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PURPOSE: Misclassification of gestational age based on the last menstrual period (LMP) in routinely collected data creates bias in newborn birthweight and gestational age-related indicators. Common correction methods have not been evaluated. We developed a normal mixture model for use with SAS software to correct misclassification of gestational age and compare its performance with other available correction methods and estimates of gestational age. METHODS: Using the 2007 United States natality file from the National Center for Health Statistics, we compared LMP preterm and postterm birth rates and gestational age-specific birthweight percentiles against a reference subset of births, where the likelihood of misclassification in gestational age was minimized, before and after correction by a normal mixture model, two truncation methods, and the clinical/obstetric estimate of gestational age. RESULTS: The mixture model corrected preterm and postterm birth rates by 90% and 41% respectively, but previous methods performed poorly. The mixture model was also superior in correcting birthweight percentiles 50 and 90 with error reductions in the range of 68% to 85% between 28 and 36 weeks of gestation, where most misclassification occurred. CONCLUSIONS: The mixture model behaved consistently better than truncation methods, particularly between weeks 28 and 36 of gestation. [ABSTRACT FROM AUTHOR]

BACKGROUND: The literature on international migration and birth outcomes shows mixed results. This study examined whether low birth weight (LBW) and preterm birth differed between non-migrants and migrant subgroups, defined by race/ethnicity and world region of origin and destination. METHODS: A systematic review and meta-regression analyses were conducted using three-level logistic models to account for the heterogeneity between studies and between subgroups within studies. RESULTS: Twenty-four studies, involving more than 30 million singleton births, met the inclusion criteria. Compared with US-born black women, black migrant women were at lower odds of delivering LBW and preterm birth babies. Hispanic migrants also exhibited lower odds for these outcomes, but Asian and white migrants did not. Sub-Saharan African and Latin-American and Caribbean women were at higher odds of delivering LBW babies in Europe but not in the USA and south-central Asians were at higher odds in both continents, compared with the native-born populations. CONCLUSIONS: The association between migration and adverse birth outcomes varies by migrant subgroup and it is sensitive to the definition of the migrant and reference groups. [ABSTRACT FROM AUTHOR]

Factors associated with IPV among immigrant women are not well understood. Using linked immigration and justice data, we compared the incidence of justice-identified IPV (JIIPV) among 58,564 international immigrant women born outside of Canada, 30,098 women born in other Canadian provinces (i.e., interprovincial migrants), and 88,662 long-term Manitoban resident women. International immigrant women had the lowest incidence of JIIPV compared to matched long-term Manitobans (adjusted hazard ratio (aHR) 0.49, 95% CI: 0.43-0.56) and interprovincial migrants (aHR 0.56, 95% CI: 0.43-0.73). Among immigrants, JIIPV varied substantially according to birthplace, increased with length of residence, and was less frequent among secondary immigrants., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Little is known about differences in child developmental vulnerability before school entry according to maternal birthplace and sex. Official immigration records were linked with the Early Development Instrument assessments among children in kindergarten in the province of Manitoba, Canada (2005-2017). Logistic regression was used to estimate odds ratios of vulnerability in five developmental domains associated with maternal birthplace and child sex. Children of immigrant mothers from most birthplaces had higher adjusted odds of developmental vulnerability than non-immigrants in domains related to language and communication skills, except those of the rest of North America & Oceania. Children of Sub-Saharan African mothers were more vulnerable in four domains. Boys were consistently more vulnerable than girls across domains and maternal birthplaces. Children of immigrant mothers exhibited higher developmental vulnerability than non-immigrants in domains related to language and communication skills, potentially reflecting exposure to English and French as second languages., (© 2024. The Author(s).)

We examined the link between discrimination and self-rated mental health (SRMH) among immigrants and Canadian-born individuals, stratified according to an individual's identification as racialized or white. Using data from Canada's General Social Survey (2014) (weighted N = 27,575,000) with a novel oversample of immigrants, we estimated the association of perceived discrimination with SRMH separately among immigrants and Canadian-born individuals and stratified by racialized status. Among immigrants, we also investigated whether age-at-arrival attenuated or strengthened associations. The prevalence of discrimination was higher among racialized compared to white immigrants (18.9% versus 11.8%), and among racialized compared to white non-immigrants (20.0% versus 10.5%). In the adjusted model with immigrants, where white immigrants not reporting discrimination were the referent group, both white (adjusted prevalence odds ratio [aPOR] 6.11, 95% confidence interval [CI] 3.08, 12.12) and racialized immigrants (aPOR 2.28, 95% CI 1.29, 4.04) who experienced discrimination reported poorer SRMH. The associations were weaker among immigrants who immigrated in adulthood. In the adjusted model with non-immigrants, compared to unexposed white respondents, Canadian-born white respondents who experienced discrimination reported poorer SRMH (aPOR 3.62, 95% CI 2.99, 4.40) while no statistically significant association was detected among racialized respondents (aPOR 2.24, 95% CI 0.90, 5.58). Racialized respondents experienced significant levels of discrimination compared to white respondents irrespective of immigrant status. Discrimination was associated with poor SRMH among all immigrants, with some evidence of a stronger association for white immigrants and immigrants who migrated at a younger age. For Canadian-born individuals, discrimination was associated with poor SRMH among white respondents only., (© 2024. The Author(s).)

