Identifying newborn discharge to child protective services: Comparing discharge codes from birth hospitalization records and child protection case files.

PURPOSE: Newborn removal by North America's child protective services (CPS) disproportionately impacts Indigenous and Black families, yet its implications for population health inequities are not well understood. To guide this as a domain for future research, we measured validity of birth hospitalization discharge codes categorizing newborns discharged to CPS. METHODS: Using data from 309,260 births in Manitoba, Canada, we compared data on newborns discharged to CPS from hospital discharge codes with the presumed gold standard of custody status from CPS case reports in overall population and separately by First Nations status (categorization used in Canada for Indigenous peoples who are members of a First Nation). RESULTS: Of 309,260 newborns, 4562 (1.48%) were in CPS custody at hospital discharge according to CPS case reports and 2678 (0.87%) were coded by hospitals as discharged to CPS. Sensitivity of discharge codes was low (47.8%), however codes were highly specific (99.8%) with a positive predictive value (PPV) of 81.4%, and a negative predictive value (NPV) of 99.2%. Sensitivity, PPV and specificity were equal for all newborns but NPV was lower for First Nations newborns. CONCLUSIONS: Canadian hospital discharge records underestimate newborn discharge to CPS, with no difference in misclassication based on First Nations status.

Prevalence and sociodemographic correlates of marriage among adolescent mothers in Canada, 1989-2018.

OBJECTIVES: Female marriage before age 18 is a global health issue related to gender inequality, but it is understudied in Canada. This study examined marriage trends among mothers aged < 18 versus older mothers and the sociodemographic correlates of marriage among adolescent mothers aged < 18 and older adolescent mothers. METHODS: Using the Canadian Vital Statistics - Birth Database, marriage prevalence was estimated by maternal age groups (< 18-year, 18-19-year, 20-24-year, and 25-49-year) between 1989-1990 and 2017-2018 (n = 10,399,250). Multivariable logistic regression was then used to examine the sociodemographic characteristics associated with marriage within adolescent maternal age group (< 18-year, 18-19-year, and 20-24-year) among births registered between 2000 and 2018. RESULTS: From 1989-1990 to 2017-2018, marriage prevalence declined 80.5%, 60.2%, 47.3%, and 16.0% in the < 18-year, 18-19-year, 20-24-year, and 25-49-year groups, respectively. Within the < 18-year, 18-19-year, and 20-24-year adolescent maternal age groups, older maternal age, larger parental age gap, foreign-born parents, rurality, and earlier birth period were associated with higher adjusted odds of marriage. Higher maternal neighbourhood income was associated with marriage among births to mothers aged 18-19 and 20-24 years but not among those to mothers aged < 18 years. CONCLUSION: Marriage prevalence declined among mothers of all ages, but the shifts away from marriage appear stronger among younger mothers. The sociodemographic correlates of marriage are generally similar among mothers below age 18 and slightly older adolescent mothers.

RéSUMé: OBJECTIFS: Le mariage des filles de moins de 18 ans est un problème de santé mondial lié aux inégalités entre les sexes, mais il est insuffisamment étudié au Canada. Notre étude porte sur les tendances du mariage chez les mères de < 18 ans comparativement aux mères plus âgées et sur les corrélats sociodémographiques du mariage chez les mères adolescentes de < 18 ans et les mères adolescentes plus âgées. MéTHODE: À l'aide de la Base canadienne de données de l'état civil ­ Naissance, nous avons estimé la prévalence des mariages selon le groupe d'âge maternel (< 18 ans, 18-19 ans, 20-24 ans et 25-49 ans) entre 1989-1990 et 2017-2018 (n = 10 399 250). Au moyen d'une analyse de régression logistique multivariée, nous avons ensuite examiné les caractéristiques sociodémographiques associées au mariage dans les groupes d'âge des mères adolescentes (< 18 ans, 18-19 ans et 20-24 ans) pour les naissances enregistrées entre 2000 et 2018. RéSULTATS: De 1989-1990 à 2017-2018, la prévalence des mariages a baissé de 80,5 %, 60,2 %, 47,3 % et 16,0 % dans les groupes de < 18 ans, de 18-19 ans, de 20-24 ans et de 25-49 ans, respectivement. Dans les groupes d'âge des mères adolescentes de < 18 ans, de 18-19 ans et de 20-24 ans, un âge maternel plus avancé, une plus grande différence d'âge des parents, la naissance des parents à l'étranger, la ruralité et la période de naissance plus précoce étaient associées à une probabilité de mariage ajustée plus élevée. Le revenu maternel plus élevé selon le quartier était associé au mariage pour les naissances de mères de 18-19 et de 20-24 ans, mais pas chez les mères de < 18 ans. CONCLUSION: La prévalence du mariage a baissé chez les mères de tout âge, mais l'abandon du mariage semble plus prononcé chez les mères plus jeunes. Les corrélats sociodémographiques du mariage sont généralement semblables chez les mères de moins de 18 ans et les mères adolescentes légèrement plus âgées.

