Pregnancy outcomes of US-born and foreign-born Japanese Americans

The application of intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to examine birthweight inequities in New York City

Exploring the intersection of dimensions of social identity is critical for understanding drivers of health inequities. We used multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to examine the intersection of age, race/ethnicity, education, and nativity status on infant birthweight among singleton births in New York City from 2012 to 2018 (N = 725,875). We found evidence of intersectional effects of various systems of oppression on birthweight inequities and identified U.S.-born Black women as having infants of lower-than-expected birthweights. The MAIHDA approach should be used to identify intersectional causes of health inequities and individuals affected most to develop policies and interventions redressing inequities.

Birth Tourism Is Associated with Fewer Neonatal Intensive Care Unit Admissions: A Healthy Migrant Effect?

OBJECTIVE

This work aimed to study perinatal, maternal, and neonatal characteristics of birth tourism (BT) mother-baby dyads and the rate of neonatal intensive care unit (NICU) admissions of BT infants.

STUDY DESIGN

Retrospective study at a regional perinatal center comparing BT mother-baby dyads to all dyads. BT infants admitted to the NICU were compared with a randomly selected group of infants admitted to the NICU during the same time period.

RESULTS

A total of 1,755 BT dyads were identified over 4 years. BT mothers were older (32 vs. 28 years, p < 0.0001), more likely to carry multiples (5.5 vs. 1.4%, p < 0.0001), deliver via cesarean section (40 vs. 34%, p < 0.0001), and require postpartum intensive care (0.6 vs. 0.1%, p < 0.0001). BT infants had significantly fewer NICU admissions 96 (5.5%) versus 3,213 (11.3%; p < 0.0001). There were no statistically significant differences in NICU course and outcome between BT and non-BT control infants.

CONCLUSION

Birth tourism is associated with unique determinants of health. In our study, there were fewer NICU admissions, potentially explained by the healthy migrant effect.

KEY POINTS

· Birthright citizenship attracts foreigners to give birth in the United States.. · BT is associated with unique social determinants of health.. · Fewer NICU admissions in our study are possibly explained by the healthy migrant effect..

Birth outcomes across the spectrum of maternal age: dissecting aging effect versus confounding by social and medical determinants

BACKGROUND

Given the trend of increasing maternal age and associated adverse reproductive outcomes in the US, this study aimed to assess whether this association is due to an independent aging or confounded by sociodemographic, biomedical, or behavioral determinants in a predominantly Black US population.

METHODS

Data was from 8509 women enrolled in the Boston Birth Cohort. Adverse reproductive outcomes included spontaneous preterm delivery, cesarean delivery, and low birth weight. Covariates included sociodemographic (parity, race/ethnicity, education, marital status, income, receipt of public assistance, nativity); biomedical (obesity, hypertensive disorders, diabetes mellitus); and behavioral (consistent intake of multivitamin supplements, support from father of baby, support from family, major stress in pregnancy, cigarette smoking, alcohol intake). Analysis included Lowess and marginal probability plots, crude and adjusted sequential logistic regression models to examine age-outcome associations and to what degree the association can be explained by the above covariables.

RESULT

Overall, the study sample had high levels of spontaneous preterm birth (18%), cesarean delivery (33%) and low birth weight (26%). Unadjusted models showed no significant difference odds of spontaneous preterm birth by maternal age but higher odds of cesarean section (aOR: 1.77, 95% CI: 1.60, 1.95) and low birth weight (aOR: 1.15, 95% CI: 1.04, 1.28) among women 30 years or older. Adjustment for sociodemographic factors, biomedical conditions and behavioral factors revealed higher odds of spontaneous preterm birth: (aOR: 1.30, 95% CI: 1.14, 1.49), cesarean section deliveries (aOR: 1.68, 95% CI: 1.51, 1.87) and low birth weight (aOR: 1.36, 95% CI: 1.21, 1.53). Across all ages, optimal BMI status and consistent multivitamin supplement intake were protective of spontaneous preterm birth and low birth weight.

CONCLUSION

In this high-risk minority population, we demonstrated that the association between increasing maternal age and adverse pregnancy outcomes was due to an independent aging effect and the presence of confounding by sociodemographic, biomedical, and behavioral factors. Some modifiable risk factors to counteract aging effect, include optimizing BMI and consistent intake of multivitamin supplement. A fundamental change in how care is provided to women, particularly low income Black women, is needed with emphasis on the protective role of optimal nutritional status.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03228875.

Incidence and risk of stillbirth among various Asian-American subgroups

BACKGROUND

Striking racial/ethnic disparities exist in pregnancy outcomes among various racial/ethnic.

OBJECTIVE

To determine the incidence and risk factors associated with stillbirth in Asian-American women.

STUDY DESIGN

We conducted this retrospective cohort study using the United States Birth and Fetal Death data files 2014-2017. We used the fetuses-at-risk approach to generate stillbirth trends by gestational age among Non-Hispanic (NH)-White and Asian-American births during the study period. We calculated the adjusted risk of stillbirth for Asian-Americans, overall, and for each Asian-American subgroup: Asian Indians, Koreans, Chinese, Vietnamese, Japanese and Filipinos, with NH-Whites as the referent category.

RESULTS

Of the 715,297 births that occurred among Asian-Americans during the study period, stillbirth incidence rate was 3.86 per 1000 births. From the gestational age of 20 weeks through 41 weeks, the stillbirth rates were consistently lower among Asian-Americans compared to NH-Whites. Stillbirth incidence ranged from a low rate of 2.6 per 1000 births in Koreans to as high as 5.3 per 1000 births in Filipinos. After adjusting for potentially confounding characteristics, Asian-Americans were about half as likely to experience stillbirth compared to NH-White mothers [adjusted hazards ratio (AHR) = 0.57, 95% confidence interval (CI) = 0.51-0.64]. This intrauterine survival advantage was evident in all Asian-American subgroups.

CONCLUSION

The risk of stillbirth is twofold lower in Asian-Americans than in NH-Whites. It will be an important research agenda to determine reasons for the improved intrauterine survival among Asian-Americans in order to uncover clues for reducing the burden of stillbirth among other racial/ethnic minority women in the United States.