Background: Rates of child removal by child protective services (CPS) in Manitoba are the highest in Canada with a profoundly disproportionate impact on First Nations families. Despite infants constituting the highest proportion of children affected, no research has examined population-level rates of infant contact with CPS., Objective: We examined the incidence of infant contact with different levels of CPS, including termination of parental rights (TPR), according to First Nations status., Participants: We identified 217,261 infants (47,416 First Nations; 169,845 non-First Nations) born between 1998 and 2014 in Manitoba, Canada and residing in the province until at least age 5., Methods: We used linked administrative data to calculate population-level rates of contact with different levels of CPS by First Nations status, including an open file before age 1, out-of-home placement before age 1, and TPR before age 5., Results: Overall 35.8 % of First Nations infants had an open file, 8.5 % experienced out-of-home placement, and 5.4 % experienced TPR. Among other infants, 8.5 % had an open file, 1.3 % experienced out-of-home placement and 0.7 % experienced TPR. The rate of early-stage contact increased the fastest among First Nations infants, with a rise of 22.4 % in our study period, compared to a rise of 1.7 % among all other infants., Conclusions: CPS contact was exceptionally high among First Nations infants compared to other infants, with early-stage contact accelerating most dramatically over time. Findings support calls to greatly reduce the disruption of system contact in the lives of First Nations families., Competing Interests: Declaration of competing interest Cheryle Dreaver and Mary Burton received honoraria from research staff for participation in the study's advisory board. All other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier Ltd.)

Purpose: Newborn removal by North America's child protective services (CPS) disproportionately impacts Indigenous and Black families, yet its implications for population health inequities are not well understood. To guide this as a domain for future research, we measured validity of birth hospitalization discharge codes categorizing newborns discharged to CPS., Methods: Using data from 309,260 births in Manitoba, Canada, we compared data on newborns discharged to CPS from hospital discharge codes with the presumed gold standard of custody status from CPS case reports in overall population and separately by First Nations status (categorization used in Canada for Indigenous peoples who are members of a First Nation)., Results: Of 309,260 newborns, 4562 (1.48%) were in CPS custody at hospital discharge according to CPS case reports and 2678 (0.87%) were coded by hospitals as discharged to CPS. Sensitivity of discharge codes was low (47.8%), however codes were highly specific (99.8%) with a positive predictive value (PPV) of 81.4%, and a negative predictive value (NPV) of 99.2%. Sensitivity, PPV and specificity were equal for all newborns but NPV was lower for First Nations newborns., Conclusions: Canadian hospital discharge records underestimate newborn discharge to CPS, with no difference in misclassication based on First Nations status., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Kathleen S. Kenny reports financial support was provided by Canadian Institutes of Health Research. Marcelo L. Urquia reports financial support was provided by Canadian Institutes of Health Research., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Female marriage before age 18 is a global health issue related to gender inequality, but it is understudied in Canada. This study examined marriage trends among mothers aged < 18 versus older mothers and the sociodemographic correlates of marriage among adolescent mothers aged < 18 and older adolescent mothers., Methods: Using the Canadian Vital Statistics - Birth Database, marriage prevalence was estimated by maternal age groups (< 18-year, 18-19-year, 20-24-year, and 25-49-year) between 1989-1990 and 2017-2018 (n = 10,399,250). Multivariable logistic regression was then used to examine the sociodemographic characteristics associated with marriage within adolescent maternal age group (< 18-year, 18-19-year, and 20-24-year) among births registered between 2000 and 2018., Results: From 1989-1990 to 2017-2018, marriage prevalence declined 80.5%, 60.2%, 47.3%, and 16.0% in the < 18-year, 18-19-year, 20-24-year, and 25-49-year groups, respectively. Within the < 18-year, 18-19-year, and 20-24-year adolescent maternal age groups, older maternal age, larger parental age gap, foreign-born parents, rurality, and earlier birth period were associated with higher adjusted odds of marriage. Higher maternal neighbourhood income was associated with marriage among births to mothers aged 18-19 and 20-24 years but not among those to mothers aged < 18 years., Conclusion: Marriage prevalence declined among mothers of all ages, but the shifts away from marriage appear stronger among younger mothers. The sociodemographic correlates of marriage are generally similar among mothers below age 18 and slightly older adolescent mothers., (© 2022. The Author(s).)

Objectives: Studies on mortality differentials between international immigrants and non-immigrants produced mixed results. The mortality of interprovincial migrants has been less studied. Our objectives were to compare mortality risk between international immigrants, interprovincial migrants, and long-term residents of the province of Manitoba, Canada, and identify factors associated with mortality among migrants., Methods: We conducted a retrospective matched-cohort study to examine all-cause and premature mortality of 355,194 international immigrants, interprovincial migrants, and long-term Manitoba residents (118,398 in each group) between January 1985 and March 2019 using linked administrative databases. Poisson regression was used to estimate adjusted incidence rate ratios (aIRR) with 95% confidence intervals (CI)., Results: The all-cause mortality risk of international immigrants (2.3 per 1000 person-years) and interprovincial migrants (4.4 per 1000) was lower than that of long-term Manitobans (5.6 per 1000) (aIRR: 0.43; 95% CI: 0.42, 0.45 and aIRR: 0.81; 95% CI: 0.80, 0.84, respectively). Compared with interprovincial migrants, international immigrants showed lower death risk (aIRR: 0.50; 95% CI: 0.47, 0.52). Similar trends were observed for premature mortality. Among international immigrants, higher mortality risk was observed for refugees, those from North America and Oceania, and those of low educational attainment. Among internal migrants, those from Eastern Canada had lower mortality risk than those migrating from Ontario and Western Canada., Conclusion: Migrants had a mortality advantage over non-migrants, being stronger for international immigrants than for interprovincial migrants. Among the two migrant groups, there was heterogeneity in the mortality risk according to migrants' characteristics., (© 2022. The Author(s).)

