Abstract
Aim
We evaluated whether stillbirth, neonatal death or severe neonatal morbidity is associated with a mother’s change in residential neighbourhood income between two consecutive births.
Methods
This population-based cohort included all mothers in Ontario, Canada with two consecutive births at 20–42 weeks’ gestation, 2003–2023. The study exposure at the first birth was: (i) livebirth unaffected by severe neonatal morbidity or neonatal death (referent); (ii) livebirth with severe neonatal morbidity but no neonatal death; (iii) livebirth with neonatal death; and (iv) stillbirth. The study outcome was a mother’s change in residential neighbourhood income quintile (Q) between two consecutive births: (i) downward income mobility, (ii) upward income mobility, or (iii) persistently residing in the lowest income Q1 at each birth. -- each relative to iv) no change in neighbourhood income Q between births (referent).
Results
There were 720,119 mothers included. Among those initially residing in income Q2-5, relative to those with an unaffected livebirth, there was a higher likelihood of downward income mobility between births if their child was affected by non-fatal severe neonatal morbidity (aOR 1.05, 95% CI 1.02-1.08). Among mothers initially residing in income Q1, the aOR for remaining in income Q1 was 1.05 (95% CI 1.01-1.08) following a livebirth affected by severe neonatal morbidity, 1.29 (95% CI 1.12-1.48) after a neonatal death, and 1.35 (95% CI 1.24-1.46) after a stillbirth – each compared to mothers with an unaffected birth.
Conclusions
Mothers with a newborn affected by severe morbidity were more likely to have a decline in neighbourhood income Q, or to persist in the lowest-income area. Those experiencing stillbirth or neonatal death were more likely to remain in a lowest-income neighbourhood or have no income mobility.
Supplementary Information
The online version contains supplementary material available at 10.1186/s40748-026-00249-8.
Keywords: Stillbirth, Neonatal morbidity, Neonatal death, Neighbourhood income
Introduction
A birth can create or exacerbate income loss for parents due to child healthcare expenses, [1] workforce absenteeism [2] and the cost of childrearing [3] – together economically termed the ‘child penalty’ [4] – and which can further influence residential affordability. This could be most taxing on women residing in low-income neighbourhoods, with financial instability prior to childbirth [5]. Research indicates that a pregnancy culminating in a stillbirth, neonatal death, or severe neonatal morbidity is associated with maternal postpartum complications, [6] along with profound short- and long-term psychological, social, and economic impacts for both parents [7–9]. Adverse pregnancy events are also more prevalent among those affected by social inequities [7, 10]. Hence, it is plausible that economic challenges may further differ if a woman experiences fetal or neonatal loss, marked by bereavement but no ongoing child-rearing costs thereafter, or has a newborn with transient morbidity followed by a potentially higher economic burden [11] (Fig. 1).
Fig. 1.
Conceptual diagram used in the current study for how stillbirth, neonatal death or severe morbidity occurring at the first birth might be associated with a mother’s subsequent change in residential neighbourhood income quintile between the first and consecutive second births
This study assessed whether a stillbirth, neonatal death or severe neonatal morbidity is associated with a mother’s subsequent change in residential neighbourhood income between two consecutive births.
Methods and data analysis
This population-based cohort study was completed using linked administrative datasets in Ontario, Canada (Table S1), where universal healthcare exists. Included were all mothers with two consecutive births at 20–42 weeks’ gestation, from April 1, 2003, to March 31, 2023 (Table S2). The online Supporting Information contains details of all methods, study variables, and analyses. The STROBE reporting guideline was followed.
The study exposure ─ an adverse perinatal event -- comprised four mutually exclusive groups at the first of two consecutive births in the study period: (i) livebirth unaffected by severe neonatal morbidity or neonatal death (referent); (ii) livebirth with severe neonatal morbidity but no neonatal death; (iii) livebirth with neonatal death; and (iv) stillbirth. Severe neonatal morbidity and neonatal death were assessed from the index birth hospitalization up to 27 days thereafter, with severe morbidity defined using a validated composite measure of serious newborn health issues [12].
The study outcome was a mother’s change in residential neighbourhood income quintile (Q) between two consecutive births, representing four exclusive mobility patterns: (i) downward income mobility, (ii) upward income mobility, or (iii) persistently residing in the lowest income Q1 at each birth -- each relative to (iv) no change in neighbourhood income Q between births (referent). The latter two exposure groups were categorized separately as they likely comprise mothers with different economic circumstances, especially since persistent residence in a lowest income neighbourhood would be indicative of long-term area-level economic instability.
