The social determinants of infant mortality and birth outcomes in Western developed nations: a cross-country systematic review

Assessing the Relationships of Expenditure and Health Outcomes in Healthcare Systems: A System Design Approach

Background/Objectives: The COVID-19 pandemic has significantly altered healthcare systems worldwide, highlighting healthcare expenditure's critical role in fostering population resilience and wellness. This extraordinary situation has brought to light the delicate balance that governments must maintain between the need to protect public health and budgetary restraints. The relationship between healthcare expenditure and outcomes, such as healthy life years, health expectancy, and standardized death rate, has become a central point in understanding the dynamics of healthcare systems and their capacity to adapt to emerging challenges. Methods: Using extensive datasets and predictive approaches such as artificial neural networks, exponential smoothing models, and ARIMA techniques, this study explores these connections in the context of the European Union. Results: The study better explains how healthcare financing schemes influence important health outcomes by examining past trends and forecasting future developments. The results show that household healthcare expenditures correlate negatively with standardized death rates and substantially benefit healthy life years and health expectancy. These findings underline the significance of household contributions in influencing health outcomes across various healthcare systems. Long-term and strategic investments in health services are essential, as the pandemic has demonstrated the proactive capacity of well-designed healthcare systems to reduce risks and enhance overall resilience. The results suggest that focused investments can raise life expectancy and lower death rates, supporting the development of robust, adaptable healthcare systems in the post-pandemic era. Conclusions: The main contribution of this research is demonstrating the significant role of healthcare expenditure, particularly household contributions, in improving key health outcomes and fostering healthcare system resilience in the EU context.

Contribution of county-level socioeconomic indicators to racial or ethnic differences in neonatal anthropometry in the USA: a prospective cohort study

Introduction

Racial and ethnic differences in fetal growth and birth size in the USA have not been adequately explained by individual-level socioeconomic status (SES) factors. We explored whether differences may be partially explained by county-level indicators of SES.

Methods

We linked participant zip codes from the National Institute of Child Health and Human Development Fetal Growth Studies (2009-2013; n=1614) to county-level US census data to calculate a neighbourhood deprivation index, education isolation index and two indices of segregation: racial isolation and evenness. Using causal mediation methods, we evaluated the extent to which racial/ethnic differences in neonatal anthropometrics could be eliminated in a hypothetical setting where everyone lived in counties with high resource availability and racial/ethnic integration.

Results

Setting racial evenness to levels consistent with the highest diversity eliminated 79.9% of the difference in birth weight between non-Hispanic White and non-Hispanic Black and all the difference (106.3%) in birth weight between Hispanic and non-Hispanic White individuals. Setting racial evenness, racial isolation and education isolation to levels consistent with higher diversity and education was also associated with similar reductions in differences for other anthropometric measures.

Conclusions

Our findings suggest that, in a hypothetical scenario where everyone lived in counties with low deprivation or segregation, race/ethnic differences in neonatal anthropometry may substantially decrease or be eliminated. Our results also highlight the importance of considering community-level and structural factors in analyses of race/ethnic health disparities.

Social Determinants of Health in Cerebral Palsy

Background/Objectives: To describe social and psychological needs, such as poverty, early trauma, or adverse childhood events, of caregivers with a child newly diagnosed with cerebral palsy (CP) or receiving a designation of high-risk for cerebral palsy (HRCP). Methods: Caregiver self-report questionnaires screening for unmet social needs, adverse childhood experiences (ACEs), depression symptoms, and trauma were collected from 97 caregivers of children with CP/HRCP seen in a high-risk infant follow-up clinic (adjusted age range 1-24 months). We compared their responses to those of 97 caregivers of age-matched controls seen in the same clinic with similar risk factors over the equivalent time period. Results: Income insecurity and positive screening rate for depressive and trauma symptoms were high for both groups (CP/HRCP, matched control group); no differences were found between CP/HRCP and control groups. Rates of food and housing insecurity and caregiver ACEs were not different between groups. All families received referrals to appropriate community support at the visit. Conclusions: Caregivers of children with CP/HRCP in high-risk infant follow-up clinics may face difficult conversations and decision-making in the context of high psychological and social adversity. Comprehensive support should be considered as early as possible.

Addressing Social and Structural Determinants of Health in the Delivery of Reproductive Health Care: ACOG Committee Statement No. 11

Social and structural determinants of health include historical, social, political, and economic forces, many of which are rooted in racism and inequality, that shape the relationship between environmental conditions and individual health. Unmet social needs can increase the risk of many conditions treated by obstetrician-gynecologists (ob-gyns), including, but not limited to, preterm birth, unintended pregnancy, infertility, cervical cancer, breast cancer, and maternal mortality. An individual health care professional's biases (whether overt or unconscious) affect delivery of care and may exacerbate and reinforce health disparities through inequitable treatment. Obstetrician-gynecologists and other health care professionals should seek to understand patients' health care decision making not simply as patients' individual-level behavior, but rather as the result of intersecting sociopolitical conditions, structural inequities, and social needs that create and maintain inequalities in health and health care. Recognizing the importance of social and structural determinants of health can help ob-gyns and other health care professionals to better understand patients, effectively communicate about health-related conditions and behavior, and contribute to improved health outcomes, including patients' experience of care and their trust in the health care system.

Contributions of neighborhood physical and social environments to racial and ethnic disparities in birth outcomes in California: A mediation analysis

BACKGROUND

Racially minoritized populations experience higher rates of adverse birth outcomes than White populations in the U.S. We estimated the mediating effect of neighborhood social and physical environments on disparities in adverse birth outcomes in California.

METHOD

We used birthing parent's residential address for California live birth records from 2019 to estimate census block group Area Deprivation Index and census tract level measures of ambient fine particulate matter (PM2.5), drinking water contamination, tree canopy coverage, as a measure of greenspace, potential heat vulnerability, and noise. We performed mediation analysis to assess whether neighborhood factors explain racial/ethnic disparities in preterm birth (PTB) and term-birth low birth weight (TLBW) comparing Black, Latinx, and Asian with White births after controlling for individual-level factors.

RESULTS

Black, Latinx, and Asian parents had PTB rates that were 67%, 36%, and 11% higher, and TLBW rates that were 150%, 38%, and 81% higher than Whites. Neighborhood deprivation contributed 7% (95% CI: 3%, 11%) to the Black-White and 9% (95% CI: 6%, 12%) to the Latinx-White disparity in PTB, and 8% (95% CI: 3%, 12%) of the Black-White and 9% (95% CI: 5%, 15%) of the Latinx-White disparity in TLBW. Drinking water contamination contributed 2% (95% CI: 1%, 4%) to the Latinx-White disparity in PTB. Lack of greenspace accounted for 7% (95% CI: 2%, 10%) of the Latinx-White PTB disparity and 7% (95% CI: 3%, 12%) of the Asian-White PTB disparity. PM2.5 contributed 11% (95% CI: 5%, 18%), drinking water contamination contributed 3% (95% CI: 1%, 7%), and potential heat vulnerability contributed 2% (95% CI: 1%, 3%) to the Latinx-White TLBW disparity. Lack of green space contributed 3% (95% CI: 1%, 6%) to the Asian-White TLBW disparity.

CONCLUSIONS

Our study suggests social environments explain portions of Black/Latinx-White disparities while physical environments explain Latinx/Asian-White disparities in PTB and TLBW.

Neighborhood Disadvantage and Birth Outcomes Among Refugees

OBJECTIVE

To examine the association between neighborhood socioeconomic disadvantage and birth outcomes among refugee women in Denmark, leveraging a natural experiment.

METHODS

This register-based study included 15 118 infants born to women who arrived in Denmark as refugees during 1986 to 1998, when a dispersal policy was in place that quasirandomly assigned newcomers to neighborhoods with varying degrees of socioeconomic disadvantage. Neighborhood disadvantage was measured using a composite index representing neighborhood-level income, education, unemployment, and welfare assistance. These data were linked to individual-level birth register data. Outcomes included low birth weight, preterm birth, and small-for-gestational-age infants. Associations between neighborhood disadvantage at resettlement and birth outcomes up to 20 years after resettlement were examined using multivariable regressions adjusting for characteristics of the women at resettlement.

RESULTS

Each SD of increase in neighborhood disadvantage was associated with an 18% increase in low birth weight risk (0.61 percentage points [pp], 95% confidence interval [CI]: 0.19-1.02), 15% increase in preterm birth risk (0.64 pp, 95% CI: 0.22-1.07), and 7% increase in small-for-gestational-age risk (0.78 pp, 95% CI: 0.01-1.54) 5 years after resettlement. Results did not differ after adjusting for urbanicity and conational density, but associations were attenuated after adjusting for municipality-level fixed effects, suggesting that local government characteristics may partially explain the associations.

CONCLUSIONS

Resettling in a disadvantaged neighborhood is associated with higher risk of adverse birth outcomes among refugee women. This highlights how policy decisions affecting settlement of refugees can have long-term consequences, including on the health of the next generation.

Association of Socioeconomic Variables with Primary Cesarean Section

OBJECTIVES

Socioeconomic characteristics may be associated with cesarean section (CS) rates. We probe the relationship between socioeconomic variables and primary cesarean section (PCS) by studying indicators of socioeconomic status (SES) in a population-based study in New York City.

METHODS

This was a retrospective study of all 80,506 women in New York City who gave birth to a live child during 2018, and who met inclusion and exclusion criteria. Data were drawn from the New York City Department of Health and Mental Hygiene and the US Census. The main outcome measure was performance of PCS as compared with vaginal birth.