Objectives: Household food insecurity is almost four times more prevalent among adolescents than among older adults in Canada, and it adversely affects their health. Our objective was to describe the sociodemographic and geographic patterning of household food insecurity among adolescents., Methods: Our analytic sample comprised all 12-17-year-old respondents to the 2017-2018 Canadian Community Health Survey with complete data on household food insecurity (n = 8416). We used bivariate and multivariable logistic regression models to identify respondent- and household-level sociodemographic characteristics associated with household food insecurity., Results: The prevalence of household food insecurity among adolescents was 20.7%. The adjusted odds of food insecurity were significantly elevated among adolescents who identified as Black or Indigenous (aOR 1.80), those living with a single parent (aOR 1.60), those living with a greater number of children ≤ 5 years (aOR 1.45) or 12-17 years (aOR 1.25), those in rented accommodation (aOR 1.98), those in households with only secondary school education (aOR 1.38), and those in households reliant on social assistance (aOR 2.03). Higher before-tax income was protective (aOR 0.99). In comparison with Ontario, the adjusted odds of food insecurity among adolescents were higher in Nunavut (aOR 6.77), Northwest Territories (aOR 2.11), and Alberta (aOR 1.48), and lower in Manitoba (aOR 0.66)., Conclusion: The markedly higher odds of exposure to household food insecurity among adolescents who are Black or Indigenous and those living in households characterized by markers of social and economic disadvantage highlight the need for more effective policy interventions to protect vulnerable families from this hardship., (© 2023. The Author(s).)

Objectives: There is little research examining transnational prenatal care (TPC) (i.e., prenatal care in more than one country) among migrant women. Using data from the Migrant-Friendly Maternity Care (MFMC) - Montreal project, we aimed to: (1) Estimate the prevalence of TPC, including TPC-arrived during pregnancy and TPC-arrived pre-pregnancy, among recently-arrived migrant women from low- and middle-income countries (LMICs) who gave birth in Montreal, Canada; (2) Describe and compare the socio-demographic, migration and health profiles and perceptions of care during pregnancy in Canada between these two groups and migrant women who received no TPC (i.e., only received prenatal care in Canada); and (3) Identify predictors of TPC-arrived pre-pregnancy vs. No-TPC., Methods: The MFMC study used a cross-sectional design. Data were gathered from recently-arrived (< 8 years) migrant women from LMICs via medical record review and interview-administration of the MFMC questionnaire postpartum during the period of March 2014-January 2015 in three hospitals, and February-June 2015 in one hospital. We conducted a secondary analysis (n = 2595 women); descriptive analyses (objectives 1 & 2) and multivariable logistic regression (objective 3)., Results: Ten percent of women received TPC; 6% arrived during pregnancy and 4% were in Canada pre-pregnancy. The women who received TPC and arrived during pregnancy were disadvantaged compared to women in the other two groups (TPC-arrived pre-pregnancy and No-TPC women), in terms of income level, migration status, French and English language abilities, access barriers to care and healthcare coverage. However, they also had a higher proportion of economic migrants and they were generally healthier compared to No-TPC women. Predictors of TPC-arrived pre-pregnancy included: 'Not living with the father of the baby' (AOR = 4.8, 95%CI 2.4, 9.8), 'having negative perceptions of pregnancy care in Canada (general experiences)' (AOR = 1.2, 95%CI 1.1, 1.3) and younger maternal age (AOR = 1.1, 95%CI 1.0, 1.1)., Conclusion: Women with more capacity may self-select to migrate during pregnancy which results in TPC; these women, however, are disadvantaged upon arrival, and may need additional care. Already-migrated women may use TPC due to a need for family and social support and/or because they prefer the healthcare in their home country., (© 2023. The Author(s).)

This study sought to estimate the prevalence and distribution of newborns to mothers under age 18 in Ecuador and the association between perinatal indicators and maternal marital status. Newborn records obtained from Ecuador's Instituto Nacional de Estadísticas y Censos (INEC) between 2015 and 2020 were used to assess the joint association between maternal age groups (10-15, 16-17, 18-19, and 20-24 years) and marital status (married, common-law, and single) with low birthweight, preterm birth, and inadequate prenatal care. The prevalence of newborns to mothers under age 18 was 9.3% overall, but declined over the study period, drastically among married mothers. The association between marital status and perinatal indicators depended on maternal age. The more favorable outcomes observed among married mothers aged 20-24 years (compared to their single counterparts) weaken or disappear among mothers under age 18. Mothers in stable unions exhibited outcomes in between those of married and single mothers.