The perinatal epidemiology of child and adolescent marriage in Brazil, 2011-2018.

Brazil is one of the top contributors of girl child marriages in the world and one of the United Nations' members that committed to end child marriage by 2030 as part of the Sustainable Development Goals. Child marriage is an indicator of gender inequality associated with poor health outcomes. However, the perinatal epidemiology of minor mothers (<18 years) according to marital status has been insufficiently studied. We used 23,163,209 birth registrations (2011-2018) to describe the sociodemographic distribution of births to minor mothers. The association between adverse outcomes and marital status and maternal age was restricted to 7,953,739 births of mothers aged ≤15, 16-17, 18-19, 20-24 years. Multinomial logistic models were used for very (24-31 weeks) and moderately preterm birth (32-36 weeks), and severe (<3rd percentile) and moderately small-for-gestational age (SGA) (3rd to <10th percentile). Logistic models were used for binary outcomes. The proportion of births to minor mothers in the study period was 8.9%, composed of those of single (6.1%), common-law (2.4%) and married girls (0.4%). Births to minor mothers decreased over time (p-value <0.001), were more common in the North Region (13.2%) and among Indigenous (17.4%). Very and moderately preterm birth increased with decreasing age but within each age group, rates were highest among single, followed by common-law and lowest among married mothers. A similar pattern was observed for SGA, low Apgar and late prenatal care initiation. Repeat birth and low age-appropriate education were less common among married compared to single mothers in all age groups, except among ≤15-year-olds [Adjusted Odds Ratio (AOR): 2.56; 95% Confidence Interval (95%CI): 2.40, 2.74 and AOR: 1.30; 95%CI: 1.03, 1.64, respectively]. The association between perinatal indicators and marital status among adolescents is strongly modified by decreasing maternal age. Marital status is relevant for the understanding of early pregnancies.

Pain-driven emergency department visits and food insecurity: a cross-sectional study linking Canadian survey and health administrative data.

BACKGROUND: As the leading cause of emergency department visits in Canada, pain disproportionately affects socioeconomically disadvantaged populations. We examine the association between household food insecurity and individuals' pain-driven emergency department visits. METHODS: We designed a cross-sectional study linking the Canadian Community Health Survey 2005-2017 to the National Ambulatory Care Reporting System 2003-2017. Food insecurity was measured using a validated questionnaire. We excluded individuals with missing food insecurity status, individuals younger than 12 years and jurisdiction-years with partial emergency department records. We assessed emergency department visits driven by pain at different sites (migraine, other headaches, chest-throat pain, abdomen-pelvis pain, dorsalgia, joint pain, limb pain, other pain) and their characteristics (frequency, cause, acuity and time of emergency department visit) in Ontario and Alberta. We adjusted for sociodemographic characteristics, lifestyle and prior non-pain-driven emergency department visits in the models. RESULTS: The sample contained 212 300 individuals aged 12 years and older. Compared with food-secure individuals, marginally, moderately and severely food-insecure people had 1.42 (95% confidence interval [CI] 1.20-1.68), 1.64 (95% CI 1.37-1.96) and 1.99 (95% CI 1.61-2.46) times higher adjusted incidence rates of pain-driven emergency department visits, respectively. The association was similar across sexes and significant among adults but not adolescents. Food insecurity was further associated with site-specific pain, with severely food-insecure individuals having significantly higher pain incidence than food-secure individuals. Severe food insecurity predicted more frequent, multicause, high-acuity and after-hours emergency department visits. INTERPRETATION: Household food insecurity status is significantly associated with pain-driven emergency department visits in the Canadian population. Policies targeting food insecurity may reduce pain and emergency department utilization.

