Patterns of social inequalities across pregnancy and birth outcomes: a comparison of individual and neighborhood socioeconomic measures

An online qualitative study exploring wants and needs for a cooking programme during pregnancy in the UK and Ireland

BACKGROUND

Optimal maternal nutrition is associated with better pregnancy and infant outcomes. Culinary nutrition programmes have potential to improve diet quality during pregnancy. Therefore, this research aimed to understand the experiences of cooking and the wants and needs of pregnant women regarding a cooking and food skills programme in the United Kingdom (UK) and Republic of Ireland (ROI).

METHODS

Online focus group discussions with pregnant women and those who had experienced a pregnancy in the UK or ROI were conducted between February and April 2022. Two researchers conducted a thematic analysis. Seven focus groups with ROI participants (n = 24) and six with UK participants (n = 28) were completed.

RESULTS

Five themes were generated. These were (1) cooking during pregnancy: barriers, motivators and solutions; (2) food safety, stress and guilt; (3) need for cooking and food skills programmes and desired content; (4) programme structure; (5) barriers and facilitators to programme participation. Overall, there was support for a programme focusing on broad food skills, including planning, food storage, using leftovers and to manage pregnancy-specific physiological symptoms such as food aversions. Participants emphasised the importance of inclusivity for a diverse range of people and lifestyles for programme design and content.

CONCLUSIONS

Current findings support the use of digital technologies for culinary nutrition interventions, potentially combined with in-person sessions using a hybrid structure to enable the development of a support network.

Supporting breastfeeding for women with low education levels, psychosocial problems, and/or socioeconomic constraints: a scoping review protocol

OBJECTIVE

This scoping review aims to identify and map interventions and/or strategies used to support the initiation and continuation of breastfeeding for women at risk of delaying initiation, early cessation, or not breastfeeding due to low levels of education, psychosocial problems, and/or socioeconomic challenges in high-income countries.

INTRODUCTION

While breastfeeding has lifelong beneficial health effects for women and infants, there is a risk of delaying initiation, early cessation, or not initiating breastfeeding at all due to factors related to health inequalities, such as low levels of education, psychosocial problems, and/or socioeconomic constraints.

INCLUSION CRITERIA

This review will include eligible quantitative, qualitative, and mixed methods studies, as well as systematic reviews and gray literature. We will encompass studies conducted in high-income countries, focusing on interventions and/or strategies to support women with low levels of education, psychosocial problems, and/or socioeconomic constraints in the initiation and continuation of breastfeeding for up to 6 months postpartum.

METHODS

This review will follow the JBI methodology for scoping reviews, using the Participants, Concept, and Context framework. The primary search will be performed in the following databases: MEDLINE (PubMed), PsycINFO (EBSCOhost), Embase (Ovid), and CINAHL (EBSCOhost). We will include publications in English, Swedish, Norwegian, Danish, German, Bulgarian, Arabic, and Spanish, published from 1991 until the present. A data charting form will be developed and applied to all the included articles.

REVIEW REGISTRATION

The study is registered in Open Science Framework, DOI 10.17605/OSF.IO/TMP4V.

The Consequences of A History of Violence on Women's Pregnancy and Childbirth in the Nordic Countries: A Scoping Review

Violence against women (VAW) is a global challenge also in the childbearing period. Despite high gender equality, there is a high prevalence of VAW in the Nordic countries. This scoping review aims to explore predictors for and consequences of a history of violence on women's pregnancy and childbirth in the Nordic countries, including women's experience of the impact of violence and the interventions used to detect, address consequences, and prevent further violence. The framework by Arksey and O'Malley was followed, and English, Finnish, Icelandic, Norwegian, Danish, and Swedish literature was included. The population was women aged ≥18 residing in the Nordic countries during the perinatal period. Eight databases were searched: MEDLINE, CINAHL, PubMed, PsycINFO, Web of Science, ASSIA, Social Services-, and Sociological abstracts. There was no limitation of the search time frame. The initial screening resulted in 1,104 records, and after removing duplicates, 452 remained. Finally, 61 papers met the inclusion criteria. The results covering the past 32 years indicated that childbearing women with a history of violence are at greater risk of common complaints and hospitalization during pregnancy, fear of childbirth, Cesarean section, breastfeeding difficulties, and physical and mental health problems. While extensive research was found on the associations between a history of and current violence and outcomes related to pregnancy, there was a lack of intervention studies and studies from Finland. Efforts must be made to scientifically test the methods used to reduce and treat the adverse effects of a history of violence and prevent further violence.

Socio-economic disadvantage and utilisation of labour epidural analgesia in Scotland: a population-based study†

Socio-economic deprivation is associated with adverse maternal and childhood outcomes. Epidural analgesia, the gold standard for labour analgesia, may improve maternal well-being. We assessed the association of socio-economic status with utilisation of epidural analgesia and whether this differed when epidural analgesia was advisable for maternal safety. This was a population-based study of NHS data for all women in labour in Scotland between 1 January 2007 and 23 October 2020, excluding elective caesarean sections. Socio-economic status deciles were defined using the Scottish Index of Multiple Deprivation. Medical conditions for which epidural analgesia is advisable for maternal safety (medical indications) and contraindications were defined according to national guidelines. Of 593,230 patients in labour, 131,521 (22.2%) received epidural analgesia. Those from the most deprived areas were 16% less likely to receive epidural analgesia than the most affluent (relative risk 0.84 [95%CI 0.82-0.85]), with the inter-decile mean change in receiving epidural analgesia estimated at -2% ([95%CI -2.2% to -1.7%]). Among the 21,219 deliveries with a documented medical indication for epidural analgesia, the socio-economic gradient persisted (relative risk 0.79 [95%CI 0.75-0.84], inter-decile mean change in receiving epidural analgesia -2.5% [95%CI -3.1% to -2.0%]). Women in the most deprived areas with a medical indication for epidural analgesia were still less likely (absolute risk 0.23 [95%CI 0.22-0.24]) to receive epidural analgesia than women from the most advantaged decile without a medical indication (absolute risk 0.25 [95%CI 0.24-0.25]). Socio-economic deprivation is associated with lower utilisation of epidural analgesia, even when epidural analgesia is advisable for maternal safety. Ensuring equitable access to an intervention that alleviates pain and potentially reduces adverse outcomes is crucial.

Association between maternal social vulnerability and cesarean delivery: A cohort study

OBJECTIVE

Although social vulnerability has been correlated to adverse obstetrical outcomes, its definition as well as its correlation to mode of delivery vary between different studies. The aim of this study is to evaluate the association between maternal social vulnerabilities and cesarean section with the inclusion of a wide range of social vulnerability characteristics.

STUDY DESIGN

The current study is a retrospective single center cohort study in a tertiary care maternity unit between January 2020 and December 2021. All women who delivered after 24 gestational weeks were included. Multiple component analysis (MCA) grouped vulnerability characteristics in three independent vulnerability axes, named after their clinical relevance as administrative, psychological, and dependency axis. Multiple logistic regression was performed, controlling for obstetrical, medical factors as well as the Robson classification.

RESULTS

In total, 7707 patients were identified. After adjustment for the aforementioned factors, a statistically significant association was shown between administrative vulnerability index and cesarean section before labor or during labor respectively (aOR 1.48 [1.23 - 1.78] and aOR 1.46 [OR 1.23 - 1.73]). In contrast, no significant correlation was found for the psychological vulnerability index (aOR 1.09 [0.86 - 1.38] and aOR 0.99 [0.78 - 1.25]) or the dependency vulnerability index (aOR 0.98 [0.76 - 1.26] and aOR 0.85 [0.64 - 1.12]).