Preterm birth (PTB) is the leading cause of infant mortality worldwide. Changes in PTB rates, ranging from -90% to +30%, were reported in many countries following early COVID-19 pandemic response measures ('lockdowns'). It is unclear whether this variation reflects real differences in lockdown impacts, or perhaps differences in stillbirth rates and/or study designs. Here we present interrupted time series and meta-analyses using harmonized data from 52 million births in 26 countries, 18 of which had representative population-based data, with overall PTB rates ranging from 6% to 12% and stillbirth ranging from 2.5 to 10.5 per 1,000 births. We show small reductions in PTB in the first (odds ratio 0.96, 95% confidence interval 0.95-0.98, P value <0.0001), second (0.96, 0.92-0.99, 0.03) and third (0.97, 0.94-1.00, 0.09) months of lockdown, but not in the fourth month of lockdown (0.99, 0.96-1.01, 0.34), although there were some between-country differences after the first month. For high-income countries in this study, we did not observe an association between lockdown and stillbirths in the second (1.00, 0.88-1.14, 0.98), third (0.99, 0.88-1.12, 0.89) and fourth (1.01, 0.87-1.18, 0.86) months of lockdown, although we have imprecise estimates due to stillbirths being a relatively rare event. We did, however, find evidence of increased risk of stillbirth in the first month of lockdown in high-income countries (1.14, 1.02-1.29, 0.02) and, in Brazil, we found evidence for an association between lockdown and stillbirth in the second (1.09, 1.03-1.15, 0.002), third (1.10, 1.03-1.17, 0.003) and fourth (1.12, 1.05-1.19, <0.001) months of lockdown. With an estimated 14.8 million PTB annually worldwide, the modest reductions observed during early pandemic lockdowns translate into large numbers of PTB averted globally and warrant further research into causal pathways., (© 2023. The Author(s).)

Adolescence is a vital period of growth and development, both of which are dependent on adequate nutrition; however, concerns persist about poor nutrition and inappropriate food behaviours. In addition to nutrition assessment, the context of food and health behaviour is necessary to understand how dietary choices are shaped and related to diet quality. This study describes food-related behaviours and health indicators associated with dietary quality among adolescents in Manitoba, Canada. A stratified two-stage sampling method was used to collect data on the diet, food behaviours and health indicators of 1587 grade nine students. Diet quality was analysed using the Healthy Eating Index-Canada. Several food behaviours and health indicators varied by gender and school region (urban, rural, northern). The Independent Samples t-test and one-way ANOVA (analysis of variance) assessed differences between groups on the Healthy Eating Index-Canada. Higher Healthy Eating Index-Canada scores were found for those eating family dinners more frequently; consuming breakfast and lunch more frequently; consuming breakfast at home; eating lunch and morning snacks at school; purchasing fewer meals and snacks from cafeterias and vending machines; believing that food and nutrition education is important; not attempting to lose weight; being classified as 'healthy weight'; and getting more sleep. Many Manitoba youth are exhibiting food and health behaviours that increase their risk of having a poor diet.

Immigrants to Canada increasingly come from regions where child marriage (<18 years) is prevalent. We described the prevalence, demographic characteristics, and reproductive health correlates of marriage among births to Canadian-born and foreign-born adolescent mothers. Using Canadian birth registrations from 1990 to 2018, marriage prevalence, parental birth region, and parental age gap were examined by maternal birthplace (Canada and 12 world regions) among births to mothers <18 years. Adjusted odds ratios (AORs) of preterm birth (PTB), small for gestational age (SGA), and repeat birth were estimated for the joint associations of adolescent maternal age group (<18-year, 18-19-year, and 20-24-year), marriage, and nativity status (n = 1,904,200). Depending on maternal birthplace, marital births represented 2.6% to 81.8% of births to mothers <18 years. Marriage among mothers giving birth at <18 years was associated with higher proportions of parents from the same birthplace and larger parental age gaps. AORs of PTB tended to increase with lower maternal age. AORs of SGA were generally higher among births to foreign-born mothers. Marriage was associated with lower AORs of PTB and SGA among births to Canadian-born mothers and PTB among births to foreign-born mothers in the older adolescent age groups, but no association existed in the <18-year group. Marriage was positively associated with repeat birth in all adolescent age groups, with stronger associations in the <18-year group. The reproductive health correlates of marriage are similar between births to Canadian-born and foreign-born mothers <18 years but some differ between births to mothers <18 years and those to older adolescent mothers., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Good nutrition and access to healthy foods are essential for child growth and development. However, there are concerns that Canadian children do not have a healthy diet, which may be related to dietary choices as well as lack of access to healthy foods. The FANS (Food and Nutrition Security for Children and Youth) study examined the nutrition and food security status of youth in the province of Manitoba, Canada. This paper describes methods, dietary intakes, and body mass index for the FANS study.  METHODS: This cross-sectional study included 1587 Manitoba grade nine students who completed a self-administered web-based survey. Data was collected on demographic characteristics, dietary intake (24-h recall), food behaviors, food security, and self-report health indicators. Dietary data was compared to national dietary guidelines (Dietary Reference Intakes and Canada's Food Guide). Mean and median nutrient and food group intakes were calculated with corresponding measures of variability. Chi-square tests compared percentage of respondents not meeting key nutrients and food groups. Significant differences in percentage of total servings for each food group were determined by a Kruskal-Wallis test, and differences between different caloric groups were assessed using Dunn's test for post-hoc comparisons.  RESULTS: Half of study respondents were female (50.5%). Median energy intake was higher in males (2281 kcal) compared with females (1662 kcal), with macronutrient distribution of 52%, 16%, and 32% for carbohydrates, protein, and fats respectively. Most participants consumed inadequate fibre (94%), vitamin D (90%), and calcium (73%), while median sodium intakes exceeded recommendations for males but not females. A majority of participants did not meet Health Canada's recommendations for food group servings: Vegetables and Fruit (93%), Milk and Alternatives (74%), Meat and Alternatives (57%) and Grain Products (43%). Other Foods, including sugar sweetened beverages and juice, were consumed by most participants. Higher energy consumers had a greater proportion of food servings coming from Other Foods. 72.1% of students were classified as having a healthy weight and 25% were classified as overweight or obese., Conclusion: Poor dietary intakes and body mass index values indicate an urgent need for policy and program strategies to support healthy eating habits and food awareness in Manitoba youth., (© 2022. The Author(s).)

