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Equity in Perinatal Equity in Perinatal Healthcare of Migrant Healthcare of Migrant WomenWomen

Carly Lang BScH MSc(c)Carly Lang BScH MSc(c)** Anita J. Gagnon RN MPH PhDAnita J. Gagnon RN MPH PhD**

Rhonda Small PhDRhonda Small PhD

Irene Sarasua RN MScIrene Sarasua RN MSc**

Canadian Public Health Association Canadian Public Health Association June 3 2008June 3 2008

*McGill University and McGill University Health Centre*McGill University and McGill University Health CentreLa Trobe University, AustraliaLa Trobe University, Australia

Jewish General Hospital, MontrealJewish General Hospital, Montreal

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Background• Perinatal health outcomes for migrant women

compared to native-born women differ by receiving country:– More harmfulMore harmful outcomes outcomes

C-section rates (Australia, Canada, Italy, UK) Perinatal mortality (UK) low birth weight infants (Italy, UK)

– ComparableComparable outcomes to native-born women outcomes to native-born women• Birth weight and perterm birth (France, Belgium, US)• Perterm birth and perinatal mortality (Italy)

– Outcomes Outcomes varyvary within the same country by source within the same country by source regionregion risk for women from Asian or Sub-Saharan African countries

(Australia, Netherlands, Norway, UK)

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Background• To examine migrant perinatal health

internationally, ROAM was created

ROAM: General objectivesROAM: General objectives

1. Identify and internationally compare indicators of perinatal health,perinatal health, migration migration and equityequity

2. Hypothesize and test for any identified international differences in distribution of perinatal health or equity of care indicators by migration indicators.

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ROAM – Reproductive Outcomes And ROAM – Reproductive Outcomes And Migration: An International Research Migration: An International Research Collaboration (self-selected; nine Collaboration (self-selected; nine countries)countries)• 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)

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BackgroundIn order to more clearly investigate

perinatal migrant health disparities internationally, it is essential to have common indicators of:

1. Perinatal health2. Migration

3. Equity3. Equity

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Definitions

1. 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)

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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)

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Research QuestionResearch Question

Is there any evidence that equity of Is there any evidence that equity of perinatal care indicators for migrant perinatal care indicators for migrant

women can be measured?women can be measured?

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IV. In Delivery of Health Care Services

 How fairly/equitably are health

care services delivered to different populations?

Equity in health: Equity in health: A Conceptual A Conceptual FrameworkFramework

I. In Health Status (Outcomes)

 How healthy are

different populations?

II. In Access to Health Care

Services 

How easily can different populations access health

care services?

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?

EQUITYEQUITY

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Methods

I. Measurement of equity indicators

II. Availability of data on equity and migration internationally

III. Feasability of using migration indicators

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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)

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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

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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

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Measurement of Equity in HealthMeasurement of Equity in Health

IV. In Delivery of Health Care Services

 How fairly/equitably are health

care services delivered to different populations?

I. In Health Status (Outcomes)

 How healthy are

different populations?

II. In Access to Health Care

Services 

How easily can different populations access health

care services?

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?

EQUITYEQUITY

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Measurement of Equity in Measurement of Equity in AccessAccess to Health Care Services to Health Care Services

Doctors/ nurses were rushed

Felt worries taken seriously

Felt had to wait long at visits

Wanted to follow customs

Did not need interpreter/ always available

Decisions made w/o respondent's wishes considered

Labor/ birth taken over

Asked to do something did not want to do

Refugee/AS (n=11)

6 (54.5%) 8 (72.7%) 2 (18.2%) 3 (27.3%) 8 (72.8%) 2 (18.2%) 2 (18.2%) 2 (18.2%)

Immigrant (n=13)

6 (46.2%) 12 (91.7%) 6 (46.2%) 2 (15.4%) 13 (100%) 1 (7.7%) 0 (0%) 1 (7.7%)

Canadian-born (n=12)

2 (16.7%) 11 (91.7%) 7 (58.3) 1 (8.3%) 12 (100%) 0 (0%) 0 (0%) 0 (0%)

In Health Status

(Outcomes)

In Access to Health

Care Services

 In Utilization of Health Care

Services 

In Delivery of Health

Care Services

 

In Health Care

Policy / Financing

 

EQUITYEQUITY

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Measurement of Equity in Measurement of Equity in UtilizationUtilization of Health Care of Health Care ServicesServices

In Health Status

(Outcomes)

In Access to Health

Care Services

 In Utilization of Health Care

Services 

In Delivery of Health

Care Services

 

In Health Care

Policy / Financing

 

