European Journal of Epidemiology

, Volume 28, Issue 12, pp 991–999 | Cite as

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

  • Miguel Angel Luque-FernandezEmail author
  • Manuel Franco
  • Bizu Gelaye
  • Michael Schomaker
  • Ignacio Gutierrez Garitano
  • Catherine D’Este
  • Michelle A. Williams


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 


Conflict of interest

The authors of this manuscript declare no competing interests.

Supplementary material

10654_2013_9859_MOESM1_ESM.jpeg (2.9 mb)
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)


  1. 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.CrossRefPubMedGoogle Scholar
  2. 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.CrossRefPubMedGoogle Scholar
  3. 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.CrossRefPubMedGoogle Scholar
  4. 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.CrossRefPubMedGoogle Scholar
  5. 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.CrossRefPubMedGoogle Scholar
  6. 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.CrossRefPubMedGoogle Scholar
  7. 7.
    Kallan JE. Rates of fetal death by maternal race, ethnicity, and nativity: New jersey, 1991–1998. JAMA. 2001;285(23):2978–9.CrossRefPubMedGoogle Scholar
  8. 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.PubMedGoogle Scholar
  9. 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.CrossRefPubMedGoogle Scholar
  10. 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.CrossRefPubMedGoogle Scholar
  11. 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.CrossRefPubMedGoogle Scholar
  12. 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.CrossRefPubMedGoogle Scholar
  13. 13.
    Diez Roux AV. Investigating neighborhood and area effects on health. Am J Public Health. 2001;91(11):1783–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Williams DR, Jackson PB. Social sources of racial disparities in health. Health Aff (Millwood). 2005;24(2):325–34.CrossRefGoogle Scholar
  15. 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.CrossRefPubMedGoogle Scholar
  16. 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.CrossRefPubMedGoogle Scholar
  17. 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.CrossRefPubMedGoogle Scholar
  18. 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.CrossRefGoogle Scholar
  19. 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.CrossRefPubMedGoogle Scholar
  20. 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.CrossRefPubMedGoogle Scholar
  21. 21.
    UNESCO. International standard classification of education: ISCED technical report. UNESCO Institute for Statistics; 1997.Google Scholar
  22. 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.CrossRefGoogle Scholar
  23. 23.
    Greenland S. A review of multilevel theory for ecologic analyses. Stat Med. 2002;21(3):389–95.CrossRefPubMedGoogle Scholar
  24. 24.
    Honjo K. Social epidemiology: definition, history, and research examples. Environ Health Prev Med. 2004;9(5):193–9.CrossRefPubMedGoogle Scholar
  25. 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.CrossRefPubMedGoogle Scholar
  26. 26.
    Rubin D. Multiple imputation after 18+ years. J Am Stat Assoc. 1996;91:473–89.CrossRefGoogle Scholar
  27. 27.
    White I, Royston P, Wood A. Multiple imputation using chained equations. Stat Med. 2011;30:377–99.CrossRefPubMedGoogle Scholar
  28. 28.
    Schafer JL. Multiple imputation: a primer. Stat Methods Med Res. 1999;8(1):3–15.CrossRefPubMedGoogle Scholar
  29. 29.
    Schafer JL, Graham JW. Missing data: our view of the state of the art. Psychol Methods. 2002;7(2):147–77.CrossRefPubMedGoogle Scholar
  30. 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.CrossRefPubMedGoogle Scholar
  31. 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.CrossRefPubMedGoogle Scholar
  32. 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.Google Scholar
  33. 33.
    Luque Fernandez MA, Bueno-Cavanillas A. Fertility in Spain, 1996–2006: foreign versus Spanish women. Gac Sanit. 2009;23(Suppl 1):67–71.CrossRefPubMedGoogle Scholar
  34. 34.
    Fren JF, Cacciatore J, McClure EM, et al. Stillbirths: why they matter. Lancet. 2011;377(9774):1353–66.CrossRefGoogle Scholar
  35. 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.CrossRefPubMedGoogle Scholar
  36. 36.
    Reime B, Jacob C, Wenzlaff P. Is parental unemployment related to an increased risk for stillbirths? J Public Health. 2009;17:363–9.CrossRefGoogle Scholar
  37. 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.CrossRefPubMedGoogle Scholar
  38. 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.CrossRefPubMedGoogle Scholar
  39. 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.CrossRefPubMedGoogle Scholar
  40. 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.CrossRefPubMedGoogle Scholar
  41. 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.CrossRefPubMedGoogle Scholar
  42. 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.CrossRefPubMedGoogle Scholar
  43. 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.CrossRefPubMedGoogle Scholar
  44. 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.CrossRefPubMedGoogle Scholar
  45. 45.
    Yudkin P, et al. Risk of unexplained stillbirth at different gestational ages. Lancet. 1987;8543:1192–4.Google Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2013

Authors and Affiliations

  • Miguel Angel Luque-Fernandez
    • 1
    Email author
  • Manuel Franco
    • 2
    • 3
  • Bizu Gelaye
    • 1
  • Michael Schomaker
    • 4
  • Ignacio Gutierrez Garitano
    • 5
  • Catherine D’Este
    • 6
  • Michelle A. Williams
    • 1
  1. 1.Department of EpidemiologyHarvard School of Public HealthBostonUSA
  2. 2.University of Alcala de HenaresMadridSpain
  3. 3.Department of EpidemiologyJohn Hopkins School of Public HealthBaltimoreUSA
  4. 4.Centre for Infectious Disease Epidemiology and ResearchUniversity of Cape TownCape TownSouth Africa
  5. 5.Department of Obstetrics and GynaecologyCruces University HospitalBilbaoSpain
  6. 6.Faculty of Health Sciences, School of Public HealthUniversity of NewcastleNewcastleAustralia

Personalised recommendations