Descriptive statistics (i.e., mean and median values and proportions) were contrasted by the adverse perinatal exposure states at the first birth. Multinomial logistic regression generated odds ratios (aORs) and 95% confidence intervals (CI) for the primary outcome of a mother’s change in neighbourhood income Q between two consecutive births in relation to the study exposure of an adverse perinatal event at the first birth.
Statistical models were adjusted for the following maternal and newborn characteristics: substance use (opioid, cocaine, stimulant, or alcohol use) 1 year before the first birth, number of prebirth comorbidities 1 year before the first birth, maternal age at the first birth, livebirth parity at the first birth, rurality at the first birth, immigrant status, and any newborn congenital or chromosomal anomaly identified within the first birth hospitalization.
Results
Of the 720,119 mothers, whose mean (SD) age was 28.6 (4.8) years at the first recorded birth, 669,232 (92.9%) had a livebirth without severe neonatal morbidity or neonatal death, 44,251 (6.1%) had a livebirth with severe neonatal morbidity but no neonatal death, 1756 (0.24%) had a livebirth with neonatal death, and 4880 (0.68%) had a stillbirth (Table 1).
Table 1.
Maternal and fetal/newborn characteristics by pregnancy outcomes at the first birth among 720,119 women who had two consecutive births in Ontario, Canada, 2003 to 2023. Data are presented as a number (%) unless otherwise indicated
| Characteristic | Livebirth without severe neonatal morbidity or neonatal death (N = 669,232) |
Livebirth with severe neonatal morbidity without neonatal deatha (N = 44,251) |
Livebirth with neonatal deathb (N = 1756) |
Stillbirthc (N = 4880) |
|---|---|---|---|---|
| Maternal, 1 to 365 days before the first birth | ||||
| Number of pre-birth comorbiditiesd | ||||
| 0–2 | 619,320 (92.5) | 39,848 (90.1) | 1528 (87.0) | 4349 (89.1) |
| ≥ 3 | 49,912 (7.5) | 4403 (10.0) | 228 (13.0) | 531 (10.9) |
| Substance use (opioid, cocaine, stimulant or alcohol use)e | 18,352 (2.7) | 2028 (4.6) | 87 (5.0) | 239 (4.9) |
| Maternal, at the first birth | ||||
| Mean (SD), Age, years | 28.6 (4.8) | 28.7 (4.9) | 29.4 (5.4) | 30.0 (5.4) |
| Neighbourhood income quintile, Q | ||||
| Q1 (Lowest) | 141,061 (21.1) | 9252 (20.9) | 450 (25.6) | 1276 (26.2) |
| Q2 | 135,799 (20.3) | 9012 (20.4) | 415 (23.6) | 1000 (20.5) |
| Q3 | 140,757 (21.0) | 9510 (21.5) | 348 (19.8) | 1019 (20.9) |
| Q4 | 141,685 (21.2) | 9461 (21.4) | 321 (18.3) | 925 (19.0) |
| Q5 (Highest) | 109,930 (16.4) | 7016 (15.9) | 222 (12.6) | 660 (13.5) |
| Parity | ||||
| 0–1 | 624,654 (93.3) | 41,969 (94.8) | 1552 (88.4) | 4260 (87.3) |
| ≥ 2 | 44,578 (6.7) | 2282 (5.2) | 204 (11.6) | 620 (12.7) |
| Rural residence | 68,070 (10.2) | 4415 (10.0) | 180 (10.3) | 476 (9.8) |
| Non-refugee immigrant | 159,328 (23.8) | 9558 (21.6) | 454 (25.9) | 1373 (28.1) |
| Fetus or newborn, at the first birth | ||||
| Female sex | 328,950 (49.1) | 18,662 (42.2) | 785 (44.7) | 61 (1.2) |
| Sex missing | 0 (0.0) | 0 (0.0) | 0 (0.0) | 4745 (97.2) |
| Gestational age at birth, mean (SD), weeks | 39.2 (1.4) | 37.3 (3.7) | 29.2 (7.4) | 30.2 (7.1) |
| Preterm livebirth or stillbirth < 37 weeks’ gestation | 27,818 (4.2) | 13,057 (29.5) | 1254 (71.1) | 3441 (70.5) |
| Any congenital or chromosomal anomaly | 17,801 (2.7) | 6306 (14.3) | 544 (31.0) | Not reported |
| Median IQR, number of months between the first & second births, years | 32 (24–47) | 32 (24–46) | 20 (14–32) | 19 (14–30) |
aArising in the index birth admission or within 27 days thereafter
bArising in the index birth admission or within 27 days thereafter
cA fetal death arising in utero, or a newborn with no signs of life at birth, at ≥ 20 weeks’ gestation
dTotal number of Johns Hopkins Adjusted Clinical Group (ACG)® System Aggregated Diagnosis Groups (ADG) (excluding “pregnancy” diagnosis), 1 to 365 days before the first birth hospitalization
eType of substance use, 1 to 365 days before the first birth hospitalization is suppressed due to small cell sizes ≤ 5
Among mothers initially residing in income areas Q2-Q5, relative to those with an unaffected livebirth, there was a higher likelihood of downward income mobility between births if their child was affected by non-fatal severe neonatal morbidity (aOR 1.05, 95% CI 1.02–1.08), with no tendencies for upward income mobility (Table 2). However, significantly lower aORs were observed for experiencing downward or upward income mobility between births if they had a neonatal death or a stillbirth.
