Skip to main content
SpringerLink
Log in

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

  • PERINATAL EPIDEMIOLOGY
  • Published:
European Journal of Epidemiology Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Arntzen A, Mortensen L, Schnor O, Cnattingius S, et al. Neonatal and post neonatal mortality by maternal education a population-based study of trends in the Nordic countries, 1981–2000. Eur J Public Health. 2008;18(3):245–51.

    Article  PubMed  Google Scholar 

  2. Arntzen A, Samuelsen SO, Bakketeig LS, et al. Socioeconomic status and risk of infantdeath. A population-based study of trends in Norway, 1967–1998. Int J Epidemiol. 2004;33(2):279–88.

    Article  PubMed  Google Scholar 

  3. Bollini P, Pampallona S, Wanner P, et al. Pregnancy outcome of migrant women and integration policy: a systematic review of the international literature. Soc Sci Med. 2009;68(3):452–61.

    Article  PubMed  Google Scholar 

  4. Krieger N, Williams DR, Moss NE. Measuring social class in us public health research: concepts, methodologies, and guidelines. Annu Rev Public Health. 1997;18:341–78.

    Article  CAS  PubMed  Google Scholar 

  5. Haglund B, Cnattingius S, Nordstrm ML. Social differences in late fetal death and infant mortality in Sweden 1985–1986. Paediatr Perinat Epidemiol. 1993;7(1):33–44.

    Article  CAS  PubMed  Google Scholar 

  6. Guildea ZE, Fone DL, Dunstan FD, et al. Social deprivation and the causes of stillbirth and infant mortality. Arch Dis Child. 2001;84(4):307–10.

    Article  CAS  PubMed  Google Scholar 

  7. Kallan JE. Rates of fetal death by maternal race, ethnicity, and nativity: New jersey, 1991–1998. JAMA. 2001;285(23):2978–9.

    Article  CAS  PubMed  Google Scholar 

  8. Chen J, Fair M, Wilkins R, Cyr M. Maternal education and fetal and infant mortality in Quebec fetal and infant mortality study group of the Canadian perinatal surveillance system. Health Rep. 1998;10(2):53–64.

    CAS  PubMed  Google Scholar 

  9. Luque-Fernandez MA, Lone NI, Gutirrez-Garitano I, et al. 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):524–9.

    Article  PubMed  Google Scholar 

  10. Reeske A, Kutschmann M, Razum O, et al. Stillbirth differences according to regions of origin: an analysis of the German perinatal database, 2004–2007. BMC Pregnancy Childbirth. 2011;11:63.

    Article  PubMed  Google Scholar 

  11. Zeitlin J, Mohangoo A, Cuttini M, et al. The European perinatal health report: comparing the health and care of pregnant women and new born babies in Europe. J Epidemiol Community Health. 2009;63(9):681–2.

    Article  PubMed  Google Scholar 

  12. Racape J, De Spiegelaere M, Alexander S, et al. High perinatal mortality rate among immigrants in Brussels. Eur J Public Health. 2010;20(5):536–42.

    Article  PubMed  Google Scholar 

  13. Diez Roux AV. Investigating neighborhood and area effects on health. Am J Public Health. 2001;91(11):1783–9.

    Article  CAS  PubMed  Google Scholar 

  14. Williams DR, Jackson PB. Social sources of racial disparities in health. Health Aff (Millwood). 2005;24(2):325–34.

    Article  Google Scholar 

  15. Catalano R, Hansen HT, Hartig T. The ecological effect of unemployment on the incidence of very low birth weight in Norway and Sweden. J Health Soc Behav. 1999;40(4):422–8.

    Article  CAS  PubMed  Google Scholar 

  16. Pattenden S, Casson K, Cook S, Dolk H. Geographical variation in infant mortality, stillbirth and low birth weight in Northern Ireland, 1992–2002. J Epidemiol Community Health. 2011;65(12):1159–65.

