1 equity in perinatal healthcare of migrant women carly lang bsch msc(c) * anita j. gagnon rn mph...
TRANSCRIPT
1
Equity in Perinatal Equity in Perinatal Healthcare of Migrant Healthcare of Migrant WomenWomen
Carly Lang BScH MSc(c)Carly Lang BScH MSc(c)** Anita J. Gagnon RN MPH PhDAnita J. Gagnon RN MPH PhD**
Rhonda Small PhDRhonda Small PhD
Irene Sarasua RN MScIrene Sarasua RN MSc**
Canadian Public Health Association Canadian Public Health Association June 3 2008June 3 2008
*McGill University and McGill University Health Centre*McGill University and McGill University Health CentreLa Trobe University, AustraliaLa Trobe University, Australia
Jewish General Hospital, MontrealJewish General Hospital, Montreal
2
Background• Perinatal health outcomes for migrant women
compared to native-born women differ by receiving country:– More harmfulMore harmful outcomes outcomes
C-section rates (Australia, Canada, Italy, UK) Perinatal mortality (UK) low birth weight infants (Italy, UK)
– ComparableComparable outcomes to native-born women outcomes to native-born women• Birth weight and perterm birth (France, Belgium, US)• Perterm birth and perinatal mortality (Italy)
– Outcomes Outcomes varyvary within the same country by source within the same country by source regionregion risk for women from Asian or Sub-Saharan African countries
(Australia, Netherlands, Norway, UK)
3
Background• To examine migrant perinatal health
internationally, ROAM was created
ROAM: General objectivesROAM: General objectives
1. Identify and internationally compare indicators of perinatal health,perinatal health, migration migration and equityequity
2. Hypothesize and test for any identified international differences in distribution of perinatal health or equity of care indicators by migration indicators.
4
ROAM – Reproductive Outcomes And ROAM – Reproductive Outcomes And Migration: An International Research Migration: An International Research Collaboration (self-selected; nine Collaboration (self-selected; nine countries)countries)• Sophie Alexander, Université libre
de Bruxelles (Belgium)• Béatrice Blondel, INSERM (France)• Simone Buitendijk, TNO Institute –
Prevention and Care (Netherlands)• Marie Desmeules, Public Health
Agency of Canada• Dominico DiLallo, Agency for Public
Health – Rome (Italy)• Anita Gagnon (co-leader), McGill
University/MUHC, (Canada)• Mika Gissler, STAKES (Finland)• Richard Glazier, Inst. For Clinical
Evaluative Sciences (Canada)• Maureen Heaman, University of
Manitoba (Canada)• Dineke Korfker, TNO Institute –
Prevention and Care (Netherlands)
• Alison Macfarlane, City University of London (UK)
• Edward Ng, Statistics Canada• Carolyn Roth, Keele University
(UK) • Rhonda Small (co-leader),
LaTrobe University (Australia)• Donna Stewart, Univ. Hlth
Network of Toronto/U of T (Canada)
• Babill Stray-Pederson, University of Oslo (Norway)
• Marcelo Urquia, Inst. For Clinical Evaluative Sciences (Canada)
• Siri Vangen, Dept Ob/Gyn of The National Hospital of Norway
• Jennifer Zeitlin, INSERM and EURO-PERISTAT (France)
• Meg Zimbeck, INSERM and EURO-PERISTAT (France)
5
BackgroundIn order to more clearly investigate
perinatal migrant health disparities internationally, it is essential to have common indicators of:
1. Perinatal health2. Migration
3. Equity3. Equity
6
Definitions
1. Perinatal Health:
Maternal, fetal and infant health during pregnancy, delivery and the post-partum period
Indicators :• Perinatal mortality
(fetus, infant, mother)
• Birth weight
2. Migration: Geographical movement of individuals across international borders
Indicators : • Country of birth• Length of time in country• Immigration status• Receiving country
language fluency• Ethnicity (defined by
maternal parents’ place of birth)
7
Definitions
3. Equity in Health: The absence of systematic and potentially remediable differences in one or more aspects of health across populations or population groups defined socially, economically, demographically, or geographically (International Society for Equity in Health)
8
Research QuestionResearch Question
Is there any evidence that equity of Is there any evidence that equity of perinatal care indicators for migrant perinatal care indicators for migrant
women can be measured?women can be measured?
9
IV. In Delivery of Health Care Services
How fairly/equitably are health
care services delivered to different populations?
Equity in health: Equity in health: A Conceptual A Conceptual FrameworkFramework
I. In Health Status (Outcomes)
How healthy are
different populations?
