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Myriam Khlat, Author's response, International Journal of Epidemiology, Volume 33, Issue 6, December 2004, Page 1412, https://doi.org/10.1093/ije/dyh246
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We have pinpointed the unexpected mortality advantage that both Moroccans in France and Turks in Germany enjoy in comparison with their host population, and wondered about the underlying factors. In relation to that, Razum and Zeeb question the expectation that ‘any mortality advantage that migrants experience would be expected to disappear quickly with time spent in the host country’, and provide a convincing demonstration of a downward trend in maternal mortality associated with acculturation in Turkish women in West Germany. It is indeed worth noting that, while the ‘Mediterranean paradox’ relates to all-cause mortality, there are specific causes of death which are associated with higher mortality levels in Mediterranean migrants, and that maternal mortality is one of them. In France too, the maternal mortality ratio of Moroccan migrants was, in the 1980s 50% higher than that of the French female population.1 The pattern of decline found by Razum and Zeeb does fit very well into the traditional rationale of migrant studies, i.e. that ‘rates in migrants are expected to converge on those of their host country’. Better access to obstetric care may play a decisive role in explaining the findings, but also increased use of contraception, resulting in a progressive reduction of the proportion of births occurring to youngest and oldest women and of high-parity births, which are attached to a higher risk of maternal mortality. Additional information may be needed, though, to support the hypothesis that the access and utilization of health services depend on ‘the length of time a migrant population has been established in the host country’, rather than on ‘the individual migrant's length of stay’. Was immigration of Turks to Germany still ongoing during the period of observation, in which case that interpretation would make sense, or are we dealing with an ageing population of migrants? Are second-generation migrants included in the analysis? Last but not least, while the case of maternal mortality is very instructive, it has to be placed in the wider context of all-cause mortality: in the long run, as the health behaviours of migrants slowly converge on those of the affluent societies in which they have settled, then the rising rates of many cancers and of cardiovascular diseases are likely to offset—by far—any decline attached to less common causes of death. Unless other factors—indirect selection, different gene–environment interaction—come into play.
