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BACKGROUND To examine perinatal health differences between foreign-born and native-born mothers in Canada across multiple outcomes and two cohorts 10 years apart. METHODS Using 94 896 and 131 271 births in the 1996 and 2006 Canadian Census-Birth Cohort, respectively, we estimated risk ratios and risk differences of preterm birth (PTB), small-for-gestational age (SGA), large-for-gestational age (LGA), stillbirth and infant mortality between foreign-born and Canadian-born mothers. RESULTS In the 1996 cohort, we observed no important differences in adverse outcomes between foreign-born and native-born mothers. In the 2006 cohort, however, foreign-born mothers had lower risks of PTB, LGA, stillbirth, and infant mortality and a higher risk of SGA on both the relative and absolute scales. Lowered risk of PTB among foreign-born mothers in the 2006 cohort was also observed within Caucasian, East Asian, Southeast Asian and South Asian mothers. Favourable outcomes associated with foreign-born status in the 2006 cohort were negatively graded by duration of residence in Canada among immigrant mothers. CONCLUSIONS Differences in perinatal health by maternal foreign-born status varied across cohorts and a more pronounced 'healthy migrant' effect was observed among more recent migrants. The native-born mothers' perinatal health over time and a more restrictive/selective immigration policy in recent years would explain our results.

Postal codes are often the only geographic identifier available for assigning contextual or environmental information to a study population. This analysis assesses the influence of three factors-delivery mode type (mode of postal delivery), representative point type (source of latitude-longitude coordinates), and community size-on the accuracy of postal code spatial assignment.PCCF+ (Postal Code Conversion File Plus) was used to assign delivery mode type, representative point type and community size to each individual in the 2011 Census of Canada. A sample (n = 1,004) was randomly selected with a minimum of 90 observations for each category of those three factors. Based on the address information of individuals in the sample, measures of positional accuracy for geocoding from residential postal codes (PCCF+) versus reference locations as determined by full street addresses (Google Maps) were calculated using a geographic information system. Accuracy was measured as the distance that the geocoded position differed from the full street address.Positional accuracy was related primarily to mode of postal delivery. Rural and mixed (partly urban, partly rural) modes had much higher geocoding error than did urban modes. Rural and small-town Canada and latitude and longitude based on dissemination area centroids had low accuracy, largely because of their close relationship to rural and mixed modes of delivery.The accuracy of geocoding from postal codes can vary. Geocoding imprecision may result in misclassification, depending on the spatial resolution of the environmental or contextual measures. The spatial resolution required for a study helps to identify subpopulations that should be excluded because of inadequate positional accuracy.

First Nations, Inuit, and Métis are at higher risk of adverse birth outcomes than are non-Indigenous people. However, relatively little perinatal information is available at the national level for Indigenous people overall or for specific identity groups.This analysis describes and compares rates of preterm birth, small-for-gestational-age birth, large-for-gestational-age birth, stillbirth, and infant mortality (neonatal, postneonatal, and cause-specific) in a nationally representative sample of First Nations, Inuit, Métis, and non-Indigenous births. The study cohort consisted of 17,547 births to Indigenous mothers and 112,112 births to non-Indigenous mothers from 2004 through 2006. The cohort was created by linking the Canadian Live Birth, Infant Death and Stillbirth Database to the long form of the 2006 Census, which contains a self-reported Indigenous identifier.With the exception of small-for-gestational-age birth, adverse birth outcomes occurred more frequently among First Nations, Inuit, and Métis women than among non-Indigenous women. Inuit had the highest preterm birth rate (11.4 per 100 births; 95% CI: 9.7 to 13.1) among the three Indigenous groups. The large-for-gestational-age rate was highest for First Nations births (20.9 per 100 births; 95% CI: 19.9 to 21.8). Infant mortality rates were more than twice as high for each Indigenous group compared with the non-Indigenous population, and rates of sudden infant death syndrome were more than seven times higher among First Nations and Inuit.The results confirm disparities in birth outcomes between Indigenous and non-Indigenous populations, and demonstrate differences among First Nations, Métis and Inuit.

Maternal socioeconomic disadvantage has been associated with increased risk of small-for-gestational-age birth and preterm birth. Few studies, however, have considered maternal education and income simultaneously to better understand the mechanisms underlying perinatal health disparities. This analysis examines both maternal education and income and their association with the risk of small-for-gestational-age birth and preterm birth.The study is based on 127,694 singleton live births from the 2006 Canadian Birth-Census Cohort, a national cohort of births registered from May 2004 to May 2006 that were linked to the 2006 long-form Census. Unadjusted rates of small-for-gestational-age birth (sex-specific birth weight below the 10th percentile for gestational age) and preterm birth (before 37 completed weeks of gestation) were estimated across selected maternal characteristics. Logistic regression was used to estimate crude and covariate-adjusted risk ratios of both outcomes according to maternal education and income adequacy quintiles.Small-for-gestational-age birth was associated with both maternal education and income adequacy, while preterm birth was associated with maternal education only. These findings persisted after taking factors including maternal age, ethnicity, and marital status into account. The results suggest that the mechanism by which maternal education is associated with these outcomes is likely not through income, nor does income replace education as a potentially meaningful measure of socioeconomic position.The mechanisms underlying associations between socioeconomic position and perinatal health disparities are complex. The results of this study indicate that more than one socioeconomic factor may play a role.

OBJECTIVES: To examine socio-economic inequalities in cause-specific mortality by examining the independent effects of education, occupation and income in a population-based study of working-age Canadian adults. METHODS: This is a secondary analysis of data from the 1991-2006 Canadian Census mortality and cancer follow-up study (n=2.7 million persons). For this analysis, the cohort was restricted to 2.3 million persons aged 25 to 64 at cohort inception, of whom 164,332 died during the follow-up period. Hazard ratios were calculated by educational attainment (4 levels), occupational skill (6 categories) and income adequacy (5 quintiles) for all-cause mortality and major causes of death. Models were run separately for men and women, controlled for multiple variables simultaneously, and some were stratified by 10-year age cohorts. RESULTS: The magnitude of socio-economic inequalities in mortality differed by indicator of socio-economic position (education, occupation, or income), age group, sex, and cause of death. Compared to age-adjusted models, hazard ratios were attenuated but remained significant in models that adjusted for both age and all three indicators of socio-economic position simultaneously. Socio-economic inequalities in mortality were evident for most of the major causes of death examined. CONCLUSION: This study demonstrates that education, occupation and income were each independently associated with mortality and were not simply proxies for each other. When evaluating socio-economic inequalities in mortality, it is important to use different indicators of socio-economic position to provide a more complete picture.

