Perinatal health in Spain during and after the Great Recession: Educational selection into fertility as a protective factor in high unemployment contexts

Background Education is considered one of the most robust determinants of health. However, it is unclear whether maternal education and paternal education have differential impacts on perinatal health outcomes. We assess maternal and paternal education differences and their association with adverse birth outcomes in a large birth cohort from Ontario, Canada. Methods The OaK Birth Cohort recruited patients from Ontario, Canada, between October 2002 and April 2009. We recruited mothers were recruited between 12 and 20 weeks’ gestation and collected both mother and infant data. The final sample size of the cohort was 8,085 participants. We use logistic regression to model the probability of preterm birth (less than 34 and 37 weeks’ gestation), small-for-gestational-age (SGA), or stillbirth as a function of maternal and paternal educational attainment. We adjust for household-level income, maternal and paternal race and ethnicity, and compare the strength of the association between maternal and paternal education on outcomes using Wald tests. Results 7,928 mother-father-offspring triads were available for the current analysis. 75% of mothers and fathers had college or university level education, and 8.7% of mothers experienced preterm delivery. Compared to mothers with college or university education, mothers with a high school education had an odds ratio of 1.37 (95% CI: 1.01–1.87) for SGA. Paternal education was not associated with infant outcomes. Comparing the odds ratios for maternal education and paternal education showed a stronger association than paternal education at the high school level for SGA birth (difference in odds ratio: 1.95, 95% CI: 1.13–3.36, p = .016) among women at least 25 years old. Conclusion Maternal education was associated with SGA, and this effect was more robust than paternal education, but both associations were weaker than previously reported.

We assessed the relationship between hospital characteristics and risk of adverse birth outcomes among minority Anglophones in Montreal, Canada. The study included 124,670 births among Anglophones in metropolitan Montreal between 1998 and 2019. We estimated risk ratios (RR) and 95% confidence intervals (CI) for the association between hospital characteristics, including residential proximity to hospitals and language in which medical services are provided, and risks of preterm birth and stillbirth. Models were adjusted for maternal socioeconomic status and other characteristics. In this study, 8% of Anglophones had a preterm birth and 0.4% a stillbirth. Anglophone women who delivered at a farther French hospital had a greater risk of stillbirth (RR 1.67, 95% CI 1.28-2.18) than preterm birth (RR 1.21, 95% CI 1.14-1.30), compared with delivery at hospitals closer to home. In contrast, delivery at a farther English hospital was associated with similar risks of stillbirth (RR 1.36, 95% CI 1.08-1.71) and preterm birth (RR 1.36, 95% CI 1.29-1.44). The greater risk of stillbirth with delivery at a farther French hospital, versus greater risk of preterm birth at a farther English hospital, remained present in analyses stratified by maternal age, education, material deprivation, and region of origin. Minority Anglophones in Montreal who travel to a farther French hospital for delivery have a greater risk of stillbirth than Anglophones who travel to a farther English hospital. This novel observation suggests the need to determine if access to perinatal healthcare in a woman's language may help reduce the risk of stillbirth.

This paper documents a counter-cyclical pattern in the health of children, and examines whether this pattern is due to selection of mothers choosing to give birth or due to behavioral changes. We study the relationship between the unemployment rate at the time of a baby's conception and parental characteristics (which we often refer to as quality), parental behaviors, and babies' health Using national data from the Natality Files from 1975 onward, we find that babies conceived in times of high unemployment have a reduced incidence of low and very low birth weight and a reduced rate of neo-natal and post-neonatal mortality. These health improvements are attributable both to selection (differences in the type of mothers that conceive during recessions) and to changes in behavior during recessions. Black mothers tend to be higher quality (as measured by education and marital status) in times of high unemployment, whereas the quality of white mothers either worsens or does not improve. In the aggregate data, we find some evidence of improved behavior in times of high unemployment, but not for all mothers (use of prenatal care increases for all mothers, but smoking and drinking increase among white mothers). In order to separate out selection and behavioral effects, we use a panel of mothers from California and compare our results to those from the national aggregate data. For blacks, we find that selection drives our results, and that behavioral effects are relatively small. For whites, we find evidence of negative selection, and consequently that behavioral effects are larger than the joint behavior-plus-selection effect. Our findings are consistent with evidence that blacks are credit constrained (and therefore opt out of fertility in times of high unemployment).

Are young workers that first participated in the labour market in times of high aggregate unemployment permanently disadvantaged, compared to other workers that entered in more favourable periods, or do they catch up later? In this chapter we address this issue by looking at the career paths of several generations of workers, focusing on their relative risk of unemployment in relation to the level of aggregate unemployment when they first participated in the labour market.

