Severe Maternal Morbidity and Mortality among Immigrant and Canadian-Born Women Residing Within Low-Income Neighborhoods in Ontario, Canada

Abstract

Importance: Evidence indicates that immigrant women and women residing within low-income neighborhoods experience higher adversity during pregnancy. Little is known about the comparative risk of severe maternal morbidity or mortality (SMM-M) among immigrant vs nonimmigrant women living in low-income areas. Objective: To compare the risk of SMM-M between immigrant and nonimmigrant women residing exclusively within low-income neighborhoods in Ontario, Canada. Design, Setting, and Participants: This population-based cohort study used administrative data for Ontario, Canada, from April 1, 2002, to December 31, 2019. Included were all 414337 hospital-based singleton live births and stillbirths occurring between 20 and 42 weeks' gestation, solely among women residing in an urban neighborhood of the lowest income quintile; all women were receiving universal health care insurance. Statistical analysis was performed from December 2021 to March 2022. Exposures: Nonrefugee immigrant status vs nonimmigrant status. Main Outcomes and Measures: The primary outcome, SMM-M, was a composite outcome of potentially life-threatening complications or mortality occurring within 42 days of the index birth hospitalization. A secondary outcome was SMM severity, approximated by the number of SMM indicators (0, 1, 2 or ≥3 indicators). Relative risks (RRs), absolute risk differences (ARDs), and odds ratios (ORs) were adjusted for maternal age and parity. Results: The cohort included 148085 births to immigrant women (mean [SD] age at index birth, 30.6 [5.2] years) and 266252 births to nonimmigrant women (mean [SD] age at index birth, 27.9 [5.9] years). Most immigrant women originated from South Asia (52447 [35.4%]) and the East Asia and Pacific (35280 [23.8%]) regions. The most frequent SMM indicators were postpartum hemorrhage with red blood cell transfusion, intensive care unit admission, and puerperal sepsis. The rate of SMM-M was lower among immigrant women (2459 of 148085 [16.6 per 1000 births]) than nonimmigrant women (4563 of 266252 [17.1 per 1000 births]), equivalent to an adjusted RR of 0.92 (95% CI, 0.88-0.97) and an adjusted ARD of -1.5 per 1000 births (95% CI, -2.3 to -0.7). Comparing immigrant vs nonimmigrant women, the adjusted OR of having 1 SMM indicator was 0.92 (95% CI, 0.87-0.98), the adjusted OR of having 2 indicators was 0.86 (95% CI, 0.76-0.98), and the adjusted OR of having 3 or more indicators was 1.02 (95% CI, 0.87-1.19). Conclusions and Relevance: This study suggests that, among universally insured women residing in low-income urban areas, immigrant women have a slightly lower associated risk of SMM-M than their nonimmigrant counterparts. Efforts aimed at improving pregnancy care should focus on all women residing in low-income neighborhoods..