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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.

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.

Food insecurity predicts poorer health, yet how it relates to health care use and costs in Canada remains understudied. Linking data from the Canadian Community Health Survey to hospital records an...

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.

The extant literature has examined social inequalities in high-risk categories of birth weight and gestational age (i.e., low birth weight and preterm birth) with little attention given to their distributional nature. As such, a scoping review was conducted to understand how researchers have conceptualized and analyzed socioeconomic inequalities in entire distributions of these birth outcomes. Bibliographic databases were searched from their inception until August 2016 for articles from five similar, English-speaking, advanced capitalist democracies: Canada, United States, United Kingdom, Australia and New Zealand. Twenty-one studies were included in the review, all of which provided rationales for examining socioeconomic inequalities in the entire distribution of birth weight. Yet, only three studies examined non-uniform associations of socioeconomic factors across the distribution of birth weight using conditional quantile regression, while the majority focused on mean birth weight using descriptive analysis or linear regression to analyze inequalities. Nevertheless, study results indicated that socioeconomic inequalities exist throughout the distribution of birth weight, extending beyond the high-risk category of low birth weight. Although social inequalities in distributions of birth weight have been conceptualized, few studies have analytically engaged with this concept. As such, this review supports further investigation of distributional inequalities in birth outcomes using methodology which allows one to empirically quantify and explain differences in population risk distributions, rather than solely between infants born low birth weight or preterm birth, versus not.

Forced migration and extended time spent migrating may lead to prolonged marginalization and increased risk of HIV. We conducted a population-based cohort study to examine whether secondary migration status, where secondary migrants resided in a transition country prior to arrival in Ontario, Canada and primary migrants arrived directly from their country of birth, modified the relationship between refugee status and HIV. Unadjusted and adjusted prevalence ratios (APR) and 95% confidence intervals (CI) were estimated using log-binomial regression. In sensitivity analysis, refugees with secondary migration were matched to the other three groups on country of birth, age and year of arrival (+/- 5 years) and analyzed using conditional logistic regression. Unmatched and matched models were adjusted for age and education. HIV prevalence among secondary and primary refugees and non-refugees was 1.47% (24/1629), 0.82% (112/13,640), 0.06% (7/11,571) and 0.04% (49/114,935), respectively. Secondary migration was a significant effect modifier (

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.

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.

Summary Background A woman's risk of venous thromboembolism during pregnancy is estimated to be two-to-six times higher than her risk when she is not pregnant. Such risk estimates are largely based on pregnancies that result in delivery of a newborn baby; no estimates exist for the risk of venous thromboembolism after induced abortion, another common pregnancy outcome. To fill this knowledge gap, we aimed to assess the risk of venous thromboembolism in women whose first pregnancy ended with induced abortion. Methods We did this propensity score-matched cohort study using data from the universal health-care system of Ontario, Canada. We included primigravid women who had an induced abortion between Jan 1, 2003, and Dec 31, 2015, and used a propensity score to match them to primigravid women who had a livebirth (1:1) or nulligravid women who were not pregnant on the procedure date of their matched counterpart and who did not conceive within 1 year afterwards (5:1). We excluded from our analysis women younger than 15 years or older than 49 years and individuals who had missing or invalid information about their sex, area of residence, residential income, or world region of origin. The primary outcome was risk of any venous thromboembolism within 42 days of the index date (defined as the date of an induced abortion, delivery date for livebirth, or for non-pregnant women the induced abortion date of their matched counterpart). We compared the rate of venous thromboembolism in primigravid women who had an induced abortion with the rate of venous thromboembolism in propensity-score-matched non-pregnant women and propensity-score-matched primigravid women whose pregnancy ended with a livebirth. We generated hazard ratios (HRs) of 42-day risk of venous thromboembolism after induced abortion using Cox proportional hazard models. Findings We identified 194 086 eligible women whose first pregnancy ended with induced abortion, of whom 176 001 (90·7%) could be matched with women whose first pregnancy ended in delivery of a newborn. These 176 001 women were also matched to 880 005 non-pregnant women. The rate of venous thromboembolism within 42 days of an induced abortion was 30·1 (95% CI 22·0–38·2) per 100 000 women compared with 13·5 (11·1–16·0) per 100 000 women in the non-pregnant group (HR 2·23, 95% CI 1·61–3·08). The HR was 0·16 (95% CI 0·12–0·22) when compared with the women in the livebirth cohort, whose venous thromboembolism rate within 42 days postpartum was 184·7 (95% CI 164·6–204·7) per 100 000 women. Interpretation The 42-day risk of venous thromboembolism after an induced abortion is double that of a matched non-pregnant woman, and is significantly lower than after a livebirth. This novel information can inform estimates of peri-procedural risk of venous thromboembolism after induced abortion. Clinicians could consider a lower threshold for ordering a diagnostic test to rule out venous thromboembolism after induced abortion than they would in a non-pregnant woman. Funding Institute for Clinical Evaluative Sciences.