CONCLUSIONS

The current study provides new insight into the correlation between social vulnerabilities and the risk of cesarean section. It demonstrates that administrative vulnerability is an independent risk factor of cesarean delivery. These patients should be identified and offered an adapted pregnancy monitoring in order to reduce cesarean section rates.

Initial programme theory development: The first step in a realist evaluation of a cross-sectoral intervention for expectant Danish parents living with psychosocial risks

A distinct inequality in maternity care exists, and women with psychosocial risks are at a greater risk of adverse birth outcomes. In several high-income countries, a psychosocial risk assessment early in pregnancy is recommended so that expectant parents are offered an appropriate level of care which facilitates relevant, tailored interventions for those in need. In 2017, a cross-sectoral and interdisciplinary intervention for expectant parents with psychosocial risks was developed and implemented in the North Denmark Region. The development process of the intervention has not been reported and theory-based knowledge about how supportive interventions bring about change for expectant parents with psychosocial risks is scarce. Through the initial phase of a realist evaluation, we aimed to elicit key contexts and mechanisms of change regarding the intervention for expectant parents with psychosocial risks. Through an initial programme theory, this article illustrates how, for whom and in which contexts the intervention is intended to work. Data is comprised of intervention documents, 14 pilot observations and 29 realist interviews with key stakeholders. A thematic analytical approach inspired by retroductive thinking was applied to identify and analyse patterns related to the incentive of the intervention, its structure, intended outcomes, generative mechanisms and contextual matters. Generative mechanisms responsible for bringing about change in the intervention were identified as healthcare professionals' approach, continuity, trust, early intervention and social network. Cross-sectoral collaboration and healthcare professionals' competencies were assumed to be central stimulating contextual factors. The initial programme theory developed in this study will serve as the basis for further refinement via empirical testing in a later phase of the realist evaluation.

Season of Conception and Risk of Cerebral Palsy

Importance

Cerebral palsy (CP) is the most prevalent neuromotor disability in childhood, but for most cases the etiology remains unexplained. Seasonal variation in the conception of CP may provide clues for their potential etiological risk factors that vary across seasons.

Objective

To evaluate whether the month or season of conception is associated with CP occurrence.

Design, Setting, and Participants

This statewide cohort study examined more than 4 million live births that were registered in the California birth records during 2007 to 2015 and were linked to CP diagnostic records (up to year 2021). Statistical analyses were conducted between March 2022 and January 2023.

Exposures

The month and season of conception were estimated based on the child's date of birth and the length of gestation recorded in the California birth records.

Main Outcomes and Measures

CP status was ascertained from the diagnostic records obtained from the Department of Developmental Services in California. Poisson regression was used to estimate the relative risk (RR) and 95% CI for CP according to the month or the season of conception, adjusting for maternal- and neighborhood-level factors. Stratified analyses were conducted by child's sex and neighborhood social vulnerability measures, and the mediating role of preterm birth was evaluated.

Results

Records of 4 468 109 children (51.2% male; maternal age: 28.3% aged 19 to 25 years, 27.5% aged 26 to 30 years; maternal race and ethnicity: 5.6% African American or Black, 13.5% Asian, 49.8% Hispanic or Latinx of any race, and 28.3% non-Hispanic White) and 4697 with CP (55.1% male; maternal age: 28.3% aged 19 to 25 years, 26.0% aged 26 to 30 years; maternal race and ethnicity: 8.3% African American or Black, 8.6% Asian, 54.3% Hispanic or Latinx of any race, and 25.8% non-Hispanic White) were analyzed. Children conceived in winter (January to March) or spring (April to June) were associated with a 9% to 10% increased risk of CP (winter: RR, 1.09 [95% CI, 1.01-1.19]; spring: RR, 1.10 [95% CI, 1.02-1.20]) compared with summer (July to September) conceptions. Analyses for specific months showed similar results with children conceived in January, February, and May being at higher risk of CP. The associations were slightly stronger for mothers who lived in neighborhoods with a high social vulnerability index, but no child sex differences were observed. Only a small portion of the estimated association was mediated through preterm birth.

Conclusions and Relevance

In this cohort study in California, children conceived in winter and spring had a small increase in CP risk. These findings suggest that seasonally varying environmental factors should be considered in the etiological research of CP.

Association between prenatal socioeconomic disadvantage, adverse birth outcomes, and inflammatory response at birth

Prenatal socioeconomic disadvantage is associated with inflammation in mid- to late-life, yet whether a pro-inflammatory phenotype is present at birth and the role of adverse birth outcomes in this pathway remains unclear. We utilized data on prenatal socioeconomic disadvantage at the individual- (i.e., mother's and father's education level, insurance type, marital status, and Women, Infants, and Children benefit receipt) and census-tract level as well as preterm (< 37 weeks gestation) and small-for-gestational-age (SGA) (i.e., < 10th percentile of sex-specific birth weight for gestational age) birth status, and assessed inflammatory markers (i.e., C-reactive protein, serum amyloid p, haptoglobin, and α-2 macroglobulin) in archived neonatal bloodspots from a Michigan population-based cohort of 1000 neonates. Continuous latent variables measuring individual- and combined individual- and neighborhood-level prenatal socioeconomic disadvantage were constructed and latent profile analysis was used to create a categorical inflammatory response variable (high versus low) based on continuous inflammatory marker levels. Structural equation models were used to estimate the total and direct effect of prenatal socioeconomic disadvantage on the inflammatory response at birth as well as indirect effect via preterm or SGA birth (among term neonates only), adjusting for mother's age, race/ethnicity, body mass index, smoking status, comorbidities, and antibiotic use/infection as well as grandmother's education level. There was a statistically significant total effect of both individual- and combined individual- and neighborhood-level prenatal socioeconomic disadvantage on high inflammatory response among all neonates as well as among term neonates only, and a positive but not statistically significant direct effect in both groups. The indirect effects via preterm and SGA birth were both negative, but not statistically significant. Our findings suggest prenatal socioeconomic disadvantage contributes to elevated neonatal inflammatory response, but via pathways outside of these adverse birth outcomes.

Trusting parent-professional relationships in interprofessional interventions for expectant and new parents in vulnerable positions: A realist evaluation

Interprofessional collaboration and trusting parent-professional relationships can be key to delivering interprofessional care to meet the needs of expectant and new parents in vulnerable positions. This, however, presents challenges. This study aimed to gain deeper understanding of how and under what circumstances trusting parent-professional relationships develop and work within interprofessional team-based care for this group, from the professionals' perspectives. Realist evaluation was undertaken based on 14 semi-structured, realist interviews with midwives and health visitors and 11 observations. Multiple interrelated mechanisms were identified including patient/family-centered care, timely and relevant interprofessional involvement in care, gentle interprofessional bridging, transparency of intervention roles and purposes, and relational continuity. Good interprofessional collaboration was a primary condition for these mechanisms. Developed, trusting relationships supported parents' engagements with interprofessional care and constituted a supportive safety net that promoted parenting skills and coping abilities. We identified harmful mechanisms: distanced encounters, uncertainty of interprofessional involvement, and compromising the safe space. These mechanisms caused distrust and disengagement. Ensuring trusting parent-professional relationships within interprofessional team-based care demands each professional involved competently engages in relational work and interprofessional collaboration. Uncontrollability is thus influenced regarding interpersonal connection and potentially gives an explanation when trust-building efforts fail.