EQUITYEQUITY

0

10

20

30

40

50

60

70

80

90

100

%

Figure II. Information, Advice and Support on Postpartum Unit*

Refugee/Asylum-Seeker Immigrant Canadian-Born

Information, Advice and Support on the Postpartum Unit

Care of Baby Health of Baby

Breastfeeding Bottle Feeding Follow-up Health of Mother

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0

10

20

30

40

50

60

Euro

pe

S &

C

Am

erica

Afr

ica

West.A

sia

,

N-A

fric

a

S-E

-C A

sia

Euro

pe

S &

C

Am

erica

Afr

ica

West.A

sia

,

N-A

fric

a

S-E

-C A

sia

Euro

pe

S &

C

Am

erica

Afr

ica

West.A

sia

,

N-A

fric

a

S-E

-C A

sia

Canada

Refugee (n=72) A-Seeker (n=117) Immigrant (n=829) Ref(2482)

% C

esare

an

Bir

ths

Measurement of Equity in Measurement of Equity in DeliveryDelivery of Health Care Services of Health Care Services

C-section by immigration status and source regionC-section by immigration status and source region

In Health Status

(Outcomes)

In Access to Health

Care Services

 In Utilization of Health Care

Services 

In Delivery of Health

Care Services

 

In Health Care

Policy / Financing

 

EQUITYEQUITY

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Availability of Equity Data InternationallyAvailability of Equity Data Internationally

IV. In Delivery of HealthCare Services

How fairly/equitably are health careservices delivered to different

populations?

I . In Health Status(Outcomes)

How healthy are differentpopulations?

II . In Access to HealthCare Services

How easily can differentpopulations access health

care services?

III . In Utilization of HealthCare Services

How frequently are health careservices utilized (or accessed) by

different populations?

V. In Health CarePolicy / Financing

How fairly/equitably arehealthcare and other

resources allocated forconditions affecting different

populations?How do healthcare policiesaffect different populations?

EQUITYEQUITY

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Availability of International Data on Availability of International Data on Access Access to Health Care Servicesto Health Care Services

In Health Status

(Outcomes)

In Access to Health

Care Services

 In Utilization of Health Care

Services 

In Delivery of Health

Care Services

 

In Health Care

Policy / Financing

 

EQUITYEQUITY

?

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Availability of International Data on Availability of International Data on Utilization Utilization of Health Care Services - of Health Care Services - Country of BirthCountry of Birth

In Health Status

(Outcomes)

In Access to Health

Care Services

 In Utilization of Health Care

Services 

In Delivery of Health

Care Services

 

In Health Care

Policy / Financing

 

EQUITYEQUITY

Utilization - National Data by COUNTRY OF BIRTH

0

0.5

1

1.5

2

2.5

3

3.5

Prenatal Care Postpartum Care Other Services

Type of Health Care Utilization

Numb

er of

Cou

ntrie

sFrance

UK

Canada

Utilization - National Data by COUNTRY OF BIRTH

Care

France

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Delivery of Services - National Data by COUNTRY OF BIRTH

0 1 2 3 4 5 6 7 8 9

Caesarean Section In duction Analgesia use Epidural u se Length of

Stay Ability to Understand Inf orm ation

Given by Staff Satisfaction with Care Feels Treated

with Respect

Indicators Collected on the Delivery of Services

Nu

mb

er

of

Co

un

trie

s

Norway Italy* Belgium* France* Finland Australia* UK Canada

Italy* – based on regional datasetBelgium* – regional datasets from Flanders and Brussels; CoB as nationality on arrival and at birthFrance* – CoB as “nationality” as defined as either French, another country from Europe, North Africa, another African country, another nationalityAustralia* - regional datasets from Victoria and New South Wales

Availability of International Data on Availability of International Data on Delivery Delivery of Health Care Services - of Health Care Services - Country of BirthCountry of Birth

In Health Status

(Outcomes)

In Access to Health

Care Services

 In Utilization of Health Care

Services 

In Delivery of Health

Care Services

 

In Health Care

Policy / Financing

 

EQUITYEQUITYDelivery of services – National Data by COUNTRY OF BIRTH

Indicators - Delivery of Services

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Feasibility of Collecting Hospital Feasibility of Collecting Hospital Data on Migration IndicatorsData on Migration Indicators

Country of Birth

Length of Time in Country

Immigration Status

Language Fluency

Ethnicity by Mother’s Place of Birth

MIGRATION MIGRATION INDICATORINDICATOR

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MigrationMigration IndicatorIndicator

Country of Birth Length of

time in country

Ethnicity by mother’s place of

birth

Language fluency

Immigration Status

Feasibility of Using Hospital Data on Feasibility of Using Hospital Data on Migration Indicators to Examine Equity by Migration Indicators to Examine Equity by Country of BirthCountry of Birth

