterm birth (n = 39)
2525
Birthweight-related (n = 66)
30%
37%
6%
27%
# Worse
# Better
# Mixed
# No Diff
2626
Mode of delivery (n=24)
41%
17%
13%
29%# Worse
# Better
# Mixed
# No Diff
2727
Feto-infant mortality (n = 38)
41%
24%
11%
24%
# Worse
# Better
# Mixed
# No Diff
2828
Infection (n = 10)
60%
10%
30%
0%
# Worse
# Better
# Mixed
# No Diff
2929
Health Promoting Behaviour (n = 11)
9%
73%
18%0%
# Worse
# Better
# Mixed
# No Diff
3030
Prenatal care (n = 12)
58%
0%
17%
25%
# Worse
# Better
# Mixed
# No Diff
3131
Maternal health (n = 31)
52%
19%
19%
10%
# Worse
# Better
# Mixed
# No Diff
3232
Congenital defects and infant morbidity (n = 15)
60%
0%
7%
33%# Worse
# Better
# Mixed
# No Diff
3333
ConclusionsConclusions
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1. 1. Being a ‘migrant’ is not consistently a marker for higher risk of poor perinatal health outcomes
Outcomes reported more commonly as:Better (in migrant compared to receiving-country women):– Health-promoting behaviour (69%)– BWT-related (36%)
Worse:– Maternal health (52%)– Mode of delivery (42%)– Feto-infant mortality (42%)– Congenital defects and infant morbidity (60%)– Infection (60%)– Prenatal care (58%)
Unclear:– Preterm births (39%)
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2. Risk status for poor perinatal 2. Risk status for poor perinatal outcomes may differ by region of origin outcomes may differ by region of origin of migrant of migrant (based on meta-analyses not shown today due to time (based on meta-analyses not shown today due to time constraints)constraints)
• Asian-born migrants may be at greater risk:– Preterm birth [n = 2; ORadj = 1.14]– Feto-infant mortality [n = 2; ORadj = 1.29]
• North African-born migrants may be at greater risk:– Feto-infant mortality [n = 3 ; ORadj = 1.25]
• North African-born migrants may be at lower risk:– Preterm birth
[OR too heterogeneous to calc an overall effect but all ORs were below 1]• Sub-Saharan African-born migrants may be at greater risk
– Preterm birth– Feto-infant mortality
[OR too heterogeneous to calc an overall effect but all ORs were below 1]• Latin-American-born migrants may be at lower risk:
– Preterm birth[OR too heterogeneous to calc an overall effect but all ORs were below
1]
3636
3. Use of the migration label ‘immigrant’ is uninformative in understanding the relationship between migration and perinatal health outcomes (unless it is used as an immigration category)
• Both descriptive analyses (i.e., the pie charts) and meta-analyses (previous slide) suggest:– Extensive variation in effects depending on migrant
subgroups
• Greater use of standardized migration indicators (as recommended by ROAM and EURO-PERISTAT) is a prerequisite for improving our understanding of the relationship between migration and perinatal health