The 1991 Canadian Census Cohort is the largest population-based cohort in Canada (N=2,734,835). Prior to the creation of this Cohort, no national population-based Canadian cohort was available to examine mortality by socioeconomic indicators. The 1991 Canadian Census Cohort was created via the linkage of a sub-sample of respondents from the mandatory 1991 Canadian Census long-form to historical tax summary files, Canadian Mortality Database, Canadian Cancer Database, 1991 Health and Activity Limitation Survey and a sub-sample of the Longitudinal Worker File. Overall ascertainment of mortality and cancer is anticipated to be nearly complete and the Cohort is broadly representative of most groups in the Canadian population. The Cohort has been used to examine mortality outcomes by different indicators of socioeconomic status, occupational categories, ethnic groups, educational attainment, and for exposure to ambient air pollution. Results have shown that the estimated remaining years of life at age 25 differed substantially by income adequacy quintile, educational attainment, housing type and Aboriginal ancestry.

Background High prevalence of infant macrosomia (up to 36%, the highest in the world) has been reported in some First Nations communities in the Canadian province of Quebec and the eastern area of the province of Ontario. We aimed to assess whether infant macrosomia was associated with elevated risks of perinatal and postneonatal mortality among First Nations people in Quebec. Methods We calculated risk ratios (RRs) of perinatal and postneonatal mortality by birthweight for gestational age, comparing births to First Nations women ( n = 5193) versus women whose mother tongue is French ( n = 653 424, the majority reference group) in Quebec 1991–2000. Results The prevalence of infant macrosomia (birthweight for gestational age > 90th percentile) was 27.5% among births to First Nations women, which was 3.3 times (confidence interval [CI] 3.2–3.5) higher than the prevalence (8.3%) among births to women whose mother tongue is French. Risk ratios for perinatal mortality among births to First Nations women were 1.8 (95% CI 1.3–2.5) for births with weight appropriate for gestational age, 4.1 (95% CI 2.4–7.0) for small-for-gestational-age ( Interpretation Macrosomia was associated with a generally protective effect against perinatal death, but substantially greater risks of postneonatal death among births to First Nations women in Quebec versus women whose mother tongue is French.

Background In circumpolar countries such as Canada, northern regions represent a unique geographical entity climatically, socioeconomically and environmentally. There is a lack of comparative data on birth outcomes among Indigenous and non-Indigenous subpopulations within northern regions and compared with southern regions. Methods A cohort study of all births by maternal mother tongue to residents of northern (2616 First Nations (North American Indians), 2388 Inuit and 5006 non-Indigenous) and southern (2563 First Nations, 810 643 non-Indigenous) Quebec, 1991–2000. Results Compared with births to southern non-Indigenous mother tongue women, births to northern women of all three mother tongue groups were at substantially elevated risks of infant death (adjusted OR (aOR) 1.7–2.9), especially postneonatal death (aOR 2.2–4.4) after controlling for maternal education, age, marital status and parity. The risk elevation in perinatal death was greater for southern First Nations (aOR 1.6) than for northern First Nations (aOR 1.2). Infant macrosomia was highly prevalent among First Nations in Quebec, especially in the north (31% vs 24% in the south). Within northern regions, Inuit births were at highest risk of preterm delivery (aOR 1.4) and infant death (aOR 1.6). Conclusion All northern infants (First Nations, Inuit or non-Indigenous) were at substantially elevated risk of infant death in Quebec, despite a universal health insurance system. Southern First Nations newborns have not benefited from the more advanced perinatal care facilities in southern regions. Environmental influences may partly account for the very high prevalence of macrosomia among First Nations in northern Quebec.

Objective: Little is known about the possible impacts of neighborhood socioeconomic status on birth outcomes and infant mortality among Aboriginal populations. We assessed birth outcomes and infant mortality by neighborhood so- cioeconomic status among First Nations and non-First Nations in Manitoba. Study Design: We conducted a retrospective birth cohort study of all live births (26,176 First Nations, 129,623 non-First Nations) to Manitoba residents, 1991-2000. Maternal residential postal codes were used to assign four measures of neigh- borhood socioeconomic status (concerning income, education, unemployment, and lone parenthood) obtained from 1996 census data. Results: First Nations women were much more likely to live in neighborhoods of low socioeconomic status. First Nations infants were much more likely to die during their first year of life (risk ratio (RR) =1.9) especially during the postneonatal period (RR=3.6). For both First Nations and non-First Nations, living in neighborhoods of low socioeconomic status was associated with an increased risk of infant death, especially postneonatal death. For non-First Nations, higher rates of pre- term and small-for-gestational-age birth were consistently observed in low socioeconomic status neighborhoods, but for First Nations the associations were less consistent across the four measures of socioeconomic status. Adjusting for neigh- borhood socioeconomic status, the disparities in infant and postneonatal mortality between First Nations and non-First Nations were attenuated. Conclusion: Low neighborhood socioeconomic status was associated with an elevated risk of infant death even among First Nations, and may partly account for their higher rates of infant mortality compared to non-First Nations in Manitoba.

Objective: There is limited and inconsistent evidence concerning rural versus urban differences in birth and in- fant outcomes for Indigenous peoples. We assessed birth and infant outcomes among Inuit, First Nations and French mother tongue groups by rural versus urban residence in Quebec, Canada. Study Deign: A retrospective birth cohort study of 5,184 First Nations, 2,527 Inuit and 652,940 French mother tongue (the majority reference) births in Quebec, 1991-2000. Results: In general, rural living was associated with slightly less favorable birth outcomes for French mother tongue women, but somewhat better outcomes for Indigenous women. For both Inuit and First Nations, rural births were half as likely to be small-for-gestational-age compared to urban births. Among First Nations, the difference in infant mortality rates comparing urban to rural areas was not statistically significant. Compared to infants of French mother tongue women, Inuit and First Nations infants were much less likely to be small-for-gestational-age in rural areas, while such an "advantage" diminished for First Nations and reversed for Inuit in urban areas. The disparities in infant mortality among First Nations versus French mother tongue births were greater in urban than in rural areas. These patterns of results re- mained after adjusting for maternal characteristics. Conclusion: Living in urban areas was not associated with better birth and infant outcomes for Inuit and First Nations in Quebec despite universal health insurance coverage, strongly indicating a need for improved socioeconomic conditions, perinatal and infant care for Indigenous people living in urban areas.

Objective: to determine the relationship of north-south place of residence to adverse birth outcomes among First Nations and non-First Nations in Manitoba, Canada, a setting with universal health insurance. Study Design: Live birth records (n=151,472) for the province of Manitoba, Canada 1991-2000 were analyzed, including 25,743 First Nations and 125,729 non-First Nations infants. North-south and rural-urban residence was determined for each birth through geocoding. Results: Comparing First Nations to non-First Nations, crude rates in North (and South) were: 7.0% versus 8.4% (9.3% versus 7.5%) for preterm birth; 6.1% versus 8.4% (8.7% versus 10.0%) for small-for-gestational-age birth, 4.2% versus 6.5% (6.2% versus 5.7%) for low birth weight, and 20.6% versus 13.7% (17.0% versus 11.0%) for large-for-gestational- age birth; and mortality per 1000 - neonatal 3.2 versus 6.2 (3.8 versus 3.3), post-neonatal 6.4 versus 6.4 (5.8 versus 1.5), and infant 9.5 versus 12.6 (9.6 versus 4.8). Adjusting for observed maternal and infant characteristics and rural versus ur- ban residence, the North was high risk for large-for-gestational-age birth for both First Nations and non-First Nations. First Nations' risk of preterm, small-for-gestational-age and low birth weight was lowest in the North, but for non-First Nations, the North was lower only for small-for-gestational-age. First Nations mortality indicators were similar North to South, but for non-First Nations, the North was high risk. Conclusion: North-South place of residence does matter for adverse birth outcomes, but the effects may differ by ethnicity and could require different intervention strategies.