Risk of Stillbirth Among Foreign-Born Mothers in the United States

The objective of this study is to assess the impact of maternal nativity on stillbirth in the US. We utilized the US Birth Data and Fetal Death Data for the years 2014-2017. Our analysis was restricted to live and stillbirths (N= of 14,867,880) that occurred within the gestational age of 20-42 weeks. The fetuses-at risk approach was used to generate stillbirth trends by gestational age. Adjusted Cox proportional hazards regression model was utilized to estimate the association between maternal nativity and stillbirth. Overall, the gestational week-specific prospective risk of stillbirth was consistently higher for native-born than their foreign-born mothers. Foreign-born mothers were 20% less likely to experience stillbirth than their native-born counterparts (AHR = 0.80; 95% CI = 0.78-0.81). Delineating the factors influencing the observed effect of maternal nativity on birth outcomes should be a research priority to inform strategies to address adverse birth outcomes in the US.

Comparison of adverse perinatal outcomes between Asians and Caucasians: a population-based retrospective cohort study in Ontario

BACKGROUND

Racial disparities in adverse perinatal outcomes have been studied in other countries, but little has been done for the Canadian population. In this study, we sought to examine the disparities in adverse perinatal outcomes between Asians and Caucasians in Ontario, Canada.

METHODS

We conducted a population-based retrospective cohort study that included all Asian and Caucasian women who attended a prenatal screening and resulted in a singleton birth in an Ontario hospital (April 1st, 2015-March 31st, 2017). Generalized estimating equation models were used to estimate the independent adjusted relative risks and adjusted risk difference of adverse perinatal outcomes for Asians compared with Caucasians.

RESULTS

Among 237,293 eligible women, 31% were Asian and 69% were Caucasian. Asians were at an increased risk of gestational diabetes mellitus, placental previa, early preterm birth (< 32 weeks), preterm birth, emergency cesarean section, 3rd and 4th degree perineal tears, low birth weight (< 2500 g, < 1500 g), small-for-gestational-age (<10th percentile, <3rd percentile), neonatal intensive care unit admission, and hyperbilirubinemia requiring treatment, but had lower risks of preeclampsia, macrosomia (birth weight > 4000 g), large-for-gestational-age neonates, 5-min Apgar score < 7, and arterial cord pH ≤7.1, as compared with Caucasians. No difference in risk of elective cesarean section was observed between Asians and Caucasians.

CONCLUSION

There are significant differences in several adverse perinatal outcomes between Asians and Caucasians. These differences should be taken into consideration for clinical practices due to the large Asian population in Canada.

Preterm birth outcomes among Asian women by maternal place of birth

OBJECTIVE

To investigate overall, spontaneous, and medically indicated preterm birth (PTB) rates between US-born and non-US-born Asian women living in California.

STUDY DESIGN

Nulliparous women with a singleton livebirth and Asian race in California between 2007 and 2011 were investigated. The prevalence of overall (<37 weeks), spontaneous, and medically indicated PTB was examined by self-reported race and place of birth among ten Asian subgroups.

RESULTS

There were marked differences in PTB rates between the individual Asian subgroups. After adjustments, non-US-born Chinese, Japanese, Vietnamese, and Indian women had lower odds of overall PTB and Chinese, Vietnamese, Cambodian, and Indian women had lower odds of spontaneous PTB compared with their US-born counterparts.

CONCLUSION

Further investigation of biological and social factors contributing to these lower odds of spontaneous PTB among the non-US-born Asian population could potentially offer clues for reducing the burden of PTB among the US born.

Reproductive health care utilization among refugees in Jordan: Provisional support and domestic violence

Objectives:

Conflict and displacement are associated with poverty, disruption of services, loss of identity, reduced care for reproductive needs, and reduced provision of health care, among other things. This article uses the framework outlined by Obermeyer and Potter to test how refugee and native status influence utilization of reproductive health services and experience with domestic violence in a context of high refugee inhabitants and strong refugee-focused non-governmental organization presence. This article addresses the following: (1) coverage, source, and method of contraceptives; (2) variation in reproductive health experience by source of contraception; and finally, (3) factors determining variation in the utilization of reproductive health services and domestic violence experiences for individuals living in and out of refugee camps.

Methods:

The data is the 2012 Jordan Demographic and Health Survey, and the method utilized is logistic regression.

Results:

Findings suggest that refugee women serviced by the United Nations Relief and Works Agency have greater access to health-related resources (family planning and contraception), but they have weaker positions in the family as evidenced by domestic violence experiences.

Conclusion:

It is plausible that provisional resources are the easiest for an aid organization to provide, while the complications of identity loss and the loss of a sense of space pose a challenge for refugees and aid organizations.

Pregnancy and Birth Outcomes Among Immigrant Women in the US and Europe: A Systematic Review

Human migration is not a new phenomenon, but it has changed significantly with the advance of globalization. We focus on differences in the published literature concerning migration and health (EU vs the US), centering specifically on reproductive health outcomes. We conducted a literature search in the Pubmed and Embase databases. We reviewed papers that contrast migrants to native-born populations and analyzed differences between countries as well as challenges for future research. The prevalence of low birthweight among migrants varies by the host country characteristics as well as the composition of migrants to different regions. The primary driver of migrant health is the migrant "regime" in different countries at specific periods of time. Future health outcomes of immigrants will depend on the societal characteristics (legal protections, institutions and health systems) of host countries.

Migrant women's utilization of prenatal care: a systematic review

Our objectives were to determine whether migrant women in Western industrialized countries have higher odds of inadequate prenatal care (PNC) compared to receiving-country women and to summarize factors that are associated with inadequate PNC among migrant women in these countries. We conducted searches of electronic databases (MEDLINE, EMBASE, and PsycINFO), reference lists, known experts, and an existing database of the Reproductive Outcomes And Migration international research collaboration for articles published between January, 1995 and April, 2010. Title and abstract review and quality appraisal were conducted independently by 2 reviewers using established criteria, with consensus achieved through discussion. In this systematic review of 29 studies, the majority of studies demonstrated that migrant women were more likely to receive inadequate PNC than receiving-country women, with most reporting moderate to large effect sizes. Rates of inadequate PNC among migrant women varied widely by country of birth. Only three studies explored predictors of inadequate PNC among migrant women. These studies found that inadequate PNC among migrant women was associated with being less than 20 years of age, multiparous, single, having poor or fair language proficiency, education less than 5 years, an unplanned pregnancy, and not having health insurance. We concluded that migrant women as a whole were more likely to have inadequate PNC and the magnitude of this risk differed by country of origin. Few studies addressed predictors of PNC utilization in migrant women and this limits our ability to provide effective PNC in this population.