Late preterm birth (LPB) is increasingly common and associated with higher morbidity and mortality than term birth. Yet, little is known about the influence of previous cesarean section (PCS) and the occurrence of LPB in subsequent pregnancies. We aim to evaluate this association along with the potential mediation by cesarean sections in the current pregnancy.We use population-based birth registry data (2005-2012) to establish a cohort of live born singleton infants born between 34 and 41 gestational weeks to multiparous mothers. PCS was the primary exposure, LPB (34-36 weeks) was the primary outcome, and an unplanned or emergency cesarean section in the current pregnancy was the potential mediator. Associations were quantified using propensity weighted multivariable Poisson regression, and mediating associations were explored using the Baron-Kenny approach.The cohort included 481,531 births, 21,893 (4.5%) were LPB, and 119,983 (24.9%) were predated by at least one PCS. Among mothers with at least one PCS, 6307 (5.26%) were LPB. There was increased risk of LPB among women with at least one PCS (adjusted Relative Risk (aRR): 1.20 (95%CI [1.16, 1.23]). Unplanned or emergency cesarean section in the current pregnancy was identified as a strong mediator to this relationship (mediation ratio = 97%).PCS was associated with higher risk of LPB in subsequent pregnancies. This may be due to an increased risk of subsequent unplanned or emergency preterm cesarean sections. Efforts to minimize index cesarean sections may reduce the risk of LPB in subsequent pregnancies.

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

Background Despite being considered high risk, little is known about the perinatal health of refugees in developed countries. Our objectives were to examine whether: (1) the healthy migrant effect applies to infants born to refugee women with respect to severe neonatal morbidity (SNM); (2) refugee status was a risk factor for SNM among immigrants; (3) refugee sponsorship status was a risk factor for SNM by comparing asylum-seekers to sponsored refugees; and (4) refugees were at greater risk of specific SNM subtypes. Methods Immigration records (1985-2010) linked to Ontario hospital data (2002-2010) were used to examine SNM. We calculated adjusted risk ratios (ARR) with 95 % confidence intervals (95 % CI) for SNM and unadjusted risk ratios with 99 % CI for SNM subtypes using log-binomial regression. Results There were borderline differences in SNM among refugees (N = 29,755) compared to both non-immigrants (N = 860,314) (ARR = 0.94, 95 % CI 0.89, 0.99) and other immigrants (N = 230,847) (ARR = 1.10, 95 % CI 1.04, 1.18) with a larger difference comparing other immigrants to non-immigrants (ARR = 0.83, 95 % CI 0.81, 0.85). Asylum-seekers did not differ from sponsored refugees (ARR = 1.07, 95 % CI 0.90, 1.27). Though rare, several SNM subtypes were significant with large effect sizes. Conclusion With respect to SNM risk, the healthy migrant effect clearly applies to non-refugee immigrants, but is weaker for refugees and may not apply. Among immigrants, refugee status was a weak risk factor for SNM and may not be clinically important. Sponsorship status was not associated with greater risk of SNM. Further investigation of several SNM subtypes is warranted.