Table 2.
Odds of a mother exclusively experiencing downward or upward income mobility between two consecutive births, or otherwise persistently residing in neighbourhood income quintile 1 (Q1) between two successive births, each in relation to having a newborn affected by a stillbirth, neonatal death or severe neonatal morbidity at the first recorded birth. Data are limited to women who had two recorded consecutive Singleton hospital births at 200/7 to 420/7 weeks’ gestation in Ontario, Canada, 2003 to 2023
| Outcome occurring between consecutive births | ||||||
|---|---|---|---|---|---|---|
| Downward income mobility | Upward income mobility | Persistently residing in Q1 | ||||
| Exposure at the first birth |
No. (%) with
outcome |
Adjusted
odds ratio (95% CI) e, f |
No. (%) with
outcome |
Adjusted
odds ratio (95% CI) e, f |
No. (%) with
outcome |
Adjusted
odds ratio (95% CI) e, f |
|
Livebirth without severe neonatal morbidity or neonatal death (N = 669,232) a |
122,443 (18.3) | 1 (Reference) | 168,199 (25.1) | 1 (Reference) | 79,465 (11.9) | 1 (Reference) |
|
Livebirth with severe neonatal morbidity without death (N = 44,251)b |
8343 (18.9) | 1.05 (1.02 to 1.08) | 11,000 (24.9) | 1.01 (0.99 to 1.04) | 5241 (11.8) | 1.05 (1.01 to 1.08) |
|
Livebirth with neonatal death (N = 1756) c |
294 (16.7) | 0.86 (0.75 to 0.99) | 326 (18.6) | 0.71 (0.62 to 0.81) | 301 (17.1) | 1.29 (1.12 to 1.48) |
|
Stillbirth (N = 4880) d |
734 (15.0) | 0.77 (0.71 to 0.84) | 837 (17.2) | 0.64 (0.59 to 0.69) | 893 (18.3) | 1.35 (1.24 to 1.46) |
a299,125 (44.7%) of mothers had no income mobility between two consecutive births, except those shown with persistent Q1
b19,667 (44.4%) of mothers had no income mobility between two consecutive births, except those shown with persistent Q1
c835 (47.6%) of mothers had no income mobility between two consecutive births, except those shown with persistent Q1
d2416 (49.5%) of mothers had no income mobility between two consecutive births, except those shown with persistent Q1
eMultinomial logistic regression, adjusted for substance use within 1 to 365 days before the first birth hospitalization, number of pre-birth comorbidities within 1 to 365 days before the first birth hospitalization (≥ 3 vs. 0–2), age at the first birth hospitalization (15–19, 20–24, 30–34, ≥ 35, vs. 25–29 years), parity (≥ 2 vs. 0–1), residence at the first birth hospitalization (rural vs. urban), immigrant status (non-refugee immigrant vs. non-immigrant), and any newborn congenital or chromosomal anomaly during the first birth hospitalization
fAn adjusted odds ratio < 1 indicates a lower tendency for downward (or upward) income mobility, and an odds ratio > 1 reflects a higher tendency for such movement
Among mothers initially residing in income Q1, the aOR for remaining in income Q1 was 1.05 (95% CI 1.01–1.08) following a livebirth affected by severe neonatal morbidity, 1.29 (95% CI 1.12–1.48) after a neonatal death, and 1.35 (95% CI 1.24–1.46) after a stillbirth – each compared to mothers with an unaffected livebirth (Table 2).