This paper examines downward nominal wage rigidity in Korea using aggregate and individual-level data. We find that the degree of downward nominal wage rigidity differs depending on the data sources used. Results from the aggregate data indicate that, on average, wages have been flexible. By contrast, evidence from the micro data suggests that nominal wages are downwardly rigid most of the time. We also find that downward nominal wage rigidity can differ across industries at both industry and individual levels. At the individual level, wage rigidity is greater in the service than in the manufacturing sector, even though the latter exhibits smaller volatility in its rate of wage growth.

SAT0532 Increased Rates of Spontaneous Abortions, but not Stillbirths in Rheumatoid Arthritis

We know little about the relationship between the macroeconomy and birth outcomes, in part due to the methodological challenge of distinguishing effects of economic conditions on fetal health from effects of economic conditions on selection into live birth. We examined associations between state-level unemployment rates in the first 2 trimesters of pregnancy and adverse birth outcomes, using natality data on singleton live births in the United States during 1990-2013. We used fixed-effect logistic regression models and accounted for selection by adjusting for state-level unemployment before conception and maternal characteristics associated with both selection and birth outcomes. We also tested whether associations between macroeconomic conditions and birth outcomes differed during and after (compared with before) the Great Recession (2007-2009). Each 1-percentage-point increase in the first-trimester unemployment rate was associated with a 5% increase in odds of preterm birth, while second-trimester unemployment was associated with a 3% decrease in preterm birth odds. During the Great Recession, however, first-trimester unemployment was associated with a 16% increase in odds of preterm birth. These findings increase our understanding of the effects of the Great Recession on health and add to growing literature suggesting that macro-level social and economic factors contribute to perinatal health.

A generation lost?: Prolonged effects of labour market entry in times of high unemployment in the Netherlands

Little is known about the risk of non-recurrent adverse birth outcomes. To evaluate the risk of stillbirth, preterm birth (PTB), and small for gestational age (SGA) as a proxy for fetal growth restriction (FGR) following exposure to one or more of these factors in a previous birth. We searched MEDLINE, EMBASE, Maternity and Infant Care, and Global Health from inception to 30 November 2016. Studies were included if they investigated the association between stillbirth, PTB, or SGA (as a proxy for FGR) in two subsequent births. Meta-analysis and pooled association presented as odds ratios (ORs) and adjusted odds ratios (aORs). Of the 3399 studies identified, 17 met the inclusion criteria. A PTB or SGA (as a proxy for FGR) infant increased the risk of subsequent stillbirth ((pooled OR 1.70; 95% confidence interval, 95% CI, 1.34-2.16) and (pooled OR 1.98; 95% CI 1.70-2.31), respectively). A combination of exposures, such as a preterm SGA (as a proxy for FGR) birth, doubled the risk of subsequent stillbirth (pooled OR 4.47; 95% CI 2.58-7.76). The risk of stillbirth also varied with prematurity, increasing three-fold following PTB <34weeks of gestation (pooled OR 2.98; 95% CI 2.05-4.34) and six-fold following preterm SGA (as a proxy for FGR) <34weeks of gestation (pooled OR 6.00; 95% CI 3.43-10.49). A previous stillbirth increased the risk of PTB (pooled OR 2.82; 95% CI 2.31-3.45), and subsequent SGA (as a proxy for FGR) (pooled OR 1.39; 95% CI 1.10-1.76). The risk of stillbirth, PTB, or SGA (as a proxy for FGR) was moderately elevated in women who previously experienced a single exposure, but increased between two- and three-fold when two prior adverse outcomes were combined. Clinical guidelines should consider the inter-relationship of stillbirth, PTB, and SGA, and that each condition is an independent risk factor for the other conditions. Risk of adverse birth outcomes in next pregnancy increases with the combined number of previous adverse events. Why and how was the study carried out? Each year, around 2.6million babies are stillborn, 15million are born preterm (<37weeks of gestation), and 32million are born small for gestational age (less than tenth percentile for weight, smaller than usually expected for the relevant pregnancy stage). Being born preterm or small for gestational age can increase the chance of long-term health problems. The effect of having a stillbirth, preterm birth, or small-for-gestational-age infant in a previous pregnancy on future pregnancy health has not been summarised. We identified 3399 studies of outcomes of previous pregnancies, and 17 were summarised by our study. What were the main findings? The outcome of the previous pregnancy influenced the risk of poor outcomes in the next pregnancy. Babies born to mothers who had a previous preterm birth or small-for-gestational-age birth were more likely to be stillborn. The smaller and the more preterm the previous baby, the higher the risk of stillbirth in the following pregnancy. The risk of stillbirth in the following pregnancy was doubled if the previous baby was born both preterm and small for gestational age. Babies born to mothers who had a previous stillbirth were more likely to be preterm or small for gestational age. What are the limitations of the work? We included a small number of studies, as there are not enough studies in this area (adverse birth outcomes followed by adverse cross outcomes in the next pregnancy). We found very few studies that compared the risk of small for gestational age after preterm birth or stillbirth. Definitions of stillbirth, preterm birth categories, and small for gestational age differed across studies. We did not know the cause of stillbirth for most studies. What are the implications for patients? Women who have a history of poor pregnancy outcomes are at greater risk of poor outcomes in following pregnancies. Health providers should be aware of this risk when treating patients with a history of poor pregnancy outcomes.