PRENATAL MATERNAL CHARACTERISTICS ASSOCIATED WITH RETINOPATHY OF PREMATURITY

PURPOSE

Determine whether prenatal maternal characteristics such as sociodemographic characteristics, comorbidities, or pregnancy complications affect retinopathy of prematurity (ROP) development.

METHODS

Medical records of 236 mother-infant dyads from our institution were reviewed, only including dyads in which infants were born at 30 weeks gestational age or earlier. The primary outcome measure was the risk of ROP (defined Stage 1 or greater in either eye) and its association with prenatal maternal variables.

RESULTS

Maternal Medicaid insurance, smoking during pregnancy, and chorioamnionitis were associated with an increased risk of ROP. For Medicaid insurance and chorioamnionitis, these risks were not appreciably altered by adjustment for potential confounders.

CONCLUSION

These results suggest that several prenatal maternal factors may independently affect the risk of ROP in preterm infants. Validation of our findings could aid in the identification of infants at high risk for ROP based on prenatal clinical features.

Severe Maternal Morbidity and Mortality Among Immigrant and Canadian-Born Women Residing Within Low-Income Neighborhoods in Ontario, Canada

IMPORTANCE

Evidence indicates that immigrant women and women residing within low-income neighborhoods experience higher adversity during pregnancy. Little is known about the comparative risk of severe maternal morbidity or mortality (SMM-M) among immigrant vs nonimmigrant women living in low-income areas.

OBJECTIVE

To compare the risk of SMM-M between immigrant and nonimmigrant women residing exclusively within low-income neighborhoods in Ontario, Canada.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used administrative data for Ontario, Canada, from April 1, 2002, to December 31, 2019. Included were all 414 337 hospital-based singleton live births and stillbirths occurring between 20 and 42 weeks' gestation, solely among women residing in an urban neighborhood of the lowest income quintile; all women were receiving universal health care insurance. Statistical analysis was performed from December 2021 to March 2022.

EXPOSURES

Nonrefugee immigrant status vs nonimmigrant status.

MAIN OUTCOMES AND MEASURES

The primary outcome, SMM-M, was a composite outcome of potentially life-threatening complications or mortality occurring within 42 days of the index birth hospitalization. A secondary outcome was SMM severity, approximated by the number of SMM indicators (0, 1, 2 or ≥3 indicators). Relative risks (RRs), absolute risk differences (ARDs), and odds ratios (ORs) were adjusted for maternal age and parity.

RESULTS

The cohort included 148 085 births to immigrant women (mean [SD] age at index birth, 30.6 [5.2] years) and 266 252 births to nonimmigrant women (mean [SD] age at index birth, 27.9 [5.9] years). Most immigrant women originated from South Asia (52 447 [35.4%]) and the East Asia and Pacific (35 280 [23.8%]) regions. The most frequent SMM indicators were postpartum hemorrhage with red blood cell transfusion, intensive care unit admission, and puerperal sepsis. The rate of SMM-M was lower among immigrant women (2459 of 148 085 [16.6 per 1000 births]) than nonimmigrant women (4563 of 266 252 [17.1 per 1000 births]), equivalent to an adjusted RR of 0.92 (95% CI, 0.88-0.97) and an adjusted ARD of -1.5 per 1000 births (95% CI, -2.3 to -0.7). Comparing immigrant vs nonimmigrant women, the adjusted OR of having 1 SMM indicator was 0.92 (95% CI, 0.87-0.98), the adjusted OR of having 2 indicators was 0.86 (95% CI, 0.76-0.98), and the adjusted OR of having 3 or more indicators was 1.02 (95% CI, 0.87-1.19).

CONCLUSIONS AND RELEVANCE

This study suggests that, among universally insured women residing in low-income urban areas, immigrant women have a slightly lower associated risk of SMM-M than their nonimmigrant counterparts. Efforts aimed at improving pregnancy care should focus on all women residing in low-income neighborhoods.

The Impact of Neighborhood Deprivation on Glycemic Control for Patients with Type 2 Diabetes During Pregnancy

Background: The impact of neighborhood level factors on glycemic control and pregnancy outcomes is understudied. The primary objective was to determine whether there is an association between glycemic control during pregnancy and level of neighborhood deprivation, defined by area deprivation index (ADI). Materials and Methods: We conducted a retrospective cohort study of women with type 2 diabetes who received care at a tertiary referral center from 2007 to 2017. Patients living in more deprived neighborhoods (ADI >85th national percentile) were compared to those living in less deprived neighborhoods (ADI ≤85th percentile). The primary outcome was change in hemoglobin A1c (HbA1c) over time. Demographic characteristics were compared between groups, and trends in mean A1c through each trimester were tested with repeated measures analysis. Results: Of 237 women meeting study criteria, 93 (39.2%) lived in less deprived (low ADI) and 144 (60.8%) lived in more deprived neighborhoods (high ADI). Women living in more deprived neighborhoods were more likely to be Black (86.8% vs. 53.8%, p < 0.01), less likely to be married (11.3% vs. 31.2%, p < 0.01), and had more severe diabetes (p = 0.05). Both groups achieved significant improvement in HbA1c across each trimester using repeated measures analysis. Those living in more deprived neighborhoods had significantly more improvement in HbA1c from their initial visit to the third trimester compared to those in less deprived neighborhoods, (p = 0.01) such that there was no longer a statistically significant disparity in HbA1c by the third trimester (6.69 ± 0.97 Less deprived vs. 6.95 ± 1.22 more deprived, p = 0.19). Conclusions: Low-income women living in more deprived neighborhoods enter pregnancy with significantly worse glycemic control than those living in less deprived neighborhoods, but the gap in glycemic control largely closes by the end of pregnancy with similar maternal and neonatal outcomes.

Social inequalities in access to care at birth and neonatal mortality: an observational study

OBJECTIVE

To look at the association of socioeconomic status (SES) with the suitability of the maternity where children are born and its association with mortality.

DESIGN

Retrospective analysis of a prospective cohort constituted using hospital discharge databases.

SETTING

France POPULATION: Live births in 2012-2014 in maternity hospitals in mainland France followed until discharge from the hospital.

MAIN OUTCOME MEASURE

Unsuitability of the maternity to newborns' needs based on birth weight and gestational age, early transfers (within 24 hours of birth) and in-hospital mortality.

RESULTS

2 149 454 births were included, among which 155 646 (7.2%) were preterm. Preterm newborns with low SES were less frequently born in level III maternities than those with high SES. They had higher odds of being born in an unsuitable maternity (OR=1.174, 95% CI 1.114 to 1.238 in the lowest SES quintile compared with the highest), and no increase in the odds of an early transfer (OR=0.966, 95% CI 0.849 to 1.099 in the lowest SES quintile compared with the highest). Overall, newborns from the lowest SES quintile had a 40% increase in their odds of dying compared with the highest (OR=1.399, 95% CI 1.235 to 1.584).

CONCLUSIONS

Newborns with the lowest SES were less likely to be born in level III maternity hospitals compared with those with the highest SES, despite having higher prematurity rates. This was associated with a significantly higher mortality in newborns with the lowest SES. Strategies must be developed to increase health equity among mothers and newborns.

