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Objectives Household food insecurity is almost four times more prevalent among adolescents than among older adults in Canada, and it adversely affects their health. Our objective was to describe the sociodemographic and geographic patterning of household food insecurity among adolescents. Methods Our analytic sample comprised all 12–17-year-old respondents to the 2017–2018 Canadian Community Health Survey with complete data on household food insecurity (n = 8416). We used bivariate and multivariable logistic regression models to identify respondent- and household-level sociodemographic characteristics associated with household food insecurity. Results The prevalence of household food insecurity among adolescents was 20.7%. The adjusted odds of food insecurity were significantly elevated among adolescents who identified as Black or Indigenous (aOR 1.80), those living with a single parent (aOR 1.60), those living with a greater number of children ≤ 5 years (aOR 1.45) or 12–17 years (aOR 1.25), those in rented accommodation (aOR 1.98), those in households with only secondary school education (aOR 1.38), and those in households reliant on social assistance (aOR 2.03). Higher before-tax income was protective (aOR 0.99). In comparison with Ontario, the adjusted odds of food insecurity among adolescents were higher in Nunavut (aOR 6.77), Northwest Territories (aOR 2.11), and Alberta (aOR 1.48), and lower in Manitoba (aOR 0.66). Conclusion The markedly higher odds of exposure to household food insecurity among adolescents who are Black or Indigenous and those living in households characterized by markers of social and economic disadvantage highlight the need for more effective policy interventions to protect vulnerable families from this hardship.

Female marriage before age 18 is a global health issue related to gender inequality, but it is understudied in Canada. This study examined marriage trends among mothers aged18 versus older mothers and the sociodemographic correlates of marriage among adolescent mothers aged18 and older adolescent mothers.Using the Canadian Vital Statistics - Birth Database, marriage prevalence was estimated by maternal age groups (18-year, 18-19-year, 20-24-year, and 25-49-year) between 1989-1990 and 2017-2018 (n = 10,399,250). Multivariable logistic regression was then used to examine the sociodemographic characteristics associated with marriage within adolescent maternal age group (18-year, 18-19-year, and 20-24-year) among births registered between 2000 and 2018.From 1989-1990 to 2017-2018, marriage prevalence declined 80.5%, 60.2%, 47.3%, and 16.0% in the18-year, 18-19-year, 20-24-year, and 25-49-year groups, respectively. Within the18-year, 18-19-year, and 20-24-year adolescent maternal age groups, older maternal age, larger parental age gap, foreign-born parents, rurality, and earlier birth period were associated with higher adjusted odds of marriage. Higher maternal neighbourhood income was associated with marriage among births to mothers aged 18-19 and 20-24 years but not among those to mothers aged18 years.Marriage prevalence declined among mothers of all ages, but the shifts away from marriage appear stronger among younger mothers. The sociodemographic correlates of marriage are generally similar among mothers below age 18 and slightly older adolescent mothers.RéSUMé: OBJECTIFS: Le mariage des filles de moins de 18 ans est un problème de santé mondial lié aux inégalités entre les sexes, mais il est insuffisamment étudié au Canada. Notre étude porte sur les tendances du mariage chez les mères de18 ans comparativement aux mères plus âgées et sur les corrélats sociodémographiques du mariage chez les mères adolescentes de18 ans et les mères adolescentes plus âgées. MéTHODE: À l’aide de la Base canadienne de données de l’état civil – Naissance, nous avons estimé la prévalence des mariages selon le groupe d’âge maternel (18 ans, 18-19 ans, 20-24 ans et 25-49 ans) entre 1989-1990 et 2017-2018 (n = 10 399 250). Au moyen d’une analyse de régression logistique multivariée, nous avons ensuite examiné les caractéristiques sociodémographiques associées au mariage dans les groupes d’âge des mères adolescentes (18 ans, 18-19 ans et 20-24 ans) pour les naissances enregistrées entre 2000 et 2018. RéSULTATS: De 1989-1990 à 2017-2018, la prévalence des mariages a baissé de 80,5 %, 60,2 %, 47,3 % et 16,0 % dans les groupes de18 ans, de 18-19 ans, de 20-24 ans et de 25-49 ans, respectivement. Dans les groupes d’âge des mères adolescentes de18 ans, de 18-19 ans et de 20-24 ans, un âge maternel plus avancé, une plus grande différence d’âge des parents, la naissance des parents à l’étranger, la ruralité et la période de naissance plus précoce étaient associées à une probabilité de mariage ajustée plus élevée. Le revenu maternel plus élevé selon le quartier était associé au mariage pour les naissances de mères de 18-19 et de 20-24 ans, mais pas chez les mères de18 ans. CONCLUSION: La prévalence du mariage a baissé chez les mères de tout âge, mais l’abandon du mariage semble plus prononcé chez les mères plus jeunes. Les corrélats sociodémographiques du mariage sont généralement semblables chez les mères de moins de 18 ans et les mères adolescentes légèrement plus âgées.

Preterm birth (PTB) is the leading cause of infant mortality worldwide. Changes in PTB rates, ranging from −90% to +30%, were reported in many countries following early COVID-19 pandemic response measures (‘lockdowns’). It is unclear whether this variation reflects real differences in lockdown impacts, or perhaps differences in stillbirth rates and/or study designs. Here we present interrupted time series and meta-analyses using harmonized data from 52 million births in 26 countries, 18 of which had representative population-based data, with overall PTB rates ranging from 6% to 12% and stillbirth ranging from 2.5 to 10.5 per 1,000 births. We show small reductions in PTB in the first (odds ratio 0.96, 95% confidence interval 0.95–0.98, P value

Background Food insecurity, as an indicator of socioeconomic disadvantages and a determinant of health, may be associated with injury by increasing risk exposure and hampering risk mitigation. We examined the association between food insecurity and common causes of injury in the general population. Methods Linking the Canadian Community Health Survey 2005–2017 to National Ambulatory Care Reporting System 2003–2017, this retrospective cohort study estimated incidence of injury-related emergency department (ED) visits by food insecurity status among 212,300 individuals 12 years and above in the Canadian provinces of Ontario and Alberta, adjusting for prior ED visits, lifestyle, and sociodemographic characteristics including income. Results Compared to those in food-secure households, individuals from moderately and severely food-insecure households had 1.16 (95% confidence interval [CI] 1.07–1.25) and 1.35 (95% CI 1.24–1.48) times higher incidence rate of ED visits due to injury, respectively, after confounders adjustment. The association was observed across sex and age groups. Severe food insecurity was associated with intentional injuries (adjusted rate ratio [aRR] 1.81; 95% CI 1.29–2.53) including self-harm (aRR 1.87; 95% CI 1.03–3.40) and violence (aRR 1.79; 95% CI 1.19–2.67) as well as non-intentional injuries (aRR 1.34; 95% CI 1.22–1.46) including fall (aRR 1.43; 95% CI 1.24–1.65), medical complication (aRR 1.39; 95% CI 1.06–1.82), being struck by objects (aRR 1.43; 95% CI 1.07–1.91), overexertion (aRR 1.31; 95% CI 1.04–1.66), animal bite or sting (aRR 1.60; 95% CI 1.08–2.36), skin piercing (aRR 1.80; 95% CI 1.21–2.66), and poisoning (aRR 1.65; 95% CI 1.05–2.59). Moderate food insecurity was associated with more injuries from violence (aRR 1.56; 95% CI 1.09–2.21), falls (aRR 1.22; 95% CI 1.08–1.37), being struck (aRR 1.20; 95% CI 1.01–1.43), and overexertion (aRR 1.25; 95% CI 1.04–1.50). Moderate and severe food insecurity were associated with falls on stairs and being struck in non-sports settings but not with falls on same level or being struck during sports. Food insecurity was not related to transport injuries. Conclusions Health inequity by food insecurity status extends beyond diseases into differential risk of injury, warranting policy intervention. Researchers and policymakers need to address food insecurity as a social determinant of injury to improve health equity.