II. In Access to Health Care
Services
How easily can different populations access health
care services?
III. In Utilization of Health Care Services
How frequently are health care services utilized (or accessed) by
different populations?
V. In Health Care Policy / Financing
How fairly/equitably are
healthcare and other resources allocated for
conditions affecting different populations?
How do healthcare policies affect different populations?
EQUITYEQUITY
10
Methods
I. Measurement of equity indicators
II. Availability of data on equity and migration internationally
III. Feasability of using migration indicators
11
Methods I - Measurement• Access:
– Canadian example: pilot (n = 36) in 2 Montreal hospitals using Migrant Friendly Hospital Initiative Questionnaires and CLAS criteria for recording care
• Utilization:– As for access
• Delivery of health services– Canadian example: data from hospital logs of births
(n = 3500) from Montreal, Toronto, and Vancouver & from study of concerns/ response to concerns (n = 341)
12
Methods II - International Availability of Data
• Indicators relating to access, utilization and delivery of services were sought across ROAM countries– Routinely collected– Nationally representative– Could be analyzed by one of the migration
indicators
13
Methods III - Feasibility of Collecting Hospital Data on Migration Indicators• Canadian example: Migration indicators
sought from women’s hospital charts in postpartum unit
• 7 hospitals in Montreal and Toronto (n=911)• Feb. 2006 - May 2008• To determine which migration indicators are
recorded in hospital
14
Measurement of Equity in HealthMeasurement of Equity in Health
IV. In Delivery of Health Care Services
How fairly/equitably are health
care services delivered to different populations?
I. In Health Status (Outcomes)
How healthy are
different populations?
II. In Access to Health Care
Services
How easily can different populations access health
care services?
III. In Utilization of Health Care Services
How frequently are health care services utilized (or accessed) by
different populations?
V. In Health Care Policy / Financing
How fairly/equitably are
healthcare and other resources allocated for
conditions affecting different populations?
How do healthcare policies affect different populations?
EQUITYEQUITY
15
Measurement of Equity in Measurement of Equity in AccessAccess to Health Care Services to Health Care Services
Doctors/ nurses were rushed
Felt worries taken seriously
Felt had to wait long at visits
Wanted to follow customs
Did not need interpreter/ always available
Decisions made w/o respondent's wishes considered
Labor/ birth taken over
Asked to do something did not want to do
Refugee/AS (n=11)
6 (54.5%) 8 (72.7%) 2 (18.2%) 3 (27.3%) 8 (72.8%) 2 (18.2%) 2 (18.2%) 2 (18.2%)
Immigrant (n=13)
6 (46.2%) 12 (91.7%) 6 (46.2%) 2 (15.4%) 13 (100%) 1 (7.7%) 0 (0%) 1 (7.7%)
Canadian-born (n=12)
2 (16.7%) 11 (91.7%) 7 (58.3) 1 (8.3%) 12 (100%) 0 (0%) 0 (0%) 0 (0%)
In Health Status
(Outcomes)
In Access to Health
Care Services
In Utilization of Health Care
Services
In Delivery of Health
Care Services
In Health Care
Policy / Financing
EQUITYEQUITY
16
Measurement of Equity in Measurement of Equity in UtilizationUtilization of Health Care of Health Care ServicesServices
In Health Status
(Outcomes)
In Access to Health
Care Services
In Utilization of Health Care
Services
In Delivery of Health
Care Services
In Health Care
Policy / Financing
EQUITYEQUITY
0
10
20
30
40
50
60
70
80
90
100
%
Figure II. Information, Advice and Support on Postpartum Unit*
Refugee/Asylum-Seeker Immigrant Canadian-Born
Information, Advice and Support on the Postpartum Unit
Care of Baby Health of Baby
Breastfeeding Bottle Feeding Follow-up Health of Mother
17
0
10
20
30
40
50
60
Euro
pe
S &
C
Am
erica
Afr
ica
West.A
sia
,
N-A
fric
a
S-E
-C A
sia
Euro
pe
S &
C
Am
erica
Afr
ica
West.A
sia
,
N-A
fric
a
S-E
-C A
sia
Euro
pe
S &
C
Am
erica
Afr
ica
West.A
sia
,
N-A
fric
a
S-E
-C A
sia
Canada
Refugee (n=72) A-Seeker (n=117) Immigrant (n=829) Ref(2482)
% C
esare
an
Bir
ths
Measurement of Equity in Measurement of Equity in DeliveryDelivery of Health Care Services of Health Care Services
C-section by immigration status and source regionC-section by immigration status and source region
In Health Status
(Outcomes)
In Access to Health
Care Services
In Utilization of Health Care
Services
In Delivery of Health
Care Services
In Health Care
Policy / Financing
EQUITYEQUITY
18
Availability of Equity Data InternationallyAvailability of Equity Data Internationally
IV. In Delivery of HealthCare Services
How fairly/equitably are health careservices delivered to different
populations?
