BackgroundAccess to health care for asylum-seekers and refugees (AS&R) in Germany is initially restricted before regular access is granted, allegedly leading to delayed care and increasing costs of care. We analyse the effects of (a) restricted access; and (b) two major policy reforms (1997, 2007) on incident health expenditures for AS&R in 1994-2013.Methods and FindingsWe used annual, nation-wide, aggregate data of the German Federal Statistics Office (1994-2013) to compare incident health expenditures among AS&R with restricted access (exposed) to AS&R with regular access (unexposed). We calculated incidence rate differences (∆IRt) and rate ratios (IRRt), as well as attributable fractions among the exposed (AFe) and the total population (AFp). The effects of between-group differences in need, and of policy reforms, on differences in per capita expenditures were assessed in (segmented) linear regression models. The exposed and unexposed groups comprised 4.16 and 1.53 million person-years. Per capita expenditures (1994–2013) were higher in the group with restricted access in absolute (∆IRt = 375.80 Euros [375.77; 375.89]) and relative terms (IRR = 1.39). The AFe was 28.07% and the AFp 22.21%. Between-group differences in mean age and in the type of accommodation were the main independent predictors of between-group expenditure differences. Need variables explained 50-75% of the variation in between-group differences over time. The 1997 policy reform significantly increased ∆IRt adjusted for secular trends and between-group differences in age (by 600.0 Euros [212.6; 986.2]) and sex (by 867.0 Euros [390.9; 1342.5]). The 2007 policy reform had no such effect.ConclusionThe cost of excluding AS&R from health care appears ultimately higher than granting regular access to care. Excess expenditures attributable to the restriction were substantial and could not be completely explained by differences in need. An evidence-informed discourse on access to health care for AS&R in Germany is needed; it urgently requires high-quality, individual-level data.

Empirical findings show that morbidity and mortality risks of migrants can differ considerably from those of populations in the host countries. However, while several explanatory models have been developed, most migrant studies still do not consider explicitly the situation of migrants before migration. Here, we discuss an extended approach to understand migrant health comprising a life course epidemiology perspective.The incorporation of a life course perspective into a conceptual framework of migrant health enables the consideration of risk factors and disease outcomes over the different life phases of migrants, which is necessary to understand the health situation of migrants and their offspring. Comparison populations need to be carefully selected depending on the study questions under consideration within the life course framework.Migrant health research will benefit from an approach using a life course perspective. A critique of the theoretical foundations of migrant health research is essential for further developing both the theoretical framework of migrant health and related empirical studies.

Summaryobjective To test the hypothesis that as a minority with lower socio‐economic status, Turkish residents in Germany might experience a higher mortality than Germans. methods All‐cause mortality rates by age group and sex of Turkish and German adults for the time period 1980–94 were calculated from death registry data and mid‐year population estimates. results The age‐adjusted mortality rate (per 100000) of Turkish males aged 25–65 years resident in Germany was 299 in 1980 and 247 in 1990, consistently half that of German males. The mortality of Turkish females in Germany was 140 in 1990, half that of German females. Mortality of Turkish males/females in Ankara was 835 and 426 in 1990. conclusion In view of the socio‐economic status of Turkish residents in Germany the large mortality difference compared to Germans is unexpected. It cannot be fully explained by a selection at the time of hiring (healthy migrant effect) because it lasts over decades and extends into the second generation. A healthy worker effect is unlikely because Turkish residents have a lower employment rate than Germans. There is little evidence for movement of gravely ill persons back to Turkey. An ‘unhealthy re‐migration effect’ in which socially successful migrants with a lower mortality risk stay in the host country while less successful ones return home even before becoming manifestly ill would partly explain our findings.

BackgroundCesarean rates are higher in women admitted to labor ward during early stages rather than at later stages of labor. In a study in Germany, crude cesarean rates among Turkish and Lebanese immigrant women were low compared to non-immigrant women. We evaluated whether these immigrant women were admitted during later stages of labor, and if so, whether this explains their lower cesarean rates.MethodsWe enrolled 1413 nulliparous women with vertex pregnancies, singleton birth, and 37+ week of gestation, excluding elective cesarean deliveries, in three Berlin obstetric hospitals. We applied binary logistic regression to adjust for social and obstetric factors; and standardized coefficients to rank predictors derived from the regression model.ResultsAt the time of admission to labor ward, a smaller proportion of Turkish migrant women was in the active phase of labor (cervical dilation: 4+ cm), compared to women of Lebanese origin and non-immigrant women. Rates of cesarean deliveries were lower in women of Turkish and Lebanese origin (15.8 and 13.9%) than in non-immigrant women (23.9%). In the logistic regression analysis, more advanced cervical dilatation was inversely associated with the outcome cesarean delivery (OR: 0.76, 95%CI: 0.70–0.82). In addition, higher maternal age (OR: 1.06, 95%CI: 1.04–1.09), application of oxytocic agents (OR: 0.55, 95%CI: 0.42–0.72), and obesity (OR: 2.25, 95%CI: 1.51–3.34) were associated with the outcome. Ranking of predictors indicate that cervical dilatation is the most relevant predictor derived from the regression model.ConclusionsAdvanced cervical dilatation at the time of admission to labor ward does not explain lower emergency cesarean delivery rates in Turkish and Lebanese migrant women, despite the fact that this is the strongest among the predictors for emergency cesarean delivery identified in this study.

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Data on the health status of migrants are still scarce. One of the reasons for this is that migration status has not been well recorded in official statistics and epidemiological studies. In order to obtain an adequate and standardised operationalisation of migrant status, we first need an exact definition of the terms "migrant" and "migration background". We discuss approaches to the definition of terms and the surveying of ethnic minorities and migrants, and then develop a basic set of migration status indicators for use in epidemiological research. This set of indicators includes country of birth of the father and mother, year of immigration, mother tongue, German language skills and status of residence. The key indicator for the identification of migrants is the country of birth of the parents and not the nationality as was previously often the case. Thus, the classification based on the judicial category of nationality is replaced by a classification based on the biographical event "migration". Migration brings with it specific life conditions and challenges that can impact health across several generations. An instrument for surveying migrant status must be further developed both to reflect the special conditions of the life situation resulting from the migration experience and to take as full account as possible of all aspects of a migrant's history.

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SummaryFirst-generation immigrant populations in industrialized countries frequently have a lower mortality than the host population, a ®nding that is unexpected and often dismissed as the result of bias. We propose an alternative explanation for a real, albeit temporal, mortality advantage. We base our argument on two premises: First, that there are differences in the progression of the health transition between the immigrants' countries of origin and industrialized host countries; and, second, that there are differences in the speed at which changes in mortality from various causes occur after migration. Mortality from treatable communicable and maternal conditions, still high in many countries of origin, quickly declines to levels close to those of the host country. Mortality from ischaemic heart disease, the most common cause of death in the host countries, takes years or decades to rise to comparable heights. This is because of the time lag between increases in risk factor levels and an increased risk of coronary death. Hence, ®rst-generation immigrants may initially experience a lower mortality than the host population, a point that has so far been under-appreciated in discussions of immigrant mortality. After adopting a western lifestyle immigrants face an increasing risk of ischaemic heart disease. The increase occurs on top of a persisting risk from conditions associated with childhood deprivation, e.g. stomach cancer and stroke ± the un®nished agenda of the health transition that immigrants experience.keywords health transition, migrants and transients, modern history of medicine, public health correspondence Dr Oliver Razum,