Is there an association between family members' season of birth that could influence birth seasonality? Evidence from Spain and France.

The number of births varies by season. Research on birth seasonality has shown that women's season of birth somehow influences that of their children, but factors underlying the intergenerational transmission of birth seasonality remain unknown. With data from Spain and France, we analysed the possibility of transmission of birth season between generations, testing whether relatives tended to be born in the same season. Results indicated that there was an association-a similarity-between parents' and children's birth seasons, partially explaining the stability of seasonal patterns over time. This association also existed between parents' birth seasons. While parents' association is directly explained by an excess of marriages with spouses born in the same month, the overall association may be explained by two facts: different socio-demographic groups show differentiated birth patterns, and relatives share socio-demographic features. Birth season seems to be related to family characteristics, which should be controlled for when assessing birth-month effects on subsequent social/health outcomes.

Selective Serotonin Reuptake Inhibitors and Risk of Noncardioembolic Ischemic Stroke: A Nested Case-Control Study.

BACKGROUND: Multiple studies have reported that the use of selective serotonin reuptake inhibitors (SSRIs) is associated with an increased risk of ischemic stroke; however, this finding may be the result of a confounding by indication. We examined the association using different approaches to minimize such potential bias. METHODS: A nested case-control study was carried out in a Spanish primary health-care database over the study period 2001 to 2015. Cases were patients sustaining an ischemic stroke with no sign of cardioembolic or unusual cause. For each case, up to 5 matched controls (for exact age, sex, and index date) were randomly selected. Antidepressants were divided in 6 pharmacological subgroups according to their mechanism of action. The current use of SSRIs (use within a 30-day window before index date) was compared with nonuse, past use (beyond 365 days) and current use of other antidepressants through a conditional logistic regression model to obtain adjusted odds ratios and 95% CI. Only initiators of SSRIs and other antidepressants were considered. RESULTS: A total of 8296 cases and 37 272 matched controls were included. Of them, 255 (3.07%) were current users of SSRIs among cases and 834 (2.24%) among controls, yielding an adjusted odds ratio of 1.14 (95% CI, 0.97-1.34) as compared with nonusers, 0.94 (95% CI, 0.77-1.13) as compared with past-users and 0.74 (95% CI, 0.58-0.93) as compared with current users of other antidepressants. No relevant differences were found by duration (≤1, >1 year), sex, age (<70, ≥70 years old) and background vascular risk. CONCLUSIONS: The use of SSRIs was not associated with an increased risk of noncardioembolic ischemic stroke. On the contrary, as compared with other antidepressants, SSRIs appeared to be protective.

Circulation and seasonality of influenza viruses in different transmission zones in Africa.

BACKGROUND: Influenza is responsible for more than 5 million severe cases and 290,000 to 650,000 deaths every year worldwide. Developing countries account for 99% of influenza deaths in children under 5 years of age. This paper aimed to determine the dynamics of influenza viruses in African transmission areas to identify regional seasonality for appropriate decision-making and the development of regional preparedness and response strategies. METHODS: We used data from the WHO FluMart website collected by National Influenza Centers for seven transmission periods (2013-2019). We calculated weekly proportions of positive influenza cases and determined transmission trends in African countries to determine the seasonality. RESULTS: From 2013 to 2019, influenza A(H1N1)pdm2009, A(H3N2), and A(H5N1) viruses, as well as influenza B Victoria and Yamagata lineages, circulated in African regions. Influenza A(H1N1)pdm2009 and A(H3N2) highly circulated in northern and southern Africa regions. Influenza activity followed annual and regional variations. In the tropical zone, from eastern to western via the middle regions, influenza activities were marked by the predominance of influenza A subtypes despite the circulation of B lineages. One season was identified for both the southern and northern regions of Africa. In the eastern zone, four influenza seasons were differentiated, and three were differentiated in the western zone. CONCLUSION: Circulation dynamics determined five intense influenza activity zones in Africa. In the tropics, influenza virus circulation waves move from the east to the west, while alternative seasons have been identified in northern and southern temperate zones. Health authorities from countries with the same transmission zone, even in the absence of local data based on an established surveillance system, should implement concerted preparedness and control activities, such as vaccination.

