Artículo de revista: GARCÍA-ARIAS, Jenny Alejandra; CASTRO-TORRES, Andrés F. (2022) “A binational analysis of infant mortality among crisis-driven diasporas and those who remain: a population-based study in Colombia and Venezuela”. BMJ Global Health, 7 (8), e009523: 1-8 (ISSN: 2059-7908). DOI:10.1136/bmjgh-2022- 009523 Original research A binational analysis of infant mortality BMJ Glob Health: first published as 10.1136/bmjgh-2022-009523 on 16 August 2022. Downloaded from http://gh.bmj.com/ on August 29, 2022 by guest. Protected by copyright. among crisis-­driven diasporas and those who remain: a population-­based study in Colombia and Venezuela Jenny Alejandra Garcia Arias ‍ ‍ ,1,2 Andres Felipe Castro Torres3,4 To cite: Garcia Arias JA, ABSTRACT Castro Torres AF. A binational Objective To assess the health cost (or benefit) of crisis-­ WHAT IS ALREADY KNOWN ON THIS TOPIC analysis of infant mortality driven migration by focusing on the infant mortality rate ⇒ Previous studies have documented higher infant among crisis-­driven mortality among children of immigrants compared (IMR) of the Colombian diaspora in Venezuela and the diasporas and those who with native-­ born in South-­ to-­ North migration. Venezuelan diaspora in Colombia. remain: a population-­based Methods We compare national to diaspora IMRs over Newborns’ health outcomes in South-­to-­South mi- study in Colombia and Venezuela. BMJ Global Health the period 1980-­2018. National IMRs are death-­to-­birth gration contexts have been relatively neglected. 2022;7:e009523. doi:10.1136/ ratios reported by the official vital statistics, whereas ⇒ Mortality differences across migration status groups bmjgh-2022-009523 diaspora IMRs are calculated by using a semiparametric depend on immigrants’ socioeconomic status and regression model on the summary birth histories collected the context of reception. Handling editor Seema Biswas in the population censuses. We analyse the diaspora IMRs WHAT THIS STUDY ADDS according to whether their arrival corresponds to precrisis ► Additional supplemental ⇒ Comparing crisis-­ driven diaspora infant mortality or crisis-­driven migration. material is published online only. rates with those of their non-­migrant counterparts To view, please visit the journal Results During crises, diaspora IMRs show better health outcomes than those of non-­migrants. The Colombian at the moment that migration occurred is key in the online (http://​dx.d​ oi.​org/​10.​ diaspora had an average annual IMR of −1.8 (95% CI −3.3 understanding of the effect of migration in health 1136/b​ mjgh-​2022-0​ 09523). to 0.28) per year and the Venezuelan diaspora had −4.5 outcomes. (95% CI −5.8 to −3.3). However, the protective role of ⇒ The protective role played by the stability of the Received 4 May 2022 migration is neither guaranteed nor consistent, as a crisis long-­term diaspora in crisis-­driven migration health Accepted 28 July 2022 in the country of destination exposes immigrants to worse outcomes may be underestimated in academic health outcomes than the non-­migrant population. studies due to the lack of data. Conclusion Migration is a survival strategy that allows HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE people to reduce the negative effects they face during a OR POLICY © Author(s) (or their crisis in their country of origin. The distinction between ⇒ Given that migrants’ survival (dis)advantages rel- employer(s)) 2022. Re-­use crisis-­driven and precrisis migration provides a framework ative to the native-­born are concentrated in the permitted under CC BY-­NC. No for assessing the cross-­border effects on health outcomes neonatal period, reliable access to prenatal and commercial re-­use. See rights due to diaspora composition, particularly when populations postpartum care in the destination country is the key and permissions. Published by to reducing a crises’ harmful effects on newborns face adverse conditions. BMJ. and their mothers. 