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.

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.

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.

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.

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.

Giving birth across the border: the San Diego-Tijuana connection.

Large immigration flows of young Mexican women to the U.S.-Mexico border are increasing the demand for maternity services in the Southwest. To date no attempt has been made to determine how U.S. births are distributed among stable, permanent residents and transient migrants, such as border residents of Mexico who enter the U.S. temporarily, yet long enough to use health services. This exploratory study examines factors associated with childbirth in California by border residents of Tijuana, Mexico. Data on 184 women, 15-44 years old, who gave birth between 1982-87, were examined using a household survey and focus group discussions. The findings indicate that 10.4% of the sample crossed the border to give birth in the United States. Socio-economic and legal status, spoken English proficiency, history of U.S. residency, annual visits across the border, single parenthood and primiparity were factors significantly associated with childbirth in the United States. These factors, in addition to social class differentials in attitudes towards U.S. obstetrical care and citizenship-by-birth need to be examined in future studies of cross-border utilization of services. The findings also demonstrate that most U.S. deliveries were in the private sector and paid for out of pocket, representing a very low public health burden. Changes in Medicaid legislation, which have extended maternity care coverage to the undocumented, may encourage deliveries in the public sector. These effects, coupled with the bridging effects that newly legalized immigrant networks exert on friends and relatives, familiarizing them with U.S. health care resources, will require monitoring to determine changes in demand for U.S. maternity care by this population.

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.

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.

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.

Dietary, alcohol, and tobacco intake among Mexican-American women of childbearing age: results from HANES data.

PURPOSE: Dietary intake and substance abuse are important predictors of pregnancy outcome yet little is known about these behaviors in Mexican Americans. Dietary, tobacco, and alcohol intake of Mexican-American and non-Hispanic white women were compared across the reproductive cycle. DESIGN: Four cross-sectional groups--interconceptional, pregnant, lactating, and postpartum non-lactating--were compared within and between ethnic groups. SUBJECTS: A stratified sample of 682 women, 16 to 44 years old, of Mexican birth or origin from the Hispanic HANES was contrasted with a similarly stratified sample of 1,396 white non-Hispanic women from the NHANES: MEASURES: Demographic, behavioral and health characteristics, food practices, and fluid intake were examined. Data on food servings were combined into five major food groups. RESULTS: Compared with white non-Hispanics, Mexican-American women had lower socioeconomic status and worse perceived health. However, Mexican Americans reported lower consumption of tobacco, alcohol, diet soda, and caffeine, particularly during pregnancy and lactation. Although portion sizes for the foods consumed were not assessed, frequency of consumption of fruits and vegetables and milk was lower and meat higher among Mexican Americans. CONCLUSIONS: Despite socioeconomic disadvantages, Mexican-American women have better health habits than white non-Hispanic women. From these data it is unclear how diet affects pregnancy outcomes in Mexican Americans.

Measuring Tijuana residents' choice of Mexican or U.S. health care services.

There is growing concern that the indigent health care burden in the southwestern United States may be caused partly by Mexican residents who cross the border to use U.S. health services. This article describes the first attempt to measure the extent of this use by border residents. It also compares factors associated with their use of health care services in both the United States and Mexico. Data were obtained from a household survey conducted in Tijuana, Mexico, near the California border, using a random, stratified analytic sample of 660 households that included a total of 2,954 persons. The dependent variables--extent and volume of contacts with health professionals--were examined according to sociodemographic characteristics, insurance coverage, payment modality, type of visit, and health care setting. The results indicate that 40.3 percent of the Tijuana population used health services exclusively in Mexico during a 6-month period, compared with only 2.5 percent who used services in the United States. Of the Mexican users of U.S. services, the largest proportion appeared to be older people, lawful permanent residents or citizens of the United States who are living in Mexico, and persons from high- or middle-income sectors. In addition to the low level of use of U.S. health services, the findings show that more than 84 percent of the visits were to providers in the private sector and, for 59 percent of the visits, a fee for services was implied. Overall, this border population does not seem to be a drain on the U.S. public health system. The findings must remain tentative, given some methodological constraints of the study; they point to the need for further assessments of the demand for specific services by distinct segments of the border population. Furthermore,since health care financing is a critical issue for Mexico as well, more studies are needed that examine the behavior of U.S. residents who use Mexican health services.

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.

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.

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 incorporation of Mexican women in seasonal migration: a study of gender differences.

"This article compares sex differences in migratory behaviors, work patterns and conjugal relations in a cohort of male and female immigrants who move seasonally between Mexico and the United States. Gender comparisons are made using survey data and information from in-depth group interviews. The findings indicate that among Mexicans immigration to the United States reinstates men's traditional roles as providers while making women assume non-traditional roles. Female role expansion, through employment in the U.S., strongly influences conjugal relations in the direction of more equality. In contrast, failure to enter the American labor force implies a role restriction resulting in a loss of autonomy for many immigrant women." (SUMMARY IN SPA)

Migration tradeoffs: men's experiences with seasonal lifestyles.

This study examines changes in work, health, and family patterns among men who migrate seasonally between Mexico and the US. A representative sample of 219 Mexican seasonal migrants to California was obtained in Jalisco, Mexico, in 1984. The data were generated through a household survey and in-depth follow-up interviews. The findings indicate that migrants experience marked changes and tradeoffs in roles and life styles which are reflected in the workplace and the family. In contrast, changes in physical health associated with seasonal migration seem far less apparent. Beyond the economic function of providing jobs and income, migration performs a significant social function which is described in the context of seasonal life styles.

At risk: health needs of Hispanic children.

Assessing the needs of vulnerable populations and targeting services for them requires a thorough examination of the special risks they face. This article identifies the psychosocial risks of Hispanic children, emphasizing that cultural, psychological, and economic factors interact to jeopardize the health and educational development of this rapidly growing segment of the population.

Health care users residing on the Mexican border. What factors determine choice of the U.S. or Mexican health system?

Using multivariate analytic techniques, this article examines the factors influencing choice of the Mexican or U.S. health care system by service users residing on the Mexican border. Data were obtained from a 1987 binational health survey of 660 households, conducted in Tijuana. The sample consisted of 1,162 household members who reported having used health services in the U.S. and/or Mexico in the 6 months prior to the interview. The findings indicate that out of all the health care users in a 6-month interval, 7% sought services in the United States and 93% sought services only in Mexico. A weighted logistic regression on entry into care shows that, after adjusting for all the other variables in the model, U.S. insurance coverage, transportation, older age, and male gender were the most significant predictors. U.S. insurance, the strongest predictor of access, was associated with a labor history and legal residence across the border. Among U.S. users, the average number of visits was 2.6 (SD = 2.7). Sex, transportation, and socioeconomic status were significant predictors of volume of visits, in a weighted least squares regression analysis. The probability of more contacts among women is linked to their reproductive needs. An increasing use of U.S. health care is expected as a consequence of the new immigration law.