title: Severe maternal morbidity associated with maternal birthplace in three high-immigration settings.
abstract: BACKGROUND
  Maternal mortality and morbidity vary substantially worldwide. It is unknown if these geographic differences translate into disparities in severe maternal morbidity among immigrants from various world regions. We assessed disparities in severe maternal morbidity between immigrant women from various world regions giving birth in three high-immigration countries.
  
  
  METHODS
  We used population-based delivery data from Victoria; Australia and Ontario, Canada and national data from Denmark, in the most recent 10-year period ending in 2010 available to each participating centre. Each centre provided aggregate data according to standardized definitions of the outcome, maternal regions of birth and covariates for pooled analyses. We used random effects and stratified logistic regression to obtain odds ratios (ORs) with 95% confidence intervals (95% CIs), adjusted for maternal age, parity and comparability scores.
  
  
  RESULTS
  We retrieved 2,322,907 deliveries in all three receiving countries, of which 479,986 (21%) were to immigrant women. Compared with non-immigrants, only Sub-Saharan African women were consistently at higher risk of severe maternal morbidity in all three receiving countries (pooled adjusted OR: 1.67; 95% CI: 1.43, 1.95). In contrast, both Western and Eastern European immigrants had lower odds (OR: 0.82; 95% CI: 0.70, 0.96 and OR: 0.64; 95% CI: 0.49, 0.83, respectively). The most common diagnosis was severe pre-eclampsia followed by uterine rupture, which was more common among Sub-Saharan Africans in all three settings.
  
  
  CONCLUSIONS
  Immigrant women from Sub-Saharan Africa have higher rates of severe maternal morbidity. Other immigrant groups had similar or lower rates than the majority locally born populations.
authors.affiliation: 1 St. Michael's Hospital, Li Ka Shing Knowledge Institute, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada marcelo.urquia@utoronto.ca.
authors.forename: Marcelo L
authors.initials: ML
authors.lastname: Urquia
authors.affiliation: 2 Institute for Clinical Evaluative Sciences, Toronto, Canada.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Glazier
authors.affiliation: 3 Institute of Public Health, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Laust
authors.initials: L
authors.lastname: Mortensen
authors.affiliation: 3 Institute of Public Health, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Anne-Marie
authors.initials: AM
authors.lastname: Nybo-Andersen
authors.affiliation: 4 Mother and Child Health Research Centre, School of Nursing and Midwifery, LaTrobe University, Melbourne, Australia.
authors.forename: Rhonda
authors.initials: R
authors.lastname: Small
authors.affiliation: 4 Mother and Child Health Research Centre, School of Nursing and Midwifery, LaTrobe University, Melbourne, Australia.
authors.forename: Mary-Ann
authors.initials: MA
authors.lastname: Davey
authors.affiliation: 5 Department of Women's and Children's Health/International Maternal Child Health, Uppsala University, Uppsala, Sweden.
authors.forename: Mattias
authors.initials: M
authors.lastname: Rööst
authors.affiliation: 5 Department of Women's and Children's Health/International Maternal Child Health, Uppsala University, Uppsala, Sweden.
authors.forename: Birgitta
authors.initials: B
authors.lastname: Essén
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara / Q000208:ethnology; D001315:Australia / Q000453:epidemiology; D002170:Canada / Q000453:epidemiology; D002318:Cardiovascular Diseases / Q000208:ethnology; D003718:Denmark; D054242:Emigrants and Immigrants / Q000706:statistics & numerical data*; D005260:Female; D014943:Global Health; D054624:Health Status Disparities; D006801:Humans; D016015:Logistic Models; D008428:Maternal Mortality / Q000208:ethnology*; D011225:Pre-Eclampsia / Q000208:ethnology; D011247:Pregnancy; D014597:Uterine Rupture / Q000208:ethnology