Antiretroviral therapy use in pregnancy, and specifically regimens containing protease inhibitors (PIs), has been associated with adverse infant outcomes including preterm birth (PTB), low birth weight (LBW) and small for gestational age (SGA) infants. However, there are conflicting results in the literature with respect to the degree of risk. These results may be related to demographic factors and confounding of maternal HIV infection and degree of immune suppression.The primary objective of our study was to assess the risk of PTB in HIV-positive pregnant women on ART compared to HIV-negative pregnant women. Secondary objectives included: comparing the risks of LBW and SGA infants in HIV-positive women on ART to HIV-negative pregnant women; comparing the risks of PTB, LBW and SGA in HIV-positive women on PI-based regimens compared to HIV-negative women.A retrospective matched cohort study of 384 women was conducted between 2007 and 2012 comparing outcomes of HIV-positive women on ART to HIV-negative women. Univariate and multivariable logistic regression models were used, adjusting for potential confounding factors, to compare the two groups on adverse infant outcomes.Unadjusted odds ratios revealed a2-fold increase in rates: PTB OR 2.6 [95% CI 1.3-5.1]; LBW OR 2.9 [95% CI 1.4-6.3]; SGA OR 2.5 [95% CI 1.3-4.7]. Once odds ratios were adjusted to account for race (p0.01), our results were no longer statistically significant as this study was underpowered to detect smaller differences: PTB aOR 1.4 [95% CI 0.5-3.6]; LBW OR 1.9 [95% CI 0.6-5.5]; SGA OR 1.8 [95% CI 0.8-4.6].Our preliminary results show an increase in PTB, LBW and SGA but due to lack of power, our adjusted results are not statistically significant. A larger prospective follow-up study is needed to further explore these findings in this population.

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.

There is an increasing body of literature focusing on differences in newborn size between different population subgroups defined by racial, ethnic, and immigration status. The interpretation of these differences as pathological or as merely reflecting normal variability is not straightforward and may have consequences for the provision of obstetric and neonatal care to minority populations. In this review, we critically assess some methodological issues affecting the assessment of newborn size and their potential implications for minority populations. In particular, we discuss the pros and cons of different types of newborn birth-weight (BW) charts (i.e., single local population-based references, minority-specific references, and a single international standard) to determine abnormal newborn size, with emphasis on immigrant populations. We conclude that size alone is not enough to inform clinical decisions and that all newborn size charts should be used as screening tools, not as diagnostic tools. Parental minority status may be regarded as a marker and used to further inquire about individual risk factors, particularly among immigrants who may not have a complete medical history in the new country. Finally, we outline areas for further research and recommendations for clinical practice.

Preterm delivery rates within industrialized countries have been reported to vary according to the parents' race, ethnicity and migrant status; however, such disparities are poorly understood. In this paper, the available evidence and potential clinical significance of racial/ethnic and migrant disparities in gestational length and preterm delivery are assessed alongside potential explanatory factors. Although measurement bias in gestational length has the potential to inflate disparities, there is a consistently higher risk of preterm birth among some racial/ethnic groups. These differences most likely reflect lasting socio-economic disadvantage and discrimination rather than genetic mechanisms. The effect of migrant status is less conclusive due to heterogeneity of populations and the healthy migrant effect; however, environmental influences in the receiving country are implicated in driving increases of overall preterm rates. When assessing preterm delivery rates across ethnic and migrant groups, the use of standardized, ultrasound-based pregnancy dating methods is crucial to minimize bias. Current evidence does not justify the provision of a different clinical care approach to minority or immigrant women solely based on their race, ethnicity or country of origin; however, these labels may serve as flags for further inquiry on individual risk factors and a detailed obstetric history.

