Associations between socioeconomic status and pregnancy outcomes: a greater magnitude of inequalities in perinatal health in Montreal than in Brussels.

BACKGROUND: Comparing health inequalities between countries helps us to highlight some factors specific to each context that contribute to these inequalities, thus contributing to the identification of courses of action likely to reduce them. This paper compares the associations between socioeconomic status (SES) and 1) low birth weight (LBW) and 2) preterm birth, in Brussels and Montreal (in general population, natives-born mothers, and immigrant mothers). METHODS: A population-based study examining associations between SES and pregnancy outcomes was conducted in each city, using administrative databases from Belgian and Quebec birth records (N = 97,844 and 214,620 births in Brussels and Montreal, respectively). Logistic regression models were developed in order to estimate the relationship between SES (maternal education and income quintile) and pregnancy outcomes, in each region. The analyses were first carried out for all births, then stratified according to the mother's origin. RESULTS: For the general population, SES is associated with LBW and preterm birth in both regions, except for income and preterm birth in Brussels. The association is stronger for mothers born in Belgium and Canada than for those born abroad. The main difference between the two regions concerns the magnitude of inequalities in perintal health, which is greater in Montreal than in Brussels among the general population. For native-born mothers, the magnitude of inequalities in perinatal health is also greater for mothers born in Canada than for those born in Belgium, except for the association between income and preterm birth. The socioeconomic gradient in perinatal health is less marked among immigrant mothers than native mothers. CONCLUSION: Significant differences in inequalities in perinatal health are observed between Brussels and Montreal. These differences can be explained by : on the one hand, the existence of greater social inequalities in Montreal than in Brussels and, on the other hand, the lower vulnerability of immigrants with low SES in Brussels. Future studies seeking to understand the mechanisms that lead to inequalities in health in different contexts should take into account a comparison of immigration and poverty contexts, as well as the public policies related to these factors.

Country of birth as a potential determinant of inadequate antenatal care use among women giving birth in Brussels. A cross-sectional study.

BACKGROUND: One of the mechanisms explaining perinatal health inequalities could be inadequate antenatal care among some immigrant groups. Few European studies compared antenatal care use between different groups of immigrants taking into account individual characteristics. This research investigates the associations of three birth regions with the use of antenatal care, by also considering socioeconomic and migration-related determinants. METHODS: We included 879 mothers born in Belgium, North Africa, and Sub-Saharan Africa, and interviewed them in four Brussels hospitals after they gave birth, using an adapted version of the Migrant-Friendly Maternity Care Questionnaire. We additionally collected clinical data from hospital records. We carried out descriptive analyses and ran univariate and multivariable logistic regression models to estimate the associations of socioeconomic and migration characteristics with a) late start of antenatal care and b) less than minimum recommended number of consultations. RESULTS: The vast majority of women in this study had adequate care in terms of timing (93.9%), frequency of consultations (82.2%), and self-reported access (95.9%). Region of birth was an independent risk factor for late initiation of care, but not for infrequent consultations. Women born in Sub-Saharan Africa were more prone to accessing care late (OR 3.3, 95%CI 1.5-7.7), but were not more at risk of infrequent consultations. Women born in North Africa, had similar adequacy of care compared to the Belgium-born population. The three groups also differed in terms of socioeconomic profiles and socioeconomic predictors of antenatal care use. Housing type, professional activity, and health insurance status were important predictors of both outcomes. CONCLUSIONS: This study showed that the region of birth was partly associated with adequacy of care, in terms of initiation, but not number of consultations. Further dimensions of adequacy of care (content, quality) should be studied in the future. Socioeconomic factors are also key determinants of antenatal care use.

Measuring the invisible: perinatal health outcomes of unregistered women giving birth in Belgium, a population-based study.

