Are pregnancy outcomes affected by the lack of legal status? A demographic study based on 850,288 live births in Switzerland.

BACKGROUND: In the context of increased global mobility, it is fundamental to understand migrants' needs and how governments can ensure equal health opportunities for both regular and irregular migrants simply by applying low-cost primary health care measures. To identify health issues in which to intervene, this study analysed the impact of a mother's lack of legal status, together with available biological and socioeconomic characteristics, on four indicators of adverse perinatal outcomes in Switzerland. METHODS: Based on the exhaustive records of the Swiss Federal Statistical Office (FSO) for its Vital Statistics (BEVNAT), different indicators of birth outcomes, including preterm birth (PTB), low and very low birth weight (LBW and VLBW), and small for gestational age (SGA), were analysed using logistic regressions on live births occurring from 2005 to 2018. These four adverse outcomes were defined as dependent variables. Statistical analysis was performed using the statistical package STATA, version 17. RESULTS: Selected pregnancy outcomes were conversely affected by an irregular legal status. Analysis run on the final sample showed that, compared to the neonates of mothers who are non-migrant legal residents in Switzerland, newborns of irregular migrants have higher risks of PTB (aOR 1.18 95% CI [1.05-1.32], p<0.01) and VLBW (aOR 1.43 [1.13-1.81], p < 0.01]). In contrast, we observed that in both irregular and regular migrant groups, the odds of SGA were lowered (aOR .76 [.68-.85] p<0.01) and aOR .93 [.91-.94], p< 0.01, respectively). A similar effect was observed when controlling for any adverse outcome (any AOs) (aOR  .90 [.83-.99] p 0.022; and aOR .93 [.91-.94] p< 0.01, respectively). CONCLUSIONS: Our results, together with those from the available literature, call for a more comprehensive assessment of all pregnancy outcomes as well as of the social determinants of health for which the analysis was adjusted. Given the complexity of the migration phenomenon, future studies should account for local structural restrictions in the organization of care, the extension of a person's network as a means of health care accessibility, diverse backgrounds and cultures and the recent arrival status of migrants. This would allow researchers to understand the long-term impact of social determinants of health on the wellbeing of a mother and child and take them into account in the adoption of health policies.

The political determinants of the health of undocumented immigrants: a comparative analysis of mortality patterns in Switzerland.

BACKGROUND: The health of undocumented immigrants is an important concern in most societies. However, there is no conclusive evidence that inclusive health care policies lead to better outcomes for this group of the population. The aim of this study is to analyse whether there is an association between inclusive health care policies and the mortality patterns of undocumented immigrants, or the distribution of different causes of death among those who have died. METHODS: We analyse individual data concerning the deceased in Switzerland between 2011 and 2017. We proceed in two steps. First, we estimate and compare the patterns of mortality of Swiss citizens, documented immigrants, and undocumented immigrants. Second, we test whether there is an association between cantonal authorities' policies and differing mortality patterns. We use logistic regressions and multinomial regressions to estimate the relationship between legal status and mortality patterns both in Switzerland and across different cantons. RESULTS: We find a difference in the patterns of mortality between undocumented immigrants and the other groups of the population. Specifically, death from circulatory system diseases is twice as frequent among undocumented immigrants compared to documented immigrants and Swiss citizens. However, this difference is smaller in the Swiss cantons that have more inclusive health care policies towards undocumented immigrants. CONCLUSIONS: We interpret these results as an indication that policies that expand access to health services lead to better outcomes for undocumented immigrants. This finding has implications for research on civic stratification and public health. Further analysis is needed to evaluate the effects of extending public health care for undocumented immigrants in different contexts.

The contribution of the foreign population to the high level of infant mortality in Switzerland: a demographic analysis.

