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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)
• Meg Zimbeck, INSERM and EURO-PERISTAT (France)
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Acknowledgements - Acknowledgements - funding:funding:
• 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
66
Research questionResearch question
• Do migrant women in ‘western industrialized countries’ have consistently poorer perinatal health outcomes than receiving-country women?
77
Study DesignStudy Design
• Systematic review of published literature
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Methods: Exclusion criteriaMethods: Exclusion criteria
• 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)
99
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)
1010
Methods: Measurement (cont’d)Methods: Measurement (cont’d)
Data sources were grouped into the following general categories (determined based on frequency of occurrence in the literature):
• Population-based routine data registries (nat’l/loc’l):– Linked birth/death certificates– Birth/maternity service registries
• Population-based surveys• Population-based hospital records:
– Large proportion of population (e.g., Kaiser Perm database in Calif.; or all hospitals in a city)
• Research studies:– Representativeness unclear (e.g., unknown proportion
of the population covered) or small– Questionnaires, interviews, record reviews
1111
Methods: Measurement (cont’d)Methods: Measurement (cont’d)
Gestational age/ pre-term birth:
Birth weight:
Mode of delivery:
Feto-infant mortality:
Maternal or infant infection/ risk:
Non-health-promoting behaviour:
Prenatal care/ entry:
Maternal health:
Congenital anomaly and infant morbidity:
= any outcome that required gestational age to define it
= any outcome that required birth weight to define it
= caesarean birth (vast majority) and operative vaginal
= neonatal and infant mortality, ‘spontaneous abortion’
= including – among others - HIV, toxoplasmosis, STIs, rubella seronegativity
= smoking, alcohol and drug use
= variously defined prenatal care
= maternal mortality, pregnancy-related morbidity, others
= as labelled
Perinatal outcomes (classified as such if main focus of paper; grouped based on frequency of occurrence & clinical relevance):
1212
Results:Results:Study sample Study sample
1313
Search resultsSearch results
556full-text articles
reviewed
427Excluded
129 129 IncludedIncluded
•Medline-----------------------------------------→826•Health Star-------------------------------------→→653•Embase-----------------------------------------→→192•PsychInfo----------------------------------------→→45•Author search, ROAM collaborators--------→→583•Citation search----------------------------------→58
22992299hitshits
1414
Results:Results:Description of the Description of the
literatureliterature
1515
Languages of publications
0
20
40
60
80
100
120
140
English French Italian Spanish Yugoslavian
Language
Nu
mb
er
of
pu
bli
cati
on
s
1616
Publication years
0
2
4
6
8
10
12
14
16
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
Nu
mb
er
of
pu
blicati
on
s
1717
Receiving countries represented in publications
0102030405060
Austra
lia
Belgi
um
Canad
a
Croat
ia
Fran
ce
Germ
any
Greec
e
Ireland
Italy
Nethe
rland
s
Norway
Portu
gal
Spain
Swed
en
Switz
erland
UK
USA
USA a
nd Fr
USA a
nd Fr a
nd B
E
Yugo
slavia
Country
Nu
mb
er
of
pu
blicati
on
s
1818
Migrants per publication (total n > 20 million!)
05
101520253035404550
0-999 1,000-9,999 10,000-99,999 100,000-999,9991,000,000-2,000,000
Nu
mb
er
of
pu
blicati
on
s
1919
Type of database
01020
30405060
7080
Population-based
registry
Population-based
survey
Population-based
hospital records
Other hospital
records
Research studies
Nu
mb
er
of
pu
blicati
on
s
2020
Database years represented in publications
0
10
20
30
40
50
60
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
Year
Nu
mb
er
of
pu
blicati
on
s
2121
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
3434
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%)
3535
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