Obstetric outcomes in adolescent pregnancies: a racial/ethnic comparison

OBJECTIVE

To examine obstetric outcomes for adolescents among the major US racial/ethnic groups.

METHODS

This is a retrospective cohort study of singleton births to nulliparous women aged 12 to 19 years from 1988 to 2008. The prevalence of preterm delivery, cesarean delivery, preeclampsia, gestational diabetes, low birth weight and low Apgar score were compared across African-American, Asian, Latina and White adolescents.

RESULTS

1865 adolescents were included in the analysis. Differences between racial/ethnic groups for rates of preterm delivery, cesarean delivery and gestational diabetes were statistically significant at p < 0.05. African Americans had lower odds of preterm delivery (OR = 0.58, 95% CI [0.38-0.90]) and gestational diabetes (OR = 0.17, 95% CI [0.05-0.55]) than White adolescents. White adolescents had increased odds of cesarean delivery compared to African-American (OR = 0.69, 95% CI [0.48-0.98]), Latina (OR = 0.62, 95% CI [0.41-0.94]) and Asian adolescents (OR = 0.41, 95% CI [0.25-0.68]). Although not statistically significant, White adolescents also had higher odds of low Apgar score. In the multivariate analysis, non-White adolescents continued to have improved outcomes, except in the case of low birth weight.

CONCLUSIONS

African-American, Asian and Latina adolescents may have similar or decreased risk of obstetric complications compared to White adolescents.

Interethnic mating and risk for preterm birth among Arab-American mothers: evidence from the Arab-American Birth Outcomes Study

Arab ethnicity (AE) mothers have lower preterm birth (PTB) risk than white mothers. Little is known about the determinants of PTB among AE women or the role of interethnic mating in shaping PTB risk among this group. We assessed the relationship between interethnic mating and risk for PTB, very PTB, and late PTB among AE mothers. Data was collected for all births (N = 21,621) to AE women in Michigan between 2000 and 2005. Self-reported ancestry was used to determine paternal AE as well as to identify AE mothers. We used bivariate chi-square tests and multivariable logistic regression to assess the relationship between paternal non-AE and risk for PTB, very PTB, and late PTB among AE mothers. All analyses were also conducted among non-Arab white mothers as a control. Among AE mothers, paternal non-Arab ethnicity was associated with higher risk of PTB (OR = 1.18, 95% CI = 1.06, 1.30) and late PTB (OR = 1.24, 95% CI = 1.20, 1.38) compared to paternal Arab ethnicity. Paternal non-Arab ethnicity was not associated with risk for any outcome among non-Arab white mothers. Future studies could assess the causal mechanisms underlying the association between interethnic mating and risk for PTB.

Intrapartum caesarean rates differ significantly between ethnic groups--relationship to induction

OBJECTIVE

Given international variation in obstetric practices and outcomes, comparison of labour outcomes in different ethnic groups could provide important information regarding the underlying reasons for rising caesarean delivery rates. Increasing numbers of women from Eastern European countries are now delivering in Irish maternity hospitals. We compared labour outcomes between Irish and Eastern European (EE) women in a large tertiary referral center.

STUDY DESIGN

This was a prospective consecutive cohort study encompassing a single calendar year. The cohort comprised 5550 Irish and 867 EE women delivered in a single institution in 2009. Women who had multiple pregnancies, breech presentation, and elective or pre-labour caesarean sections (CS) were excluded. Data obtained from birth registers included maternal age, nationality, parity, gestation, onset of labour, mode of delivery and birth weight.

RESULTS

The overall intrapartum CS rate was 11.4% and was significantly higher in Irish compared to EE women (11.8% vs. 8.8%; p=0.008). The proportion of primiparas was lower in Irish compared to EE women (44.8% vs. 63.6%; p<0.0001). The intrapartum CS rate was almost doubled in Irish compared to EE primiparas (20.7% vs. 11.0%; p<0.0001). Analysis of primiparas according to labour onset revealed a higher intrapartum CS rate in Irish primiparas in both spontaneous (13.5% vs. 7.2%; p<0.0001) and induced labour (29.5% vs. 19.3%; p=0.005). Irish women were older with 19.7% of primiparas aged more than 35, compared to 1.6% of EE women (p<0.0001). The primigravid CS rate in Irish women was significantly higher in women aged 35 years or older compared women aged less than 35 (30.6% vs. 18.3%; p<0.0001) consistent in both spontaneous and induced labour. The primiparous induction rate was 45.4% in Irish women compared to 32% in EE women, and more Irish women were induced before 41 weeks gestation.

CONCLUSION

The results highlight that primigravid intrapartum CS rates were significantly lower in EE compared to Irish women. This could potentially be explained by the younger age and lower induction rates in EE primiparas. Further studies are required to determine the factors for this significant difference in labour outcomes for these two Caucasian groups.

Perinatal outcomes in native Chinese and Chinese-American women

This study aimed to compare perinatal outcomes in native Chinese, foreign-born and US-born Chinese-American women by analysing a cohort of 950,624 singleton pregnancies in south-east China and 293,849 singleton births from the US live and stillbirth certificates from 1995 to 2004. Only births at 28 weeks or later were included. Compared with US-born Chinese-American women, native Chinese and foreign-born Chinese-American women had substantially lower risks of having a small-for-gestational age (SGA) infant (adjusted relative risk [aRR] ranging from 0.46 to 0.66) or preterm birth (aRR ranging from 0.53 to 0.82). While having a White or Black father had a reduced risk of SGA (aRR=0.45 and 0.62, respectively), it has an increased risk for preterm birth (aRR=1.13 and 1.57, respectively). Infants with Chinese father and foreign-born mother were heavier than those with Chinese father and US-born mothers. All findings were statistically significant. Our findings demonstrated the protective role of foreign-born status on low birthweight and preterm delivery. The paternal contribution to fetal size is substantial.