RESULTS

Approximately 21% of neonates were delivered by PCS. Multivariate multilevel mixed-effects logistic regression analysis showed higher odds for PCS for women with an upper-middle class median household income of US$108,500 to $380,499 (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.07-1.76, P = 0.001), and the percentage enrolled in the Supplemental Nutrition Assistance Program (OR 1.01, 95% CI 1.001-1.012, P = 0.02). Lower odds for PCS occurred for all middle-class categories of per capita income: US$32,500 to $54,499 (OR 0.91, 95% CI 0.84-0.99, P = 0.02), US$54,500 to $108,499 (OR 0.76, 95% CI 0.66-0.88, P < 0.001), and US$108,500 to $380,499 (OR 0.80, 95% CI 0.66-0.96, P = 0.02). No significant association occurred for women receiving public assistance.

CONCLUSIONS

Patient preferences in favor or against CS may be related to SES. There may be conflicts between obstetric care that is maximally beneficial and a patient's desire for delivery mode. Clinicians should be aware of the potential implications of this dilemma.

Association Between Household Food Insecurity and Low Birth Weight: A Population-Based Case-Control Study

BACKGROUND

Low birth weight (LBW) is a major public health issue associated with increased neonatal morbidity and mortality. This study aimed to examine the association between household food insecurity and LBW in Mashhad, Iran. Study Design: A population-based case-control study.

METHODS

This study involved 6294 mothers (3247 cases and 3247 controls) who visited healthcare centers affiliated with Mashhad University of Medical Sciences for term births between March 2019 and March 2022. Cases included women who delivered neonates weighing<2500 g, while controls delivered babies≥2500 g. Food security was measured using the validated Household Food Insecurity Access Scale. Logistic regression models examined the associations between food insecurity and LBW. Geographic information system techniques mapped LBW distribution in Mashhad.

RESULTS

Household food insecurity was significantly associated with higher odds of LBW (adjusted odds ratio [AOR]=1.25, 95% confidence interval [CI]: 1.03, 1.53). Other risk factors included younger maternal age (AOR=1.03, 95% CI: 1.01, 1.04), lower maternal education (AOR=0.55, 95% CI: 0.43, 0.71), cesarean delivery (AOR=1.70, 95% CI: 1.40, 2.06), and exposure to secondhand smoke (AOR=1.68, 95% CI: 1.02, 2.75). Gestational diabetes demonstrated a protective effect (AOR=0.37, 95% CI: 0.15, 0.91). Geographic mapping revealed that regions with higher food insecurity had elevated LBW prevalence.

CONCLUSION

These findings underscore the importance of addressing food insecurity among pregnant women to reduce the risk of LBW and improve newborn outcomes.

Factors associated with preventable infant mortality in 2020: a Brazilian population-based study

OBJECTIVES

to identify factors associated with preventable infant deaths, classified as neonatal and post-neonatal.

METHODS

this is an epidemiological and population-based study relating to 2020. Data from the Mortality Information System (MIS) and the preventability classification proposed in the Brazilian Health System List of Causes of Deaths Preventable by Interventions were used.

RESULTS

prematurity, living in the North and Northeast regions and the occurrence of the event at home were associated with preventable neonatal deaths. To the avoidable post-neonatal component, death outside the hospital, low maternal education and children of brown or yellow color/race were associated.

CONCLUSIONS

the main risk factor associated with preventable deaths was prematurity, in the case of neonatal death. Low maternal education and occurrence outside the hospital were associated with post-neonatal deaths.

Risk factors of children's low birth weight and infant mortality in Bangladesh: Evidence from binary logistic regression and Cox PH models

Background

Low birth weight is recognized as a pivotal risk factor affecting child survival and growth. Although Bangladesh has made commendable progress in public health, an infant mortality rate of 38 per 1000 live births and a 16% prevalence of low birth weight remain significant concerns compared to other developing countries. This situation poses a significant challenge for the formulation of future health policies in Bangladesh. As a result, this study aims to identify potential risk factors contributing to low birth weight and infant mortality among children in Bangladesh.

Methods

The data is extracted from the 2014 Bangladesh Demographic and Health Survey. The response variables are infant mortality and low birth weight. In the bivariate analysis, Log-rank tests and Chi-square tests of independence were conducted. Cox proportional hazards and binary logistic regression models were utilized to determine the impact of risk factors on infant mortality and low birth weight.

Results

This study identified several significant factors associated with children's low birth weight, including wealth index, parental education, birth order, twin births, mother's body mass index, and child sex. Additionally, wealth index, parental education, twin status, media exposure, birth order, antenatal care visits, prenatal care assistance, and low birth weight were identified as potential risk factors for infant mortality in Bangladesh.

Conclusion

This study revealed that maternal and child characteristics, along with knowledge about child health care during pregnancy, can potentially reduce the risk of low birth weight and infant mortality among children in Bangladesh. To improve child health and survival, policymakers should prioritize community-based health education programs, and encourage parents to seek healthcare information from institutional medical facilities during pregnancy and after birth.

An Application of Social Vulnerability Index to Infant Mortality Rates in Ohio Using Geospatial Analysis- A Cross-Sectional Study

BACKGROUND

Ohio ranks 43rd in the nation in infant mortality rates (IMR); with IMR among non-Hispanic black infants is three times higher than white infants.

OBJECTIVE

To identify the social factors determining the vulnerability of Ohio counties to IMR and visualize the spatial association between relative social vulnerability and IMR at county and census tract levels.

METHODS

The social vulnerability index (SVICDC) is a measure of the relative social vulnerability of a geographic unit. Five out of 15 social variables in the SVICDC were utilized to create a customized index for IMR (SVIIMR) in Ohio. The bivariate descriptive maps and spatial lag model were applied to visualize the quantitative relationship between SVIIMR and IMR, accounting for the spatial autocorrelation in the data.

RESULTS

Southeastern counties in Ohio displayed highest IMRs and highest overall SVIIMR; specifically, highest vulnerability to poverty, no high school diploma, and mobile housing. In contrast, extreme northwestern counties exhibited high IMRs but lower overall SVIIMR. Spatial regression showed five clusters where vulnerability to low per capita income in one county significantly impacted IMR (p = 0.001) in the neighboring counties within each cluster. At the census tract-level within Lucas county, the Toledo city area (compared to the remaining county) had higher overlap between high IMR and SVIIMR.

CONCLUSION

The application of SVI using geospatial techniques could identify priority areas, where social factors are increasing the vulnerability to infant mortality rates, for potential interventions that could reduce disparities through strategic and equitable policies.

Supporting the Development of Grassroots Maternal and Childhood Health Leaders through a Public-Health-Informed Training Program

The purpose of this research was to assess leadership growth (i.e., changes in personal capacity and social capital) among women living in high-risk infant mortality zip codes who completed a grassroots maternal and childhood health leadership (GMCHL) training program. We used semi-structured qualitative interviews and thematic analysis. Three major themes associated with the training program experience were identified: (1) building personal capacity and becoming community brokers; (2) linking and leveraging through formal organizations; and (3) how individual change becomes community change. Although many of the grassroots leaders were already brokers (i.e., connecting individuals to information/services), they were able to become community brokers by gaining new skills and knowledge about strategies to reduce adverse birth outcomes in their community. In particular, joining and participation in formal organizations aimed at improving community health led to the development of linking or vertical ties (e.g., "people in high places"). The grassroots leaders gained access to people in power, such as policymakers, which enabled leaders to access more resources and opportunities for themselves and their social networks. We outline the building blocks for supporting potential grassroots leaders by enhancing personal capacity and social capital, thus leading to increases in collective efficacy and collective action.

Frameworks for measuring population health: A scoping review

INTRODUCTION

Many regions in the world are using the population health approach and require a means to measure the health of their population of interest. Population health frameworks provide a theoretical grounding for conceptualization of population health and therefore a logical basis for selection of indicators. The aim of this scoping review was to provide an overview and summary of the characteristics of existing population health frameworks that have been used to conceptualize the measurement of population health.

METHODS

We used the Population, Concept and Context (PCC) framework to define eligibility criteria of frameworks. We were interested in frameworks applicable for general populations, that contained components of measurement of health with or without its antecedents and applied at the population level or used a population health approach. Eligible reports of eligible frameworks should include at least domains and subdomains, purpose, or indicators. We searched 5 databases (Pubmed, EMBASE, Web of Science, NYAM Grey Literature Report, and OpenGrey), governmental and organizational sites on Google and websites of selected organizations using keywords from the PCC framework. Characteristics of the frameworks were summarized descriptively and narratively.

RESULTS

Fifty-seven frameworks were included. The majority originated from the US (46%), Europe (23%) and Canada (19%). Apart from 1 framework developed for rural populations and 2 for indigenous populations, the rest were for general urban populations. The numbers of domains, subdomains and indicators were highly variable. Health status and social determinants of health were the most common domains across all frameworks. Different frameworks had different priorities and therefore focus on different domains.

CONCLUSION

Key domains common across frameworks other than health status were social determinants of health, health behaviours and healthcare system performance. The results in this review serve as a useful resource for governments and healthcare organizations for informing their population health measurement efforts.

Race and Ethnicity, Deprivation, and Infant Mortality in England, 2019-2022

Importance

England has one of the highest infant mortality rates in Europe. Much of the variation in infant mortality rates between races and ethnicities may be due to socioeconomic factors, but how deprivation and race and ethnicity are associated with infant mortality is unclear.

Objectives

To investigate the association of infant race and ethnicity with the infant mortality rate in England, adjusted for preterm birth and level of deprivation.

