{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,7]],"date-time":"2026-04-07T14:26:06Z","timestamp":1775571966525,"version":"3.50.1"},"reference-count":37,"publisher":"Public Library of Science (PLoS)","issue":"4","license":[{"start":{"date-parts":[[2025,4,29]],"date-time":"2025-04-29T00:00:00Z","timestamp":1745884800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000024","name":"Canadian Institute of Health Research","doi-asserted-by":"crossref","award":["159451"],"award-info":[{"award-number":["159451"]}],"id":[{"id":"10.13039\/501100000024","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Refugees often face increased risks of poor perinatal health outcomes compared to native-born individuals and non-refugee immigrants. However, limited research has explored how birth outcomes vary across refugee subgroups in Canada, especially compared to economic immigrants and among refugee groups themselves. This study aimed to (1) compare the risk of preterm birth (PTB), small-for-gestational-age (SGA), large-for-gestational-age (LGA), stillbirth, and infant mortality between refugee subgroups and economic immigrants, and (2) examine differences among Government-Assisted Refugees (GARs), Privately Sponsored Refugees (PSRs), and In-Canada Refugees (ICRs).<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>This population-based study used data from the Migrant Maternal and Infant Morbidity and Mortality (MIMMM) dataset, including 706,620 singleton births from 2000 to 2017. Generalized estimating equation models calculated adjusted risk ratios (aRRs) for birth outcomes, accounting for maternal and immigration-related factors.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>All refugee subgroups had higher PTB (6.26\u20136.41 per 100 births) and LGA rates (8.65\u20139.17 per 100 births) but lower SGA rates (9.53\u201310.40 per 100 births) compared to economic immigrants (PTB: 5.95, LGA: 7.36, SGA: 10.96). After adjustment, GARs maintained higher PTB risks, and all refugee subgroups had lower SGA and higher LGA risks than economic immigrants. Within refugee subgroups, ICRs had higher SGA risks (aRR = 1.09; 95% CI: 1.04\u20131.14) than GARs, and PSRs (aRR = 1.22; 95% CI: 1.04\u20131.44) and ICRs (aRR = 1.28; 95% CI: 1.07\u20131.52) had higher stillbirth risks than GARs.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusion<\/jats:title>\n<jats:p>Refugee women in Canada have higher risks of PTB and LGA births compared to economic immigrants. ICRs had higher risks of SGA births and stillbirths than other refugee subgroups but lower risks of SGA and stillbirths compared to economic immigrants. These disparities are partly explained by maternal and immigration-related factors. Further research is needed to better understand these factors and inform policies aimed at reducing health disparities among immigrant populations in Canada.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0321453","type":"journal-article","created":{"date-parts":[[2025,4,29]],"date-time":"2025-04-29T18:02:10Z","timestamp":1745949730000},"page":"e0321453","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Comparative analysis of perinatal health outcomes among refugee subgroups and economic immigrants in Canada (2000\u20132017)"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4953-7346","authenticated-orcid":true,"given":"Marwa","family":"Ramadan","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gabriel D.","family":"Shapiro","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Seungmi","family":"Yang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Edward","family":"Ng","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bilkis","family":"Vissandj\u00e9e","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zoua M.","family":"Vang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2025,4,29]]},"reference":[{"issue":"1","key":"pone.0321453.ref001","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1186\/s12916-018-1064-0","article-title":"Perinatal health outcomes and care among asylum seekers and refugees: a systematic review of systematic reviews","volume":"16","author":"N Heslehurst","year":"2018","journal-title":"BMC Med"},{"issue":"10","key":"pone.0321453.ref002","doi-asserted-by":"crossref","first-page":"e0287617","DOI":"10.1371\/journal.pone.0287617","article-title":"Fifty years of evidence on perinatal experience among refugee and asylum-seeking women in Organization for Economic Co-operation and Development (OECD) countries: A scoping review","volume":"18","author":"M Ramadan","year":"2023","journal-title":"PLoS One"},{"issue":"7","key":"pone.0321453.ref003","doi-asserted-by":"crossref","first-page":"730","DOI":"10.1177\/1403494818777432","article-title":"Being a refugee or having a refugee status? 