    Article  PubMed  Google Scholar 

  17. Tromp M, Eskes M, Reitsma JB, et al. Regional perinatal mortality differences in the Netherlands; care is the question. BMC Public Health. 2009;9:102.

    Article  PubMed  Google Scholar 

  18. Fernandez MAL, Cavanillas AB, Dramaix-Wilmet M, et al. Increase in maternal mortality associated with change in the reproductive pattern in Spain: 1996–2005. J Epidemiol Community Health. 2009;63(6):433–8.

    Article  Google Scholar 

  19. Lawn JE, Yakoob MY, Haws RA, et al. 3.2 million stillbirths: epidemiology and overview of the evidence review. BMC Pregnancy Childbirth. 2009;9(Suppl 1):S2.

    Article  PubMed  Google Scholar 

  20. Cousens S, Blencowe H, Stanton C, Chou D, Ahmed S, Steinhardt L, et al. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet. 2011;377(9774):1319–30.

    Article  PubMed  Google Scholar 

  21. UNESCO. International standard classification of education: ISCED technical report. UNESCO Institute for Statistics; 1997.

  22. von Elm E, Altman DG, Egger M, et al. The strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–7.

    Article  Google Scholar 

  23. Greenland S. A review of multilevel theory for ecologic analyses. Stat Med. 2002;21(3):389–95.

    Article  PubMed  Google Scholar 

  24. Honjo K. Social epidemiology: definition, history, and research examples. Environ Health Prev Med. 2004;9(5):193–9.

    Article  PubMed  Google Scholar 

  25. Merlo J, Chaix B, Yang M, et al. A brief conceptual tutorial of multilevel analysis in social epidemiology: linking the statistical concept of clustering to the idea of contextual phenomenon. J Epidemiol Community Health. 2005;59(6):443–9.

    Article  PubMed  Google Scholar 

  26. Rubin D. Multiple imputation after 18+ years. J Am Stat Assoc. 1996;91:473–89.

    Article  Google Scholar 

  27. White I, Royston P, Wood A. Multiple imputation using chained equations. Stat Med. 2011;30:377–99.

    Article  PubMed  Google Scholar 

  28. Schafer JL. Multiple imputation: a primer. Stat Methods Med Res. 1999;8(1):3–15.

    Article  CAS  PubMed  Google Scholar 

  29. Schafer JL, Graham JW. Missing data: our view of the state of the art. Psychol Methods. 2002;7(2):147–77.

    Article  PubMed  Google Scholar 

  30. Bryant AS, Worjoloh A, Caughey AB, et al. Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants. Am J Obstet Gynecol. 2010;202(4):335–43.

    Article  PubMed  Google Scholar 

  31. Flenady V, Koopmans L, Middleton P, et al. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet. 2011;377(9774):1331–40.

    Article  PubMed  Google Scholar 

  32. Duran A, Lara JL, van Waveren M. Spain: health system review, health systems in transition. Technical Report; European Observatory on Health Systems and Policies. World Health Organization. 2006.

  33. Luque Fernandez MA, Bueno-Cavanillas A. Fertility in Spain, 1996–2006: foreign versus Spanish women. Gac Sanit. 2009;23(Suppl 1):67–71.

    Article  PubMed  Google Scholar 

  34. Fren JF, Cacciatore J, McClure EM, et al. Stillbirths: why they matter. Lancet. 2011;377(9774):1353–66.

    Article  Google Scholar 

  35. Lumey LH, Reijneveld SA. Perinatal mortality in a first generation immigrant population and its relation to unemployment in the Netherlands. J Epidemiol Community Health. 1995;49(5):454–9.

    Article  CAS  PubMed  Google Scholar 

  36. Reime B, Jacob C, Wenzlaff P. Is parental unemployment related to an increased risk for stillbirths? J Public Health. 2009;17:363–9.