Influence of sociodemographic factors in birth seasonality in Spain.

OBJECTIVES: The goal of the present research is to establish for the first time a hierarchy of sociodemographic factors according to their importance influencing birth seasonality. METHODS: We used Vital Statistics data on all births registered in Spain in the period 2016-2019. Differences in the degree of seasonality between sociodemographic groups (defined by maternal age, maternal marital status, maternal education, birth order, maternal job qualification, maternal employment status, maternal location population size, and maternal country of birth) were first examined with descriptive techniques. Secondly, analysis through alternative Data Mining techniques determined the association between sociodemographic factors and birth seasonality and the factors importance rank. RESULTS: Those factors related to maternal labor status (employment status, job qualification, and education) were found to be the most relevant influencing birth seasonality. It was found that the overall seasonal pattern in Spain was driven by lower skilled employed mothers, in contrast with not employed or high skilled employed mothers, who showed a different or weaker seasonality. Finally, we found that a change in the rhythm pattern has taken place in the last decades in Spain. CONCLUSIONS: Birth seasonality is to a large extent related to maternal employment status. Employed mothers, normally more affected by the seasonality of work calendar than the unemployed, show higher conception rates structured around holidays. This may indicate that the observed change of seasonal pattern in Spain in the last decades, as in other European countries, may be specifically driven by the progressive higher participation of women in labor market.

Differential effects of antidepressant subgroups on risk of acute myocardial infarction: A nested case-control study.

The primary objective of this study was to investigate the association between antidepressants use and the risk of acute myocardial infarction (AMI). METHODS: We conducted a nested case-control study using a primary care database over the period 2002-2015. From a cohort of patients aged 40-99 years, we identified incident AMI cases and randomly selected 5 controls per case, matched to cases for exact age, sex and index date. Exposure to antidepressants were categorised as current, recent, past and nonusers. Adjusted odds ratio (AOR) and 95% confidence interval (CI) were computed using conditional logistic regression to assess the association between the current use of different antidepressants subgroups and AMI as compared to nonuse. Dose and duration effects were explored. RESULTS: Totals of 24 155 incident AMI cases and 120 775 controls were included. The current use of antidepressants as a group was associated with a reduced risk (AOR = 0.86; 95% CI: 0.81-0.91), but mainly driven by selective serotonin reuptake inhibitors (AOR = 0.86; 95% CI:0.81-0.93). A reduced risk was also observed with trazodone (AOR = 0.76;95% CI: 0.64-0.91), and clomipramine (AOR = 0.62; 95% CI: 0.40-0.96), whereas no significant effect was observed with other antidepressants. A duration-dependent effect was suggested for selective serotonin reuptake inhibitors, trazodone and clomipramine, while there was no clear dose-dependency. CONCLUSION: This study suggests that current use of antidepressants interfering selectively with the reuptake of serotonin, and those antagonizing the 5-HT2A receptor, are associated with a decrease in AMI risk and should be the antidepressants of choice in patients at cardiovascular risk.

How the choice of ethnic indicator influences ethnicity-based inequities in maternal health care in four Latin American countries: who is indigenous?