RESUMEN Los objetivos de este artículo son describir las características del abordaje de vinculación de bases de datos administrativos y sus usos en investigación en salud pública, y discutir las potencialidades y retos para su implementación en Ecuador. La vinculación de bases de datos permite integrar datos de una misma persona dispersos en distintos subsectores como salud, educación, justicia, inmigración y programas sociales, y posibilita investigaciones que informen una gestión más eficiente de programas y políticas sociales y de salud. Las principales ventajas del uso de bases de datos relacionadas son la diversidad de datos, la cobertura poblacional, la estabilidad temporal y el costo menor en comparación con la recolección de datos primarios. A pesar de la disponibilidad de herramientas para procesar, vincular y analizar grandes conjuntos de datos, el uso de este abordaje es mínimo en los países de América Latina. Ecuador tiene un alto potencial para explotar este abordaje, debido a la obligatoriedad del uso de un identificador único en la prestación de servicios de salud, que permite la vinculación con otros sistemas de información nacionales. Sin embargo, enfrenta una serie de retos técnicos, ético-legales, culturales y políticos. Para aprovechar su potencial, Ecuador necesita desarrollar una estrategia de gobernanza de datos que incluya normativas de acceso y uso de los datos, de manera simultánea con mecanismos de control y calidad de los datos, una mayor inversión en formación profesional en el uso de los datos dentro y fuera del sector salud, y colaboraciones entre entidades gubernamentales, universidades y organizaciones de la sociedad civil.

Studies on mortality differentials between international immigrants and non-immigrants produced mixed results. The mortality of interprovincial migrants has been less studied. Our objectives were to compare mortality risk between international immigrants, interprovincial migrants, and long-term residents of the province of Manitoba, Canada, and identify factors associated with mortality among migrants.We conducted a retrospective matched-cohort study to examine all-cause and premature mortality of 355,194 international immigrants, interprovincial migrants, and long-term Manitoba residents (118,398 in each group) between January 1985 and March 2019 using linked administrative databases. Poisson regression was used to estimate adjusted incidence rate ratios (aIRR) with 95% confidence intervals (CI).The all-cause mortality risk of international immigrants (2.3 per 1000 person-years) and interprovincial migrants (4.4 per 1000) was lower than that of long-term Manitobans (5.6 per 1000) (aIRR: 0.43; 95% CI: 0.42, 0.45 and aIRR: 0.81; 95% CI: 0.80, 0.84, respectively). Compared with interprovincial migrants, international immigrants showed lower death risk (aIRR: 0.50; 95% CI: 0.47, 0.52). Similar trends were observed for premature mortality. Among international immigrants, higher mortality risk was observed for refugees, those from North America and Oceania, and those of low educational attainment. Among internal migrants, those from Eastern Canada had lower mortality risk than those migrating from Ontario and Western Canada.Migrants had a mortality advantage over non-migrants, being stronger for international immigrants than for interprovincial migrants. Among the two migrant groups, there was heterogeneity in the mortality risk according to migrants' characteristics.RéSUMé: OBJECTIFS: Les études sur les écarts dans la mortalité entre les immigrants internationaux et les non-immigrants produisent des résultats mitigés. La mortalité des migrants interprovinciaux est moins étudiée. Nous avons cherché à comparer le risque de mortalité des immigrants internationaux, des migrants interprovinciaux et des résidents à long terme de la province du Manitoba, au Canada, et à cerner les facteurs associés à la mortalité chez les migrants. MéTHODE: Nous avons mené une étude de cohorte assortie rétrospective pour examiner la mortalité toutes causes confondues et la mortalité prématurée chez 355 194 immigrants internationaux, migrants interprovinciaux et résidents à long terme du Manitoba (118 398 dans chaque groupe) entre janvier 1985 et mars 2019 à l’aide de bases de données administratives maillées. Par régression de Poisson, nous avons estimé les rapports de taux d’incidence ajustés (RTAa) avec des intervalles de confiance (IC) de 95 %. RéSULTATS: Le risque de mortalité toutes causes confondues des immigrants internationaux (2,3 pour 1 000 personnes-années) et des migrants interprovinciaux (4,4 pour 1 000) était plus faible que celui des résidents à long terme du Manitoba (5,6 pour 1 000) (RTAa : 0,43; IC de 95 % : 0,42, 0,45 et RTAa : 0,81; IC de 95 % : 0,80, 0,84, respectivement). Comparativement aux migrants interprovinciaux, les immigrants internationaux présentaient un risque de mortalité plus faible (RTAa : 0,50; IC de 95 % : 0,47, 0,52). Des tendances semblables ont été observées pour la mortalité prématurée. Chez les immigrants internationaux, un risque de mortalité plus élevé a été observé chez les réfugiés, les immigrants de l’Amérique du Nord et de l’Océanie et ceux ayant un faible niveau d’instruction. Chez les migrants intérieurs, ceux de l’Est du Canada présentaient un risque de mortalité plus faible que ceux de l’Ontario et de l’Ouest canadien. CONCLUSION: Les migrants présentaient un avantage sur le plan de la mortalité par rapport aux non-migrants; cet avantage était plus prononcé chez les immigrants internationaux que chez les migrants interprovinciaux. Dans ces deux groupes de migrants, il y avait hétérogénéité dans le risque de mortalité selon les caractéristiques des migrants.

ObjectivesThere is a paucity of research on patterns of cyber-victimization in minority groups, including immigrants. This study aimed to identify individual, interpersonal and contextual characteristics associated with cyber-victimization among immigrants and non-immigrants.MethodsWe drew on nationally representative data from adolescents and adults in the Canadian General Social Survey on victimization (2014). We used multivariable logistic regression to identify potential factors associated with cyber-victimization in the last 12 months, stratified by immigrant status and sex.ResultsAmong 27,425 survey respondents, the weighted prevalence of cyber-victimization in the last 12 months was 2.1% among immigrants and 2.3% among non-immigrants. Cyber-victimization rates differed significantly by sex among immigrants (2.8% for males vs. 1.4% for females), but not among non-immigrants (2.1% for males vs. 2.4% for females). While most other factors associated with cyber-victimization were similar for immigrants and non-immigrants, there were pronounced associations of past child maltreatment (adjusted prevalence odds ratio [aPOR] 4.85, 95% confidence interval [CI] 2.76, 8.52) and residence in an unwelcoming neighbourhood (aPOR 5.08, 95% CI 2.44, 10.55) with cyber-victimization among immigrants that were diminished or absent among non-immigrants. Additionally, sex-stratified analyses among immigrants showed cyber-victimization to be strongly associated with having a mental health condition (aPOR 3.50, 95% CI 1.36, 8.97) among immigrant males only, and with perceived discrimination (aPOR 4.08, 95% CI 1.65, 10.08), as well as being under 24 years old (aPOR 3.24, 95% CI 1.09, 9.60) among immigrant females.ConclusionsImmigration status and sex were differentially associated with cyber-victimization. Findings support the salience of a social-ecological perspective and gender-stratified analyses to better elucidate complex pathways linking cyber-victimization to potential gender-based health inequities among immigrants.