Maternal, Perinatal and Neonatal Outcomes of Triplet Pregnancies According to Chorionicity: A Systematic Review of the Literature and Meta-Analysis

Triplet pregnancies are rare events that affect approximately 93 in 100,000 deliveries in the world, especially due to the increased use of assisted reproductive techniques and older maternal age. Triplet pregnancies are associated with a higher risk of fetal and maternal morbidity and mortality compared to twins and singletons. Chorionicity has been proposed as a major determinant of perinatal and maternal outcomes in triplet pregnancies, although further evidence is needed to clarify the extent and real influence of this factor. Thus, the aim of this study was to conduct a systematic review of the literature and a meta-analysis of the maternal and perinatal outcomes of triplet pregnancies, evaluating how chorionicity may influence these results. A total of 46 studies with 43,653 triplet pregnancies and 128,145 live births were included. Among the main results of our study, we found a broad spectrum of fetal and maternal complications, especially in the group of monochorionic and dichorionic pregnancies. Risk of admission to NICU, respiratory distress, sepsis, necrotizing enterocolitis, perinatal and intrauterine mortality were all found to be higher in non-TCTA pregnancies than in TCTA pregnancies. To date, our meta-analysis includes the largest population sample and number of studies conducted in this field, evaluating a wide variety of outcome measures. The heterogeneity and retrospective design of the studies included in our research represent the main limitations of this review. More evidence is needed to fully assess outcome measures that could not be studied in this review due to scarcity of publications or insufficient sample size.

Socio-economic determinants of healthcare costs in early life: a register-based study in the Netherlands

Background

Children with low socioeconomic status (SES) have an increased risk of a suboptimal start in life with ensuing higher healthcare costs. This study aims to investigate the effects of individual- (monthly household income) and contextual-level SES (household income and neighborhood deprivation), and perinatal morbidity (preterm birth and small for gestational age ((<10th percentile), SGA)) on healthcare costs in early life (0–3 years of age).

Methods

Individual-linked data from three national registries (Perinatal Registry Netherlands, Statistics Netherlands, and Healthcare Vektis) were obtained of all children born between 2011 and 2014 (N = 480,471) in the Netherlands. Binomial logistic regression was used to model annual healthcare costs as a function of their household income (per €1000), neighborhood deprivation index (range − 13.26 – 10.70), their perinatal morbidity and demographic characteristics. Annual healthcare cost were dichotomized into low healthcare costs (Q1-Q3 below €1000) and high healthcare costs (Q4 €1000 or higher).

Results

Children had a median of €295 annual healthcare costs, ranging from €72 to €4299 (5–95%). Binomial logistic regression revealed that for every €1000 decrease in monthly household income, the OR for having high healthcare costs is 0.99 (0.99–0.99). Furthermore, for every one-unit increase in neighborhood deprivation the OR for having high healthcare costs increase 1.02 (1.01–1.02). Finally, the model revealed an OR of 2.55 (2.48–2.61) for preterm born children, and an OR of 1.44 (1.41–1.48) for children SGA, to have high healthcare costs compared to their healthy peers.

Conclusion

More neighborhood deprivation was directly related to higher healthcare costs in young children. On top of this, lower household income was consistently and independently related to higher healthcare costs. By optimizing conditions for low SES populations, the impact of low SES circumstances on their healthcare costs can be positively influenced. Additionally, policies that influence more timely and appropriate healthcare use in low SES populations can reduce healthcare costs further.

Associations between Residential Proximity to Oil and Gas Drilling and Term Birth Weight and Small-for-Gestational-Age Infants in Texas: A Difference-in-Differences Analysis

BACKGROUND

Oil and natural gas extraction may produce environmental pollution at levels that affect reproductive health of nearby populations. Available studies have primarily focused on unconventional gas drilling and have not accounted for local population changes that can coincide with drilling activity.

OBJECTIVE

Our study sought to examine associations between residential proximity to oil and gas drilling and adverse term birth outcomes using a difference-in-differences study design.

METHODS

We created a retrospective population-based term birth cohort in Texas between 1996 and 2009 composed of mother-infant dyads (n=2,598,025) living <10km from an oil or gas site. We implemented a difference-in-differences approach to estimate associations between drilling activities and infant health: term birth weight and term small for gestational age (SGA). Using linear and logistic regression, we modeled interactions between births before (unexposed) or during (exposed) drilling activity and residential proximity near (0-1, 1-2, or 2-3km) or far (3-10km) from an active or future drilling site, adjusting for individual- and neighborhood-level characteristics.

RESULTS

The adjusted mean difference in term birth weight for mothers living 0-1 vs. 3-10km from a current or future drilling site was -7.3g [95% confidence interval (CI): -11.6, -3.0] for births during active vs. future drilling. The corresponding adjusted odds ratio for SGA was 1.02 (95% CI: 0.98, 1.06). Negative associations with term birth weight were observed for the 1-2 and 2-3km near groups, and no consistent differences were identified by type of drilling activity. Larger, though imprecise, adverse associations were found for infants born to Hispanic women, women with the lowest educational attainment, and women living in cities.

CONCLUSIONS

Residing near oil and gas drilling sites during pregnancy was associated with a small reduction in term birth weight but not SGA, with some evidence of environmental injustices. Additional work is needed to investigate specific drilling-related exposures that might explain these associations. https://doi.org/10.1289/EHP7678.

Assessing the effectiveness of vehicle emission regulations on improving perinatal health: a population-based accountability study

BACKGROUND

Since the 1990s, extensive regulations to reduce traffic-related air pollution (TRAP) have been implemented, yet the effectiveness of these regulations has not been assessed with respect to improving infant health. In this study, we evaluate how infant health risks associated with maternal residences near highways during pregnancy have changed over time.

METHODS

We created a population-based retrospective birth cohort with geocoded residential addresses in Texan metropolitan areas from 1996 through 2009 (n = 2 259 411). We compared term birthweight (37-42 weeks of gestation) among maternal residences <300 m from a highway (high TRAP exposure) (n = 394 346) and 500-3500 m from a highway (comparison group) (n = 1 865 065). We implemented linear regressions to evaluate interactions between high TRAP exposure and birth year, adjusting for demographics, socioeconomic status and neighbourhood context. In addition, we used propensity score matching to further reduce residual confounding.

RESULTS

From 1996 to 2009, outdoor NO2 decreased by 51.3%, based on regulatory monitoring data in Texas. Among pregnant women who resided in the high TRAP zone during pregnancy, interaction terms between residential location and birth year show that birthweight increased by 1.1 g [95% confidence interval CI): 0.7, 1.5) in unadjusted models and 0.3 g (95% CI: 0.0, 0.6) in matched models. Time-stratified models also show decreasing impacts of living in high TRAP areas on birthweight when comparing infants born in 1996-97 with 2008-09. Sensitivity analyses with alternative exposure and control groups show consistent results.

CONCLUSIONS

Infant health risks associated with maternal residence near highways have reduced over time, paralleling regulatory measures to improve exhaust pipe emissions.

