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A Comprehensive Review on Social Inequalities and Pregnancy Outcome—Identification of Relevant Pathways and Mechanisms
Open accessAbstract
Scientific literature tends to support the idea that the pregnancy and health status of fetuses and newborns can be affected by maternal, parental, and contextual characteristics. In addition, a growing body of evidence reports that social determinants, measured at individual and/or aggregated level(s), play a crucial role in fetal and newborn health. Numerous studies have found social factors (including maternal age and education, marital status, pregnancy intention, and socioeconomic status) to be linked to poor birth outcomes. Several have also suggested that beyond individual and contextual social characteristics, living environment and conditions (or “neighborhood”) emerge as important determinants in health inequalities, particularly for pregnant women. Using a comprehensive review, we present a conceptual framework based on the work of both the Commission on Social Determinants of Health and the World Health Organization (WHO), aimed at describing the various pathways through which social characteristics can affect both pregnancy and fetal health, with a focus on the structural social determinants (such as socioeconomic and political context) that influence social position, as well as on intermediary determinants. We also suggest that social position may influence more specific intermediary health determinants; individuals may, on the basis of their social position, experience differences in environmental exposure and vulnerability to health-compromising living conditions. Our model highlights the fact that adverse birth outcomes, which inevitably lead to health inequity, may, in turn, affect the individual social position. In order to address both the inequalities that begin in utero and the disparities observed at birth, it is important for interventions to target various unhealthy behaviors and psychosocial conditions in early pregnancy. Health policy must, then, support: (i) midwifery availability and accessibility and (ii) enhanced multidisciplinary support for deprived pregnant women.
Checked 2026-11-13 · 2 references not checked yet
Overview
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TL;DR
This comprehensive review of 35 studies finds excess risk of low birthweight (LBW) and preterm birth (PTB) among deprived pregnant women and those living in deprived neighborhoods. It proposes a WHO/CSDH-based conceptual framework linking structural social determinants through material circumstances, behaviors/lifestyle, psychosocial environment, and healthcare access to adverse pregnancy outcomes.
Key findings
- From 359 screened studies, 35 met inclusion criteria and most showed increased LBW or decreased birthweight with adverse socioeconomic conditions: maternal education LBW risk ranged from OR = 2.0 [1.49–2.71] to RR = 3.77 [2.26–6.30]; unemployment during pregnancy OR = 1.7 [1.37–2.10]; maternal income OR = 1.7 [1.58–2.84]; employment precarity RR = 1.48 [1.11–1.98].
- Birthweight decreased by beta = −103 g [−108; −97] for lower vs. higher maternal education and beta = −56 g [−61; −50] for paternal education; living in the most deprived areas was associated with beta = −113.4 g [−133.0; −93.8].
- PTB risk was higher in the highest county poverty quartile (OR = 1.18; 95% CI [1.03, 1.35]), in deprived vs. privileged neighborhoods (OR = 1.16; 95% CI [1.06–1.27]), and in most deprived vs. most privileged groups (OR = 1.5; 95% CI [1.3; 1.7]).
- SGA was associated with social characteristics in all but two studies: unemployment OR ≈ 1.3, low parental education up to 2.8, lowest income decile OR = 2.0 [1.78; 2.26], less skilled family head occupation RR = 1.79 [1.29; 2.47], and most deprived neighborhoods OR = 1.18 [1.07; 1.30].
Methods
- Comprehensive review following PRISMA: PubMed search for English-language articles published January 2000–April 2022, plus reference-list and citation screening, using keywords for deprivation, socioeconomic inequality, neighborhood, lifestyle, and outcomes including LBW, birthweight, PTB, gestational age, and SGA.
- Inclusion criteria were human studies, peer-reviewed English papers after 2000, restricted to pregnant women and pregnancy outcomes; non-original studies were excluded. Two authors independently screened and extracted data; 359 studies were screened and 35 met criteria.
