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Canadian Journal of Public Health = Revue Canadienne de Santé Publique logoLink to Canadian Journal of Public Health = Revue Canadienne de Santé Publique
. 2013 Mar 1;104(2):e148–e153. doi: 10.1007/BF03405679

Educational Inequality in Stillbirth: Temporal Trends in Québec From 1981 to 2009

Noémie Savard 114, Nathalie Auger 114,214,314,✉, Alison L Park 214,314, Ernest Lo 214, Jérôme Martinez 214
PMCID: PMC6973859  PMID: 23618208

Abstract

OBJECTIVE: Educational inequality in stillbirth has been documented in high-income countries and the province of Québec, Canada, but temporal trends are poorly understood. Our objective was to determine time trends in inequality related to maternal education for all-cause and cause-specific stillbirth over the past three decades in Québec.

METHODS: We included 2,397,971 live births and 9,983 stillbirths from 1981 through 2009 using Québec vital statistics. For each decade, we computed measures of inequality capturing relative (relative index of inequality, RII) and absolute (slope index of inequality, SII) differences between the least- and most-educated mothers for all-cause and cause-specific stillbirth, adjusting for maternal characteristics.

RESULTS: Stillbirth rates decreased over time for all education levels. Absolute educational inequality (SII 2.5 per 1000 births, 95% CI 2.1–2.8; all periods combined) was stable over time, whereas relative inequality increased (RII1981–1989 1.8 vs. RII2000–2009 2.3). Absolute inequality decreased for stillbirths caused by placental abruption (SII1981–1989 0.6 vs. SII2000–2009 0.3), but increased for unspecified causes (SII1981–1989 0.2 vs. SII2000–2009 0.7).

CONCLUSIONS: Absolute educational inequality in stillbirth persisted and relative inequality increased over the past three decades, despite an overall decrease in stillbirth rates. The decrease in absolute inequality for placental abruption was countered by an increase for unspecified causes. A better understanding of the underlying components of unspecified causes is needed to further address educational inequality in stillbirth.

Key Words: Cause of death, educational status, fetal death, socioeconomic factors, stillbirth, trend, temporal

Footnotes

Acknowledgements: NA was supported by a Chercheur-boursier Junior 1 award from the Fonds de recherche du Québec - Santé.

Conflict of Interest: None to declare.