BACKGROUND: The unregistered population remains under-researched because of its "invisible" status in statistics. Studies on perinatal health outcomes of unregistered women remains particularly limited. Our objectives were 1) to describe the sociodemographic profiles of women who are not legally residing in Belgium and 2) to analyze the associations of registration status with pregnancy outcomes according to socioeconomic status and nationality. METHODS: We analysed data from birth and death certificates taken from the Belgian civil registration system, linked with the National Population Registry (NPR). The data relates to all singleton babies born between 2010 and 2016 (n = 871,283), independent of their mother's NPR registration status. We used logistic regression to estimate the odds ratios for the associations between perinatal outcomes (perinatal mortality, prematurity and low birth weight) and maternal NPR registration status according to socioeconomic status and maternal nationality. RESULTS: Over the study period, 1.9% of births were to mothers without NPR-registration. Unregistered women from newer EU member states and non-European countries were particularly disadvantaged from a socioeconomic point of view. Apart from women with a South American nationality, all other groups of unregistered women had higher rates of prematurity, low birth weight, and perinatal mortality, compared to registered mothers (p < 0.0001). Unregistered women from Belgium and EU15 nationalities had particularly higher rates of prematurity, low birth weight, and perinatal mortality, compared to registered mothers, even after adjustment for socioeconomic status (p < 0.0001). The excess of perinatal mortality for non-European unregistered mothers could partly be explained by their precarious socioeconomic situation. CONCLUSIONS: This is the first study to include data on mothers who were not legally residing in Belgium. Unregistered women giving birth in Belgium are likely a heterogeneous socioeconomic group. Overall, unregistered women have increased risks of adverse perinatal outcomes, but it is likely that the causal mechanisms differ starkly between Belgian, European and non-European women. Further research is needed to understand the mechanisms behind these accrued rates. It is important to keep measuring the health outcomes of the populations which are "invisible" in national statistics, in order to identify the groups in most need of integration and access to services.

Risk of Low Birth Weight According to Household Composition in Brussels and Montreal: Do Income Support Policies Variations Explain the Differences Observed between Both Regions?

Variations in social policy between countries provide opportunities to assess the impact of these policies on health inequities. This study compares the risk of low birth weight in Brussels and Montreal, according to household composition, and discusses the impact of income support policies. For each context, we estimated the impact of income support policies on the extent of poverty of welfare recipients, using the model family method. Based on the differences found, we tested hypotheses on the association between low birth weight and household composition, using administrative data from the birth register and social security in each region. The extent of poverty of welfare families differs according to household composition. In Quebec, the combination of low welfare benefits and larger family allowances widens the gap between households with children and those without children. The risk of LBW also differs between these two contexts according to the number of children. Compared to children born into large welfare families, first-born children are more at risk in Montreal than in Brussels. In addition to the usual comparative studies on the topic, our study highlights the importance of an evaluative perspective that considers the combination of different types of income support measures to better identify the most vulnerable households.

Mothers' experiences of perinatal care in Belgian public hospitals: exploring the social inequalities. Protocol for a cross-sectional survey.

INTRODUCTION: In Europe, the social inequalities in perinatal health are usually found to be to the disadvantage of non-European immigrants and women with lower levels of education and income. Among the possible underlying mechanisms are inadequate access to healthcare services and suboptimal care. To explore this hypothesis in the Belgian context, our research will describe detailed maternal socioeconomic and migration characteristics, explore how these factors relate to each other, and how they relate to women's perinatal care trajectories and experiences of care. METHODS: Using a modified version of the Migrant-Friendly Maternity Care Questionnaire, we will survey 900 mothers of Belgian nationality or a nationality from a North or Sub-Saharan African country, and having given birth in four maternity wards in Brussels. The questionnaire has been adapted to the study objectives and the Belgian context. Interviewers will administer the 116-item questionnaire to all women agreeing to participate and meeting inclusion criteria, within 14 days of having given birth. Clinical information will be extracted from hospital records. ANALYSIS: We will estimate the associations of women's socioeconomic and migration characteristics with:Women's antenatal care trajectories (timing of first antenatal consultation, minimum recommended number of consultations, and problems accessing care).Obstetric practices such as episiotomies, emergency caesarean sections, and inductions.Patient experience such as feelings of discrimination, respect, and understanding of information.We will use descriptive statistics, multiple correspondence analysis, and simple and multiple logistic regressions. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the hospital Ethics Committees and from the Université libre de Bruxelles (No: P2017/055/B406201730877). Written informed consent will be sought from all participants.In addition to disseminating findings and recommendations to the scientific community through open-source journal articles and conferences, we will also address local organisations and healthcare professionals via a written report and seminars.