Discussion
Mothers with a newborn affected by severe morbidity were more likely to have a decline in neighbourhood income Q, or to persist in the lowest-income area. Those experiencing a stillbirth or neonatal death were more likely to remain in the same neighbourhood income quintile at a subsequent birth (i.e., having no income mobility across births).
Study limitations include a lack of information on a mother’s individual-level income, profession, race, or details about the non-birthing parent, and other unmeasured confounders included in Fig. 1. Individual income changes may not correspond with neighbourhood income mobility. While the current study accounted for livebirth bias at the first birth, survivorship selection bias was likely introduced by the study design, necessitating having a second birth for cohort entry [13]. Maternal peripartum morbidity was not included as a confounder since it is likely a causal mediator of the relation between the study exposure of an adverse perinatal event at the first birth and the ensuing outcome of a mother’s change in residential neighbourhood income quintile [6, 14].
We propose that the nature of a pregnancy outcome can be a ‘socioeconomic stress test’ for the parent(s). This stress test may be greater if the newborn experiences severe morbidity: it is plausible that the ongoing requirements of parental care for a newborn affected by morbidity can have both physical, mental, and economic ramifications for one or both parents [15, 16]. In contrast, if the fetus or newborn dies, the economic burden on the family may not persist, despite the emotional burden of that loss.
The exception appears to be among those residing in low-income areas, in which a fetal or neonatal morbidity/loss may profoundly affect her socioeconomic trajectory.
Conclusions
Future studies should elucidate the causal pathways between having a pregnancy ending in either a stillbirth, neonatal death, or severe morbidity experience and the various patterns of subsequent neighbourhood income movement. Further research should also investigate whether, following an adverse perinatal event, supports such as financial supplements can help a mother at risk of income decline, especially among those already residing in the lowest income areas preceding an adverse perinatal event.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We thank IQVIA Solutions Canada Inc. for use of their Drug Information File. Parts of this material are based on data and information compiled and provided by the Ontario Ministry of Health.
This document used data adapted from the Statistics Canada Postal CodeOM Conversion File, which is based on data licensed from Canada Post Corporation, and/or data adapted from the Ontario Ministry of Health Postal Code Conversion File, which contains data copied under license from ©Canada Post Corporation and Statistics Canada. This does not constitute an endorsement by Statistics Canada of this product. Parts of this material are based on data and/or information compiled and provided by the Canadian Institute for Health Information and the Ontario Ministry of Health. Parts or whole of this material are based on data and/or information compiled and provided by Immigration, Refugees, and Citizenship Canada Permanent Resident (IRCC-PR) data set current to September 30, 2020. However, the analyses, conclusions, opinions, and statements expressed in the material are those of the authors, and not necessarily those of IRCC. The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.
Author contributions
JAJ conceptualized and designed the study, participated in the acquisition, analysis, or interpretation of data, conducted statistical analysis, drafted the manuscript, critically reviewed and revised the manuscript for important intellectual content, and obtained funding. JAJ had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. EC, CD, HB, JG and HKB participated in the acquisition, analysis, or interpretation of data, and critically reviewed and revised the manuscript for important intellectual content. JGR conceptualized and designed the study, participated in the acquisition, analysis, or interpretation of data, drafted the manuscript, critically reviewed and revised the manuscript for important intellectual content, provided administrative, technical or material support, supervised the study and obtained funding. All authors approve the final manuscript as submitted and agree to be accountable for all aspects of the work.
Funding
This study was funded by a grant from the Ontario Academic Health Sciences Centre AFP Innovation Fund, as well as from the Canadian Institutes of Health Research. This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC). Dr. Jairam received funding through a Keenan Postdoctoral Fellow Scholarship from the St. Michael’s Hospital Foundation, and a Studentship Award from the Edwin S.H. Leong Centre for Healthy Children at the University of Toronto and The Hospital for Sick Children. Role of Funder/Sponsor (if any): The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Data availability
The dataset from this study is held securely in coded form at ICES. While legal data sharing agreements between ICES and data providers (e.g., healthcare organizations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS (email: das@ices.on.ca). The full dataset creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are, therefore, either inaccessible or may require modification.