Background: Perinatal risk factors can vary by immigration status. We examined psychosocial and behavioral perinatal health indicators according to immigration status and immigrant characteristics., Methods: We conducted a population-based cross-sectional study of 33,754 immigrant and 172,342 non-immigrant childbearing women residents in Manitoba, Canada, aged 15-55 years, who had a live birth and available data from the universal newborn screen completed within 2 weeks postpartum, between January 2000 and December 2017. Immigration characteristics were from the Canadian federal government immigration database. Logistic regressions models were used to obtain Odds Ratios (OR) with 95% confidence intervals (CI) for the associations between immigration characteristics and perinatal health indicators, such as social isolation, relationship distress, partner violence, depression, alcohol, smoking, substance use, and late initiation of prenatal care., Results: More immigrant women reported being socially isolated (12.3%) than non-immigrants (3.0%) (Adjusted Odds Ratio (aOR): 6.95, 95% CI: 6.57 to 7.36) but exhibited lower odds of depression, relationship distress, partner violence, smoking, alcohol, substance use, and late initiation of prenatal care. In analyses restricted to immigrants, recent immigrants (< 5 years) had higher odds of being socially isolated (aOR: 9.04, 95% CI: 7.48 to 10.94) and late initiation of prenatal care (aOR: 1.50, 95% CI: 1.07 to 2.12) compared to long-term immigrants (10 years or more) but lower odds of relationship distress, depression, alcohol, smoking and substance use. Refugee status was positively associated with relationship distress, depression, and late initiation of prenatal care. Secondary immigrants, whose last country of permanent residence differed from their country of birth, had lower odds of social isolation, relationship distress, and smoking than primary migrants. There were also differences by maternal region of birth., Conclusion: Immigrant childbearing women had a higher prevalence of social isolation but a lower prevalence of other psychosocial and behavioral perinatal health indicators than non-immigrants. Health care providers may consider the observed heterogeneity in risk to tailor care approaches for immigrant subgroups at higher risk, such as refugees, recent immigrants, and those from certain world regions., (© 2022. The Author(s).)

Background: Although marriage is associated with favourable reproductive outcomes among adult women, it is not known whether the marriage advantage applies to girls (< 18 years). The contribution of girl child marriage (< 18 years) to perinatal health is understudied in the Americas., Methods: National singleton birth registrations were used to estimate the prevalence of girl child marriage among mothers in Brazil (2011-2018, N = 23,117,661), Ecuador (2014-2018, N = 1,519,168), the USA (2014-2018, N = 18,618,283) and Canada (2008-2018, N = 3,907,610). The joint associations between marital status and maternal age groups (< 18, 18-19 and 20-24 years) with preterm birth (< 37 weeks), small-for-gestational age (SGA < 10 percentile) and repeat birth were assessed with logistic regression., Results: The proportion of births to < 18-year-old mothers was 9.9% in Ecuador, 8.9% in Brazil, 1.5% in the United States and 0.9% in Canada, and marriage prevalence among < 18-year-old mothers was 3.0%, 4.8%, 3.7% and 1.7%, respectively. In fully-adjusted models, marriage was associated with lower odds of preterm birth and SGA among 20-24-year-old mothers in the four countries. Compared to unmarried 20-24-year-old women, married and unmarried < 18-year-old girls had higher odds of preterm birth in the four countries, and slightly higher odds of SGA in Brazil and Ecuador but not in the USA and Canada. In comparisons within age groups, the odds of repeat birth among < 18-year-old married mothers exceeded that of their unmarried counterparts in Ecuador [AOR: 1.99, 95%CI: 1.82, 2.18], the USA [AOR: 2.96, 95%CI: 2.79, 3.14], and Canada [AOR: 2.17, 95%CI: 1.67, 2.82], although minimally in Brazil [AOR: 1.09, 95%CI: 1.07, 1.11]., Conclusions: The prevalence of births to < 18-year-old mothers varies considerably in the Americas. Girl child marriage was differentially associated with perinatal health indicators across countries, suggesting context-specific mechanisms., (© 2022. The Author(s).)

Brazil is one of the top contributors of girl child marriages in the world and one of the United Nations' members that committed to end child marriage by 2030 as part of the Sustainable Development Goals. Child marriage is an indicator of gender inequality associated with poor health outcomes. However, the perinatal epidemiology of minor mothers (<18 years) according to marital status has been insufficiently studied. We used 23,163,209 birth registrations (2011-2018) to describe the sociodemographic distribution of births to minor mothers. The association between adverse outcomes and marital status and maternal age was restricted to 7,953,739 births of mothers aged ≤15, 16-17, 18-19, 20-24 years. Multinomial logistic models were used for very (24-31 weeks) and moderately preterm birth (32-36 weeks), and severe (<3rd percentile) and moderately small-for-gestational age (SGA) (3rd to <10th percentile). Logistic models were used for binary outcomes. The proportion of births to minor mothers in the study period was 8.9%, composed of those of single (6.1%), common-law (2.4%) and married girls (0.4%). Births to minor mothers decreased over time (p-value <0.001), were more common in the North Region (13.2%) and among Indigenous (17.4%). Very and moderately preterm birth increased with decreasing age but within each age group, rates were highest among single, followed by common-law and lowest among married mothers. A similar pattern was observed for SGA, low Apgar and late prenatal care initiation. Repeat birth and low age-appropriate education were less common among married compared to single mothers in all age groups, except among ≤15-year-olds [Adjusted Odds Ratio (AOR): 2.56; 95% Confidence Interval (95%CI): 2.40, 2.74 and AOR: 1.30; 95%CI: 1.03, 1.64, respectively]. The association between perinatal indicators and marital status among adolescents is strongly modified by decreasing maternal age. Marital status is relevant for the understanding of early pregnancies., Competing Interests: The authors have no conflicts of interest to disclose., (© 2022 The Authors.)

