Unintended Perinatal Health Consequences Associated With a Swedish Family Policy.

Importance: The 1980 and 1986 Swedish so-called speed premium policies aimed at protecting parents' income-based parental leave benefits for birth intervals shorter than 24 and 30 months, respectively, but indirectly encouraged shorter birth spacing and childbearing at older ages, both risk factors for several perinatal health outcomes. Whether those policy changes are associated with perinatal health remains unknown. Objective: To evaluate the association between the 1980 and 1986 speed premium policies and perinatal health outcomes. Design, Setting, and Participants: This cross-sectional study investigated data from 1 762 784 singleton births in the Swedish Medical Birth Register from January 1, 1974, through December 31, 1991. Data were analyzed from October 11, 2022, to December 12, 2023. Interventions: Speed premium policy introduction (January 1, 1980) and extension (January 1, 1986). Main Outcomes and Measures: Total population register data were used in an interrupted time series analysis with segmented logistic regression to calculate the odds of preterm birth, low birth weight, small for gestational age (SGA) at preterm, and stillbirth measured before and after the speed premium policy reforms. Subgroup analyses by maternal origin were conducted to evaluate changes by different policy responses. Results: Among 1 762 784 births analyzed, 4.8% were preterm (of which 12.0% were SGA), 3.2% had low birth weight, and 0.3% were stillbirths. The 1980 speed premium policy was associated with a 0.3% monthly increase in the odds of preterm birth compared with the period before the reform (odds ratio [OR], 1.0029 [95% CI, 1.002-1.004]), equivalent to a 26.4% increase from January 1, 1980, to December 31, 1985. After the 1986 relaxation of the policy, preterm birth odds decreased 0.5% per month (OR, 0.9951 [95% CI, 0.994-0.996]), equivalent to an 11.1% decrease across the next 6 years. Low birth weight displayed a similar pattern for both reform periods, that is, increased 0.2% (OR, 1.0021; 95% CI, 1.001-1.003) per month in 1980 through 1985 compared with baseline, and decreased 0.3% (OR, 0.9975; 95% CI, 0.996-0.998) per month in the following period, but was attenuated when considering low birth weight at term. Odds of SGA at preterm were decreased after 1980 (OR, 0.9965; 95% CI, 0.994-0.999) but not in 1986 (OR, 1.0009; 95% CI, 0.998-1.003), whereas stillbirths did not change following either reform (1980: OR, 1.0020 [95% CI, 0.999-1.005]; 1986: OR, 1.0002 [95% CI, 0.997-1.003]). Subgroup analyses suggested that perinatal health changes were restricted to births to Swedish- and Nordic-born mothers, the primary groups to adjust their fertility behaviors to the reforms. Conclusions and Relevance: Despite its economic advantages for couples, especially for mothers, the introduction of the speed premium policy was associated with adverse perinatal health consequences, particularly for preterm births. Family policies should be carefully designed with a "Health in All Policies" lens to avoid possible unintended repercussions for fertility behaviors and, in turn, perinatal health.

Alcohol-related morbidity and mortality by fathers' parental leave: A quasi-experimental study in Sweden.