Introduction Although ethnically mixed couples are on the rise in industrialized countries, their health behaviors are poorly understood. We examined the associations between partner’s birthplace, age at immigration, and smoking during pregnancy among foreign-born women. Methods Population-based register study including all pregnancies resulting in a livebirth or stillbirth in Sweden (1991–2012) with complete information on smoking and parental country of birth. We compared the prevalence of smoking during pregnancy between women in dual same-origin foreign-born unions (n = 213 111) and in mixed couples (immigrant women with a Swedish-born partner) (n = 111 866) using logistic regression. Swedish-born couples were used as a benchmark. Results The crude smoking rate among Swedish women whose partners were Swedish was 11%. Smoking rates of women in dual same-origin foreign-born unions varied substantially by birthplace, from 1.3% among women from Asian countries to 23.2% among those from other Nordic countries. Among immigrant groups with prevalences of pregnancy smoking higher than that of women in dual Swedish-born unions, having a Swedish-born partner was associated with lower odds of smoking (adjusted odds ratios: 0.72–0.87) but with higher odds among immigrant groups with lower prevalence (adjusted odds ratios: 1.17–5.88). These associations were stronger among women immigrating in adulthood, whose smoking rates were the lowest. Conclusions Swedish-born partners “pull” smoking rates of immigrant women toward the level of smoking of Swedish-born women, particularly among women arrived during adulthood. Consideration of a woman’s and her partner’s ethnic background and life stage at migration may help understand smoking patterns of immigrant women. Implications We found that having a Swedish-born partner is associated with higher rates of smoking during pregnancy among immigrants from regions where women smoke less than Swedish women, but with lower smoking rates among immigrants from regions where women smoke more. This implies that prevention efforts should concentrate on newly arrived single women from low prevalence regions, such as Africa and Asia, whereas cessation efforts may target women from high prevalence regions, such as other European countries. These findings suggest that pregnancy smoking prevention or cessation interventions may benefit from including partners and approaches culturally tailored to mixed unions.

BACKGROUND: Food insecurity affects 1 in 8 households in Canada, with serious health consequences. We investigated the association between household food insecurity and all-cause and cause-specific mortality. METHODS: We assessed the food insecurity status of Canadian adults using the Canadian Community Health Survey 2005–2017 and identified premature deaths among the survey respondents using the Canadian Vital Statistics Database 2005–2017. Applying Cox survival analyses to the linked data sets, we compared adults’ all-cause and cause-specific mortality hazard by their household food insecurity status. RESULTS: Of the 510 010 adults sampled (3 390 500 person-years), 25 460 died prematurely by 2017. Death rates of food-secure adults and their counterparts experiencing marginal, moderate and severe food insecurity were 736, 752, 834 and 1124 per 100 000 person-years, respectively. The adjusted hazard ratios (HRs) of all-cause premature mortality for marginal, moderate and severe food insecurity were 1.10 (95% confidence interval [CI] 1.03–1.18), 1.11 (95% CI 1.05–1.18) and 1.37 (95% CI 1.27–1.47), respectively. Among adults who died prematurely, those experiencing severe food insecurity died on average 9 years earlier than their food-secure counterparts (age 59.5 v. 68.9 yr). Severe food insecurity was consistently associated with higher mortality across all causes of death except cancers; the association was particularly pronounced for infectious-parasitic diseases (adjusted HR 2.24, 95% CI 1.42–3.55), unintentional injuries (adjusted HR 2.69, 95% CI 2.04–3.56) and suicides (adjusted HR 2.21, 95% CI 1.50–3.24). INTERPRETATION: Canadian adults from food-insecure households were more likely to die prematurely than their food-secure counterparts. Efforts to reduce premature mortality should consider food insecurity as a relevant social determinant.

Immigrants to Canada increasingly come from regions where child marriage (18 years) is prevalent. We described the prevalence, demographic characteristics, and reproductive health correlates of marriage among births to Canadian-born and foreign-born adolescent mothers. Using Canadian birth registrations from 1990 to 2018, marriage prevalence, parental birth region, and parental age gap were examined by maternal birthplace (Canada and 12 world regions) among births to mothers18 years. Adjusted odds ratios (AORs) of preterm birth (PTB), small for gestational age (SGA), and repeat birth were estimated for the joint associations of adolescent maternal age group (18-year, 18-19-year, and 20-24-year), marriage, and nativity status (n = 1,904,200). Depending on maternal birthplace, marital births represented 2.6% to 81.8% of births to mothers18 years. Marriage among mothers giving birth at18 years was associated with higher proportions of parents from the same birthplace and larger parental age gaps. AORs of PTB tended to increase with lower maternal age. AORs of SGA were generally higher among births to foreign-born mothers. Marriage was associated with lower AORs of PTB and SGA among births to Canadian-born mothers and PTB among births to foreign-born mothers in the older adolescent age groups, but no association existed in the18-year group. Marriage was positively associated with repeat birth in all adolescent age groups, with stronger associations in the18-year group. The reproductive health correlates of marriage are similar between births to Canadian-born and foreign-born mothers18 years but some differ between births to mothers18 years and those to older adolescent mothers.

Background: The Truth and Reconciliation Commission of Canada has called for better reporting of health disparities between First Nations people and other Canadians to close gaps in health outcomes. We sought to evaluate changes in these disparities using indicators of health and health care use over the last 2 decades. Methods: We used linked, whole-population, administrative claims data from the Manitoba Centre for Health Policy for fiscal years 1994/95 to 1998/99 and 2012/13 to 2016/17. We measured indicators of health and health care use among registered First Nations and all other Manitobans, and compared differences between these groups over the 2 time periods. Results: Over time, the relative gap between First Nations and all other Manitobans widened by 51% (95% confidence interval [CI] 42% to 60%) for premature mortality rate. For potential years of life lost, the gap widened by 54% (95% CI 51% to 57%) among women and by 32% (95% CI 30% to 35%) among men. The absolute gap in life expectancy widened by 3.14 years (95% CI 2.92 to 3.36) among men and 3.61 years (95% CI 3.38 to 3.84) among women. Relative gaps widened by 20% (95% CI 12% to 27%) for ambulatory specialist visits, by 14% (95% CI 12% to 16%) for hospital separations and by 50% (95% CI 39% to 62%) for days spent in hospital, but narrowed by 33% (95% CI −36% to −30%) for ambulatory primary care visits, by 22% (95% CI −27% to −16%) for mammography and by 27% (95% CI −40% to −23%) for injury hospitalizations. Interpretation: Disparities between First Nations and all other Manitobans in many key indicators of health and health care use have grown larger over time. New approaches are needed to address these disparities and promote better health with and for First Nations.