Declarations
Ethics approval and consent to participate
The use of deidentified data in this study was authorized under section 45 of Ontario’s Personal Health Information Protection Act and exempt from a research ethics board review and informed consent.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Cahn J, Sundaram A, Balachandar R, et al. The association of childbirth with medical debt in the USA, 2019–2020. J Gen Intern Med. 2023;38(10):2340–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Zhang X. The post-childbirth employment of Canadian mothers and the earnings trajectories of their continuously employed counterparts, 1983 to 2004. Statistic Canada; 2008.
- 3.Taylor K, Compton S, Kolenic GE, et al. Financial hardship among pregnant and postpartum women in the United States, 2013 to 2018. JAMA Netw Open. 2021;4(10):e2132103. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Machado W, Jaspers E. Money. Birth, gender: explaining unequal earnings trajectories following parenthood. Sociol Sci. 2023;10:429–53. [Google Scholar]
- 5.Jairam JA, Vigod S, Siddiqi A, Guan J, Boblitz A, Wang X, O’Campo P, Ray JG. Morbidity and mortality of newborns born to immigrant and nonimmigrant females residing in low-income neighbourhoods. CMAJ. 2023;195(15):E537–47. [DOI] [PMC free article] [PubMed]
- 6.Aoyama K, Park AL, Davidson AJF, Ray JG. Severe maternal morbidity and infant mortality in Canada. Pediatrics 2020;146(3). [DOI] [PubMed]
- 7.Murphy-Kaulbeck L, Belzile N, Tsundu D, Cook JL. Preventing stillbirth in Canada: A need for a coordinated National action plan. J Obstet Gynecol Canada: JOGC = J D’obstetrique Et Gynecologie Du Can: JOGC. 2025;47(Suppl 1):102945. [DOI] [PubMed] [Google Scholar]
- 8.Flenady V, Boyle F, Koopmans L, Wilson T, Stones W, Cacciatore J. Meeting the needs of parents after a stillbirth or neonatal death. BJOG. 2014;121(Suppl 4):137–40. [DOI] [PubMed] [Google Scholar]
- 9.Cimpian DM, Strete GE, Cimpian CI, et al. The Impact of preterm birth on parents’ mental health and the role of family-centred interventions: a narrative review. Child (Basel). 2025;12(10). [DOI] [PMC free article] [PubMed]
- 10.Jairam JA, Vigod SN, Siddiqi A, et al. Neighborhood income mobility and risk of neonatal and maternal morbidity. JAMA Netw Open. 2023;6(5):e2315301. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Heazell AEP, Siassakos D, Blencowe H, et al. Stillbirths: economic and psychosocial consequences. Lancet. 2016;387(10018):604–16. [DOI] [PubMed] [Google Scholar]
- 12.Nelson CR, Ray JG, Auger N, et al. Neonatal adverse outcomes among hospital livebirths in Canada: a national retrospective study. Neonatology 2024. [DOI] [PMC free article] [PubMed]
- 13.Heinke D, Rich-Edwards JW, Williams PL, et al. Quantification of selection bias in studies of risk factors for birth defects among livebirths. Paediatr Perinat Epidemiol. 2020;34(6):655–64. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Ray JG, Berger H, Aoyama K, Cook JL, Aflaki K, Park AL. Does infant birthweight percentile identify mothers at risk of severe morbidity? A Canadian population-based cohort study. Matern Health Neonatol Perinatol. 2025;11(1):19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Cohen E, Horvath-Puho E, Ray JG, et al. Association between the birth of an infant with major congenital anomalies and subsequent risk of mortality in their mothers. JAMA. 2016;316(23):2515–24. [DOI] [PubMed] [Google Scholar]
- 16.Rotberg B, Horvath-Puho E, Vigod S, Ray JG, Sorensen HT, Cohen E. Increased maternal new-onset psychiatric disorders after delivering a child with a major anomaly: a cohort study. Acta Psychiatr Scand. 2020;142(4):264–74. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The dataset from this study is held securely in coded form at ICES. While legal data sharing agreements between ICES and data providers (e.g., healthcare organizations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS (email: das@ices.on.ca). The full dataset creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are, therefore, either inaccessible or may require modification.