1 UR5 Health, Epidemiology and Mortality, Institut National d'Etudes Demographiques, Paris, France INTRODUCTION flow has become reversed since 2014, when 2 International Health, Johns Colombia and Venezuela share a 1378-­mile Venezuela began to undergo a profound social Hopkins University Bloomberg School of Public Health, border along seven Colombian Departamentos and economic crisis that drove Venezuelan Baltimore, Maryland, USA and five Venezuelan Estados (states herein). families to pursue emigration as a crucial 3 Research group on families, These two countries have historically main- survival strategy. From 2014 to 2021, the main inequalities, and social tained active cross-­border populations and destination for Venezuelans was Colombia, change, Centro de Estudios economic exchanges1 2 nurtured by large which received approximately 1.8 million Demográficos, Bellaterra, Spain 4 Laboratory of Fertility and numbers of binational families in circular Venezuelans in that period.5 According to the Well-­being, Max Planck Institut mobility.3 4 Mass migration from Colombia figures cited here, the Venezuelan population für Demografische Forschung, to Venezuela occurred from the 1970s until fled their country at a much faster rate than Rostock, Germany the early 2010s, with around one million Colombians migrating to Venezuela, and the Correspondence to Colombians going to Venezuela throughout process is still ongoing. Dr Jenny Alejandra Garcia Arias; the 70-­year undeclared civil war known as the We measure the health cost (or benefit) of ​jgarci98@​jh.e​ du Colombian armed conflict. This migratory migration by examining the infant mortality Garcia Arias JA, Castro Torres AF. BMJ Global Health 2022;7:e009523. doi:10.1136/bmjgh-2022-009523  1 BMJ Global Health rate (IMR) of the Colombian diaspora in Venezuela (the us with the annual birth and death counts for the periods BMJ Glob Health: first published as 10.1136/bmjgh-2022-009523 on 16 August 2022. Downloaded from http://gh.bmj.com/ on August 29, 2022 by guest. Protected by copyright. Colombian diaspora herein) and the Venezuelan dias- 1980–2019 for Colombia and 1980–2014 for Venezuela. pora in Colombia (the Venezuelan diaspora herein), The census data give us the summary birth histories particularly during crises. We focus on IMR because, in (SBH), which include information on: (1) the number addition to being part of international developmental of children ever born; (2) the number of children still agendas such as the Developmental Millennium Goals, alive; (3) children born and still alive during the year IMR is a very sensitive measure of population health. previous to the census and (4) the date of birth for the Social, economic and violence-­related crises can nega- last child ever born to all woman aged 15–49. We use the tively affect healthcare systems by reducing coverage and 1981, 1990, 2001 and 2011 Venezuelan censuses and, diminishing the availability of resources and personnel for Colombia, the 1993, 2005 and 2018 censuses (online while simultaneously raising barriers for vulnerable supplemental appendix 1). groups (eg, forcibly displaced populations). All of these are likely to translate into lower quality care and atten- tion, particularly for even more vulnerable populations METHODS (eg, pregnant women and newborns). By measuring the National infant mortality IMR among diasporas (at destination), we are capturing We calculate national IMR as the death-­to-­birth ratios the potential role played by migration in one important using the official CRVS data for both countries. We assess aspect of population health. CRVS data quality and completeness for the entire period From a theoretical perspective, migration can improve of analysis (online supplemental appendix 2), and we or worsen infant mortality. On the one hand, migration adjust the undercounts of births and deaths by inter/ can reduce infant mortality because it allows families to extrapolating their differences to the IMRs provided by escape violence, hunger and extreme deprivation, all the LAMBdA inter-­ census life tables10 (online supple- of which negatively affect infant health.6 7 On the other mental appendix 3.1). hand, migration may be associated with worse health outcomes for infants because migrant women may face Diaspora infant mortality barriers to accessing healthcare services and prenatal We apply the Trussell variant of the Brass method to the care at the destination, which could in turn translate into SBHs to estimate diaspora IMRs.11 This method allows us higher mortality risk for newborns. Likewise, migration-­ to overcome challenges in estimating diaspora IMRs due related and violence-­related stress as well as other adverse to data availability (online supplemental appendix 3.3). conditions during migration may affect foetal health, The Brass method produces estimates for up to 15 years which could worsen birth outcomes.8 9 prior to each census round. Infant mortality estimates are Using census data