Ethnic variation between white European women in labour outcomes in a setting in which the management of labour is standardised-a healthy migrant effect?

OBJECTIVE

To test the hypothesis that women from Eastern European countries have lower caesarean delivery rates and higher spontaneous labour rates relative to Irish women in a setting in which the management of labour is standardised.

DESIGN

A retrospective review of prospectively collected data.

SETTING

Tertiary referral centre, Dublin, Ireland.

POPULATION

All Irish and Eastern European term nulliparous women who laboured and delivered in 2008.

METHODS

A comparison of labour outcomes between women from Ireland and women from Eastern European countries.

MAIN OUTCOME MEASURES

The principal outcomes measured were the gestational age at onset of labour, whether labour was spontaneous or induced, the need for oxytocin augmentation, duration of labour, mode of delivery, epidural use and birthweight.

RESULTS

Of 2556 Irish (n = 2041) and Eastern European (n = 511) term cephalic singleton labours in the calendar year 2008, women from Eastern Europe were significantly more likely to labour spontaneously (74.6% versus 65.9%, P < 0.001), required less epidural analgesia (68.4% versus 59.7%) and were significantly less likely to require delivery by caesarean section (8.6% versus 15.7%, P < 0.001) than Irish women. This is despite no significant difference between the two groups with regard to mean birthweight (3581 g versus 3569 g, P = 0.6) or macrosomia (birthweight over 4000 g) (18% versus 16%, P = 0.4). There were significant differences in maternal age at delivery (27.2 years versus 29.2 years, P < 0.001) and body mass index (BMI) (24.1 kg/m² versus 25.4 kg/m², P < 0.001) between the two groups.

CONCLUSION

These findings confirm our hypothesis that economic migrants from Eastern European countries exhibit a so-called 'healthy migrant effect' in terms of obstetric outcomes.

Life with a new baby: how do immigrant and Australian-born women's experiences compare?

OBJECTIVE

Little is known about immigrant mothers' experiences of life with a new baby, apart from studies on maternal depression. Our objective was to compare the post-childbirth experiences of Australian-born and immigrant mothers from non-English speaking countries.

METHODS

A postal survey of recent mothers at six months postpartum in Victoria (August 2000 to February 2002), enabled comparison of experiences of life with a new baby for two groups of immigrant women: those born overseas in non-English-speaking countries who reported speaking English very well (n=460); and those born overseas in non-English-speaking countries who reported speaking English less than very well (n=184) and Australian-born women (n=9,796).

RESULTS

Immigrant women were more likely than Australian-born women to be breastfeeding at six months and were equally confident in caring for their baby and talking to health providers. No differences were found in anxiety or relationship problems with partners. However, compared with Australian-born women, immigrant mothers less proficient in English did have a higher prevalence of depression (28.8% vs 15%) and were more likely to report wanting more practical (65.2% vs 55.4%) and emotional (65.2% vs 44.1%) support. They were more likely to have no 'time out' from baby care (47% vs 28%) and to report feeling lonely and isolated (39% vs 17%).

CONCLUSION AND IMPLICATIONS

Immigrant mothers less proficient in English appear to face significant additional challenges post-childbirth. Greater awareness of these challenges may help to improve the responsiveness of health and support services for women after birth.

Birth outcomes of Koreans by birthplace of infants and their mothers, the United States versus Korea, 1995-2004

The acculturation effect of immigrant women on birth outcomes varies by race. We examined birth outcomes of three groups of births for the period 1995-2004, USA births to the USA-born Korean mothers, USA births to the non-USA-born Korean mothers, and births in Korea. In singleton USA births to both Korean parents, average birth weight was 3,294 g for the USA-born Korean mothers and 3,323 g for the non-USA-born Korean mothers. However, this difference was not significant, once controlled for other maternal sociodemographic, obstetric and medical factors. Low birth weight and prematurity prevalence were not different by maternal nativity between these two singleton groups. Average birth weight of all births including multiplets in Korea was 3,270 g, compared to 3,297 g for all USA-born infants including multiplets and births either to both or one Korean parents. This difference might have reflected a significantly lower educational attainment of mothers in Korea compared to Korean mothers in the USA. Low birth weight rate was consistently lower in infants born in Korea compared to the USA-born, but this difference became less, 4.2% and 4.6% respectively by 2004. These observations suggest that in the USA acculturation effect of Korean immigrants on birth outcomes is negligible.

Perinatal outcomes for Asian, Native Hawaiian, and other Pacific Islander mothers of single and multiple race/ethnicity: California and Hawaii, 2003-2005

OBJECTIVES

We examined characteristics and birth outcomes of Asian/Pacific Islander (API) mothers to determine whether differences in outcomes existed between mothers of single race/ethnicity and multiple race/ethnicity.

METHODS

We used data from California and Hawaii birth certificates from 2003 through 2005 to describe variation in birth outcomes for API subgroups by self-reported maternal race/ethnicity (single versus multiple race or API subgroup), and we also compared these outcomes to those of non-Hispanic White women.

RESULTS

Low birthweight (LBW) and preterm birth (PTB) varied more among API subgroups than between mothers of single versus multiple race/ethnicity. After adjustment for sociodemographic and behavioral risk factors, API mothers of multiple race/ethnicity had outcomes similar to mothers of single race/ethnicity, with exceptions for multiple-race/ethnicity Chinese (higher PTB), Filipino (lower LBW and PTB), and Thai (higher LBW) subgroups. Compared with single-race non-Hispanic Whites, adverse outcomes were elevated for most API subgroups: only single-race/ethnicity Korean mothers had lower rates of both LBW (3.4%) and PTB (5.6%); single-race/ethnicity Cambodian, Laotian, and Marshallese mothers had the highest rates of both LBW (8.8%, 9.2%, and 8.4%, respectively) and PTB (14.0%, 13.7%, and 18.8%, respectively).

CONCLUSIONS

Strategies to improve birth outcomes for API mothers should consider variations in risk by API subgroup and multiple race/ethnicity.