I . In Health Status(Outcomes)
How healthy are differentpopulations?
II . In Access to HealthCare Services
How easily can differentpopulations access health
care services?
III . In Utilization of HealthCare Services
How frequently are health careservices utilized (or accessed) by
different populations?
V. In Health CarePolicy / Financing
How fairly/equitably arehealthcare and other
resources allocated forconditions affecting different
populations?How do healthcare policiesaffect different populations?
EQUITYEQUITY
19
Availability of International Data on Availability of International Data on Access Access to Health Care Servicesto Health Care Services
In Health Status
(Outcomes)
In Access to Health
Care Services
In Utilization of Health Care
Services
In Delivery of Health
Care Services
In Health Care
Policy / Financing
EQUITYEQUITY
?
20
Availability of International Data on Availability of International Data on Utilization Utilization of Health Care Services - of Health Care Services - Country of BirthCountry of Birth
In Health Status
(Outcomes)
In Access to Health
Care Services
In Utilization of Health Care
Services
In Delivery of Health
Care Services
In Health Care
Policy / Financing
EQUITYEQUITY
Utilization - National Data by COUNTRY OF BIRTH
0
0.5
1
1.5
2
2.5
3
3.5
Prenatal Care Postpartum Care Other Services
Type of Health Care Utilization
Numb
er of
Cou
ntrie
sFrance
UK
Canada
Utilization - National Data by COUNTRY OF BIRTH
Care
France
21
Delivery of Services - National Data by COUNTRY OF BIRTH
0 1 2 3 4 5 6 7 8 9
Caesarean Section In duction Analgesia use Epidural u se Length of
Stay Ability to Understand Inf orm ation
Given by Staff Satisfaction with Care Feels Treated
with Respect
Indicators Collected on the Delivery of Services
Nu
mb
er
of
Co
un
trie
s
Norway Italy* Belgium* France* Finland Australia* UK Canada
Italy* – based on regional datasetBelgium* – regional datasets from Flanders and Brussels; CoB as nationality on arrival and at birthFrance* – CoB as “nationality” as defined as either French, another country from Europe, North Africa, another African country, another nationalityAustralia* - regional datasets from Victoria and New South Wales
Availability of International Data on Availability of International Data on Delivery Delivery of Health Care Services - of Health Care Services - Country of BirthCountry of Birth
In Health Status
(Outcomes)
In Access to Health
Care Services
In Utilization of Health Care
Services
In Delivery of Health
Care Services
In Health Care
Policy / Financing
EQUITYEQUITYDelivery of services – National Data by COUNTRY OF BIRTH
Indicators - Delivery of Services
22
Feasibility of Collecting Hospital Feasibility of Collecting Hospital Data on Migration IndicatorsData on Migration Indicators
Country of Birth
Length of Time in Country
Immigration Status
Language Fluency
Ethnicity by Mother’s Place of Birth
MIGRATION MIGRATION INDICATORINDICATOR
23
MigrationMigration IndicatorIndicator
Country of Birth Length of
time in country
Ethnicity by mother’s place of
birth
Language fluency
Immigration Status
Feasibility of Using Hospital Data on Feasibility of Using Hospital Data on Migration Indicators to Examine Equity by Migration Indicators to Examine Equity by Country of BirthCountry of Birth
Information on COUNTRY OF BIRTH at Discharge (7 Canadian Hospitals)
n=911
74%
26% 0% 0%
Available Unavailable Not Applicable Unknown
24
Can equity of perinatal care for Can equity of perinatal care for migrant women be measured?migrant women be measured?
