Study finds large inequalities in pregnancy outcomes between ethnic and socio-economic groups in England

A national study of more than one million births in the English National Health Service (NHS) between 2015 and 2017, published in The Lancet, found great inequalities in pregnancy outcomes between ethnic and socioeconomic groups in England.

The results suggest that current national programs to make pregnancy safer, which focus on risk and behavior in women and their antenatal care, will not be enough to improve outcomes for babies born in England. The authors say that to reduce disparities in birth outcomes nationally, politicians, public health professionals and health care providers must work together to combat racism and discrimination and improve the social situation, social support and women’s health throughout their lives.

“The harsh reality is that across England, women’s socio-economic and ethnic origin is still strongly linked to their likelihood of experiencing serious negative consequences for their babies. I think people will be shocked that these inequalities are still responsible for a substantial proportion of adverse pregnancy outcomes in England, ”says co-lead author Dr Jennifer Jardine of the Royal College of Obstetrics and Gynecologists, UK.

She continues: “Over the past decades, efforts to close the gap in birth outcomes by focusing primarily on improving maternity care and targeting individual behaviors have not been successful. Birth outcomes do not only represent a woman’s health during pregnancy, but also reflect her health. Although we need to continue to encourage healthy behaviors during pregnancy, we also need public health professionals and politicians are stepping up their efforts to address the cumulative and continuing impact of racism and social and economic inequalities on the health of women, families, and communities. “

The NHS has set a goal of halving stillbirth and neonatal mortality rates and reducing preterm birth rates by 25% by 2025. Socio-economic deprivation and minority ethnicity are risk factors known adverse pregnancy outcomes. However, little is known about the strength of these risk factors or the magnitude of their impact at the population level. Additionally, a lack of information on how differences in pregnancy outcomes relate to women’s societal status and pre-existing health conditions may hamper efforts to improve pregnancy outcomes and reduce inequalities. .

To find out more, a team from the National Maternity and Perinatal Audit analyzed birth certificates between April 1, 2015 and March 31, 2017 in NHS hospitals in England to quantify socio-economic and ethnic inequalities in stillbirths ( death of a fetus after 24 weeks of pregnancy), premature birth (live birth before 37 weeks) and restriction of fetal growth (FGR) in England.

The team calculated the proportion of adverse pregnancy outcomes that would not have occurred if all women had the same risk of pregnancy as women in the 20% of less deprived neighborhoods or those of white ethnicity. with and without adjustment for smoking status, body mass index (BMI) and other risk factors for pregnancy. Socioeconomic status was measured for each local area using the multiple deprivation index which combines information on income, employment, education, housing, crime and living environment.

A total of 1,155,981 women with a single birth were included in the study, of which 77% were white, 12% South Asian, 5% black, 2% mixed race / ethnicity and 4% other race / ethnicity. . Overall, 4,505 women experienced a stillbirth (0.4% [ranging from 0.3% in the least socioeconomically deprived group to 0.5% in the most deprived group]). Of the 1,151,476 babies born alive, 69,175 (6% [4.9% to 7.2%]) were premature births and 22,679 (2% [1.2% to 2.2%]) were births with RGF.

The analysis estimates that 24% of stillbirths, 19% of live premature births, and 31% of live births with FGR have been attributed to socio-economic inequalities and would not have occurred if all women had had the same risk of unfavorable outcome of pregnancy than women in less disadvantaged group. Adjusting for ethnicity, maternal smoking, and BMI dramatically reduced these inequalities (to 12%, 12%, and 16%, respectively), suggesting that these characteristics may explain a considerable portion of the socio-economic inequalities in pregnancy outcomes.

Complications of pregnancy disproportionately affected black and ethnic minority women, with 12% of all stillbirths, 1% of premature births, and 17% of births with FGR attributed to ethnic inequality. Importantly, adjusting for socioeconomic deprivation, maternal smoking, and BMI had little impact on these associations, indicating that other factors related to discrimination based on age. ethnicity and culture can contribute to poor pregnancy outcomes.

However, the largest increases in the risk of excessive stillbirth and FGR occurred among the most socioeconomically disadvantaged South Asian and black women (Figure 3). For example, more than half of stillbirths and three-quarters of births with FGR among the poorest South Asian women were attributable to socio-economic and ethnic inequalities and therefore could be preventable.

There are many possible reasons for these disparities. Women from disadvantaged neighborhoods and from black and minority ethnic groups may be disadvantaged due to their environment, for example due to pollution, substandard housing, social isolation, limited access to maternity and health care health, job insecurity, poor working conditions and stressful life events. National goals to make pregnancy safer will only be achieved if there is a concerted effort by midwives, obstetricians, public health professionals and politicians to tackle more socio-economic and ethnic inequalities. wide. “

Professor Jan van der Meulen, co-lead author, London School of Hygiene & Tropical Medicine, United Kingdom

The authors propose three key measures to reduce inequalities in pregnancy outcome. The first measure includes targeting high-risk groups with clinical interventions during pregnancy, such as smoking cessation and nutrition programs, and improved access to high-quality antenatal care (e.g., monitoring fetal growth plus precisely and more frequently, and suggest inducing labor when the risk of stillbirth is increased). They also recommend public health strategies to reduce inequalities in women’s health before pregnancy, focusing on smoking and eating habits as well as broader aspects of maternal adversity, such as problems with pregnancy. mental health, substance abuse and stress related to social disadvantage. Finally, the authors call for more comprehensive policies to address the root causes of inequality, such as income, education and employment, which indirectly influence pregnancy outcomes.

The authors recognize that their results show differences in observation and note certain methodological limitations. They used an area-based measure of socioeconomic deprivation, which may not accurately represent the range of individual socioeconomic status in a particular area. In addition, their results assume that the effects of socioeconomic deprivation and ethnicity are not altered by other circumstances, such as overall health, lifestyle, and nutrition, which may limit the effects of socioeconomic deprivation. conclusions that can be drawn.

Writing in a related commentary, Dr Katherine Grantz of the US National Institutes of Health (who was not involved in the study) said: “So it is crucial to develop population-level solutions to change the rates of adverse births at the national level Given the volume of evidence that racial and socio-economic disparities persist in perinatal and women’s health, upstream approaches that target systemic causes of inequality and discrimination are more likely to help nations meet their population goals than the downstream approaches that have traditionally been used to target individuals. behaviors. “