International migration and adverse birth outcomes: role of ethnicity, region of origin and destination

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.

Differences in the self-reported racism experiences of US-born and foreign-born Black pregnant women

Differential exposure to minority status stressors may help explain differences in United States (US)-born and foreign-born Black women's birth outcomes. We explored self-reports of racism recorded in a survey of 185 US-born and 114 foreign-born Black pregnant women enrolled in Project Viva, a prospective cohort study of pregnant women in Boston, Massachusetts, USA. Self-reported prevalence of personal racism and group racism was significantly higher among US-born than foreign-born Black pregnant women, with US-born women having 4.1 and 7.8 times the odds, respectively, of childhood exposure. In multivariate analyses, US-born women's personal and group racism exposure also was more pervasive across the eight life domains we queried. Examined by immigrant subgroups, US-born women were more similar in their self-reports of racism to foreign-born women who moved to the US before age 18 than to women who immigrated after age 18. Moreover, US-born women more closely resembled foreign-born women from the Caribbean than those from Africa. Differential exposure to self-reported racism over the life course may be a critically important factor that distinguishes US-born Black women from their foreign-born counterparts.

Children with special health care needs: how immigrant status is related to health care access, health care utilization, and health status

To compare health care access, utilization, and perceived health status for children with SHCN in immigrant and nonimmigrant families. This cross-sectional study used data from the 2003 California Health Interview Survey to identify 1404 children (ages 0-11) with a special health care need. Chi-square and logistic regression analyses were used to examine relations between immigrant status and health access, utilization, and health status variables. Compared to children with special health care needs (CSHCN) in nonimmigrant families, CSHCN in immigrant families are more likely to be uninsured (10.4 vs. 4.8%), lack a usual source of care (5.9 vs. 1.9%), report a delay in medical care (13.0 vs. 8.1%), and report no visit to the doctor in the past year (6.8 vs. 2.6%). They are less likely to report an emergency room visit in the past year (30.0 vs. 44.0%), yet more likely to report fair or poor perceived health status (33.0 vs. 16.0%). Multivariate analyses suggested that the bivariate findings for children with SHCN in immigrant families largely reflected differences in family socioeconomic status, parent's language, parental education, ethnicity, and children's insurance status. Limited resources, non-English language, and limited health-care use are some of the barriers to staying healthy for CSHCN in immigrant families. Public policies that improve access to existing insurance programs and provide culturally and linguistically appropriate care will likely decrease health and health care disparities for this population.

The impact of migration on the health of voluntary migrants in western societies

The authors reviewed literature on the health of voluntary migrants to Western societies and factors affecting their health. Health indicators include mortality rates and life expectancy, birth outcomes, risk of illness, patterns of deteriorating health, cardiovascular disease, body mass index, hypertension, and depression. Multiple factors explain variability, including length of residence and acculturation, disease exposure, life style and living conditions, risky behaviors, healthy habits, social support networks, cultural and linguistic barriers, experiences with racism, and levels of awareness of cultural health practices among health care providers. Evidence exists for superior health among many migrants to Western countries relative to native-born persons, but the differential disappears over time. Migration is a dynamic, extended process with effects occurring years after physical relocation. Systemic change is required, including health policies that ensure equity for migrants, culturally appropriate health promotion, and routine assessment of migration history, cultural health practices, and disease exposure.

Maternal nativity status and birth outcomes in Asian immigrants

BACKGROUND

The study examines the relationship between maternal nativity, maternal risks and birth outcomes in six Asian sub-populations.

METHODS

U.S.- versus foreign-born immigrants of Chinese (67,222), Japanese (18,275) and Filipino (87,1208), Vietnamese (45,229), Cambodian/Laotian (21,237), and Korean (23,430) singleton live births were assessed for maternal risks and birth outcomes.

RESULTS

U.S.-born Chinese and Japanese mothers had lower risk and increased preterm births but similar infant mortality, while U.S.-born Filipino mothers had higher risk and higher infant mortality. U.S.-born mothers of more recent Cambodian/Laotian and Vietnamese immigrants had higher risk and delivered more small and preterm births, while U.S.-born Korean mothers had higher risk but no differences in preterm and low birthweight delivery.

DISCUSSION

Asians in America are a distinctly heterogenous population in terms of the relationship between maternal risk factors and birth outcomes and the influence of maternal nativity on this relationship.

Perinatal outcomes among foreign-born and US-born Chinese Americans, 1995-2000

This paper examines nativity differences in adverse perinatal outcomes of Chinese-American mothers. Singleton live births to US-resident Chinese women (150,620 foreign-born, 15,040 US-born) and a random sample of 150,620 non-Hispanic White mothers were selected from 1995 to 2000 national linked birth/infant death certificate files. Associations between maternal nativity status and adverse perinatal outcomes were assessed using multivariable logistic regressions. Compared to US-born Chinese mothers, foreign-born Chinese mothers were less likely to be unmarried, teen mothers, have a non-Hispanic White or other race partner, be rural residents, and more likely to be less educated, or utilize prenatal care inadequately. Controlling for these factors, foreign-born Chinese-American mothers had significantly lower risks for low birth weight, preterm birth, and small-for-gestational age, whereas risks for infant mortality, neonatal mortality, and post-neonatal mortality did not differ significantly from those of infants of US-born Chinese mothers. Chinese Americans exhibited clear nativity differentials for adverse birth outcomes.

Health of foreign-born people in the United States: a review

This paper identifies the overarching patterns of immigrant health in the US. Most studies indicate that foreign-born individuals are in better health than native-born Americans, including individuals of the same race/ethnicity. They tend to have lower mortality rates and are less likely to suffer from circulatory diseases, overweight/obesity, and some cancers. However, many foreign-born groups have higher rates of diabetes, some infections, and occupational injuries. There is heterogeneity in health among immigrants, whose health increasingly resembles that of natives with duration of US residence. Prospective studies are needed to better understand migrant health and inform interventions for migrant health maintenance.

The influence of maternal mobility on birth outcomes of non-hispanic blacks

BACKGROUND

We investigated whether the "healthy migrant" effect is applicable to an internally mobile U.S.-born population, that is, whether infants born to women that moved within the United States had better birth outcomes compared to those infants whose mothers did not move.

