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Naturalize to Stay Alive

Social determinants possess a tremendous impact on health outcomes. A Belgian study shows the correlation between perinatal death and immigration status. It serves as clarion call to US health and immigration policy makers.

Disparities in neonatal mortality and pregnancy outcomes among immigrants are poorly understood.  Both positive and negative correlations have been shown between immigration status and perinatal mortality depending on geographical origin and destination.  Adjustments for background information are not sufficient to explain these differences.

In Belgium, integration refers to a successful immigration process and is closely related to the naturalization process.  Studies reveal that strong integration policies are associated with reduced risk of perinatal mortality.  This study sought to evaluate the relationship between naturalization and perinatal outcomes by comparing perinatal mortality rates in immigrant mothers of varying citizenship status.

Using birth certificates from the 2008 birth registry, this population-based study reflected data in the regions of Brussels and Walloon, which house a German-speaking minority. The birth registry included birth certificates of all live births and stillbirths from 500 grams or 22 weeks’ gestation. The registry also included births by women staying in Belgium illegally, asylum seekers, and planned and unplanned home births. Neonatal, maternal, socioeconomic and medical information were linked.

Parents were defined as immigrants or nonimmigrants based on their nationality at birth; immigrants were defined as naturalized or not naturalized based on their present nationality.

Belgian citizens were categorized as non-immigrants. Border country natives who did not abandon their original nationality were also categorized as non-immigrants.  Immigrants were categorized as naturalized if their present nationality was Belgian or one of the four border country nationalities.

A total of 60,881 births were included in the analysis; 4.2 percent were border country natives.  Stillbirths and early neonatal deaths (<7 days after birth) were included.  The data were adjusted for maternal age, education, number of pregnancies, marital status, comorbidities like hypertension and diabetes, previous neonatal deaths, and paternal employment status.

Immigrant mothers accounted for 34.3 percent of births. Four hundred thirty-seven perinatal deaths were registered of which 76.9 percent were stillbirths. Using multivariate analyses, statistically significant differences in perinatal death rates were noted between natives (0.64 percent) and immigrants (0.86 percent).  Amongst immigrants, differences in perinatal mortality rates were noted by naturalization status (0.06 percent in naturalized immigrants and 0.10 percent in non-naturalized immigrants).  This trend held true across all immigrant subgroups.

Non-naturalized immigrants tended to be younger, had fewer pregnancies, less education, and fathers were less likely to be employed compared to their naturalized counterparts. Risk factors for perinatal morbidities were fewer amongst non-immigrants than immigrants.  Despite several study limitations, receiving citizenship was indeed related with a decreased risk of perinatal mortality.


The Affordable Care Act (ACA) is estimated to reduce the number of uninsured by 32 million and to extend Medicaid coverage to 16 million.  However, the ACA is not all-inclusive.

All US citizens, native-born and naturalized immigrants, will have the same protection and obligations under the new health reform.  This includes Medicaid and CHIP coverage for young adults and children up to 133 percent of the federal poverty level and an individual mandate to have insurance coverage.  Refugees and asylees will have the same requirements and obligations as US citizens.

Legal permanent residents (documented immigrants) are subject to the individual mandate, but Medicaid/CHIP coverage restrictions, such as the 5-year waiting period, remain the same. Some states have opted to waive this waiting period to provide coverage for their legal immigrants.  Undocumented immigrants will not be protected or have any coverage obligations under the ACA, except for the case of emergency Medicaid for labor and delivery.  Other emergencies would be covered under EMTALA.

Belgium’s health care system is accessible to all including undocumented immigrants, while the US system intentionally excludes this population.  Yet, undocumented immigrants in the US will continue to receive some level of care through EMTALA regardless of insurance coverage.

The infant mortality rate in Belgium is 4.28/1000 compared to the higher US rate of 5.98/1000. The US may experience the same trend of perinatal deaths amongst its immigrant populations.  Ultimately, these poor medical outcomes become subsidized by taxpayers.

The resistance to offering a are both punitive in nature yet self-defeating; US taxpayers continue to bare the economic burden and newly born Americans suffer.  Marginalization of the undocumented hurts all of us.

Minsart AF, et al. “Naturalization of immigrants and perinatal mortality.” Eur J Public Health. 2013 Apr;23(2):269-74.


Renée Volny, DO, MBA

Renée Volny Darko, DO, MBA
About Renée Volny Darko, DO, MBA

Dr. Darko is a board-certified OB/GYN who currently practices in Pennsylvania. She has contributed to Policy Prescriptions since 2009. Contact: Facebook | Twitter | More Posts

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