Design, Setting, and Participants

This cohort study included children who died younger than 1 year of age, born at or after 22 weeks' gestation, occurring from April 1, 2019, to March 31, 2022, in England. Characteristics of the infant were derived from death notifications.

Exposures

The racial and ethnic groups were derived from National Health Service data and were reported by the parents and characterized using the Office of National Statistics classification: Asian or Asian British (Bangladeshi, Chinese, Indian, Pakistani, or any other Asian background), Black or Black British (African, Caribbean, or any other Black background), multiracial (White and Asian, White and Black African, White and Black Caribbean, or any other multiracial background), White or White British (British, Irish, any other White background, or Gypsy or Irish Traveler), and other (Arab or any other racial or ethnic group).

Main Outcomes and Measures

Risk of death for all racial and ethnic groups and relative risk of death compared with the reference group (White) were calcuated. Analyses were repeated, adjusting for deprivation, gestational age of infants, and region of England.

Results

A total of 5621 infants who died younger than 1 year of age were reported to the National Child Mortality Database. A total of 2842 of 5130 infants (55.4%) were male; the median gestational age was 33 weeks (IQR, 25-38 weeks); of 5149 infants, 927 (18.0%) were Asian, 448 (8.7%) were Black, 3318 (64.4%) were White, 343 (6.7%) were multiracial, and 113 (2.2%) were from other racial and ethnic groups; and the median deprivation score was 4 (IQR, 3-5). In the unadjusted analysis, the relative risk of death compared with White infants was higher for Black (1.93 [95% CI, 1.75-2.13]) and Asian (1.67 [95% CI, 1.55-1.80]) infants. The population attributable risk fraction for all mortality rates among infants who were not White was 12.0% (95% CI, 10.3%-13.8%) (unadjusted), 9.8% (95% CI, 8.0%-11.7%) (adjusted for deprivation), 7.7% (95% CI, 5.9%-9.5%) (adjusted for gestational age at birth), and 12.8% (95% CI, 11.0%-14.5%) (adjusted for region of England).

Conclusions and Relevance

This cohort study suggests that the proportion of infants who died before 1 year of age is associated with race and ethnicity, with a population attributable risk fraction of 12.0%. An overconservative adjustment for deprivation did not explain the overall patterns seen. Approximately half the population attributable risk fraction may be due to increased risk of preterm birth in Asian and Black communities. Work is needed to identify what can be done to reduce this incidence of infant mortality.

A cohort study of maternal near-miss events and its adverse perinatal outcomes: an obstetrical finding in Northwest Ethiopia

BACKGROUND

Globally, various studies have reported that most adverse perinatal outcomes were associated with maternal near-misses. In Ethiopia, studies on adverse perinatal outcomes from maternal near-miss are scarce.

OBJECTIVE

This study aimed to assess the incidence, determinants, and maternal near-miss effects on perinatal outcomes among women at public hospitals in the South Gondar zone in 2021.

STUDY DESIGN

A facility-based prospective cohort study was conducted from January 10, 2021, to May 10, 2021. The chi-square test, multivariable logistic regression methods, and SPSS software were used. The strength of associations and significance level were examined using P values and odds ratios with 95% confidence intervals, respectively. In addition, multicollinearity and model fitness were checked.

RESULTS

A total of 304 respondents (76 exposed and 228 unexposed) were included in the study with a response rate of 100.0%. The incidence rates of adverse perinatal outcomes among exposed and unexposed groups were 71.1% (95% confidence interval, 60.0-73.8) and 21.1% (95% confidence interval, 15.8-28.8), respectively. Multivariable logistic regression showed that short interbirth interval (adjusted odds ratio, 8.39; 95% confidence interval, 5.36-16.08), lower household income (adjusted odds ratio, 3.61; 95% confidence interval, 1.12-6.54), rural residence (adjusted odds ratio, 2.54; 95% confidence interval, 1.21-4.07), previous stillbirth (adjusted odds ratio, 4.24; 95% confidence interval, 1.04-17.31), absence of antenatal care (adjusted odds ratio, 9.84; 95% confidence interval, 4.89-17.51), and anemia (adjusted odds ratio, 4.19; 95% confidence interval, 1.01-17.46) were significantly associated with increased odds of adverse perinatal outcomes.

CONCLUSION

This study revealed that the incidence of adverse perinatal outcomes was significantly higher among exposed groups than unexposed groups. The result signified the need for improving the health of mothers by all stakeholders to improve perinatal outcomes.

The social determinants of mental health and disorder: evidence, prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

Overadjustment bias in systematic reviews and meta-analyses of socio-economic inequalities in health: a meta-research scoping review

BACKGROUND

Overadjustment bias occurs when researchers adjust for an explanatory variable on the causal pathway from exposure to outcome, which leads to biased estimates of the causal effect of the exposure. This meta-research review aimed to examine how previous systematic reviews and meta-analyses of socio-economic inequalities in health have managed overadjustment bias.

METHODS

We searched Medline and Embase until 16 April 2021 for systematic reviews and meta-analyses of observational studies on associations between individual-level socio-economic position and health outcomes in any population. A set of criteria were developed to examine methodological approaches to overadjustment bias adopted by included reviews (rated Yes/No/Somewhat/Unclear).

RESULTS

Eighty-four reviews were eligible (47 systematic reviews, 37 meta-analyses). Regarding approaches to overadjustment, whereas 73% of the 84 reviews were rated as Yes for clearly defining exposures and outcomes, all other approaches were rated as Yes for <55% of reviews; for instance, 5% clearly defined confounders and mediators, 2% constructed causal diagrams and 35% reported adjusted variables for included studies. Whereas only 2% included overadjustment in risk of bias assessment, 54% included confounding. Of the 37 meta-analyses, 16% conducted sensitivity analyses related to overadjustment.

CONCLUSIONS

Our findings suggest that overadjustment bias has received insufficient consideration in systematic reviews and meta-analyses of socio-economic inequalities in health. This is a critical issue given that overadjustment bias is likely to result in biased estimates of health inequalities and accurate estimates are needed to inform public health interventions. There is a need to highlight overadjustment bias in review guidelines.

Renal deficit and associated factors in children born with low birth weight

INTRODUCTION

Kidney problems may be due to low birth weight alone or may occur in association with other conditions. The objective this study was to evaluate the association between maternal and birth characteristics, anthropometric measurements, and kidney function deficit in low birth weight infants.

METHODS

Cross-sectional study with children who were born weighing < 2500 grams and were under outpatient follow-up. Maternal factors investigated were prenatal care and presence of hypertension, diabetes, and infection during pregnancy. The children's variables were sex, gestational age, birth weight, Apgar score, use of nephrotoxic medications, age, body weight at the time of evaluation, height, and serum creatinine and cystatin C dosages. The glomerular filtration rate (GFR) was estimated with the combined Zapittelli equation. Multivariate logistic regression model was used for identification of associated factors, with renal function deficit (GFR < 60 mL/min/1.73 m2) as the dependent variable.

RESULTS

Of the 154 children evaluated, 34.42% had kidney function deficit. Most of them had a gestational age > 32 weeks (56.6%), a mean birth weight of 1439.7 grams, and mean estimated GFR of 46.9 ± 9.3 mL/min/1.73 m2. There was a significant association of GFR < 60 mL/min/1.73 m2 with children's current weight and use of nephrotoxic drugs.

DISCUSSION

Children born with low birth weight had a high prevalence of kidney function deficit and current normal weight was a protective factor while the use of nephrotoxic drugs during perinatal period increased the chance of kidney deficit. These findings reinforce the need to evaluate the kidney function in these children, especially those who use nephrotoxic drugs.

Understanding the social determinants of child mortality in Latin America over the last two decades: a machine learning approach

The reduction of child mortality rates remains a significant global public health challenge, particularly in regions with high levels of inequality such as Latin America. We used machine learning (ML) algorithms to explore the relationship between social determinants and child under-5 mortality rates (U5MR) in Brazil, Ecuador, and Mexico over two decades. We created a municipal-level cohort from 2000 to 2019 and trained a random forest model (RF) to estimate the relative importance of social determinants in predicting U5MR. We conducted a sensitivity analysis training two more ML models and presenting the mean square error, root mean square error, and median absolute deviation. Our findings indicate that poverty, illiteracy, and the Gini index were the most important variables for predicting U5MR according to the RF. Furthermore, non-linear relationships were found mainly for Gini index and U5MR. Our study suggests that long-term public policies to reduce U5MR in Latin America should focus on reducing poverty, illiteracy, and socioeconomic inequalities. This research provides important insights into the relationships between social determinants and child mortality rates in Latin America. The use of ML algorithms, combined with large longitudinal data, allowed us to evaluate the effects of social determinants on health more carefully than traditional models.

Socio-economic differences among low-birthweight infants in Hungary. Results of the Cohort '18 -Growing Up in Hungary birth cohort study

BACKGROUND

As Hungary had the fifth-highest rate of low-birthweight (LBW) in the EU27 in 2020, LBW still remains a public health problem for the country.

OBJECTIVE

Our goal is to examine whether LBW in Hungary is determined by the mothers' educational attainment, adjusted for other maternal characteristics (SES, health behaviour and psychological status during pregnancy) among mothers who gave birth in 2018-2019 in Hungary.