Background It is unknown whether the risk of preterm birth (PTB) is elevated for forced (refugee) international migrants and whether prolonged displacement amplifies risk. While voluntary migrants who arrive from a country other than their country of birth (ie, secondary migrants) have favourable birth outcomes compared with those who migrated directly from their country of birth (ie, primary migrants), secondary migration may be detrimental for refugees who experience distinct challenges in transition countries. Our objectives were (1) to determine whether refugee status was associated with PTB and (2) whether the relation between refugee status and PTB differed between secondary and primary migrants. Methods We conducted a retrospective population-based cohort study. Ontario immigration (2002–2010) and hospitalisation data (2002–2010) were linked to estimate adjusted cumulative odds ratios (ACOR) of PTB (22–31, 32–36, 37–41 weeks of gestation), with 95% CIs (95% CI) comparing refugees with non-refugees. We further included a product term between refugee status and secondary migration. Results Overall, refugees (N=12 913) had 17% greater cumulative odds of short gestation (ACOR=1.17, 95% CI 1.07 to 1.28) compared with non-refugees (N=110 640). Secondary migration modified the association between refugee status and PTB (p=0.007). Secondary refugees had 58% greater cumulative odds of short gestation (ACOR=1.58, 95% CI 1.25 to 2.00) than secondary non-refugees, while primary refugees had 12% greater cumulative odds of short gestation (ACOR=1.12, 95% CI 1.02 to 1.23) than primary non-refugee immigrants. Conclusions Refugee status, jointly with secondary migration, influences PTB among migrants.

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 identify patterns of health system-identified early childhood maltreatment by maternal birthplace and child sex, within a multicultural society with universal access to healthcare. Study design This retrospective population-based cohort study included 1240946 children born in Ontario, Canada, between 2002 and 2012, and followed from birth to age 5 years using administrative data. Modified Poisson regression was used to estimate adjusted rate ratios for maltreatment—physical abuse or neglect—among the children of immigrant vs nonimmigrant mothers. Conditional logistic regression was used to estimate further the odds of maltreatment comparing a daughter vs son of the same mother. Results Maltreatment rates were 36% lower (adjusted rate ratio, 0.64; 95% CI, 0.61-0.66) among children of immigrant mothers (10 per 1000) than those of nonimmigrant mothers (16 per 1000). Maltreatment rates were 27%-48% lower among children of maternal immigrant groups relative to that among Canadian-born mothers, except children of Caribbean-born mothers (16 per 1000). No significant differences were seen between daughters and sons in the odds of early childhood health system-identified maltreatment by maternal birthplace. Conclusions Health system-identified maltreatment in early childhood is highest among children of Canadian- and Caribbean-born mothers. Maltreatment did not differ between daughters and sons of the same mother. These data may inform strategies aimed at decreasing maltreatment among vulnerable groups.

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.

IntroductionPrevious studies have reported an intergenerational association between maternal and offspring preterm birth (PTB) but the nature of the association remains unclear. Objectives and ApproachThe objective was to revisit the association between maternal and offspring preterm birth using a quasi-experimental sibling design and distinguishing between preterm birth types. 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 matched subcohort of 1033 sister mothers with discordant PTB status and compared offspring PTB rates between 2,499 differentially exposed cousins using log-binomial fixed-effects generalized estimating equation models. PTB was defined as a delivery < 37 gestation weeks, divided into spontaneous and provider-initiated. ResultsIn the population, mothers born preterm were more likely to give birth preterm [Adjusted Relative Risk (ARR): 1.39; 95\% Confidence Interval (CI): 1.25, 1.54]. The intergenerational association was not apparent among births to sisters with discordant PTB status [ARR: 1.02; 95\% CI: 0.77, 1.34]. However, the lack of association in the sibling analyses is explained by the fact that infants whose maternal aunts, but not their mothers, were born preterm had similarly elevated risk of PTB (10\%) than infants whose mothers were born preterm. Intergenerational patterns were observed for spontaneous PTB but not for provider-initiated PTB. Conclusion/ImplicationsThese findings suggest that it is not the fact of having been born preterm that puts women at higher risk of delivering preterm, but the fact of having been born to a mother who ever delivered a preterm baby. Consideration of family history of PTB may better identify women-at-risk.

