Inequalities In Perinatal Health Research Articles

Exploring social inequalities in the use and experience of prenatal care in Brussels

Abstract Background The underlying mechanisms of perinatal health inequalities remain under-researched. A possible explanation is inadequate access to healthcare services and suboptimal care for certain groups. To explore this, our study analyses the mothers’ prenatal care trajectories and experiences of care in relation to socioeconomic and migration characteristics. Methods A survey of 750 migrant and non-migrant mothers interviewed in 4 maternity wards in Brussels. Based on the adaptation of the Migrant-Friendly Maternity Care Questionnaire, the survey focuses on mothers with a Belgian, North African (NA) and Subsaharan African (SSA) nationality. The data are analysed through descriptive statistics and logistic regression. Results This ongoing survey has a high response rate (83%). Preliminary subsample analyses (n = 276) show that the socioeconomic profiles of mothers vary substantially depending on nationality, with mothers from NA generally having a lower level of education, and mothers from SSA being strongly at risk of poverty. SSA women are particularly at risk of starting prenatal care late (32% compared to 4% of Belgians and NAs) and of having less than 7 recommended consultations (25% compared to 6% Belgians and 9% NAs). Low household income and maternal education were also strong predictors of late and infrequent prenatal care. Women from all three nationality groups had the same rate (10%) of planned C-sections, but women from SSA were much more likely to have an emergency c-section (16% vs 7% of Belgians and NAs). Women with a higher household income were less likely to have a c-section at all. Women from both NA and SSA were less likely to always have understood the information given by healthcare professionals. 90% of women with secondary school education understood all the information, compared to 60% of women without it. Conclusions Women’s care trajectories and experiences of care vary strongly depending on their nationality and socioeconomic situation. Key messages North African and Subsaharan African immigrants in Brussels live in different socioeconomic situations. Their care trajectories and experiences of care also show important differences. Socioeconomic characteristics, in addition to women’s migration status, are important factors affecting women’s perinatal care.

Educational disparities in perinatal health in Denmark in the first decade of the 21st century: a register-based cohort study

ObjectiveTo investigate socioeconomic differences in six perinatal health outcomes in Denmark in the first decade of the 21st century.DesignA population-based cohort study.SettingDanish national registries.ParticipantsA total of 646 829 live born...

Supporting parenting to address social inequalities in health: a synthesis of systematic reviews

BackgroundIn 2009, the World Health Organization’s Commission on Social Determinants of Health set out its recommendations for action, which included establishing equity from early childhood onwards by enabling all children and their mothers to benefit from a comprehensive package of quality programmes. In order to address social inequalities in health, it is recommended that action be taken from early childhood, and actions providing support for parenting are an effective lever in this respect.The aim of this review of systematic reviews is to analyse, on the one hand, the components and characteristics of effective interventions in parenting support and, on the other, the extent to which the reviews took into account social inequalities in health.MethodsA total of 796 reviews were selected from peer-reviewed journals published between 2009 and 2016 in French or English. Of these, 21 reviews responding to the AMSTAR and selected ROBIS criteria were retained. These were analysed in relation to the consideration they gave to social inequalities in health according to PRISMA-equity.ResultsThe reviews confirmed that parenting support programmes improved infants’ sleep, increased mothers’ self-esteem and reduced mothers’ anger, anxiety and stress levels. The mainly authors noted that the contexts in which the interventions had taken place were described either scantly or not at all, making it difficult to evaluate them.Only half of the reviews had addressed the question of social inequalities in health. In particular, there had been little research conducted on the relational aspect and the social link.ConclusionIn terms of addressing social inequalities in perinatal health, the approach remains both modest and reductive. Understanding how, for whom and in what conditions interventions operate is one way of optimising their results. Further research is needed to study the interactions between the interventions and their contexts.