Background: Studies in low- and middle-income regions suggest that child marriage (<18 years) is a risk factor for poor reproductive outcomes among women. However, in high-income-country contexts where childbearing before age 18 occurs predominantly outside marriage, it is unknown whether marriage is adversely associated with reproductive health among mothers below age 18. This study examined the joint associations of marriage and adolescent maternal age group (<18, 18-19, and 20-24 years) with reproductive, maternal, and infant health indicators in the United States., Methods and Findings: Birth registrations with US resident mothers aged ≤24 years with complete information on marital status were drawn from the 2014 to 2019 Natality Public Use Files (n = 5,669,824). Odds ratios for the interaction between marital status and maternal age group were estimated using multivariable logistic regression, adjusting for covariates such as maternal race/ethnicity and nativity status, federal program participation, and paternal age. Marriage prevalence was 3.6%, 13.2%, and 34.1% among births to mothers aged <18, 18-19, and 20-24 years, respectively. Age gradients in the adjusted odds ratios (AORs) were present for most indicators, and many gradients differed by marital status. Among births to mothers aged <18 years, marriage was associated with greater adjusted odds of prior pregnancy termination (AOR 1.64, 95% CI 1.52-1.77, p < 0.001), repeat birth (AOR 2.84, 95% CI 2.68-3.00, p < 0.001), maternal smoking (AOR 1.24, 95% CI 1.15-1.35, p < 0.001), and infant morbidity (AOR 1.07, 95% CI 1.01-1.14, p = 0.03), but weaker or reverse associations existed among births to older mothers. For all maternal age groups, marriage was associated with lower adjusted odds of late or no prenatal care initiation, sexually transmitted infection, and no breastfeeding at hospital discharge, but these beneficial associations were weaker among births to mothers aged <18 and 18-19 years. Limitations of the study include its cross-sectional nature and lack of information on marriage timing relative to prior pregnancy events., Conclusions: Marriage among mothers below age 18 is associated with both adverse and favorable reproductive, maternal, and infant health indicators. Heterogeneity exists in the relationship between marriage and reproductive health across adolescent maternal age groups, suggesting girl child marriages must be examined separately from marriages at older ages., Competing Interests: The authors have declared that no competing interests exist.

Background: As the leading cause of emergency department visits in Canada, pain disproportionately affects socioeconomically disadvantaged populations. We examine the association between household food insecurity and individuals' pain-driven emergency department visits., Methods: We designed a cross-sectional study linking the Canadian Community Health Survey 2005-2017 to the National Ambulatory Care Reporting System 2003-2017. Food insecurity was measured using a validated questionnaire. We excluded individuals with missing food insecurity status, individuals younger than 12 years and jurisdiction-years with partial emergency department records. We assessed emergency department visits driven by pain at different sites (migraine, other headaches, chest-throat pain, abdomen-pelvis pain, dorsalgia, joint pain, limb pain, other pain) and their characteristics (frequency, cause, acuity and time of emergency department visit) in Ontario and Alberta. We adjusted for sociodemographic characteristics, lifestyle and prior non-pain-driven emergency department visits in the models., Results: The sample contained 212 300 individuals aged 12 years and older. Compared with food-secure individuals, marginally, moderately and severely food-insecure people had 1.42 (95% confidence interval [CI] 1.20-1.68), 1.64 (95% CI 1.37-1.96) and 1.99 (95% CI 1.61-2.46) times higher adjusted incidence rates of pain-driven emergency department visits, respectively. The association was similar across sexes and significant among adults but not adolescents. Food insecurity was further associated with site-specific pain, with severely food-insecure individuals having significantly higher pain incidence than food-secure individuals. Severe food insecurity predicted more frequent, multicause, high-acuity and after-hours emergency department visits., Interpretation: Household food insecurity status is significantly associated with pain-driven emergency department visits in the Canadian population. Policies targeting food insecurity may reduce pain and emergency department utilization., Competing Interests: Competing interests: None declared., (© 2022 CMA Impact Inc. or its licensors.)

This study examined the elevated risk of intimate partner violence (IPV) among persons with mental health-related disabilities (MH-RD) and the extent to which known risk factors accounted for this phenomenon. Data were drawn from a nationally representative sample of 33,127 Canadians collected in 2014 as part of Statistics Canada's General Social Survey. Results showed that respondents with MH-RD had more than three-fold increased odds of both overall and severe IPV victimization. Although females were more likely to possess a MH-RD, males and females with MH-RD reported similarly elevated odds of IPV victimization. Risk factors that contributed to a significant reduction in elevated odds of IPV for respondents with MH-RD were child maltreatment (CM), respondents' nonprescription drug abuse, and perpetrators' jealous, monitoring, and socially isolating behaviors. The inability to test additional risk factors and bidirectionality in the relationship between MH-RD and IPV may have contributed to the failure to fully account for these respondents' elevated odds of IPV. Future research is needed to understand the complex mechanisms contributing to the elevated risk of IPV and enhance prevention and intervention strategies for this underresearched and underserved vulnerable population.

