Disparities in pre-eclampsia and eclampsia among immigrant women giving birth in six industrialised countries.

OBJECTIVE: To assess disparities in pre-eclampsia and eclampsia among immigrant women from various world regions giving birth in six industrialised countries. DESIGN: Cross-country comparative study of linked population-based databases. SETTING: Provincial or regional obstetric delivery data from Australia, Canada, Spain and the USA and national data from Denmark and Sweden. POPULATION: All immigrant and non-immigrant women delivering in the six industrialised countries within the most recent 10-year period available to each participating centre (1995-2010). METHODS: Data was collected using standardised definitions of the outcomes and maternal regions of birth. Pooled data were analysed with multilevel models. Within-country analyses used stratified logistic regression to obtain odds ratios (OR) with 95% confidence intervals (95% CI). MAIN OUTCOME MEASURES: Pre-eclampsia, eclampsia and pre-eclampsia with prolonged hospitalisation (cases per 1000 deliveries). RESULTS: There were 9,028,802 deliveries (3,031,399 to immigrant women). Compared with immigrants from Western Europe, immigrants from Sub-Saharan Africa and Latin America & the Caribbean were at higher risk of pre-eclampsia (OR: 1.72; 95% CI: 1.63, 1.80 and 1.63; 95% CI: 1.57, 1.69) and eclampsia (OR: 2.12; 95% CI: 1.61, 2.79 and 1.55; 95% CI: 1.26, 1. 91), respectively, after adjustment for parity, maternal age and destination country. Compared with native-born women, European and East Asian immigrants were at lower risk in most industrialised countries. Spain exhibited the largest disparities and Australia the smallest. CONCLUSION: Immigrant women from Sub-Saharan Africa and Latin America & the Caribbean require increased surveillance due to a consistently high risk of pre-eclampsia and eclampsia.

Access to care for children of the working poor.

CONTEXT: Recent evidence suggests that children in working poor families lack health resources, placing them at risk for inadequate access to care. OBJECTIVES: To examine financial and nonfinancial access and utilization of health services among children in working poor families, and to compare these data with those of children from both nonworking poor and moderate to affluent families. DESIGN: A cross-sectional study of 13 785 children younger than 18 years. PARTICIPANTS: Subjects from the 1997 National Health Interview Survey. MAIN OUTCOME MEASURES: Prevalence and continuity of health insurance coverage, of delayed or missed care, and of unmet care needs; presence and type of usual source of care; and the amount of visits to physicians, emergency departments, and hospitals. RESULTS: Compared with children of nonworking poor parents and moderate to affluent children, more working poor children were uninsured (22% vs 12% and 5%, respectively; P<.01) and experienced disruptions in insurance coverage (P<.01). After adjusting for other covariates, disparities in insurance coverage and continuity persisted, as did delays in care and unmet care needs; these delays were far higher for the working poor. Although these children had access to a regular source of care and had utilization rates comparable with those of other poor children, they differed markedly from moderate to affluent children on structural access and utilization (adjusted odds ratios, 1.5-3.4). CONCLUSIONS: Children in working poor families experience far more barriers to care than other children. Health insurance expansions through the Children's Health Insurance Program and Medicaid, which reduce financial and nonfinancial barriers to care, may help correct these disparities.

Orientations to motherhood and male partner support among women in Mexico and Mexican-origin women in the United States.

Previous studies suggest that favorable pregnancy outcomes among Mexican immigrant women in the United States may be attributed to a protective sociocultural orientation, but few have explored the attitudes and values that shape Mexican women's perceptions of motherhood. This exploratory study examines orientation towards motherhood among Mexican and Mexican-origin women living in Mexico and the United States and their perceptions of their male partners' attitudes and roles. Focus groups were conducted with 60 pregnant low-income women in rural and urban communities in Mexico with high rates of migration to the US, among immigrant communities in rural and urban California and with US-born women of Mexican descent (Mexican Americans) in urban California. Notable differences were observed between women in Mexico and the US and between immigrant and Mexican American women in California as more women articulated life plans. Life plans seemed to reflect both processes of individuation and changing gender roles. While participants in Mexico largely abided by the conventional discourse on motherhood and domesticity, immigrants in California alternated between this ethos and the discourse of working mother, depending on financial resources. In contrast, Mexican American participants assumed multiple roles. These differing orientations may be linked to other factors, including fertility control, the amount and type of partner support, and stress during pregnancy.