• Equity can be most easily assessed by:• Health Status• Delivery of health care services
• Country of Birth is the most widely available, feasible migration indicator
• Future equity research is likely to be related to delivery of servicesdelivery of services by country of birthcountry of birth
25
Challenges
• Difficulties in obtaining data– Some equity indicators not routinely
available across countries/institutions– Many equity indicators not standardized– Migration indicators need to be put into
place
26
E-mail: [email protected]: [email protected]
Thanks to Thanks to ROAMROAM, , CIHRCIHR for funding this project, to for funding this project, to Andraea Van Andraea Van HulstHulst for for cesarean section graphscesarean section graphs, to , to Marie-Pier JolyMarie-Pier Joly for for
feasibility data, feasibility data, & to & to Lisa Merry, Zeinab Jeambey Lisa Merry, Zeinab Jeambey andand Jacquie Jacquie BockingBocking for general support. for general support.
Thank Thank you !you !
27
On admission based on all births in two hospitals in Montreal over an 18-day period (Apr 15 – May 3 2008)Discharge data from CHARSNN participants (Feb 2006-present)
MigratioMigrationn
IndicatorIndicator
I. Country of Birth II. Length of time
in country
V. Ethnicity by mother’s parental
place of birth
IV. Language fluency
III. Immigration Status
No data
Health InsuranceNote: Not recognized by Delphi
Information on COUNTRY OF BIRTH on Admission
(2 Montreal Hospitals)
n=443
62% 31%
7% Available Not Available in Record Record Not Available
Information on COUNTRY OF BIRTH at Discharge (7 Canadian Hospitals)
n=911
74%
26% 0% 0%
Available Unavailable Not Applicable Unknown
Information on LENGTH OF TIME on Admission (2 Montreal Hospitals)
n=443
7%
49% 6%
38% Available Not Available in Record Record Not Available Canadian Born
Information on LENGTH OF TIME at Discharge
(7 Canadian Hospitals)
n=911
39%
38%
23% 0% Available Unavailable Not Applicable Unknown
Information on IMMIGRATION STATUS on Admission
(2 Montreal Hospitals) n=443
1%
93%
6% Available Not Available in Record Record Not Available
Information on LANGUAGE on Admission (2 Montreal Hospitals
n=443
87%
10% 3%
Available Not Available in Record Record Not Available
Information on HEALTH INSURANCE on Admission (2 Montreal Hospitals)
n=443
93%
3% 4%
Available Not Available in Record Record Not Available
Information on IMMIGRATION STATUS at Discharge atatDiscahrgedigh (7 Canadian Hospitals)
n=911
28%
49%
23% 0% Available Unavailable Not Applicable Unknown
Information on HEALTH INSURANCE at Discharge (7 Canadian Hospitals)
n=911
93%
7% 0% 0%
Available Unavailable Not Applicable Unknown
Information on LANGUAGE at Discharge (7 Canadian Hospitals)
n=911
93%
6% 0% 1%
Available Unavailable Not Applicable Unknown
Feasibility of using hospital data on migration indicators to examine equity in care
28
MigrationMigration IndicatorIndicator
I. Country of Birth II. Length of
time in country
V. Ethnicity by mother’s
parental place of birth
IV. Language fluency
III. Immigration Status
Information on LENGTH OF TIME on Admission (2 Montreal Hospitals)
n=443
7%
49% 6%
38% Available Not Available in Record Record Not Available Canadian Born
Information on LENGTH OF TIME at Discharge
(7 Canadian Hospitals)
n=911
39%
38%
23% 0% Available Unavailable Not Applicable Unknown
29
MigrationMigration IndicatorIndicator
I. Country of Birth
II. Length of time in country
V. Ethnicity by mother’s parental
place of birth
IV. Language fluency
III. Immigration Status
Information on IMMIGRATION STATUS on Admission
(2 Montreal Hospitals) n=443
1%
93%
6% Available Not Available in Record Record Not Available
Information on IMMIGRATION STATUS at Discharge atatDiscahrgedigh (7 Canadian Hospitals)
n=911
28%
49%
23% 0% Available Unavailable Not Applicable Unknown
30
MigrationMigration IndicatorIndicator
I. Country of Birth II. Length of
time in country
V. Ethnicity by mother’s
parental place of birth
IV. Language fluency
III. Immigration Status
No data
31
MigrationMigration IndicatorIndicator
I. Country of Birth
II. Length of time in country
V. Ethnicity by mother’s parental
place of birth
IV. Language fluency
III. Immigration Status
Health InsuranceNote: Not recognized by Delphi
Information on HEALTH INSURANCE on Admission (2 Montreal Hospitals)
n=443
93%
3% 4%
Available Not Available in Record Record Not Available
Information on HEALTH INSURANCE at Discharge (7 Canadian Hospitals)
n=911
93%
7% 0% 0%
Available Unavailable Not Applicable Unknown
Note: Health Insurance not a category recognized by Delphi