BACKGROUND AND AIMS: Fathers' parental leave has been associated with decreased risks of alcohol-related hospitalizations and mortality. Whether this is attributable to the health protections of parental leave itself (through stress reduction or behavioral changes) or to selection into leave uptake remains unclear, given that fathers are more likely to use leave if they are in better health. Using the quasi-experimental variation of a reform incentivizing fathers' leave uptake (the 1995 Father's quota reform), this study aimed to assess whether fathers' parental leave influences alcohol-related morbidity and mortality. DESIGN: Quasi-experimental interrupted time series and instrumental variable analyses. SETTING: Sweden. PARTICIPANTS: Fathers of singleton children born from January 1992 to December 1997 (n = 220 412). MEASUREMENTS: Exposure was indicated by the child's birthdate before or after the reform and used to instrument fathers' 2- and 8-year parental leave uptake. Outcomes included fathers' hospitalization rates for acute alcohol-related (intoxication; mental and behavioral disorders) and chronic alcohol-related diagnoses (cardiovascular, stomach and other diseases; liver diseases), as well as alcohol-related mortality, up to 2, 8 and 18 years after the first child's birthdate. FINDINGS: In interrupted time series analyses, fathers of children born after the reform exhibited immediate decreases in alcohol-related hospitalization rates up to 2 (incidence rate ratio [IRR] = 0.66, 95% confidence interval [CI] = 0.51-0.87), 8 (IRR = 0.74, 95% CI = 0.57-0.96) and 18 years after birth (IRR = 0.72, 95% CI = 0.54-0.96), particularly in acute alcohol-related hospitalization rates, compared with those with children born before. No changes were found for alcohol-related mortality. Instrumental variable results suggest that alcohol-related hospitalization decreases were driven by fathers' parental leave uptake (e.g. 2-year hospitalizations: IRR = 0.16, 95% CI = 0.03-0.84). CONCLUSIONS: In Sweden, a father's parental leave eligibility and uptake may protect against alcohol-related morbidity.

Is duration of residence a proxy for acculturation? The case of health risk behaviors among international immigrants.

AIMS: Among international immigrants, health changes by duration of residence are commonly interpreted as an expression of acculturation to the receiving country context. This study compares changes in immigrants' health risk behaviors by duration of residence to changes by acculturation levels, in order to assess whether duration of residence can be regarded as a proxy for acculturation. METHODS: Using data from a previous systematic review, we identified 17 quantitative studies examining changes in alcohol, tobacco and drug use, physical inactivity, and diet by both duration of residence and acculturation level in the same population. We compared the directionality and consistency of these associations through tabulation and vote counting. RESULTS: The majority of studies reported no or inconsistent changes in health risk behaviors by duration of residence versus by acculturation, including with opposite directionality. Four studies reported significant estimates with consistent directionality, while five reported consistent, non-significant estimates. CONCLUSIONS: Our findings suggest that duration of residence should not be used as a proxy for acculturation when studying health risk behaviors among immigrants. Researchers should consider additional time-dependent factors to explain behavioral changes by duration of residence.

Explaining COVID-19 mortality among immigrants in Sweden from a social determinants of health perspective (COVIS): protocol for a national register-based observational study.

INTRODUCTION: Adopting a social determinants of health perspective, this project aims to study how disproportionate COVID-19 mortality among immigrants in Sweden is associated with social factors operating through differential exposure to the virus (eg, by being more likely to work in high-exposure occupations) and differential effects of infection arising from socially patterned, pre-existing health conditions, differential healthcare seeking and inequitable healthcare provision. METHODS AND ANALYSIS: This observational study will use health (eg, hospitalisations, deaths) and sociodemographic information (eg, occupation, income, social benefits) from Swedish national registers linked using unique identity numbers. The study population includes all adults registered in Sweden in the year before the start of the pandemic (2019), as well as individuals who immigrated to Sweden or turned 18 years of age after the start of the pandemic (2020). Our analyses will primarily cover the period from 31 January 2020 to 31 December 2022, with updates depending on the progression of the pandemic. We will evaluate COVID-19 mortality differences between foreign-born and Swedish-born individuals by examining each mechanism (differential exposure and effects) separately, while considering potential effect modification by country of birth and socioeconomic factors. Planned statistical modelling techniques include mediation analyses, multilevel models, Poisson regression and event history analyses. ETHICS AND DISSEMINATION: This project has been granted all necessary ethical permissions from the Swedish Ethical Review Authority (Dnr 2022-0048-01) for accessing and analysing deidentified data. The final outputs will primarily be disseminated as scientific articles published in open-access peer-reviewed international journals, as well as press releases and policy briefs.

The effect of parental leave on parents' mental health: a systematic review.