Social disparities in low birth weight among Spanish mothers during the economic crisis (2007-2015)

to evaluate the impact of the economic crisis on the disparities in the prevalence and risk of low birth weight (LBW) according to the maternal socioeconomic profile. the data analysed corresponds to 1,779,506 single births to Spanish mothers in the years 2007, 2009, 2011, 2013 and 2015. The temporal changes in available maternal-foetal variables are described. Secondly, the possible increase in disparities in prevalence and risk of LBW due to the occupation and education of the mother is evaluated, taking 2007 as the reference year. a trend of the maternal profile is described among women who had children during this period, with an increasing contribution of highly qualified professional and educated women, a trend already existing before the economic crisis, but which was deepened by the recession. The prevalence of LBW increased in all socio-economic groups, with a marked increase in disparities during the worst years of the economic crisis. results confirm the persistence of social inequalities in perinatal health described prior to the economic crisis, as well as a possibly negative effect of the recession between 2007 and 2015. Results also confirm that disparities in LBW are more clearly associated with the educational level of mothers than with their occupation.

Geographical differences in perinatal health and child welfare in the Netherlands: rationale for the healthy pregnancy 4 all-2 program

BackgroundGeographical inequalities in perinatal health and child welfare require attention. To improve the identification, and care, of mothers and young children at risk of adverse health outcomes, the HP4All-2 program was developed. The program consists of three studies, focusing on creating a continuum for risk selection and tailored care pathways from preconception and antenatal care towards 1) postpartum care, 2) early childhood care, as well as 3) interconception care. The program has been implemented in ten municipalities in the Netherlands, aiming to target communities with a relatively disadvantageous position with regard to perinatal and child health outcomes. To delineate the position of the ten participating municipalities, we present municipal and regional differences in the prevalence of perinatal mortality, perinatal morbidity, children living in deprived neighbourhoods, and children living in families on welfare.MethodsData on all singleton births in the Netherlands between 2009 and 2014 were analysed for the prevalence of perinatal mortality and morbidity. In addition, national data on children living in deprived neighbourhoods and children living in families on welfare between 2009 and 2012 were analysed. The prevalence of these outcomes were calculated and ranked for 62 geographical areas, the 50 largest municipalities and the 12 provinces, to determine the position of the municipalities that participate in HP4All-2.ResultsConsiderable geographical differences were present for all four outcomes. The municipalities that participate in HP4All-2 are among the 25 municipalities with the highest prevalence of perinatal mortality, perinatal morbidity, children living in deprived neighbourhoods, or children in families on welfare.ConclusionThis study illustrates geographical differences in perinatal health and/or child welfare outcomes and demonstrates that the HP4All-2 program targets municipalities with a relative unfavourable position. By targeting these municipalities, the program is expected to contribute most to improving the care for young children and their mothers at risk, and hence to reducing their risks and health inequalities.

Poorer detection rates of severe fetal growth restriction in women of likely refugee background: Acase for re-focusing pregnancy care.

Severe fetal growth restriction (FGR) (<third centile) in a singleton pregnancy undelivered by 40weeks is one of a number of Victorian Perinatal Services Performance Indicators, which aim to provide a measure of the quality and safety of maternity care. Women of refugee background have been found to have poorer perinatal outcomes compared to others and these outcomes can in part be explained by previous history. However, less access to and engagement with pregnancy care may also be contributing factors. This study examined the impact of likely refugee background on severe FGR in a singleton pregnancy undelivered by 40weeks. A retrospective study was undertaken utilising data on women who gave birth to a severely growth-restricted infant at Monash Health during January 2013-July 2015. Unadjusted and adjusted analyses were undertaken to examine the association between the mother being of likely refugee background and severe FGR in singletons delivered after 40weeks. There was an association between the mother being of likely refugee background and giving birth to a severely growth-restricted baby after 40weeks with these mothers at two and half times the odds compared to mothers of non-refugee background (adjusted odds ratio 2.52; 95% confidence interval: 1.44-4.42). While detecting FGR is clinically challenging, our findings suggest that maternity services need to be supported to offer care tailored to the specific needs of vulnerable and disadvantaged populations. Providing quality, culturally responsive and accessible care is fundamental to addressing refugee maternal and perinatal health inequalities.