    Article  Google Scholar 

  37. Borrell C, Cirera E, Ricart M, et al. Social inequalities in perinatal mortality in a southern European city. Eur J Epidemiol. 2003;18(1):5–13.

    Article  CAS  PubMed  Google Scholar 

  38. Garcia-Subirats I, Prez G, Rodrguez-Sanz M, et al. Recentimmigration and adverse pregnancy outcomes in an urban setting in Spain. Matern Child Health J. 2011;15(5):561–9.

    Article  PubMed  Google Scholar 

  39. Garcia-Subirats I, Prez G, Rodrguez-Sanz M, et al. Neighborhood inequalities in adverse pregnancy outcomes in an urban setting in Spain: a multilevel approach. J Urban Health. 2012;89(3):447–63.

    Article  PubMed  Google Scholar 

  40. Vintzileos AM, Ananth CV, Smulian JC, et al. The impact of prenatal care in the United States on preterm births in the presence and absence of antenatal high-risk conditions. Am J Obstet Gynecol. 2002;187(5):1254–7.

    Article  PubMed  Google Scholar 

  41. Vintzileos AM, Ananth CV, Smulian JC, et al. The impact of prenatal care on neonatal deaths in the presence and absence of antenatal high-risk conditions. Am J Obstet Gynecol. 2002;186(5):1011–6.

    Article  PubMed  Google Scholar 

  42. Vintzileos AM, Ananth CV, Smulian JC, et al. Prenatal care and black-white fetal death disparity in the United States: heterogeneity by high-risk conditions. Obstet Gynecol. 2002;99(3):483–9.

    Article  PubMed  Google Scholar 

  43. Vintzileos A, Ananth CV, Smulian JC, et al. The impact of prenatal care on postneonatal deaths in the presence and absence of antenatal high-risk conditions. Am J Obstet Gynecol. 2002;187(5):1258–62.

    Article  PubMed  Google Scholar 

  44. Stephansson O, Dickman PW, Johansson AL, Cnattingius S. The influence of socioeconomic status on stillbirth risk in Sweden. Int J Epidemiol. 2001;30(6):1296–301.

    Article  CAS  PubMed  Google Scholar 

  45. Yudkin P, et al. Risk of unexplained stillbirth at different gestational ages. Lancet. 1987;8543:1192–4.

    Google Scholar 

Download references

Conflict of interest

The authors of this manuscript declare no competing interests.

Author information

Authors and Affiliations

  1. Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA

    Miguel Angel Luque-Fernandez, Bizu Gelaye & Michelle A. Williams

  2. University of Alcala de Henares, Madrid, Spain

    Manuel Franco

  3. Department of Epidemiology, John Hopkins School of Public Health, Baltimore, MD, USA

    Manuel Franco

  4. Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa

    Michael Schomaker

  5. Department of Obstetrics and Gynaecology, Cruces University Hospital, Bilbao, Spain

    Ignacio Gutierrez Garitano

  6. Faculty of Health Sciences, School of Public Health, University of Newcastle, Newcastle, Australia

    Catherine D’Este

Authors
  1. Miguel Angel Luque-Fernandez
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Manuel Franco
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Bizu Gelaye
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Michael Schomaker
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ignacio Gutierrez Garitano
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Catherine D’Este
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Michelle A. Williams
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Miguel Angel Luque-Fernandez.

Electronic supplementary material

Below is the link to the electronic supplementary material.

10654_2013_9859_MOESM1_ESM.jpeg

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)

Supplementary material 2 (DOC 73 kb)

Supplementary material 3 (DOC 75 kb)

Supplementary material 4 (DOC 96 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Luque-Fernandez, M.A., Franco, M., Gelaye, B. et al. Unemployment and stillbirth risk among foreign-born and Spanish pregnant women in Spain, 2007–2010: a multilevel analysis study. Eur J Epidemiol 28, 991–999 (2013). https://doi.org/10.1007/s10654-013-9859-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10654-013-9859-y

Keywords

Search

Navigation