Equity in Perinatal Healthcare of Migrant Women

1. Equity in Perinatal Healthcare of Migrant Women Carly Lang BScH MSc(c)* Anita J. Gagnon RN MPH PhD* Rhonda Small PhD Irene Sarasua RN MSc* *McGill University and McGill University Health Centre La Trobe University, Australia Jewish General Hospital, Montreal Canadian Public Health Association June 3 2008

2. Background • Perinatal health outcomes for migrant women compared to native-born women differ by receiving country: • More harmful outcomes •  C-section rates (Australia, Canada, Italy, UK) •  Perinatal mortality (UK) •  low birth weight infants (Italy, UK) • Comparable outcomes to native-born women • Birth weight and perterm birth (France, Belgium, US) • Perterm birth and perinatal mortality (Italy) • Outcomes vary within the same country by source region •  risk for women from Asian or Sub-Saharan African countries (Australia, Netherlands, Norway, UK)

3. Background • To examine migrant perinatal health internationally, ROAM was created ROAM: General objectives 1. Identify and internationally compare indicators of perinatal health,migration and equity 2. Hypothesize and test for any identified international differences in distribution of perinatal health or equity of care indicators by migration indicators.

4. Sophie Alexander, Université libre de Bruxelles (Belgium) Béatrice Blondel, INSERM (France) Simone Buitendijk, TNO Institute – Prevention and Care (Netherlands) Marie Desmeules, Public Health Agency of Canada Dominico DiLallo, Agency for Public Health – Rome (Italy) Anita Gagnon (co-leader), McGill University/MUHC, (Canada) Mika Gissler, STAKES (Finland) Richard Glazier, Inst. For Clinical Evaluative Sciences (Canada) Maureen Heaman, University of Manitoba (Canada) Dineke Korfker, TNO Institute – Prevention and Care (Netherlands) Alison Macfarlane, City University of London (UK) Edward Ng, Statistics Canada Carolyn Roth, Keele University (UK) Rhonda Small (co-leader), LaTrobe University (Australia) Donna Stewart, Univ. Hlth Network of Toronto/U of T (Canada) Babill Stray-Pederson, University of Oslo (Norway) Marcelo Urquia, Inst. For Clinical Evaluative Sciences (Canada) Siri Vangen, Dept Ob/Gyn of The National Hospital of Norway Jennifer Zeitlin, INSERM and EURO-PERISTAT (France) Meg Zimbeck, INSERM and EURO-PERISTAT (France) ROAM – Reproductive Outcomes And Migration: An International Research Collaboration (self-selected; nine countries)

5. Background In order to more clearly investigate perinatal migrant health disparities internationally, it is essential to have common indicators of: • Perinatal health • Migration 3. Equity

6. Perinatal Health: Maternal, fetal and infant health during pregnancy, delivery and the post-partum period Indicators : Perinatal mortality (fetus, infant, mother) Birth weight 2. Migration: Geographical movement of individuals across international borders Indicators : Country of birth Length of time in country Immigration status Receiving country language fluency Ethnicity (defined by maternal parents’ place of birth) Definitions

7. Definitions 3. Equity in Health: The absence of systematic and potentially remediable differences in one or more aspects of health across populations or population groups defined socially, economically, demographically, or geographically (International Society for Equity in Health)

8. Research Question Is there any evidence that equity of perinatal care indicators for migrant women can be measured?

9. Equity in health: A Conceptual Framework II. In Access to Health Care Services How easily can different populations access health care services? I. In Health Status (Outcomes) How healthy are different populations? III. In Utilization of Health Care Services How frequently are health care services utilized (or accessed) by different populations? V. In Health Care Policy / Financing How fairly/equitably are healthcare and other resources allocated for conditions affecting different populations? How do healthcare policies affect different populations? EQUITY IV. In Delivery of Health Care Services How fairly/equitably are health care services delivered to different populations?

10. Methods • Measurement of equity indicators • Availability of data on equity and migration internationally • Feasability of using migration indicators

11. Methods I - Measurement • Access: • Canadian example: pilot (n = 36) in 2 Montreal hospitals using Migrant Friendly Hospital Initiative Questionnaires and CLAS criteria for recording care • Utilization: • As for access • Delivery of health services • Canadian example: data from hospital logs of births (n = 3500) from Montreal, Toronto, and Vancouver & from study of concerns/ response to concerns (n = 341)

12. Methods II - International Availability of Data • Indicators relating to access, utilization and delivery of services were sought across ROAM countries • Routinely collected • Nationally representative • Could be analyzed by one of the migration indicators

13. Methods III - Feasibility of Collecting Hospital Data on Migration Indicators • Canadian example: Migration indicators sought from women’s hospital charts in postpartum unit • 7 hospitals in Montreal and Toronto (n=911) • Feb. 2006 - May 2008 • To determine which migration indicators are recorded in hospital

14. Measurement of Equity in Health II. In Access to Health Care Services How easily can different populations access health care services? I. In Health Status (Outcomes) How healthy are different populations? III. In Utilization of Health Care Services How frequently are health care services utilized (or accessed) by different populations? V. In Health Care Policy / Financing How fairly/equitably are healthcare and other resources allocated for conditions affecting different populations? How do healthcare policies affect different populations? EQUITY IV. In Delivery of Health Care Services How fairly/equitably are health care services delivered to different populations?