Information on COUNTRY OF BIRTH at Discharge (7 Canadian Hospitals)

n=911

74%

26% 0% 0%

Available Unavailable Not Applicable Unknown

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Can equity of perinatal care for Can equity of perinatal care for migrant women be measured?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 servicesdelivery of services by country of birthcountry of birth

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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

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E-mail: carly.lang@mail.mcgill.caE-mail: carly.lang@mail.mcgill.ca

Thanks to Thanks to ROAMROAM, , CIHRCIHR for funding this project, to for funding this project, to Andraea Van Andraea Van HulstHulst for for cesarean section graphscesarean section graphs, to , to Marie-Pier JolyMarie-Pier Joly for for

feasibility data, feasibility data, & to & to Lisa Merry, Zeinab Jeambey Lisa Merry, Zeinab Jeambey andand Jacquie Jacquie BockingBocking for general support. for general support.

Thank Thank you !you !

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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)

MigratioMigrationn

IndicatorIndicator

I. Country of Birth II. Length of time

in country

V. Ethnicity by mother’s parental

place of birth

IV. Language fluency

III. Immigration Status

No data

Health InsuranceNote: Not recognized by Delphi

Information on COUNTRY OF BIRTH on Admission

(2 Montreal Hospitals)

n=443

62% 31%

7% Available Not Available in Record Record Not Available

Information on COUNTRY OF BIRTH at Discharge (7 Canadian Hospitals)

n=911

74%

26% 0% 0%

Available Unavailable Not Applicable Unknown

Information on LENGTH OF TIME on Admission (2 Montreal Hospitals)

n=443

7%

49% 6%

38% Available Not Available in Record Record Not Available Canadian Born

Information on LENGTH OF TIME at Discharge

(7 Canadian Hospitals)

n=911

39%

38%

23% 0% Available Unavailable Not Applicable Unknown

Information on IMMIGRATION STATUS on Admission

(2 Montreal Hospitals) n=443

1%

93%

6% Available Not Available in Record Record Not Available

Information on LANGUAGE on Admission (2 Montreal Hospitals

n=443

87%

10% 3%

Available Not Available in Record Record Not Available

Information on HEALTH INSURANCE on Admission (2 Montreal Hospitals)

n=443

93%

3% 4%

Available Not Available in Record Record Not Available

Information on IMMIGRATION STATUS at Discharge atatDiscahrgedigh (7 Canadian Hospitals)

n=911

28%

49%

23% 0% Available Unavailable Not Applicable Unknown

Information on HEALTH INSURANCE at Discharge (7 Canadian Hospitals)

n=911

93%

7% 0% 0%

Available Unavailable Not Applicable Unknown

Information on LANGUAGE at Discharge (7 Canadian Hospitals)

n=911

93%

6% 0% 1%

Available Unavailable Not Applicable Unknown

Feasibility of using hospital data on migration indicators to examine equity in care

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MigrationMigration IndicatorIndicator

I. Country of Birth II. Length of

time in country

V. Ethnicity by mother’s

parental place of birth

IV. Language fluency

III. Immigration Status

Information on LENGTH OF TIME on Admission (2 Montreal Hospitals)

n=443

7%

49% 6%

38% Available Not Available in Record Record Not Available Canadian Born

Information on LENGTH OF TIME at Discharge

(7 Canadian Hospitals)

n=911

39%

38%

23% 0% Available Unavailable Not Applicable Unknown

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MigrationMigration IndicatorIndicator

I. Country of Birth

II. Length of time in country

V. Ethnicity by mother’s parental

place of birth

IV. Language fluency

III. Immigration Status

Information on IMMIGRATION STATUS on Admission

(2 Montreal Hospitals) n=443

1%

93%

6% Available Not Available in Record Record Not Available

Information on IMMIGRATION STATUS at Discharge atatDiscahrgedigh (7 Canadian Hospitals)

n=911

28%

49%

23% 0% Available Unavailable Not Applicable Unknown

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MigrationMigration IndicatorIndicator

I. Country of Birth II. Length of

time in country

V. Ethnicity by mother’s

parental place of birth

IV. Language fluency

III. Immigration Status

No data

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MigrationMigration IndicatorIndicator

I. Country of Birth

II. Length of time in country

V. Ethnicity by mother’s parental

place of birth

IV. Language fluency

III. Immigration Status

Health InsuranceNote: Not recognized by Delphi

Information on HEALTH INSURANCE on Admission (2 Montreal Hospitals)

n=443

93%

3% 4%

Available Not Available in Record Record Not Available

Information on HEALTH INSURANCE at Discharge (7 Canadian Hospitals)

n=911

93%

7% 0% 0%

Available Unavailable Not Applicable Unknown

Note: Health Insurance not a category recognized by Delphi