Intimate Partner Violence Among Persons With Mental Health-Related Disabilities in Canada.

This study examined the elevated risk of intimate partner violence (IPV) among persons with mental health-related disabilities (MH-RD) and the extent to which known risk factors accounted for this phenomenon. Data were drawn from a nationally representative sample of 33,127 Canadians collected in 2014 as part of Statistics Canada's General Social Survey. Results showed that respondents with MH-RD had more than three-fold increased odds of both overall and severe IPV victimization. Although females were more likely to possess a MH-RD, males and females with MH-RD reported similarly elevated odds of IPV victimization. Risk factors that contributed to a significant reduction in elevated odds of IPV for respondents with MH-RD were child maltreatment (CM), respondents' nonprescription drug abuse, and perpetrators' jealous, monitoring, and socially isolating behaviors. The inability to test additional risk factors and bidirectionality in the relationship between MH-RD and IPV may have contributed to the failure to fully account for these respondents' elevated odds of IPV. Future research is needed to understand the complex mechanisms contributing to the elevated risk of IPV and enhance prevention and intervention strategies for this underresearched and underserved vulnerable population.

Changes in health indicator gaps between First Nations and other residents of Manitoba.

BACKGROUND: The Truth and Reconciliation Commission of Canada has called for better reporting of health disparities between First Nations people and other Canadians to close gaps in health outcomes. We sought to evaluate changes in these disparities using indicators of health and health care use over the last 2 decades. METHODS: We used linked, whole-population, administrative claims data from the Manitoba Centre for Health Policy for fiscal years 1994/95 to 1998/99 and 2012/13 to 2016/17. We measured indicators of health and health care use among registered First Nations and all other Manitobans, and compared differences between these groups over the 2 time periods. RESULTS: Over time, the relative gap between First Nations and all other Manitobans widened by 51% (95% confidence interval [CI] 42% to 60%) for premature mortality rate. For potential years of life lost, the gap widened by 54% (95% CI 51% to 57%) among women and by 32% (95% CI 30% to 35%) among men. The absolute gap in life expectancy widened by 3.14 years (95% CI 2.92 to 3.36) among men and 3.61 years (95% CI 3.38 to 3.84) among women. Relative gaps widened by 20% (95% CI 12% to 27%) for ambulatory specialist visits, by 14% (95% CI 12% to 16%) for hospital separations and by 50% (95% CI 39% to 62%) for days spent in hospital, but narrowed by 33% (95% CI -36% to -30%) for ambulatory primary care visits, by 22% (95% CI -27% to -16%) for mammography and by 27% (95% CI -40% to -23%) for injury hospitalizations. INTERPRETATION: Disparities between First Nations and all other Manitobans in many key indicators of health and health care use have grown larger over time. New approaches are needed to address these disparities and promote better health with and for First Nations.

Examining the relationship between food insecurity and causes of injury in Canadian adults and adolescents.

BACKGROUND: Food insecurity, as an indicator of socioeconomic disadvantages and a determinant of health, may be associated with injury by increasing risk exposure and hampering risk mitigation. We examined the association between food insecurity and common causes of injury in the general population. METHODS: Linking the Canadian Community Health Survey 2005-2017 to National Ambulatory Care Reporting System 2003-2017, this retrospective cohort study estimated incidence of injury-related emergency department (ED) visits by food insecurity status among 212,300 individuals 12 years and above in the Canadian provinces of Ontario and Alberta, adjusting for prior ED visits, lifestyle, and sociodemographic characteristics including income. RESULTS: Compared to those in food-secure households, individuals from moderately and severely food-insecure households had 1.16 (95% confidence interval [CI] 1.07-1.25) and 1.35 (95% CI 1.24-1.48) times higher incidence rate of ED visits due to injury, respectively, after confounders adjustment. The association was observed across sex and age groups. Severe food insecurity was associated with intentional injuries (adjusted rate ratio [aRR] 1.81; 95% CI 1.29-2.53) including self-harm (aRR 1.87; 95% CI 1.03-3.40) and violence (aRR 1.79; 95% CI 1.19-2.67) as well as non-intentional injuries (aRR 1.34; 95% CI 1.22-1.46) including fall (aRR 1.43; 95% CI 1.24-1.65), medical complication (aRR 1.39; 95% CI 1.06-1.82), being struck by objects (aRR 1.43; 95% CI 1.07-1.91), overexertion (aRR 1.31; 95% CI 1.04-1.66), animal bite or sting (aRR 1.60; 95% CI 1.08-2.36), skin piercing (aRR 1.80; 95% CI 1.21-2.66), and poisoning (aRR 1.65; 95% CI 1.05-2.59). Moderate food insecurity was associated with more injuries from violence (aRR 1.56; 95% CI 1.09-2.21), falls (aRR 1.22; 95% CI 1.08-1.37), being struck (aRR 1.20; 95% CI 1.01-1.43), and overexertion (aRR 1.25; 95% CI 1.04-1.50). Moderate and severe food insecurity were associated with falls on stairs and being struck in non-sports settings but not with falls on same level or being struck during sports. Food insecurity was not related to transport injuries. CONCLUSIONS: Health inequity by food insecurity status extends beyond diseases into differential risk of injury, warranting policy intervention. Researchers and policymakers need to address food insecurity as a social determinant of injury to improve health equity.