A lost generation of youth in the labour market? A lost generation of youth in the labour market? After the economic crisis of the 1980s concerns have been raised whether the high youth unemployment during that period produced a ‘lost generation’ of young people. The same question has been asked recently after the emergence of the currently high youth unemployment. But how justified is this issue? In order to find this out, it is investigated in this article to what extent recent cohorts of young people are (permanently) disadvantaged by high unemployment levels at labour market entry. To address this question, repeated cross-sections from the Labour Force Survey (1993-2011) were used and pseudo-panel analysis was applied in order to ‘follow’ labour market entry cohorts during the early career. The results show that labour market entry in times of high unemployment has negative effects on later employment opportunities and occupational status attainment. However, these negative effects disappear after a few years in the labour market. These findings imply that the negative effects of high unemployment at labour market entry are not permanent, but diminish during the early career. All in all, young people experience negative effects of labour market entry in times of high unemployment, but these effects do not produce a lost generation.

Small Vulnerable Newborns (SVNs)-including low birth weight (LBW), preterm birth (PB), and small for gestational age (SGA)-represent a major global concern, with 35.3million cases reported in 2020. Despite the growing overlap between migration and perinatal health, evidence on birth outcomes among Venezuelan migrants in Colombia remains limited. This study examined the association between maternal nationality and the likelihood of SVN, LBW, and PB among live births in Colombia from 2018 to 2022. We conducted a cross-sectional analysis of 3,111,716 births using national vital statistics (DANE). The primary exposure was maternal nationality. Outcomes included LBW (< 2,500g), PB (< 37 weeks), and the combined SVN indicator. Logistic regression models were adjusted for sociodemographic variables (maternal age, education, marital status, region, newborn sex, and year), followed by additional adjustment for maternal factors (parity, interbirth interval, multiple births). Interaction models were also developed between maternal origin and maternal education, marital status, region, and interbirth interval. After sociodemographic and maternal-factor adjustment, Venezuelan mothers had higher odds of SVN (OR: 1.18, 95% CI: 1.13-1.22), LBW (OR: 1.19, 95% CI: 1.15-1.24), and PB (OR 1.06, 95% CI: 1.02-1.10). Interaction analyses showed that associations varied across geographic, educational, and reproductive contexts. For SVN, differences emerged particularly among women with missing education, missing marital status, and shorter interbirth intervals. These findings highlight the vulnerability of migrant mothers and underscore the need for equity-oriented maternal and child health policies in host countries.

Background: Restricting to live births can induce bias in studies of pregnancy and developmental outcomes, but whether this live-birth bias results in underestimating disparities is unknown. Bias may arise from collider stratification due to an unmeasured common cause of fetal loss and the outcome of interest, or depletion of susceptibles, where exposure differentially causes fetal loss among those with underlying susceptibility. Methods: We conducted a simulation study to examine the magnitude of live-birth bias in a population parameterized to resemble one year of conceptions in California (N=625,000). We simulated exposure to a non-time-varying environmental hazard, risk of spontaneous abortion, and time to live birth using 1,000 Monte Carlo simulations. Our outcome of interest was preterm birth. We included a social vulnerability factor to represent social disadvantage, and estimated overall risk differences for exposure and preterm birth using linear probability models and stratified by the social vulnerability factor. We calculated how often confidence intervals included the true point estimate (CI coverage probabilities) to illustrate whether effect estimates differed qualitatively from the truth. Results: Depletion of susceptibles resulted in a larger magnitude of bias compared with collider stratification, with larger bias among the socially vulnerable group. Coverage probabilities were not adversely affected by bias due to collider stratification. Depletion of susceptibles reduced coverage, especially among the socially vulnerable (coverage among socially vulnerable = 46%, coverage among non-socially vulnerable = 91% in the most extreme scenario). Conclusions: In simulations, hazardous environmental exposures induced live birth bias and the bias was larger for socially vulnerable women. Keywords: live-birth bias; simulation; health disparities; environmental justice; fetal loss