Mental health disorders during the post-partum period are a common morbidity, but parental leave might help alleviate symptoms by preventing or reducing stress. We aim to summarise available evidence on the effect of different types of parental leave on mental health outcomes among parents. For this systematic review, we searched Ovid MEDLINE, Web of Science, PsycINFO, CINAHL, and Scopus from database inception to Aug 29, 2022, for peer-reviewed, quantitative studies written in English. We included studies if the exposure was postnatal parental leave; a relevant comparison group was present (eg, paid vs unpaid leave); and if indicators related to general mental health, including depression, anxiety, stress, and suicide, for either parent were evaluated or recorded at any time after childbirth. The Review is registered with PROSPERO (registration number CRD42021227499). Of the 3441 records screened, 45 studies were narratively synthesised. Studies were done in high-income countries, and they examined generosity by any parental leave (n=5), benefit amount (n=13), and leave duration (n=31). 38 studies were of medium or high quality. Improved mental health was generally observed among women (referred to as mothers in this Review) with more generous parental leave policies (ie, leave duration and paid vs unpaid leave). For example, increased duration of leave was generally associated with reduced risk of poor maternal mental health, including depressive symptoms, psychological distress and burnout, and lower mental health-care uptake. However, the association between fathers' leave and paternal mental health outcomes was less conclusive as was the indirect effect of parental leave use on partners' mental health.

Mental health by native-immigrant intermarriage in Sweden: a register-based retrospective cohort study.

BACKGROUND: Native-immigrant intermarriage is often regarded as a proxy for integration, given that intermarried immigrants are more socioeconomically and culturally similar to natives than intramarried immigrants. This study aimed to assess whether integration affects mental health and care-seeking behaviours, examining prescription hazards for psychotropic medications by native-immigrant marital composition in Sweden. METHODS: Total population register data were used to identify first-time married couples residing in Sweden between 31 December 2005 and 31 December 2016. Index persons were distinguished by gender and partners' origin (native vs. immigrant), as well as by immigrants' regions of origin, with intramarried natives as references. Using Cox regression, hazard ratios (HRs) with 95% confidence intervals (95% CIs) were calculated for antidepressant and anxiolytic prescriptions and adjusted for socioeconomic factors, presence of children and length and quality of marriage. RESULTS: Intramarried immigrant women had higher psychotropic prescription hazards than intramarried native references (HR 1.11, 95% CI 1.10-1.12), whereas intermarried immigrant women had equal hazards. Immigrant women's hazards were lower than native references after adjustment. Intramarried immigrant men had the greatest prescription hazards (HR 1.33, 95% CI 1.32-1.34), and intermarried immigrant men slightly higher hazards (HR 1.11, 95% CI 1.10-1.13), than intramarried natives. All were partly attenuated after adjustment. Intermarriage hazards increased by similarities in regions of origin, especially among men. CONCLUSIONS: Integration indicated by intermarriage appears to be protective for the mental health of immigrants, especially for immigrant men. Future research should empirically disentangle the social, cultural and socioeconomic mechanisms underlying these health differences.

Health Risk Behaviours by Immigrants' Duration of Residence: A Systematic Review and Meta-Analysis.

Objectives: The aim was to systematically review and synthesise international evidence on changes in health risk behaviours by immigrants' duration of residence. Methods: We searched literature databases for peer-reviewed quantitative studies published from 2000 to 2019, examining alcohol, drug and tobacco use; physical inactivity; and dietary habits by duration of residence. Results: Narrative synthesis indicated that immigrants tend to adopt health risk behaviours with longer residence in North America, with larger variation in effect sizes and directionality in other contexts. Random-effects meta-analyses examining the pooled effect across all receiving countries and immigrant groups showed lower odds of smoking (OR 0.54, 0.46-0.63, I 2 = 68.7%) and alcohol use (OR 0.61, 0.47-0.75, I 2 = 93.5%) and higher odds of physical inactivity (OR 1.71, 1.40-2.02, I 2 = 99.1%) among immigrants than natives, but did not provide support for a universal trend by duration of residence. Conclusion: Findings suggest that duration of residence could serve as an effective instrument to monitor immigrants' health changes. However, differences in receiving country contexts and immigrant populations' composition seem to be important to predict the level and direction of behavioural change. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, PROSPERO CRD42018108881.