Integration of mental health care in private not-for-profit health centres in Guinea, West Africa: a systemic entry point towards the delivery of more patient-centred care?

BACKGROUND: Patient-centred care is an essential component of quality of health care. We hypothesize that integration of a mental health care package into versatile first-line health care services can strengthen patient participation, an important dimension of patient-centred care. The objective of this study is to analyse whether consultations conducted by providers in facilities that integrated mental health care score higher in terms of patient participation. METHODS: This study was conducted in Guinea in 12 not-for-profit health centres, 4 of which had integrated a mental health care package (MH+) and 8 had not (MH-). The study involved 450 general curative consultations (175 in MH+ and 275 in MH- centres), conducted by 18 care providers (7 in MH+ and 11 in MH- centres). Patients were interviewed after the consultation on how they perceived their involvement in the consultation, using the Patient Participation Scale (PPS). The providers completed a self-administered questionnaire on their perception of patient's involvement in the consultation. We compared scores of the PPS between MH+ and MH- facilities and between patients and providers. RESULTS: The mean PPS score was 24.21 and 22.54 in MH+ and MH- health centres, respectively. Participation scores depended on both care providers and the health centres they work in. The patients consulting an MH+ centre were scoring higher on patient participation score than the ones of an MH- centre (adjusted odds ratio of 4.06 with a 95% CI of 1.17-14.10, p = 0.03). All care providers agreed they understood the patients' concerns, and patients shared this view. All patients agreed they wanted to be involved in the decision-making concerning their treatment; providers, however, were reluctant to do so. CONCLUSION: Integrating a mental health care package into versatile first-line health services can promote more patient-centred care.

[Integrating mental health in community health centers in Guinea]. / Intégration de la santé mentale dans les centres de santé communautaires en Guinée Conakry.

This study investigates effects of integrating mental health on staff attitudes in 5 community health centers in Guinea: more specifically, on destigmatizing mental health problems and on adopting patient-centered care approaches. It is based on semi-structured interviews with 27 health workers from health centers having integrated mental health care (Santé Mentale +, with acronym SM+); and, as a comparison group, with 11 health workers working in facilities that do not have integrated mental health (SM-). Attitudinal change among SM+ health workers contrasts sharply with the stigmatizing discourse of SM- health workers. The former, strengthened by their successes in treating mental health patients, have overcome their fears and developed positive attitudes vis-à-vis mental health patients. Furthermore, part of the SM+ workers discovered and adopted a patient-centered approach to care, whereas others remained confined to a biomedical logic. A facilitating factor of change has been the organization of an in-service training program (joint consultations, teamwork and community action) taking into account health workers' emotional needs and providing patient-centered role models. However, this training set-up only functioned optimally in the non-bureaucratic organizational context of a community health center staffed with a stable and qualified team. Our study indicates that, beyond improved access to psychiatric care, integrating mental health in health centers can also reinforce the quality of the therapeutic relationship in general. The contents and modalities of the training program in mental health are crucial; but so is the way the health services are being organized.

Is the socioeconomic status of immigrant mothers in Brussels relevant to predict their risk of adverse pregnancy outcomes?