and civil registration vital statistics modelled into annual figures via independent p-­spline (CRVS), we reconstruct the IMR time series for non-­ models11 in order to obtain a yearly diaspora proportional migrant populations and diasporas from 1980 to 2018. factor for each country, that is, a diaspora-­to-­national We define the diaspora population as those residing in a ratio for infant mortality. These ratios capture whether country that is different from their country of birth. Next, and how much infant mortality is higher or lower among we analyse IMR trends during crises by zooming into two the diaspora population with respect to non-­ migrants critical periods: the bloodiest years of the Colombian in the country of destination. We apply these ratios to armed conflict (1998–2003) and the most severe years of the adjusted estimates using CRVS data (online supple- Venezuela’s socioeconomic crisis (2013–2018). Our main mental appendix 3.4). hypothesis is that IMR differences between diasporas Our analytical sample comprises women who migrated and non-­migrants are influenced by the socioeconomic before age 20, a selection criterion that allows us to background of those in the diaspora, their composition include only women whose entire reproductive years in terms of time since arrival (eg, recent, crisis-­driven vs were likely spent in the destination country. Addition- long-­term or precrisis migration) and the host country’s ally, we consider women with up to one child whose capacity to respond to the specific health needs of recent date of birth was posterior to the mother’s declared year arrivals. Hence, higher socioeconomic background of arrival. We address women with one child because and long-­term migration correlate with better mortality censuses only include the date of birth for the last child conditions, whereas recent migration and low socioeco- born. These sample selection strategies let us focus on nomic status are associated with higher IMR, although all births and child deaths occurring at destination (ie, the these associations are contingent on pre-­existing condi- IMR of diasporas). tions at destination. Since migration influxes are considerably high, espe- cially during crises, we have reasonable sample sizes (online supplemental appendix 3.5) for reconstructing DATA the time series of the diasporas’ infant mortality. However, We combine CRVS and census data to estimate infant the selectivity of our analytical sample (first and unique mortality rates (IMR) for diasporas and non-­ migrant births and women who migrated before age 20) may populations in each country. Specifically, CRVS provides imply some biases in our estimates. Due to the positive 2 Garcia Arias JA, Castro Torres AF. BMJ Global Health 2022;7:e009523. doi:10.1136/bmjgh-2022-009523 BMJ Global Health correlation between higher risk of dying through life and assess and interpret the magnitude and statistical signif- BMJ Glob Health: first published as 10.1136/bmjgh-2022-009523 on 16 August 2022. Downloaded from http://gh.bmj.com/ on August 29, 2022 by guest. Protected by copyright. birth order,12 13 we expect our IMR estimates to under- icance of the regression coefficient as a way to summa- estimate the actual IMR. Moreover, since our selection rise our findings. Admittedly, these associations do not concerns only the diasporas, the diaspora/non-­migrant measure causal effects. IMR ratios are likely to be underestimated, thus making our results conservative. Patient and public involvement statement Neither the study participants nor the public were Crisis-driven and pre-crisis diaspora infant mortality involved in designing, planning, conducting, reporting Analogously, we analyse the diaspora infant mortality or disseminating our research. differential according to their arrival at the destination, that is, whether they represent precrises (long-­ term migration) or crisis-­driven (recent) migration. We create RESULTS annual ratios of precrises and crisis-­ driven migrations National and diaspora infant mortality trends to the whole diaspora, which are also applied to the Figure 1 captures the broad historical patterns (1980– adjusted IMR calculated from CRVS data (online supple- 2019) and mortality shocks during the two periods of mental appendix 3.5). In addition, we use linear regres- crisis-­driven migrations in each country. Whereas over- sion models to contrast the conditional means of the arching historical patterns are consistent with