Background Previous studies have reported an intergenerational association between maternal and offspring preterm birth (PTB) but the nature of the association remains unclear. We assessed the association between maternal and offspring preterm birth using a quasi-experimental sibling design and distinguishing between preterm birth types. Methods We conducted a retrospective intergenerational cohort study of 39,573 women born singleton in Manitoba, Canada (1980–2002) who gave birth to 79,198 singleton infants (1995–2016). To account for familial confounding we defined a subcohort of 1033 sisters with discordant PTB status who subsequently gave birth and compared offspring PTB rates between 2499 differentially exposed cousins using log-binomial fixed-effects generalized estimating equation models. PTB was defined as a delivery

BACKGROUND: Intentional injury, including suicide and assault, is a leading cause of maternal morbidity and mortality. We aimed to determine whether immigrant and nonimmigrant women differ in their 1-year risk of intentional injury after birth. METHODS: This population-based retrospective cohort study used administrative data from Ontario from 2002 to 2012. Risk of self-inflicted injury (self-harm or suicide), and injury inflicted by others (assault or homicide), were each analyzed within 1 year after delivery of a live-born infant for immigrant and nonimmigrant mothers. Relative risks (RRs) were adjusted for maternal age, parity, income, resource utilization and psychiatric history. RESULTS: The study included 327 279 immigrant and 942 502 nonimmigrant mothers. Risk of self-inflicted injury was similar among immigrants and nonimmigrants (adjusted RR 0.91, 95% confidence interval [CI] 0.78–1.04), with no variation by duration of residence or refugee status. Immigrants were at lower risk than nonimmigrants for injury inflicted by others (adjusted RR 0.57, 95% CI 0.51–0.64); that risk was higher among refugees than among nonrefugee immigrants (adjusted RR 1.79, 95% CI 1.33–2.41), and it was higher among long-term (adjusted RR 2.27, 95% CI 1.76–2.91) and medium-term (adjusted RR 1.58, 95% CI 1.19–2.11) immigrants than among recent immigrants. Variability by country of origin was observed for both injury types. INTERPRETATION: Immigrant mothers have a reported risk for self-inflicted injury after birth similar to that of their Canadian-born counterparts. The extent to which selective underreporting of intentional injury in immigrant women might explain our findings is a key consideration for future research.

BackgroundCanadian health data repositories link datasets at the provincial level, based on their residents’ registrations to provincial health insurance plans. Linking national datasets with provincial health care registries poses several challenges that may result in misclassification and impact the estimation of linkage rates. A recent linkage of a federal immigration database in the province of Manitoba illustrates these challenges. Objectivesa) To describe the linkage of the federal Immigration, Refugees and Citizenship Canada Permanent Resident (IRCC-PR) database with the Manitoba healthcare registry and b) compare data linkage methods and rates between four Canadian provinces accounting for interprovincial mobility of immigrants. MethodsWe compared linkage rates by immigrant’s province of intended destination (province vs. rest of Canada). We used external nationwide immigrant tax filing records to approximate actual settlement and obtain linkage rates corrected for interprovincial mobility. ResultsThe immigrant linkage rates in Manitoba before and after accounting for interprovincial mobility were 84.8% and 96.1, respectively. Linkage rates did not substantially differ according to immigrants’ characteristics, with a few exceptions. Observed linkage rates across the four provinces ranged from 74.0% to 86.7%. After correction for interprovincial mobility, the estimated linkage rates increased >10 percentage points for the provinces that stratified by intended destination (British Columbia and Manitoba) and decreased up to 18 percentage points for provinces that could not use immigration records of those who did not intend to settle in the province (New Brunswick and Ontario). ConclusionsDespite variations in methodology, provincial linkage rates were relatively high. The use of a national immigration dataset for linkage to provincial repositories allows a more comprehensive linkage than that of province-specific subsets. Observed linkage rates can be biased downwards by interprovincial migration, and methods that use external data sources can contribute to assessing potential selection bias and misclassification.

Chronic pain has been on the rise in recent decades in Canada. Accordingly, the use of prescription opioids (PO) in Canada increased drastically between 2005 and 2014, only starting to decrease in 2015. Both pain and PO use have serious public health repercussions, disproporionately affecting select socially disadvantaged populations. Food insecurity is a strong risk factor for mental disorders and suicidal outcomes, yet its relationship to chronic pain and PO use is largely unknown. Using two recent cycles from the population representative Canadian Community Health Survey (CCHS), we examined the association of household food insecurity status with chronic pain and PO use among Canadians 12 years and older, adjusting for health and sociodemographic characteristics. Compared to food-secure individuals, marginally, moderately, and severely food-insecure individuals had 1.31 (95% confidence interval [CI] 1.15–1.48), 1.89 (95% CI 1.71–2.08), and 3.29 (95% CI 2.90–3.74) times higher odds of experiencing chronic pain and 1.55 (95% CI 1.30–1.85), 1.77 (95% CI 1.54–2.04), and 2.65 (95% CI 2.27–3.09) times higher odds of using PO in the past year, respectively. The graded association with food insecurity severity was also found in severe pain experience and pain-induced activity limitations among chronic pain patients and, less consistently, in intensive, excess, and alternative use of PO and its acquisition through means other than medical prescription among past-year PO users. Food insecurity was a much more powerful predictor of chronic pain and PO use than other well-established social determinants of health like income and education. Policies reducing food insecurity may lower incidence of chronic pain and help contain the opioid crisis., Highlights • Food insecurity is associated with chronic pain and prescription opioids use. • Food-insecure people's pain is more likely to be severe and cause activity limitation. • Food insecurity predicts intensive, excess, and alternative use of prescription opioids. • Food insecurity is a more powerful predictor of pain and prescription opioids use than income.

Preterm birth is the leading cause of infant death worldwide, but the causes of preterm birth are largely unknown. During the early COVID-19 lockdowns, dramatic reductions in preterm birth were reported; however, these trends may be offset by increases in stillbirth rates. It is important to study these trends globally as the pandemic continues, and to understand the underlying cause(s). Lockdowns have dramatically impacted maternal workload, access to healthcare, hygiene practices, and air pollution - all of which could impact perinatal outcomes and might affect pregnant women differently in different regions of the world. In the international Perinatal Outcomes in the Pandemic (iPOP) Study, we will seize the unique opportunity offered by the COVID-19 pandemic to answer urgent questions about perinatal health. In the first two study phases, we will use population-based aggregate data and standardized outcome definitions to: 1) Determine rates of preterm birth, low birth weight, and stillbirth and describe changes during lockdowns; and assess if these changes are consistent globally, or differ by region and income setting, 2) Determine if the magnitude of changes in adverse perinatal outcomes during lockdown are modified by regional differences in COVID-19 infection rates, lockdown stringency, adherence to lockdown measures, air quality, or other social and economic markers, obtained from publicly available datasets. We will undertake an interrupted time series analysis covering births from January 2015 through July 2020. The iPOP Study will involve at least 121 researchers in 37 countries, including obstetricians, neonatologists, epidemiologists, public health researchers, environmental scientists, and policymakers. We will leverage the most disruptive and widespread “natural experiment” of our lifetime to make rapid discoveries about preterm birth. Whether the COVID-19 pandemic is worsening or unexpectedly improving perinatal outcomes, our research will provide critical new information to shape prenatal care strategies throughout (and well beyond) the pandemic.