BACKGROUND: Understanding and tackling perinatal health inequities in industrialized countries requires analysing the socioeconomic determinants of adverse pregnancy outcomes among immigrant populations. Studies show that among certain migrant groups, education is not associated with adverse pregnancy outcomes. We aim to extend this analysis to further dimensions of socioeconomic status (SES) and to other settings. The objective of this study is to identify sociodemographic characteristics associated with adverse pregnancy outcomes, according to the origin of mothers residing in Brussels. METHODS: We analysed all singleton live births in Brussels between 2005 and 2010 (n = 97,844). The data arise from the linkage between three administrative databases. Four groups of women were included according to their place of birth: Belgium, EU, North Africa, and Sub-Saharan Africa. For each group, logistic regression was carried out to estimate the odds ratios of low birthweight (LBW) and small for gestational age (SGA) according to SES indicators (household income, maternal employment status, maternal education) and single parenthood. RESULTS: Three key findings emerge from this study: 1) 25% of children were born into a household under the poverty threshold. This proportion was much higher for mothers born outside of the EU. 2) For North African immigrants, SES indicators didn't influence the pregnancy outcomes, whereas their risk of LBW increased with single parenthood. 3) For Sub-Saharan Africans the risk of LBW increased with low household income. CONCLUSION: In a region where immigrant mothers are at high poverty risk, we observe a classic social gradient in perinatal outcomes only for mothers born in Belgium or the EU. In the other groups, SES influences perinatal outcomes less systematically. To develop interventions to reduce inequities from birth, it's important to identify the determinants of perinatal health among immigrants and to understand the underlying mechanisms in different contexts.

Evaluating the effect of income support policies on social health inequalities (SHIs) at birth in Montreal and Brussels using a contextualised comparative approach and model family method: a study protocol.

INTRODUCTION: Assessing the effects of social policies on social health inequalities (SHIs) is a complex issue. Variations in social policy between countries or regions provide natural experiments in policy implementation to perform comparative research. Comparisons are most enlightening when: the object of the evaluation is well defined (types of policies, population groups); the context of policy is analysed (history, implementation); the impact of policy on household poverty is outlined in detail; the influence of various factors (other than poverty) on SHI is taken into consideration. METHODS AND ANALYSIS: This study aims to understand how income support policies (ISPs) in Brussels and Montreal influence the poverty level of households receiving social assistance, and how they are associated with SHI at birth. Two cases studies will be carried out from a comparative perspective. The analysis includes four stages : (1) The model family method will be used to compare ISPs and their impact on disposable income and poverty of households receiving social assistance in both regions. (2) Statistical analysis of administrative databases will enable the description and comparison of SHI in adverse pregnancy outcomes across the two regions. (3) Analysis of databases and documents will allow for description of various factors which are likely to interact with poverty and influence SHI at birth. (4) Based on the Diderichsen model, results from the previous stages will be used to formulate hypotheses about the mechanisms by which ISPs contribute to increasing or reducing SHI at birth in both regions. ETHICS AND DISSEMINATION: This research was approved by the Human Research Ethics Committee for Health research of Université de Montréal. In Belgium, the access to linked databases was approved by the Commission for the Protection of Privacy. Databases de-identified according to Belgian and Canadian legislation will be used. Results will be disseminated in scientific publications and will be shared with policy makers and field actors through collaborations with local organisations in Brussels and Montreal.

[Stigmatisation of mental illness by medical students in Conakry, Guinea]. / Stigmatisation de la maladie mentale par les étudiants en médecine en Guinée, Conakry.

INTRODUCTION: Stigmatisation of mental illness constitutes a major problem in the development of mental healthcare programs, especially when it originates from health professionals themselves. The aim of this research is to investigate possible attitudes of stigmatisation among first and final year medical students registered at the University of Conakry faculty of medicine in Guinea-Conakry (West Africa). METHODS: Focus group discussions identified students' attitudes and perceptions in relation to mental illness, their explanatory models, their opinions concerning traditional and modern therapeutic practices with regard to mental illness, and their interest to possibly incorporate psychiatry in their future medical practice. RESULTS: Many students explicitly regret the stigmatisation of mental health patients, but nevertheless share the general population's prevailing attitudes of discrimination. The dominant stereotype of mental illness is that of madness, although final year medical students describe a more diverse spectrum of mental health problems. There is strong adherence to secular occult explanations of mental illness and advocacy for traditional medicine in addressing these illnesses, including among final year medical students. DISCUSSION: No student would opt for psychiatry as a specialisation, although some expressed interest in integrating psychiatry into their future medical practice. However, this research indicates that stigmatising attitudes are not cut in stone. Under the impetus of specific teaching programmes, attitudes can evolve to create room for tolerance and compassion.