BACKGROUND: In 2011 Switzerland reported the highest infant mortality rate among Western European countries, as well as the highest percentage of foreign population (23%). The comparison of the Swiss and foreign population in terms of reproductive health has received so far insufficient attention. The aim of the present study is to analyze the infant (IMR) and neonatal mortality rates (NMR) of Swiss and foreign children over the last 30 years. METHODS: Vital statistics from the period 1980 to 2011 were used to compute IMR and NMR according to year and/or citizenship. The main analyses were made contrasting Swiss versus foreigners as a single category, as well as by country of origin. Comparisons between groups were done using relative risks. RESULTS: In 1980-1989, IMR was 14% higher among foreign children as compared to Swiss children, and NMR 28% higher. In 2006-2010, IMR was 18% higher among foreign children than among Swiss children, and NMR 29% higher. The highest gap of IMR was observed during the period 1990-1993 (+21%). Looking at single countries, in 2008-2010 children of migrants from Germany, Portugal, Turkey, Italy, France, Kosovo and Spain had a higher level of IMR as compared to Swiss children. CONCLUSIONS: The analysis of vital statistics confirms that over the last 30 years the gap of IMR and NMR between Swiss and foreign children has not decreased. Whatever the combination of mechanisms, which cause the observed difference, this fundamental inequity needs to be investigated and remedied by a large scale, concerted effort.

Linguistic difference in the effect of organized programs on socioeconomic inequalities in breast cancer screening: ecological study in Switzerland.

OBJECTIVE: The objective of this study is to examine how the effect of organized mammography screening programs on breast cancer screening participation differ between socioeconomic strata and how this relationship may be modified by the context of linguistic differences. Switzerland, marked by its diverse linguistic landscape, reflects cultural variations alongside differences in public health strategies. The goal of this study was to assess potential socioeconomic differences in regional mammography screening programs effectiveness to improve breast cancer screening participation. METHODS: Data on 14 173 women in the regionally adapted breast cancer screening age range was drawn from five cross-sectional waves of the nationally representative Swiss Health Interview Survey (1997-2017). Socioeconomic indicators included education, household income, and employment status. Poisson regression was used to estimate the adjusted prevalence ratios of up-to-date (last 2 years) mammography uptake. Inequality was assessed using relative index of inequality and the slope index of inequality. RESULTS: Organized screening programs were generally effective and increased up-to-date mammography uptake by close to 20 percentage points in both regions. While in the Latin cantons, screening programs had no impact on socioeconomic inequalities in screening, it reduced inequalities for women with lower education in the German cantons. This modification effect of screening programs was not seen for income and employment-related inequalities and did not differ across linguistic regions. CONCLUSIONS: Public health agencies should consider the different cultural reception of programs as addressing these differences could help ensure that breast cancer screening initiatives are not only effective, but also culturally equitable across different socioeconomic groups.

Self-reported health among migrants. Does contextual discrimination matter?

Background: Switzerland is characterised by significant flows of migrants from different countries of origin and with different levels of education. More than half of recent migrants have reported experiencing prejudice or discriminatory practices in the last 24 months. Methods: Based on a 2018 survey of 7,740 adult migrants (aged 24-64) who arrived in Switzerland in 2006 or later, we examine whether self-reported health is statistically associated with the perception of being a victim of prejudice or discrimination. Ordered logistic regressions are estimated using two indicators of discrimination: the frequency of discrimination and the number of places where discrimination occurs. Results: The regression results show that discrimination, which is not necessarily based on ethnicity or migrant status, is associated with health status, even after controlling for possible confounding factors. Discussion: Our results confirm those already observed in other countries of immigration. They suggest a likely association between perceived discrimination and self-reported health.

Effect of covering perinatal health-care costs on neonatal outcomes in Switzerland: a quasi-experimental population-based study.