Psychiatric consequences of a father's leave policy by nativity: a quasi-experimental study in Sweden.

BACKGROUND: Parental leave use has been found to promote maternal and child health, with limited evidence of mental health impacts on fathers. How these effects vary for minority populations with poorer mental health and lower leave uptake, such as migrants, remains under-investigated. This study assessed the effects of a Swedish policy to encourage fathers' leave, the 1995 Father's quota, on Swedish-born and migrant fathers' psychiatric hospitalisations. METHODS: We conducted an interrupted time series analysis using Swedish total population register data for first-time fathers of children born before (1992-1994) and after (1995-1997) the reform (n=198 589). Swedish-born and migrant fathers' 3-year psychiatric hospitalisation rates were modelled using segmented negative binomial regression, adjusting for seasonality and autocorrelation, with stratified analyses by region of origin, duration of residence, and partners' nativity. RESULTS: From immediately pre-reform to post-reform, the proportion of fathers using parental leave increased from 63.6% to 86.4% of native-born and 37.1% to 51.2% of migrants. Swedish-born fathers exhibited no changes in psychiatric hospitalisation rates post-reform, whereas migrants showed 36% decreased rates (incidence rate ratio (IRR) 0.64, 95% CI 0.47 to 0.86). Migrants from regions not predominantly consisting of Organisation for Economic Cooperation and Development countries (IRR 0.50, 95% CI 0.19 to 1.33), and those with migrant partners (IRR 0.23, 95% CI 0.14 to 0.38), experienced the greatest decreases in psychiatric hospitalisation rates. CONCLUSION: The findings of this study suggest that policies oriented towards promoting father's use of parental leave may help to reduce native-migrant health inequalities, with broader benefits for family well-being and child development.

Unintended health consequences of Swedish parental leave policy (ParLeHealth): protocol for a quasi-experimental study.

INTRODUCTION: Sweden has long been praised for a generous parental leave policy oriented towards facilitating a gender-equitable approach to work and parenting. Yet certain aspects of Swedish parental leave could also be responsible for the maintenance of (or even the increase in) health inequalities. Using a 'Health in All Policies' lens, this research project aims to assess the unintended health consequences of various components of Sweden's parental leave policy, including eligibility for and uptake of earnings based benefits. METHODS AND ANALYSIS: We will use individual-level data from multiple Swedish registers. Sociodemographic information, including parental leave use, will be retrieved from the total population register, Longitudinal Integration Database for Health Insurance and Labour Market Studies and Social Insurance Agency registers. Health information for parents and children will be retrieved from the patient, prescribed drug, cause of death, medical birth and children's health registers. We will evaluate parents' mental, mothers' reproductive and children's general health outcomes in relation to several policy reforms aiming to protect parental leave benefits in short birth spacing (the speed premium) and to promote father's uptake (the father's quota) and sharing of parental leave days (the double days reform). We will also examine effects of increases in basic parental leave benefit levels. Using quasi-experimental designs, we will compare health outcomes across these reforms and eligibility thresholds with interrupted time series, difference-in-difference and regression discontinuity approaches to reduce the risk of health selection and assess causality in the link between parental leave use and health. ETHICS AND DISSEMINATION: This project has been granted all necessary ethical permissions from the Stockholm Regional Ethical Review Board (Dnr 2019-04913) for accessing and analysing deidentified data. The final outputs will primarily be disseminated as scientific articles published in open-access, high-impact peer-reviewed international journals, as well as press releases and policy briefs.

Health risk behaviours among migrants by duration of residence: protocol for a systematic review and meta-analysis.