METHODS

Source of data is the first and second wave of the Cohort '18 -Growing Up in Hungary longitudinal birth cohort study (n = 8185). It is based on a nationwide representative sample of pregnant women who gave birth between March 2018 and April 2019. All data were self-reported by mothers. We examined the association between maternal educational attainment and the risk of giving birth to an LBW-child (<2500g) by using logistic regression analysis. The highest educational attainment of the mother is measured by a five-value categorical variable (ISCED 97: 0-1; 2; 3C; 3-4; 5-6).

RESULTS

5.9% of women had LBW children. This rate is 18.0% among the lowest educated women with ISCED 97: 0-1; and it is 3.6% among the highest educated women with ISCED 97: 5-6. The adjusted predicted probabilities of LBW for these two groups of women are 13.5%, and 3.4% respectively, adjusted for household income quantiles, Roma ethnic background, residence place, smoking, alcohol consumption, and depression during pregnancy; controlled for mother's height, age at birth, parity and child's sex. Compared to women with the lowest level of education, the risk of giving birth to an LBW child decreases by 34.6% for those with the second level of education, by 60.1% for those with the third level of education, by 72.5% for those with the fourth level of education and by 77.2% for those with the highest level of education. Smoking during pregnancy significantly increases the risk of giving birth to an LBW by 54.9%. Being depressed at 7th month of pregnancy decreased the risk of giving birth to an LBW child in our sample by 13.2%, however the relationship is not significant.

CONCLUSION

Our analysis confirmed that maternal educational attainment has a significant impact on the risk of LBW net of by other maternal SES and health behaviour factors. Nevertheless, even after adjusting for these covariates, inequality in LBW by maternal educational attainment persists.

An evolutionary perspective on social inequality and health disparities: Insights from the producer-scrounger game

There is growing concern with social disparities in health, whether relating to gender, ethnicity, caste, socio-economic position or other axes of inequality. Despite addressing inequality, evolutionary biologists have had surprisingly little to say on why human societies are prone to demonstrating exploitation. This article builds on a recent book, 'The Metabolic Ghetto', describing an overarching evolutionary framework for studying all forms of social inequality involving exploitation. The dynamic 'producer-scrounger' game, developed to model social foraging, assumes that some members of a social group produce food, and that others scrounge from them. An evolutionary stable strategy emerges when neither producers nor scroungers can increase their Darwinian fitness by changing strategy. This approach puts food systems central to all forms of human inequality, and provides a valuable lens through which to consider different forms of gender inequality, socio-economic inequality and racial/caste discrimination. Individuals that routinely adopt producer or scrounger tactics may develop divergent phenotypes. This approach can be linked with life history theory to understand how social dynamics drive health disparities. The framework differs from previous evolutionary perspectives on inequality, by focussing on the exploitation of foraging effort rather than inequality in ecological resources themselves. Health inequalities emerge where scroungers acquire different forms of power over producers, driving increasing exploitation. In racialized societies, symbolic categorization is used to systematically assign some individuals to low-rank producer roles, embedding exploitation in society. Efforts to reduce health inequalities must address the whole of society, altering producer-scrounger dynamics rather than simply targeting resources at exploited groups.

Impact of cash transfer programs on birth and child growth outcomes: systematic review

To investigate the impact of cash transfer (CTs) on birth outcomes, including birth weight, low birth weight and prematurity, as well as child physical growth were included, as assessed by anthropometric indices in children under five years of age. Searching was performed using the PubMed/Medline, Embase, LILACS, Cochrane Library, Scopus and Web of Science databases. Quantitative observational, experimental and quasi-experimental. Eleven studies were included in the review. The majority (81.8%) were carried out in low-and middle-income countries and most involved conditional CTs (63.6%). Four were clinical trials and seven were observational studies. Conditional CTs were found to be associated with a reduction in height-for-age (-0.14; 95%CI -0.27, -0.02); (OR 0.85; 95%CI 0.77-0.94); (OR = 0.44; 95%CI 0.19-0.98), a significantly reduced chance of low weight-for-age (OR = 0.16; 95%CI -0.11-0.43), low weight-for-height (OR = -0.68; 95%CI -1.14, -0.21), and low weight-for-age (OR = 0.27; 95%CI 0.10; 0.71). Unconditional CTs were associated with reduced birth weight (RR = 0.71; 95%CI 0.63-0.81; p < 0.0001) and preterm births (RR = 0.76; 95%CI 0.69-0.84; p < 0.0001). Conditional CTs can positively influence birth outcomes and child growth.

Modeling the Likelihood of Low Birth Weight: Findings from a Chicago-Area Health System

OBJECTIVE

This study presents a statistical model of the incidence of low birth weight (LBW) births in a large, Chicago-area hospital system. The study was undertaken to provide a strategic framework for future health system interventions.

METHODS

Administrative and electronic health records were matched to census Zip Code Tabulation Area (ZCTA) household poverty data for 42,681 births in 2016-2019 at seven system hospitals, serving a diverse patient population. A logistic regression model of LBW incidence was estimated to test the independent significance of maternal sociodemographic characteristics after controlling for clinical risk factors.

RESULTS

The incidence of LBW was 6.3% overall but 11.3% among non-Hispanic Black patients as compared to 5.1% among non-Hispanic White patients. LBW incidence ranged from 9.2% for patients from the poorest ZCTA (20% + poor households) compared to 5.6% of patients from the most affluent (< 5% poor) ZCTA. Nulliparous patients, patients with pre-existing chronic conditions, and patients with hypertensive disorders of pregnancy were significantly more likely to have LBW births. After controlling for clinical risk factors and poverty level, non-Hispanic Black patients were still over 80% more likely and to have a LBW birth.

DISCUSSION

Study findings reveal the joint effects of social and clinical risk factors. Findings profile our highest-risk populations for targeted interventions. Promising prenatal care redesign programs include pregnancy patient navigators, home and group visits, eHealth telemonitoring, improved mental health screening, and diversification of the maternity care workforce. Decreasing LBW births should be a national public health policy priority and will require major investments in the most impacted communities.

Inadequate dietary diversity during pregnancy increases the risk of maternal anemia and low birth weight in Africa: A systematic review and meta-analysis

Inadequately diversified food consumption during pregnancy can lead to micronutrient deficiencies, which can affect maternal and newborn health outcomes. Previous studies on maternal dietary diversity have either been limited to a specific geographical region or consist entirely of systematic reviews, without meta-analyses. Thus, this study aimed to determine the pooled estimate of the association between inadequate dietary diversity during pregnancy, maternal anemia, and low birth weight in Africa. A systematic review of observational studies published between January 2000 and April 2022 was undertaken using the Google Scholar, PubMed, and CINAHL databases. The PRISMA checklist was followed to present the results. Microsoft Excel was used to abstract the data. STATA version 17 was used to analyze the data, and a random-effects meta-analysis model was applied to compute the pooled estimates. The study was registered in PROSPERO with protocol number CRD42022320873. A total of 22 publications with 9,696 participants were included in the final meta-analysis. The pooled adjusted odds ratio (AOR) for inadequate dietary diversity and maternal anemia was 2.15 (95% CI, 1.66-2.65), while that for low birth weight was 2.04 (95% CI, 1.46-2.63). The highest pooled estimate of maternal anemia was reported in Cameroon (AOR = 9.8, 95% CI: 1.68-17.92), followed by Ethiopia (AOR = 2.6, 95% CI: 1.95-3.25). Similarly, the pooled estimates of low birth weight were highest in Cameroon (AOR = 3.04, 95% CI: 1.19-4.88) and Ethiopia (AOR = 1.8, 95% CI: 1.29-2.39). In Africa, pregnant mothers with inadequate dietary diversity are two times more likely to develop anemia and low birth weight. Social protection policies that prioritize pregnant women, maternal nutrition promotion in the community, and dietary counseling during antenatal care visits, using national food-based dietary guidelines, should be strengthened.

Intergenerational transmission of birth weight: a systematic review and meta-analysis

The objectives of this study were (1) to systematically review the literature on the association between birth weight in children born in the first and second generation and (2) to quantify this association by performing a meta-analysis. A systematic review was carried out in six databases (PubMed, Science Direct, Web of Science, Embase, Scopus, CINAHL and LILACS), in January 2021, for studies that recorded the birth weight of parents and children. A meta-analysis using random effects to obtain a pooled effect of the difference in birth weight and the association of low birth weight (LBW) between generations was performed. Furthermore, univariable meta-regression was conducted to assess heterogeneity. Egger's tests were used to possible publication biases. Of the 9878 identified studies, seventy were read in full and twenty were included in the meta-analysis (ten prospective cohorts and ten retrospective cohorts), fourteen studies for difference in means and eleven studies for the association of LBW between generations (twenty-three estimates). Across all studies, there was no statistically significant mean difference (MD) birth weight between first and second generation (MD 19·26, 95 % CI 28·85, 67·36; P = 0·43). Overall, children of LBW parents were 69 % more likely to have LBW (pooled effect size 1·69, 95 % CI (1·46, 1·95); I2:85·8 %). No source of heterogeneity was identified among the studies and no publication bias. The average birth weight of parents does not influence the average birth weight of children; however, the proportion of LBW among the parents seems to affect the offspring's birth weight.

The Impact of Sociodemographic, Macroeconomic, and Health Status and Resources on Infant Mortality Rates in Oman: Evidence from 1980 to 2022

BACKGROUND

The infant mortality rate (IMR) is an important reflection of the well-being of infants and the overall health of the population. This study aims to examine the macroeconomic (ME), sociodemographic (SD), and health status and resources (HSR) effects on IMR, as well as how they may interact with each other.

METHODS

A retrospective time-series study using yearly data for Oman from 1980 to 2022. Partial Least Squares-Structural Equation Modelling (PLS-SEM) was utilized to develop the exploratory model of the determinants of IMR.