those subpopulations’ IMRs during crises and according to the reported in the cited literature, short-­term changes (eg, time since arrival. We consider the non-­migrant popu- peaks, declines and crossovers within a 5-­year period) lation’s IMR as reference. The statistical analysis allows need to be considered cautiously, as some of them may be us to determine differences in the rate of change of the affected by random fluctuations. However, considering conditional means among the subpopulations, which we the strong consistency with country-­specific events such measure as changes in IMR per 1000 live births during as peaks of violence and the onset of crises, this indicates the period (online supplemental appendix 3.5). We that our correction approaches work as expected and Figure 1 IMR in Colombia and Venezuela, 1980–2018. Source: Author’s own estimates based on civil registrations; vital statistics; Venezuelan population and household censuses from 1981, 1990, 2001 and 2011; Colombian population censuses from 1993, 2005 and 2018 and the LAMBdA. IMR, infant mortality rate; LAMBdA, Latin American Mortality Database. Garcia Arias JA, Castro Torres AF. BMJ Global Health 2022;7:e009523. doi:10.1136/bmjgh-2022-009523 3 BMJ Global Health short-­term patterns are unlikely to be spurious or simply armed actors are found in Colombian border states, which BMJ Glob Health: first published as 10.1136/bmjgh-2022-009523 on 16 August 2022. Downloaded from http://gh.bmj.com/ on August 29, 2022 by guest. Protected by copyright. driven by random variations. also have the highest concentrations of Venezuelan-­born Hence, though the initial levels and relative paces differ, migrants. For more than a 10-­year period (2003–2014), the IMR has been decreasing in both countries since the the trend continued to decrease for the Venezuelan dias- 1980s, with Venezuela beginning at a much lower level pora’s IMR until a positive trend is again observed after and Colombia catching up to them in the 1990s. Figure 1 2015. The reappearance of an increasing trend coincides shows that, around 1993, the national IMRs converged to with the period of massive migration flows, which makes 23 deaths per thousand live births. the trend more like that of the non-­migrant Venezuelans. In Colombia, this convergence point was followed by 6 years of improving IMR up to 1998, which is the starting Infant mortality during crisis-driven migration periods point of when the armed conflict intensified. The IMR To better understand the potential mechanisms behind trends after 1998 suggest that the conflict contributed the heterogeneous influence of crises on diaspora to wiping out the 6 years of progress and restored the IMRs, we zoom into the two periods of crises and divide country’s IMR to levels observed at the beginning of the the diasporas into crisis-­driven migration and precrisis decade. Consistent with previous research, the increased migration. During the period of intensified conflict in IMR overlapped the bloodiest years of the Colombian Colombia (left panel in figure 2), the IMR increased and armed conflict.14 15 With the 2010 peace agreement, stalled at high levels among Colombian non-­ migrants conflict-­related violence declined along with the IMR, while the IMRs of all Colombian diasporas declined and which returned to its preconflict trend. show lower levels. These declines and overall lower dias- Overall, the national IMR for Venezuela has decreased pora IMRs may be due to the positive selection of Colom- continuously since the seventies—with a few brief excep- bian migrants, who have the lowest IMRs, particularly tions. Sudden increases in the IMR potentially reflect among precrisis migrants. The precrisis migrants show the upsurges in economic shocks that hit the country, even lower levels than Venezuelans who did not migrate including the popular uprising against price increases known as El Caracazo (1989); the political and economic after the year 2002. For the crisis-­driven migrants, the instability incurred by two attempted coups (1992 and results suggest that migration also acts as a protective 1993);16 the 1994 banking crisis; another failed coup factor. However, these groups of migrants may be facing d'état (2002) and the 2002–2003 national oil strike that depressing health outcomes due to the intensification of led to food and fuel shortages, impacted most of the the conflict, which precrisis migrants have avoided; thus, population and fuelled an