Pregnancy and COVID-19

There are many unknowns for pregnant women during the coronavirus disease 2019 (COVID-19) pandemic. Clinical experience of pregnancies complicated with infection by other coronaviruses e.g., Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome, has led to pregnant woman being considered potentially vulnerable to severe SARS-CoV-2 infection. Physiological changes during pregnancy have a significant impact on the immune system, respiratory system, cardiovascular function, and coagulation. These may have positive or negative effects on COVID-19 disease progression. The impact of SARS-CoV-2 in pregnancy remains to be determined, and a concerted, global effort is required to determine the effects on implantation, fetal growth and development, labor, and neonatal health. Asymptomatic infection presents a further challenge regarding service provision, prevention, and management. Besides the direct impacts of the disease, a plethora of indirect consequences of the pandemic adversely affect maternal health, including reduced access to reproductive health services, increased mental health strain, and increased socioeconomic deprivation. In this review, we explore the current knowledge of COVID-19 in pregnancy and highlight areas for further research to minimize its impact for women and their children.

Multilevel prenatal socioeconomic determinants of Mexican American children's weight: Mediation by breastfeeding

Objective: Mexican American (MA) children are more likely to grow up in poverty than their non-Hispanic/Latinx white peers and are at an elevated risk for early onset obesity. The current study evaluated the effects of prenatal family- and neighborhood-level disadvantage on children's weight and weight gain from 12 months through 4.5 years of age. Maternal breastfeeding duration was evaluated as a potential mechanism underlying the relation between multilevel disadvantage and weight. Methods: Data was collected from 322 low-income, MA mother-child dyads. Women reported the degree of family socioeconomic disadvantage and breastfeeding status. Neighborhood disadvantage was evaluated with census-level metrics. Children's weight and height were measured at laboratory visits. Results: Greater prenatal neighborhood disadvantage predicted higher child Body Mass Index (BMI) at 12 months, over and above family-level disadvantage; this effect remained stable through 4.5 years. Breastfeeding duration partially mediated the effect of neighborhood disadvantage on child BMI. Breastfeeding duration predicted child BMI at all timepoints. Conclusions: Maternal prenatal residence in a neighborhood with high concentrated disadvantage may place low-income, MA children at increased risk of elevated weight status during the first few years of life. Breastfeeding duration emerged as potentially modifiable pathway through which the prenatal neighborhood impacts children's early life weight. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Influence of Family Income Level on Obstetric and Perinatal Outcomes in Spain

For pregnant women, having a low family income status is associated with late prenatal attendance and an increased risk of adverse outcomes during pregnancy, delivery, and immediately after delivery. However, the influence of the socioeconomic level on maternal and child health may be minimal as long as the health system model is able to neutralise health inequity. For this reason, the objective of this study is to determine the relationship between the socioeconomic level assessed through monthly household income and obstetric and perinatal outcomes in the Spanish Health System, where midwives play a relevant role. To meet this objective, a cross-sectional observational study aimed at women who have been mothers between 2013 and 2018 in Spain was developed. The final study population was 5942 women. No statistically significant differences with linear trend were found between income level and obstetric and perinatal outcomes after the adjustment by confounding factors (pregnancy composite morbidity, p = 0.447; delivery composite morbidity, p = 0.590; perinatal composite morbidity, p = 0.082; postpartum composite morbidity, p = 0.407). The main conclusion is that, in the current Spanish health system, household income as an indicator of socioeconomic status is not related to perinatal outcomes after the adjustment by confounding factors. These results are likely due to the public model of our health system that serves all citizens on equal footing, although other social and individual factors may have influenced these results

'It requires something drastic': Interviews with health care leaders about organisational responses to social disadvantage

PROBLEM

Persisting disparities in maternal and child health outcomes in high income countries require new insights for health service response.

BACKGROUND

Significant social hardship, including factors related to migration, are associated with perinatal morbidity and mortality. The universality of maternity and child health care offers opportunities to reduce health disparities. Process evaluation of health service initiatives to address refugee health inequalities in Melbourne, Australia, is the setting for the study.

AIM

To explore the views of health service leaders about health system and service capacity to tailor care to address social adversity and reduce disparities in maternal and child health outcomes.

METHODS

In-depth interviews with leaders of maternity and maternal and child health services with questions guided by a diagram to promote discussion. Thematic analysis of transcribed interviews.

FINDINGS

Health care leaders recognised the level of social complexity and diversity of their clientele. The analysis revealed three key themes: grappling with the complexity of social disadvantage; 'clinical risk' versus 'social risk'; and taking steps for system change.

DISCUSSION

Priority given to clinical requirements and routine practices together with the rising demand for services is limiting service response to families experiencing social hardship and hampering individualised care. System change was considered possible only if health service decision makers engaged with consumer and community perspectives and that of front-line staff.

CONCLUSION

Achieving equity in maternal and child health outcomes requires engagement of all key stakeholders (communities, clinicians, managers) to facilitate effective system re-design.

An Australian doula program for socially disadvantaged women: Developing realist evaluation theories

PROBLEM

Volunteer doula support has achieved favourable outcomes for socially disadvantaged women around the world. There is limited explanatory understanding of how, why and when doula support programs improve outcomes.

BACKGROUND

A community organisation is providing free doula support for women experiencing socioeconomic disadvantage in Melbourne, Australia. The program aims to complement the mainstream maternity care system, to promote equity in women's care, and experiences of pregnancy, birth and early parenting. This program is the first of its kind in Australia and has not previously been evaluated.

AIM

To develop hypothesised program theories for the realist evaluation of an Australian doula program.

METHODS

As the first stage of a realist evaluation, three key informant interviews and rapid realist review of literature were conducted in December 2017 - January 2019.

FINDINGS

Seven theories were developed in four categories: critical elements of implementation (Attracting and activating the right doulas, and Good matching); outcomes for women (Being by her side, and Facilitating social connection), outcomes in maternity care system (Complementing or enhancing maternity care, and Doula as a witness - demanding accountability in others), and outcomes for doulas (Doulas as beneficiaries). These theories were framed in accordance with a realist understanding of causation, as Context - Mechanism - Outcome (CMO) configurations.

DISCUSSION AND CONCLUSION

The development of theories from multiple sources of evidence provides a strong theoretical base for program evaluation. The theories hypothesise how, why, for whom and when the doula program works. Subsequent stages of the evaluation will test and refine the theories.

Gestational age, kindergarten-level literacy, and effect modification by maternal socio-economic and demographic factors

BACKGROUND

Shorter gestational age at birth is associated with worse academic performance in childhood. Socio-economic and demographic factors that affect a child's development may modify the relationship between gestational age and later academic performance.

OBJECTIVE

The purpose of this study was to investigate socio-economic and demographic effect modification of gestational age's association with kindergarten-level literacy skills in a longitudinal Wisconsin birth cohort.

METHODS

We sampled 153 145 singleton births (2007-2010) that linked to Phonological Awareness Literacy Screening-Kindergarten (PALS-K) scores (2012-2016 school years). PALS-K outcomes included meeting the screening benchmark (≥28 points, range 0-102 points) and the standardised score. Multivariable linear regressions of PALS-K outcomes on gestational age (completed weeks) included individual interactions for five maternal attributes measured at delivery: Medicaid coverage, education, age, race/ethnicity, and marital status.

RESULTS

Each additional completed gestational week was associated with a 0.5 percentage point increase in the probability of meeting the PALS-K literacy benchmark. The benefit of an additional week of gestational age was 0.5 percentage points (95% confidence interval 0.3, 0.7 percentage points) greater for Medicaid-covered births (0.8 percentage points) relative to non-Medicaid births (0.3 percentage points). Relative to only completing high school, having college education weakened this association by 0.3-0.6 percentage points, depending on years in college. Similar but modest relations emerged with standardised scores.