Exploration of the functions of health impact assessment in real-world policymaking in the field of social health inequality: towards a conception of conceptual learning.

With the implementation of health impact assessment (HIA)'s conceptual model into real-world policymaking, a number of fundamental issues arise concerning its decision-support function. Rooted in a rational vision of the decision-making process, focus regarding both conceptualisation and evaluation has been mainly on the function of instrumental policy-learning. However, in the field of social health inequalities, this function is strongly limited by the intrinsic 'wickedness' of the policy issue. Focusing almost exclusively on this instrumental function, the real influence HIA can have on policymaking in the longer term is underestimated and remains largely unexploited. Drawing insights from theoretical models developed in the field of political science and sociology, we explore the different decision-support functions HIA can fulfill and identify conceptual learning as potentially the most important. Accordingly, dominant focus on the technical engineering function, where knowledge is provided in order to 'rationalise' the policy process and to tackle 'tame' problems, should be complemented with an analysis of the conditions for conceptual learning, where knowledge introduces new information and perspectives and, as such, contributes in the longer term to a paradigm change.

Are all immigrant mothers really at risk of low birth weight and perinatal mortality? The crucial role of socio-economic status.

BACKGROUND: Increasing studies show that immigrants have different perinatal health outcomes compared to native women. Nevertheless, we lack a systematic examination of the combined effects of immigrant status and socioeconomic factors on perinatal outcomes. Our objectives were to analyse national Belgian data to determine 1) whether socioeconomic status (SES) modifies the association between maternal nationality and perinatal outcomes (low birth weight and perinatal mortality); 2) the effect of adopting the Belgian nationality on the association between maternal foreign nationality and perinatal outcomes. METHODS: This study is a population-based study using the data from linked birth and death certificates from the Belgian civil registration system. Data are related to all singleton births to mothers living in Belgium between 1998 and 2010. Perinatal mortality and low birth weight (LBW) were estimated by SES (maternal education and parental employment status) and by maternal nationality (at her own birth and at her child's birth). We used logistic regression to estimate the odds ratios for the associations between nationality and perinatal outcomes after adjusting for and stratifying by SES. RESULTS: The present study includes, for the first time, all births in Belgium; that is 1,363,621 singleton births between 1998 and 2010. Compared to Belgians, we observed an increased risk of perinatal mortality in all migrant groups (p < 0.0001), despite lower rates of LBW in some nationalities. Immigrant mothers with the Belgian nationality had similar rates of perinatal mortality to women of Belgian origin and maintained their protection against LBW (p < 0.0001). After adjustment, the excess risk of perinatal mortality among immigrant groups was mostly explained by maternal education; whereas for sub-Saharan African mothers, mortality was mainly affected by parental employment status. After stratification by SES, we have uncovered a significant protective effect of immigration against LBW and perinatal mortality for women with low SES but not for high SES. CONCLUSIONS: Our results show a protective effect of migration in relation to perinatal mortality and LBW among women of low SES. Hence, the study underlines the importance of taking into account socioeconomic status in order to understand more fully the relationship between migration and perinatal outcomes. Further studies are needed to analyse more finely the impact of socio-economic characteristics on perinatal outcomes.

Neonatal outcomes in obese mothers: a population-based analysis.