METHODS

This study used 1995-2001 National Center for Health Statistics live birth/infant death cohort files of singleton infants born in the U.S. to non-Hispanic Black women.

RESULTS

Infants born to women who moved had significantly lower risks of low birth weight, preterm birth, and SGA compared to the non-mobile group.

CONCLUSIONS

There is evidence to support the healthy migrant effect in an internally migrant Black population. The findings of this study suggest infants of non-Hispanic Black mothers who were born in one state and moved prior to delivery had more positive birth outcomes when compared to those infants of women who did not move prior to delivery.

Heterogeneity within Asian Subgroups: A Comparison of Birthweight Between Infants of US and Non-US Born Asian Indian and Chinese Mothers

OBJECTIVES

Birthweight distributions and proportions of low birthweight (LBW) are commonly used to assess the health of populations. However, the "population" is difficult to define due to differences by race, socioeconomic status, age distribution, and cultural identity. This study analyzes birth outcomes in two Asian subgroups to examine variation within the Asian population.

METHODS

Analysis of the 1998-2003 National Center for Health Statistics' natality file for 293,211 singleton births in Asian Indian and Chinese mothers compared birthweight distributions, mean birthweights, proportions of very low birthweight (VLBW) and moderately low birthweight (MLBW) infants, and the influence of maternal nativity on these outcomes. A multiple logistic regression analysis, stratified by maternal nativity, was done to control for established confounders of maternal age, marital status, education, and parity.

RESULTS

Maternal characteristics and birthweight distributions varied by race subgroup and nativity. Infants of Asian Indian mothers had a lower mean birthweight and higher proportions of VLBW and MLBW than Chinese. After controlling for differences in maternal characteristics, infants of US born Asian Indian mothers were more likely to be VLBW (AOR 1.87, 95% CI: 1.27-2.75) or MLBW (AOR 1.59, 1.39-1.82) than infants of US born Chinese mothers. Similarly, infants of non-US born Asian Indian mothers were more likely to be VLBW (AOR 2.13, 2.06-2.21) or MLBW (AOR 2.26, 2.18-2.35) then infants of non-US born Chinese mothers.

CONCLUSIONS

Our study demonstrates variation in birth outcomes by maternal race and nativity in two Asian subgroups. The heterogeneity within a single commonly used "population" is likely not limited to these two Asian subgroups, but is probably applicable to many populations in the United States. Analyses should try to account for these differences to ensure a more accurate representation of various populations in the US. The difficulty of defining a population by race adds to the complexity of examining disparities in birth outcomes.

Is neighborhood deprivation independently associated with maternal and infant health? Evidence from Florida and Washington

OBJECTIVES

To determine whether a widely used measure of neighborhood-level socioeconomic deprivation was associated with unintended pregnancy, delayed/no prenatal care, low birth weight (LBW), and not breastfeeding, after adjusting for a more comprehensive set of individual-level socioeconomic factors than previously reported.

METHODS

Data from CDC's Pregnancy Risk Assessment Monitoring System (PRAMS) in Washington and Florida (1997-1998) were linked with census tract-level data (2000) based on birth certificate addresses. For each state, logistic regression models were estimated for associations between neighborhood deprivation measured by the Townsend Index and each dependent variable, unadjusted and then adjusting for maternal age, parity, racial/ethnic group, and education; paternal education; and family income. Similar models were estimated for each racial/ethnic group separately.

RESULTS

Despite significant unadjusted associations between neighborhood deprivation and all dependent variables except LBW in Washington, few statistically significant associations were found in the adjusted models overall. In stratified models, African American women in low-deprivation Florida neighborhoods had higher odds of delayed/no prenatal care compared with their moderate-deprivation counterparts, and only among European American women were high-deprivation neighborhoods associated with increased odds of delayed/no prenatal care.

CONCLUSIONS

These results, which may not be generalizable beyond Florida and Washington or to other health indicators, suggest that some previously reported associations between neighborhood characteristics and the selected health indicators may reflect residual confounding by individual-level socioeconomic status/position. Until methodological and conceptual challenges regarding mediation ("over-controlling") and measurement of neighborhood exposure are overcome, conclusions regarding independent neighborhood associations should be made with caution.

Differences in neonatal mortality among whites and Asian American subgroups: evidence from California

OBJECTIVE

To obtain information about health outcomes in neonates in 9 subgroups of the Asian population in the United States.

DESIGN

Cross-sectional comparison of outcomes for births to mothers of Cambodian, Chinese, Filipino, Indian, Japanese, Korean, Laotian, Thai, and Vietnamese origin and for births to non-Hispanic white mothers. Regression models were used to compare neonatal mortality across groups before and after controlling for various risk factors.

SETTING

All California births between January 1,1991, and December 31, 2001.

PARTICIPANTS

More than 2.3 million newborn infants.

MAIN EXPOSURE

Racial and ethnic groups.

MAIN OUTCOME MEASURE

Neonatal mortality (death within 28 days of birth).

RESULTS

The unadjusted mortality rate for births to non-Hispanic white mothers was 2.0 per 1000. The unadjusted mortality rate for births to Chinese and Japanese mothers was significantly lower (Chinese: 1.2 per 1000, P<.001; Japanese: 1.2 per 1000, P=.004), and for births to Korean mothers the rate was significantly higher (2.7 per 1000, P=.003). For infants of Chinese mothers, observed risk factors explain the differences observed in unadjusted data. For infants of Cambodian, Japanese, Korean, and Thai mothers, differences persist or widen after risk factors are considered. After risk adjustment, infants of Cambodian, Japanese, and Korean mothers have significantly lower neonatal mortality rates compared with infants born to non-Hispanic white mothers (adjusted odds ratios, 0.58 for infants of Cambodian mothers, 0.67 for infants of Japanese mothers, and 0.69 for infants of Korean mothers; all P<.05); infants of Thai mothers have higher neonatal mortality rates (adjusted odds ratio, 1.89; P<.05).