CONCLUSIONS

Socio-economic advantage as indicated by non-Medicaid coverage or higher levels of completed maternal education may diminish the cost of preterm birth on a child's kindergarten-level literacy skills.

Neighbourhood Income and Risk of Having an Infant With Concomitant Preterm Birth and Severe Small for Gestational Age Birth Weight

OBJECTIVE

Socioeconomic position gradients have been individually demonstrated for preterm birth (PTB) at <37 weeks gestation and severe small for gestational age birth weight at <5th percentile (SGA). It is not known how neighbourhood income is related to the combination of PTB and severe SGA, a state reflective of greater placental dysfunction and higher risk of neonatal morbidity and mortality than PTB or severe SGA alone.

METHODS

This population-based study comprised all 1 367 656 singleton live births in Ontario from 2002 to 2011. Multinomial logistic regression was used to estimate the odds of PTB with severe SGA, PTB without severe SGA, and severe SGA without PTB, compared with neither PTB nor severe SGA, in relation to neighbourhood income quintile (Q). The highest income quintile, Q5, served as the exposure referent. Adjusted odds ratios (aORs) were adjusted for maternal age at delivery, parity, marital status, and world region of birth (Canadian Task Force Classification II-2).

RESULTS

Relative to women residing in Q5 (2.3 per 1000), the rate of PTB with severe SGA was highest among those in Q1 (3.6 per 1000), with an aOR of 1.34 (95% confidence interval [CI] 1.20-1.50). The corresponding aORs were 1.23 (95% CI 1.09-1.37) for Q2, 1.14 (95% CI 1.02-1.28) for Q3, and 1.06 (95% CI 0.95-1.20) for Q4. Less pronounced aORs were seen for each individual outcome of PTB and severe SGA.

CONCLUSION

Women residing in the lowest-income areas are at highest risk of having a fetus born too small and too soon. Future research should focus on identifying those women most predisposed to combined PTB and severe SGA.

Does neighborhood socioeconomic status predict the risk of preterm birth? A community-based Canadian cohort study

OBJECTIVE

This study developed and internally validated a predictive model for preterm birth (PTB) to examine the ability of neighbourhood socioeconomic status (SES) to predict PTB.

DESIGN

Cohort study using individual-level data from two community-based prospective pregnancy cohort studies (All Our Families (AOF) and Alberta Pregnancy Outcomes and Nutrition (APrON)) and neighbourhood SES data from the 2011 Canadian census.

SETTING

Calgary, Alberta, Canada.

PARTICIPANTS

Pregnant women who were <24 weeks of gestation and >15 years old were enrolled in the cohort studies between 2008 and 2012. Overall, 5297 women participated in at least one of these cohorts: 3341 women participated in the AOF study, 2187 women participated in the APrON study and 231 women participated in both studies. Women who participated in both studies were only counted once.

PRIMARY AND SECONDARY OUTCOME MEASURES

PTB (delivery prior to 37 weeks of gestation).

RESULTS

The rates of PTB in the least and most deprived neighbourhoods were 7.54% and 10.64%, respectively. Neighbourhood variation in PTB was 0.20, with an intra-class correlation of 5.72%. Neighbourhood SES, combined with individual-level predictors, predicted PTB with an area under the receiver-operating characteristic curve (AUC) of 0.75. The sensitivity was 91.80% at a low-risk threshold, with a high false-positive rate (71.50%), and the sensitivity was 5.70% at a highest risk threshold, with a low false-positive rate (0.90%). An agreement between the predicted and observed PTB demonstrated modest model calibration. Individual-level predictors alone predicted PTB with an AUC of 0.60.

CONCLUSION

Although neighbourhood SES combined with individual-level predictors improved the overall prediction of PTB compared with individual-level predictors alone, the detection rate was insufficient for application in clinical or public health practice. A prediction model with better predictive ability is required to effectively find women at high risk of preterm delivery.

The Association of Inadequate and Intensive Prenatal Care With Maternal, Fetal, and Infant Outcomes: A Population-Based Study in Manitoba, Canada

OBJECTIVE

Little is known about how prenatal care influences health outcomes in Canada. The objective of this study was to examine the association of prenatal care utilization with maternal, fetal, and infant outcomes in Manitoba.

METHODS

This retrospective cohort study conducted at the Manitoba Centre for Health Policy investigated all deliveries of singleton births from 2004-2005 to 2008-2009 (N = 67 076). The proportion of women receiving inadequate, intermediate/adequate, and intensive prenatal care was calculated. Multivariable logistic regression was used to examine the association of inadequate and intensive prenatal care with maternal and fetal-infant health outcomes, health care use, and maternal health-related behaviours.

RESULTS

The distribution of prenatal care utilization was 11.6% inadequate, 84.4% intermediate/adequate, and 4.0% intensive. After adjusting for sociodemographic factors and maternal health conditions, inadequate prenatal care was associated with increased odds of stillbirth, preterm birth, low birth weight, small for gestational age (SGA), admission to the NICU, postpartum depressive/anxiety disorders, and short interpregnancy interval to next birth. Women with inadequate prenatal care had reduced odds of initiating breastfeeding or having their infant immunized. Intensive prenatal care was associated with reduced odds of stillbirth, preterm birth, and low birth weight and increased odds of postpartum depressive/anxiety disorders, initiation of breastfeeding, and infant immunization.

CONCLUSION

Inadequate prenatal care was associated with increased odds of several adverse pregnancy outcomes and lower likelihood of health-related behaviours, whereas intensive prenatal care was associated with reduced odds of some adverse pregnancy outcomes and higher likelihood of health-related behaviours. Ensuring women receive adequate prenatal care may improve pregnancy outcomes.

Retrospective analysis of risk factors for low 1-minute Apgar scores in term neonates

The current study was designed to investigate the perinatal risk factors for low 1-min Apgar scores in term neonates. We retrospectively analyzed the maternal and neonatal clinical data of 10,550 infants who were born through vaginal delivery from 37 weeks 0 days to 41 weeks 6 days of single gestation from January 2013 to July 2018. Because the 1-min Apgar score reflects neonatal status at birth, we analyzed the risk factors for low (score <7) 1-min Apgar scores through logistic regression. Among these 10,550 neonates, 339 (3.2%) had low (score <7) 1-min Apgar scores. Among them, 321 (94.7%) were admitted to the neonatology department for further observation or treatment. Multivariate analysis revealed that educational background, body mass index, gestational age, pathological obstetrics, longer duration of the second stage of labor, forceps delivery or vacuum extraction, neonatal weight, neonatal sex, and meconium-stained amniotic fluid were independent risk factors for 1-min Apgar scores <7. Neonates who had low 1-min Apgar scores were more frequently admitted to the neonatology department for further observation or treatment. Early detection of risk factors and timely intervention to address these factors may improve neonatal outcomes at birth and reduce the rate of admission to the neonatology department.

The impact of a patient's social status on the cost of vaginal deliveries: an observational study in a French university hospital

INTRODUCTION

We aimed to assess the association between a patient's social status and the cost of stay for a single uncomplicated vaginal delivery. Currently, few data have been reported.

MATERIAL AND METHODS

We conducted an observational study with data retrieved from the medical and administrative databases of a university hospital in North-West France. We included all patients admitted in 2014 and classified in either Diagnosis-Related Group (DRG) « Single uncomplicated vaginal deliveries in a primiparous patient » or DRG « Single uncomplicated vaginal deliveries in a multiparous patient ». Criteria defining poor social status were: a specific healthcare benefit in relation to low income or for foreign undocumented patients, and/or a consultation with a social worker during the hospital stay except if no social problem was diagnosed. We compared the cost of stay between patients with poor social status and patients with good social status using a multivariate median regression stratified on parity, and adjusted for age, gestational age and neonatal hospitalization.