BACKGROUND: Low birthweight and preterm birth are associated with an increased risk of neonatal death and chronic conditions across the life course. Reducing these adverse birth outcomes is a global public health priority and requires strategies to improve health care during pregnancy. We aimed to assess the effect of a Swiss health policy expansion fully covering illness-related costs during pregnancy on health outcomes in newborn babies. METHODS: We implemented a quasi-experimental difference in regression discontinuity design to assess the effect of expansion of Swiss health insurance (on March 1, 2014), to fully cover health-care costs during pregnancy and 8 weeks postpartum, on neonatal outcomes. Before this reform, only costs specific to the standard monitoring of a normal pregnancy were covered. Babies born before March 1, 2014, and their mothers were assigned to the unexposed group, and babies born on or after March 1, 2014, and their mothers were assigned to the exposed group. We included nearly all children born 2011-19 in Switzerland within a period of 9 months around the date March 1, 2014, and control years 2012, 2016, and 2018. Outcomes were birthweight, low birthweight, very low birthweight, gestational age, preterm or extremely preterm birth, and neonatal death. We estimated the intention-to-treat effect of the policy using parametric regression models. FINDINGS: 61 910 children were born 9 months before and 63 991 were born 9 months after March 1, 2014. 382 861 children were born in the same time period around the three control dates. In the period before policy implementation, mean birthweight was 3289 g, gestational age was 275 days, and 6·5% of children had low birthweight, 1·0% very low birthweight, 7·1% were preterm, 0·4% were extremely preterm, and 0·3% died within the first 28 days of life. After initiation of the policy (vs before) mean birthweight increased by 23 g (95% CI 5 to 40) and the predicted proportion of low birthweight births decreased by 0·81% (0·14 to 1·48) and of very low birthweight births decreased by 0·41% (0·17 to 0·65). The effect on very low birthweight was not robust in sensitivity analyses. The policy had a negligible effect on gestational age (mean difference 1 day, 95% CI 0 to 1) and no clear effects on the other examined outcomes. The change in predicted proportion for preterm births was -0·39% (95% CI -1·2 to 0·38), for extremely preterm births was -0·09% (-0·27 to 0·08), and for neonatal death was -0·07% (-0·2 to 0·07). INTERPRETATION: Free access to prenatal care in Switzerland reduced the risk of some adverse health outcomes in newborn babies. Expanding health-care coverage is a relevant health system intervention to reduce the risk of adverse health outcomes in the newborn baby and, potentially, across the life course. FUNDING: Swiss National Science Foundation.

Smoking trends and health equity in Switzerland between 1992 and 2017: dependence of smoking prevalence on educational level and social determinants.

Background: Switzerland ranks among the top three healthcare systems in the world with regards to healthcare access, suggesting a high degree of health equity. However, Switzerland has few preventive strategies against smoking abuse. The aim of this study is to clarify whether educational level and citizenship status have an influence on the prevalence of smoking in Switzerland and whether there is health inequity related to a lack of preventive strategies. Methods: We based our analysis on publicly available health data published in the Swiss government's Swiss health survey (1992-2017). We compared the prevalence of smoking across the years and correlated these data with levels of educational attainment, citizenship status and age. Results: A continuous significant decline in smokers is observed in the highest education group (TERT). Over time, prevalence was reduced from 29% in 1992 to 23% in 2017 (p < 0.001). The intermediate-level educational group (SEK 2) showed smaller but also significant decline on a 0.05 sigificance level over the same period, from 31% to 29% (p = 0.003). The lowest educational group showed a nonsignificant decline from 28% to 27% (p = 0.6). The population who holds Swiss citizenship showed a decrease in smoking from 28% to 26% within the time frame (p < 0.001). People without Swiss citizenship had a much higher prevalence of smokers, at 38% in 1992 and declining to 32% in 2017 (p < 0.001). All cohorts from age 15 to age 64 have a far higher prevalence of smokers than cohorts at an older age, with the highest prevalence in the 25-34 age group. Conclusion: In Switzerland, individuals with lower levels of education and non-Swiss populations are more susceptible to health risk of smoking. This is despite the existence of a high-quality healthcare system that has nevertheless failed to negated health inequities.

A Longitudinal Analysis of Naturalization and International Migration in Switzerland, 2011-2017.

