Susitha Wanigaratne1, Donald C Cole1, Kate Bassil1, Ilene Hyman1, Rahim Moineddin1, Marcelo L Urquia1. 1. At the time of the study, Susitha Wanigaratne was a doctoral student at the Dalla Lana School of Public Health, University of Toronto, Ontario, Canada at the time of this study. Donald C. Cole and Ilene Hyman are with the Dalla Lana School of Public Health. Kate Bassil is with Toronto Public Health, Toronto, Ontario, Canada. Rahim Moineddin is with the Department of Family and Community Medicine, University of Toronto. Marcelo L. Urquia is with the Centre for Research on Inner City Health, St. Michael's Hospital, Toronto, Ontario, Canada.
Abstract
OBJECTIVES: We compared severe maternal morbidity (SMM) and SMM subtypes, including HIV, of refugee women with those of nonrefugee immigrant and nonimmigrant women. METHODS: We linked 1,154,421 Ontario hospital deliveries (2002-2011) to immigration records (1985-2010) to determine the incidence of an SMM composite indicator and its subtypes. We determined SMM incidence according to immigration periods, which were characterized by lifting restrictions for all HIV-positive immigrants (in 1991) and refugees who may place "excessive demand" on government services (in 2002). RESULTS: Refugees had a higher risk of SMM (17.1 per 1000 deliveries) than did immigrants (12.1 per 1000) and nonimmigrants (12.4 per 1000). Among SMM subtypes, refugees had a much higher risk of HIV than did immigrants (risk ratio [RR] = 7.94; 95% confidence interval [CI] = 5.64, 11.18) and nonimmigrants (RR = 17.37; 95% CI = 12.83, 23.53). SMM disparities were greatest after the 2002 policy came into effect. After exclusion of HIV cases, SMM disparities disappeared. CONCLUSIONS: An apparent higher risk of SMM among refugee women in Ontario, Canada is explained by their high prevalence of HIV, which increased over time parallel to admission policy changes favoring humanitarian protection.
OBJECTIVES: We compared severe maternal morbidity (SMM) and SMM subtypes, including HIV, of refugee women with those of nonrefugee immigrant and nonimmigrant women. METHODS: We linked 1,154,421 Ontario hospital deliveries (2002-2011) to immigration records (1985-2010) to determine the incidence of an SMM composite indicator and its subtypes. We determined SMM incidence according to immigration periods, which were characterized by lifting restrictions for all HIV-positive immigrants (in 1991) and refugees who may place "excessive demand" on government services (in 2002). RESULTS: Refugees had a higher risk of SMM (17.1 per 1000 deliveries) than did immigrants (12.1 per 1000) and nonimmigrants (12.4 per 1000). Among SMM subtypes, refugees had a much higher risk of HIV than did immigrants (risk ratio [RR] = 7.94; 95% confidence interval [CI] = 5.64, 11.18) and nonimmigrants (RR = 17.37; 95% CI = 12.83, 23.53). SMM disparities were greatest after the 2002 policy came into effect. After exclusion of HIV cases, SMM disparities disappeared. CONCLUSIONS: An apparent higher risk of SMM among refugee women in Ontario, Canada is explained by their high prevalence of HIV, which increased over time parallel to admission policy changes favoring humanitarian protection.
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