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Cited by 158Maternal and Neonatal HealthcareHealth disparities and outcomesGlobal Maternal and Child Health

The DOI matches its Crossref record; 79 of the 88 references it cites were found in a registry or an index; none of the 82 sources its claims cite is checked for support yet.

Socioeconomic inequalities and adverse pregnancy outcomes in the UK and Republic of Ireland: a systematic review and meta-analysis

Open access
Thomson, Katie, Moffat, Malcolm, Arisa, Oluwatomi, Jesurasa, Amrita, Richmond, Catherine, Odeniyi, Adefisayo, Bambra, Clare, Rankin, Judith, Brown, Heather, Bishop, Julie, Wing, Susan, McNaughton, Amy, Heslehurst, Nicola·2021·BMJ Open
DOI 10.1136/bmjopen-2020-042753PMC PMC7959237
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Abstract

Objective: There has been an unprecedented rise in infant mortality associated with deprivation in recent years in the United Kingdom (UK) and Republic of Ireland. A healthy pregnancy can have significant impacts on the life chances of children. The objective of this review was to understand the association between individual-level and household-level measures of socioeconomic status and adverse pregnancy outcomes. Design: Systematic review and meta-analysis. Data sources: Nine databases were searched (Medline, Embase, Scopus, ASSIA, CINAHL, PsycINFO, BNI, MIDRIS and Google Scholar) for articles published between 1999 and August 2019. Grey literature searches were also assessed. Study selection criteria: Studies reporting associations between individual-level or household socioeconomic factors on pregnancy outcomes in the UK or Ireland. Results: Among the 82 353 search results, 53 821 titles were identified and 35 unique studies met the eligibility criteria. Outcomes reported were neonatal, perinatal and maternal mortality, preterm birth, birth weight and mode of delivery. Pooled effect sizes were calculated using random-effects meta-analysis. There were significantly increased odds of women from lower levels of occupation/social classes compared with the highest level having stillbirth (OR 1.40, 95% CI 1.23 to 1.59, I 2 98.62% ), neonatal mortality (OR 1.39, 95% CI 1.22 to 1.57, I 2 97.09% ), perinatal mortality (OR 1.39, 95% CI 1.23 to 1.57, I 2 98.69% ), preterm birth (OR 1.41, 95% CI 1.33 to 1.50, I 2 70.97% ) and low birth weight (OR 1.40, 95% CI 1.19 to 1.61, I 2 99.85% ). Limitations relate to available data, unmeasured confounders and the small number of studies for some outcomes. Conclusions: This review identified consistent evidence that lower occupational status, especially manual occupations and unemployment, were significantly associated with increased risk of multiple adverse pregnancy outcomes. Strategies to improve pregnancy outcomes should incorporate approaches that address wider determinants of health to provide women and families with the best chances of having a healthy pregnancy and baby and to decrease pregnancy-related health inequalities in the general population. PROSPERO registration number: PROSPERO CRD42019140893.

Overview

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TL;DR

This systematic review and meta-analysis of 35 UK/Republic of Ireland studies (17,130,631 mothers and babies) found that lower occupation/social class was associated with significantly increased odds of stillbirth, neonatal and perinatal mortality, preterm birth, and low birth weight. Evidence was strongest for occupation-derived social class, with limited and inconsistent data for education, income, housing, and car ownership.

Key findings

  • Pooled lowest/intermediate versus highest occupation/social class showed increased odds of stillbirth (OR 1.40, 95% CI 1.23 to 1.59, I² 98.62%), neonatal mortality (OR 1.39, 95% CI 1.22 to 1.57, I² 97.09%), perinatal mortality (OR 1.39, 95% CI 1.23 to 1.57, I² 98.69%), preterm birth (OR 1.41, 95% CI 1.33 to 1.50, I² 70.97%), and low birth weight (OR 1.40, 95% CI 1.19 to 1.61, I² 99.85%); lowest-level occupation subgroups had higher odds (e.g., stillbirth OR 1.61, 95% CI 1.37 to 1.88; preterm birth OR 1.51, 95% CI 1.42 to 1.60; low birth weight OR 1.55, 95% CI 1.24 to 1.86).
  • No significant pooled association was found for very low birth weight (OR 1.18, 95% CI 0.89 to 1.57), while macrosomia showed decreased odds (OR 0.89, 95% CI 0.79 to 0.99); caesarean delivery showed reduced odds for lower occupation/social class (any caesarean OR 0.80, 95% CI 0.74 to 0.86; emergency OR 0.85, 95% CI 0.77 to 0.94; elective OR 0.83, 95% CI 0.76 to 0.91).
  • Narrative findings included increased odds of stillbirth among unemployed mothers (OR 1.24, 95% CI 1.00 to 1.54) and fathers (OR 2.26, 95% CI 1.69 to 3.02), and increased maternal mortality among unemployed women (AOR 1.81, 95% CI 1.08 to 3.04); education, income, housing, and car ownership evidence was limited or inconsistent.
  • Of 35 unique studies, 27 were UK and 8 ROI; 23 reported occupation-derived social class, 17 education, 7 employment and income/finances, 4 housing, and 1 car ownership; all studies were moderate or high quality, but GRADE evidence was low or very low for several outcomes.

Methods

  • Systematic review and meta-analysis registered with PROSPERO (CRD42019140893) and conducted in line with MOOSE; nine databases were searched from 1 January 1999 to 7 August 2019, supplemented by citation chaining, grey literature searches, and expert contact.
  • Eligible studies were observational (cohort, case–control, longitudinal, or cross-sectional) in the UK or ROI, reporting individual-level or household-level socioeconomic exposures (not aggregate area-level measures) and pregnancy outcomes for the fetus, neonate, or mother up to 28 days postnatal; from 53,821 titles after duplicates, 1,439 full texts were screened, 41 met inclusion criteria, and 35 unique studies were included.
  • Random-effects meta-analysis pooled odds ratios for occupation-derived social class where at least two studies reported comparable exposures and outcomes; narrative synthesis covered other exposures; Newcastle-Ottawa Scale and GRADE were used for quality appraisal, with analyses in Stata V.16.