- Extracted measures included ORs, HRs, RRs, and other association metrics, preferentially from fully adjusted models; the paper then adapted the CSDH/WHO conceptual framework to propose pathways and mechanisms.
Limitations
- The paper states that heterogeneous statistical methods and confounding factors make comparison across studies difficult; most studies used classical multivariate regression, only five performed multilevel analysis, and two tested mediation via structural equation models.
- The paper states that none of the reviewed studies adjusted on household characteristics such as family income, parental life course factors, and family smoking status, and none explored paternal characteristics except one study.
- Evident from the text: the search was limited to PubMed and English-language articles, and the included studies were heavily concentrated in the United States, with only six from Europe/UK, one from Asia, and one covering four countries; no formal quality appraisal or meta-analytic pooling is reported.
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In the paper
“For instance, the risk of PTB is significantly linked with a low level of maternal education (compared to those having a higher level of education), with a risk of about 1.2 in Kaufman et al. [33] and El-Sayed et al. [47].”
§ A Comprehensive Review on Social Inequalities and Pregnancy Outcome—Identification of Relevant Pathways and Mechanisms > 3. Results > 3.7. Findings in Terms of Social Determinants and Health Inequalities
What the sources say
- Not checked yetcites [33] Kaufman, J.S., Alonso, F.T., and Pino, P. (2008). Multi-Level Modeling of Social Factors and Preterm Delivery in Santiago de Chile. BMC Pregnancy Childbirth, 8. source
- Not checked yetcites [47] Galea, 2012, Temporal Changes in Socioeconomic Influences on Health: Maternal Education and Preterm Birth, Am. J. Public Health source
plainstates an association- Asserted: passes — The authors put it forward as true.
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In the paper
“In addition, when comparing mothers with lower vs. higher levels of education, the decrease in birthweight was equal to beta = −103; 95%CI [−108; −97] [52].”
§ A Comprehensive Review on Social Inequalities and Pregnancy Outcome—Identification of Relevant Pathways and Mechanisms > 3. Results > 3.7. Findings in Terms of Social Determinants and Health Inequalities
What the sources say
- Not checked yetcites [52] Mortensen, 2008, Social Inequality in Fetal Growth: A Comparative Study of Denmark, Finland, Norway and Sweden in the Period 1981–2000, J. Epidemiol. Community Health source
plainstates an association- Asserted: passes — The authors put it forward as true.
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In the paper
“The risk of LBW increased far more among African American women living in low-poverty neighborhoods than it did for white women living in low-poverty neighborhoods (OR: 5.23; 95%CI [2.26;12.10]) in the study by Wallace et al. [39].”
§ A Comprehensive Review on Social Inequalities and Pregnancy Outcome—Identification of Relevant Pathways and Mechanisms > 3. Results > 3.7. Findings in Terms of Social Determinants and Health Inequalities
What the sources say
- Not checked yetcites [39] Wallace, 2013, Neighborhood Poverty, Allostatic Load, and Birth Outcomes in African American and White Women: Findings from the Bogalusa Heart Study, Health Place source
plainstates a cause- Asserted: passes — The authors put it forward as true.
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In the paper
“For instance, a significant decrease in birthweight was observed in the most deprived areas, in comparison with the least deprived (Beta = –113.4 g (95%CI [ –133.0; –93.8]) [51].”
§ A Comprehensive Review on Social Inequalities and Pregnancy Outcome—Identification of Relevant Pathways and Mechanisms > 3. Results > 3.7. Findings in Terms of Social Determinants and Health Inequalities
What the sources say
- Not checked yetcites [51] Glinianaia, S.V., Ghosh, R., Rankin, J., Pearce, M.S., Parker, L., and Pless-Mulloli, T. (2013). No Improvement in Socioeconomic Inequalities in Birthweight and Preterm Birth over Four Decades: A Population-Based Cohort Study. BMC Public Health, 13. source
plainstates an association- Asserted: passes — The authors put it forward as true.