INTRODUCTION: International migrants' health has often been found to deteriorate in new countries, partly due to changes in health risk behaviours such as alcohol consumption, tobacco use, physical inactivity, and poor dietary habits. However, limited efforts have been made to comprehensively evaluate the extent to which migrants adopt unhealthy risk behaviours with longer duration of residence. This systematic review and meta-analysis will summarise evidence on international migrants' behavioural patterns by duration of residence in multiple country contexts. METHODS AND ANALYSIS: PubMed/MEDLINE, Web of Science and ProQuest databases will be searched for quantitative or mixed-method observational studies published in peer-reviewed scientific journals between 1 January 2000 and 31 December 2019. Studies comparing foreign-born individuals by duration of residence will be included. Information on study characteristics, descriptive statistics and measures of effect will be extracted. All included studies will be quality assessed using a modified Newcastle-Ottawa scale. The review will include narrative synthesis and, if sufficient and comparable data are available, random effects meta-analyses. The review will be conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. ETHICS AND DISSEMINATION: Ethical approval is not required since previously published information from peer-reviewed studies will be assessed. The results of this review will be published in peer-reviewed journals and presented at scientific conferences. Other forms of dissemination will include communication to broader audiences using well-established channels, including through university-based press releases. Progress will be regularly updated on the International Prospective Register of Systematic Reviews to ensure full transparency. PROSPERO REGISTRATION NUMBER: CRD42018108881.

Psychological distress by age at migration and duration of residence in Sweden.

Migrants suffer from worse psychological health than natives in many countries, yet the extent to which this varies by age at migration and duration of residence in the receiving context remains unexplored in Sweden. Drawing on a life course approach, we investigate differences in psychological distress by age at migration and duration of residence in working-age migrants to Sweden, and examine the role of various social determinants of health in explaining these differences relative to Swedish-born. Using pooled cross-sectional data from the 2011/2015 Health on Equal Terms survey in Västra Götaland Region, Sweden (n = 58,428), we applied logistic regression analysis to calculate predicted probabilities and average marginal effects (AME) of migrant status, by age at migration and duration of residence, on psychological distress. Analyses were stratified by sex and region of origin and controlled for indicators of socioeconomic status (SES), social cohesion, and discrimination to assess their potential contribution to differences in migrants' and natives' psychological distress. All migrants except men from OECD-predominant regions had a greater probability of psychological distress than Swedish-born (ranging from AME 0.031 [95% Confidence Interval or CI 0.000-0.062] for OECD women to AME 0.115 [95% CI 0.074-0.156] for non-OECD men). Marginal effects of migration status on psychological distress probabilities generally increased with age at migration and duration of residence. Differences between migrants and natives were largely attenuated after controlling for social determinants, the greatest contribution coming from inequalities in social cohesion, followed by inequalities in discrimination and SES. Our results suggest a relative health advantage of early-life compared to later-life migration, albeit with worse outcomes with longer residence in Sweden. The predominance of integration opportunities in childhood strengthens calls for supportive policies to assist older migrants' integration directly upon arrival, which may ultimately improve their psychological wellbeing.

Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysis.