Objective: We assessed individual- and community-level disparities and trends in birth outcomes and infant mortality among First Nations (North American Indians) and Inuit versus other populations in Quebec, Canada. Methods: A retrospective birth cohort study of all births to Quebec residents, 1991-2000. At the individual level, we ex- amined outcomes comparing births to First Nations and Inuit versus other mother tongue women. At the community level, we compared outcomes among First Nations and Inuit communities versus other communities. Results: First Nations and Inuit births were much less likely to be small-for-gestational-age but much more likely to be large-for-gestational-age compared to other births at the individual or community level, especially for First Nations. At both levels, Inuit births were 1.5 times as likely to be preterm. At the individual level, total fetal and infant mortality rates were 2 times as high for First Nations, and 3 times as high for Inuit. Infant mortality rates were 2 times as high for First Nations, and 4 times as high for Inuit. There were no reductions in these disparities between 1991-1995 and 1996-2000. Modestly smaller disparities in total fetal and infant mortality were observed for First Nations at the community level (risk ratio=1.6), but for Inuit there were similar disparities at both levels. These disparities remained substantial after adjusting for maternal characteristics. Conclusion: There were large and persistent disparities in fetal and infant mortality among First Nations and Inuit versus other populations in Quebec based on individual- or community-level assessments, indicating a need to improve socio- economic conditions as well as perinatal and infant care for Aboriginal peoples.

Objective: Little is known about community remoteness in relation to birth outcomes among Indigenous popu- lations. We assessed whether community remoteness matters for perinatal outcomes and infant mortality in Quebec First Nations communities. Study Design: A retrospective cohort study of all births (n=11,033) to residents of First Nations communities in Quebec 1991-2000, using linked vital statistics data. First Nations communities were grouped by community remoteness into four zones from the least to most remote. Results: Preterm birth rates declined progressively from the least remote (8.0%) to the most remote (5.7%) zones (p=0.002). In contrast, total fetal and infant mortality rose progressively from the least remote (10.4 per 1000) to the most remote (22.7 per 1000) zones (p

Objective: To describe the association between occupation and risk of suicide among working-age men and women in Canada. Method: This study of suicide mortality over an 11-year period is based on a broadly representative 15% sample of the noninstitutionalized population of Canada aged 30 to 69 years at cohort inception. Age-standardized mortality rates (ASMRs) and rate ratios were calculated for men and women in 5 categories of skill level and 80 specific occupational groups, as well as for people not occupationally active. Results: The suicide mortality rate was 20.1/100 000 person years for occupationally active men (during 9 600 000 person years of follow-up) and 5.3/100 000 person years for occupationally active women (during 8 100 000 person years of follow-up). Among occupationally active men, elevated rates of suicide mortality were observed for 9 occupational groups and protective effects were observed for 6 occupational groups. Among women, elevated rates of suicide were observed in 4 occupational groups and no protective effects were observed. For men and women, ASMRs for suicide were inversely related to skill level. Conclusions: The limited number of associations between occupational groups and suicide risk observed in this study suggests that, with few exceptions, the characteristics of specific occupations do not substantially influence the risk for suicide. There was a moderate gradient in suicide mortality risk relative to occupational skill level. Suicide prevention strategies in occupational settings should continue to emphasize efforts to restrict and limit access to lethal means, one of the few suicide prevention policies with proven effectiveness.

Birth outcomes are persistently worse among Aboriginal as compared to non-Aboriginal populations even in developed countries.1–10 The underlying causes remain incompletely understood. Several studies indicate that the place of residence may affect the disparities in birth outcomes and infant mortality when comparing Aboriginal versus non-Aboriginal populations. Among North American Indians (the Canadian equivalent term “First Nations”) and Alaskan Natives compared to whites in the United States, greater disparities in infant mortality have been reported in some urban areas than in rural areas.3,4 In British Columbia, the disparity in infant mortality when comparing First Nations to non-First Nations declined less substantially and less consistently in urban versus rural areas.2 A recent Australian study found that the disparity in infant mortality when comparing Aboriginal versus non-Aboriginal populations was larger in remote rural areas.6 However, it is unknown whether the degree of rural isolation per se may affect birth outcomes and infant mortality differentially among Aboriginal versus non-Aboriginal populations. The question may be of particular importance due to the increasing migration of Aboriginal people to less isolated areas over recent decades. Although many Aboriginal people have moved from rural to urban or near-urban areas, substantially higher proportions of the Aboriginal population remain living in rural and more isolated areas compared to the non-Aboriginal population. According to the 2001 census, 57% of the First Nations population of Canada lived in rural areas, compared to 20% of the non-Aboriginal population. We hypothesized that the degree of rural isolation may affect birth outcomes and infant mortality differentially among Aboriginal and non-Aboriginal populations, presumably because of the Aboriginal versus non-Aboriginal differences in access to and effective use of the better care facilities in urban centers, and the differences in socioeconomic conditions and other risk factors. The primary aim of this study was to evaluate whether the degree of rural isolation may differentially affect birth outcomes and infant mortality among First Nations and non-First Nations in Manitoba, Canada, a setting with universal health insurance.

Background: Information on health disparities between Aboriginal and non-Aboriginal populations is essential for developing public health programs aimed at reducing such disparities. The lack of data on disparities in birth outcomes between Inuit and non-Inuit populations in Canada prompted us to compare birth outcomes in Inuit-inhabited areas with those in the rest of the country and in other rural and northern areas of Canada. Methods: We conducted a cohort study of all births in Canada during 1990–2000 using linked vital data. We identified 13 642 births to residents of Inuit-inhabited areas and 4 054 489 births to residents of all other areas. The primary outcome measures were preterm birth, stillbirth and infant death. Results: Compared with the rest of Canada, Inuit-inhabited areas had substantially higher rates of preterm birth (risk ratio [RR] 1.45, 95% confidence interval [CI] 1.38–1.52), stillbirth (RR 1.68, 95% CI 1.38–2.04) and infant death (RR 3.61, 95% CI 3.17–4.12). The risk ratios and absolute differences in risk for these outcomes changed little over time. Excess mortality was observed for all major causes of infant death, including congenital anomalies (RR 1.64), immaturity-related conditions (RR 2.96), asphyxia (RR 2.43), sudden infant death syndrome (RR 7.15), infection (RR 8.32) and external causes (RR 7.30). Maternal characteristics accounted for only a small part of the risk disparities. Substantial risk ratios for preterm birth, stillbirth and infant death remained when the comparisons were restricted to other rural or northern areas of Canada. Interpretation: The Inuit-inhabited areas had much higher rates of preterm birth, stillbirth and infant death compared with the rest of Canada and with other rural and northern areas. There is an urgent need for more effective interventions to improve maternal and infant health in Inuit-inhabited areas.

