Royal College of Obstetricians and Gynaecologists, London, UK; Department of Health Services Research, London School of Hygiene & Tropical Medicine, London, UK.
Department of Health Services Research, London School of Hygiene & Tropical Medicine, London, UK.
Lancet. 2021 Nov 20;398(10314):1905-1912. doi: 10.1016/S0140-6736(21)01595-6. Epub 2021 Nov 1.
Socioeconomic deprivation and minority ethnic background are risk factors for adverse pregnancy outcomes. We aimed to quantify the magnitude of these socioeconomic and ethnic inequalities at the population level in England.
In this cohort study, we used data compiled by the National Maternity and Perinatal Audit, based on birth records from maternity information systems used by 132 National Health Service hospitals in England, linked to administrative hospital data. We included women who gave birth to a singleton baby with a recorded gestation between 24 and 42 completed weeks. Terminations of pregnancy were excluded. We analysed data on stillbirth, preterm birth (<37 weeks of gestation), and fetal growth restriction (FGR; liveborn with birthweight <3rd centile by the UK definition) in England, and compared these outcomes by socioeconomic deprivation quintile and ethnic group. We calculated attributable fractions for the entire population and specific groups compared with least deprived groups or White women, both unadjusted and with adjustment for smoking, body-mass index (BMI), and other maternal risk factors.
We identified 1 233 184 women with a singleton birth between April 1, 2015, and March 31, 2017, of whom 1 155 981 women were eligible and included in the analysis. 4505 (0·4%) of 1 155 981 births were stillbirths. Of 1 151 476 livebirths, 69 175 (6·0%) were preterm births and 22 679 (2·0%) were births with FGR. Risk of stillbirth was 0·3% in the least socioeconomically deprived group and 0·5% in the most deprived group (p<0·0001), risk of a preterm birth was 4·9% in the least deprived group and 7·2% in the most deprived group (p<0·0001), and risk of FGR was 1·2% in the least deprived group and 2·2% in the most deprived group (p<0·0001). Population attributable fractions indicated that 23·6% (95% CI 16·7-29·8) of stillbirths, 18·5% (16·9-20·2) of preterm births, and 31·1% (28·3-33·8) of births with FGR could be attributed to socioeconomic inequality, and these fractions were substantially reduced when adjusted for ethnic group, smoking, and BMI (11·6% for stillbirths, 11·9% for preterm births, and 16·4% for births with FGR). Risk of stillbirth ranged from 0·3% in White women to 0·7% in Black women (p<0·0001); risk of preterm birth was 6·0% in White women, 6·5% in South Asian women, and 6·6% in Black women (p<0·0001); and risk of FGR ranged from 1·4% in White women to 3·5% in South Asian women (p<0·0001). 11·7% of stillbirths (95% CI 9·8-13·5), 1·2% of preterm births (0·8-1·6), and 16·9% of FGR (16·1-17·8) could be attributed to ethnic inequality. Adjustment for socioeconomic deprivation, smoking, and BMI only had a small effect on these ethnic group attributable fractions (13·0% for stillbirths, 2·6% for preterm births, and 19·2% for births with FGR). Group-specific attributable fractions were especially high in the most socioeconomically deprived South Asian women and Black women for stillbirth (53·5% in South Asian women and 63·7% in Black women) and FGR (71·7% in South Asian women and 55·0% in Black women).
Our results indicate that socioeconomic and ethnic inequalities were responsible for a substantial proportion of stillbirths, preterm births, and births with FGR in England. The largest inequalities were seen in Black and South Asian women in the most socioeconomically deprived quintile. Prevention should target the entire population as well as specific minority ethnic groups at high risk of adverse pregnancy outcomes, to address risk factors and wider determinants of health.
Healthcare Quality Improvement Partnership.
社会经济贫困和少数族裔背景是不良妊娠结局的风险因素。我们旨在量化英格兰人群中这些社会经济和族裔不平等的程度。
在这项队列研究中，我们使用了国家母婴和围产儿审计（National Maternity and Perinatal Audit）基于 132 家英国国家卫生服务（NHS）医院使用的产妇信息系统中的分娩记录编制的数据，这些记录与医院管理数据相关联。我们纳入了记录了妊娠 24 至 42 周完整周的单胎婴儿分娩的女性。排除了终止妊娠。我们分析了英格兰的死产、早产（<37 周妊娠）和胎儿生长受限（FGR；根据英国定义，出生体重低于第 3 百分位数的活产儿）的结局，并按社会经济贫困五分位数和族裔进行了比较。我们计算了全人群以及与最不贫困群体或白人女性相比的特定群体的归因分数，包括未调整和调整吸烟、体重指数（BMI）和其他母婴风险因素后的分数。
我们确定了 2015 年 4 月 1 日至 2017 年 3 月 31 日期间 1 233 184 名单胎分娩的女性，其中 1 155 981 名女性符合条件并纳入分析。1 155 981 例活产中，4505 例（0·4%）为死产。在 1 151 476 例活产中，69 175 例（6·0%）为早产，22 679 例（2·0%）为 FGR。最不贫困组的死产风险为 0·3%，最贫困组为 0·5%（p<0·0001）；最贫困组的早产风险为 4·9%，最不贫困组为 7·2%（p<0·0001）；最贫困组的 FGR 风险为 1·2%，最不贫困组为 2·2%（p<0·0001）。人群归因分数表明，23·6%（95%CI 16·7-29·8）的死产、18·5%（16·9-20·2）的早产和 31·1%（28·3-33·8）的 FGR 可归因于社会经济不平等，这些分数在调整族裔、吸烟和 BMI 后显著降低（死产为 11·6%，早产为 11·9%，FGR 为 16·4%）。死产风险从白人女性的 0·3%到黑人女性的 0·7%（p<0·0001）；早产风险在白人女性中为 6·0%，在南亚裔女性中为 6·5%，在黑人女性中为 6·6%（p<0·0001）；FGR 风险从白人女性的 1·4%到南亚裔女性的 3·5%（p<0·0001）。11·7%的死产（95%CI 9·8-13·5）、1·2%的早产（0·8-1·6）和 16·9%的 FGR（16·1-17·8）可归因于族裔不平等。仅调整社会经济贫困、吸烟和 BMI 对这些族裔归因分数的影响很小（死产为 13·0%，早产为 2·6%，FGR 为 19·2%）。在最贫困的南亚裔和黑人女性中，特定群体的归因分数特别高，尤其是在死产（南亚裔女性为 53·5%，黑人女性为 63·7%）和 FGR（南亚裔女性为 71·7%，黑人女性为 55·0%）。
我们的研究结果表明，在英格兰，社会经济和族裔不平等是死产、早产和 FGR 不良妊娠结局的主要原因。在最贫困的五分之一中，黑人女性和南亚裔女性的差异最大。预防措施应针对整个人群以及高风险的特定少数族裔群体，以解决风险因素和更广泛的健康决定因素。
医疗保健质量改进伙伴关系。