The role of provincial social policies and economic environments in shaping food insecurity among Canadian families with children.

Food insecurity, inadequate access to food due to financial constraints, affects 17.3% of Canadian children, with serious health repercussions. Capitalizing on the geo-temporal variation in social policies and economic environments across Canadian provinces between 2005 and 2018, we examined the association between provincial policies and economic environments and likelihood of experiencing food insecurity among households with children. Drawn from 13 years of the Canadian Community Health Survey, our sample comprised 123,300 households with below-median income with children under 18 in the ten provinces. We applied generalized ordered logit models on the overall sample and subsamples stratified by Low-Income Measure (LIM). Higher minimum wage, lower income tax, and lower unemployment rate were associated with lower odds of food insecurity in the overall sample. A hypothetical one-dollar increase in minimum wage was associated with 0.8 to 1.0-percentage-point decrease in probability of food insecurity. The probability of food security increased by 1.2 to 1.6 percentage points following a one-percentage-point drop in bottom-bracket income tax rate. One-percentage-point lower unemployment rate corresponded to 0.6 to 0.8-percentage-point higher probability of food security. Higher welfare income and lower housing price predicted lower likelihood of severe food insecurity in the below-LIM subsample. Higher sales tax and median wage predicted higher likelihood of food insecurity among above-LIM households. Income support policies, favorable labor market conditions, and affordable living costs were all related to reduced food insecurity among Canadian households with children. Policies that increase minimum wage, reduce taxes, and create jobs may help alleviate food insecurity.

Food insecurity, chronic pain, and use of prescription opioids.

Chronic pain has been on the rise in recent decades in Canada. Accordingly, the use of prescription opioids (PO) in Canada increased drastically between 2005 and 2014, only starting to decrease in 2015. Both pain and PO use have serious public health repercussions, disproporionately affecting select socially disadvantaged populations. Food insecurity is a strong risk factor for mental disorders and suicidal outcomes, yet its relationship to chronic pain and PO use is largely unknown. Using two recent cycles from the population representative Canadian Community Health Survey (CCHS), we examined the association of household food insecurity status with chronic pain and PO use among Canadians 12 years and older, adjusting for health and sociodemographic characteristics. Compared to food-secure individuals, marginally, moderately, and severely food-insecure individuals had 1.31 (95% confidence interval [CI] 1.15-1.48), 1.89 (95% CI 1.71-2.08), and 3.29 (95% CI 2.90-3.74) times higher odds of experiencing chronic pain and 1.55 (95% CI 1.30-1.85), 1.77 (95% CI 1.54-2.04), and 2.65 (95% CI 2.27-3.09) times higher odds of using PO in the past year, respectively. The graded association with food insecurity severity was also found in severe pain experience and pain-induced activity limitations among chronic pain patients and, less consistently, in intensive, excess, and alternative use of PO and its acquisition through means other than medical prescription among past-year PO users. Food insecurity was a much more powerful predictor of chronic pain and PO use than other well-established social determinants of health like income and education. Policies reducing food insecurity may lower incidence of chronic pain and help contain the opioid crisis.

Smoking During Pregnancy Among Immigrant Women With Same-Origin and Swedish-Born Partners.