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None of the sources cited for this claim have been checked yet.
In the paper
“However, a few studies [35,48,49] suggested that from fully adjusted models (including both individual- and family-level characteristics), the effect of neighborhood socioeconomic status was not as important as previously demonstrated [35,48].”
§ A Comprehensive Review on Social Inequalities and Pregnancy Outcome—Identification of Relevant Pathways and Mechanisms > 3. Results > 3.7. Findings in Terms of Social Determinants and Health Inequalities
What the sources say
- Not checked yetcites [35] Young, 2010, A Multilevel Non-Hierarchical Study of Birth Weight and Socioeconomic Status, Int. J. Health. Geogr. source
- Not checked yetcites [48] Narla, 2013, Comparison of Individual-Level versus Area-Level Socioeconomic Measures in Assessing Health Outcomes of Children in Olmsted County, Minnesota, J. Epidemiol. Community Health source
- Not checked yetcites [49] Carvalho, 2005, Similarity between Neonatal Profile and Socioeconomic Index: A Spatial Approach, Cad. Saúde Pública source
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Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ A Comprehensive Review on Social Inequalities and Pregnancy Outcome—Identification of Relevant Pathways and Mechanisms > 3. Results > 3.7. Findings in Terms of Social Determinants and Health Inequalities
“most studies confirmed that the risk of PTB was associated with individual or family socioeconomic characteristics [31,33,36,37,38,39,42,44,46,47,50,54]”
§ A Comprehensive Review on Social Inequalities and Pregnancy Outcome—Identification of Relevant Pathways and Mechanisms > 3. Results > 3.7. Findings in Terms of Social Determinants and Health Inequalities
“all but four studies reached this conclusion [37,39,50,54].”
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ A Comprehensive Review on Social Inequalities and Pregnancy Outcome—Identification of Relevant Pathways and Mechanisms > 3. Results > 3.7. Findings in Terms of Social Determinants and Health Inequalities
“Huang et al. found an association between a grandmother’s education at the time of a mother’s birth and the birthweight of her grandchild, independent of the mother’s mediating life course”
§ A Comprehensive Review on Social Inequalities and Pregnancy Outcome—Identification of Relevant Pathways and Mechanisms > 3. Results > 3.7. Findings in Terms of Social Determinants and Health Inequalities
“(beta = −54 g 95%CI [−14.0; 122.1]) per increase in educational level [45].”
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ A Comprehensive Review on Social Inequalities and Pregnancy Outcome—Identification of Relevant Pathways and Mechanisms > 3. Results > 3.4. Assessment of Social Inequalities
“just five studies performed multilevel analysis [26,30,33,34,35].”
§ A Comprehensive Review on Social Inequalities and Pregnancy Outcome—Identification of Relevant Pathways and Mechanisms > References
“36. Urquia M.L. Frank J.W. Moineddin R. Glazier R.H. Does Time Since Immigration Modify Neighborhood Deprivation Gradients in Preterm Birth? A Multilevel Analysis”
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ A Comprehensive Review on Social Inequalities and Pregnancy Outcome—Identification of Relevant Pathways and Mechanisms > 3. Results > 3.6. Definition of Social Determinants
“Others used neighborhood socioeconomic characteristics only [28,30,51,53]”
§ A Comprehensive Review on Social Inequalities and Pregnancy Outcome—Identification of Relevant Pathways and Mechanisms > 3. Results > 3.6. Definition of Social Determinants
“Most studies, however, used both individual and neighborhood socioeconomic characteristics [32,33,34,35,39,40,42,43,45,46,48,51,57].”