RESULTS

Among 686 primiparous patients, 21% had poor social status, which was associated with an increase in the median cost of stay (+€475; 95% CI [+334 to +616]), mostly explained by a 1-day increase in the median length of stay.Among 899 multiparous patients, 29% had poor social status, which was not associated with the cost of stay.

DISCUSSION

Social status had an impact on the cost of vaginal deliveries in primiparous patients. Our findings suggest a need to redefine the DRG classification according to patients' social status.

Is the socioeconomic status of immigrant mothers in Brussels relevant to predict their risk of adverse pregnancy outcomes?

BACKGROUND

Understanding and tackling perinatal health inequities in industrialized countries requires analysing the socioeconomic determinants of adverse pregnancy outcomes among immigrant populations. Studies show that among certain migrant groups, education is not associated with adverse pregnancy outcomes. We aim to extend this analysis to further dimensions of socioeconomic status (SES) and to other settings. The objective of this study is to identify sociodemographic characteristics associated with adverse pregnancy outcomes, according to the origin of mothers residing in Brussels.

METHODS

We analysed all singleton live births in Brussels between 2005 and 2010 (n = 97,844). The data arise from the linkage between three administrative databases. Four groups of women were included according to their place of birth: Belgium, EU, North Africa, and Sub-Saharan Africa. For each group, logistic regression was carried out to estimate the odds ratios of low birthweight (LBW) and small for gestational age (SGA) according to SES indicators (household income, maternal employment status, maternal education) and single parenthood.

RESULTS

Three key findings emerge from this study: 1) 25% of children were born into a household under the poverty threshold. This proportion was much higher for mothers born outside of the EU. 2) For North African immigrants, SES indicators didn't influence the pregnancy outcomes, whereas their risk of LBW increased with single parenthood. 3) For Sub-Saharan Africans the risk of LBW increased with low household income.

CONCLUSION

In a region where immigrant mothers are at high poverty risk, we observe a classic social gradient in perinatal outcomes only for mothers born in Belgium or the EU. In the other groups, SES influences perinatal outcomes less systematically. To develop interventions to reduce inequities from birth, it's important to identify the determinants of perinatal health among immigrants and to understand the underlying mechanisms in different contexts.

The association of the Bolsa Familia Program with children's oral health in Brazil

Background

Several studies have demonstrated that Conditional Cash Transfer (CCT) programs reduce poverty/inequity and childhood mortality. However, none of these studies investigated the link between CCT programs and children’s oral health. This study examines the association between receiving the Brazilian conditional cash transfer, Bolsa Familia Program (BFP), and the oral health of five-year-old children in the Northeast of Brazil.

Methods

We conducted a cross-sectional study with 230 caregivers/children randomly selected in primary health care clinics in the city of Fortaleza in 2016. Interviews and oral health examinations were performed. Descriptive statistics and multiple logistic regression analyses were conducted to identify factors associated with dental caries among five-year-old children enrolled in the BFP.

Results

Around 40% of children enrolled in the BFP had dental caries. However, those who received Bolsa Familia (BF) for a period up to two years (OR = 0.13, 95% CI 0.05–0.35) had substantially lower adjusted odds of having dental caries than those who had never received BF. In addition, the association of BF and dental caries was more prominent among extremely poor families (OR = 0.05, 95% CI 0.01–0.28).

Conclusions

Although initial enrolment in the BFP predicted low dental caries among five-year-old children, the prevalence of dental caries in this population is still high, thus, public health programs should target BF children’s oral health. An ongoing effort should be made to reduce oral health inequalities among children in Brazil.

Childbirth-Related Hospital Burden by Socioeconomic Status in a Universal Health Care Setting

INTRODUCTION

Hospital utilization varies across socioeconomic and demographic strata in Canada, a country with a universal health care system. Rates of adverse birth outcomes are known to differ among women of high and low socioeconomic status (SES), but less is known of the excess hospital burden related to SES over the course of childbirth across Canadian provinces.

OBJECTIVE

To examine length of stay and risk of hospitalization surrounding delivery, relative to women's socio-demographic characteristics.

METHODS

A population-based record linkage between the Canadian Community Health Survey (CCHS) years 2005-2011 and the Discharge Abstract Database (DAD) allowed the tracking of hospital utilization for linked survey respondents between 2005 and 2011. Hourly length of stay for delivery, risk of readmission, and risk of admission prior to delivery was modeled by socio-demographic factors, controlling for other clinical and individual-level characteristics.

RESULTS

There were 21,914 complete delivery records from 15,458 female CCHS respondents who agreed to link and share their information. Average length of stay (for both vaginal and Caesarian deliveries) dropped over the study period from 67.86 hours in 2005 to 59.37 hours in 2011. In multivariate analyses, women with the lowest income had on average, two-hour longer stays for vaginal delivery as compared to high-income women (IRR 1.04, 95% CI 1.00-1.08) and higher risk of admission prior to delivery (OR 1.43, CI 1.13-1.81). Low-income women, Aboriginal women and women living in rural areas were also at elevated risk for longer hospital stays and for hospital admission prior to delivery. There was no consistent socioeconomic patterning of hospital burden for Caesarian deliveries.

CONCLUSION

The length of hospital stays for childbirth has declined in Canada. Length of stay remains modestly longer, and risk of hospitalization in the perinatal period higher, for low income women, Aboriginal women and rural women. The absence of egregious income-related differences in hospital burden related to childbirth is reassuring for the equity goals of the Canadian health care system. The persistence of marginally longer, and in turn, costlier visits for low-income and Aboriginal women before and during delivery is, however, suggestive that resources targeted to the prenatal period might be highly cost-effective if they achieve population-wide reductions in length of stay and hospitalization in the perinatal period.

Health of mothers of young children in Canada: identifying dimensions of inequality based on socio-economic position, partnership status, race, and region

OBJECTIVES

Little is known about the nature of health inequalities present among women who are mothers of young children in Canada. Therefore, the purpose of the study is to identify dimensions of inequalities based on socio-economic position, race, partner status, and region and determine whether each type of inequality is independent of another.

METHODS

Data are from the 2014 Canadian Community Health Survey. Women identifying as a parent living with a child ≤ 5 years, with complete data on the variables of interest, were selected (n = 2656). Poor health was defined as the presence of two or more chronic conditions. Exposures included partner status, education level, race, income, and region (Québec vs. rest of Canada). Logistic regression was used to estimate the odds of poor health according to each exposure unadjusted and adjusted for all other exposures. All analyses controlled for age and employment status.

RESULTS

In the fully adjusted model, among mothers of young children, the odds of poor health were significantly higher among non-white identifying (OR = 1.72; 95% CI = 1.34-2.21) and lone mothers (OR = 1.80; 95% CI = 1.35-2.39), but were significantly lower among those with higher incomes (OR[per decile] = 0.86; 95% CI = 0.82-0.90) and those from Québec (vs. the rest of Canada; OR = 0.50; 95% CI = 0.38-0.67).

CONCLUSIONS

Living in Québec compared to elsewhere in Canada appears to protect against poor health among mothers of young children. Regardless of region, health inequalities exist by socio-economic position, race, and partnership status. These findings have implications for public health programs and policies, such as universal child care.