increase in violence. The they display higher IMRs during the entire period. overall declining trend stalled around 2009, potentially On the Venezuelan side (right panel in figure 2) until due to the ongoing economic and social crises. In 2018, 2012, the IMRs of non-­migrant Venezuelans were lower the official figures set IMR at 21 per thousand live births, than those of their Colombian counterparts, an advan- setting the country back to levels observed at the end of tage that the precrisis Venezuelan diaspora potentially the 1990s.17 benefited from until 2013, when the Venezuelan-­born The diaspora IMRs also show declining trends, although flows began arriving in the Colombian border states. they responded differently to the crises compared with Throughout the most acute period of the Venezuelan their countries of origin and the local populations. In socioeconomic crisis (2017–2018), the Venezuelan dias- Venezuelan territory, the Colombian diaspora’s IMR pora’s IMR rose and remained above that of Colombians showed a slow decrease up to the mid-­1990s, then culmi- who did not migrate, regardless of the time of migration. nated in its steepest decrease during the most acute years In contrast to the Colombian diaspora in Venezuela, the of Colombia’s crisis (1998–2003) and up until 2007, IMRs of the precrisis Venezuelan diaspora are higher when it became more similar to Venezuela’s national than those for the crisis-­driven diaspora during the entire IMR levels and finished, from the perspective of a point period under analysis. estimate, better off than any other subpopulation’s IMR. Despite the higher IMRs of Venezuelan diasporas rela- When the Venezuelan crisis started hitting the country, tive to non-­migrant Colombians, a positive association the Colombian diaspora’s IMR continued to maintain still exists between migration and newborn health when lower levels than that of Venezuelans, but was not better considering the IMRs of non-­migrant Venezuelans during than the non-­migrant Colombians back home. their national crisis. Two important roles in modelling In sharp contrast, among Venezuelans on the other the rise of the Venezuelan diaspora’s IMR may be played side of the border (ie, in Colombian territory), this dias- by, on the one hand, the socioeconomic characteristics of pora’s IMR saw a constant and accelerated decrease from the migrants (who are probably more negatively selected the 1980s up to 1997, when the armed conflict intensi- during this time of crisis and travelling under precarious fied. This intensification negatively influenced the IMRs conditions) and, on the other hand, the limited access of both the Colombian and Venezuelan diasporas, as to health services at destination. Compared with other evidenced by the post-­1998 patterns. These descriptive countries in the region, Colombian health systems rank patterns could be related to the fact that some of the poorly in terms of per capita investments, availability and highest rates of armed conflict and highest numbers of access to health services.18 4 Garcia Arias JA, Castro Torres AF. BMJ Global Health 2022;7:e009523. doi:10.1136/bmjgh-2022-009523 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2022-009523 on 16 August 2022. Downloaded from http://gh.bmj.com/ on August 29, 2022 by guest. Protected by copyright. Figure 2 Diaspora IMRs, 1997–2004 and 2012–2018. Source: Author’s own estimates based on population census, civil registrations, vital statistics and the LAMBdA. IMR, infant mortality rate; LAMBdA, Latin American Mortality Database. Figure 3 summarises the annual average rate of non-­migrant counterparts, their levels are higher than changes in all subpopulations’ IMRs during the crisis the non-­migrants in the country of destination. periods: 1998–2003 for Colombia (top panel) and 2013– 2018 for Venezuela (bottom panel). The black vertical line indicates the reference category (IMR among non-­ DISCUSSION migrants in the country of origin). All coefficients of dias- In the contexts of the violence and socioeconomic crises pora subgroups are negative, meaning that the average in Colombia and Venezuela, the interdependence of diaspora IMRs are lower compared with those of non-­ societal and demographic processes yielded a heteroge- migrants during the crises in the country of origin. The neous spectrum of relationships between migration and newborn survival opportunities. By reconstructing the Colombian diaspora IMR was, on average, 1.8 (95% CI long-­term