BACKGROUND: The current focus on monitoring health inequalities and the complexity around ethnicity requires careful consideration of how ethnic disparities are measured and presented. This paper aims to determine how inequalities in maternal healthcare by ethnicity change according to different criteria used to classify indigenous populations. METHODS: Nationally representative demographic surveys from Bolivia, Guatemala, Mexico, and Peru (2008-2016) were used to explore coverage gaps across maternal health care by ethnicity using different criteria. Women were classified as indigenous through self-identification (SI), spoken indigenous language (SIL), or indigenous household (IH). We compared the gaps through measuring coverage ratios (CR) with adjusted Poisson regression models. RESULTS: Proportions of indigenous women changed significantly according to the identification criterion (Bolivia:SI-63.1%/SIL-37.7%; Guatemala:SI-49.7%/SIL-28.2%; Peru:SI-34%/SIL-6.3% & Mexico:SI-29.7%/SIL-6.9%). Indigenous in all countries, regardless of their identification, had less coverage. Gaps in care between indigenous and non-indigenous populations changed, for all indicators and countries, depending on the criterion used (e.g., Bolivia CR for contraceptive-use SI = 0.70, SIL = 0.89; Guatemala CR for skilled-birth-attendant SI = 0.77, SIL = 0.59). The heterogeneity persists when the reference groups are modified and compare just to non-indigenous (e.g., Bolivia CR for contraceptive-use under SI = 0.64, SIL = 0.70; Guatemala CR for Skilled-birth-attendant under SI = 0.77, SIL = 0.57). CONCLUSIONS: The indigenous identification criteria could have an impact on the measurement of inequalities in the coverage of maternal health care. Given the complexity and diversity observed, it is not possible to provide a definitive direction on the best way to define indigenous populations to measure inequalities. In practice, the categorization will depend on the information available. Our results call for greater care in the analysis of ethnicity-based inequalities. A greater understanding on how the indigenous are classified when assessing inequalities by ethnicity can help stakeholders to deliver interventions responsive to the needs of these groups.

Indigenous language and inequitable maternal health care, Guatemala, Mexico, Peru and the Plurinational State of Bolivia.

Latin America and the Caribbean still have high maternal mortality rates and access to health care is very uneven in some countries. Indigenous women, in particular, have poorer maternal health outcomes than the majority of the population and are less likely to benefit from health-care services. Therefore, inequities in maternal health between different ethnic groups should be monitored to identify critical factors that could limit health-care coverage. In adopting the United Nations' sustainable development goals, governments have committed to providing equitable and universal health coverage. It is, therefore, the right time to assess ethnic disparities in maternal health care. However, finding a standard method of identifying ethnicity has been difficult, because ethnicity involves several features, such as language, religion, tribe, territory and race. In this study, spoken indigenous language was used successfully as a proxy for ethnicity to detect inequities in maternal health-care coverage between indigenous and non-indigenous populations in four Latin American countries: Guatemala, Mexico, Peru and the Plurinational State of Bolivia. Although, quantifying ethnic inequities in health care is just a starting point, this quantification can help policy-makers and other stakeholders justify the need for monitoring these inequities. This monitoring is essential for designing more culturally appropriate programmes and policies that will reduce the risks associated with maternity among indigenous woman. As long as inequities persist, identifying them is an important step towards their elimination.

L'Amérique latine et les Caraïbes continuent d'afficher des taux de mortalité maternelle élevés et dans certains pays, l'accès aux soins de santé est très inégal. Les femmes autochtones, en particulier, sont dans un plus mauvais état de santé maternelle que la majorité de la population et sont moins susceptibles de bénéficier des services de santé. Il convient donc de suivre les inégalités relatives à la santé maternelle entre les différents groupes ethniques pour identifier les facteurs déterminants qui peuvent limiter la couverture sanitaire. En adoptant les objectifs de développement durable des Nations Unies, les gouvernements se sont engagés à fournir une couverture sanitaire équitable et universelle. Il est donc temps d'évaluer les disparités ethniques en matière de soins de santé maternelle. Il s'est néanmoins avéré difficile de trouver une méthode standard permettant de définir l'appartenance ethnique, car cette dernière implique plusieurs caractéristiques, telles que la langue, la religion, la tribu, le territoire et la race. Dans cette étude, la langue autochtone parlée a été utilisée avec succès en tant qu'indicateur d'appartenance ethnique pour détecter les inégalités concernant la couverture des soins de santé maternelle entre les populations autochtones et non autochtones de quatre pays latino-américains: l'État plurinational de Bolivie, le Guatemala, le Mexique et le Pérou. Bien que la quantification des inégalités ethniques en matière de soins de santé ne soit qu'un point de départ, elle peut aider les responsables politiques et d'autres parties prenantes à justifier la nécessité d'un suivi de ces inégalités. Ce suivi est essentiel pour concevoir des programmes et des politiques mieux adaptés à la culture des populations et réduire ainsi les risques associés à la maternité chez les femmes autochtones. Tant que des inégalités persistent, les identifier est une étape importante vers leur élimination.