BACKGROUND: If it is well known that obesity increases morbidity for both mother and fetus and is associated with a variety of adverse reproductive outcomes, then few studies have assessed the relation between obesity and neonatal outcomes. This is the aim of the present study after taking into account type of labor and delivery, as well as social, medical and hospital characteristics in a population-based analysis. METHODS: This study used 2009 data from the Belgian birth register data pertaining to the regions of Brussels and Wallonia and included 38,675 consecutive births. Odds ratio and 95% confidence intervals for admission to neonatal intensive care unit, Apgar score, and perinatal mortality were calculated by logistic regression analyses adjusting for medical, social and hospital characteristics using obesity as the primary independent variable. The impact of analyzing all delivery sites together was tested using mixed-effect analyses. RESULTS: The adjusted odds ratio for neonatal intensive care unit admission was higher for obese mothers by 38% compared to non-obese mothers (95% confidence interval (CI): 1.22-1.56), and by 45% (CI: 1.21-1.73) and 34% (CI: 1.10-1.63) after spontaneous and induced labour respectively. The adjusted odds ratio was 1.18 (CI: 0.86-1.63) after caesarean section. The adjusted odds ratio for 1 minute Apgar score inferior to 7 was higher for obese mothers by 31% compared to non-obese mothers (CI: 1.15-1.49) and by 26% (CI: 1.04-1.52) and 38% (CI: 1.12-1.69) after spontaneous and induced labour respectively. The adjusted odds ratio was 1.50 (CI: 0.96-2.36) after caesarean section. The adjusted odds ratio for perinatal mortality was 1.36 (CI: 0.75-2.45) for obese mothers compared to non-obese mothers. CONCLUSIONS: Neonatal admission to intensive care and low Apgar scores were more likely to occur in infants from obese mothers, both after spontaneous and induced labor.

Effect of adopting host-country nationality on perinatal mortality rates and causes among immigrants in Brussels.

OBJECTIVES: Perinatal mortality rates vary between ethnic groups but the relation with immigrant status is unclear. Previous research suggested that birth outcomes may either improve or deteriorate with duration of residence, depending on the migrant group. The objectives of this study are to describe and measure inequalities in pregnancy outcomes, perinatal mortality and causes of perinatal deaths according to current citizenship versus national origin of the mother, in Brussels. STUDY DESIGN: This is a population-based cohort study using data from linked birth and death certificates from the Belgian civil registration system. The data relate to all babies born between 1998 and 2008, whose mothers were living in Brussels, irrespective of the place of delivery. We used a logistic regression to estimate the odds ratios (ORs) for the association between mortality, causes of deaths and nationality. RESULTS: Women from Morocco, sub-Saharan Africa and Turkey experience an 80% excess in perinatal mortality (p<0.0001) compared to Belgians, but this excess of perinatal mortality is not observed for mothers with Belgian citizenship at delivery. For sub-Saharan African women, this excess is caused mainly by immaturity-related conditions and reflects a high rate of preterm deliveries, low birth weight and a low socio-economic level. Moroccan and Turkish mothers have favourable pregnancy outcomes that persist after adopting Belgian nationality, but they experience a strong excess of perinatal mortality, mainly due to congenital anomalies and asphyxia or unexplained deaths prior to the onset of labour. CONCLUSION: In Brussels, perinatal mortality varies according to nationality but those differences do not persist after adopting Belgian nationality. The explanation of this positive effect is probably due to a mix of determinants such as acculturation, use of health services or cultural contexts. Further analysis should help to better understand the results observed.

Classification of cesarean sections among immigrants in Belgium.

OBJECTIVE: To provide insight into the differential effect of immigration on cesarean section (CS) rates, using the Robson classification. DESIGN: A population-based study using birth certificates from the birth registry of 2009. SETTING: All births in two of the three Belgian regions excluding Flanders. POPULATION: 37 628 deliveries from Belgian and immigrant mothers from sub-Saharan Africa, Maghreb and Eastern Europe. METHODS: Multivariate analyses using CS as the dependent variable and immigration status as the primary independent variable. Several multivariate logistic regression models were built including medical, anthropometric, socio-economic characteristics, and medical interventions. The impact of analyzing all delivery sites together was tested using mixed-effect analyses. MAIN OUTCOME MEASURES: CSs of immigrant subgroups compared with Belgian women. RESULTS: CS rates varied according to immigrant subgroups. Mothers from sub-Saharan Africa had an adjusted odds ratio of 2.06 (1.62-2.63) for CS compared with Belgian natives. Increased risk for mothers from sub-Saharan Africa compared with Belgian natives was found among nulliparous and multiparous women without previous CS, and a term, singleton fetus in cephalic position. In comparison, nulliparous East European mothers with a term singleton fetus in cephalic position in spontaneous labor had an adjusted odds ratio of 0.29 (0.08-0.99) for CS. CONCLUSIONS: CS rates currently vary between Robson categories in immigrant subgroups. Immigrant mothers from sub-Saharan Africa with a term, singleton infant in cephalic position, without previous CS, appear to carry the highest burden.