Background Migrants commonly maintain transnational ties as they relocate and settle in a new country. There is a growing body of research examining transnationalism and health. We sought to identify how transnationalism has been defined and operationalized in migrant health research in high income countries and to document which populations and health and well-being outcomes have been studied in relation to this concept. Methods We conducted a scoping review using the methodology recommended by the Joanna Briggs Institute (JBI). We searched nine electronic databases; no time restrictions were applied. Studies published in English or French in peer-reviewed journals were considered. Studies were eligible if they included a measure of transnationalism (or one of its dimensions; social, cultural, economic, political and identity ties and/or healthcare use) and examined health or well-being. Results Forty-seven studies, mainly cross-sectional designs (81%), were included; almost half were conducted in the United States. The majority studied immigrants, broadly defined; 23% included refugees and/or asylum-seekers while 36% included undocumented migrants. Definitions of transnationalism varied according to the focus of the study and just over half provided explicit definitions. Most often, transnationalism was defined in terms of social connections to the home country. Studies and measures mainly focused on contacts and visits with family and remittance sending, and only about one third of studies examined and measured more than two dimensions of transnationalism. The operationalization of transnationalism was not consistent and reliability and validity data, and details on language translation, were limited. Almost half of the studies examined mental health outcomes, such as emotional well-being, or symptoms of depression. Other commonly studied outcomes included self-rated health, life satisfaction and perceived discrimination. Conclusion To enhance comparability in this field, researchers should provide a clear, explicit definition of transnationalism based on the scope of their study, and for its measurement, they should draw from validated items/questions and be consistent in its operationalization across studies. To enhance the quality of findings, more complex approaches for operationalizing transnationalism (e.g., latent variable modelling) and longitudinal designs should be used. Further research examining a range of transnationalism dimensions and health and well-being outcomes, and with a diversity of migrant populations, is also warranted.

IntroductionRoutine health care information systems only capture a portion of violence against women because some victimized women may not seek health care and some events may not require medical attention. Population-based estimates of the risk of violent injury (VI) among women with a history of intimate partner victimization (IPV) are lacking. Objectives and ApproachTo determine the risk of violent injury following IPV among women living in Manitoba, Canada, 2004-2016. Linked administrative justice, healthcare, and social databases were used. Exposure began after a woman was first involved with the Manitoba Justice system as a victim of IPV, assessed through provincial prosecution and disposition records. IPV victims (n= 20,469) were matched to three non-victims (n= 61,407) on age, relationship status and place of residence at the date of the IPV incident. The main outcomes were first health care use for violent injury and violent death. Outcomes were assessed through emergency department, hospital and vital statistics records. Conditional Cox Regression was used to obtain Hazard Ratios with 95% confidence intervals (CI). ResultsThe crude risk of VI was 8.5 per 1000 women among non-victims and 55.8 among victims of IPV. Compared to non-victims, IPV victims were 3.8 [95% confidence interval (CI): 3.4, 4.3] times more likely to suffer IIIO and 4.5 [95% CI: 2.3, 9.0] times to have a violent death, after adjustment. Victims had approximately half the risk of VI if the accused is on probation. Conclusion / ImplicationsJustice System-identified victims of IPV are at higher risk of assault and violent death than women not exposed to IPV. Justice involvement represents an opportunity for prevention of violent injury and homicide among IPV victims.

Food insecurity, inadequate access to food due to financial constraints, affects 17.3% of Canadian children, with serious health repercussions. Capitalizing on the geo-temporal variation in social policies and economic environments across Canadian provinces between 2005 and 2018, we examined the association between provincial policies and economic environments and likelihood of experiencing food insecurity among households with children. Drawn from 13 years of the Canadian Community Health Survey, our sample comprised 123,300 households with below-median income with children under 18 in the ten provinces. We applied generalized ordered logit models on the overall sample and subsamples stratified by Low-Income Measure (LIM). Higher minimum wage, lower income tax, and lower unemployment rate were associated with lower odds of food insecurity in the overall sample. A hypothetical one-dollar increase in minimum wage was associated with 0.8 to 1.0-percentage-point decrease in probability of food insecurity. The probability of food security increased by 1.2 to 1.6 percentage points following a one-percentage-point drop in bottom-bracket income tax rate. One-percentage-point lower unemployment rate corresponded to 0.6 to 0.8-percentage-point higher probability of food security. Higher welfare income and lower housing price predicted lower likelihood of severe food insecurity in the below-LIM subsample. Higher sales tax and median wage predicted higher likelihood of food insecurity among above-LIM households. Income support policies, favorable labor market conditions, and affordable living costs were all related to reduced food insecurity among Canadian households with children. Policies that increase minimum wage, reduce taxes, and create jobs may help alleviate food insecurity.

ObjectivesTo explore gender disparities in infant routine preventive care across maternal countries of birth (MCOB) and by mother tongue among infants of Indian-born mothers.SettingRetrospective population-based administrative cohort in Ontario, Canada (births between 2002 and 2014).Participants350 366 (inclusive) healthy term singletons belonging to families with a minimum of one opposite gender child.Outcome measuresFixed effects conditional logistic regression generated adjusted ORs (aORs) for a daughter being underimmunised and having an inadequate number of well-child visits compared with her brother, stratified by MCOB. Moderation by maternal mother tongue was assessed among children to Indian-born mothers.ResultsUnderimmunisation and inadequate well-child visits were common among both boys and girls, ranging from 26.5% to 58.2% (underimmunisation) and 10.5% to 47.8% (inadequate well-child visits). depending on the maternal birthplace. Girls whose mothers were born in India had 1.19 times (95% CI 1.07 to 1.33) the adjusted odds of inadequate well-child visits versus their brothers. This association was only observed among the Punjabi mother tongue subgroup (aOR: 1.26, 95% CI 1.08 to 1.47). In the Hindi mother tongue subgroup, girls had lower odds of underimmunisation than their brothers (aOR: 0.73, 95% CI 0.54 to 0.98).ConclusionsGender equity in routine preventive healthcare is mostly achieved among children of immigrants. However, daughters of Indian-born mothers whose mother tongue is Punjabi, appear to be at a disadvantage for well-child visits compared with their brothers. This suggests son preference may persist beyond the family planning stage among some Indian immigrants.