time series of the diaspora IMRs in Colombia −3.3 to 0.28) units lower than the annual average rate and Venezuela, this study sheds light on two important of changes in the IMR of Colombian non-­ migrants. aspects: first, how populations react to the societal pres- Likewise, the Venezuelan diaspora’s IMR was 4.5 (95% sures stemming from violent conflicts and acute economic CI −5.8 to −3.3) units lower than that of its non-­migrant crises; and, second, how infants’ health outcomes evolve counterpart. during periods of stability. The historical migration flows Figure 3 also shows evidence of the difference between between Colombia and Venezuela are particularly inter- the average rate of change in the IMRs of immigrants esting due to the changing conditions at origin and desti- and the non-­ migrant populations. We use the term nation. ‘immigrants’ to refer to Venezuelan-­ born migrants Our analysis reveals that migration served as a protec- living in Colombia between 1998 and 2003 as well as to tive factor for the diasporas, which had lower IMRs Colombian-­born migrants living in Venezuela from 2013 than their respective national counterparts during their to 2018. According to these results, the immigrant popu- native countries’ periods of intense crises. At the same lations on both sides of the border are those who bene- time, it also suggests that the protective role of migra- fited the least from migration when crises occurred in tion is neither guaranteed nor constant. The Venezuelan their countries of destination. Despite the advantageous diaspora had worse health outcomes than non-­migrant position that all diaspora IMRs have relative to their Venezuelans until their country’s current socioeconomic Garcia Arias JA, Castro Torres AF. BMJ Global Health 2022;7:e009523. doi:10.1136/bmjgh-2022-009523 5 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2022-009523 on 16 August 2022. Downloaded from http://gh.bmj.com/ on August 29, 2022 by guest. Protected by copyright. Figure 3 Diasporas IMR conditional means to non-­migrants IMR (reference) during crises. Source: Author’s own estimates based on a regression model on IMR during the period of crisis in each country. Colombia 1998−2003 and Venezuela 2013−2018. The annual average rate of changes comes from the regression ß1 coefficients. IMR, infant mortality rate. crisis began. In contrast, the Colombian diaspora did of socioeconomic status was a feature of the Colom- better than its non-­migrant counterparts from the late bian diaspora during the 1970s and 1980s, when migra- nineties onward. Focusing on the destination reveals that tion was driven by the economic boom in Venezuela.19 the increasing flow of Venezuelans worsens the condi- Middle-­class Colombian families were more likely than tions of that country’s long-­term diaspora, whose IMR their lower-­class counterparts to have enough resources had successfully coped with the non-­ migrant Colom- to benefit from economic conditions in their neigh- bian population’s increased IMR resulting from the bouring country. They were also more likely to relocate Colombian-­armed conflict. beyond the bordering cities and settle in the interior, The changing cause of binational migration flows and where living conditions and access to services are gener- the consequent heterogeneity in the socioeconomic ally better in comparison to the border.20 By the time, the composition of the migrant populations could be the Colombian-­armed conflict intensified, these middle-­class underlying reason why infant mortality is influenced by families represented 77% of the Colombian diaspora. In the interaction of: time since migration; the socioeco- contrast, lower-­class families and rural populations were nomic backgrounds of diaspora members and the social greatly affected by the armed conflict and pushed out and economic crises occurring at origin and destina- of the country mostly towards bordering cities in Vene- tion. As we hypothesise, the direction of IMR differences zuela, thereby increasing the share of recent Colombian between diasporas and non-­ migrants depends on the diaspora migrants. This different socioeconomic compo- diaspora’s composition in terms of socioeconomic back- sition and spatial scope of the migrations also appears ground and time since arrival. Positive selection in terms in the Venezuelan exodus to Colombia. Whereas it is 6 Garcia Arias JA, Castro Torres AF. BMJ Global Health 2022;7:e009523. doi:10.1136/bmjgh-2022-009523 