Selective study participation can theoretically lead to selection bias. We explored this issue in the context of a multicentre cohort study of socio-economic disparities in preterm birth. Women with singleton pregnancies were recruited from four large Montreal maternity hospitals and invited to return for an interview, vaginal examination and venepuncture at 24-26 weeks of gestation. We compared the observed preterm birth rate (ultrasound confirmed) among the 5146 cohort women to that expected based on all 108 724 Montreal Census Metropolitan Area (CMA) singleton births for 1998-2000. The observed preterm birth rate in the study cohort was 5.1%, compared with 6.3% in the CMA (P < 0.001) (unadjusted morbidity ratio [95% CI] = 0.80 [0.71, 0.90]). Within each stratum of maternal education and neighbourhood income (the latter based on postal code matched links to the 2001 Canadian census), cohort women had substantially lower rates of preterm birth than women from the CMA. No significant association between socio-economic status (SES) and preterm birth was observed in the study cohort, except among 'indicated' (non-spontaneous) cases. The association between neighbourhood income and preterm birth was biased to the null in the study cohort, with adjusted odds ratios in the poorest vs. richest quintiles of 1.01 [0.63, 1.64] in the cohort vs. 1.28 [1.18, 1.39] in the CMA, although no such bias was observed for the association with maternal education assessed at the individual level. We speculate that the lower-than-expected preterm birth rate and attenuated association between neighbourhood income and preterm birth may be related to selective participation by women more psychologically invested in their pregnancies. Investigators should consider the potential for biased associations in pregnancy/birth cohort studies, especially associations based on SES or race/ethnicity, and carry out sensitivity analyses to gauge their effects.

OBJECTIVE. We sought to determine the influence of neighborhood income on homicides among children living in urban Canada. METHODS. Homicides among children RESULTS. During the 3-year study period, there were 87 homicides among children CONCLUSION. Effective child homicide-prevention strategies should be focused on children

Background: There is a lack of data on the safety of midwife-led maternity care in remote or Indigenous communities. In a de facto natural "experiment", we assessed birth outcomes by primary birthing attendant in two sets of remote Inuit communities. Methods: A geocoding-based retrospective birth cohort study in 14 Inuit communities of Nunavik, Canada, 1989-2000: primary birth attendants were Inuit midwives in the Hudson Bay (1,529 Inuit births) versus Western physicians in Ungava Bay communities (1,197 Inuit births). The primary outcome was perinatal death. Secondary outcomes included stillbirth, neonatal death, postneonatal death, preterm, small-for-gestational-age and low birth weight birth. Multi-level logistic regression was used to obtain the adjusted odds ratios (aOR) controlling for maternal age, marital status, parity, education, infant sex and plurality, community size and community-level random effects. Results: The aOR (95% confidence interval) for perinatal death comparing the Hudson Bay versus Ungava Bay communities were 1.29 (0.63, 2.64) for all Inuit births, and 1.13 (0.48, 2.47) for Inuit births at >=28 weeks of gestation. There were no statistically significant differences in the crude or adjusted risks of any of the outcomes examined. Conclusion: Risks of perinatal death were somewhat but not significantly higher in the Hudson Bay communities with midwife-led maternity care as compared to the Ungava Bay communities with physician-led maternity care. Our findings are inconclusive, although the results excluding extremely preterm births are more reassuring concerning the safety of midwife-led maternity care in remote Indigenous communities.

Nous présentons ici un indice synthétique de l’état de santé qui tient compte à la fois de la mortalité et de la morbidité dans une population. Le calcul de cet indice est relativement facile car il ne s’agit que d’un prolongement des méthodes classiques en démographie. Dans le cas présent, les données sur l’incapacité (restrictions quelconques sur le plan des activités habituelles) proviennent de l’Enquête Santé Canada, de même que des établissements hospitaliers de soins prolongés et des centres d’accueil. La distribution de l’espérance de vie parmi les différents états de santé est d’un grand intérêt. Elle démontre, par exemple, qu’à la naissance, au Québec, les incapacités majeures et mineures retranchent de la vie moyenne environ neuf années chez les hommes et quatorze années chez les femmes. D’autres analyses sont présentées, désagrégées par âge et par région.

Little is known about how birth outcomes vary in rural areas by degree of rural isolation. We conducted a retrospective cohort study of all births in Quebec, 1991-2000 to assess birth outcomes by the degree of rural isolation according to metropolitan influence as measured by work force commuting flows between rural and urban areas. Compared with urban areas, crude risks of preterm birth, small-for-gestational age birth, stillbirth, neonatal death and postneonatal death were similar in rural areas with strong metropolitan influence, but were significantly higher for preterm birth, stillbirth and postneonatal death in rural areas with weak or no metropolitan influence, and for neonatal death in rural areas with no metropolitan influence. Adjustment for maternal characteristics (age, mother tongue, education, marital status, parity, plurality and infant sex) attenuated the associations. The adjusted odds ratios [95% confidence intervals] were 1.36 [1.12, 1.64] for stillbirth in rural areas with weak metropolitan influence, 1.63 [1.14, 2.32] for neonatal death in rural areas with no metropolitan influence, 1.78 [1.21, 2.63] and 1.37 [1.07, 1.75] for postneonatal death in rural areas with weak and no metropolitan influence, respectively. Much higher neonatal death rates were observed for preterm or low-birthweight babies in rural areas with no metropolitan influence, suggesting inadequate access to optimal neonatal care. We conclude that birth outcomes in rural areas differ according to the degree of rural isolation. Fetuses and infants of mothers from rural areas with weak or no metropolitan influence are particularly vulnerable to the risks of death during the perinatal and postnatal periods.

Evidence on socioeconomic and ethnocultural disparities in perinatal health in Canada tends to be limited to analyses by neighbourhood or for selected provinces. In 2010, the Canadian Institutes of Health Research awarded funding for a project on perinatal outcomes. This article describes the resulting 2006 Canadian Birth-Census Cohort Database.From the Canadian Live Birth, Infant Death and Stillbirth Database, 687,340 records of children born in Canada from May 16, 2004 through May 15, 2006 to mothers whose usual place of residence was Canada were selected as in-scope births. Deterministic rules were applied to link each person on the birth record-child, mother, father-to 2006 Census data.The cohort was restricted to records linked to a long-form questionnaire, and a cohort weight was developed. Cohort rates (unweighted and weighted) for five birth outcomes-preterm birth, small-for-gestational age, large-for-gestational age, stillbirth, and infant mortality-were compared with rates for all in-scope births across birth characteristics. Cohort rates for these birth outcomes were examined across selected census characteristics.Linkage rates were 91% for births surviving to age 1, 76% for stillbirths, and 80% for infant deaths matched to a birth registration. The cohort estimates were similar to those for all in-scope births, particularly after the cohort weight was applied. The cohort data produced plausible estimates of selected birth outcomes across maternal ethnocultural categories and levels of education.The 2006 Canadian Birth-Census Cohort data can help inform perinatal surveillance and research in Canada.