IntroductionThere is substantial evidence that cancer screening rates are lower among Canadians with low socioeconomic status (SES) than they are among those with higher SES. In order to optimize cancer screening, there is a need to reduce inequities in cancer screening. Objectives and ApproachThe purpose of this study is to understand how breast, colorectal and cervical cancer screening participation varies by socioeconomic status within local geographic areas (LGAs) in the city of Calgary. A Bayesian multilevel regression method with a spatial component was used to estimate Standardized Incidence Rates (SIR) at the LGA level. Bivariate spatial clustering analyses between screening rates at the Dissemination Area (DA) level and Pampalon material and social deprivation index was performed to better understand spatial structures of low and high screening rates compared to high and low material and social deprivation scores within LGAs. ResultsThe effect of material (income, education and employment) and social (living alone, separated, and divorced or windowed) deprivation on lower screening rates was stronger for breast cancer screening, compared to cervical and colorectal screening. Estimated likelihood of screening significantly decreased from the least deprived to the most deprived (9% for the material component and 18% for the social component for Breast cancer; 8% for the material component and 10% for the social component for cervical cancer screening). Clusters of lower screening rates and higher social and material deprivation were identified in the northeastern and central areas of the city. Conclusion/ImplicationsThe study allowed identifying LGAs and neighborhoods within those LGAs that have lower screening rates likely to be explained by the material and social deprivation of the population. The approach provides additional evidence for planning targeted interventions and reducing inequities for screening.

IntroductionMothers can influence on a teen’s knowledge and attitude about sexual and reproductive health practices. Prior studies on intergenerational teen pregnancy between mother and daughter were largely limited to livebirths. Objectives and ApproachTo estimate the odds of intergenerational teenage pregnancy, and whether there is a coupling tendency between mother and daughter in how their teen pregnancies end, such as induced abortion (IA) vs. livebirth. A cohort study was conducted in Ontario, Canada among 15,097 mothers and their 16,177 daughters. The mother and her daughter were each assessed, between ages 15-19 years, for the number and nature of teenage pregnancy. The nature of teen pregnancy was categorized as i) no teen pregnancy, ii) ≥1 teen pregnancy, all exclusively ending with livebirth, and iii) ≥1 teen pregnancy, with at least one ending with IA. Results13,036 daughters’ mothers had a teen pregnancy and 3,141 daughters’ mothers did not. Teen pregnancy occurred among 3,777(29.0%) and 513(16.2%) daughters, respectively. The adjusted odds ratio (aOR) of a daughter having a teen pregnancy was 1.42 (95% CI 1.25-1.61) if her mother had 1, 1.97 (95% CI 1.71-2.26) if her mother had 2, and 2.17 (95% CI 1.84-2.56) if her mother had ≥3 teen pregnancies, relative to none. If a mother had ≥1 teen pregnancy ending with IA, then her daughter had an aOR of 2.12 (95% CI 1.76-2.56) for having a teen pregnancy also ending with IA; whereas, if a mother had ≥1 teen pregnancy, all ending with livebirth, then her daughter had an aOR of 1.73 (95% CI 1.46-2.05) for that same outcome. Conclusion/ImplicationsThere is a strong intergenerational occurrence of teenage pregnancy between a mother and daughter, including a coupling tendency in how the pregnancy ends. Such evidence supports the use of family-centered interventions that engage parents to reduce unprotected sex and unintended pregnancies among teenagers.

Background Immigrants to Western countries increasingly originate from countries with pervasive gender inequalities, where women experience disproportionately high rates of threats to their well-being. Health and social services in countries of settlement encounter several adverse outcomes linked to gender bias among immigrant groups. Little is known about interventions implemented to address manifestations of gender bias among immigrant populations. Methods A scoping review was undertaken to describe the literature on existing interventions and determine knowledge gaps. Nine academic and grey literature databases were searched for literature, with four reviewers screening the results. Results Of the 29 included reports, most targeted domestic violence amongst the Latino population in the United States, with few interventions focusing on other outcomes, populations, and settings. The majority reported achieving their objective, although 13 interventions were not evaluated. Conclusions Future research and practice to address gender bias among immigrants may benefit from expanding on ethnic diversity, designing and reporting evaluations, addressing the context of gender inequities, tailoring to local community needs, and engaging community-based groups. Electronic supplementary material The online version of this article (10.1186/s12905-018-0604-2) contains supplementary material, which is available to authorized users.