INTRODUCTION: Although ethnically mixed couples are on the rise in industrialized countries, their health behaviors are poorly understood. We examined the associations between partner's birthplace, age at immigration, and smoking during pregnancy among foreign-born women. METHODS: Population-based register study including all pregnancies resulting in a livebirth or stillbirth in Sweden (1991-2012) with complete information on smoking and parental country of birth. We compared the prevalence of smoking during pregnancy between women in dual same-origin foreign-born unions (n = 213 111) and in mixed couples (immigrant women with a Swedish-born partner) (n = 111 866) using logistic regression. Swedish-born couples were used as a benchmark. RESULTS: The crude smoking rate among Swedish women whose partners were Swedish was 11%. Smoking rates of women in dual same-origin foreign-born unions varied substantially by birthplace, from 1.3% among women from Asian countries to 23.2% among those from other Nordic countries. Among immigrant groups with prevalences of pregnancy smoking higher than that of women in dual Swedish-born unions, having a Swedish-born partner was associated with lower odds of smoking (adjusted odds ratios: 0.72-0.87) but with higher odds among immigrant groups with lower prevalence (adjusted odds ratios: 1.17-5.88). These associations were stronger among women immigrating in adulthood, whose smoking rates were the lowest. CONCLUSIONS: Swedish-born partners "pull" smoking rates of immigrant women toward the level of smoking of Swedish-born women, particularly among women arrived during adulthood. Consideration of a woman's and her partner's ethnic background and life stage at migration may help understand smoking patterns of immigrant women. IMPLICATIONS: We found that having a Swedish-born partner is associated with higher rates of smoking during pregnancy among immigrants from regions where women smoke less than Swedish women, but with lower smoking rates among immigrants from regions where women smoke more. This implies that prevention efforts should concentrate on newly arrived single women from low prevalence regions, such as Africa and Asia, whereas cessation efforts may target women from high prevalence regions, such as other European countries. These findings suggest that pregnancy smoking prevention or cessation interventions may benefit from including partners and approaches culturally tailored to mixed unions.

Factors associated with cyber-victimization among immigrants and non-immigrants in Canada: a cross-sectional nationally-representative study.

OBJECTIVES: There is a paucity of research on patterns of cyber-victimization in minority groups, including immigrants. This study aimed to identify individual, interpersonal and contextual characteristics associated with cyber-victimization among immigrants and non-immigrants. METHODS: We drew on nationally representative data from adolescents and adults in the Canadian General Social Survey on victimization (2014). We used multivariable logistic regression to identify potential factors associated with cyber-victimization in the last 12 months, stratified by immigrant status and sex. RESULTS: Among 27,425 survey respondents, the weighted prevalence of cyber-victimization in the last 12 months was 2.1% among immigrants and 2.3% among non-immigrants. Cyber-victimization rates differed significantly by sex among immigrants (2.8% for males vs. 1.4% for females), but not among non-immigrants (2.1% for males vs. 2.4% for females). While most other factors associated with cyber-victimization were similar for immigrants and non-immigrants, there were pronounced associations of past child maltreatment (adjusted prevalence odds ratio [aPOR] 4.85, 95% confidence interval [CI] 2.76, 8.52) and residence in an unwelcoming neighbourhood (aPOR 5.08, 95% CI 2.44, 10.55) with cyber-victimization among immigrants that were diminished or absent among non-immigrants. Additionally, sex-stratified analyses among immigrants showed cyber-victimization to be strongly associated with having a mental health condition (aPOR 3.50, 95% CI 1.36, 8.97) among immigrant males only, and with perceived discrimination (aPOR 4.08, 95% CI 1.65, 10.08), as well as being under 24 years old (aPOR 3.24, 95% CI 1.09, 9.60) among immigrant females. CONCLUSIONS: Immigration status and sex were differentially associated with cyber-victimization. Findings support the salience of a social-ecological perspective and gender-stratified analyses to better elucidate complex pathways linking cyber-victimization to potential gender-based health inequities among immigrants.

Induced abortion according to immigrants' birthplace: a population-based cohort study.