To examine neighbourhood income differences in deaths amenable to medical care and public health over a 25-year period after the establishment of universal insurance for doctors and hospital services in Canada.Data for census metropolitan areas were obtained from the Canadian Mortality Database and population censuses for the years 1971, 1986, 1991 and 1996. Deaths amenable to medical care, amenable to public health, from ischaemic heart disease and from other causes were considered. Data on deaths were grouped into neighbourhood income quintiles on the basis of the census tract percentage of population below Canada's low-income cut-offs.From 1971 to 1996, differences between the richest and poorest quintiles in age-standardised expected years of life lost amenable to medical care decreased 60% (p0.001) in men and 78% (p0.001) in women, those amenable to public health increased 0.7% (p = 0.94) in men and 20% (p = 0.55) in women, those lost from ischaemic heart disease decreased 58% in men and 38% in women, and from other causes decreased 15% in men and 9% in women. Changes in the age-standardised expected years of life lost difference for deaths amenable to medical care were significantly larger than those for deaths amenable to public health or other causes for both men and women (p0.001).Reductions in rates of deaths amenable to medical care made the largest contribution to narrowing socioeconomic mortality disparities. Continuing disparities in mortality from causes amenable to public health suggest that public health initiatives have a potentially important, but yet un-realized, role in further reducing mortality disparities in Canada.

The authors examined the relation between neighborhood income, as a measure of socioeconomic status, and childhood cancer. Incident cases of childhood solid tumor and lymphoma in 1985-2001 were identified from provincial cancer registries in Canada. Residential postal codes at the time of diagnosis were used to assign cases to census neighborhoods. Person-years at risk were determined from quintiles of population by neighborhood income, sex, and 5-year age group, constructed using census population data. Poisson regression was used to calculate incidence rate ratios across neighborhood income quintiles. Compared with the incidence rate in the richest income quintile, moderately lower rate ratios of 0.73 (95% confidence interval: 0.63, 0.86) and 0.84 (95% confidence interval: 0.69, 1.04) were observed, respectively, for carcinomas and renal tumors in the poorest income quintile. No association was found for other types of cancer. Although a potential relation between socioeconomic status and childhood cancer cannot be excluded, the overall pattern seems compatible with random variation.

Knowledge of socioeconomic disparities in health is of interest to both the general public and public health policymakers. It is unclear how disparities in birth outcomes by socioeconomic status have changed over time, particularly in settings with universal health insurance and favorable socioeconomic conditions.We identified a cohort of all births (n = 713,950) registered in British Columbia, 1985-2000. We compared rates and relative risks (RRs) of preterm birth, small-for-gestational-age (SGA), stillbirth, and neonatal and postneonatal death across neighborhood-income quintiles from Q1 (richest, the reference) to Q5 (poorest) by 4-year intervals in rural and urban areas. Logistic regression was used to control for maternal and pregnancy characteristics.Maternal characteristics varied widely across neighborhood-income quintiles in both rural and urban areas. There were moderate and persistent disparities in birth outcomes across neighborhood-income quintiles in urban but not rural areas. The relative disparities in urban areas did not diminish over time for all birth outcomes and actually rose for postneonatal mortality. For example, crude RRs (95% confidence intervals) for Q5 versus Q1 in urban areas for SGA were 1.44 (1.37-1.52) in 1985-1988 and 1.41 (1.33-1.49) in 1997-2000; for postneonatal death, the corresponding results were 1.61 (1.17-2.20) and 2.20 (1.24-3.92), respectively. Most of the observed disparities could not be explained by observed maternal and pregnancy characteristics.Moderate disparities in birth outcomes by neighborhood income persist in urban areas (although not rural areas) of British Columbia, despite a universal health insurance system and generally favorable socioeconomic conditions.

SUMMARY This article shows how mortality and morbidity patterns differ for women and men 45 years of age and older. The impact on disability-free life expectancy was calculated for selected risk factors and chronic conditions: low income, low education, abnormal body mass index, lack of physical activity, smoking, cancer, diabetes, and arthritis. For each factor, the expected number of years free of disability was calculated for men and women using multi-state life tables. In terms of disability-free life expectancy, the greatest impacts on affected women were for diabetes (14.1 years), arthritis (8.8 years), and physical inactivity (6.0 years), while for affected men, the greatest impacts were for diabetes (10.5 years), smoking (6.9 years), arthritis (6.5 years), and cancer (6.4 years). The implications of these results are discussed from the perspective of developing programs designed to improve population health status.

The present study offers information about independence and life satisfaction over the lifespan for individuals with traumatic spinal cord injuries.The study uses the health expectancy methodology to estimate expectations of the remaining years of life that may be spent in states of independence and satisfaction with life.The cohort studied had all incurred a spinal cord injury between the ages of 25 and 34, between the years 1945 and 1990 in central and south-eastern Ontario.The study found that levels of independence and quality of life in the sample conformed closely to those found in other similar studies with the spinal cord injured population: 22% reported their own functional status as dependent, and 22% reported fair to poor life satisfaction. Expectations of independence appeared to decline steadily over the five decades studied, while expectations of modified independence increased proportionally. Estimates varied significantly for those with paraplegia vs. quadriplegia, and those with complete vs. incomplete lesions. Expectations of life satisfaction appeared to change after the 30 year mark; at that point, the balance changed so that expectations of dissatisfaction outweighed expectations of satisfaction. Multiple regression showed that independence was related to lesion level, completeness and recency of injury, and both independence and satisfaction were related to marriage and employment.

The object of this paper is to combine two concepts which have developed on the interface between public health and demography: health expectancy and the analysis of linkage in demographic models. The paper addresses in the general case the question: what are the marginal effects of changes in incidence or mortality rates on the expectation of life with and without a particular irreversible non-communicable disease or type of disability? A simple model of disease in a population is described and general solutions for the two components of the expectation of life are obtained.... It is shown that under certain conditions the entropy of the expectation of disease free life with respect to changes in incidence can be approximated by an extension of Sullivans index. Data on dementia among elderly Canadians obtained from the Canadian Study of Health and Aging are used for illustration. (EXCERPT) (SUMMARY IN FRE)

People with lower incomes tend to have less favourable health outcomes than do people with higher incomes. Because death registrations in Canada do not contain information about the income of the deceased, vital statistics cannot be used to examine mortality by income at the individual level. However, through record linkage, information on the individual or family income of people followed for mortality can be obtained. Recently, a large, population-based sample of Canadian adults was linked to almost 16 years of mortality data.This study examines cause-specific mortality rates by income adequacy among Canadian adults. It is based on data from the 1991 to 2006 Canadian census mortality and cancer follow-up study, which followed 2.7 million people aged 25 or older at baseline, 426,979 of whom died during the 16-year period. Age-standardized mortality rates (ASMRs), rate ratios, rate differences and excess mortality were calculated by income adequacy quintile for various causes of death.For most causes examined, ASMRs were clearly graded by income: highest among people in the in the lowest income quintile, and lowest among people in the highest income quintile. Inter-quintile rate ratios (quintile 1/quintile 5) were greater than 2.00 for HIV/AIDS, diabetes mellitus, suicide, cancer of the cervix, and causes of death closely associated with smoking and alcohol.These individually based results provide cause-specific information by income adequacy quintile that was not previously available for Canada.