The notion of residential settlement associated with the acquisition of new citizenship has been recently challenged by a number of studies highlighting its instrumentality as a subsequent mobility factor. The long and diverse history of Switzerland as a country of immigration and the availability of rich data on naturalization and international migration that allow individuals to be followed over time make this country a valuable case for investigating the impact of naturalization on international (return or onward) migration. Using longitudinal data, we follow 88,900 immigrants who entered the country between 1998 and 2000 over a period of 84 months between January 2011 and December 2017, documenting changes in naturalization status and in migratory movements and their direction. Using different implementations of a Cox proportional hazards model, we examine whether and under what conditions the international migration behaviour of naturalized persons differs from that of non-naturalized persons. Our results show that the population accessing naturalization tends to be less mobile, but also that among third-country nationals, naturalization can trigger further international mobility, in particular among those with poor economic performance and with no family ties in Switzerland.

How effective are integration policy reforms? The case of asylum-related migrants.

The marked increase of asylum seekers arriving in Western Europe after 2014 has renewed debates on policy measures that countries should put into place to support their integration. Although implemented by many countries in recent years, research has neglected the effect of integration policy reform packages combining economic and social policy measures on asylum-related immigrants' adjustment processes. Exploiting a comprehensive integration policy reform in Switzerland, using survey data from the Health Monitoring of the Swiss Migrant Population, and registering data on the whole asylum-related population, our difference-in-differences analyses reveal that provisionally admitted individuals benefiting from the reform have higher employment probability, increased income levels, better language skills, and feel less lonely or without a homeland relative to comparable asylum seekers who did not benefit from the reform. Robustness checks assessing common pre-reform trends support our findings, which highlight the importance of evaluating entire reform packages when assessing integration policies' effectiveness.

COVID-19-Related Health Literacy of Socioeconomically Vulnerable Migrant Groups.

Objective: Understand the COVID-19-related health literacy of socioeconomically vulnerable migrant groups. Methods: We conducted a survey available in 8 languages among 2,354 members of the target population in Switzerland in 2020. We measured health literacy in four dimensions (finding, understanding, evaluating and applying health information) and assessed adherence to official recommendations during the COVID-19 pandemic. Results: Most migrants felt well informed about the pandemic. Using an extended index of health literacy, we found a moderate correlation (r = -0.28 [-0.24, -0.32]) between COVID-19-related health literacy and socioeconomic vulnerability. The most socioeconomically vulnerable migrants tended to have more difficulty finding and understanding health information about COVID-19 and adhered more to unscientific theses that were not part of the official communication. Conclusion: Special communication efforts by public health authorities have reached most migrants, but socioeconomic vulnerability can be a barrier to taking precautions.

Self-reported cardiovascular risk factors in immigrants and Swiss nationals.

OBJECTIVE: The purpose of this study was to investigate whether the prevalence of self-reported cardiovascular risk factors differs between immigrants and Swiss nationals. DESIGN AND SAMPLE: This study is a secondary data analysis of the Swiss Health Survey 2002, a cross-sectional survey. In total, 19,249 individuals living in Switzerland were included. MEASURES: The prevalence of hypertension, high cholesterol level, smoking, diabetes, overweight, low fruit and vegetable intake, and physical inactivity were calculated for major immigrant groups and Swiss nationals. Demographic data were used to control for age and socioeconomic status. RESULTS: Major immigrant groups were people from Italy, Germany, former Yugoslavia, Spain, Portugal, France, and Turkey. Compared with Swiss women, women from former Yugoslavia were more likely to have hypertension, and women from Germany were more likely to have high cholesterol levels. Women from Italy, former Yugoslavia, Spain, Portugal, and Turkey were more likely to show physical inactivity and (except Turkish women) to be overweight. Men from these countries (except Spanish men) were more likely to be overweight than Swiss men. CONCLUSIONS: Differences exist in the prevalence of modifiable cardiovascular risk factors between Swiss nationals and many of the immigrant groups. Age and socioeconomic status could only partly explain the differences.