RESULTS

The model indicates that HSR determinants directly, but negatively, affect IMR (β = -0.617, p < 0.001). SD directly and positively affects IMR (β = 0.447, p < 0.001). ME only indirectly affects IMR (β = -0.854, p < 0.001). ME determinants also exert some direct influences on both HSR (β = 0.722, p < 0.001) and SD (β = -0.916, p < 0.001) determinants.

CONCLUSIONS

This study has indicated that IMR is a multi-faceted issue. It also highlighted the interplay of numerous variables and their influence on IMR, particularly the role that social status, the health sector, and the wealth of the country and its population play in reducing IMR. These findings indicate that an integrated policy that addresses socioeconomic and health-related factors and the overall ME environment is necessary for the health and well-being of the children and the population overall in Oman.

Infant Mortality Trends and Determinants in Kazakhstan

Infant mortality rate (IMR) is a crucial indicator of healthcare performance and a reflection of a country's socioeconomic development. We analyzed the trends of IMR in Central Asia (CA) countries and its determinants in Kazakhstan, which is a middle-income country. Linear regression was used for IMR trend analysis in CA countries from 2000 to 2020 and for exploring associations between IMR and socioeconomic factors, health service-related factors, and population health indicators-related factors. A gamma generalized linear model was applied to define associations with various determinants. Our analysis revealed that IMR has decreased in all CA countries, with Kazakhstan having the lowest rate in 2000 and 2020. Our results suggest that socioeconomic indicators, such as total unemployment, Gini index, current health expenditure, gross domestic product (GDP), proportion of people living in poverty, and births by 15-19-year-old mothers, were associated with increased infant mortality rates. Improving socioeconomic conditions, investing in healthcare systems, reducing poverty and income inequality, and improving access to education, are all potential issues for further development. Addressing these factors may be critical for improving maternal and child health outcomes in the region.

Nomogram for predicting the risk of preterm birth in women undergoing in vitro fertilization cycles

BACKGROUND

The aim of this study was to develop a nomogram for predicting the risk of preterm birth in women undergoing in vitro fertilization (IVF) cycles.

METHODS

A retrospective study of 4266 live birth cycles collected from January 2016 to October 2021 at the Center for Reproductive Medicine, First Hospital of Jilin University was performed. The sample size was sufficient based on the minimal ten events per variable (EPV) rule. The primary outcome of this study was preterm birth. The cycles were divided into the preterm birth group (n = 827) and the full-term delivery group (n = 3439). A nomogram was established based on the multivariate logistic regression analysis results. The area under the curve (AUC) was calculated to assess the prediction accuracy of the nomogram model. The calibration curve was used to measure the calibration of the nomogram.

RESULTS

Multivariate logistic regression analyses showed that female obesity or overweight (OR = 1.366, 95% CI: 1.111-1.679; OR = 1.537, 95% CI: 1.030-2.292), antral follicle count (AFC) of more than 24 (OR = 1.378, 95% CI: 1.035-1.836), multiple pregnancies (OR = 6.748, 95% CI: 5.559-8.190), gestational hypertension (OR = 9.662, 95% CI: 6.632-14.078) and gestational diabetes (OR = 4.650, 95% CI: 2.289-9.445) were the independent risk factors for preterm birth in IVF patients. The area under curve (AUC) under the receiver operating characteristic (ROC) curve in the prediction model was 0.781(95%CI: 0.763-0.799). The calibration curve of the nomogram showed that the prediction model had a good calibration.

CONCLUSIONS

We used five risk factors to conduct a nomogram to predict preterm birth rates for patients undergoing IVF cycles. This nomogram can provide a visual assessment of the risk of preterm birth for clinical consultation.

Examining Twitter-Derived Negative Racial Sentiment as Indicators of Cultural Racism: Observational Associations With Preterm Birth and Low Birth Weight Among a Multiracial Sample of Mothers, 2011-2021

BACKGROUND

Large racial and ethnic disparities in adverse birth outcomes persist. Increasing evidence points to the potential role of racism in creating and perpetuating these disparities. Valid measures of area-level racial attitudes and bias remain elusive, but capture an important and underexplored form of racism that may help explain these disparities. Cultural values and attitudes expressed through social media reflect and shape public norms and subsequent behaviors. Few studies have quantified attitudes toward different racial groups using social media with the aim of examining associations with birth outcomes.

OBJECTIVE

We used Twitter data to measure state-level racial sentiments and investigate associations with preterm birth (PTB) and low birth weight (LBW) in a multiracial or ethnic sample of mothers in the United States.

METHODS

A random 1% sample of publicly available tweets from January 1, 2011, to December 31, 2021, was collected using Twitter's Academic Application Programming Interface (N=56,400,097). Analyses were on English-language tweets from the United States that used one or more race-related keywords. We assessed the sentiment of each tweet using support vector machine, a supervised machine learning model. We used 5-fold cross-validation to assess model performance and achieved high accuracy for negative sentiment classification (91%) and a high F1 score (84%). For each year, the state-level racial sentiment was merged with birth data during that year (~3 million births per year). We estimated incidence ratios for LBW and PTB using log binomial regression models, among all mothers, Black mothers, racially minoritized mothers (Asian, Black, or Latina mothers), and White mothers. Models were controlled for individual-level maternal characteristics and state-level demographics.

RESULTS

Mothers living in states in the highest tertile of negative racial sentiment for tweets referencing racial and ethnic minoritized groups had an 8% higher (95% CI 3%-13%) incidence of LBW and 5% higher (95% CI 0%-11%) incidence of PTB compared to mothers living in the lowest tertile. Negative racial sentiment referencing racially minoritized groups was associated with adverse birth outcomes in the total population, among minoritized mothers, and White mothers. Black mothers living in states in the highest tertile of negative Black sentiment had 6% (95% CI 1%-11%) and 7% (95% CI 2%-13%) higher incidence of LBW and PTB, respectively, compared to mothers living in the lowest tertile. Negative Latinx sentiment was associated with a 6% (95% CI 1%-11%) and 3% (95% CI 0%-6%) higher incidence of LBW and PTB among Latina mothers, respectively.

CONCLUSIONS

Twitter-derived negative state-level racial sentiment toward racially minoritized groups was associated with a higher risk of adverse birth outcomes among the total population and racially minoritized groups. Policies and supports establishing an inclusive environment accepting of all races and cultures may decrease the overall risk of adverse birth outcomes and reduce racial birth outcome disparities.

Etiological Factors of Molar Incisor Hypomineralization: A Systematic Review and Meta-Analysis

Molar incisor hypomineralization (MIH) is a defect of the dental enamel that predominantly affects first molars and permanent incisors. Identifying the significant risk factors associated with MIH occurrence is essential for the implementation of prevention strategies. The purpose of this systematic review was to determine the etiological factors associated with MIH. A literature search was carried out from six databases until 2022; it covered pre-, peri-, and postnatal etiological factors. The PECOS strategy, PRISMA criteria, and the Newcastle-Ottawa scale were used, and 40 publications were selected for qualitative analysis as well as 25 for meta-analysis. Our results revealed an association between a history of illness during pregnancy (OR 4.03 (95% CI, 1.33-12.16), p = 0.01) and low weight at birth (OR 1.23 (95% CI, 1.10-1.38), p = 0.0005). Furthermore, general illness in childhood (OR 4.06 (95% CI, 2.03-8.11), p = 0.0001), antibiotic use (OR 1.76 (95% CI, 1.31-2.37), p = 0.0002), and high fever during early childhood (OR 1.48 (95% CI, 1.18-1.84), p = 0.0005) were associated with MIH. In conclusion, the etiology of MIH was found to be multifactorial. Children with health disorders in the first years of life and those whose mothers underwent illnesses during pregnancy might be more susceptible to MIH.

Déficit renal e fatores associados em crianças nascidas com baixo peso

RESUMO Introdução: Problemas renais podem ser devido apenas ao baixo peso ao nascer ou podem ocorrer em associação com outras condições. O objetivo deste estudo foi avaliar a associação entre características maternas e de nascimento, medidas antropométricas e déficit da função renal em bebês de baixo peso ao nascer. Métodos: Estudo transversal com crianças que nasceram com peso < 2500 gramas e estavam sob acompanhamento ambulatorial. Os fatores maternos investigados foram cuidados pré-natal e presença de hipertensão, diabetes e infecção durante a gravidez. As variáveis das crianças foram sexo, idade gestacional, peso ao nascer, índice Apgar, uso de medicamentos nefrotóxicos, idade, peso corporal no momento da avaliação, altura e dosagens séricas de creatinina e cistatina C. A taxa de filtração glomerular (TFG) foi estimada com a equação combinada de Zapittelli. Utilizou-se um modelo de regressão logística multivariada para identificação de fatores associados, com déficit da função renal (TFG < 60 mL/min/1,73 m2) como variável dependente. Resultados: Das 154 crianças avaliadas, 34,42% apresentaram déficit da função renal. A maioria tinha idade gestacional > 32 semanas (56,6%), peso médio ao nascer de 1439,7 gramas, e TFG média estimada de 46,9 ± 9,3 mL/min/1,73 m2. Houve uma associação significativa da TFG < 60 mL/min/1,73 m2 com o peso atual das crianças e o uso de medicamentos nefrotóxicos. Discussão: Crianças nascidas com baixo peso apresentaram alta prevalência de déficit da função renal e o peso atual normal foi um fator de proteção, enquanto o uso de medicamentos nefrotóxicos durante o período perinatal aumentou a chance de déficit renal. Estes achados reforçam a necessidade de avaliar a função renal destas crianças, especialmente aquelas que usam medicamentos nefrotóxicos.