América Latina y el Caribe siguen teniendo altas tasas de mortalidad materna y el acceso a la atención sanitaria es muy desigual en algunos países. Las mujeres indígenas, en particular, tienen peores resultados en salud materna que la mayoría de la población y menos probabilidades de beneficiarse de los servicios de atención sanitaria. Por tanto, deben vigilarse las desigualdades en temas de salud materna entre los diferentes grupos étnicos para determinar los factores críticos que podrían limitar la cobertura de la atención sanitaria. Al adoptar los objetivos de desarrollo sostenible de las Naciones Unidas, los gobiernos se han comprometido a proporcionar una cobertura sanitaria equitativa y universal. Por tanto, es el momento adecuado para evaluar las disparidades étnicas en la atención sanitaria materna. Sin embargo, ha sido difícil encontrar un método estándar para identificar la etnia, pues esta tiene varias características, como el idioma, la religión, la tribu, el territorio y la raza. En este estudio, el idioma indígena hablado se utilizó con éxito como indicador de la etnicidad para detectar las desigualdades en la cobertura de la atención sanitaria materna entre las poblaciones indígenas y no indígenas en cuatro países de América Latina: el Estado Plurinacional de Bolivia, Guatemala, México y Perú. Aunque la cuantificación de las inequidades étnicas en la atención sanitaria es solo un punto de partida, esta cuantificación puede ayudar a los responsables de la formulación de políticas y a otros interesados a justificar la necesidad de monitorizar estas inequidades. Esta monitorización es esencial para diseñar programas y políticas culturalmente más adecuadas que reduzcan los riesgos asociados con la maternidad entre las mujeres indígenas. Mientras persistan las desigualdades, identificarlas es un paso importante hacia su eliminación.

Missing girls among deliveries from Indian and Chinese mothers in Spain 2007-2015.

Deliveries from Indian and Chinese mothers present a higher than expected male:female ratio in their own countries, in northern Europe, EEUU and Canada. No studies have been carried out in southern European countries. We explored whether the high male-to-female ratio common in Indian and Chinese communities, also exists among families from those regions who live in Spain. For that purpose we designed a cross-sectional population-based study containing data on 3,133,908 singleton live births registered in the Spanish Vital Statistics Registry during the period 2007-2015. The ratio of male:female births by area of origin was calculated using binary intercept-only logistic regression models without reference category for the whole sample of births and taking into account a possible effect modification of birth order and sex of the previous males. Interaction effects of sociodemographic mothers' and fathers' characteristics was also assesed. In Spain, the ratio male:female is higher than expected for Indian-born mothers, especially for deliveries from mothers with no previous male births and, to a lesser extent, for Chinese-born women, specifically for third or higher order births and slightly influenced by the sex of the previous births. Therefore, the increased sex male:female ratio observed in other countries among Indian and Chinese mothers is also observed in Spain. This reinforces the notion that culture and values of the country of origin are more influential than the country of residence.

International variations in the gestational age distribution of births: an ecological study in 34 high-income countries.

Background: Few studies have investigated international variations in the gestational age (GA) distribution of births. While preterm births (22-36 weeks GA) and early term births (37-38 weeks) are at greater risk of adverse health outcomes compared to full term births (39-40 weeks), it is not known if countries with high preterm birth rates also have high early term birth rates. We examined rate associations between preterm and early term births and mean term GA by mode of delivery onset. Methods: We used routine aggregate data on the GA distribution of singleton live births from up to 34 high-income countries/regions in 1996, 2000, 2004, 2008 and 2010 to study preterm and early term births overall and by spontaneous or indicated onset. Pearson correlation coefficients were adjusted for clustering in time trend analyses. Results: Preterm and early term births ranged from 4.1% to 8.2% (median 5.5%) and 15.6% to 30.8% (median 22.2%) of live births in 2010, respectively. Countries with higher preterm birth rates in 2004-2010 had higher early term birth rates (r > 0.50, P < 0.01) and changes over time were strongly correlated overall (adjusted-r = 0.55, P < 0.01) and by mode of onset. Conclusion: Positive associations between preterm and early term birth rates suggest that common risk factors could underpin shifts in the GA distribution. Targeting modifiable population risk factors for delivery before 39 weeks GA may provide a useful preterm birth prevention paradigm.