Background: The Truth and Reconciliation Commission of Canada has called for better reporting of health disparities between First Nations people and other Canadians to close gaps in health outcomes. We sought to evaluate changes in these disparities using indicators of health and health care use over the last 2 decades., Methods: We used linked, whole-population, administrative claims data from the Manitoba Centre for Health Policy for fiscal years 1994/95 to 1998/99 and 2012/13 to 2016/17. We measured indicators of health and health care use among registered First Nations and all other Manitobans, and compared differences between these groups over the 2 time periods., Results: Over time, the relative gap between First Nations and all other Manitobans widened by 51% (95% confidence interval [CI] 42% to 60%) for premature mortality rate. For potential years of life lost, the gap widened by 54% (95% CI 51% to 57%) among women and by 32% (95% CI 30% to 35%) among men. The absolute gap in life expectancy widened by 3.14 years (95% CI 2.92 to 3.36) among men and 3.61 years (95% CI 3.38 to 3.84) among women. Relative gaps widened by 20% (95% CI 12% to 27%) for ambulatory specialist visits, by 14% (95% CI 12% to 16%) for hospital separations and by 50% (95% CI 39% to 62%) for days spent in hospital, but narrowed by 33% (95% CI -36% to -30%) for ambulatory primary care visits, by 22% (95% CI -27% to -16%) for mammography and by 27% (95% CI -40% to -23%) for injury hospitalizations., Interpretation: Disparities between First Nations and all other Manitobans in many key indicators of health and health care use have grown larger over time. New approaches are needed to address these disparities and promote better health with and for First Nations., Competing Interests: Competing interests: Alan Katz serves on the advisory board of the Manitoba Centre for Health Policy in an ex officio capacity. No other competing interests were declared., (© 2021 CMA Joule Inc. or its licensors.)

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., (© 2021. The Author(s).)

The incidence of intimate partner violence (IPV) varies according to IPV definitions and data collection approaches. The criminal Justice system assesses IPV through a review of the evidence gathered by the police and the court hearings. We aimed to determine the association between IPV, as identified in criminal Justice disposition records, and subsequent healthcare-identified intentional injury inflicted by others, including violent death. We conducted a retrospective population-based matched-cohort study using linked multisectoral databases. Female adult Manitoba residents identified as victims of IPV in provincial prosecution and disposition records 2004 to 2016 (n = 20,469) were matched to three non-victims (n = 61,407) of similar age, relationship status and place of residence at the date of the IPV incident. Outcomes were first healthcare use for intentional injury and violent death, assessed in Emergency Department visits, hospitalizations and Vital Statistics deaths records. Conditional Cox Regression was used to obtain Hazard Ratios (HR) with 95% confidence intervals (CI). The risk of intentional injury was 8.5 per 1000 women among non-victims of IPV and 55.8 per 1000 women among IPV victims. The Hazard Ratios associated with IPV were 3.8 (95% CI: 3.4, 4.3) for intentional injury and 4.6 (95% CI: 2.3, 9.2) for violent death, after adjustment. IPV victims experienced half the risk of subsequent intentional injury if the accused received a probation sentence. Our findings suggest that Justice involvement represents an opportunity for intersectoral collaborative prevention of subsequent intentional injury among IPV victims., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To examine recent vaccination trends among Brazilian children during their first year of life, and the impact of the coronavirus disease 2019 (COVID-19) pandemic on these trends., Methods: Monthly vaccination and birth data from the DATASUS (Department of Informatics of the Unified Health System) database of the Ministry of Health of Brazil were obtained from January 2017 to December 2020. Interrupted time series analysis was used to compare vaccination trends before and after March 2020, when isolation measures were first implemented in Brazil., Results: There was no strong evidence of a significant change in trends during the study period, or before and during the pandemic at national level. However, the mean number of vaccinations per child was 10.6, which is lower than the 13 doses expected under the immunization schedule., Conclusions: Although the pandemic did not appreciably impact on vaccinations, incomplete immunization among children aged <1 year in Brazil is cause for concern. A potential impact of the COVID-19 pandemic on specific antigens or regional and sociodemographic disparities in vaccinations cannot be ruled out without further research., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Canadian 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., Objectives: a) 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., Methods: We 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., Results: The 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)., Conclusions: Despite 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., Competing Interests: Statement on conflicts of interest: The authors have no conflicts to declare.

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., Competing Interests: The authors declared no competing interests., (© 2021 The Author(s).)

This study aims to examine whether disparities in gestational age outcomes between foreign and Swedish-born mothers are contingent on the measure used to estimate gestational age and, if so, to identify which maternal factors are associated with the discrepancy. Using population register data, we studied all singleton live births in Sweden from 1992-2012 (n = 1,317,265). Multinomial logistic regression was performed to compare gestational age outcomes classified into very (<32 weeks) and late preterm (32-36 weeks), term and post-term derived from the last menstrual period (LMP) and ultrasound estimates in foreign- and Swedish-born women. Compared to Swedish-born women, foreign-born women had similar odds of very preterm birth (OR: 0.98 [95% CI: 0.98, 1.01]) and lower odds of moderately preterm birth (OR: 0.95 [95% CI: 0.92, 0.98]) based on ultrasound, while higher risks based on LMP (respectively, OR: 1.10 [95% CI: 1.07, 1.14] and 1.09 [95% CI: 1.06, 1.13]). Conclusions on disparities in gestational age-related outcomes by mother's country of origin depend on the method used to estimate gestational age. Except for very preterm, foreign-born women had a health advantage when gestational age is based on ultrasound, but a health disadvantage when based on LMP. Studies assessing disparities in very preterm birth by migration status are not affected by the estimation method but caution should be taken when interpreting disparities in moderately preterm and preterm birth rates., Competing Interests: The authors have declared that no competing interests exist.