CONTEXTE : La mortalité infantile a diminué au Canada depuis les années 1990 et 2000 mais nous ignorons si toutes les classes socioéconomiques ont bénéficié également de ce progrès. OBJECTIFS : La présente étude portait sur les différences entre les taux de mortalité néonatale et postnéonatale et de mort subite du nourrisson entre les différents quintiles de revenu des quartiers au Canada de 1991 à 2005. MÉTHODES : Le fichier couplé des naissances vivantes et des décès infantiles au Canada a été utilisé à l’exclusion des naissances survenues en Ontario, au Yukon, dans les Territoires du Nord-ouest et au Nunavut. Les taux de mortalité néonatale et postnéonatale et de mort subite du nourrisson ont été calculé par quintile de revenu des quartiers et par période (1991-1995, 1996-2000, 2001-2005). Les rapports de risque (RR) ont été calculés par quintile de revenu et période avec ajustement pour la province de résidence, l’âge de la mère, la parité, le sexe du nourrisson et les naissances multiples. RÉSULTATS : En zone urbaine, pour toute la période étudiée (1991- 2005), le quintile de revenu le plus pauvre avait un risque plus élevé de mortalité néonatale (RR ajusté 1,24; IC 95% 1,15-1,34), de mortalité postnéonatale (RR ajusté 1,58; IC 95% 1,41-1,76) et de mort subite du nourrisson (RR ajusté 1,83; IC 95% 1,49-2,26) par rapport au quintile le plus riche. Les taux de mortalité post néonatale et de mort subite du nourrisson ont décliné respectivement de 37 % et de 57 % de 1991- 1995 à 2001-2005 alors que le taux de mortalité néonatale n’a pas changé de façon significative. Cette diminution de la mortalité postnéonatale et de la mort subite du nourrisson a été observée dans tous les quintiles de revenu. CONCLUSION : Malgré une diminution de la mortalité postnéonatale et du syndrome de mort subite du nourrisson dans tous les quintiles de revenu, les inégalités subsistent au Canada. Ce résultat démontre le besoin de stratégies efficaces de promotion de la santé visant spécifiquement les populations vulnérables. MOTS CLÉS : mort subite du nourrisson; mortalité infantile; statut socioéconomique, [À l'origine dans / Was originally part of : ESPUM - Dép. médecine sociale et préventive - Travaux et publications]

There is little research examining the attitudes of small business owners and managers toward labour relations and trade unions. Based on data from 149 owners and managers in small and medium-size manufacturing businesses, the results indicated that respondents favoured more laws limiting the power of unions, perceived that unions interfered with the efficient running of a business, and believed that dealing with a union makes managing a business more difficult. There was also strong support for the position that unionized firms are less productive and less profitable. Overall, respondents in nonunion firms tended to have more negative views of unions relative to executives from union organizations.

People with lower levels of education tend to have higher rates of disease and death, compared with people who have higher levels of education. However, because death registrations in Canada do not contain information on the education of the deceased, unlinked vital statistics cannot be used to examine mortality differentials by education.This study examines cause-specific mortality rates by education in a broadly representative sample of Canadians aged 25 or older. The data are from the 1991 to 2006 Canadian census mortality follow-up study, which included about 2.7 million people and 426,979 deaths. Age-standardized mortality rates (ASMRs) were calculated by education for different causes of death. Rate ratios, rate differences and excess mortality were also calculated.All-cause ASMRs were highest among people with less than secondary graduation and lowest for university degree-holders. If all cohort members had the mortality rates of those with a university degree, the overall ASMRs would have been 27% lower for men and 22% lower for women. The causes contributing most to that "excess" mortality were ischemic heart disease, lung cancer, chronic obstructive pulmonary disease, stroke, diabetes, injuries (men), and respiratory infections (women). Causes associated with smoking and alcohol abuse had the steepest gradients.A mortality gradient by education was evident for many causes of death.

Previously, little information has been available about life expectancy and the probability of survival by socio-economic status or for Aboriginal groups. However, data from the 1991 to 2001 Canadian census mortality follow-up study made it possible to construct life tables for the non-institutional population aged 25 or older by a range of census variables. Those life tables have now been updated to include deaths through to the end of 2006. This report summarizes the updated findings. Life expectancy at age 25 and the probability of survival to age 75 tended to be low for people with low income and education, for residents of shelters, rooming houses and hotels, and for Registered Indians, non-Status Indians and Métis. In general, socio-economic disparities in mortality were greater for men than for women.

OBJECTIVE: Little is known about the possible impacts of neighborhood socioeconomic status on birth outcomes and infant mortality among Aboriginal populations. We assessed birth outcomes and infant mortality by neighborhood socioeconomic status among First Nations and non-First Nations in Manitoba. STUDY DESIGN: We conducted a retrospective birth cohort study of all live births (26,176 First Nations, 129,623 non-First Nations) to Manitoba residents, 1991-2000. Maternal residential postal codes were used to assign four measures of neighborhood socioeconomic status (concerning income, education, unemployment, and lone parenthood) obtained from 1996 census data. RESULTS: First Nations women were much more likely to live in neighborhoods of low socioeconomic status. First Nations infants were much more likely to die during their first year of life [risk ratio (RR) =1.9] especially during the postneonatal period (RR=3.6). For both First Nations and non-First Nations, living in neighborhoods of low socioeconomic status was associated with an increased risk of infant death, especially postneonatal death. For non-First Nations, higher rates of pre-term and small-for-gestational-age birth were consistently observed in low socioeconomic status neighborhoods, but for First Nations the associations were less consistent across the four measures of socioeconomic status. Adjusting for neighborhood socioeconomic status, the disparities in infant and postneonatal mortality between First Nations and non-First Nations were attenuated. CONCLUSION: Low neighborhood socioeconomic status was associated with an elevated risk of infant death even among First Nations, and may partly account for their higher rates of infant mortality compared to non-First Nations in Manitoba.

