M igration to western industrialized countries and perinatal health: A systematic review

1. Migration to western industrialized countries and perinatal health:A systematic review Many, many thanks to Hilary Elkins (in New York) & Diane Habbouche (in Montreal) for diligently searching, locating, photocopying, scanning, and ultimately providing all the literature in an electronic format that has made up this review. Anita J Gagnon, Jennifer Zeitlin, Meg Zimbeck, and the ROAM collaboration

2. 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) What is ROAM?(Reproductive Outcomes And Migration: an international research collaboration)

3. Acknowledgements - 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)

4. Why is migrant perinatal health 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

5. 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 to 1. 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

6. Research question • Do migrant women in ‘western industrialized countries’ have consistently poorer perinatal health outcomes than receiving-country women?

7. Study Design • Systematic review of published literature

8. Methods: 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)

9. Methods: Measurement Migration labels were grouped into the following general categories (based on frequency of occurrence in the literature) 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”

10. 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

11. Methods: Measurement (cont’d) Perinatal outcomes (classified as such if main focus of paper; grouped based on frequency of occurrence & clinical relevance): = 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 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:

12. Results:Study sample

13. Search results • Medline-----------------------------------------→826 • Health Star-------------------------------------→653 • Embase-----------------------------------------→192 • PsychInfo----------------------------------------→45 • Author search, ROAM collaborators--------→583 • Citation search----------------------------------→58 2299 hits

14. Results:Description of the literature

15. Languages of publications 140 120 100 80 Number of publications 60 40 20 0 English French Italian Spanish Yugoslavian Language

16. Publication years 16 14 12 10 Number of publications 8 6 4 2 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year

17. Receiving countries represented in publications 60 50 40 30 Number of publications 20 10 0 Italy UK USA Spain Ireland Norway France Croatia Greece Belgium Portugal Sweden Australia Canada Germany Yugoslavia Switzerland Netherlands USA and Fr USA and Fr and BE Country

18. Migrants per publication (total n > 20 million!) 50 45 40 35 Number of publications 30 25 20 15 10 5 0 0-999 1,000-9,999 10,000-99,999 100,000-999,999 1,000,000-2,000,000

19. Type of database 80 70 60 50 Number of publications 40 30 20 10 0 Population-based Other hospital Research studies Population-based Population-based hospital records records registry survey

20. Database years represented in publications 60 50 40 Number of publications 30 20 10 0 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 Year

21. Nat'l Reg'l Geographic coverage of publications within receiving countries (n=129) 33% 43% Loc'l 24%

23. Results:Perinatal outcomes of migrants vs. receiving-country born(unadjusted)

24. Preterm birth (n = 39) 28% # Worse 38% # Better # Mixed # No Diff 3% 31%

25. Birthweight-related (n = 66) 27% 30% # Worse # Better # Mixed 6% # No Diff 37%

26. # Better # Mixed # No Diff Mode of delivery (n=24) 29% # Worse 41% 13% 17%

27. Feto-infant mortality (n = 38) 24% # Worse 41% # Better # Mixed 11% # No Diff 24%

28. Infection (n = 10) 0% 30% # Worse # Better # Mixed 60% # No Diff 10%

29. Health Promoting Behaviour (n = 11) 0% 9% 18% # Worse # Better # Mixed # No Diff 73%

30. Prenatal care (n = 12) 25% # Worse # Better # Mixed 58% # No Diff 17% 0%

31. Maternal health (n = 31) 10% # Worse 19% # Better 52% # Mixed # No Diff 19%

32. Congenital defects and infant morbidity (n = 15) 33% # Worse # Better # Mixed 60% # No Diff 7% 0%

33. Conclusions

34. 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%)

35. 2. Risk status for poor perinatal outcomes may differ by region of origin of migrant (based on meta-analyses not shown today due to time 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]

36. 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

37. Discussion….Thank you!anita.gagnon@mcgill.ca