Does Educational Mismatch Affect Emigration Behaviour?

This paper uses linked Swiss administrative and survey data to examine the relationship between educational mismatch in the labour market and emigration decisions, carrying out the analysis for both Swiss native and previous immigrant workers. In turn, migrants' decisions separate returning home from onward migration to a third country. We find that undereducation is positively associated with the probability of emigration and return to the country of origin. In contrast, the reverse relationship is found between overeducation and emigration, especially among non-European immigrant workers. According to the predictions of the traditional model of migration, based on self-selection, migrants returning home are positively selected relative to migrants emigrating to other countries. We also find that immigrants from a country outside the EU27/EFTA have little incentive to return home and generally accept jobs for which they are mismatched in Switzerland. These results highlight the relevance to understand emigration behaviours in relation to the type of migrant that is most integrated, and productive, in the Swiss market, hence enabling better migration and domestic labour market policy design.

Adverse perinatal outcomes among children in Switzerland: the impact of national origin and socio-economic group.

OBJECTIVES: We examined the effect of the mother's origin and socio-economic characteristics on adverse perinatal outcomes in Switzerland. METHODS: Births occurring from 2011 to 2017 were identified in the Swiss population register and merged with the Swiss civil register and the Register of the first pillar to obtain information on the migration origin and socio-economic level. Four indicators of adverse perinatal outcomes were defined. RESULTS: Logistic regressions show that both the migration origin and the socio-economic level are measured by the parents' income, influence risk. Compared to the children of mothers born in Switzerland, those of mothers from EU/EFTA countries have a lower risk of infant mortality, low birth weight and extreme prematurity. The highest risk is observed for children born to mothers from the rest of the world. High levels of risk consistently characterize children with low-income parents (first decile). CONCLUSIONS: Our results justify further investigations at the level of health services to better identify the factors causing differences in the prevalence of adverse outcomes and to take them into account in adapted health policies.

Pregnancy outcome of migrant women and integration policy: a systematic review of the international literature.

Immigrant mothers in developed countries often experience worse pregnancy outcomes than native women. Several epidemiological studies have described the pregnancy outcome of immigrant women in European receiving countries, with conflicting results. The present systematic review makes a quantitative synthesis of available evidence on the association between pregnancy outcomes and integration policies. We reviewed all epidemiological studies comparing the pregnancy outcome of native versus immigrant women in European countries from 1966 to 2004 and retained 65 for analysis, from 12 host countries. Overall, as compared to native women, immigrant women showed a clear disadvantage for all the outcomes considered: 43% higher risk of low birth weight, 24% of pre-term delivery, 50% of perinatal mortality, and 61% of congenital malformations. The risks were clearly and significantly reduced in countries with a strong integration policy. This trend was maintained even after adjustment for age at delivery and parity. On the basis of an analysis of naturalisation rates, five countries in our sample could be categorised as having a strong policies promoting the integration of immigrant communities. The mechanisms through which integration policies may be protective include the increased participation of immigrant communities in the life of the receiving society, and the decreased stress and discrimination they may face. The results of this study highlight a serious problem of equity in perinatal health across European countries. Immigrant women clearly need targeted attention to improve the health of their newborn, but a deep societal change is also necessary to integrate and respect immigrant communities in receiving societies.

[Mortality of 1880-1980 generations in Switzerland: a rereading of evolution of mortality based on longitudinal data]. / Mortalité des générations 1880-1980 en Suisse: une relecture de l'évolution de la mortalité à partir de données longitudinales.