BACKGROUND: Most abortions occur due to unintended pregnancy. Unintended pregnancies are linked to poor health outcomes. Canada receives immigrants from countries with disparate sexual and reproductive health contexts which may influence abortion rates post-migration. We examined the association between abortion and region of birth and birth order among Canadian immigrants. METHODS: We conducted a population-based person-years (PY) cohort study in Ontario, Canada using administrative immigration (1991-2012) and health care data (1991-2013). Associations between induced abortion and an immigrant's region of birth were estimated using poisson regression. Rate ratios were adjusted for age, landing year, education, neighborhood income quintile and refugee status and stratified by birth order within regions. RESULTS: Immigrants born in almost all world regions (N = 846,444) were 2-5 times more likely to have an induced abortion vs. those born in the US/Northern & Western Europe/Australia & New Zealand (0.92 per 100 PY, 95% CI 0.89-0.95). Caribbean (Adjusted Rate Ratio [ARR] = 4.71, 95% CI 4.55-4.87), West/Middle/East African (ARR = 3.38, 95% CI 3.26-3.50) and South American (ARR = 3.20, 95% CI 3.09-3.32) immigrants were most likely to have an abortion. Most immigrants were less likely to have an abortion after vs. prior to their 1st birth, except South Asian immigrants (RR = 1.60, 95% CI 1.54-1.66; RR = 2.23, 95% CI 2.12-2.36 for 2nd and 3rd vs 1st birth, respectively). Secondary analyses included further stratifying regional models by year, age, education, income quintile and refugee status. CONCLUSIONS: Induced abortion varies considerably by both region of birth and birth order among immigrants in Ontario.

Food Insecurity Is Associated With Higher Health Care Use And Costs Among Canadian Adults.

Food insecurity predicts poorer health, yet how it relates to health care use and costs in Canada remains understudied. Linking data from the Canadian Community Health Survey to hospital records and health care expenditure data, we examined the association of food insecurity with acute care hospitalization, same-day surgery, and acute care costs among Canadian adults, adjusting for sociodemographic characteristics. Compared with fully food-secure adults, marginally, moderately, and severely food-insecure adults presented 26 percent, 41 percent, and 69 percent higher odds of acute care admission and 15 percent, 15 percent, and 24 percent higher odds of having same-day surgery, respectively. Conditional on acute care admission, food-insecure adults stayed from 1.48 to 2.08 more days in the hospital and incurred $400-$565 more per person-year in acute care costs than their food-secure counterparts, with this excess cost representing 4.4 percent of total acute care costs. Programs reducing food insecurity, such as child benefits and public pensions, and policies enhancing access to outpatient care may lower health care use and costs.

Receipt of routine preventive care among infant daughters and sons of immigrant mothers in Ontario, Canada: a retrospective cohort study.

OBJECTIVES: To explore gender disparities in infant routine preventive care across maternal countries of birth (MCOB) and by mother tongue among infants of Indian-born mothers. SETTING: Retrospective population-based administrative cohort in Ontario, Canada (births between 2002 and 2014). PARTICIPANTS: 350 366 (inclusive) healthy term singletons belonging to families with a minimum of one opposite gender child. OUTCOME MEASURES: Fixed effects conditional logistic regression generated adjusted ORs (aORs) for a daughter being underimmunised and having an inadequate number of well-child visits compared with her brother, stratified by MCOB. Moderation by maternal mother tongue was assessed among children to Indian-born mothers. RESULTS: Underimmunisation and inadequate well-child visits were common among both boys and girls, ranging from 26.5% to 58.2% (underimmunisation) and 10.5% to 47.8% (inadequate well-child visits). depending on the maternal birthplace. Girls whose mothers were born in India had 1.19 times (95% CI 1.07 to 1.33) the adjusted odds of inadequate well-child visits versus their brothers. This association was only observed among the Punjabi mother tongue subgroup (aOR: 1.26, 95% CI 1.08 to 1.47). In the Hindi mother tongue subgroup, girls had lower odds of underimmunisation than their brothers (aOR: 0.73, 95% CI 0.54 to 0.98). CONCLUSIONS: Gender equity in routine preventive healthcare is mostly achieved among children of immigrants. However, daughters of Indian-born mothers whose mother tongue is Punjabi, appear to be at a disadvantage for well-child visits compared with their brothers. This suggests son preference may persist beyond the family planning stage among some Indian immigrants.

Association between household food insecurity and mortality in Canada: a population-based retrospective cohort study.