Gender equality and smoking: a theory-driven approach to smoking gender differences in Spain.

BACKGROUND: The intersection between gender and class can aid in understanding gender differences in smoking. AIM: To analyse how changes in gender inequality relate to differences in smoking prevalence by gender, education and birth cohort in Spain over the past five decades (1960-2010). METHODS: The Gender Inequality Index (GII) was calculated in 5-year intervals from 1960 to 2010. GII ranges from 0 to 1 (1=highest inequality) and encompasses three dimensions: reproductive health, empowerment and labour market. Estimates of female and male smoking prevalence were reconstructed from representative National Health Surveys and stratified by birth cohort and level of education. We calculated female-to-male smoking ratios from 1960 to 2010 stratified by education and birth cohort. RESULTS: Gender inequality in Spain decreased from 0.65 to 0.09 over the past 50 years. This rapid decline was inversely correlated (r=-0.99) to a rising female-to-male smoking ratio. The youngest birth cohort of the study (born 1980-1990) and women with high education levels had similar smoking prevalences compared with men. Women with high levels of education were also the first to show a reduction in smoking prevalence, compared with less educated women. CONCLUSIONS: Gender inequality fell significantly in Spain over the past 50 years. This process was accompanied by converging trends in smoking prevalence for men and women. Smoking prevalence patterns varied greatly by birth cohort and education levels. Countries in earlier stages of the tobacco epidemic should consider gender-sensitive tobacco control measures and policies.

Socioeconomic inequalities in stillbirth rates in Europe: measuring the gap using routine data from the Euro-Peristat Project.

BACKGROUND: Previous studies have shown that socioeconomic position is inversely associated with stillbirth risk, but the impact on national rates in Europe is not known. We aimed to assess the magnitude of social inequalities in stillbirth rates in European countries using indicators generated from routine monitoring systems. METHODS: Aggregated data on the number of stillbirths and live births for the year 2010 were collected for three socioeconomic indicators (mothers' educational level, mothers' and fathers' occupational group) from 29 European countries participating in the Euro-Peristat project. Educational categories were coded using the International Standard Classification of Education (ISCED) and analysed as: primary/lower secondary, upper secondary and postsecondary. Parents' occupations were grouped using International Standard Classification of Occupations (ISCO-08) major groups and then coded into 4 categories: No occupation or student, Skilled/ unskilled workers, Technicians/clerical/service occupations and Managers/professionals. We calculated risk ratios (RR) for stillbirth by each occupational group as well as the percentage population attributable risks using the most advantaged category as the reference (post-secondary education and professional/managerial occupations). RESULTS: Data on stillbirth rates by mothers' education were available in 19 countries and by mothers' and fathers' occupations in 13 countries. In countries with these data, the median RR of stillbirth for women with primary and lower secondary education compared to women with postsecondary education was 1.9 (interquartile range (IQR): 1.5 to 2.4) and 1.4 (IQR: 1.2 to 1.6), respectively. For mothers' occupations, the median RR comparing outcomes among manual workers with managers and professionals was 1.6 (IQR: 1.0-2.1) whereas for fathers' occupations, the median RR was 1.4 (IQR: 1.2-1.8). When applied to the entire set of countries with data about mothers' education, 1606 out of 6337 stillbirths (25 %) would not have occurred if stillbirth rates for all women were the same as for women with post-secondary education in their country. CONCLUSIONS: Data on stillbirths and socioeconomic status from routine systems showed widespread and consistent socioeconomic inequalities in stillbirth rates in Europe. Further research is needed to better understand differences between countries in the magnitude of the socioeconomic gradient.

The current deconstruction of paradoxes: one sign of the ongoing methodological "revolution".