15. Measurement of Equity in Access to Health Care Services In Health Status (Outcomes) In Access to Health Care Services In Health Care Policy / Financing EQUITY In Utilization of Health Care Services In Delivery of Health Care Services

16. Measurement of Equity in Utilization of Health Care Services Information, Advice and Support on the Postpartum Unit In Health Status (Outcomes) In Access to Health Care Services In Health Care Policy / Financing EQUITY In Utilization of Health Care Services In Delivery of Health Care Services Care of Baby Health of Baby Breastfeeding Bottle Feeding Follow-up Health of Mother

17. Measurement of Equity in Delivery of Health Care Services In Health Status (Outcomes) In Access to Health Care Services In Health Care Policy / Financing EQUITY In Utilization of Health Care Services In Delivery of Health Care Services C-section by immigration status and source region

18. Availability of Equity Data Internationally

19. Availability of International Data on Access to Health Care Services ? In Health Status (Outcomes) In Access to Health Care Services In Health Care Policy / Financing EQUITY In Utilization of Health Care Services In Delivery of Health Care Services

20. Availability of International Data on Utilization of Health Care Services - Country of Birth Utilization - National Data by COUNTRY OF BIRTH In Health Status (Outcomes) In Access to Health Care Services In Health Care Policy / Financing EQUITY In Utilization of Health Care Services In Delivery of Health Care Services France Care

21. Availability of International Data on Delivery of Health Care Services - Country of Birth In Health Status (Outcomes) In Access to Health Care Services Delivery of services – National Data by COUNTRY OF BIRTH In Health Care Policy / Financing EQUITY In Utilization of Health Care Services In Delivery of Health Care Services Italy* – based on regional dataset Belgium* – regional datasets from Flanders and Brussels; CoB as nationality on arrival and at birth France* – CoB as “nationality” as defined as either French, another country from Europe, North Africa, another African country, another nationality Australia* - regional datasets from Victoria and New South Wales Indicators - Delivery of Services

22. Feasibility of Collecting Hospital Data on Migration Indicators Length of Time in Country Country of Birth MIGRATION INDICATOR Immigration Status Ethnicity by Mother’s Place of Birth Language Fluency

23. Country of Birth Length of timein country Migration Indicator Ethnicity by mother’s place of birth Immigration Status Languagefluency Feasibility of Using Hospital Data on Migration Indicators to Examine Equity by Country of Birth

24. Can equity of perinatal care for migrant women be measured? • Equity can be most easily assessed by: • Health Status • Delivery of health care services • Country of Birth is the most widely available, feasible migration indicator • Future equity research is likely to be related to delivery of services by country of birth

25. Challenges • Difficulties in obtaining data • Some equity indicators not routinely available across countries/institutions • Many equity indicators not standardized • Migration indicators need to be put into place

26. E-mail: carly.lang@mail.mcgill.ca Thank you ! Thanks to ROAM, CIHR for funding this project, to Andraea Van Hulst for cesarean section graphs, to Marie-Pier Joly for feasibility data, & to Lisa Merry, Zeinab Jeambey and Jacquie Bocking for general support.

27. I. Country of Birth II. Length of timein country Migration Indicator V. Ethnicity by mother’s parental place of birth III. Immigration Status IV. Languagefluency Feasibility of using hospital data on migration indicators to examine equity in care On admission based on all births in two hospitals in Montreal over an 18-day period (Apr 15 – May 3 2008) Discharge data from CHARSNN participants (Feb 2006-present) No data Health Insurance Note: Not recognized by Delphi

28. I. Country of Birth II. Length of timein country Migration Indicator V. Ethnicity by mother’s parental place of birth III. Immigration Status IV. Languagefluency Figure 3. Feasability of Using Hospital Data on Migration Indicators to Examine Equity in Care by Length of Time

29. I. Country of Birth II. Length of timein country Migration Indicator V. Ethnicity by mother’s parental place of birth III. Immigration Status IV. Languagefluency Figure 3. Feasability of Using Hospital Data on Migration Indicators to Examine Equity in Care by Immigration Status

30. I. Country of Birth II. Length of timein country Migration Indicator V. Ethnicity by mother’s parental place of birth III. Immigration Status IV. Languagefluency Figure 3. Feasability of Using Hospital Data on Migration Indicators to Examine Equity in Care by Ethnicity No data

31. I. Country of Birth II. Length of timein country Migration Indicator V. Ethnicity by mother’s parental place of birth III. Immigration Status IV. Languagefluency Figure 3. Feasability of Using Hospital Data on Migration Indicators to Examine Equity in Care by Health Insurance Note: Health Insurance not a category recognized by Delphi Health Insurance Note: Not recognized by Delphi