Missing information in birth certificates in Brussels after reinforcement of data collection, and variation according to immigration status. A population-based study.

BACKGROUND: A problem repeatedly reported in birth certificate data is the presence of missing data. In 2008, a Centre for Perinatal Epidemiology was created inter alia to assist the Health Departments of Brussels-Capital City Region to check birth certificates. The purpose of this study is to assess the changes brought by the Centre in terms of completeness of data registration for the entire population and according to immigration status. METHODS: Birth certificates from the birth registry of 2008 and 2009 of Brussels were considered. We evaluated the initial missing information in January 2008 (baseline situation) and the corresponding rate at the end of 2008 after oral and written information had been given to the city civil servants and health providers. The data were evaluated again at the end of 2009 where no reinforcement rules were adopted. We also measured residual missing data after correction in socio-economic and medical data, for the entire population and according to maternal nationality of origin. Changes in registration of stillbirths were estimated by comparison to 2007 baseline data, and all multiple births were checked for complete identification of pairs. RESULTS: Missing information initially accounted for 64.0%, 20.8% and 19.5% of certificates in January 2008, December 2008, and 2009 respectively. After correction with lists sent back to the hospitals or city offices, the mean residual missing data rate was 2.1% in 2008 and 0.8% in 2009. Education level and employment status were missing more often in immigrant mothers compared to Belgian natives both in 2008 and 2009. Mothers from Sub-Saharan Africa had the highest missing rate of socio-economic data. The stillbirth rate increased from 4.6 ‰ in 2007 to 8.2 ‰ in 2009. All twin pairs were identified, but early loss of a co-twin before 22 weeks was rarely reported. CONCLUSIONS: Reinforcement of data collection was associated with a decrease of missing information. The residual missing data rate was very low. The stillbirth rate was also improved but the early loss of a co-twin before 22 weeks seems to remain underreported.

The associations between nationality, fertility history and diabetes-related mortality: a retrospective cohort study in the Brussels-Capital Region (2001-2005).

BACKGROUND: The relationship between women's parity and diabetes mortality has been investigated in several studies, with mixed results. This study aims to establish if parity and age at first birth are associated with diabetes-related mortality and if these factors contribute to variations in diabetes-related mortality among women with different nationalities. METHODS: Data of the 2001 census are linked to registration records of all deaths and emigrations (period 2001-2005). The study population comprises all female inhabitants of the Brussels-Capital Region aged 45-74 of either Belgian or North African nationality (n = 108 296). Age-standardized mortality rates (direct standardization) and mortality rate ratios (Poisson's regression) are computed. RESULTS: Both parity and age at first birth are associated with diabetes-related mortality. Highest risks of dying from diabetes are observed among grandmultiparous women and teenage mothers. Differences in diabetes-related mortality according to nationality are observed. Age-standardized diabetes mortality rates are higher in North African [ASMR = 417.4/100,000; 95% confidence interval (CI) 227.2-607.7] than in Belgian women (ASMR = 184.0/100,000; 95% CI 157.3-210.8). Taking parity, age at first birth and education into account, these differences largely disappear. CONCLUSIONS: Reproductive factors are associated with diabetes-related mortality and play an important part in the higher diabetes-related mortality of North African compared with Belgian women.