BMJ Global Health mostly middle-­class families that comprise flows to cities which later reverses during the postnatal period and BMJ Glob Health: first published as 10.1136/bmjgh-2022-009523 on 16 August 2022. Downloaded from http://gh.bmj.com/ on August 29, 2022 by guest. Protected by copyright. such as Bogota or Medellin, the crisis-­driven migration throughout the life course.26 Because our data corre- flow that rapidly spread across the border involved mostly spond to a retrospective collection, we believe our esti- poor families.21 In the case of the Venezuelan diaspora, mations somewhat smooth the differentials. the precrisis migration represented only 7% of the total Although the IMR is internationally recognised as a diaspora. fundamental measure of a population’s health, it does Beyond the composition effect, another factor is the not cover all dimensions of this concept. In a context protective role played by the stability of the long-­term such as binational migration between Colombia and diaspora in crisis-­ driven migration health outcomes. Venezuela, other equally important and relevant aspects When large numbers of binational families in circular are reproductive health, overall mortality and violence-­ mobility are able to nurture stable networks and mobility related mortality, just to mention a few. We acknowledge patterns, they can expand their survival strategies beyond the importance of these other measures and hope to see national borders. Although the lack of data in Venezuela more research on these outcomes in the future. renders these mobility patterns invisible in the context of the Colombian armed conflict, the official Colom- Policy implications bian figures provide us with some information on the The different diaspora IMR outcomes found in our study increasing number of non-­migrant Venezuelans seeking may be strongly related to healthcare access. Given that medical assistance and prenatal care.22 migrants’ survival (dis)advantages relative to the native-­ When comparing diaspora IMRs with those of their born are concentrated in the neonatal period,27 access non-­migrant counterparts, migrations correlate to better to prenatal and postpartum care in the destination health outcomes during times of crisis, as migration country is the key to reducing a crisis’ negative effects results in a successful survival strategy. However, these on newborns and their mothers. If health systems are gains do not necessarily persist in the context of a crisis overwhelmed and institutional barriers prevent migrants at the destination because immigrant IMR can be highly from accessing them, migration can be associated with sensitive to a local crisis, as seen for both diasporas under worse mortality outcomes. study in this analysis. Health outcomes are better among the Colombian dias- The patterns and trends documented here speak pora than for non-­migrant Colombians, and even better to the complexity of interrelated social and demo- than those of non-­migrant Venezuelans during the crises. graphic processes such as armed conflicts, social unrest/ Since 1961, Venezuela has maintained a parallel contrib- upheavals, migration and mortality. Contrary to the utory and unremarkable welfare system for assisting and classic assimilation model of immigrant adjustment, protecting all persons in the national territory, regardless which suggests that the health outcomes of immigrant of whether or not they are native-­born Venezuelans or groups improve the longer they reside in the country of otherwise citizens of the Venezuelan state.28 Likewise, the destination,23 24 our results show that migration’s positive Colombian diaspora might benefit from having access to effect on reducing diaspora IMR relative to the native-­ the health systems in both countries. In contrast, access born and their countries of origin is not straightforward. to healthcare in Colombia is determined by the migrant’s The contradiction may arise from the fact that assimila- legal immigration status. According to the Constitutional tion models are used to explain south-­to-­north migration Court of Colombia’s 15 November 2017 unanimous flows. Our results are similar to those of other studies sentence on SU677/17, access to the health system is reporting excess mortality among diaspora IMRs rela- limited to emergency services if a migrant has irregular tive to the native-­born, which highlight that two of the residence status, which is the case for 