Inégalités sociales de santé maternelle

Although medical literature on social inequalities in perinatal health is qualitatively heterogeneous, it is quantitatively important and reveals the existence of a social gradient in terms of perinatal risk. However, published data regarding maternal health, if also qualitatively heterogeneous, are relatively less numerous. Nevertheless, it appears that social inequalities also exist concerning severe maternal morbidity as well as maternal mortality. Analyses are still insufficient to understand the mechanisms involved and explain how the various dimensions of the women social condition interact with maternal health indicators. Inadequate prenatal care and suboptimal obstetric care may be intermediary factors, as they are related to both social status and maternal outcomes, in terms of maternal morbidity, its worsening or progression, and maternal mortality.

Perinatal health inequalities and accessibility of maternity services in a rural French region: Closing maternity units in Burgundy

Maternity unit closures in France have increased travel time for pregnant women in rural areas. We assessed the impact of travel time to the closest unit on perinatal outcomes and care in Burgundy using multilevel analyses of data on deliveries from 2000 to 2009. A travel time of 30min or more increased risks of fetal heart rate anomalies, meconium-stained amniotic fluid, out-of-hospital births, and pregnancy hospitalizations; a positive but non-significant gradient existed between travel time and perinatal mortality. The effects of long travel distances on perinatal outcomes and care should be factored into closure decisions.

Inequalities in perinatal and maternal health

To describe inequalities in perinatal and maternal mortality, and morbidity from an international high-income country perspective. Measures of inequalities are socioeconomic status, ethnic background, and living area. Despite decreasing overall perinatal and maternal mortality in high-income countries, perinatal and maternal health inequalities persist. Inequalities in fetal, neonatal, and maternal adverse outcome relate to specific groups of risk factors. They commonly have a background in so-called structural risk factors, that is low level of education and income, being a migrant and living in disadvantaged areas. Structural risk factors therefore drive inequalities, and simultaneously represent the common perspective to judge perinatal and maternal health gaps. The effect of risk factors is further magnified in urban areas through risk accumulation.As mother and child share their background, neonatal, and maternal adverse health outcome patterns coincide, resulting in similar inequalities and similar epidemiological trends. The structural background explains the difficulty of improving this. Inequalities in perinatal and maternal outcome persist in women from lower socioeconomic groups, from specific ethnic groups, and from those living in deprived areas. In view of the lifelong consequences, these marked social disparities pose an important challenge for the political decision makers and the healthcare system.

Social deprivation and adverse perinatal outcomes among Western and non-Western pregnant women in a Dutch urban population

Social deprivation is considered a key factor in adverse perinatal outcomes. Rotterdam, the second largest city in The Netherlands, has large inequalities in perinatal health and a high number of deprived neighbourhoods. Social deprivation is measured here through a composite variable: ‘Social Index’ (SI). We studied the impact of the SI (2008–2009; 5 categories) in terms of perinatal mortality, congenital anomalies, preterm birth, small for gestational age (SGA) and low 5-minute Apgar score as registered in The Netherlands Perinatal Registry (Rotterdam 2000–2007, n = 56,443 singleton pregnancies). We applied ethnic dichotomisation as Western (European/North-American/Australian) vs. Non-Western (all others) ethnicity was expected to interact with the impact of SI. Tests for trend and multilevel regression analysis were applied. Gradually decreasing prevalence of adverse perinatal outcomes was observed in Western women from the lowest SI category (low social quality) to the highest SI category (high social quality). In Western women the low-high SI gradient for prevalence of spontaneous preterm birth (per 1000) changed from 57.2 to 34.1, for iatrogenic preterm birth from 35.2 to 19.0, for SGA from 119.6 to 59.4, for low Apgar score from 10.9 to 8.2, and for perinatal mortality from 14.9 to 7.6. These trends were statistically confirmed by Chi2-tests for trend (p < 0.001). For non-Western women such trends were absent. These strong effects for Western women were confirmed by significant odds ratios for almost all adverse perinatal outcomes estimated from multilevel regression analysis. We conclude social deprivation to play a different role among Western vs. non-Western women. Our results suggest that improvements in social quality may improve perinatal outcomes in Western women, but alternative approaches may be necessary for non-Western groups. Suggested explanations for non-Western ‘migrant’ groups include the presence of ‘protective’ effects through knowledge systems or intrinsic resilience. Implications concern both general and targeted policies.

