European Journal of Epidemiology

, Volume 28, Issue 12, pp 991–999

Unemployment and stillbirth risk among foreign-born and Spanish pregnant women in Spain, 2007–2010: a multilevel analysis study


    • Department of EpidemiologyHarvard School of Public Health
  • Manuel Franco
    • University of Alcala de Henares
    • Department of EpidemiologyJohn Hopkins School of Public Health
  • Bizu Gelaye
    • Department of EpidemiologyHarvard School of Public Health
  • Michael Schomaker
    • Centre for Infectious Disease Epidemiology and ResearchUniversity of Cape Town
  • Ignacio Gutierrez Garitano
    • Department of Obstetrics and GynaecologyCruces University Hospital
  • Catherine D’Este
    • Faculty of Health Sciences, School of Public HealthUniversity of Newcastle
  • Michelle A. Williams
    • Department of EpidemiologyHarvard School of Public Health

DOI: 10.1007/s10654-013-9859-y

Cite this article as:
Luque-Fernandez, M.A., Franco, M., Gelaye, B. et al. Eur J Epidemiol (2013) 28: 991. doi:10.1007/s10654-013-9859-y


We describe stillbirth and unemployment rates by autonomous region in Spain and analyse whether women who gave birth in regions with high unemployment rates were more likely to have a stillborn. We designed a multilevel population-based observational study of births from 2007 to 2010. We defined stillbirth as the outcome, individual maternal socioeconomic and pregnancy-related characteristics as covariates, and maternal autonomous region of residence as the contextual covariate. We used mixed-logistic regression models to account for differences across regions. In total, 1,920,235 singleton births and 5,560 stillbirths were included in the study. Women residing in autonomous regions with the highest rates of unemployment had a two-times-greater chance of delivering a stillborn (adjusted OR 2.60; 95 % CI 2.08–3.21). The region where women resided explained 14 % of the total individual differences in the risk of delivering a stillborn. The odds of stillbirth were 1.82 (95 % CI 1.62–2.05) times higher for African-born women than for Spanish-born women and 1.90 (95 % CI 1.68–2.15) times higher for women with low educational attainment than for women with higher education. In conclusion, regional disparities in stillbirth rates in Spain in the period 2007–2010 were mainly associated with mothers who had low levels of education, were African-born, and lived in regions with higher unemployment.


Multilevel analysis Stillbirth Unemployment Epidemiology Spain

Supplementary material

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Supplementary Figure 1: 1A. Stillbirth rates by autonomous region and year, Spain 2007-2010. 1B. Unemployment rates per 100 people by autonomous region and year, Spain 2007-2010. (JPEG 2946 kb)
10654_2013_9859_MOESM2_ESM.doc (73 kb)
Supplementary material 2 (DOC 73 kb)
10654_2013_9859_MOESM3_ESM.doc (74 kb)
Supplementary material 3 (DOC 75 kb)
10654_2013_9859_MOESM4_ESM.doc (96 kb)
Supplementary material 4 (DOC 96 kb)

Copyright information

© Springer Science+Business Media Dordrecht 2013