BACKGROUND: Food insecurity affects 1 in 8 households in Canada, with serious health consequences. We investigated the association between household food insecurity and all-cause and cause-specific mortality. METHODS: We assessed the food insecurity status of Canadian adults using the Canadian Community Health Survey 2005-2017 and identified premature deaths among the survey respondents using the Canadian Vital Statistics Database 2005-2017. Applying Cox survival analyses to the linked data sets, we compared adults' all-cause and cause-specific mortality hazard by their household food insecurity status. RESULTS: Of the 510 010 adults sampled (3 390 500 person-years), 25 460 died prematurely by 2017. Death rates of food-secure adults and their counterparts experiencing marginal, moderate and severe food insecurity were 736, 752, 834 and 1124 per 100 000 person-years, respectively. The adjusted hazard ratios (HRs) of all-cause premature mortality for marginal, moderate and severe food insecurity were 1.10 (95% confidence interval [CI] 1.03-1.18), 1.11 (95% CI 1.05-1.18) and 1.37 (95% CI 1.27-1.47), respectively. Among adults who died prematurely, those experiencing severe food insecurity died on average 9 years earlier than their food-secure counterparts (age 59.5 v. 68.9 yr). Severe food insecurity was consistently associated with higher mortality across all causes of death except cancers; the association was particularly pronounced for infectious-parasitic diseases (adjusted HR 2.24, 95% CI 1.42-3.55), unintentional injuries (adjusted HR 2.69, 95% CI 2.04-3.56) and suicides (adjusted HR 2.21, 95% CI 1.50-3.24). INTERPRETATION: Canadian adults from food-insecure households were more likely to die prematurely than their food-secure counterparts. Efforts to reduce premature mortality should consider food insecurity as a relevant social determinant.

A Scoping Review of Socioeconomic Inequalities in Distributions of Birth Outcomes: Through a Conceptual and Methodological Lens.

INTRODUCTION: The extant literature has examined social inequalities in high-risk categories of birth weight and gestational age (i.e., low birth weight and preterm birth) with little attention given to their distributional nature. As such, a scoping review was conducted to understand how researchers have conceptualized and analyzed socioeconomic inequalities in entire distributions of these birth outcomes. METHODS: Bibliographic databases were searched from their inception until August 2016 for articles from five similar, English-speaking, advanced capitalist democracies: Canada, United States, United Kingdom, Australia and New Zealand. RESULTS: Twenty-one studies were included in the review, all of which provided rationales for examining socioeconomic inequalities in the entire distribution of birth weight. Yet, only three studies examined non-uniform associations of socioeconomic factors across the distribution of birth weight using conditional quantile regression, while the majority focused on mean birth weight using descriptive analysis or linear regression to analyze inequalities. Nevertheless, study results indicated that socioeconomic inequalities exist throughout the distribution of birth weight, extending beyond the high-risk category of low birth weight. DISCUSSION: Although social inequalities in distributions of birth weight have been conceptualized, few studies have analytically engaged with this concept. As such, this review supports further investigation of distributional inequalities in birth outcomes using methodology which allows one to empirically quantify and explain differences in population risk distributions, rather than solely between infants born low birth weight or preterm birth, versus not.

Placement in Care in Early Childhood and School Readiness: A Retrospective Cohort Study.

The current study examined school readiness for children placed in care of child protection services before age 5. This association was assessed using a population-based cohort of children born in Manitoba, Canada, between 2000 and 2009 ( n = 53,477) and subcohorts of discordant siblings (one sibling taken into care, one sibling not taken into care; n = 809) and discordant cousins ( n = 517). In the population analysis, children placed in care were significantly less likely to be ready for school; this difference was not seen in the discordant sibling or cousin analysis. The findings suggested that differences in school readiness for children placed in care are a result of broader social factors affecting families, not placement into care.

Severe Maternal Morbidity Associated With Maternal Birthplace: A Population-Based Register Study.