The current deconstruction of paradoxes is one among several signs that a profound renewal of methods for clinical and epidemiological research is taking place; perhaps for some basic life sciences as well. The new methodological approaches have already deconstructed and explained long puzzling apparent paradoxes, including the (non-existent) benefits of obesity in diabetics, or of smoking in low birth weight. Achievements of the new methods also comprise the elucidation of the causal structure of long-disputed and highly complex questions, as Berkson's bias and Simpson's paradox, and clarifying reasons for deep controversies, as those on estrogens and endometrial cancer, or on adverse effects of hormone replacement therapy. These are signs that the new methods can go deeper and beyond the methods in current use. A major example of a highly relevant idea is: when we condition on a common effect of a pair of variables, then a spurious association between such pair is likely. The implications of these ideas are potentially vast. A substantial number of apparent paradoxes may simply be the result of collider biases, a source of selection bias that is common not just in epidemiologic research, but in many types of research in the health, life, and social sciences. The new approaches develop a new framework of concepts and methods, as collider, instrumental variables, d-separation, backdoor path and, notably, Directed Acyclic Graphs (DAGs). The current theoretical and methodological renewal-or, perhaps, "revolution"-may be changing deeply how clinical and epidemiological research is conceived and performed, how we assess the validity and relevance of findings, and how causal inferences are made. Clinical and basic researchers, among others, should get acquainted with DAGs and related concepts.

Validation of a method for reconstructing historical rates of smoking prevalence.

The validity of methods for reconstructing historical rates of smoking prevalence has not been assessed before. Our objective was to assess their validity. We reconstructed smoking prevalence rates for each calendar year from 1940 to 2007 for men and women in Spain, using data on ages of smoking initiation and cessation available in the Spanish National Health Surveys of 2003-2004 and 2006-2007. To assess the validity of the reconstruction, we computed the differences between the reconstructed smoking prevalence and the contemporary observed smoking prevalence measured in the Spanish National Health Surveys of 1987, 1993, 1995, 1997, and 2001. We also compared reconstructed smoking prevalence trends with 35-year lagged lung cancer mortality rates in Spain as a proxy for the real prevalence trends. Reconstructed smoking prevalence rates compared with contemporary measured rates showed small differences in men (between -2.1% and 2.1%) and an overestimation in women (between 2.0% and 5.7%). Reconstructed smoking prevalence trends were significantly correlated with lagged lung cancer mortality trends (P = 0.004 for men, P < 0.0001 for women). The reconstruction of smoking prevalence rates through this methodology offers a feasible tool with which countries lacking previous smoking surveys can understand historical trends in their tobacco epidemic, which aids in designing and implementing adequate tobacco control interventions.

Varying gestational age patterns in cesarean delivery: an international comparison.

BACKGROUND: While international variations in overall cesarean delivery rates are well documented, less information is available for clinical sub-groups. Cesarean data presented by subgroups can be used to evaluate uptake of cesarean reduction policies or to monitor delivery practices for high and low risk pregnancies based on new scientific evidence. We studied differences and patterns in cesarean delivery rates by multiplicity and gestational age in Europe and the United States. METHODS: This study used routine aggregate data from 17 European countries and the United States on the number of singleton and multiple live births with cesarean versus vaginal delivery by week of gestation in 2008. Overall and gestation-specific cesarean delivery rates were analyzed. We computed rate differences to compare mode of delivery (cesarean vs vaginal birth) between selected gestational age groups and studied associations between rates in these subgroups namely: very preterm (26-31 weeks GA), moderate preterm (32-36 weeks GA), near term (37-38 weeks GA), term (39-41 weeks GA) and post-term (42+ weeks GA) births, using Spearman's rank tests. RESULTS: High variations in cesarean rates for singletons and multiples were observed everywhere. Rates for singletons varied from 15% in The Netherlands and Slovenia, to over 30% in the US and Germany. In singletons, rates were highest for very preterm births and declined to a nadir at 40 weeks of gestation, ranging from 8.0% in Sweden and Norway, to 22.5% in the US. These patterns differed across countries; the average rate difference between very preterm and term births was 43 percentage points, but ranged from 14% to 61%. High variations in rate differences were also observed for near term versus term births. For multiples, rates declined by gestational age in some countries, whereas in others rates were similar across all weeks of gestation. Countries' overall cesarean rates were highly correlated with gestation-specific subgroup rates, except for very preterm births. CONCLUSIONS: Gestational age patterns in cesarean delivery were heterogeneous across countries; these differences highlight areas where consensus on best practices is lacking and could be used in developing strategies to reduce cesareans.