OBJECTIVES: Seek to explain the declining mortality rates observed in Switzerland using a different approach from conventional period analyses. METHODS: Analysis of the mortality rates for cohorts born between 1880 and 1980 in Switzerland. RESULTS: While the mortality transition was a constant feature of the 20th century, mortality receded most sharply among the 1900 to 1940 birth cohorts. Life expectancy gains were much lower for the pre-1900 cohorts, while early trends for the post-1940 cohorts point to a slowdown in the rate of mortality decline. These findings may be connected with the social and health conditions in which the different cohorts lived. CONCLUSION: In contrast to the cross-sectional analysis, the longitudinal approach shows that the decline in mortality suddenly stops with the 1940 cohort.

Trends in maternal mortality in Switzerland among Swiss and foreign nationals, 1969-2006.

OBJECTIVES: To test whether maternal mortality was higher among immigrant women than Swiss women. METHODS: All maternal deaths and live births in Switzerland from 1969 to 2006 from official vital statistics were considered. We calculated maternal mortality ratios (MMRs) in four time intervals (1969-1979, 1980-1989, 1990-1999, 2000-2006) for both Swiss and immigrant women overall, and for Italian, Spanish and Turkish women. We also computed the odds ratios and 95% confidence intervals of maternal mortality over the four time periods, considering maternal deaths as cases, and live births as controls. RESULTS: From 1969 to 2006 there were 279 maternal deaths, 204 of Swiss women and 75 of immigrant women. Women's age, marital status and cause of death were similar in the two groups. For immigrant women, the crude odds ratio of a pregnancy ending with maternal death, not homogeneous across the four periods, was 4.38 (95% CI 1.88-10.55) in 2000-2006. CONCLUSIONS: Immigrant women have a higher risk of maternal mortality than Swiss women. A closer scrutiny of risk factors and quality of care is necessary to identify opportunities for prevention.

The self-reported health of immigrant groups in Switzerland.

BACKGROUND: More than 20% of people living in Switzerland are immigrants, defined as people with foreign nationality. This study examines health disparities between the main immigrant groups in Switzerland and the majority Swiss population. METHODS: Epidemiological analysis of the 2002 Swiss Health Survey (SHS): the SHS contains health-related information about 19,706 people who were randomly sampled from among people living in Switzerland. Bi-variate and multivariate analyses of six variables on self-reported health were performed. FINDINGS: The data from the 2002 Swiss Health Survey provide some evidence of health disparities between Swiss people and immigrants. Although the self-reported health of "Northern immigrants" (people from Germany and France) does not differ significantly from that of the majority Swiss population, "Southern immigrants" (people from Italy, Former Yugoslavia, Portugal, Spain and Turkey) report lower levels of health in several areas. Lower levels of health are particularly likely to be reported by Italian men and women. CONCLUSION: The self-reported health of immigrants is currently inferior to that of the Swiss. If it is the position of the Swiss health care system to ensure equal health provision for all Swiss residents, including immigrant groups, and to strive for equal health outcomes for all, self-reported ill health among immigrants is a useful basis for health policy and planning.

Pregnancy outcomes and migration in Switzerland: results from a focus group study.

OBJECTIVES: To explore the issues of pregnancy and delivery in migrant women in their interaction with the Swiss healthcare system. METHODS: Focus groups were conducted with women of the Turkish and Portuguese communities. Swiss women were included as the reference group. Interpreters were used when needed. Group discussions were recorded and transcribed; all communications were categorized by specific themes and subdivided as to content. RESULTS: Eight focus groups were held: there were a total of 40 participants including 14 Turkish, 17 Portuguese, 9 Swiss. The study revealed that migrant women in Switzerland face stressful situations, which may differ according to nationality and length of stay in the country. Main factors negatively affecting pregnancy were stress due to precarious living conditions, heavy work during pregnancy, inadequate communication with healthcare providers, and feelings of racism and discrimination in society. CONCLUSIONS: Main findings of this qualitative study confirm that migrant communities need focused health attention because of numerous barriers to healthcare experienced in Switzerland. Improving the reproductive health of the migrant community is a priority that can be addressed by public health interventions, including integration of migrants into the society, strict observance of labor regulations, improved communication with healthcare providers, and better information targeting migrant communities.