Unfriendly shores: how immigrant children fare in the U.S. health system.

The proliferation of poor immigrant children in the United States raises concern about their high uninsurance rates and access to care. We examined the joint effects of health insurance status and place of birth on use of health services by children of the working poor. Of foreign-born children, 52 percent were uninsured and 66 percent had a regular care source, compared with 20 percent and 92 percent, respectively, of native-born children. Foreign-born uninsured children were less likely than their native-born peers were to have a regular care source or to have sought care. Health insurance and immigration policies must act in concert to increase health care access for foreign-born children.

Healthcare utilization among Hispanics: findings from the 1994 Minority Health Survey.

OBJECTIVE: To assess the effects of health need, enabling factors, and predisposing factors on entry into any type of care, volume of care, use of emergency services, hospitalization, and receipt of preventive services. STUDY DESIGN: Multiple regression analysis with cross-sectional data. PATIENTS AND METHODS: Participants were the 1001 adults who identified themselves as Hispanic in the Commonwealth Fund Minority Health Survey; a telephone survey of noninstitutionalized persons designed to oversample minorities was conducted. RESULTS: The 3 Hispanic subpopulations had similar sociodemographic profiles and similar patterns of healthcare utilization, except that Hispanics of other national origins were more likely to use preventive care compared with Mexican Americans and Puerto Ricans. Overall, 78% of the Hispanics surveyed entered the healthcare system in the past year, making an average of 5.25 visits. After controlling for other factors, immigrants had fewer visits and were less likely to have received preventive care. A regular source of care and insurance coverage influenced entry and volume of care, but was not associated with emergency services or hospitalizations. CONCLUSIONS: Access to care for Hispanics remains a major problem, significantly affected by structural and financial factors, personal experiences with the healthcare system, and predisposing factors. Policy solutions that address the health service needs of the uninsured will largely benefit Hispanics. In addition, as managed care plans compete for contracts and become more multicultural, access to care for Hispanics, including the uninsured, may improve through market forces.

Children of working low-income families in California: does parental work benefit children's insurance status, access, and utilization of primary health care?

OBJECTIVE: To examine financial and nonfinancial access to care and utilization of primary health care services among children of working low-income families earning below 200 percent of the federal poverty level in California, and to compare them to children in nonworking low-income families and in families earning over 200 percent of poverty. DATA SOURCES/STUDY SETTING: The 1994 National Health Interview survey weighted to reflect population estimates for California. STUDY DESIGN: This cross-sectional study of 3,831 children under age 19 focuses on financial access, that is, the prevalence and continuity of health insurance coverage; structural access, including the presence of a usual source of care, the predominant care source, its responsiveness to patient's needs, and any indications of delayed or missed care; and utilization of health care measured by the presence of an outpatient doctor's visit and the mean number of visits relative to child health status. DATA COLLECTION: The study uses secondary analysis. FINDINGS: Compared to children of nonworking low-income parents and to nonpoor children, children of working low-income parents were more likely to be uninsured (32.1 percent versus 15.6 percent and 10.3 percent, p = .0001) and to experience disruptions in insurance coverage (p = .0009). These differences persisted after controlling for other covariates in multivariate analyses. Children of working low-income parents did not differ significantly from children of nonworking low-income parents on measures of structural access or utilization, after adjusting for other covariates. However, they differed significantly from nonpoor children on structural access and utilization, and these differences mostly persisted after adjusting for other covariates (odds ratios from 1.5 to 2.9). Similar patterns were observed when children of full-time, year-round working parents with low earnings were compared with the two reference populations. CONCLUSION: Children in working low-income families in California have some of the worst access problems. Even full attachment to the workforce does not guarantee health insurance benefits, access to care, or improved health care use for children of low-income parents. These children are not better off than other low-income children of nonworking parents and are much worse off than nonpoor children. Expansion of health insurance coverage through Healthy Families and Medi-Cal, and attention to nonfinancial barriers to care for working low-income families may help to reduce these disparities.