Objective To estimate the intergenerational association in teenage pregnancy, and whether there is a coupling tendency between a mother and daughter in how their teen pregnancies end, such as a termination of pregnancy (TOP) versus a live birth. Design Population-based cohort study. Setting Ontario, Canada. Population A total of 15 097 mothers and their 16 177 daughters. Methods Generalised estimating equations generated adjusted odds ratios (aOR) of a daughter experiencing a teen pregnancy in relation to the number of teen pregnancies her mother had. Multinomial logistic regression estimated the odds that a teen pregnancy ended with TOP among both mother and daughter. All models were adjusted for maternal age and world region of origin, the daughter's socio-demographic characteristics and comorbidities, mother-daughter cohabitation, and neighbourhood-level teen pregnancy rate. Main outcome measures Teen pregnancy in the daughter, between ages 15 and 19 years, and also the nature of the daughter's teen pregnancy, categorised as (1) no teen pregnancy, (2) at least one teen pregnancy, all exclusively ending with a live birth, and (3) at least one teen pregnancy, with at least one teen pregnancy ending with a TOP. Results The proportion of daughters having a teen pregnancy among those whose mother had zero, one, two, or at least three teen pregnancies was 16.3, 24.9, 33.5 and 36.3%, respectively. The aOR of a daughter having a teen pregnancy was 1.42 (95% CI 1.25-1.61) if her mother had one, 1.97 (95% CI 1.71-2.26) if she had two, and 2.17 (95% CI 1.84-2.56) if her mother had three or more teen pregnancies, relative to none. If a mother had at least one teen pregnancy ending with TOP, then her daughter had an aOR of 2.12 (95% CI 1.76-2.56) for having a teen pregnancy also ending with TOP; whereas, if a mother had at least one teen pregnancy, all ending with a live birth, then her daughter had an aOR of 1.73 (95% CI 1.46-2.05) for that same outcome. Conclusion There is a strong intergenerational occurrence of teenage pregnancy between a mother and daughter, including a coupling tendency in how the pregnancy ends. Tweetable abstract Strong intergenerational association for teenage pregnancy between mother and daughter.

BackgroundSon-biased sex ratios at birth (M:F), an extreme manifestation of son preference, are predominately found in East and South Asia. Studies have examined sex ratios among first-generation migrants from these regions, but few have examined second-generation descendants. Our objective was to determine whether son-biased sex ratios persist among second-generation mothers with South Asian ethnicity in Ontario, Canada.MethodologyA surname algorithm identified a population-based cohort of mothers with South Asian ethnicity who gave birth in Ontario between 1993 and 2014 (n=59 659). Linking to official immigration data identified births to first-generation mothers (ie, immigrants). Births not to immigrants were designated as being to second-generation mothers (ie, born in Canada) (n=10 273). Sex ratios and 95% CI were stratified by the sex of previous live births and by whether it was preceded by ≥1 abortion for both first-generation and second-generation mothers.ResultsAmong mothers with two previous daughters and at least one prior abortion since the second birth, both second-generation mothers and first-generation mothers had elevated sex ratios at the third birth (2.80 (95% CI 1.36 to 5.76) and 2.46 (95% CI 1.93 to 3.12), respectively). However, among mothers with no prior abortion, second-generation mothers had a normal sex ratio, while first-generation mothers gave birth to 142 boys for every 100 girls (95% CI 125 to 162 boys for every 100 girls).ConclusionSon preference persists among second-generation mothers of South Asian ethnicity. Culturally sensitive and community-driven gender equity interventions are needed.