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A systematic review of the healthy immigrant effect in Canada","volume":"22","author":"ZM Vang","year":"2017","journal-title":"Ethn Health"},{"key":"pone.0321453.ref022","unstructured":"Health Data Integration Unit. Centre for Population Health Data, Statistics Canada. The mothers-centric linkage: integration of livebirth, stillbirth, deaths, immigration and hospital data into Mothers File. Validation report, linkage number 016-2019. 2020."},{"key":"pone.0321453.ref023","first-page":"3","article-title":"Canadian perinatal health report, 2003","author":"Health Canada","year":"2003","journal-title":"Minist Public Works Serv Can"},{"key":"pone.0321453.ref024","author":"WHO","year":"Nov 2023"},{"issue":"2","key":"pone.0321453.ref025","doi-asserted-by":"crossref","first-page":"E35","DOI":"10.1542\/peds.108.2.e35","article-title":"A new and improved population-based Canadian reference for birth weight for gestational age","volume":"108","author":"MS Kramer","year":"2001","journal-title":"Pediatrics"},{"key":"pone.0321453.ref026","unstructured":"Statistics Canada. Vital Statistics - Stillbirth Database (CVSS). 1 Sep 2022 [cited 24 Nov 2023]. Available: https:\/\/www23.statcan.gc.ca\/imdb\/p2SV.pl?Function=getSurvey&SDDS=3234"},{"issue":"4","key":"pone.0321453.ref027","doi-asserted-by":"crossref","first-page":"296","DOI":"10.1016\/S1701-2163(15)30604-6","article-title":"Obstetric risks and outcomes of refugee women at a single centre in Toronto","volume":"36","author":"T Kandasamy","year":"2014","journal-title":"J Obstet Gynaecol Can"},{"issue":"1","key":"pone.0321453.ref028","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1093\/aje\/kwf176","article-title":"Maternal stress and preterm birth","volume":"157","author":"N Dole","year":"2003","journal-title":"Am J Epidemiol"},{"key":"pone.0321453.ref029","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1186\/s12884-015-0775-x","article-title":"Effect of maternal stress during pregnancy on the risk for preterm birth","volume":"16","author":"C Lilliecreutz","year":"2016","journal-title":"BMC Pregnancy Childbirth"},{"issue":"3","key":"pone.0321453.ref030","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1016\/j.wombi.2015.02.003","article-title":"The effects of maternal depression, anxiety, and perceived stress during pregnancy on preterm birth: a systematic review","volume":"28","author":"A Staneva","year":"2015","journal-title":"Women Birth"},{"issue":"2","key":"pone.0321453.ref031","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1023\/A:1011353216619","article-title":"Stress and preterm birth: neuroendocrine, immune\/inflammatory, and vascular mechanisms","volume":"5","author":"PD Wadhwa","year":"2001","journal-title":"Matern Child Health J"},{"key":"pone.0321453.ref032","doi-asserted-by":"crossref","first-page":"643","DOI":"10.1016\/j.jad.2020.09.077","article-title":"The impact of maternal stress on offspring birth weight and the mediating effect of dietary patterns: the Shanghai Maternal-Child Pairs Cohort study","volume":"278","author":"Q Wei","year":"2021","journal-title":"J Affect Disord"},{"key":"pone.0321453.ref033","first-page":"352","article-title":"Public health response and health status of asylum seekers: a review of the international literature and implications for the Canadian context","author":"J Hwang","year":"2017","journal-title":"Natl Collab Cent Infect Dis"},{"key":"pone.0321453.ref034","first-page":"1","volume-title":"Refugee health care cuts in Canada","author":"S Marwah","year":"2014"},{"issue":"6","key":"pone.0321453.ref035","doi-asserted-by":"crossref","first-page":"1048","DOI":"10.1093\/eurpub\/ckz120","article-title":"Perinatal health of refugee and asylum-seeking women in Sweden 2014-17: a register-based cohort study","volume":"29","author":"C Liu","year":"2019","journal-title":"Eur J Public Health"},{"issue":"1","key":"pone.0321453.ref036","doi-asserted-by":"crossref","first-page":"320","DOI":"10.1186\/s12884-020-02985-x","article-title":"Pregnancy outcomes in asylum seekers in the North of the Netherlands: a retrospective documentary analysis","volume":"20","author":"AEH Verschuuren","year":"2020","journal-title":"BMC Pregnancy Childbirth"},{"issue":"2","key":"pone.0321453.ref037","doi-asserted-by":"crossref","first-page":"e0247138","DOI":"10.1371\/journal.pone.0247138","article-title":"Preterm disparities between foreign and Swedish born mothers depend on the method used to estimate gestational age. 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