Health services utilization among Latinos and white non-Latinos: results from a national survey.

Utilization patterns may be changing as managed care organizations actively market services to Latinos. This study compares use of any care, emergency services, inpatient hospitalization, nonemergency outpatient care only, and preventive care among 1,001 self-identified Latino and 1,107 white non-Latino adults. Data were from the 1994 Commonwealth Fund Survey of Minority Health. Latinos were less likely than white non-Latinos to have entered the health system for any type of care, to have been admitted to a hospital, or to have used preventive care. Access to a regular source of care along with financial factors reduced the ethnic/racial gap in the use of any care and preventive care, yet cultural and behavioral factors contributed little. Latinos in managed care plans, compared with fee-for-service systems, were twice as likely to receive preventive care. This suggests that managed care has the potential to reduce inequities in preventive care utilization.

Perceptions of hormonal contraceptive safety and side effects among low-income Latina and non-Latina women.

OBJECTIVES: We explored perceptions of the safety and side effects of oral and injectable hormonal contraceptives among low-income women at high risk of unintended pregnancy. METHODS: Overall safety perceptions, specific health concerns, and the relationship between these safety perceptions and contraceptive choices were determined by focus groups and questionnaires obtained from white non-Latina (n = 19), English-speaking (n = 21), and Spanish-speaking Latina women (n = 19). RESULTS: Uncertainty or ambivalence about the safety of oral and injectable contraceptives was reported by 41% and 70% of respondents respectively, while 20% considered these methods to be mostly harmful. Personal experiences and stories from social networks proved to be more salient than medical opinions in shaping safety perceptions. Side effects and concerns about long-term health effects were common themes. While white non-Latina women focused predominantly on physical side effects, emotional side effects also contributed to Latinas' decisions about contraceptive switching. Spanish-speaking Latinas differed from English-speaking Latinas in other attitudinal dimensions, contraceptive use prevalence, and access to contraceptive services. CONCLUSION: Low-income mothers lacked confidence in method safety and had many concerns about the side effects of oral and injectable contraceptives. Because such concerns can be a barrier to contraceptive use, these perceptions need to be corrected to encourage more effective use of hormonal methods and to prevent unintended pregnancies. Culturally appropriate interventions should focus on client-provider interactions, social networks, and access to care.

Informed policy making for the prevention of unwanted pregnancy. Understanding low-income women's experiences with family planning.

California health and welfare officials asked the authors to identify ways that their programs could encourage service use among low-income women. The project posed a challenge: The clients wanted to identify supply-side barriers amenable to intervention, but prior research suggested other factors might be more influential. The approach was to examine service-related issues, but in the broader context of women's experiences. The authors identify factors amenable to intervention, including inaccurate beliefs about methods. Other important influences--such as instability of relationships, skepticism about planning, or unsatisfactory method experiences--may be beyond the reach of specific policies, but are nevertheless critical to understanding program context. Findings suggest that punitive messages and policies based on a simplistic model of behavior may be unrealistic and ineffective.

[The relationship between health and job quitting in female workers of the electronics assembly industry in Tijuana]. / Relación entre salud y renuncia al empleo en trabajadoras de la industria maquiladora electrónica de Tijuana.