Background Gender inequality varies across countries and is associated with poor outcomes including violence against women and depression. Little is known about the relationship of source county gender inequality and poor health outcomes in female immigrants. Methods We used administrative databases to conduct a cohort study of 299,228 female immigrants ages 6–29 years becoming permanent residence in Ontario, Canada between 2003 and 2017 and followed up to March 31, 2020 for severe presentations of suffering assault, and selected mental health disorders (mood or anxiety, self-harm) as measured by hospital visits or death. Poisson regression examined the influence of source-country Gender Inequality Index (GII) quartile (Q) accounting for individual and country level characteristics. Results Immigrants from countries with the highest gender inequality (GII Q4) accounted for 40% of the sample, of whom 83% were from South Asia (SA) or Sub-Saharan Africa (SSA). The overall rate of assault was 10.9/10,000 person years (PY) while the rate of the poor mental health outcome was 77.5/10,000 PY. Both GII Q2 (Incident Rate Ratio (IRR): 1.48, 95% Confidence Interval (CI): 1.08, 2.01) and GII Q4 (IRR: 1.58, 95%CI: 1.08, 2.31) were significantly associated with experiencing assault but not with poor mental health. For females from countries with the highest gender inequality, there were significant regional differences in rates of assault, with SSA migrants experiencing high rates compared with those from SA. Relative to economic immigrants, refugees were at increased risk of sustaining assaults (IRR: 2.96, 95%CI: 2.32, 3.76) and poor mental health (IRR: 1.73, 95%CI: 1.50, 2.01). Higher educational attainment (bachelor’s degree or higher) at immigration was protective (assaults IRR: 0.64, 95%CI: 0.51, 0.80; poor mental health IRR: 0.69, 95% CI: 0.60, 0.80). Conclusion Source country gender inequality is not consistently associated with post-migration violence against women or severe depression, anxiety and self-harm in Ontario, Canada. Community-based research and intervention to address the documented socio-demographic disparities in outcomes of female immigrants is needed.

Background Most abortions occur due to unintended pregnancy. Unintended pregnancies are linked to poor health outcomes. Canada receives immigrants from countries with disparate sexual and reproductive health contexts which may influence abortion rates post-migration. We examined the association between abortion and region of birth and birth order among Canadian immigrants. Methods We conducted a population-based person-years (PY) cohort study in Ontario, Canada using administrative immigration (1991–2012) and health care data (1991–2013). Associations between induced abortion and an immigrant’s region of birth were estimated using poisson regression. Rate ratios were adjusted for age, landing year, education, neighborhood income quintile and refugee status and stratified by birth order within regions. Results Immigrants born in almost all world regions (N = 846,444) were 2–5 times more likely to have an induced abortion vs. those born in the US/Northern & Western Europe/Australia & New Zealand (0.92 per 100 PY, 95% CI 0.89–0.95). Caribbean (Adjusted Rate Ratio [ARR] = 4.71, 95% CI 4.55–4.87), West/Middle/East African (ARR = 3.38, 95% CI 3.26–3.50) and South American (ARR = 3.20, 95% CI 3.09–3.32) immigrants were most likely to have an abortion. Most immigrants were less likely to have an abortion after vs. prior to their 1st birth, except South Asian immigrants (RR = 1.60, 95% CI 1.54–1.66; RR = 2.23, 95% CI 2.12–2.36 for 2nd and 3rd vs 1st birth, respectively). Secondary analyses included further stratifying regional models by year, age, education, income quintile and refugee status. Conclusions Induced abortion varies considerably by both region of birth and birth order among immigrants in Ontario.

We examined whether women experiencing severe maternal morbidity (SMM) are more likely to be treated for a psychiatric illness or be prescribed psychotropic medications in the postpartum year than mothers who did not experience SMM. We also examine the relationship between SMM and specific mental health-related outcomes, and the relationship between specific SMM diagnoses/procedures and postpartum mental-health-related outcomes. The national registers in Sweden were used to create a population-based matched cohort. Every delivery with SMM between July 1, 2006, and December 31, 2012 (n = 8558), was matched with two deliveries without SMM (n = 17,116). Conditional logistic regression models assessed the relationship between SMM and postpartum mental health-related outcomes. Women who experienced SMM had significantly greater odds of being treated for a psychiatric disorder (aOR 1.22; 95% CI 1.03-1.45) and being prescribed psychotropic medications (aOR 1.40; 95% CI 1.24-1.58) in the postpartum year. Specifically, they had significantly greater odds of being treated for neuroses (aOR 1.35; 95% CI 1.09-1.69) and having a prescription for anxiolytics/hypnotics (aOR 1.36; 95% CI 1.18-1.58) or antidepressants (aOR 1.35; 95% CI 1.17-1.55). Women who were diagnosed with shock or uterine rupture/obstetric laparotomy during delivery had the greatest odds of postpartum mental health-related outcomes. This study identified mothers with SMM as a group at high risk for postpartum mental illness. Postpartum mental health services should be provided to ensure the well-being of these high-risk mothers.

Background The symptoms of anemia and depression are very similar suggesting that there may be an association between the two entities. The aim of this study is to assess whether postpartum anemia (PPA) is an independent risk factor for de novo postpartum depression (PPD)in women undergoing elective cesarean section. Methods Women after an uncomplicated term cesarean section were recruited and their hemoglobin and iron status were measured on day 3–5 post section and again at 6 weeks. Postpartum depression was screened using the Edinburgh Postnatal Depression Scale (EPDS) and functional capacity was assessed with the RAND 12-item Health survey. Results One hundred and three women completed the study. The incidence of probable postpartum depression (PPD) as defined by EPDS score ≥ 10 was 17% at 6 weeks. There was no difference in hemoglobin or iron status in women who had PPD compared to those without (OR-0.69; 95% CI-0.15-2.49). Similarly, there was no significant association between low hemoglobin and maternal functional status (OR -1.03; 95% CI-0.34 - 2.94). Conclusions Neither anemia or low iron stores were found to be an independent risk factors for postpartum depression or decreased postpartum functional capacity in women who undergo an elective cesarean section.

Objective This study sought to quantify the risk of severe maternal morbidity (SMM) according to maternal country of birth in Canada. Methods The study analyzed 1 252 543 in-hospital deliveries of Ontario residents discharged between April 1, 2002, and March 31, 2012. The main outcome measure was a composite indicator of SMM used for surveillance. The top 10 most common component conditions were also evaluated. Maternal country of birth and other immigration characteristics were obtained through linkage with official immigration records. We used modified Poisson regression with generalized estimating equations to assess associations according to maternal country of birth. Results Overall, immigrant women (N = 335 544) did not differ from Canadian-born women (n = 916 999) in SMM rates (12.1 vs. 12.0 cases per 1000 deliveries, respectively). However, SMM varied substantially according to maternal region of birth, from 9.2 cases per 1000 deliveries among immigrants from Western countries to 23.0 cases per 1000 deliveries among immigrants from Sub-Saharan Africa. Even larger variations were found when immigrants were categorized by their specific countries of birth. The top 10 contributing conditions to SMM among Canadian-born women were also the main contributors among immigrant subgroups. The notable exception was HIV infection, the top contributor among immigrants from Sub-Saharan Africa, whose rate of HIV infection was 43 times that of Canadian-born women (95% CI 34.39–55.23). After excluding HIV cases, disparities in SMM were largely reduced among Sub-Saharan African women but did not disappear. Conclusion There is large heterogeneity in SMM and its component conditions among Canadian immigrants depending on country of origin.