Living in deprived urban districts increases perinatal health inequalities

Objective: Analyses of the effects of place of residence, socioeconomic status and ethnicity on perinatal mortality and morbidity in the Netherlands. Methods: Epidemiological analysis of all singleton deliveries > 22 gestational weeks (871,889 live born and 5927 stillborn) from the Dutch National Perinatal Registry 2002–2006. Multiple logistic regression analysis was used to determine whether place of residence (deprived neighborhood, or not) contributed to the adverse perinatal outcome (defined as perinatal mortality, preterm birth, small for gestational age, congenital abnormalities or Apgar score <7, 5 min after birth), additional to individual pregnancy characteristics, demographic characteristics, ethnic background and socioeconomic class. Results: Incidence of adverse perinatal outcome was 16.7%. After adjustment the excess risk for perinatal mortality in deprived districts was 21%, for preterm birth 16%, for small-for-gestational age 11%, and for Apgar score <7 after 5 min 11%. Conclusions: Perinatal inequalities appear impressive in both urban and nonurban areas, with a significant additive risk of living in a deprived neighborhood. Excess risk for perinatal mortality generally outranges that for morbidity, suggesting both an etiological and prognostic pathway for neighborhood effects. A distinct pattern exists for congenital anomalies, for which first trimester adverse selection effects may be responsible.

Francophone and Anglophone perinatal health: temporal and regional inequalities in a Canadian setting, 1981–2008

We evaluated temporal and regional inequalities in adverse birth outcomes between Anglophones and Francophones of a Canadian province. Odds ratios and rate differences in preterm birth (PTB, <37 gestational weeks) and small-for-gestational-age (SGA) birth were computed for Anglophones relative to Francophones for singleton live births in Québec from 1981 to 2008 (N = 2,292,237), adjusting for maternal characteristics. Trends over time and residential region were evaluated. Rates of PTB and SGA birth overall were lower for Anglophones relative to Francophones, but temporal and regional trends varied by outcome. Although PTB rates increased over time, inequalities between Francophones and Anglophones were relatively stable. In contrast, inequalities in SGA birth narrowed over time as Francophone rates declined more than Anglophones. Inequalities in SGA birth favored Anglophones overall, but the gap gradually reversed in Montréal (the largest metropolitan center) to currently favor Francophones. PTB and SGA birth rates favored Anglophones over Francophones. The linguistic gap was generally stable over time for PTB, but narrowed or reversed for SGA birth. Language may be used to capture inequalities in perinatal health in countries where different linguistic groups predominate.

Rising Disparities in Severe Adverse Birth Outcomes Among Haitians in Québec, Canada, 1981–2006

Perinatal health data for Haitians are scant. We evaluated adverse birth outcomes for Haitians in Québec, Canada. We analyzed 2,124,909 live births from 1981 to 2006. Haitian ethnicity was assessed using maternal birth country (Haiti, other Caribbean country, other foreign country, Canada) and home language (Creole, French/English but Creole mother tongue, French/English, other). Associations between ethnicity and preterm birth (PTB), low birth weight (LBW), and small-for-gestational-age (SGA) birth were calculated. Adverse birth outcomes were more common among mothers with Haitian ethnicity. Relative to Canadian-born mothers, odds for Haitian-born mothers were 4 times greater for extreme PTB (≤27 weeks), twice greater for very PTB (28-31 weeks), and 25% higher for moderate PTB (32-36 weeks). Patterns were similar for SGA birth and severe cases of LBW. Despite overall decreases LBW and SGA birth, relative and absolute inequalities increased over time. Perinatal health inequalities are increasing for Haitian-born mothers.