Association of State-Level Tax Policy and Infant Mortality in the United States, 1996-2019

Importance

Infant mortality in the United States is highest among peer nations; it is also inequitable, with the highest rates among Black infants. The association between tax policy and infant mortality is not well understood.

Objective

To examine the association between state-level tax policy and state-level infant mortality in the US.

Design, Setting, and Participants

This state-level, population-based cross-sectional study investigated the association between tax policy and infant mortality in the US from 1996 through 2019. All US infant births and deaths were included, with data obtained from the National Center for Health Statistics. Data were analyzed from November 28, 2021, to July 9, 2022.

Exposures

State-level tax policy was operationalized as tax revenue per capita and tax progressivity. The Suits index was used to measure tax progressivity, with higher progressivity indicating increased tax rates for wealthier individuals.

Main Outcomes and Measures

The association between tax policy and infant mortality rates was analyzed using a multivariable, negative binomial, generalized estimating equations model. Since 6 years of tax progressivity data were available (1995, 2002, 2009, 2012, 2014, and 2018), 300 state-years were included. Adjusted incidence rate ratios (aIRRs) were calculated controlling for year, state-level demographic variables, federal transfer revenue, and other revenue. Secondary analyses were conducted for racial and ethnic subgroups.

Results

There were 148 336 infant deaths in the US from 1996 through 2019, including 27 861 Hispanic infants, 1882 non-Hispanic American Indian or Alaska Native infants, 5792 non-Hispanic Asian or Pacific Islander infants, 41 560 non-Hispanic Black infants, and 68 666 non-Hispanic White infants. The overall infant mortality rate was 6.29 deaths per 1000 live births. Each $1000 increase in tax revenue per capita was associated with a 2.6% decrease in the infant mortality rate (aIRR, 0.97; 95% CI, 0.95-0.99). An increase of 0.10 in the Suits index (ie, increased tax progressivity) was associated with a 4.6% decrease in the infant mortality rate (aIRR, 0.95; 95% CI, 0.91-0.99). Increased tax progressivity was associated with decreased non-Hispanic White infant mortality (aIRR, 0.95; 95% CI, 0.91-0.99), and increased tax revenue was associated with increased non-Hispanic Black infant mortality (aIRR, 1.04; 95% CI, 1.01-1.08).

Conclusions and Relevance

In this cross-sectional study, an increase in tax revenue and the Suits index of tax progressivity were both associated with decreased infant mortality. These associations varied by race and ethnicity. Tax policy is an important, modifiable social determinant of health that may influence state-level infant mortality.

Differences in birth weight between immigrants' and natives' children in Europe and Australia: a LifeCycle comparative observational cohort study

OBJECTIVE

Research on adults has identified an immigrant health advantage, known as the 'immigrant health paradox', by which migrants exhibit better health outcomes than natives. Is this health advantage transferred from parents to children in the form of higher birth weight relative to children of natives?

SETTING

Western Europe and Australia.

PARTICIPANTS

We use data from nine birth cohorts participating in the LifeCycle Project, including five studies with large samples of immigrants' children: Etude Longitudinale Française depuis l'Enfance-France (N=12 494), the Raine Study-Australia (N=2283), Born in Bradford-UK (N=4132), Amsterdam Born Children and their Development study-Netherlands (N=4030) and the Generation R study-Netherlands (N=4877). We include male and female babies born to immigrant and native parents.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome is birth weight measured in grams. Different specifications were tested: birth weight as a continuous variable including all births (DV1), the same variable but excluding babies born with over 4500 g (DV2), low birth weight as a 0-1 binary variable (1=birth weight below 2500 g) (DV3). Results using these three measures were similar, only results using DV1 are presented. Parental migration status is measured in four categories: both parents natives, both born abroad, only mother born abroad and only father born abroad.

RESULTS

Two patterns in children's birth weight by parental migration status emerged: higher birth weight among children of immigrants in France (+12 g, p<0.10) and Australia (+40 g, p<0.10) and lower birth weight among children of immigrants in the UK (-82 g, p<0.05) and the Netherlands (-80 g and -73 g, p<0.001) compared with natives' children. Smoking during pregnancy emerged as a mechanism explaining some of the birth weight gaps between children of immigrants and natives.

CONCLUSION

The immigrant health advantage is not universally transferred to children in the form of higher birth weight in all host countries. Further research should investigate whether this cross-national variation is due to differences in immigrant communities, social and healthcare contexts across host countries.

Promising Perinatal Outcome after Using a Simplified Low-Cost IVF Culture System Specifically Designed for Resource-Poor Countries

Background: Assisted reproductive techniques services are often not accessible to the majority of infertile couples in Low and Middle Income Countries (LMIC) due to high costs. Lowering IVF laboratory costs is a crucial step to make IVF affordable for a larger part of the world population. We developed a simplified culture system (SCS) which has proven to be effective, and the next step is to prove its safety.Methods: Preterm birth (PTB) and low birthweight (LBW) of 176 singletons born after using the SCS, 105 after fresh embryo transfer (fresh ET), and 71 after frozen embryo transfer (frozen ET) were compared with all IVF/ICSI singletons born in Belgium between 2013 and 2018. When comparing our 105 SCS babies born after fresh ET with all Belgian babies born after conventional IVF only, we also adjusted for 7 risk factors known to influence perinatal outcome, namelythe mother’s age, day of transfer, pituitary inhibition protocol, rank of cycles, number of oocytes retrieved, number of embryos transferred, and gender of the baby.Findings: Before adjustment, we found a significantly higher PTB (10.2% vs. 3.8%, OR 2.852, 95% CI [1.042–7.803], p-value 0.0413) and LBW (9.8% vs. 2.9%, OR 3.692, 95% CI [1.163–11.721], p-value 0.0267) in the conventional IVF group versus SCS after fresh ET. After adjusting for seven risk parameters, these differences remained significant (PTB: OR 2.627, 95% CI [1.013–6.816], p-value 0.0471) and LBW: OR 3.267, 95% CI [1.118–9.549], p-value 0.0305). PTB and LBW between both groups was not significantly different for singletons born after frozen ET. Interpretation: Taking into account the small series, PTB and LBW rates in SCS singletons in FRET cycles are very reassuring and significantly lower compared to babies born after conventional IVF in Belgium. Being aware of its effectiveness, our results offer a good perspective for SCS to become an important tool to implement low-cost IVF in LMIC.

Racial differentials in American Indian- White American Postneonatal Mortality in the United States: evidence from cohort linked birth/infant death records

Purpose

Postneonatal mortality (PNM), which differs from infant and perinatal mortality, has been observed in the past 25 years with respect to the health outcomes of children. While infant and perinatal mortality have been well-evaluated regarding racial differentials, there are no substantial data on PNM in this perspective. The purpose of this study was to assess whether or not social determinants of health adversely affect racial/ethnic PNM differentials in the USA.

Design/methodology/approach

A cross-sectional, nonexperimental epidemiologic study design was used to assess race as an exposure function of PNM using Cohort Linked Birth/Infant Death Data (2013). The outcome variable assessed PNM, while the main independent variables were race, social demographic variables (i.e. sex and age) and social determinants of health (i.e. marital status and maternal education). The chi-square statistic was used to assess the independence of variables by race, while the logistic regression model was used to assess the odds of PNM by race and other confounding variables.

Findings

During 2013, there were 4,451 children with PNM experience. The cumulative incidence of PNM was 23.6% (n = 2,795) among white infants, 24.3% (n = 1,298) among Black/African-Americans (AA) and 39.5% (n = 88) were American-Indian infants (AI), while 21.3% (n = 270) were multiracial, χ2 (3) = 35.7, p < 0.001. Racial differentials in PNM were observed. Relative to White infants, PNM was two times as likely among AI, odds ratio (OR) 2.11 (95% confidence interval [CI] 1.61, 2.78). After controlling for the confounding variables, the burden of PNM persisted among AI, although slightly marginalized, adjusted odds ratio (aOR) 1.70, (99% CI 1.10, 2.65).

Originality/value

In a representative sample of US children, there were racial disparities in PNM infants who are AI compared to their white counterparts, illustrating excess mortality. These findings suggest the need to allocate social and health resources in transforming health equity in this direction.

Temporal and geographical variations in survival of children born with congenital anomalies in Europe: A multi-registry cohort study

BACKGROUND

Congenital anomalies are a major cause of perinatal, neonatal and infant mortality.

OBJECTIVES

The aim was to investigate temporal changes and geographical variation in survival of children with major congenital anomalies (CA) in different European areas.

METHODS

In this population-based linkage cohort study, 17 CA registries members of EUROCAT, the European network for the surveillance of CAs, successfully linked data on 115,219 live births with CAs to mortality records. Registries estimated Kaplan-Meier survival at 28 days and 5 years of age and fitted Cox's proportional hazards models comparing mortality at 1 year and 1-9 years of age for children born during 2005-2014 with those born during 1995-2004. The hazard ratios (HR) from each registry were combined centrally using a random-effects model. The 5-year survival conditional on having survived to 28 days of age was calculated.

RESULTS

The overall risk of death by 1 year of age for children born with any major CA in 2005-2014 decreased compared to 1995-2004 (HR 0.68, 95% confidence interval [CI] 0.53, 0.89). Survival at 5 years of age ranged between registries from 97.6% to 87.0%. The lowest survival was observed for the registry of OMNI-Net (Ukraine) (87.0%, 95% CI 86.1, 87.9).