Background Immigrants have been shown to possess a health advantage, yet are also more likely to reside in arduous economic conditions. Little is known about if and how the socioeconomic gradient for all-cause, premature and avoidable mortality differs according to immigration status. Methods Using several linked population-based vital and demographic databases from Ontario, we examined a cohort of all deaths in the province between 2002 and 2012. We constructed count models, adjusted for relevant covariates, to attain age-adjusted mortality rates and rate ratios for all-cause, premature and avoidable mortality across income quintile in immigrants and long-term residents, stratified by sex. Results A downward gradient in age-adjusted all-cause mortality was observed with increasing income quintile, in immigrants (males: Q5: 13.32, Q1: 20.18; females: Q5: 9.88, Q1: 12.51) and long-term residents (males: Q5: 33.25, Q1: 57.67; females: Q5: 22.31, Q1: 36.76). Comparing the lowest and highest income quintiles, male and female immigrants had a 56% and 28% lower all-cause mortality rate, respectively. Similar trends were observed for premature and avoidable mortality. Although immigrants had consistently lower mortality rates compared with long-term residents, trends only differed statistically across immigration status for females (p

BACKGROUND: Food insecurity, defined as inadequate access to food owing to financial constraints, has been associated with poor disease management. Because cost-related nonadherence to prescription drugs is a possible explanation for such association, we examined the link between food insecurity and cost-related medication nonadherence in Canada. METHODS: Drawing on data for adult respondents (age ≥ 18 yr) who participated in the Canadian Community Health Survey 2016 Rapid Response module on prescription medication use, we assessed the association between household food insecurity and cost-related nonadherence to prescription drugs in the previous 12 months. We further examined the self-perceived health consequences of cost-related nonadherence among nonadherents. We applied Poisson models with bootstrap weights adjusting for sociodemographic characteristics. RESULTS: Of the 11 172 respondents in our sample, 930 (8.3%) reported cost-related nonadherence. Food insecurity affected 10.5% (95% confidence interval [CI] 9.1% to 11.8%) of adherents and 47.9% (95% CI 38.1% to 57.7%) of nonadherents. After adjustment for confounders, moderate and severe food insecurity were associated with 3.83 (95% CI 2.44 to 6.03) and 5.05 (95% CI 3.27 to 7.81) times higher prevalence of cost-related nonadherence, respectively, relative to food security. Despite being associated with lower probability of cost-related nonadherence, having drug insurance did not change the relation between food insecurity and cost-related nonadherence (p > 0.1 for all interactions). Severe food insecurity was correlated with higher prevalence of health deterioration and greater use of health care services as perceived consequences of cost-related nonadherence (p < 0.01 for both). INTERPRETATION: Food-insecure adults in Canada have a higher likelihood of cost-related nonadherence to prescription medications than their food-secure counterparts, which may constitute a burden on their health and lead to greater use of health care services.

Deliveries from Indian and Chinese mothers present a higher than expected male:female ratio in their own countries, in northern Europe, EEUU and Canada. No studies have been carried out in southern European countries. We explored whether the high male-to-female ratio common in Indian and Chinese communities, also exists among families from those regions who live in Spain. For that purpose we designed a cross-sectional population-based study containing data on 3,133,908 singleton live births registered in the Spanish Vital Statistics Registry during the period 2007-2015. The ratio of male:female births by area of origin was calculated using binary intercept-only logistic regression models without reference category for the whole sample of births and taking into account a possible effect modification of birth order and sex of the previous males. Interaction effects of sociodemographic mothers' and fathers' characteristics was also assesed. In Spain, the ratio male:female is higher than expected for Indian-born mothers, especially for deliveries from mothers with no previous male births and, to a lesser extent, for Chinese-born women, specifically for third or higher order births and slightly influenced by the sex of the previous births. Therefore, the increased sex male:female ratio observed in other countries among Indian and Chinese mothers is also observed in Spain. This reinforces the notion that culture and values of the country of origin are more influential than the country of residence. This study was funded by the Instituto de Salud Carlos III Grant PI13-0258. Sí

Objective: To examine the association between maternal country of birth and the risk of preeclampsia+preterm birth (PTB). Study Design: We completed a population-based study in the entire province of Ontario, where there is universal access to obstetrical care. We included 881 700 singleton livebirths among Canadian-born mothers and 305 547 births among immigrant mothers. Adjusted risk ratios (aRRs) were adjusted for maternal age, parity and income quintile. Results: Compared with a rate of preeclampsia+PTB of 4.0 per 1000 among Canadian-born mothers, the aRR of preeclampsia+PTB at 24 to 36 weeks was significantly higher for immigrant women from Nigeria (1.79, 95% confidence interval (CI) 1.12 to 2.84), the Philippines (1.54, 95% CI 1.30 to 1.86), Colombia (1.68, 95% CI 1.04 to 2.73), Jamaica (2.06, 95% CI 1.66 to 2.57) and Ghana (2.12, 95% CI 1.40 to 3.21). The aRRs generally followed a similar pattern for secondary outcomes. Specifically, women from Ghana were at highest risk of preeclampsia+very PTB (4.55, 95% CI 2.57 to 8.06), and women from Jamaica at the highest risk of preeclampsia+indicated PTB (1.89, 95% CI 1.43 to 2.50). Conclusion: The risk of preeclampsia+PTB is highest among women from a select number of countries. This information can enhance initiatives aimed at reducing the risk of PTB related to preeclampsia.

Background.Perinatal HIV transmission is less than 1% with antiretroviral (ARV) prophylaxis. Transmission risk appears higher in “high risk” dyads, yet this is not well defined, possibly exposing more infants to combination ARV compared with standard care.Objective.To describe characteristics of mother-infant dyads where infants received ARVs and how these characteristics relate to specific ARV regimens.Methods.Retrospective chart review of ARV-receiving newborns at St. Michael’s Hospital from 2007 to 2012 (and their mothers). Numerical and categorical variables were analyzed usingt-tests/ANOVAF-tests and Fisher’s exact tests, respectively.Results.Maternal HIV status at delivery was as follows: 69% positive and 24% unknown. Maternal factors significantly associated with newborn-triple therapy are Canadian origin, substance abuse, unstable housing, lost custody of previous children, and sex work. Neonatal factors are child protective services involvement, NICU, and lengthier admission. Maternal factors associated with monotherapy are African origin, HIV-positive, employment, and education. Further analysis based on maternal presentation at delivery demonstrated unequal distribution of many aforementioned factors.Discussion.This cohort revealed associations between particular factors and newborn-monotherapy or triple therapy that exist, suggesting that sociodemographic factors may influence the choice of ARV regimen. Canadian perinatal HIV transmission guidelines should qualify how to risk stratify newborns and consider use of rapid HIV antibody testing.