Ethnic differences in diabetes-related mortality in the Brussels-Capital Region (2001-05): the role of socioeconomic position.

OBJECTIVES: To examine if and to what extent ethnic differences in diabetes-related mortality are associated with differences in education and housing status. METHODS: The data consist of a cohort study linking the 2001 census to emigration and mortality data for the period 2001-05. The study population comprises all Belgian and North African inhabitants of the Brussels-Capital Region (BCR) aged 25-74. Age-standardized mortality rates (ASMRs) (direct standardization) and mortality rate ratios (MRRS) (Poisson regression) are computed. RESULTS: North Africans have a higher diabetes-related mortality compared to Belgians. The ASMRs for North African and Belgian women are 54.8 (95% confidence interval (CI) 31.5-78.2) and 23.8 (95% CI 20.3-27.3), respectively. These differences in diabetes-related mortality largely disappear when differences in education are taken into account. The MRRs for North African versus Belgian origin drop from 1.62 (95% CI 1.11-2.37) to 1.19 (95% CI 0.73-1.93) in men and from 3.35 (95% CI 2.08-5.41) to 1.88 (95% CI 0.95-3.69) in women. CONCLUSIONS: Differences in education play an important part in the excess diabetes-related mortality among North Africans in the BCR.

High perinatal mortality rate among immigrants in Brussels.

BACKGROUND: The relation between immigration status and perinatal mortality is unclear. The objective of this study is to describe and measure inequalities in perinatal mortality and causes of perinatal deaths according to maternal nationality and socioeconomic status. METHODS: A population-based cohort study related to all babies born during the period of 1998-2006 whose mothers were living in Brussels, irrespective of the place of delivery. Perinatal and post-perinatal mortality were analysed according to the nationality and sociodemographic characteristics of the mothers at birth. We used logistic regression to estimate the odds ratios (ORs) for the association between mortality and nationality. RESULTS: The women of sub-Saharan Africa experience a 50% excess in perinatal mortality, which primarily reflects a high rate of preterm deliveries and low birth weight, as well as a low socioeconomic level. Paradoxically, despite their favourable rates of preterm and low-birth-weight births, Maghrebian and Turkish women experience a strong excess (50-70%) of perinatal mortality caused primarily by congenital anomalies. Differences in age, parity distributions and multiple births play no significant role, and the excess does not reflect low socioeconomic levels. This excess of perinatal mortality contrasts with the absence of an excess of post-perinatal mortality. CONCLUSION: In Brussels, patterns of inequalities in perinatal mortality and causes of perinatal deaths vary according to nationality; perinatal mortality is increased in particular ethnic groups independently of socioeconomic status and maternal characteristics.

[Health and living conditions: reflections around an attempt for a multiple and sectoral approach]. / Santé et habitat: réflexion à propos d'une tentative d'approche multiple et sectorielle.

There is consensus amongst community members, local practitioners and policy and decision makers on the need for an inter-sectoral approach to health, environment and living conditions. The author analyses the processes of linking various sectors involved in six health and environment projects developed at the local or regional level in Brussels-Capital. The question of inter-sectoral collaboration is addressed differently at the regional and local levels. This question is also dealt with according to the underpinning conceptual framework of a given project. Three conceptual frameworks were identified, each reflecting the processes of knowledge development or action from the sector having initiated the project. Each framework is characterised by a clear demarcation between the fields of health and habitation and a particular linking between these two fields and other aspects of life. The sector initiating the project imposes its own model, logic and expertise, which then leads to difficulties in ensuring active participation of the other sectors implicated. The linkage of vertical or specialised approaches and broad, general ones is too often solely reduced to the integration of specialised aspects into all purpose actions. The analysis of the different projects demonstrates the lack of awareness by specialists, in this case being environmental, of the composition and complexity of the interaction between multiple aspects of life when trying to link with other sectors. Finally, the viable preservation and continuation of overarching, universal approaches are impeded by the lack of recognition and absence of funding for interventions which aim at affecting multiple aspects of life.