OBJECTIVE: Little is known about community remoteness in relation to birth outcomes among Indigenous populations. We assessed whether community remoteness matters for perinatal outcomes and infant mortality in Quebec First Nations communities. STUDY DESIGN: A retrospective cohort study of all births (n=11,033) to residents of First Nations communities in Quebec 1991-2000, using linked vital statistics data. First Nations communities were grouped by community remoteness into four zones from the least to most remote. RESULTS: Preterm birth rates declined progressively from the least remote (8.0%) to the most remote (5.7%) zones (p=0.002). In contrast, total fetal and infant mortality rose progressively from the least remote (10.4 per 1000) to the most remote (22.7 per 1000) zones (p0.001). The excess infant mortality in the more remote zones was mainly due to higher rates of postneonatal mortality. Similar patterns were observed after adjusting for maternal age, education, parity and marital status. Substantially elevated risks in most remote communities remained for perinatal death (adjusted OR=2.1), postneonatal death (adjusted OR=2.7), and total fetal and infant death (adjusted OR=2.3). CONCLUSION: Living in more remote First Nations communities was associated with a substantially higher risk of fetal and infant death, especially postneonatal death, despite a lower risk of preterm delivery. There is a need for more effective perinatal and infant care programs in more remote First Nations communities to reduce perinatal and infant mortality.

OBJECTIVE: We assessed individual- and community-level disparities and trends in birth outcomes and infant mortality among First Nations (North American Indians) and Inuit versus other populations in Quebec, Canada. METHODS: A retrospective birth cohort study of all births to Quebec residents, 1991-2000. At the individual level, we examined outcomes comparing births to First Nations and Inuit versus other mother tongue women. At the community level, we compared outcomes among First Nations and Inuit communities versus other communities. RESULTS: First Nations and Inuit births were much less likely to be small-for-gestational-age but much more likely to be large-for-gestational-age compared to other births at the individual or community level, especially for First Nations. At both levels, Inuit births were 1.5 times as likely to be preterm. At the individual level, total fetal and infant mortality rates were 2 times as high for First Nations, and 3 times as high for Inuit. Infant mortality rates were 2 times as high for First Nations, and 4 times as high for Inuit. There were no reductions in these disparities between 1991-1995 and 1996-2000. Modestly smaller disparities in total fetal and infant mortality were observed for First Nations at the community level (risk ratio=1.6), but for Inuit there were similar disparities at both levels. These disparities remained substantial after adjusting for maternal characteristics. CONCLUSION: There were large and persistent disparities in fetal and infant mortality among First Nations and Inuit versus other populations in Quebec based on individual- or community-level assessments, indicating a need to improve socioeconomic conditions as well as perinatal and infant care for Aboriginal peoples.

In developed countries, women of higher socioeconomic status often have higher breast cancer incidence rates, compared with women of lower socioeconomic status.Data were extracted from the Canadian Cancer Registry for the 229,955 cases of adult female invasive breast cancer diagnosed from 1992 through 2004. Postal code at diagnosis was used to determine neighbourhood income quintile. Breast cancer incidence was examined by year, region, age and neighbourhood income quintile. Census data for 1991 on children ever born and British Columbia data for 2006 on first-time attendance at mammography screening were analyzed by neighbourhood income quintile.Residence in the lowest as opposed to the highest neighbourhood income quintile was associated with a 15% lower risk of being diagnosed with breast cancer. Higher income levels were associated with lower parity in 1991 and a higher prevalence of first-time screening mammography in British Columbia in 2006.Canadian data support an association between the diagnosis of invasive breast cancer and neighbourhood income quintile. Parity and mammography screening may account for some differences in incidence.

Compared with other Canadians, First Nations peoples experience a disproportionate burden of illness and disease. Potential years of life lost (PYLL) before age 75 highlights the impact of youthful or early deaths.The 1991 to 2001 Canadian census mortality follow-up study tracked a 15% sample of adults aged 25 or older over more than a decade. This study examined mortality among people aged 25 to 74-55,600 Status Indians (39,200 on reserve and 16,500 off reserve) and 2,475,700 non-Aboriginal adults-all of whom were enumerated by the 1991 census long-form questionnaire. Age-standardized PYLL rates were calculated, based on the number of person-years at risk before age 75.Status Indian adults had 2.5 times the risk of dying before age 75, compared with non-Aboriginal adults. Results did not differ greatly by residence on or off reserve. Relative and absolute inequalities were greatest for unintentional and intentional injuries. Socio-economic factors such as income, education, housing and employment explained a substantial share of the disparities in premature death.Status Indian adults had higher rates of premature mortality. Socio-economic factors played an important role in those disparities. Injuries were important contributors to both relative and absolute inequalities.

Aboriginal peoples experience a disproportionate burden of disease, compared with other Canadians. However, relatively little information is available about mortality among Métis and non-Status Indians.This study calculates potential years of life lost before age 75 (PYLL) for people aged 25 to 74 by all-cause and cause-specific mortality, and examines the effect of socio-economic factors on premature mortality. Age-specific and age-standardized PYLL rates were calculated for 11,600 Métis, 5,400 non-Status Indians, and 2,475,700 non-Aboriginal adults based on the number of person-years at risk up to age 75.Métis and non-Status Indian adults had about twice the risk of dying before age 75, compared with non-Aboriginal adults. While the largest percentage of PYLL was due to non-communicable diseases such as cardiovascular disease and cancer, relative and absolute inequalities were greatest for injuries. Socioeconomic indicators such as income, education and employment explained a large share of the disparities in premature mortality.The results highlight the losses of potential years of life due to chronic diseases, as well as the possible importance of injury prevention programs for Métis and non-Status Indians.

Objective: To describe the incidence of avoidable mortality for causes amenable to medical care among occupation groups in Canada. Method: A cohort study over an 11-year period among a representative 15% sample of the non-institutionalized population of Canada aged 30-69 at cohort inception. Age-standardized mortality rates for causes amenable to medical care and all other causes of death were calculated for occupationally-active men and women in five categories of skill level and 80 specific occupational groups as well as for persons not occupationally active. Results: Age-standardized mortality rates per 100,000 person-years at risk for causes amenable to medical care and for all other causes were 132.3 and 218.6, respectively, for occupationally-active women, and 216.6 and 449.3 for occupationally-active men. For causes amenable to medical care and for all other causes, for both sexes, there was a gradient in mortality relative to the five-level ranking by occupational skill level, but the gradient was less strong for women than for men. Across the 80 occupation minor groups, for both men and women, there was a linear relationship between the rates for causes amenable to medical care and the rates for all other causes. Conclusions: For occupationally-active adults, this study found similar gradients in mortality for causes amenable to medical care and for all other causes of mortality over the period 1991-2001. Avoidable mortality is a valuable indicator of population health, providing information on outcomes pertinent to the organization and delivery of health care services. Key words: Occupations; cause of death; health services research

Little information has been published about the mortality of the Métis people of Canada. This study describes mortality patterns among Métis and Registered Indian adults, compared with the non-Aboriginal population.The 1991 to 2001 Canadian census mortality followup study tracked mortality among a 15% sample of respondents aged 25 or older, including 11,800 Métis, 56,700 Registered Indians and 2,624,300 non-Aboriginal adults, all of whom were enumerated by the 1991 census long-form questionnaire. Age-specific and age-standardized mortality rates and period life tables based on the number of person-years at risk were calculated across the various groups. Métis were defined by ethnic origin (ancestry).Compared with non-Aboriginal members of the cohort, life expectancy at age 25 was 3.3 and 5.5 years shorter for Métis men and women, respectively, and 4.4 and 6.3 years shorter for Registered Indians. For both Aboriginal groups, mortality rate ratios were highest at younger ages. Mortality rate differences among Métis men were particularly elevated for external causes and circulatory, respiratory and digestive system diseases; among Métis women, for circulatory system diseases, cancers, and digestive and respiratory system diseases. Generally, rate differences for Registered Indian men and women were further elevated.Métis adults had higher mortality rates compared with non-Aboriginal members of the cohort, but lower rates than did Registered Indians.

