Race and Socioeconomic Background Impact Pregnancy Outcomes: Study

Vanessa Sibbald

November 03, 2021

A new study looking at pregnancies in England has found that race and socioeconomic inequalities play a large part in pregnancy outcomes. Looking at more than one million pregnancies, the study found racial and social factors affected a quarter of stillbirths, a fifth of preterm births, and a third of births with foetal growth restriction (FGR). South Asian and Black women living in the poorest areas experienced the largest inequalities.

The study, published in The Lancet, analysed NHS birth records from 2015 to 2017 to quantify socioeconomic and ethnic inequalities in stillbirth (the death of a foetus after 24 weeks of pregnancy), preterm birth (live birth before 37 weeks), and FGR in England.

"The stark reality is that across England, women's socioeconomic and ethnic background are still strongly related to their likelihood of experiencing serious adverse outcomes for their baby. I think that people will be shocked to see that these inequalities are still responsible for a substantial proportion of adverse pregnancy outcomes in England," said co-lead author Dr Jennifer Jardine from the Royal College of Obstetrics and Gynaecologists.

Adverse Pregnancy Outcomes

Researchers calculated the proportion of adverse pregnancy outcomes that would not have occurred if all women had the same pregnancy risk as the women in the least deprived 20% of neighbourhoods or as those from a White ethnic background, both with and without adjusting for smoking status, body mass index, and other maternal risk factors. Socioeconomic status was measured for each local area using the Index of Multiple Deprivation that combines information on income, employment, education, housing, crime, and the living environment. Researchers say that adjusting for socioeconomic deprivation, maternal smoking, and BMI had little impact on these associations, indicating that other factors related to discrimination based on ethnicity and culture may contribute to poor pregnancy outcomes.

Estimates suggested that more than half of stillbirths and three-quarters of births with FGR in South Asian women living in the most deprived 20% of neighbourhoods could be avoidable if they had the same risks as White women from the most affluent neighbourhoods. Similarly, about two-thirds of stillbirths and nearly half of births with FGR occurred in Black women.

In total, 1,155,981 women with a singleton birth were included in the study, of whom 77% were White, 12% South Asian, 5% Black, 2% mixed race/ethnicity, and 4% other race/ethnicity. Overall, 4505 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 liveborn babies, 69,175 (6% - 4.9% to 7.2%) were preterm births and 22,679 (2% - 1.2% to 2.2%) were births with FGR.

Pregnancy complications disproportionately affected Black and Minority Ethnic women, with 12% of all stillbirths, 1% of preterm births, and 17% of births with FGR attributed to ethnic inequality.

Pregnancy complications disproportionately affected Black and minority ethnic women, with 12% of all stillbirths, 1% of preterm births, and 17% of births with FGR attributed to ethnic inequality.

Possible Reasons

"There are many possible reasons for these disparities," said co-lead author Professor Jan van der Meulen from the London School of Hygiene & Tropical Medicine. "Women from deprived neighbourhoods and Black and Minority Ethnic groups may be at a disadvantage because of their environment, for example, because of pollution, poor housing, social isolation, limited access to maternity and health care, insecure employment, poor working conditions, and stressful life events.”

NHS England has set a target of halving stillbirth and neonatal death rates and reducing levels of preterm birth by 25% by 2025. Poverty and Minority Ethnic background are known risk factors for adverse pregnancy outcomes. The findings suggest that current national programmes to make pregnancy safer, which focus on individual women's risk and behaviour 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 at a national level, politicians, public health professionals, and healthcare providers must work together to address racism and discrimination and improve women's social circumstances, social support, and health throughout their lives.

Measures to Reduce Inequalities

Three measures are proposed by the authors to reduce these inequalities: targeting high-risk groups with clinical interventions during pregnancy, such as smoking cessation and nutrition programmes, as well as better access to high-quality antenatal care; public health strategies to address inequalities before pregnancy, focusing on nutrition, smoking, substance abuse, mental health, and other broader aspects of maternal adversity, and comprehensive policies to address the fundamental causes of inequality, such as income, education, and employment, which indirectly influence pregnancy outcomes.

The authors acknowledge that their findings show observational differences and note some methodological limitations. They used an area-based measure of socioeconomic deprivation, which might not accurately represent the range of individual socioeconomic status within a particular area. Additionally, their findings assume the effects of socioeconomic deprivation and ethnicity are not modified by other circumstances, such as overall health, lifestyle, and nutrition, which may limit the conclusions that can be drawn.

Adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities in England: a national cohort study. Lancet. Published:November 01, 2021DOI:https://doi.org/10.1016/S0140-6736(21)01595-6

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