OBJECTIVE: This study sought to quantify the risk of severe maternal morbidity (SMM) according to maternal country of birth in Canada. METHODS: The study analyzed 1 252 543 in-hospital deliveries of Ontario residents discharged between April 1, 2002, and March 31, 2012. The main outcome measure was a composite indicator of SMM used for surveillance. The top 10 most common component conditions were also evaluated. Maternal country of birth and other immigration characteristics were obtained through linkage with official immigration records. We used modified Poisson regression with generalized estimating equations to assess associations according to maternal country of birth. RESULTS: Overall, immigrant women (N = 335 544) did not differ from Canadian-born women (n = 916 999) in SMM rates (12.1 vs. 12.0 cases per 1000 deliveries, respectively). However, SMM varied substantially according to maternal region of birth, from 9.2 cases per 1000 deliveries among immigrants from Western countries to 23.0 cases per 1000 deliveries among immigrants from Sub-Saharan Africa. Even larger variations were found when immigrants were categorized by their specific countries of birth. The top 10 contributing conditions to SMM among Canadian-born women were also the main contributors among immigrant subgroups. The notable exception was HIV infection, the top contributor among immigrants from Sub-Saharan Africa, whose rate of HIV infection was 43 times that of Canadian-born women (95% CI 34.39-55.23). After excluding HIV cases, disparities in SMM were largely reduced among Sub-Saharan African women but did not disappear. CONCLUSION: There is large heterogeneity in SMM and its component conditions among Canadian immigrants depending on country of origin.

Partner Disengagement from Pregnancy and Adverse Maternal and Infant Outcomes.

OBJECTIVE: To assess whether partner disengagement from pregnancy is associated with adverse maternal and infant outcomes. MATERIALS AND METHODS: We analyzed data from the 2006-2007 Canadian Maternity Experiences Survey, comprising a cross-sectional representative sample of 6,421 childbearing women. Multiple logistic regression assessed the association between adverse outcomes and three indicators of partner disengagement: (1) partner did not want the pregnancy, (2) partner argued more than usual in the year prior to the baby's birth, and (3) partner was absent at the delivery. RESULTS: Of all respondents, 3.8% had partners who did not want the pregnancy, 16.1% argued more than usual with their partner in the past year, and 7.6% had partners who were absent at the delivery. Women whose partner did not want the pregnancy were more likely to report intimate partner violence (IPV) (adjusted odds ratio [AOR] 3.55; 95% confidence interval [95% CI] 2.36-5.14), elevated depressive symptoms in the extended postpartum period (AOR 2.56, 95% CI 1.70-3.83), and nonroutine child healthcare visits after birth (AOR 1.54, 95% CI 1.13-2.11). Women whose partner argued more in the past year had higher odds of IPV (AOR 4.82, 95% CI 3.69-6.30), elevated depressive symptoms in the extended postpartum period (AOR 3.63; 95% CI 2.84-4.64), and nonroutine child healthcare visits (AOR 1.49, 95% CI 1.26-1.77), after adjustment for potential confounders. CONCLUSIONS: Partner disengagement is common and is associated with adverse maternal and infant outcomes. Affected women may benefit from special assistance during pregnancy and after delivery.

Severe Neonatal Morbidity Among Births to Refugee Women.

Background Despite being considered high risk, little is known about the perinatal health of refugees in developed countries. Our objectives were to examine whether: (1) the healthy migrant effect applies to infants born to refugee women with respect to severe neonatal morbidity (SNM); (2) refugee status was a risk factor for SNM among immigrants; (3) refugee sponsorship status was a risk factor for SNM by comparing asylum-seekers to sponsored refugees; and (4) refugees were at greater risk of specific SNM subtypes. Methods Immigration records (1985-2010) linked to Ontario hospital data (2002-2010) were used to examine SNM. We calculated adjusted risk ratios (ARR) with 95 % confidence intervals (95 % CI) for SNM and unadjusted risk ratios with 99 % CI for SNM subtypes using log-binomial regression. Results There were borderline differences in SNM among refugees (N = 29,755) compared to both non-immigrants (N = 860,314) (ARR = 0.94, 95 % CI 0.89, 0.99) and other immigrants (N = 230,847) (ARR = 1.10, 95 % CI 1.04, 1.18) with a larger difference comparing other immigrants to non-immigrants (ARR = 0.83, 95 % CI 0.81, 0.85). Asylum-seekers did not differ from sponsored refugees (ARR = 1.07, 95 % CI 0.90, 1.27). Though rare, several SNM subtypes were significant with large effect sizes. Conclusion With respect to SNM risk, the healthy migrant effect clearly applies to non-refugee immigrants, but is weaker for refugees and may not apply. Among immigrants, refugee status was a weak risk factor for SNM and may not be clinically important. Sponsorship status was not associated with greater risk of SNM. Further investigation of several SNM subtypes is warranted.