CONCLUSIONS

There are significant variations in neonatal mortality between subgroups of the Asian American population that are not entirely explained by differences in observable risk factors. Efforts to improve clinical care that treat Asian Americans as a homogeneous group may miss important opportunities for improving infant health in specific subgroups.

Reproductive outcomes among Mexico-born women in San Diego and Tijuana: testing the migration selectivity hypothesis

Mexican immigrants to the United States have better reproductive outcomes than do U.S.-born non-Latina whites. Explanations offered for this "epidemiologic paradox" include (1) poor outcomes among Mexican women may be hidden by their return to Mexico; (2) Mexican women may have a higher fetal death rate that alters the pattern of live birth outcomes; (3) Mexican women may have socioeconomic characteristics which, if properly measured, would explain the outcome; (4) Mexican women may have personal characteristics which would explain the outcome, if properly measured; (5) there may be ameliorative or salutogenic "protective" effects of culture; and (6) migration may be selective of healthier women who are thus more prone to positive outcomes. We test these explanations, with an emphasis on the last one, using a data set that combines reproductive histories and birth outcomes for Mexico-born women delivering in San Diego, California and Mexican women delivering in Tijuana, Mexico. These data are compared with U.S.-born Latinas and U.S.-born non-Latina Whites. Multivariate logistic regression analysis suggests that when controlling for birth history (stillbirths and miscarriages), socioeconomic characteristics (education and prenatal visits), personal characteristics (age, parity, time in area, history of family problems), and health characteristics (history of smoking, alcohol use, drug use, anemia, vaginal bleeding, urinary infection), the adjusted odds of a positive birth outcome (measured as a live birth of 2500 grams or more) is highest for women delivering in Tijuana, implying that migrants may not be so selective when compared to the country of origin. The number of prenatal visits was an important explanatory variable.

The healthy migrant theory: Variations in pregnancy outcomes among US-born migrants

Various studies have observed that infants born to foreign-born women have better birth outcomes (lower rates of preterm, low birth weight, and infant mortality) than those delivered to US-born women. While much attention has been given to the "healthy migrant effect" as an explanation for these positive outcomes, this theory has not been examined in an internally migrant population. The purpose of this study is to examine the relationship between maternal mobility history and birth outcomes among infants born to US resident mothers of Mexican origin. The study used 1995-1999 National Center for Health Statistics (NCHS) live birth/infant death cohort files of singleton infants delivered in the US to white women of Mexican origin (n = 2,446,253). Maternal mobility history (MMH), which refers to the relationship between the maternal place of birth and the state of residence at delivery, was categorized into the four following groups: (a) foreign-born-place of birth outside the US and delivery in the US; (b) outside-region-place of birth in one US region and delivery in another US region; (c) within-region-place of birth in one US region and delivery in a different state in the same US region; and (d) within-state-place of birth and delivery in the same US state. Consistently, there is evidence to support the healthy migrant effect in an internally migrant population. Unique to this study are the findings that infants born to mothers with outside-region MMH had a lower risk of low birth weight (LBW) and small-for-gestational age (SGA) compared to those who did not move. Overall, this study provides evidence that the healthy migrant effect and its relationship to birth outcomes can be applied to an internally migrant population.

Intrauterine growth retardation in full-term newborn infants with birth weights greater than 2,500 g

Intrauterine growth retardation (IUGR) is an overlooked problem in full-term infants with birth weights greater than 2,500 g. Birth weight less than the 10th percentile underestimates the presence of IUGR. The purpose of this study was to determine the prevalence of IUGR in full-term infants and to identify sociodemographic and maternal characteristics associated with IUGR. The Ohio Department of Health Vital Statistics database was used to obtain data related to sociodemographic and maternal characteristics. The fetal growth ratio (FGR) was used to determine the presence of IUGR. The sample consisted of 1,569 infants with normal ratios and 1,364 infants classified as IUGR. Infants with IUGR were more often male and African American or Asian American. Maternal characteristics associated with IUGR included history of smoking during pregnancy, lower pre-pregnancy weight, lower weight gain during pregnancy, and inadequate prenatal care. IUGR is present in a significant number of full-term infants with birth weights greater than 2,500 g. The long-term effects of IUGR in these infants remain to be determined.

[Characteristics of immigrant women and their neonates]

BACKGROUND

Immigrant status is frequently assumed to constitute a health risk because migration is inevitably associated with a period of significant adjustment and stress.

OBJECTIVE

To compare the social characteristics and perinatal outcomes of mothers who deliver in a third level hospital in Spain according to their socioeconomic level of the country of origin.

METHODS

From December 2000 to March 2001, women who delivered were selected according to the socioeconomic status of their birth country. All women from low and middle income countries (immigrant mothers) and a sample (1:2) of those from high income countries (mainly Spanish-born mothers) completed a questionnaire on antenatal care, demographic and social characteristics, and country of birth and were followed-up to monitor neonatal clinical features.

RESULTS

During the three months of the study, 203/1352 (15 %, CI 13.2-17.1) of the delivering mothers were immigrants. Most were from Central and South America (56 %, CI 49-62). Prenatal care was appropriate in most of the women (in 92.1 % of immigrant mothers and in 96.8 % of Spanish mothers, p 5 0.01). The proportions of premature births, low birth weight and very-low birth weight showed no statistically significant differences between immigrant and Spanish mothers (15 vs. 10.6, 6.4 vs. 9.4, and 2.1 vs. 1.5, respectively, p > 0.05 in all comparisons). Perinatal complications, including an Apgar score < or = 6, and the need for admission to the neonatal unit or to the intensive or intermediate care units, were not more frequent in the newborns of immigrant mothers. Immigrant women had less social or family support after delivery and maternity leave was much less frequent (62 % vs. 90 %, p < 0.001).

CONCLUSIONS

Most of the immigrant women had healthy pregnancies and healthy birth outcomes. Perinatal complications do not seem to be more frequent among immigrant women. Differences were found in social support. To improve the health of these children, social support to immigrant women and their children should be intensified.

Pregnancy outcomes in foreign-born and US-born women

OBJECTIVES

To compare pregnancy outcomes between foreign-born women and women born in the United States (US-born).

METHODS

A retrospective cohort study (1991-2001) of all deliveries at Grady Memorial Hospital in Atlanta, Georgia.