Health-adjusted life expectancy is a summary measure of population health that combines mortality and morbidity data into a single index. This article profiles differences in health-adjusted life expectancy across income categories for a representative sample of the Canadian population.Mortality data were obtained from the 1991-2001 Canadian census mortality follow-up study, which linked a 15% sample of the 1991 adult non-institutional population with 11 years of death records from the Canadian Mortality Data Base. Information on morbidity was obtained from the Health Utilities Index Mark 3 instrument on the 2000/2001 Canadian Community Health Survey. The Sullivan method was used to compute health-adjusted life expectancy for national deciles of population ranked by income.For both sexes, and with few exceptions, a nearly linear gradient across income deciles emerged for health-adjusted life expectancy at age 25. Compared with people in higher-income deciles, those in lower-income deciles had fewer years of health-adjusted life expectancy. These disparities were substantially larger than those revealed by life expectancy alone.These findings highlight the generally worse health-related quality of life of lower-income groups. The results demonstrate that assessments of socio-economic disparities in health should include the effects of both mortality and morbidity.

Objective To examine mortality in a representative nationwide sample of homeless and marginally housed people living in shelters, rooming houses, and hotels. Design Follow-up study. Setting Canada 1991-2001. Participants 15 100 homeless and marginally housed people enumerated in 1991 census. Main outcome measures Age specific and age standardised mortality rates, remaining life expectancies at age 25, and probabilities of survival from age 25 to 75. Data were compared with data from the poorest and richest income fifths as well as with data for the entire cohort Results Of the homeless and marginally housed people, 3280 died. Mortality rates among these people were substantially higher than rates in the poorest income fifth, with the highest rate ratios seen at younger ages. Among those who were homeless or marginally housed, the probability of survival to age 75 was 32% (95% confidence interval 30% to 34%) in men and 60% (56% to 63%) in women. Remaining life expectancy at age 25 was 42 years (42 to 43) and 52 years (50 to 53), respectively. Compared with the entire cohort, mortality rate ratios for men and women, respectively, were 11.5 (8.8 to 15.0) and 9.2 (5.5 to 15.2) for drug related deaths, 6.4 (5.3 to 7.7) and 8.2 (5.0 to 13.4) for alcohol related deaths, 4.8 (3.9 to 5.9) and 3.8 (2.7 to 5.4) for mental disorders, and 2.3 (1.8 to 3.1) and 5.6 (3.2 to 9.6) for suicide. For both sexes, the largest differences in mortality rates were for smoking related diseases, ischaemic heart disease, and respiratory diseases. Conclusions Living in shelters, rooming houses, and hotels is associated with much higher mortality than expected on the basis of low income alone. Reducing the excessively high rates of premature mortality in this population would require interventions to address deaths related to smoking, alcohol, and drugs, and mental disorders and suicide, among other causes.

An important step in monitoring progress toward reducing or eliminating inequalities in health is to determine the distribution of mortality rates across various groups defined by education, occupation, income, language, ethnicity, and Aboriginal, visible minority and disability status. This article describes the methods used to link census data from the long-form questionnaire to mortality data, and reports simple findings for the major groups.Mortality from June 4, 1991 to December 31, 2001 was tracked among a 15% sample of the adult population of Canada, who completed the 1991 census long-form questionnaire (about 2.7 million, including 260,000 deaths). Age-specific and age-standardized mortality rates were calculated across the various groups, as were hazard ratios and period life tables.Compared with people of higher socio-economic status, mortality rates were elevated among those of lower socio-economic status, regardless of whether status was determined by education, occupation or income. The findings reveal a stair-stepped gradient, with bigger steps near the bottom of the socio-economic hierarchy.

Because of a lack of Aboriginal identifiers on death registrations, standard data sources and methods cannot be used to estimate basic health indicators for Inuit in Canada. Instead, a geographic-based approach was used to estimate life expectancy for the entire population of Inuit-inhabited areas.The data are from the Canadian Mortality Database and the Census of Canada.Areas where at least 33% of residents were Inuit were identified, based on census results. Vital statistics death records for 1989 through 2003 and census population counts for 1991, 1996 and 2001 were used to compute abridged life tables for the Inuit-inhabited areas in each of the three 5-year periods centered around those census years.In 1991, life expectancy at birth in the Inuit-inhabited areas was about 68 years, which was 10 years lower than for Canada overall. From 1991 to 2001, life expectancy in the Inuit-inhabited areas did not increase, although it rose by about two years for Canada as a whole. As a result, the gap widened to more than 12 years. Life expectancy in the Inuit-inhabited areas was generally highest in the Inuvialuit region (Northwest Territories) and Nunavut (Territory), followed by Nunatsiavut (Labrador) and Nunavik (Quebec). While these results are not specific to the Inuit population, such geographic-based methods can be used with any administrative datasets that include postal codes or municipal-level locality codes.

Background Birth weight for gestational age is a widely-used proxy for fetal growth. Although the need for different standards for males and females is generally acknowledged, the physiologic vs pathologic nature of ethnic differences in fetal growth is hotly debated and remains unresolved. Methods We used all stillbirth, live birth, and deterministically linked infant deaths in British Columbia from 1981 to 2000 to examine fetal growth and perinatal mortality in Chinese (n = 40,092), South Asian (n = 38,670), First Nations, i.e., North American Indian (n = 56,097), and other (n = 731,109) births. We used a new analytic approach based on total fetuses at risk to compare the four ethnic groups in perinatal mortality, mean birth weight, and "revealed" (< 10th percentile) small-for-gestational age (SGA) among live births based on both a single standard and four ethnic-specific standards. Results Despite their lower mean birth weights and higher SGA rates (when based on a single standard), Chinese and South Asian infants had lower perinatal mortality risks throughout gestation. The opposite pattern was observed for First Nations births: higher mean birth weights, lower revealed SGA rates, and higher perinatal mortality risks. When SGA was based on ethnic-specific standards, however, the pattern was concordant with that observed for perinatal mortality. Conclusion The concordance of perinatal mortality and SGA rates when based on ethnic-specific standards, and their discordance when based on a single standard, strongly suggests that the observed ethnic differences in fetal growth are physiologic, rather than pathologic, and make a strong case for ethnic-specific standards.