HIV testing and counselling for migrant populations living in high-income countries: a systematic review.

BACKGROUND: The barriers to HIV testing and counselling that migrants encounter can jeopardize proactive HIV testing that relies on the fact that HIV testing must be linked to care. We analyse available evidence on HIV testing and counselling strategies targeting migrants and ethnic minorities in high-income countries. METHODS: Systematic literature review of the five main databases of articles in English from Europe, North America and Australia between 2005 and 2009. RESULTS: Of 1034 abstracts, 37 articles were selected. Migrants, mainly from HIV-endemic countries, are at risk of HIV infection and its consequences. The HIV prevalence among migrants is higher than the general population's, and migrants have higher frequency of delayed HIV diagnosis. For migrants from countries with low HIV prevalence and for ethnic minorities, socio-economic vulnerability puts them at risk of acquiring HIV. Migrants have specific legal and administrative impediments to accessing HIV testing-in some countries, undocumented migrants are not entitled to health care-as well as cultural and linguistic barriers, racism and xenophobia. Migrants and ethnic minorities fear stigma from their communities, yet community acceptance is key for well-being. CONCLUSIONS: Migrants and ethnic minorities should be offered HIV testing, but the barriers highlighted in this review may deter programs from achieving the final goal, which is linking migrants and ethnic minorities to HIV clinical care under the public health perspective.

The quality of vital statistics for studying perinatal health: the Spanish case.

BACKGROUND: Birthweight and gestational age are key indicators for perinatal health obtained through the birth certificate. Knowing the validity of birth certificate data is crucial when identifying needs and evaluating birth outcomes. In Spain, vital information is reported by parents and is not checked for consistency with any hospital document. Therefore, to perform a validation study and describe the variables associated with misreporting is essential to improve the quality of birth certificates. METHODS: A database was created using birth information from hospital medical records that were individually linked with the Spanish National Institute of Statistics (INE) birth certificate files. Measures of reliability and validity were used to compare the data from the two sources. Logistic regression models were adjusted to model the odds of being misreported in birthweight and gestational age, controlling for relevant variables. RESULTS: INE overestimated the prevalence of birthweight and gestational age. The degree of agreement between the two sources was good for most gestational age groups (Kappa = 0.74), very good for the very preterm (Kappa = 0.85) and very good also for all categories of birthweight (Kappa = 0.88). Misreporting was significantly higher among immigrants, unmarried mothers and girls. Being a preterm birth increased the odds of being declared with errors in gestational age; having low birthweight and missing information on gestational age were associated with misreporting birthweight. CONCLUSIONS: The reliability of INE information could be greatly improved if hospitals included birthweight and gestational age on the document provided to parents for registering the birth.

Adverse birth outcomes in New York City women: Revisiting the Hispanic Paradox.

In the United States, African American or non-Hispanic Black infants experienced worst birth outcomes whereas Hispanic and Asian infants have intermediate or similar outcomes compared with non-Hispanic white infants. The findings of better birth outcomes for Hispanic women have been coined the "Hispanic Paradox" given their low education, income, and access to care. New York City (NYC) has a great racial/ethnic diversity with implications for neighborhood racial/ethnic composition on birth outcomes by protecting women from psychosocial stress via social support that may buffer against racial/ethnic discrimination and/or racism. Data from 2012 to 2018 were used to examine the association of NYC women's race/ethnicity and neighborhood racial/ethnic minority composition with adverse birth outcomes (low birthweight [LBW], small for gestational age [SGA], preterm birth and infant mortality); and whether the association between mother's race/ethnicity and each birth outcome differed by neighborhood racial/ethnic composition. Multilevel logistic regression was used to control for the clustering of outcomes within neighborhoods. Black, Asian, and American Indian women have poorer birth outcomes than white women. Infants of Mexican American, Central American, and South American women were less likely to be of LBW whereas the opposite was true for infants of Cuban and other Hispanic women compared with infants of white women. When compared with white women, Mexican American, and South American women were less likely to have an SGA infant whereas Puerto Rican and other Hispanic women were more likely to have an SGA infant. All Hispanic women were more likely to have a preterm birth than white women whereas for infant mortality, greater odds of dying were observed for infants of Puerto Rican, Dominican, and other Hispanic women. Higher neighborhood racial/ethnic minority composition was associated with greater odds of having an adverse outcome. Finally, we observed heterogeneity of the associations between mother's race/ethnicity and birth outcomes by neighborhood racial/ethnic minority composition.

