A nationwide study of over 1 million births in the English National Health Service (NHS) between 2015 and 2017, published in The Lancet, has found large inequalities in pregnancy outcomes between ethnic and socioeconomic groups in England.
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.
“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,” says co-lead author Dr Jennifer Jardine from the Royal College of Obstetrics and Gynaecologists, UK. [1]
She continues, “Over the past few decades, efforts to close the gap in birth outcomes focusing primarily on improving maternity care and targeting individual behaviours have not been successful. Birth outcomes don’t only represent a woman’s health during pregnancy but also reflect her health and wellbeing across her entire life. While we must continue to encourage healthy behaviours during pregnancy, we also need public health professionals and politicians to strengthen efforts to address the lifelong, cumulative impact of racism and social and economic inequalities on the health of women, families, and communities.” [1]
The NHS has set a target of halving stillbirth and neonatal death rates and reducing levels of preterm birth by 25% by 2025. Socioeconomic deprivation and minority ethnic background are known risk factors for adverse pregnancy outcomes. However, little is known about the strength of these risk factors or the scale of their impact at the population level. Moreover, a lack of information about how differences in pregnancy outcomes are related to women’s societal circumstances and pre-existing health conditions can hamper efforts to improve pregnancy outcomes and reduce inequalities.
To find out more, a team from the National Maternity and Perinatal Audit analysed birth records between 1st April 2015 and 31st March 2017 in NHS hospitals in England to quantify socioeconomic and ethnic inequalities in stillbirth (the death of a fetus after 24 weeks of pregnancy), preterm birth (live birth before 37 weeks), and fetal growth restriction (FGR) in England.
The team 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 (BMI), and other pregnancy 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.
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, 4,505 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 (table 1).
The analysis estimates that 24% of stillbirths, 19% of live preterm births, and 31% of live births with FGR were attributed to socioeconomic inequality and would not have occurred if all women had the same risk of adverse pregnancy outcomes as women in the least deprived group. Adjusting for ethnicity, maternal smoking, and BMI substantially reduced these inequalities (to 12%, 12%, and 16%, respectively)—suggesting that these characteristics can explain a considerable part of the socioeconomic inequalities in pregnancy outcomes.
Pregnancy complications disproportionately affected Black and minority ethnic women—with 12% of all stillbirths, 1% of preterm