Racial inequalities and perinatal health in the southeast region of Brazil

Few studies are available about racial inequalities in perinatal health in Brazil and little is known about whether the existing inequality is due to socioeconomic factors or to racial discrimination per se. Data regarding the Ribeirão Preto birth cohort, Brazil, whose mothers were interviewed from June 1, 1978 to May 31, 1979 were used to answer these questions. The perinatal factors were obtained from the birth questionnaire and the ethnic data were obtained from 2063 participants asked about self-reported skin color at early adulthood (23-25 years of age) in 2002/2004. Mothers of mulatto and black children had higher rates of low schooling (< or = 4 years, 27.2 and 38.0%) and lower family income (< or = 1 minimum wage, 28.6 and 30.4%). Mothers aged less than 20 years old predominated among mulattos (17.0%) and blacks (14.0%). Higher rates of low birth weight and smoking during pregnancy were observed among mulatto individuals (9.6 and 28.8%). Preterm birth rate was higher among mulattos (9.5%) and blacks (9.7%) than whites (5.5%). White individuals had higher rates of cesarean delivery (34.9%). Skin color remained as an independent risk factor for low birth weight (P < 0.001), preterm birth (P = 0.01), small for gestational age (P = 0.01), and lack of prenatal care (P = 0.02) after adjustment for family income and maternal schooling, suggesting that the racial inequalities regarding these indicators are explained by the socioeconomic disadvantage experienced by mulattos and blacks but are also influenced by other factors, possibly by racial discrimination and/or genetics.

Analysis of Social Inequalities in Perinatal Health Using Census Data

<titre>R&#233;sum&#233;</titre>En Afrique sub-saharienne, les mesures &#224; large &#233;chelle, sur l&#8217;ensemble d&#8217;un pays ou d&#8217;une r&#233;gion, montrent que le recours aux m&#233;thodes modernes de contraception tend &#224; progresser, mais lentement, donnant l&#8217;impression que les &#233;volutions ne peuvent que prendre du temps dans ce domaine. Pour mieux comprendre les raisons de cette faible diffusion, principalement en zone rurale, nous avons &#233;tudi&#233; de fa&#231;on d&#233;taill&#233;e l&#8217;histoire de la contraception dans une population rurale du S&#233;n&#233;gal, r&#233;sidant &#224; Bandafassi. En utilisant plusieurs sources d&#8217;information, nous avons pu retracer la progression du recours &#224; la contraception ann&#233;e apr&#232;s ann&#233;e et examiner quels en avaient &#233;t&#233; les facteurs. L&#8217;&#233;tude pr&#233;sent&#233;e ici montre que contrairement aux id&#233;es re&#231;ues, la contraception peut se diffuser tr&#232;s rapidement dans des campagnes africaines peu favoris&#233;es sur le plan socio-&#233;conomique mais que cette diffusion n&#8217;est que difficilement mesurable en raison d&#8217;une sous-d&#233;claration importante de la pratique contraceptive et que sa p&#233;rennit&#233; n&#8217;est pas assur&#233;e.

Desigualdades sócio-econômicas do baixo peso ao nascer e da mortalidade perinatal no Município do Rio de Janeiro, 2001

Socioeconomic inequalities in early infant mortality have been evidenced in Brazil, with a greater mortality risk associated with the mother's socioeconomic status (SES). The aim of this paper is to identify socioeconomic inequalities in relation to low birth weight and perinatal mortality in the City of Rio de Janeiro, Brazil, discussing the appropriateness of the main health inequality indexes proposed in the international literature. As the information source, we use data collected in a survey of approximately 10,000 mothers selected for interview within 48 hours after delivery in public and private hospitals in the city. Using educational level and head of household's income as indicators of SES, as well as population attributable risk and slope index of inequality as health inequality measures, the results show a steep socioeconomic gradient in the proportion of low birth weight, and especially in the perinatal mortality rate. The persistent association between socioeconomic indicators and adverse results in pregnancy indicates (at least partially) the health system's inefficacy in diminishing perinatal health inequalities in Rio de Janeiro.

Social support in pregnancy: the 'soft' way to increase birthweight?

This paper examines the thesis that social support in pregnancy is capable of affecting birthweight as one easily measurable aspect of pregnancy outcome. The focus of the paper is on birthweight, since low birthweight is a relatively stable and important factor in social inequalities in perinatal health. The paper reviews the published literature on social support in pregnancy including simple observational and nonrandomized intervention studies and also randomized controlled trials of 'social' interventions. The methodological problems associated with some of these studies are discussed. However, it is concluded that there is considerable evidence to suggest that intervention programmes aimed at improving the 'social' side of antenatal care are capable of affecting birthweight and other 'hard' measures of pregnancy outcome. It is suggested that traditional professional approaches to pregnancy which divide the medical from the social perspective, have acted to prevent recognition of this evidence and its relevance to maternity care policy.