Citations
Cites
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Epidemiology and causes of preterm birth
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Air Pollution Removal by Urban Trees and Shrubs in the United States
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- Gray, R., Headley, J., Oakley, L., Kurinczuk, J.J., Brocklehurst, P., and Hollowell, J. (2022, August 20). Towards an Understanding of Variations in Infant Mortality Rates between Different Ethnic Groups in England and Wales. Available online: https://www.semanticscholar.org/paper/Towards-an-understanding-of-variations-in-infant-in-Graya-Headleyb/d7a8fb6fb35f6b7516e7d6cfdbceb24f70cd080b.
Cited by
Cytokine modulation and immunoregulation of uterine NK cells in pregnancy disorders
Zhou, J., Yan, P., Ma, W., & Li, J. (2024) · Cytokine & Growth Factor Reviews · doi:10.1016/j.cytogfr.2024.11.007 · Cited by 44
Tackling racism in maternal health
Catalão, R., Zephyrin, L., Richardson, L., Coghill, Y., Smylie, J. K., & Hatch, S. L. (2023) · BMJ · doi:10.1136/bmj-2023-076092 · Cited by 32
Fell, D. B., Török, E., Sprague, A. E., Regan, A. K., Dhinsa, T., Alton, G. D., Dimanlig-Cruz, S., MacDonald, S. E., Buchan, S. A., Kwong, J. C., et al. (2023) · Vaccine · doi:10.1016/j.vaccine.2023.01.073 · Cited by 21
Inclusion in Motion: Promoting Equitable Physical Activity and Health in Childhood and Adolescence
Ulset, V. S., Oppici, L., Hamre, K., Rudd, J. R., Stornæs, A. V., Haraldsen, H. M., & Säfvenbom, R. (2025) · Children · doi:10.3390/children12070942 · Cited by 16
Buciu, V. B., Șerban, D. M., Olariu, S., Novacescu, D., Cîtu, C., Ciurescu, S., Tomescu, L. C., Rațiu, A., Sas, I., Ionac, M. E., et al. (2025) · Journal of Clinical Medicine · doi:10.3390/jcm14113937 · Cited by 9
Metadata
- Authors
- Simoncic, V., Deguen, S., Enaux, C., Vandentorren, S., & Kihal-Talantikite, W.
- Affiliations
- Centre National de la Recherche Scientifique (FR)
- Université de Bordeaux (FR)
- LIVE UMR 7362 CNRS (Laboratoire Image Ville Environnement), University of Strasbourg, 67100 Strasbourg, France
- Corresponding author
- Simoncic, Valentin
- Venue
- International Journal of Environmental Research and Public Health
- Publisher
- MDPI AG
- Published
- 2022-12-10
- Volume
- 19
- Issue
- 24
- Pages
- 16592
- ISSN
- 1660-4601 (ISSN-L)
- PMC
- PMC9779203
- OpenAlex
- W4311133980
- Semantic Scholar
- 6294f896280979870a158299965bc5d52cf55ecb
- Cited by
- 83
- References
- 272
- Citations by year
- 2026: 27 · 2025: 36 · 2024: 11 · 2023: 9
- FWCI
- 3.07
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- International Journal of Environmental Research and Public Health (publishedVersion, cc-by)
- PubMed (publishedVersion)
- PubMed Central (publishedVersion, cc-by)
- HAL (submittedVersion, cc-by)
- RePEc: Research Papers in Economics (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Oskar-Bordeaux (Universite de Bordeaux) (submittedVersion, cc-by)
- Funders
- Grand Est Region
- Topics
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and Neonatal Healthcare
- Social Sciences › Health › Public Health and Social Inequalities
- Social Sciences › Health › Health disparities and outcomes
- Keywords
- birth outcomes, social determinants of health, maternal socioeconomic status, neighborhood effects, health disparities, fetal well-being, maternal age, maternal education, marital status, pregnancy intention, social status, environmental exposure, psychosocial risk factors
- MeSH terms
- Female, Humans, Infant, Newborn, Pregnancy, Pregnancy Outcome, Prenatal Care, Social Class, Socioeconomic Factors, Pregnant People
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