We conducted a simulation study to examine the magnitude of live-birth bias in a population parameterized to resemble one year of conceptions in California (N = 625,000). We simulated exposure to a non-time-varying environmental hazard, risk of spontaneous abortion, and time to live birth using 1000 Monte Carlo simulations. Our outcome of interest was preterm birth. We included a social vulnerability factor to represent social disadvantage, and estimated overall risk differences for exposure and preterm birth using linear probability models and stratified by the social vulnerability factor. We calculated how often confidence intervals included the true point estimate (CI coverage probabilities) to illustrate whether effect estimates differed qualitatively from the truth. Depletion of susceptibles resulted in a larger magnitude of bias compared with collider stratification, with larger bias among the socially vulnerable group. Coverage probabilities were not adversely affected by bias due to collider stratification. Depletion of susceptibles reduced coverage, especially among the socially vulnerable (coverage among socially vulnerable = 46%, coverage among nonsocially vulnerable = 91% in the most extreme scenario). In simulations, hazardous environmental exposures induced live-birth bias and the bias was larger for socially vulnerable women.

Background: Stillbirth remains a critical indicator of maternal and perinatal health, with global disparities influenced by time, season, and fetal sex. Understanding localized patterns is essential to evaluate the impact of health interventions. This five-year retrospective study examined temporal trends and sex-related disparities in live births and stillbirths at Ring Road General Hospital, Ibadan, Nigeria (2020–2024), in the context of targeted maternal care improvements. Objective: To assess temporal and seasonal trends in birth outcomes and evaluate sex-based disparities in stillbirth risk over a five-year period. Method: A retrospective analysis of 4,294 birth records (live and stillbirths) was conducted from January 2020 to December 2024. Time-series analysis was used to identify seasonal and annual trends. Kruskal-Wallis and chi-square goodness-of-fit tests assessed differences in outcomes across time and sex. Logistic regression was employed to examine the association between fetal sex and stillbirth risk. Results: Live births showed significant seasonal variation, with peaks in the first and second quarters of each year. Stillbirth rates declined substantially from 21.38 to 2.99 per 1,000 births over the study period (p &lt; 0.05), suggesting improved outcomes. The sex ratio remained stable for both live births (1.07 male-to-female) and stillbirths (1.00), with no significant deviation from expected norms. Male fetuses had 22.6% higher odds of stillbirth compared to females, though this difference was not statistically significant (OR = 1.226, p = 0.159). Conclusion: This study revealed a marked reduction in stillbirth rates over five years, likely reflecting the success of maternal health interventions and enhanced data surveillance. The consistent sex ratios and lack of significant sex-based disparity in stillbirth risk diverge from global patterns, indicating equitable maternal and neonatal care practices within the study setting.

BackgroundThe association between area characteristics and birth outcomes is modified by race. Whether such associations vary according to social class indicators beyond race has not been assessed.MethodsThis study evaluated effect modification by maternal birthplace and education of the relationship between neighbourhood characteristics and birth outcomes of newborns from 1999–2003 in the province of Québec, Canada (N = 353,120 births). Areas (N = 143) were defined as administrative local health service delivery districts. Multi-level logistic regression was used to model the association between three area characteristics (median household income, immigrant density and income inequality) and the two outcomes preterm birth (PTB) and small-for-gestational age (SGA) birth. Effect modification by social class indicators was evaluated in analyses stratified according to maternal birthplace and education.ResultsRelative to the lowest tertile, high median household income was associated with SGA birth among Canadian-born mothers (odds ratio (OR) 1.13, 95% confidence interval (CI) 1.06, 1.20) and mothers with high school education or less (OR 1.13, 95% CI 1.02, 1.24). Associations between median household income and PTB were weaker. Relative to the highest tertile, low immigrant density was associated with a lower odds of PTB among foreign-born mothers (OR 0.79, 95% CI 0.63, 1.00) but a higher odds of PTB among Canadian-born mothers (OR 1.14, 95% CI 1.07, 1.21). Associations with income inequality were weak or absent.ConclusionThe association between area factors and birth outcomes is modified by maternal birthplace and education. Studies have found that race interacts in a similar manner. Public health policies focussed on perinatal health must consider the interaction between individual and area characteristics.