Refugee maternal and perinatal health in Ontario, Canada: a retrospective population-based study

Abstract

Objectives: Immigrants are thought to be healthier than their native-born counterparts, but less is known about the health of refugees or forced migrants. Previous studies often equate refugee status with immigration status or country of birth (COB) and none have compared refugee to non-refugee immigrants from the same COB. Herein, we examined whether: (1) a refugee mother experiences greater odds of adverse maternal and perinatal health outcomes compared with a similar non-refugee mother from the same COB and (2) refugee and non-refugee immigrants differ from Canadian-born mothers for maternal and perinatal outcomes.

Design: This is a retrospective population-based database study. We implemented two cohort designs: (1) 1:1 matching of refugees to non-refugee immigrants on COB, year and age at arrival (±5 years) and (2) an unmatched design using all data.

Setting and participants: Refugee immigrant mothers (n=34 233), non-refugee immigrant mothers (n=243 439) and Canadian-born mothers (n=615 394) eligible for universal healthcare insurance who had a hospital birth in Ontario, Canada, between 2002 and 2014.

Primary outcomes: Numerous adverse maternal and perinatal health outcomes.

Results: Refugees differed from non-refugee immigrants most notably for HIV, with respective rates of 0.39% and 0.20% and an adjusted OR (AOR) of 1.82 (95% CI 1.19 to 2.79). Other elevated outcomes included caesarean section (AOR 1.04, 95% CI 1.00 to 1.08) and moderate preterm birth (AOR 1.08, 95% CI 0.99 to 1.17). For the majority of outcomes, refugee and non-refugee immigrants experienced similar AORs when compared with Canadian-born mothers.

Conclusions: Refugee status was associated with a few adverse maternal and perinatal health outcomes, but the associations were not strong except for HIV. The definition of refugee status used herein may not sensitively identify refugees at highest risk. Future research would benefit from further refining refugee status based on migration experiences.

Keywords: epidemiology; maternal medicine; perinatology; public health; social medicine.

Figure 1

Adverse maternal outcomes comparing 29 023 first births in Ontario to refugee immigrants (black circles) versus 29 023 first births in Ontario births to non-refugee immigrants (open circles), 1:1 matched on country of birth, year and age at arrival (±5 years). ORs adjusted for maternal age, parity, income quintile, official language ability, education and duration of residence. AOR, adjusted OR; ICU, intensive care unit; SMM, severe maternal morbidity.

Figure 2

Adverse perinatal outcomes comparing first births in Ontario to refugee immigrants (black circles) versus first births in Ontario to non-refugee immigrants (open circles), 1:1 matched on country of birth, year and age at arrival (±5 years). Denominators vary with the outcome examined. ORs adjusted for maternal age, parity, income quintile, official language ability, education and duration of residence. AOR, adjusted OR; NICU, neonatal intensive care unit.

Figure 3

Adverse maternal outcomes comparing 52 360 births to refugee immigrants (black circles) and 360 007 births to non-refugee immigrants (grey circles) versus 977 045 births to Canadian-born (open circles) mothers. ORs adjusted for maternal age, parity and income quintile. AOR, adjusted OR; ICU, intensive care unit; SMM, severe maternal morbidity.

Figure 4

Adverse perinatal outcomes comparing births to refugee immigrants (black circles) and births to non-refugee immigrants (grey circles) versus births to Canadian-born mothers (open circles). Denominators vary with the outcome examined. ORs adjusted for maternal age, parity and income quintile. AOR, adjusted OR; NICU, neonatal intensive care unit.