Effect of emergency obstetric care and proximity to comprehensive facilities on facility-based delivery in Malawi and Haiti.

Proximity of households to comprehensive obstetric care is a key determinant for preventing maternal mortality due to obstetric emergencies. The relationship between proximity to comprehensive care and facility delivery is further complicated by the use of varied methods in measuring facility obstetric capacity-which may misrepresent the real scenario of obstetric care availability in a service environment. We investigated the joint effects of proximity and two emergency obstetric care assessment (EmOC) methods on women's place of delivery in Malawi and Haiti. Household level and health facility data were obtained from the 2013-2018 Demographic and Health Surveys and Service Provision Assessment surveys. Records of women aged 15 to 49 years who had a childbirth in the last 5 years were linked to obstetric facilities within 5km, 10km and 15km from their households using Kernel Density Estimation. Log-binomial models were fitted to estimate the joint effects of proximity to comprehensive facilities on place of delivery and two EmOC methods (1. the facility's recent performance of signal functions only, and 2. a composite index of obstetric care), and whether this varied by urban/rural setting. Proximity to comprehensive facilities was significantly associated with facility delivery in Malawi among women living 5km of a comprehensive facility (using EmOC method 2), in addition, living further (15km) from facilities with high capacity of EmOC was associated with reduced likelihood for facility delivery in urban settings in stratified analyses. In contrast, positive associations were present in Haiti in both urban and rural settings, with the likelihood of facility delivery being higher with greater proximity of women to comprehensive facilities, regardless of methods to define EmOC. Women living within 5km of a comprehensive facility in Haiti were the most likely to deliver in facilities based on EmOC method 1 (APR: 1.81, 95% CI 1.56, 2.09). Findings from Malawi elucidates the relevance of context and suggests the need for research in diverse settings.

Educational level and HIV disease progression before and after the introduction of HAART: a cohort study in 989 HIV seroconverters in Spain.

OBJECTIVES: To analyse the effect of educational level on the progression from HIV seroconversion to highly active antiretroviral therapy (HAART) requirement, HAART initiation, AIDS and death from any cause at different periods of the HIV epidemic in Spain. METHODS: Open, prospective, multicentre cohort of HIV seroconverters set up in 1983. The risk of progression was calculated by the multiple decrements method. Effect of educational level was estimated by Fine and Gray model, adjusting for sex, HIV transmission category, age and method to estimate seroconversion. Calendar period was introduced as a variable that could change over time (<1997; 1997-2003; >2003). RESULTS: Up to 2009, 989 HIV seroconverters with information on educational level were identified. Some 52% and 48% had a low and a high educational level respectively. Persons with higher education had 32% lower risk of death (HR: 0.68; 95% CI 0.45 to 1.03). Regarding progression to AIDS, educational level had no effect in the pre-HAART era (HR: 1.47; 95% CI 0.91 to 2.38), but did show an effect in the period 1997-2003 (HR: 0.58; 95% CI 0.34 to 0.99), which was accentuated after 2004 (HR: 0.26; 95% CI 0.10 to 0.68). No difference was found in time to HAART requirement or initiation. CONCLUSIONS: Results suggest that, despite similar access to HAART, persons with low educational level are at increased risk of HIV disease progression, highlighting the impact of social inequities on health. The availability of more effective treatments over time will strengthen the protective effect of higher education on the development of AIDS.