References

  • 1.Fretts RC. The study of stillbirth. Am J Obstet Gynecol. 2009;201(5):429–30. doi: 10.1016/j.ajog.2009.06.058. [DOI] [PubMed] [Google Scholar]
  • 2.Flenady V, Koopmans L, Middleton P, Froen JF, Smith GC, Gibbons K, et al. Major risk factors for stillbirth in high-income countries: A systematic review and meta-analysis. Lancet. 2011;377(9774):1331–40. doi: 10.1016/S0140-6736(10)62233-7. [DOI] [PubMed] [Google Scholar]
  • 3.Luque-Fernández M, Lone NI, Gutiérrez-Garitano I, Bueno-Cavanillas A. Stillbirth risk by maternal socio-economic status and country of origin: A population-based observational study in Spain, 2007–08. Eur J Public Health. 2012;22(4):524–29. doi: 10.1093/eurpub/ckr074. [DOI] [PubMed] [Google Scholar]
  • 4.Rom AL, Mortensen LH, Cnattingius S, Arntzen A, Gissler M, Andersen AM. A comparative study of educational inequality in the risk of stillbirth in Denmark, Finland, Norway and Sweden 1981–2000. J Epidemiol Community Health. 2012;66(3):240–46. doi: 10.1136/jech.2009.101188. [DOI] [PubMed] [Google Scholar]
  • 5.Auger N, Delezire P, Harper S, Platt RW. Maternal education and stillbirth: Estimating gestational-age-specific and cause-specific associations. Epidemiol. 2012;23(2):247–54. doi: 10.1097/EDE.0b013e31824587bc. [DOI] [PubMed] [Google Scholar]
  • 6.Luo ZC, Wilkins R, Kramer MS. Effect of neighbourhood income and maternal education on birth outcomes: A population-based study. CMAJ. 2006;174(10):1415–20. doi: 10.1503/cmaj.051096. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Froen JF, Arnestad M, Frey K, Vege A, Saugstad OD, Stray-Pedersen B. Risk factors for sudden intrauterine unexplained death: Epidemiologic characteristics of singleton cases in Oslo, Norway, 1986–1995. Am J Obstet Gynecol. 2001;184(4):694–702. doi: 10.1067/mob.2001.110697. [DOI] [PubMed] [Google Scholar]
  • 8.Rasmussen S, Albrechtsen S, Irgens LM, Dalaker K, Maartmann-Moe H, Vlatkovic L, et al. Risk factors for unexplained antepartum fetal death in Norway 1967–1998. Early Hum Dev. 2003;71(1):39–52. doi: 10.1016/S0378-3782(02)00111-1. [DOI] [PubMed] [Google Scholar]
  • 9.Winbo I, Serenius F, Dahlquist G, Kallen B. Maternal risk factors for causespecific stillbirth and neonatal death. Acta Obstet Gynecol Scand. 2001;80(3):235–44. doi: 10.1034/j.1600-0412.2001.080003235.x. [DOI] [PubMed] [Google Scholar]
  • 10.Neasham D, Dolk H, Vrijheid M, Jensen T, Best N. Stillbirth and neonatal mortality due to congenital anomalies: Temporal trends and variation by small area deprivation scores in England and Wales, 1986–96. Paediatr Perinat Epidemiol. 2001;15(4):364–73. doi: 10.1046/j.1365-3016.2001.0379a.x. [DOI] [PubMed] [Google Scholar]
  • 11.Mahony R, Mulcahy C, McAuliffe F, Herlihy CO, Carroll S, Foley ME. Fetal death in twins. Acta Obstet Gynecol Scand. 2011;90611:1274–80. doi: 10.1111/j.1600-0412.2011.01239.x. [DOI] [PubMed] [Google Scholar]
  • 12.Raghunathan TE. What do we do with missing data? Some options for analysis of incomplete data. Annu Rev Public Health. 2004;25:99–117. doi: 10.1146/annurev.publhealth.25.102802.124410. [DOI] [PubMed] [Google Scholar]
  • 13.Mackenbach JP, Kunst AE. Measuring the magnitude of socio-economic inequalities in health: An overview of available measures illustrated with two examples from Europe. Soc Sci Med. 1997;44(6):757–71. doi: 10.1016/S0277-9536(96)00073-1. [DOI] [PubMed] [Google Scholar]
  • 14.Wilcox AJ, Weinberg CR, Basso O. On the pitfalls of adjusting for gestational age at birth. Am J Epidemiol. 2011;174(9):1062–68. doi: 10.1093/aje/kwr230. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Borrell C, Cirera E, Ricart M, Pasarin MI, Salvador J. Social inequalities in perinatal mortality in a Southern European city. Eur J Epidemiol. 2003;18(1):5–13. doi: 10.1023/A:1022524914396. [DOI] [PubMed] [Google Scholar]
  • 16.Dummer TJ, Dickinson HO, Pearce MS, Charlton ME, Parker L. Stillbirth risk with social class and deprivation: No evidence for increasing inequality. J Clin Epidemiol. 2000;53(2):147–55. doi: 10.1016/S0895-4356(99)00169-9. [DOI] [PubMed] [Google Scholar]
  • 17.BMJ Open. 2012.
  • 18.Ananth CV, Smulian JC, Vintzileos AM. Incidence of placental abruption in relation to cigarette smoking and hypertensive disorders during pregnancy: A meta-analysis of observational studies. Obstet Gynecol. 1999;93(4):622–28. doi: 10.1016/s0029-7844(98)00408-6. [DOI] [PubMed] [Google Scholar]
  • 19.Gray R, Bonellie SR, Chalmers J, Greer I, Jarvis S, Kurinczuk JJ, et al. Contribution of smoking during pregnancy to inequalities in stillbirth and infant death in Scotland 1994–2003: Retrospective population based study using hospital maternity records. BMJ. 2009;339:b3754. doi: 10.1136/bmj.b3754. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Aubé-Maurice J, Rochette L, Blais C. Relation entre la défavorisation et l’incidence de l’hypertension artérielle chez les individus de 20 ans et plus au Québec en 2006–2007. Québec, QC: Institut national de santé publique du Québec; 2010. [Google Scholar]
  • 21.Lamontagne P, Hamel D. Poids corporel de la population adulte québécoise: Mise à jour 2005 / Exploitation des données de l’ESCC 3.1. Québec: Institut national de santé publique du Québec; 2008. [Google Scholar]
  • 22.Lasnier B, Leclerc B-S, Hamel D. Les inégalités sociales de santé en matière de tabagisme et d’exposition à la fumée de tabac dans l’environnement au Québec. Québec: Institut national de santé publique du Québec; 2012. [Google Scholar]
  • 23.De Wals P, Tairou F, Van Allen MI, Uh SH, Lowry RB, Sibbald B, et al. Reduction in neural-tube defects after folic acid fortification in Canada. N Engl J Med. 2007;357(2):135–42. doi: 10.1056/NEJMoa067103. [DOI] [PubMed] [Google Scholar]
  • 24.Allen VM, Armson BA, Wilson RD, Blight C, Gagnon A, Johnson J-A, et al. Teratogenicity associated with pre-existing and gestational diabetes. J Obstet Gynaecol Can. 2007;29(11):927–44. doi: 10.1016/S1701-2163(16)32653-6. [DOI] [PubMed] [Google Scholar]
  • 25.Hollier LM, Leveno KJ, Kelly MA, McIntire DD, Cunningham FG. Maternal age and malformations in singleton births. Obstet Gynecol. 2000;96(5Pt1):701–6. doi: 10.1016/s0029-7844(00)01019-x. [DOI] [PubMed] [Google Scholar]
  • 26.DemographicsRisk Indicators Working Group DRIWG . Canadian Congenital Anomalies Surveillance Network (CCASN) Ottawa, ON: Public Health Agency of Canada; 2010. [Google Scholar]
  • 27.Public Health Agency of Canada. Canadian Perinatal Health Report, 2008 Edition. Ottawa, ON: PHAC; 2008. [Google Scholar]
  • 28.Auger N, Denis G. Late pregnancy abortions: An analysis of Québec stillbirth data, 1981–2006. Int J Public Health. 2012;57:443–46. doi: 10.1007/s00038-011-0313-1. [DOI] [PubMed] [Google Scholar]
  • 29.Flenady V, Middleton P, Smith GC, Duke W, Erwich JJ, Khong TY, et al. Stillbirths: The way forward in high-income countries. Lancet. 2011;377(9778):1703–17. doi: 10.1016/S0140-6736(11)60064-0. [DOI] [PubMed] [Google Scholar]
  • 30.Heaman MI, Green CG, Newburn-Cook CV, Elliott LJ, Helewa ME. Social inequalities in use of prenatal care in Manitoba. J Obstet Gynaecol Can. 2007;29(10):806–16. doi: 10.1016/S1701-2163(16)32637-8. [DOI] [PubMed] [Google Scholar]

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