56.4% of the Vene- leading non-­demographic predictors of the differential zuelan diaspora in 2020.29 are failure to detect complications and poor prenatal The Colombian government has undertaken many care.25 initiatives for regularising Venezuelan-­ born residency, from the Special Permanence Permit in 2017 to the Limitations implementation of a Temporary Protection Statute We have focused on IMR and strategically combined a for Venezuelan Migrants in 2021. All these initiatives meticulously selected sample from the SBH (women who demand national ID documents, which represent a chal- migrated before age 20 and women with up to one child lenge for the Venezuelan diaspora. Therefore, their born after their year of arrival), from census data and success in enlarging access to healthcare is limited. The from the CRVS services in both countries. The migrant most impactful initiative undertaken by the Colom- and non-­migrant populations in these two countries can bian government may be the naturalisation of about 45 plausibly be compared due to their similar fertility trends. 000 Venezuelan-­born children in 2020.30 This measure The main limitation of our study is the existence of birth avoided the risk of statelessness faced by the children and order differentials in infant mortality, which makes our allowed better healthcare for these newborns. Further diaspora IMR estimates conservative. However, more initiatives must be undertaken to provide prenatal detailed studies point to a neonatal mortality disadvan- care for the Venezuelan and other diasporas living in tage for firstborns compared with later-­ born siblings, Colombia. Garcia Arias JA, Castro Torres AF. BMJ Global Health 2022;7:e009523. doi:10.1136/bmjgh-2022-009523 7 BMJ Global Health Twitter Jenny Alejandra Garcia Arias @jennylind2000 8 Torche F. The effect of maternal stress on birth outcomes: exploiting BMJ Glob Health: first published as 10.1136/bmjgh-2022-009523 on 16 August 2022. Downloaded from http://gh.bmj.com/ on August 29, 2022 by guest. Protected by copyright. a natural experiment. Demography 2011;48:1473–91. Contributors All authors contributed equally. JA acts as guarantor author. 9 Torche F, Villarreal A. Prenatal exposure to violence and birth weight in Mexico. Am Sociol Rev 2014;79:966–92 https://doi.org/10.1177/​ Funding JA received funding from the European Union's Horizon 2020 Excellent 0003122414544733 Science, Marie Skłodowska–Curie, Individual fellowship program 2019 (Grant 10 University of Wisconsin. Latin America mortality database. Available: agreement No: 892134). AF aknowledges funding from the Spanish MInistry https://www.ssc.wisc.edu/cdha/latinmortality/ [Accessed 25 Mar of Science and Innovation through the Juan de la Cierva fellowship (FJC2020-­ 2019]. 042965-­I). 11 Wand M. Package ‘SemiPar’: Functions for semiparametric regression analysis. In: Ruppert D, Wand MP, Carroll RJ, eds. Competing interests None declared. Semiparametric regression. Cambridge University Press, 2003. Patient and public involvement Patients and/or the public were not involved in https://cran.r-project.org/web/packages/SemiPar/index.html 12 Donrovich R, Puschmann P, Matthijs K. Rivalry, solidarity, and the design, or conduct, or reporting, or dissemination plans of this research. longevity among siblings: a life course approach to the impact Patient consent for publication Not applicable. of sibship composition and birth order on later life mortality risk, Antwerp (1846–1920). Demographic Research 2014;31:1167–98 Ethics approval Not applicable. http://www.jstor.org/stable/26350092 Provenance and peer review Not commissioned; externally peer reviewed. 13 Modin B. Birth order and mortality: a life-­long follow-­up of 14,200 boys and girls born in early 20th century Sweden. Soc Sci Med Data availability statement All data relevant to the study are included in the 2002;54:1051–64. article or uploaded as supplementary information. 14 Urdinola BP. Could political violence affect infant mortality? the Colombian case. In: Rev. de Salud Pública. 20, 2018. Supplemental material This content has been supplied by the author(s). It has 15 Salas LG. Corredores y Territorios Estratégicos del Conflicto Armado not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been Colombiano: Una Prioridad POR Territorializar en La Geopolítica de peer-­reviewed. Any opinions or recommendations discussed are solely those Los Actores Armados. 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