Limitations

  • The paper states that findings are limited to the UK and ROI; occupational classifications changed over time and broad groupings may not reflect within-group differences; national datasets required aggregate frequency data and could not account for potential confounders; adjusted data were limited for occupation-derived social class; some outcome/SES combinations had few studies; publication bias was evident for stillbirth; GRADE quality was typically low or very low; and there were protocol deviations (UK/ROI restriction and meta-analysis of two studies).
  • The paper states that heterogeneity was high for all meta-analyses and was not explained by meta-regression, and sensitivity analyses showed birth weight results were not robust (e.g., significance changed for low birth weight intermediate subgroup, macrosomia, and very low birth weight).
  • The text makes evident that causal inference is not possible from observational data, and that data were very limited for housing, income, car ownership, and other individual/household inequality measures such as poverty and social isolation.

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Integrity signals

Registry

Crossref · 10.1136/bmjopen-2020-042753

Cites

79 of 79 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Figures

Figure 1 PRISMA flow chart. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Figure 1 PRISMA flow chart. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.CC BY-NC · PubMed Central
Figure 2 Forest plot of stillbirth. REML, Restricted Maximum Likelihood
Figure 2 Forest plot of stillbirth. REML, Restricted Maximum LikelihoodCC BY-NC · PubMed Central
Figure 3 Forest plot of perinatal mortality.
Figure 3 Forest plot of perinatal mortality.CC BY-NC · PubMed Central
Figure 4 Forest plot of neonatal mortality.
Figure 4 Forest plot of neonatal mortality.CC BY-NC · PubMed Central
Figure 5 Forest plot of VLBW.
Figure 5 Forest plot of VLBW.CC BY-NC · PubMed Central
Figure 6 Forest plot of LBW.
Figure 6 Forest plot of LBW.CC BY-NC · PubMed Central
Figure 7 Forest plot of macrosomia.
Figure 7 Forest plot of macrosomia.CC BY-NC · PubMed Central
Figure 8 Forest plot for preterm birth (<37 weeks gestation).
Figure 8 Forest plot for preterm birth (<37 weeks gestation).CC BY-NC · PubMed Central
Figure 9 Forest plot of emergency caesarean section.
Figure 9 Forest plot of emergency caesarean section.CC BY-NC · PubMed Central
Figure 10 Forest plot of elective caesarean section.
Figure 10 Forest plot of elective caesarean section.CC BY-NC · PubMed Central
Figure 11 Forest plot of any caesarean section.
Figure 11 Forest plot of any caesarean section.CC BY-NC · PubMed Central

Verification

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Citations

Cites

Research works printed but not linked: 3

  1. Veritas Health Innovation . Covidence systematic review software, 2019. Available: www.covidence.org
  2. Office for National Statistics . Standard occupational classification 2010: volume 3 the National statistics socio-economic classification: (Rebased on the SOC2010) user manual. Palgrave Macmillan, 2010.
  3. Marmot M , Allen J , Goldblatt P . Fair society healthy lives (the Marmot review). 242. London: Institute of Health Equity, University College London, 2010.

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Metadata

Authors
Thomson, K., Moffat, M., Arisa, O., Jesurasa, A., Richmond, C., Odeniyi, A., Bambra, C., Rankin, J., Brown, H., Bishop, J., Wing, S., McNaughton, A., & Heslehurst, N.
Affiliations
  • Newcastle University (GB)
  • Public Health Wales (GB)
Corresponding author
Heslehurst, Nicola
ORCID
Venue
BMJ Open
Publisher
BMJ
Published
2021-03
Volume
11
Issue
3
Pages
e042753
ISSN
2044-6055 (ISSN-L)
DOI
10.1136/bmjopen-2020-042753
PMC
PMC7959237
OpenAlex
W3136152613
Semantic Scholar
0a7ae73c11d60f05e6bdd9af8cb3a508425db4db
Cited by
154
References
88
Citations by year
2026: 28 · 2025: 42 · 2024: 36 · 2023: 23 · 2022: 16 · 2021: 9
FWCI
4.67
Type
journal article
Language
en
Open access
Licence
Locations
  • BMJ Open (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • PubMed Central (publishedVersion, cc-by-nc)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
  • Lancaster EPrints (Lancaster University) (submittedVersion)
  • Newcastle University ePrints (Newcastle Univesity) (cc-by-nc)
Funders
Public Health Wales (NA)
Topics
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and Neonatal Healthcare
  • Social Sciences › Health › Health disparities and outcomes
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
Keywords
socioeconomic disparities, adverse pregnancy outcomes, socioeconomic status, occupational status, social class, stillbirth, neonatal mortality, perinatal mortality, preterm birth, low birth weight, mode of delivery, unemployment, manual occupations, health determinants, infant mortality, United Kingdom, Republic of Ireland, child health outcomes, health disparities
MeSH terms
Child, Female, United Kingdom, Humans, Infant, Infant, Newborn, Ireland, Pregnancy, Pregnancy Outcome, Socioeconomic Factors, Premature Birth

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Data sources

Bibliographic data: Semantic Scholar, OpenAlex, Crossref.

Contains information from the Semantic Scholar Academic Graph Datasets, made available under the ODC Attribution License (ODC-BY 1.0).

Semantic Scholar’s data is described in: Kinney, R., et al. (2023). The Semantic Scholar Open Data Platform. arXiv:2301.10140.