CONCLUSIONS

Survival of children with CAs improved for births in 2005-2014 compared with 1995-2004. The use of CA registry data linked to mortality data enables investigation of survival of children with CAs. Factors such as defining major CAs, proportion of terminations of pregnancy for foetal anomaly, source of mortality data and linkage methods are important to consider in the design of future studies and in the interpretation of the results on survival of children with CAs.

Acceptability of the Kangaroo Mother Care at the University Hospital of Treichville in Côte d’Ivoire

Background

Kangaroo Mother Care (KMC) is a low-tech, highimpact intervention for preterm and low-birth-weight newborns. In 2019, Côte d’Ivoire opened its first KMC unit. We wanted to determine KMC’s acceptability in Côte d’Ivoire after a year.

Methods

This qualitative study used semi-structured interviews in September 2020 at the Teaching Hospital of Treichville’s first KMC unit. Mothers of preterm and low birth weight babies who received KMC were studied. Deductive (TFA-driven) framework analysis was performed. Coded using Nvivo 12.

Results

KMC was acceptable overall. Mothers knew KMC’s goal and benefits, including self-confidence and breastfeeding benefits. Most women reported that the method was easy to implement and were confident in implementing KMC at the unit or in the household, even though some of them found KMC not aligned with their cultural values. Some mothers, especially housewives and self-employed, highlighted the benefits of KMC, but they must have given up.

Conclusions

Our study highlighted the need to increase KMC awareness, advocacy, education, and training for pregnant women and the community to reduce preterm and low birth weight infant mortality and morbidity.

Determinants of preterm birth: proposal for a hierarchical theoretical model

Abstract Preterm birth (PB) is a syndrome resulting from a complex relationship between multiple factors which do not have fully understood relationships and causality. This article discusses a hierarchical theoretical model of PB determinants, considering maternal characteristics such as sociodemographic, psychosocial, nutritional, behavioral and biological aspects, traditionally associated with increased risk of PB. The variables were distributed in six dimensions within three hierarchical levels (distal, intermediate and proximal). In this model, the socioeconomic determinants of the mother, family, household and neighborhood play indirect effects on PB through variables at the intermediate level, which in turn affect biological risk factors at the proximal level that have a direct effect on PB. The study presents a hierarchical theoretical model of the factors involved in the PB determination chain and their interrelationships. Understanding these interrelationships is an important step in trying to break the causal chain that makes some women vulnerable to preterm birth.

Determinants of preterm birth: proposal for a hierarchical theoretical model

Preterm birth (PB) is a syndrome resulting from a complex relationship between multiple factors which do not have fully understood relationships and causality. This article discusses a hierarchical theoretical model of PB determinants, considering maternal characteristics such as sociodemographic, psychosocial, nutritional, behavioral and biological aspects, traditionally associated with increased risk of PB. The variables were distributed in six dimensions within three hierarchical levels (distal, intermediate and proximal). In this model, the socioeconomic determinants of the mother, family, household and neighborhood play indirect effects on PB through variables at the intermediate level, which in turn affect biological risk factors at the proximal level that have a direct effect on PB. The study presents a hierarchical theoretical model of the factors involved in the PB determination chain and their interrelationships. Understanding these interrelationships is an important step in trying to break the causal chain that makes some women vulnerable to preterm birth.

Impact of Point of Care Quality Improvement Training and Coaching on Quality Perceptions of Health Care Workers: Implication for Quality Policy

Background

The quality of infant healthcare service is one of the essential factors in preventing infant mortality. The purpose of the study was to analyze the quality performance in primary healthcare centers (PHC) and hospitals before and after the point of care quality improvement (POCQI) training for Infant Healthcare Services (IHS).

Methods

This is a mixed-method study design with convergence triangulation strategy, conducted at six public PHCs and four hospitals in two districts of West Java Province, Indonesia. One hundred health care workers (HCWs) were involved for quantitative study at baseline and end of intervention. An additional 40 patients participated as informants for qualitative study. Quantitative data analysis was performed by Rasch modeling and independent t-test for all variables, followed by content analysis for qualitative data.

Results

There were significant changes in the variables of POCQI skill (mean diff: 5.14, p=0.001), quality improvement (QI) understanding (mean diff: 1.2; p=0.001), and QI engagement (mean diff: 1.7; p=0.001) in the PHC group. Although there was an increase in process and outcome variables, the changes were not significant. There was a significant change in all variables in the hospital group which were outcome (mean diff: 2.32 (p=0.19); POCQI skill (mean diff: 2.80, p=0.001); process (mean diff: 1.48, p= 0.01); QI understanding (mean diff: 1.01; p=0.01), and QI engagement (mean diff: 1.52; p=0.03). Patient perception in the qualitative study showed that PHCs and Hospitals’ services improved. Moreover, health care workers found they have a better understanding of service quality and created quality changes and improved POCQI steps.

Conclusion

Implementation of POCQI in PHC and hospitals improved the performance of the quality of his, therefore assuring that POCQI is an appropriate approach and tool to be adopted in the policy for strengthening the health system.

Prevalence, predictors of low birth weight and its association with maternal iron status using serum ferritin concentration in rural Eastern Ethiopia: a prospective cohort study

Introduction

Low birth weight (LBW) is one of the major predictors of perinatal survival, infant morbidity, and mortality, as well as the risk of developmental disabilities and illnesses in future lives. The effect of the nutritional status of pregnant women on birth outcomes is becoming a common research agenda, but evidence on the level of low birth weight (LBW) and its association with prenatal iron status in Ethiopia, particularly among rural residents, is limited. Thus, this study aimed to assess the prevalence, predictors of LBW, and its association with maternal iron status using serum ferritin concentration in Haramaya district, eastern Ethiopia, 2021.

Methods

A community-based prospective cohort study design was conducted. Of a total of 427 eligible pregnant women followed until birth, 412 (96.48%) were included in the final analysis. Iron status was determined using serum ferritin (SF) concentration from venous blood collected aseptically from the ante-cubital veins analyzed on a fully automated Cobas e411 (German, Japan Cobas 4000 analyzer series) immunoassay analyzer. Iron deficiency(ID) and iron deficiency anemia (IDA) were classified as having SF less than 15 μg/L and SF less than 15 μg/L and Hb level of < 11.0 g/dl during the first or third trimester or < 10.5 g/dl during the second trimester as well, respectively. Birthweight was measured within 72 h of birth and < 2500 g was considered LBW. Birthweight was measured within 72 h of birth and < 2500 g was considered as LBW. A Poisson regression model with robust variance estimation was used to investigate the factors associated with LBW and the association between maternal iron status and LBW. An adjusted prevalence ratio with a 95% confidence interval was reported to show an association using a p-value < 0.05.

Results

About 20.2% (95% CI: 16%-24%) of neonates were born with LBW. The prevalence of LBW was 5.04 (95% CI = 2.78–9.14) times higher among women who were iron deficient during pregnancy compared to those who were normal. The neonates of women who were iron deficient during pregnancy had lower birth weight (aPR=5.04; 95% CI = 2.78–9.14) than the neonates of women who were normal. Prevalence of LBW was higher among mothers who were undernourished (MUAC < 23cm) (aPR = 1.92; 95% CI= 1.33–2.27), stunted (height <145cm) (aPR=1.54; 95% CI=1.04–2.27) and among female neonates (aPR=3.70; 95% CI= 2.28–6.00). However, women who were supplemented with iron and folic acid (IFAS) during pregnancy had a 45% decreased chance of delivering low birth weight (aPR= 0.55; 95% CI=0.36–0.84).

Conclusion

We found that LBW is of public health significance in this predominantly rural setting. ID during pregnancy is found to have a negative effect on birth weight. IFA supplementation, the maternal under-nutrition, height, and sex of neonates were identified as predictors of low weight at birth. To improve maternal nutritional status, health interventions must address targeted strategies promoting desirable food behavior and nutritional practices. These include; promoting the consumption of diversified and rich iron food to improve the maternal nutritional status. A continued effort is needed in enhancing universal access and compliance with IFA supplementation to improve maternal health. Intervention strategies that are complementary and comprehensive across the vulnerable periods for women during pregnancy and their neonates that are based on a life-cycle approach are suggested.

Associations between socioeconomic status and pregnancy outcomes: a greater magnitude of inequalities in perinatal health in Montreal than in Brussels

Background

Comparing health inequalities between countries helps us to highlight some factors specific to each context that contribute to these inequalities, thus contributing to the identification of courses of action likely to reduce them. This paper compares the associations between socioeconomic status (SES) and 1) low birth weight (LBW) and 2) preterm birth, in Brussels and Montreal (in general population, natives-born mothers, and immigrant mothers).

Methods

A population-based study examining associations between SES and pregnancy outcomes was conducted in each city, using administrative databases from Belgian and Quebec birth records (N = 97,844 and 214,620 births in Brussels and Montreal, respectively). Logistic regression models were developed in order to estimate the relationship between SES (maternal education and income quintile) and pregnancy outcomes, in each region. The analyses were first carried out for all births, then stratified according to the mother’s origin.

Results

For the general population, SES is associated with LBW and preterm birth in both regions, except for income and preterm birth in Brussels. The association is stronger for mothers born in Belgium and Canada than for those born abroad. The main difference between the two regions concerns the magnitude of inequalities in perintal health, which is greater in Montreal than in Brussels among the general population. For native-born mothers, the magnitude of inequalities in perinatal health is also greater for mothers born in Canada than for those born in Belgium, except for the association between income and preterm birth. The socioeconomic gradient in perinatal health is less marked among immigrant mothers than native mothers.