RESULTS

Among 49,904 deliveries, 27% were to foreign-born mothers representing 164 countries grouped into eight geographic regions. Compared with US-born women, foreign-born women had a higher mean birthweight (3315 vs. 3083 g), and a lower risk of preterm delivery (RR 0.46, 95% CI 0.43-0.49), perinatal mortality (RR 0.40, 95% CI 0.36-0.45), hypertension (RR 0.31, 95% CI 0.23-0.41), and HIV infection (RR 0.13, 95% CI 0.10-0.18). However, foreign-born women had an increased risk of diabetes (RR 1.63, 95% CI 1.48-1.79), perineal laceration (RR 1.71; 95% CI 1.66-1.76), and postpartum hemorrhage (RR 1.10; 95% CI 1.05-1.15).

CONCLUSIONS

Foreign-born women have better health behaviors, pregnancy outcomes, and a lower risk of infectious diseases than US-born women, but they have a higher risk of certain medical conditions and obstetric complications.

Fertility and perinatal health among Finnish immigrants in Sweden

Several studies have reported poorer infant outcome among immigrants, but contrary evidence also exists. Between 1940 and 1999 more than a half million Finns emigrated to Sweden, which made Finns the largest minority group in Sweden. Our aim was to investigate fertility trends, parturients' background and pregnancy outcomes among Finns in Sweden, and to compare the findings with those obtained among Swedes in Sweden and Finns in Finland. The data came from the Finnish and Swedish Medical Birth Registers for the years 1987-1998. All deliveries by women born in Finland and having given birth in Sweden (N=33874) were compared with a 10% sample of all deliveries by Swedish parturients in Sweden (N=108549) and of all Finnish deliveries (n=75133). Among Finns in Sweden, the number of live births per 1000 women aged 15-49 years declined significantly in the late 1990s. The change in the total fertility rate was less dramatic: the rate for Finns in Sweden followed the total Swedish rate although it remained from 5% to 10% higher up to the mid-1990s. Finns who had given birth in Sweden were older, had a higher parity and a higher prevalence of previous miscarriages, and smoked more often than did Swedes in Sweden or Finns in Finland. The crude infant outcomes of Finns having given birth in Sweden were equal to those among Swedes in Sweden (except for the incidence of small for gestational age), but poorer than in Finland. Biological factors explained the differences between Finns in Sweden and Finland in being small for gestational age, and biological factors and smoking explained the difference in prematurity. The difference in low birth weight remained statistically significant (3.9% versus 3.6% among singletons). In conclusion, fertility trends followed the pattern prevailing in the resident country. The relatively good outcome of children whose mothers were born in Finland but who had given birth in Sweden can partly be explained by the healthy migrant effect.

Association of language spoken at home with health and school issues among Asian American adolescents

The study examined the association of language spoken at home with the school and health risks and behaviors of Asian American adolescents. Using the United States component of the 1997-1998 World Health Organization Study of Health Behavior in School Children, bivariate and multiple logistic regression analyses were conducted of records for Asian children to explore the relationship between language spoken at home and outcome variables regarding health behaviors, psychosocial and school risk factors, and parental factors. Compared to those who usually speak English at home, adolescents who usually speak another language, or who speak two languages equally, face a greater risk for health risk factors, psychosocial and school risk factors, and parental risk factors. Not speaking English at home was associated with higher health risks, including not wearing seat belts and bicycle helmets; higher psychosocial and school risk factors, including feeling that they do not belong at school, difficulty making new friends, and lacking confidence; and higher parental risks, including reporting that parents were not ready to help them or willing to talk to teachers. Adolescents less acculturated to the United States experience a variety of physical and psychosocial risks. School-based interventions such as early identification and outreach, needs assessment, and counseling and support services should be provided to immigrant students and their families.

Prenatal care use among selected Asian American groups

OBJECTIVES

This study examined the predictors of 3 patterns of prenatal care use (no care, late initiation of care, and inadequate use after early initiation) for 4 Asian American ethnic groups in the United States.

METHODS

Single live births to US resident mothers of Chinese, Japanese, Korean, and Vietnamese ancestry (n = 273 604) were selected from the 1992-1996 US natality files. Logistic regression was used to analyze the effects of maternal characteristics on the 3 use measures.

RESULTS

Korean Americans and Vietnamese Americans had the lowest levels of prenatal care use. Young or single motherhood, high parity for age, and low educational attainment were the main risk factors for low use.

CONCLUSIONS

Considerable variability exists in prenatal care use among Asian American ethnic groups.

An assessment of the use and impact of ancillary prenatal care services to Medicaid women in managed care

OBJECTIVES

Managed care plans under Medicaid are becoming a usual source of care for low-income pregnant women. This study describes an ancillary prenatal care service intervention developed by one managed care organization (MCO) for Medicaid-enrolled women, assesses the extent to which the intervention services were used, and appraises the influence of the intervention on prenatal care participation.

METHOD

There were 226 intervention and 258 control women with a single live birth delivered between 28 and 44 weeks gestation who (1) were enrolled in the MCO's Medicaid program, (2) were high-risk based on a prenatal risk assessment, and (3) started prenatal care prior to 26 weeks gestation. Less than adequate and intensive prenatal care utilization were chosen as intervention outcomes measures.

RESULTS

Family planning, a 2-month postpartum baby visit, a maternal postpartum visit, and a WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) referral were among the most self-selected intervention services for this population; home health aide and breast-feeding support were the least requested services. Over 90% of those needing family planning or breast-feeding services received the services, while over 20% of the intervention group refused child care, food assistance and family violence referrals, and home health aide and smoking cessation services. The intervention group had a significantly lower risk of less than adequate utilization of prenatal care (OR = .32; 95% CI: 0.17-0.60) and was more likely to have an intensive number of prenatal care visits (OR = 1.61; 95% CI: 1.05-2.48).

CONCLUSIONS

The ability of managed care organizations to provide ongoing prenatal care to Medicaid populations in a cost-effective manner depends partly on their development of packages of prenatal services that foster positive preventive health care utilization behaviors and good pregnancy outcomes. The results of this project suggest that the intervention was beneficial in the area of improving utilization of prenatal care.