Perceptions of pregnancy preparation in women with a low to intermediate educational attainment: A qualitative study

OBJECTIVE

in the promotion of periconceptional health, appropriate attention has to be given to the perceptions of those who are most vulnerable, such as women with a relatively low socioeconomic status based on their educational attainment. The aim of this study was to explore these women's perceptions of pregnancy preparation and the role they attribute to healthcare professionals.

DESIGN

we conducted semi-structured interviews with women with a low to intermediate educational attainment and with a desire to conceive, of which a subgroup had experience with preconception care. Thematic content analysis was applied on the interview transcripts.

FINDINGS

the final sample consisted of 28 women. We identified four themes of pregnancy preparation perceptions: (i)"How to prepare for pregnancy?", which included health promotion and seeking healthcare; (ii) "Why prepare for pregnancy?", which mostly related to fertility and health concerns; (iii) "Barriers and facilitators regarding pregnancy preparation", such as having limited control over becoming pregnant as well as the health of the unborn; (iv) "The added value of preconception care", reported by women who had visited a consultation, which consisted mainly of reassurance and receiving information.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

the attained insights into the perceptions of women with a low to intermediate education are valuable for adapting the provision of preconception care to their views. We recommend the proactive offering of preconception care, including information on fertility, to stimulate adequate preparation for pregnancy and contribute to improving perinatal health among women who are socioeconomically more vulnerable.

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

Background

Geographical 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.

Methods

Data 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.

Results

Considerable 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.

Conclusion

This 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.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1425-2) contains supplementary material, which is available to authorized users.

Mother's education and the risk of several neonatal outcomes: an evidence from an Italian population-based study

Background

Maternal socioeconomic disparities strongly affect child health, particularly in low and middle income countries. We assessed whether neonatal outcomes varied by maternal education in a setting where healthcare system provides universal coverage of health services to all women, irrespective of their socioeconomic status.

Methods

A population-based study was performed on 383,103 singleton live births occurring from 2005 to 2010 in Lombardy, an Italian region with approximately 10 million inhabitants. The association between maternal education, birthplace and selected neonatal outcomes (preterm birth, low birth weight, small-for-gestational age, low 5-min Apgar score, severe congenital anomalies, cerebral distress and respiratory distress) was estimated by fitting logistic regression models. Model adjustments were applied for sociodemographic, reproductive and medical maternal traits.

Results

Compared with low-level educated mothers, those with high education had reduced odds of preterm birth (Odds Ratio; OR = 0.81, 95% CI 0.77–0.85), low birth weight (OR = 0.78, 95% CI 0.70–0.81), small for gestational age (OR = 0.82, 95% CI 0.79–0.85), and respiratory distress (OR = 0.84, 95% CI 0.80–0.88).

Mothers born in a foreign country had higher odds of preterm birth (OR = 1.16, 95% CI 1.11–1.20), low Apgar score (OR = 1.18, 95% CI 1.07–1.30) and respiratory distress (OR = 1.19, 95% CI 1.15–1.24) than Italian-born mothers. The influence of maternal education on neonatal outcomes was confirmed among both, Italian-born and foreign-born mothers.

Conclusions

Low levels of education and maternal birthplace are important factors associated with adverse neonatal outcomes in Italy. Future studies are encouraged to investigate factors mediating the effects of socioeconomic inequality for identifying the main target groups for interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1418-1) contains supplementary material, which is available to authorized users.

Association between maternal social deprivation and prenatal care utilization: the PreCARE cohort study

Background

Maternal social deprivation is associated with an increased risk of adverse maternal and perinatal outcomes. Inadequate prenatal care utilization (PCU) is likely to be an important intermediate factor. The health care system in France provides essential health services to all pregnant women irrespective of their socioeconomic status. Our aim was to assess the association between maternal social deprivation and PCU.

Methods

The analysis was performed in the database of the multicenter prospective PreCARE cohort study. The population source consisted in all parturient women registered for delivery in 4 university hospital maternity units, Paris, France, from October 2010 to November 2011 (N = 10,419). This analysis selected women with singleton pregnancies that ended after 22 weeks of gestation (N = 9770). The associations between maternal deprivation (four variables first considered separately and then combined as a social deprivation index: social isolation, poor or insecure housing conditions, no work-related household income, and absence of standard health insurance) and inadequate PCU were tested through multivariate logistic regressions also adjusted for immigration characteristics and education level.

Results

Attendance at prenatal care was poor for 23.3% of the study population. Crude relative risks and confidence intervals for inadequate PCU were 1.6 [1.5–1.8], 2.3 [2.1–2.6], and 3.1 [2.8–3.4], for women with a deprivation index of 1, 2, and 3, respectively, compared to women with deprivation index of 0. Each of the four deprivation variables was significantly associated with an increased risk of inadequate PCU. Because of the interaction observed between inadequate PCU and mother’s country of birth, we stratified for the latter before the multivariate analysis. After adjustment for the potential confounders, this social gradient remained for women born in France and North Africa. The prevalence of inadequate PCU among women born in sub-Saharan Africa was 34.7%; the social gradient in this group was attenuated and no longer significant. Other factors independently associated with inadequate PCU were maternal age, recent immigration, and unplanned or unwanted pregnancy.

Conclusion

Social deprivation is independently associated with an increased risk of inadequate PCU. Recognition of risk factors is an important step in identifying barriers to PCU and developing measures to overcome them.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1310-z) contains supplementary material, which is available to authorized users.

Preterm Birth in the Context of Increasing Income Inequality

OBJECTIVE

Preterm birth is a leading cause of infant morbidity and mortality. Little is known about the contextual effect of U.S. income inequality on preterm birth, an issue of increasing concern given that the current economic divide is the largest since 1928.

METHODS

We examined changes in inequality over time in relation to preterm birth among singleton deliveries from an electronic medical record-based cohort (n = 223,512) conducted in 11 U.S. states and the District of Columbia from 2002 to 2008. Increasing income inequality was defined as a positive change in state-level Gini coefficient from the year prior to birth. Multi-level models estimated the independent effect of increasing inequality on preterm birth (>22 and <37 weeks) controlling for maternal demographics, health behaviors, insurance status, chronic medical conditions, and state-level poverty and unemployment during the year of birth.

RESULTS

The preterm birth rate was 12.3% where inequality increased and 10.9% where it did not. After adjustment, increasing inequality remained significantly associated with preterm birth (adjusted odds ratio 1.07, 95% confidence interval 1.04, 1.11). We observed no significant interaction by insurance status or race, suggesting that increasing inequality had a broad effect across the population.

CONCLUSIONS

The contextual effect of increasing income inequality on preterm birth risk merits further study.

A biopsychosocial approach to the interrelation between motherhood and women's excessive weight

Portugal is characterized by a high prevalence of overweight and obesity among women, whose weight increases most rapidly in early adulthood. Individual genetic features and behaviours, along with social, cultural and environmental factors interact in complex relationships with body weight and with its variation throughout time. Motherhood may trigger an increase in weight, potentially influencing the associations between excessive weight and several other health determinants. Taking into account the quality of prenatal care within Portugal's health care system, regarding coverage and success in improved outcomes, we theoretically demonstrate why pregnancy and motherhood should be seen as opportunities for prevention and why a deeper knowledge about the interplay of biological, social and psychological determinants of weight at this stage of life can be useful to design more effective weight control interventions towards this population.