Conclusion

Significant differences in inequalities in perinatal health are observed between Brussels and Montreal. These differences can be explained by : on the one hand, the existence of greater social inequalities in Montreal than in Brussels and, on the other hand, the lower vulnerability of immigrants with low SES in Brussels. Future studies seeking to understand the mechanisms that lead to inequalities in health in different contexts should take into account a comparison of immigration and poverty contexts, as well as the public policies related to these factors.

Incarceration exposure during pregnancy and maternal disability: findings from the Pregnancy Risk Assessment Monitoring System

BACKGROUND

Extant research reveals that currently and formerly incarcerated individuals exhibit higher rates of disability. Moreover, recent research highlights that women exposed to incarceration during pregnancy -either personally or vicariously through a partner- face poorer health. However, prior research has not detailed the connection between incarceration exposure and risk for maternal disability.

METHODS

The aim of this study is to evaluate the association between a women's exposure to incarceration during pregnancy and disability including difficulty with: communication, hearing, remembering, seeing, self-care, or walking. Data are from Pregnancy Risk Assessment Monitoring System (PRAMS), 2019 (N = 12,712). Logistic and negative binomial regression were used to assess the relationship between incarceration exposure and maternal disability.

RESULTS

Among the sample of women who delivered a recent live birth, approximately 3.3% of the sample indicated they were personally or vicariously exposed to incarceration in the 12 months before birth. Compared to those who did not have incarceration exposure, women with incarceration exposure have elevated odds of several disabilities, including difficulty remembering (Adjusted Odds Ratio [AOR] = 1.971; 95% Confidence Interval [CI] = 1.429, 2.718), difficulty seeing (AOR = 1.642, 95% CI = 1.179, 2.288), difficulty walking (AOR = 1.896, 95% CI = 1.413, 2.544), and a greater number of cumulative disabilities (Incidence Risk Ratio [IRR] = 1.483; 95% CI = 1.271, 1.731).

CONCLUSIONS

Women personally or vicariously exposed to incarceration during pregnancy endure greater odds of having a disability. Considering both incarceration and disability are important public health issues with implications for maternal and child well-being, these findings highlight the need for further research that can better understand the connection between incarceration and disability.

The relationship between early-life conditions in the home country and adult outcomes among child immigrants in the United States

We examine the impact of health and economic conditions at birth on the adult outcomes of child immigrants using the Children of Immigrants Longitudinal Study. Our sample consists of children from 39 countries who were brought to the United States before the age of 13. We estimate immigrant outcomes as a function of the infant mortality rate (IMR) and GDP per capita of their home country in the year of birth, controlling for birth-year, year-of-arrival and country-of-birth fixed effects, as well as demographic characteristics. IMR has a significant negative impact on English reading ability and GPA in middle school. IMR significantly decreases first job prestige, years of schooling, working hours and log earnings. Some of these effects appear to be working through the lower middle school GPA. IMR does not influence self-rated health or labor market participation in adulthood, and there is no statistically significant relationship between GDP per capita and adult outcomes. Detrimental effects of IMR are significantly lower for children who arrived younger and whose parents have high school degree or above. Our estimates are of economic significance: the impact of being born in 1975 versus 1976 in Nicaragua in terms of the impact of IMR on earnings is equal to the gender effect on earnings. Our results cannot be explained by selection on observables: the pre-migration characteristics of children and parents are not associated significantly with the health and economic conditions at birth. Also, several tests show that our results cannot be explained by potential selection on unobservables.

Bioethics and COVID-19: Considering the Social Determinants of Health

In this paper, we focus on a novel bioethical approach concerning the ethical implications of the Social Determinants of Health (SDs) in the time of COVID-19, offering a fresh interpretation of our agency and responsibility in the current pandemic era. Our interpretation is grounded on the idea that our health basically depends on factors that go beyond our organism. In this sense, we stress the radical importance of circumstances to ethically assess an action, in the current pandemic context. Moreover, due the centrality of the SDs in our bioethical assessments-that implies that our health does not exclusively depend on our choices, behaviors, and lifestyle-we can affirm that we are not entirely responsible for our wellness or diseases. As health depends on economic, social, cultural, and environmental factors, we argue that the analysis of personal responsibility facing personal health status should receive further consideration. In this sense, following the "social connection model," we stress the importance of the concept of "shared responsibility" in collective decisions: if we make many decisions collectively, we are also collectively responsible of these decisions. Furthermore, to responsibly tackle the social inequalities that are the underlying cause of disparities in health outcomes, we propose two main strategies based on the Capability Approach: 1. empowering the individuals, especially the most vulnerable ones; and 2. designing preventive policies and interventions that provides an opportunity to address the disparities moving forward. This will help us going beyond the "individualistic medical ethics paradigm" and integrating our concept of health with social factors (e.g., the SDs), based on a more relational and interdependent anthropological thought.

Association between maternal smoking and survival among infants with trisomy 21

BACKGROUND

Trisomy 21 (T21) is common, with affected infants having an increased risk of infant mortality (5.9-7.1%). Maternal smoking is associated with infant mortality in the general population, and we evaluated if similar associations were present among infants with T21.

METHODS

We identified infants with T21 from the Texas Birth Defects Registry, and maternal smoking and infant vital status were obtained from linked birth and death certificate data, respectively. Cox proportional hazards regression models were used to calculate hazard ratios between maternal smoking and death between 0 to ≤ 364 days, 28-364 days, and 0-27 days.

RESULTS

We found a significant association between maternal smoking and death between 0 to ≤ 364 (unadjusted HR 1.72, 95% CI 1.07, 2.77), which was no longer statistically significant after adjustment for covariates (adjusted HR 1.55, 95% CI 0.94, 2.56). A similar pattern was observed for death between 28-364 days (adjusted HR: 1.68, 95% CI 0.93, 3.03), whereas the association for 0-27 days (adjusted HR: 1.30, 95% CI 0.51, 3.29) was not statistically significant before and after adjustment.

CONCLUSIONS

The observed magnitudes of associations were similar to previous estimates among the general population. Further work considering the role of other maternal and infant risk factors and social determinants of health is necessary to better understand the observed results.

Background predictors of time to death in infancy: evidence from a survival analysis of the 2018 Nigeria DHS data

Background

Nigeria’s child health profile is quite concerning with an infant mortality rate of 67 deaths per 1000 live births and a significant slowing down in progress towards improving child health outcomes. Nigeria’s 2018 Demographic and Health Survey (DHS) suggests several bio-demographic risk factors for child death, including mother’s poor education, poverty, sex of child, age of mother, and location (rural vs urban) but studies are yet to explore the predictive power of these variables on infant survival in Nigeria.

Methods

The study extracted data for all births in the last 12 months preceding the 2018 Nigeria DHS and used the Cox proportional hazard model to predict infant survival in Nigeria. Failure in this analysis is death with two possible outcomes – dead/alive – while the survival time variable is age at death. We censored infants who were alive at the time of the study on the day of the interview. Covariates in the analysis were: age of mother, education of mother, wealth quintile, sex of child, location, region, place of delivery, and age of pregnancy.

Results

The study found that a higher education of a mother compared to no education (β = .429; p-value < 0.05); belonging to a household in the richer wealth quintile (β = .618; p-value < 0.05) or the highest quintile (β = .553; p-value < 0.05), compared to the lowest wealth quintile; and living in North West (β = 1.418; p-value < 0.05) or South East zone (β = 1.711; p-value < 0.05), significantly predict infant survival.

Conclusion

Addressing Nigeria’s infant survival problem requires interventions that give attention to the key drivers – education, socio-economic status, and socio-cultural contextual issues. We therefore recommend full implementation of the universal basic education policy, and child health education programs targeted at mothers as long- and short-term solutions to the problem of poor child health outcomes in Nigeria. We also argue in favor of better use of evidence in policy and program development in Nigeria.

Social determinants and inequitable maternal and perinatal outcomes in Aotearoa New Zealand

Objectives:

Aotearoa New Zealand has demonstrable maternal and perinatal health inequity. We examined the relationships between adverse outcomes in a total population sample of births and a range of social determinant variables representing barriers to equity.

Methods:

Using the Statistics New Zealand Integrated Data Infrastructure suite of linked administrative data sets, adverse maternal and perinatal outcomes (mortality and severe morbidity) were linked to socio-economic and health variables for 97% of births in New Zealand between 2003 and 2018 (~970,000 births). Variables included housing, economic, health, crime and family circumstances. Logistic regression examined the relationships between adverse outcomes and social determinants, adjusting for demographics (socio-economic deprivation, education, parity, age, rural/urban residence and ethnicity).

Results:

Māori (adjusted odds ratio = 1.21, 95% confidence interval = 1.18–1.23) and Asian women (adjusted odds ratio 1.39, 95% confidence interval = 1.36–1.43) had poorer maternal or perinatal outcomes compared to New Zealand European/European women. High use of emergency department (adjusted odds ratio = 2.68, 95% confidence interval = 2.53–2.84), disability (adjusted odds ratio = 1.98, 95% confidence interval = 1.83–2.14) and lack of engagement with maternity care (adjusted odds ratio = 1.89, 95% confidence interval = 1.84–1.95) had the strongest relationship with poor outcomes.

Conclusion:

Maternal health inequity was strongly associated with a range of socio-economic and health determinants. While some of these factors can be targeted for interventions, the study highlights larger structural and systemic issues that affect maternal and perinatal health.