OBJECTIVE: To examine the health, labor and social factors which contribute to quitting work in two transnational electronic parts factories in Tijuana, Mexico. MATERIAL AND METHODS: A cohort study of 725 women employed either at a Japanese or an American electronic parts factory in Tijuana was performed between January 1992 and March 1994. The sample was stratified in two time intervals < or = 30 or > 30 days of work. Follow up was continued until quitting or end of the observation period, by recollecting data regarding health, social and occupational variables from different logs and reports provided by the employer. Reasons for quitting and accuracy of data obtained from logs and reports were evaluated through a follow up interview applied to 46% (n = 148) of the women who had quit, and were located approximately 12 months after ceasing to work (SD = 6.7). RESULTS: The estimated cumulative probabilities of quitting were 67% during the first year and 81% during the second. Newcomers to the work force, a day shift and the company is nationality were predictors the of quitting within 30 days. Smoking, surgical antecedents and paid leave due to illness were predictors for quitting after 30 days. In contrast, quitting rate after 30 days was lower in women with a history of chronic disease. CONCLUSIONS: Quitting work is high and selective among workers female electronic factories. While occupational factors are associated with workers quitting early, health factors are stronger predictors for quitting after 30 days.

Birth outcomes of immigrant women in the United States, France, and Belgium.

OBJECTIVES: To compare maternal characteristics and birth outcomes of Mexico-born and native-born mothers in the United States and those of North African mothers living in France and Belgium to French and Belgian nationals. METHODS: We examined information from single live birth certificates for 285,371 Mexico-born and 3,131,632 U.S.-born mothers (including 2,537,264 U.S.-born White mothers) in the United States, 4,623 North African and 103,345 Belgian mothers in Belgium, and a French national random sample consisting of 632 North African and 11,185 French mothers. The outcomes were mean birthweight, low birthweight, and preterm births. Differences between native/nationals and foreign-born mothers in each country were assessed in bivariate and multivariate analyses controlling for maternal risk factors. RESULTS: The adjusted odds for low birthweight were lower for immigrants than native/nationals by 32% in the United States, by 32% in Belgium, and by 30% in France. The adjusted odds for preterm births were lower for immigrants compared with native/nationals by 11% in the United States and by 23% in Belgium. In France, the odds for preterm births were comparable for immigrants and naturalized mothers. Infants of immigrant mothers also had higher mean birthweights in all three countries. CONCLUSION: Despite their disadvantaged status, Mexico-born and North African-born women residing in the United States, France, and Belgium show good birth outcomes. These cannot be explained solely by traditional risk factors. Protective factors and selective migration may offer further clues.

Women who quit maquiladora work on the U.S.-Mexico border: assessing health, occupation, and social dimensions in two transnational electronics plants.

This cohort study of 725 women examined the health, occupational, and social factors that contribute to quitting work in two transnational electronics maquiladoras (assembly plants) in Tijuana, Mexico. The estimated cumulative probabilities of quitting were 68% and 81% by 1 and 2 years of employment. After adjusting for other factors, women who had a history of smoking or surgery and those who returned to work after a paid leave due to illness were more likely to quit. In contrast, women with a history of chronic illness had lower quitting rates. The nationality of the company and the work shift also significantly influenced quitting rates, but demographic characteristics and health care visits did not have a significant effect. Women selectively leave maquiladora employment, often due to health-related events. The healthy worker effect is difficult to measure in a mobile population with high turnover.

Thermometer use among Mexican immigrant mothers in California.

A community-based household survey was utilized to assess the relationship between thermometer use, home treatment and utilization of health care services. Using a cross-sectional design, the study surveyed 688 low income Mexican origin mothers of children between the ages of 8 and 16 months in San Diego County. Mothers were asked how they determine that their child has fever and how often they use a thermometer. Nearly 40% of low income Mexican mothers interviewed in San Diego county never used a thermometer for determining childhood fever. Approximately two-thirds (64.7%) relied either primarily or exclusively on embodied methods such as visual observation or touch to determine fever in their child. A multivariate logistic regression analysis determined that low education and a separated or divorced marital status decreased the odds of thermometer use, whereas regular contact with the health care system doubled the likelihood of thermometer use. Mothers who relied on embodied methods were more likely to use over-the-counter medications than those who relied on thermometers; however, no significant differences were found between groups using other methods of home treatment. Fever determination modalities can be used to screen for lack of access to care and to provide for other health care needs in a culturally appropriate manner. While clinicians' expectations may include parental experience with temperature taking, current pediatric literature questions the need for home-based thermometer use. Possible alternatives to the traditional rectal thermometer might include digital thermometers and color coded thermometer strips.