BackgroundWhile literature has documented strong gradients in child maltreatment (CM) by socioeconomic status and family composition in the general population, how these patterns extend to immigrants remain inconclusive. Using population-based administrative data, we examined, for the first time, whether gradients in CM by neighbourhood income and childbirth order vary by immigrant status.MethodsWe used linked hospitalisation, emergency department visits, small-area income, birth and death records with an official Canadian immigration database to create a retrospective cohort of all 1 240 874 children born from 2002 to 2012 in Ontario, Canada, followed from 0 to 5 years. We estimated rate ratios of CM among immigrants and non-immigrants using modified Poisson regression.ResultsCM rates were 1.6 per 100 children among non-immigrants and 1.0 among immigrants. CM was positively associated with neighbourhood deprivation. The adjusted rate ratio (ARR) of CM in the lowest neighbourhood income quintile versus the highest quintile was 1.57 (95% CI 1.49 to 1.66) for non-immigrants and 1.33 (95% CI 1.15 to 1.54) for immigrants. The socioeconomic gradient disappeared when restricted to children of immigrant mothers arrived at 25+ years and in analyses excluding emergency department visits. Compared to a first child, the ARR of CM for a fourth or higher-order child was 1.75 (95% CI 1.63 to 1.89) among non-immigrants and 0.57 (95% CI 0.44 to 0.74) among immigrants.ConclusionsImmigrants exhibited lower CM rates than non-immigrants across neighbourhood income quintiles and differences were greatest in more deprived neighbourhoods. The contrasting birth order gradients between immigrants and non-immigrants require further investigation.

Objective To determine the risk of overall preterm birth (PTB) and spontaneous PTB in a pregnancy after a caesarean section (CS) at term. Design Longitudinal linked national cohort study. Setting The Dutch Perinatal Registry (1999–2009). Population 268 495 women with two subsequent singleton pregnancies were identified. Methods A cohort study based on linked registered data from two subsequent pregnancies in the Netherlands. Main outcome measures The incidence of overall PTB and spontaneous PTB with subgroup analysis on gestational age at first delivery and type of CS (planned or unplanned). Results Of 268 495 women with a singleton first pregnancy who delivered at term, 15.76% (n = 42 328) had a CS. The incidence of PTB in the second pregnancy was 2.79% (n = 1182) in women with a previous CS versus 2.46% (n = 5570) in women with a previous vaginal delivery (adjusted odds ratio [aOR] 1.14, 95% confidence interval [CI] 1.07–1.21). This increased risk is mainly driven by an increased risk of spontaneous PTB after previous CS at term (aOR 1.50, 95% CI 1.38–1.70). Analysis for type of CS compared with vaginal delivery showed an aOR on spontaneous PTB of 1.86 (95% CI 1.58–2.18) for planned CS and an aOR of 1.40 (95% CI 1.24–1.58) for unplanned CS. Conclusions CS at term is associated with a marginally increased risk of spontaneous PTB in a subsequent pregnancy. Tweetable abstract Caesarean section at term is associated with a marginally increased risk of spontaneous PTB in a subsequent pregnancy., Tweetable abstract Caesarean section at term is associated with a marginally increased risk of spontaneous PTB in a subsequent pregnancy.

Highlights • Population health of migrants with insecure residency remains largely unknown. • It is unclear if women with insecure residency are more likely to die from childbirth. • They showed apparent lower risks of diagnosing pregnancy-related complications in Swedish national birth hospitalization data. • However, women with insecure residency status were more likely to develop potentially life-threatening conditions. • Such conditions may be preventable by access to better maternity care, Background Migrants with insecure residency status (i.e., undocumented migrants and asylum-seekers, who are denied or waiting for authorized residency) often experience social and psychosocial adversities and limited access to health care. Nonetheless, they have not been profiled on the risk of severe maternal morbidity (SMM), a sentinel measure of maternal health and maternity care. Methods A cohort study on all births recorded in the Swedish Medical Birth Register from 2000–2014 (N = 1,570,472). Lacking a maternal personal identification number was used as an indicator for insecure residency status (1.3% of all births). We used Poisson regression models to estimate risk ratios of SMM in migrant women with insecure residency status compared to the Swedish-born or migrant women with long-term residency, adjusting for the calendar year of birth, maternal age, and parity. Results Overall SMM rate among migrant women with insecure residency status was 21.5/1000 and 14.7/1000 among Swedish-born women. Compared to Swedish-born, migrants with insecure residency status had 50% higher risk of overall SMM (adjusted risk ratio (aRR)=1.54 [1.37–1.74]) and over 80% higher risk of SMM excluding transfusion-only cases (aRR=1.88 [1.37–2.57]). When compared to migrant women with long-term residency, migrant women with insecure residency also had a higher risk of SMM (overall SMM aRR=1.42 [1.26,1.61]; SMM excluding transfusion only cases aRR=1.43 [1.04,1.97]), suggesting that insecure residency conferred additional risks of SMM beyond migration. Conclusion Migrant women with insecure residency status had increased risk of severe maternal morbidity.

ObjectiveTo describe trends in mental health service use of youth by immigration status and characteristics.DesignPopulation-based longitudinal cohort study from 1996 to 2012 using linked health and administrative datasets.SettingOntario, Canada.ParticipantsYouth 10–24 years, living in Ontario, Canada.ExposureThe main exposure was immigration status (recent immigrants vs long-term residents). Secondary exposures were region of origin and refugee status.Main outcome measureMental health hospitalisations, emergency department (ED) visits and outpatient visits within consecutive 3-year time periods. Poisson regression models estimated rate ratios (RR).ResultsOver 2.5 million person years per period were included. Rates of recent immigrant mental health service utilisation were at least 40% lower than long-term residents (pMental health hospitalisation and ED visit rates increased in long-term residents (hospitalisations, RR 1.09 (95% CI 1.08 to 1.09); ED visits, RR 1.15 (1.14 to 1.15)) and recent immigrants (hospitalisations RR 1.05 (1.03 to 1.07); ED visits, RR 1.08 (1.05 to 1.11)). Mental health outpatient visit rates increased in long-term residents (RR 1.03 (1.03 to 1.03)) but declined in recent immigrant (RR 0.94 (0.93 to 0.95)). Comparable divergent trends in acute care and outpatient service use were observed among refugees and across most regions of origin. Recent immigrant acute care use was driven by longer-term refugees (hospitalisations RR 1.12 (1.03 to 1.21); ED visits RR 1.11 (1.02 to 1.20)).ConclusionsMental health service utilisation was lower among recent immigrants than long-term residents. While acute care use is increasing at a faster rate among long-term residents than recent immigrants, the decrease in outpatient mental health visits in immigrants highlights a potential emerging disparity in access to preventative care.

The current study examined school readiness for children placed in care of child protection services before age 5. This association was assessed using a population-based cohort of children born in Manitoba, Canada, between 2000 and 2009 ( n = 53,477) and subcohorts of discordant siblings (one sibling taken into care, one sibling not taken into care; n = 809) and discordant cousins ( n = 517). In the population analysis, children placed in care were significantly less likely to be ready for school; this difference was not seen in the discordant sibling or cousin analysis. The findings suggested that differences in school readiness for children placed in care are a result of broader social factors affecting families, not placement into care.