To examine the co-contribution of maternal and paternal country of origin to preterm birth, and the differences in PTB rates between immigrants giving birth in Canada and those giving birth in their country of origin.Using a population-based study for all of Ontario, we included 1 200 864 singleton and twin livebirths from 2002 to 2011. The risk of PTB in infants of immigrant parents from the same country was compared to those whose parents were both Canadian-born. Logistic regression analysis adjusted for maternal and paternal age, parity, marital status, income, infant sex, and twins. We also measured differences in the calculated rate of PTB among immigrants by parental country of birth minus the published PTB rate within their native country. The main outcome measures were PTB37 weeks, late PTB at 34 to 36 weeks, and very PTB32 weeks.Compared with infants of two Canadian-born parents, those of immigrant parents from the same country had a lower risk of PTB (aOR 0.94, 95% CI 0.92 to 0.96) and late PTB (aOR 0.92, 95% CI 0.89 to 0.94) but a higher risk of very PTB (aOR 1.09, 95% CI 1.04 to 1.16). Infants of couples from Guyana, Trinidad and Tobago, the Philippines, and Jamaica were at increased risk of PTB, late PTB, and very PTB. The rate of PTB was, on average, 3% lower for newborns of immigrant parents than the published rate of PTB in their native country.The rate of PTB is influenced by maternal and paternal country of birth. That rate is generally lower among immigrants than the rate in their native country of origin.

Background Rates of postpartum haemorrhage and atonic postpartum haemorrhage have increased in several high-income countries. We carried out a study to examine if drug use in pregnancy, or drug and other interactions, explained this increase in postpartum haemorrhage. Methods The linked administrative and hospital databases of the Quebec Pregnancy Cohort were used to define a cohort of pregnant women in Quebec, Canada, from 1998 to 2009 (n = 138 704). Case–control studies on any postpartum haemorrhage and atonic postpartum haemorrhage were carried out within this population, with up to five controls randomly selected for each case after matching on index date and hospital of delivery (incidence density sampling). Conditional logistic regression was used to estimate the effects of drug use on postpartum haemorrhage and atonic postpartum haemorrhage. Results There was an unexpected non-linear, declining temporal pattern in postpartum haemorrhage and atonic postpartum haemorrhage between 1998 and 2009. Use of antidepressants (mainly selective serotonin reuptake inhibitors) was associated with higher rates of postpartum haemorrhage [adjusted rate ratio (aRR) 1.48, 95% confidence interval (CI) 1.23, 1.77] and atonic postpartum haemorrhage [aRR 1.40, 95% CI 1.13, 1.74]. Thrombocytopenia was also associated with higher rates of postpartum haemorrhage [aRR 1.52, 95% CI 1.16, 2.00]. There were no statistically significant drug interactions. Adjustment for maternal factors and drug use had little effect on temporal trends in postpartum haemorrhage and atonic postpartum haemorrhage. Conclusions Although antidepressant use and thrombocytopenia were associated with higher rates of atonic postpartum haemorrhage, antidepressant and other drug use did not explain temporal trends in postpartum haemorrhage.

Background Many births in industrialised countries are to immigrant parents, or to one immigrant and one domestically born parent. Their newborn outcomes have not been well studied. Methods We conducted a study of 1 690 423 singleton infants born in Sweden between 1987 and 2008, including those of immigrants from East Asia, South Asia, Sub-Saharan Africa, and East Africa. Preterm delivery and small for gestational age (SGA) were assessed among infants of (i) immigrant parents from the same world region, (ii) an immigrant mother and a Swedish-born father, and (iii) a Swedish-born mother and an immigrant father; each compared to (iv) two Swedish-born parents. Log binomial regression analysis generated adjusted risk ratios (ARRs) and 95% confidence intervals (CIs) for preterm delivery and SGA. Results Compared with infants of two Swedish-born parents, infants born to immigrant mothers from East Asia, South Asia, and Sub-Saharan African were at higher risk of preterm delivery (ARR ranging from 1.2 to 1.9), irrespective of whether the father was from the same world region or Swedish-born, with the only exception of East African women, who had lower risk. Infants born to two foreign-born parents had the highest risks of SGA, particularly South Asians (ARR 4.69; 95% CI 4.29, 5.12). Mixed couples exhibited intermediate risks of SGA. Conclusions Adverse birth outcomes differ according to a couple's ethnic composition. Having a Swedish-born partner is associated with lower risk of SGA among immigrant mothers and fathers, and with lower risk of preterm delivery among immigrant fathers but not mothers.