Pregnancy outcomes and risk factors in Mexican Americans: the effect of language use and mother's birthplace.

Effects of acculturation have been thought to contribute adversely to poor reproductive health in Mexican immigrants, and a traditional Mexican orientation has been hypothesized to be protective against poor birth outcomes. A population-based cross-sectional study of 4404 births of Mexico-born and U.S.-born Mexican-American women was conducted in California in 1992 to examine the effect of language use (as a proxy measure of acculturation) on reproductive outcomes. Utilizing birth certificates, supplemental questionnaires, and 1990 U.S. Census data, the study analyzed differences in the proportions of pregnancy risk factors, low birth weight infants, and preterm deliveries in six nativity/language subgroups. Compared to U.S.-born English-speakers, U.S.-born Spanish-speakers had a higher risk profile and Mexico-born English-speakers had a lower risk profile for adverse pregnancy outcomes. After controlling for covariates, U.S.-born Spanish-speakers had the highest odds for low birth weight (OR = 1.98, 95% C.I. = 1.00, 3.93) and Mexico-born English-speakers had the lowest odds for preterm delivery (OR = 0.70, 95% C.I. = 0.35, 1.40) compared to U.S.-born English-speakers. These nativity/language differences in risk profiles and pregnancy outcomes suggest that Mexican Americans do not experience a simple negative mode of adaptation to U.S. society, but rather a complex process of positive and negative acculturation, which may be dependent on socio-economic conditions or selection factors related to immigration.

Effect of United States residence on birth outcomes among Mexican immigrants: an exploratory study.

Adverse pregnancy outcomes such as low birth weight are increased among US-born mothers of Mexican descent compared with immigrant mothers born in Mexico. It is unknown whether adverse reproductive outcomes change among Mexican immigrants after only 5 years of US residence. The authors conducted a study of 1,114 Mexican immigrant mothers and their infants in two California counties. The relation between US residence status and birth outcomes was examined, controlling for sociodemographic factors and maternal behaviors. Long-term immigrants who have lived in the United States for more than 5 years were more likely to deliver preterm infants (odds ratio (OR) = 1.9, 95% confidence interval (CI) 1.1-3.3) and low birth weight infants (OR = 1.5, 95% CI 0.8-2.7) than newcomers who have lived in the United States for 5 years or less. Long-term immigrants had higher parity, more pregnancy complications, and fewer planned pregnancies, and were more likely to smoke than newcomers. After controlling for confounders, the effect of residence status on preterm delivery was of borderline significance (adjusted OR = 1.8, 95% CI 1.0-3.2). Pregnancy complications was an intervening variable between residence status and preterm delivery. Length of US residence is associated with an increase in low birth weight via a decrease in gestational age rather than intrauterine growth retardation.

The effects of maternal health behaviors and other risk factors on immunization status among Mexican-American infants.