BACKGROUND: Government policies can strongly influence migrants' health. Using a Health in All Policies approach, we systematically reviewed evidence on the impact of public policies outside of the health-care system on migrant health. METHODS: We searched the PubMed, Embase, and Web of Science databases from Jan 1, 2000, to Sept 1, 2017, for quantitative studies comparing the health effects of non-health-targeted public policies on migrants with those on a relevant comparison population. We searched for articles written in English, Swedish, Danish, Norwegian, Finnish, French, Spanish, or Portuguese. Qualitative studies and grey literature were excluded. We evaluated policy effects by migration stage (entry, integration, and exit) and by health outcome using narrative synthesis (all included studies) and random-effects meta-analysis (all studies whose results were amenable to statistical pooling). We summarised meta-analysis outcomes as standardised mean difference (SMD, 95% CI) or odds ratio (OR, 95% CI). To assess certainty, we created tables containing a summary of the findings according to the Grading of Recommendations Assessment, Development, and Evaluation. Our study was registered with PROSPERO, number CRD42017076104. FINDINGS: We identified 43 243 potentially eligible records. 46 articles were narratively synthesised and 19 contributed to the meta-analysis. All studies were published in high-income countries and examined policies of entry (nine articles) and integration (37 articles). Restrictive entry policies (eg, temporary visa status, detention) were associated with poor mental health (SMD 0·44, 95% CI 0·13-0·75; I2=92·1%). In the integration phase, restrictive policies in general, and specifically regarding welfare eligibility and documentation requirements, were found to increase odds of poor self-rated health (OR 1·67, 95% CI 1·35-1·98; I2=82·0%) and mortality (1·38, 1·10-1·65; I2=98·9%). Restricted eligibility for welfare support decreased the odds of general health-care service use (0·92, 0·85-0·98; I2=0·0%), but did not reduce public health insurance coverage (0·89, 0·71-1·07; I2=99·4%), nor markedly affect proportions of people without health insurance (1·06, 0·90-1·21; I2=54·9%). INTERPRETATION: Restrictive entry and integration policies are linked to poor migrant health outcomes in high-income countries. Efforts to improve the health of migrants would benefit from adopting a Health in All Policies perspective. FUNDING: Swedish Council for Health, Working Life, and Social Research; UK Medical Research Council; Scottish Government Chief Scientist Office.

Mortality by country of birth in the Nordic countries - a systematic review of the literature.

BACKGROUND: Immigration to the Nordic countries has increased in the last decades and foreign-born inhabitants now constitute a considerable part of the region's population. Several studies suggest poorer self-reported health among foreign-born compared to natives, while results on mortality and life expectancy are inconclusive. To date, few studies have summarized knowledge on mortality differentials by country of birth. This article aims to systematically review previous results on all-cause and cause-specific mortality by country of birth in the Nordic countries. METHODS: The methodology was conducted and documented systematically and transparently using a narrative approach. We identified 43 relevant studies out of 6059 potentially relevant studies in August 2016, 35 of which used Swedish data, 8 Danish and 1 Norwegian. RESULTS: Our findings from fully-adjusted models on Swedish data support claims of excess mortality risks in specific categories of foreign-born. Most notably, immigrants from other Nordic countries, especially Finland, experience increased risk of mortality from all causes, and specifically by suicide, breast and gynaecological cancers, and circulatory diseases. Increased risks in people from Central and Eastern Europe can also be found. On the contrary, decreased risks for people with Southern European and Middle Eastern origins are found for all-cause, suicide, and breast and gynaecological cancer mortality. The few Danish studies are more difficult to compare, with conflicting results arising in the analysis. Finally, results from the one Norwegian study suggest significantly decreased mortality risks among foreign-born, to be explored in further research. CONCLUSIONS: With new studies being published on mortality differentials between native and foreign-born populations in the Nordic countries, specific risk patterns have begun to arise. Regardless, data from most Nordic countries remains limited, as does the information on specific causes of death. The literature should be expanded in upcoming years to capture associations between country of birth and mortality more clearly.

Social support and protection from depression: systematic review of current findings in Western countries.

BACKGROUND: Numerous studies report an association between social support and protection from depression, but no systematic review or meta-analysis exists on this topic. AIMS: To review systematically the characteristics of social support (types and source) associated with protection from depression across life periods (childhood and adolescence; adulthood; older age) and by study design (cross-sectional v cohort studies). METHOD: A systematic literature search conducted in February 2015 yielded 100 eligible studies. Study quality was assessed using a critical appraisal checklist, followed by meta-analyses. RESULTS: Sources of support varied across life periods, with parental support being most important among children and adolescents, whereas adults and older adults relied more on spouses, followed by family and then friends. Significant heterogeneity in social support measurement was noted. Effects were weaker in both magnitude and significance in cohort studies. CONCLUSIONS: Knowledge gaps remain due to social support measurement heterogeneity and to evidence of reverse causality bias.