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., Competing Interests: Competing interests: Helga Zoega is an employee of the Centre for Big Data Research in Health, UNSW Sydney which has received funding from AbbVie Australia to conduct research unrelated to the submitted work. Andrew Morris reports grants from the Bill & Melinda Gates Foundation during the conduct of this work. Kristin Palmer reports grants from GlaxoSmithKline, grants from Cerebral Palsy Alliance, grants from Equity Trustees, outside the submitted work. Clare Whitehead reports research funding from Bill & Melinda Gates Foundation Ferring International, unrelated to the submitted work. Aziz Sheikh reports grants from Health Data Research UK. He is a member of the ICODA Executive Leadership Team and Director of the Health Data Research UK BREATHE Hub., (Copyright: © 2021 Stock SJ et al.)

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., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Background: While 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., Methods: We 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., Results: CM 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., Conclusions: Immigrants 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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Household food insecurity has been associated with pregnancy complications and poorer birth outcomes in the United States and with maternal mental disorders in the United Kingdom, but there has been little investigation of the effects of food insecurity during this life stage in Canada., Objectives: Our objective was to examine the relationship between the food insecurity status of women during pregnancy and maternal and birth outcomes and health in infancy in Canada., Methods: We drew on data from 1998 women in Ontario, Canada, whose food insecurity was assessed using the Household Food Security Survey Module on the Canadian Community Health Survey, cycles 2005 to 2011-2012. These records were linked to multiple health administrative databases to identify indications of adverse health outcomes during pregnancy, at birth, and during children's first year of life. We included women who gave birth between 9 months prior and 6 months after their interview date, and for whom infant outcome data were available. Multivariable Poisson regression models were used to compare outcomes by maternal food security status, expressed as adjusted relative risks (aRR) with 95% CIs., Results: While pregnant, 5.6% of women were marginally food insecure and 10.0% were moderately or severely food insecure. Food insecurity was unrelated to pregnancy complications and adverse birth outcomes, but 26.8% of women with moderate or severe food insecurity had treatment for postpartum mental disorders in the 6-month postpartum period, compared to 13.9% of food-secure women (aRR, 1.86; 95% CI, 1.40-2.46). Children born to food-insecure mothers were at elevated risk of being treated in an emergency department in the first year of life (aRR, 1.18; 95% CI, 1.01-1.38)., Conclusions: Maternal food insecurity during pregnancy in Ontario, Canada, is associated with postpartum mental disorders and a greater likelihood of infants being treated in an emergency department., (Copyright © The Author(s) on behalf of the American Society for Nutrition 2020.)

Objectives: There 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., Methods: We 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., Results: Among 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., Conclusions: Immigration 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.

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.

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 and health care expenditure data, we examined the association of food insecurity with acute care hospitalization, same-day surgery, and acute care costs among Canadian adults, adjusting for sociodemographic characteristics. Compared with fully food-secure adults, marginally, moderately, and severely food-insecure adults presented 26 percent, 41 percent, and 69 percent higher odds of acute care admission and 15 percent, 15 percent, and 24 percent higher odds of having same-day surgery, respectively. Conditional on acute care admission, food-insecure adults stayed from 1.48 to 2.08 more days in the hospital and incurred $400-$565 more per person-year in acute care costs than their food-secure counterparts, with this excess cost representing 4.4 percent of total acute care costs. Programs reducing food insecurity, such as child benefits and public pensions, and policies enhancing access to outpatient care may lower health care use and costs.

Objectives: To explore gender disparities in infant routine preventive care across maternal countries of birth (MCOB) and by mother tongue among infants of Indian-born mothers., Setting: Retrospective population-based administrative cohort in Ontario, Canada (births between 2002 and 2014)., Participants: 350 366 (inclusive) healthy term singletons belonging to families with a minimum of one opposite gender child., Outcome Measures: Fixed 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., Results: Underimmunisation 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)., Conclusions: Gender 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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: International migration is the main source of population growth in Canada. Research on the birth outcomes of immigrants has largely been based on Canadian provincial data, raising concerns about whether the findings can be generalized between provinces or between the provinces and Canada. Provincial time trends and variations in birth outcomes are described according to the 20 top maternal birthplaces., Data and Methods: Statistics Canada's Vital Statistics-Birth Database (2000 to 2016) was used to extract 5,831,580 records on live births for analyses. Rates of preterm birth (PTB, referring to births at 22 to 36 gestation weeks) and mean birth weight (at 39 to 40 gestation weeks) were compared across provinces between immigrant mothers, according to the top 20 maternal birthplaces, and Canadian-born mothers., Results: The proportion of births to immigrant mothers rose overall from 23.7% in 2000 to 30.7% in 2016, but rose unevenly across the provinces. Increases were modest in British Columbia and Ontario; twofold in Alberta, Manitoba and Quebec; and fourfold in Saskatchewan. Compared with PTB rates among Canadian-born mothers, PTB rates were lower among various Asian, African and Western immigrant groups and higher among those from Bangladesh, the Philippines and the Caribbean. Lower birth weights were seen for most source countries, except the United States. These differences were uniform across the provinces, with a few exceptions., Discussion: There were large provincial variations in the proportion of births to immigrant mothers. However, disparities in birth outcomes did not substantially vary across provinces for most immigrant maternal birthplaces, suggesting some degree of generalizability for provincial birth data.