OBJECTIVE: Few studies have investigated the effect of maternal health behaviors on the utilization of childhood preventive care. We evaluated a sample of 788 Latino mother-infant pairs to determine whether, in addition to other characteristics, maternal health risk behaviors are associated with infant immunization status. METHODOLOGY: We conducted a cross-sectional survey of Mexican origin mothers of infants 8 to 16 months of age living in San Diego County, CA. In addition to sociodemographic and health care factors, we assessed maternal behaviors such as tobacco and alcohol consumption, safety precautions, and the organization of the home environment, and examined their relation to adequate childhood immunization status. RESULTS: When grouped together in a maternal health risk index, maternal health behaviors showed a dose-response relationship with inadequate immunization status. After controlling for confounders, each point increase on the health risk index was associated with a 20% increase in the likelihood of inadequate childhood immunizations. Marital status, parity, life stress, time lived in neighborhood, Spanish language, and child age were also important predictors. CONCLUSION: Early identification of children at risk for underimmunization may be aided by focusing on maternal health behaviors in addition to other sociodemographic characteristics.

Infants of Mexican immigrants. Health status of an emerging population.

Previous studies suggest that infants of Mexican immigrants have favorable birth outcomes despite their high socioeconomic risks. These favorable outcomes have been associated with a protective sociocultural orientation among immigrants. A sample of 708 infants of Mexican origin was assessed to determine whether such health advantages at birth are sustained at 8 to 16 months of age, or alternatively, whether their health deteriorates because of adverse socioeconomic conditions. A a cross-sectional survey was conducted in San Diego County to determine whether the child was healthy or ill (the latter indicating a history of serious infectious disease) and the factors associated with this outcome. Among infants born without serious medical problems, 74% remained healthy. For 26% of the infants, their health status was eroded by social conditions. Factors associated with illness were large households, barriers to care, and maternal characteristics including smoking, pregnancy complications, and employment. Women born in Mexico who were newcomers to the United States and spoke Spanish exclusively were more likely than non-newcomers to have ill children. In this population, one fourth of Latino infants of immigrants were at high risk for serious infectious disease despite using preventive care.

Dietary intake among Mexican-American women: generational differences and a comparison with white non-Hispanic women.

OBJECTIVES: Although Mexican Americans consume diets that may protect them against adverse health, dietary advantages may disappear with increased acculturation. This study examined whether the nutrient intake of second-generation Mexican-American women of childbearing age deteriorates compared with that of first-generation Mexican-American women and approximates that of White non-Hispanic women. METHODS: Data on the absolute and relative intake of eight nutrients were obtained from a 24-hour recall and compared among 475 first-generation and 898 second-generation Mexican-American women, and among 2326 White non-Hispanic women. RESULTS: Although first-generation Mexican-American women were of lower socioeconomic status than were second-generation or White non-Hispanic women, they had a higher average intake of protein; vitamins A, C, and folic acid; and calcium than the other two groups. Whereas the mean adequacy ratio of the eight nutrients studied was highest in first-generation Mexican women, it was lowest in their second-generation counterparts. CONCLUSIONS: First-generation Mexican women stand a markedly lower risk of eating a poor diet than second-generation Mexican women, whose nutrient intake resembles that of White non-Hispanic women.

Fetal deaths in Mexican-American, black, and white non-Hispanic women seeking government-funded prenatal care.

Hispanics of Mexican origin constitute the largest minority population in the Southwestern United States, yet little is known about their reproductive health. This study assessed ethnic differentials in fetal mortality at 20 or more weeks gestation and identified the social and behavioral predictors associated with this outcome among low-income Hispanic, black non-Hispanic and white non-Hispanic women. Records were used of 80,431 patients attending federally funded prenatal care clinics in California from 1984 through 1989. The fetal death rate per 1,000 live births and fetal deaths was 7.8 for Hispanic, 8.4 for white non-Hispanic and 20.5 for black non-Hispanic women. These rates indicated favorable reproductive outcomes for Mexican Americans despite their social risk profile. An analysis of stillbirths by gestational age showed that Hispanic women stood a significantly lower risk of short-gestational stillbirths than non-Hispanics. In contrast, Hispanic women had a higher proportion of term stillbirths. Hispanic acculturation was a significant predictor of short-term gestation fetal deaths only. The inability to pay for health care was a strong predictor of fetal deaths for all ethnic groups, underscoring the need to ensure adequate access to maternity care for low-income women.