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Mediation of socioeconomic inequalities in preterm birth. A cohort analysis of Welsh linked data

Philip McHale Orcid Logo, Daniela K. Schlüter, Hoda Abbasizanjani Orcid Logo, Ashley Akbari Orcid Logo, Ben Barr, David Taylor‐Robinson

Acta Obstetricia et Gynecologica Scandinavica, Volume: 104, Issue: 6, Pages: 1081 - 1091

Swansea University Authors: Hoda Abbasizanjani Orcid Logo, Ashley Akbari Orcid Logo

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DOI (Published version): 10.1111/aogs.15101

Abstract

IntroductionConsistent socioeconomic inequalities in preterm birth prevalence are seen internationally. Understanding the pathways to inequalities in preterm birth and the mediators that contribute to these inequalities is essential to inform policies and interventions to reduce health inequalities...

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Published in: Acta Obstetricia et Gynecologica Scandinavica
ISSN: 0001-6349 1600-0412
Published: Wiley 2025
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URI: https://cronfa.swan.ac.uk/Record/cronfa69566
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Understanding the pathways to inequalities in preterm birth and the mediators that contribute to these inequalities is essential to inform policies and interventions to reduce health inequalities across the life course.Material and MethodsWe conducted a causal mediation analysis using routinely collected, anonymised population-scale, individual-level linked data within the SAIL Databank on all singleton live births in Wales between 1 January, 2000 and 30 September, 2019. Our outcome was preterm birth, and exposure was area-based deprivation. Mediators were smoking during pregnancy, maternal mental health, hospitalisation due to maternal physical health and obstetric conditions. We calculated inequalities in preterm birth (dichotomised as before or after 37&#x2009;weeks) and estimated two measures of mediation: proportion eliminated, the percentage of the effect of deprivation on preterm birth eliminated by removing the mediators, through the Controlled Direct Effects; and proportion mediated, the percentage of the inequality removed by equalising the distribution of the mediators across socioeconomic strata. Multiple multivariate imputations by chained equations were used to deal with missing data.ResultsThe final sample included 609&#x2009;610 live births with 6.1% preterm. Socioeconomic gradients were seen in preterm birth and exposure to mediators, with a higher occurrence in mothers residing in the most compared to the least deprived quintiles. Compared with the least deprived quintile, the odds ratio for preterm births in the most deprived quintile was 1.26 (95% confidence interval 1.22&#x2013;1.31). The proportion eliminated by the removal of all mediators at the same time was 21%. The proportion mediated by maternal smoking during pregnancy was 26%, and less than 10% for other mediators.DiscussionSmoking during pregnancy is a significant mediator of preterm birth inequalities. Maternal mental and physical health during pregnancy and obstetric conditions also lie on the pathway from socioeconomic status to preterm birth but mediate the relationship to a lesser extent. Significant socioeconomic inequalities remained after the effect of mediators was removed. 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spelling 2025-06-09T17:05:14.0471874 v2 69566 2025-05-23 Mediation of socioeconomic inequalities in preterm birth. A cohort analysis of Welsh linked data 93dd7e747f3118a99566c68592a3ddcc 0000-0002-9575-4758 Hoda Abbasizanjani Hoda Abbasizanjani true false aa1b025ec0243f708bb5eb0a93d6fb52 0000-0003-0814-0801 Ashley Akbari Ashley Akbari true false 2025-05-23 MEDS IntroductionConsistent socioeconomic inequalities in preterm birth prevalence are seen internationally. Understanding the pathways to inequalities in preterm birth and the mediators that contribute to these inequalities is essential to inform policies and interventions to reduce health inequalities across the life course.Material and MethodsWe conducted a causal mediation analysis using routinely collected, anonymised population-scale, individual-level linked data within the SAIL Databank on all singleton live births in Wales between 1 January, 2000 and 30 September, 2019. Our outcome was preterm birth, and exposure was area-based deprivation. Mediators were smoking during pregnancy, maternal mental health, hospitalisation due to maternal physical health and obstetric conditions. We calculated inequalities in preterm birth (dichotomised as before or after 37 weeks) and estimated two measures of mediation: proportion eliminated, the percentage of the effect of deprivation on preterm birth eliminated by removing the mediators, through the Controlled Direct Effects; and proportion mediated, the percentage of the inequality removed by equalising the distribution of the mediators across socioeconomic strata. Multiple multivariate imputations by chained equations were used to deal with missing data.ResultsThe final sample included 609 610 live births with 6.1% preterm. Socioeconomic gradients were seen in preterm birth and exposure to mediators, with a higher occurrence in mothers residing in the most compared to the least deprived quintiles. Compared with the least deprived quintile, the odds ratio for preterm births in the most deprived quintile was 1.26 (95% confidence interval 1.22–1.31). The proportion eliminated by the removal of all mediators at the same time was 21%. The proportion mediated by maternal smoking during pregnancy was 26%, and less than 10% for other mediators.DiscussionSmoking during pregnancy is a significant mediator of preterm birth inequalities. Maternal mental and physical health during pregnancy and obstetric conditions also lie on the pathway from socioeconomic status to preterm birth but mediate the relationship to a lesser extent. Significant socioeconomic inequalities remained after the effect of mediators was removed. These findings suggest that there is a need to reduce inequalities in smoking during pregnancy and direct action on socioeconomic status during pregnancy. Journal Article Acta Obstetricia et Gynecologica Scandinavica 104 6 1081 1091 Wiley 0001-6349 1600-0412 epidemiology, mediation, pregnancy, preterm birth, socioeconomic inequalities 1 6 2025 2025-06-01 10.1111/aogs.15101 COLLEGE NANME Medical School COLLEGE CODE MEDS Swansea University Another institution paid the OA fee Medical Research Council, Grant/Award Number: MR/T00794X/1; NIHRPublic Health Policy Research Unit;NIHR Applied Research CollaborationNorthwest Coast, Grant/Award Number:NIHR200182; National Institute forHealth and Care Research, Grant/AwardNumber: NIHR302438; NIHR School forPublic Health Research, Grant/AwardNumber: NIHR204000 2025-06-09T17:05:14.0471874 2025-05-23T21:30:58.7190372 Faculty of Medicine, Health and Life Sciences Swansea University Medical School - Health Data Science Philip McHale 0000-0002-8560-2291 1 Daniela K. Schlüter 2 Hoda Abbasizanjani 0000-0002-9575-4758 3 Ashley Akbari 0000-0003-0814-0801 4 Ben Barr 5 David Taylor‐Robinson 6 69566__34439__bc676042430a467da92ad7322a9c8c69.pdf 69566.VoR.pdf 2025-06-09T17:04:33.8871057 Output 1393717 application/pdf Version of Record true © 2025 The Author(s). This is an open access article under the terms of the Creative Commons Attribution License. true eng http://creativecommons.org/licenses/by/4.0/
title Mediation of socioeconomic inequalities in preterm birth. A cohort analysis of Welsh linked data
spellingShingle Mediation of socioeconomic inequalities in preterm birth. A cohort analysis of Welsh linked data
Hoda Abbasizanjani
Ashley Akbari
title_short Mediation of socioeconomic inequalities in preterm birth. A cohort analysis of Welsh linked data
title_full Mediation of socioeconomic inequalities in preterm birth. A cohort analysis of Welsh linked data
title_fullStr Mediation of socioeconomic inequalities in preterm birth. A cohort analysis of Welsh linked data
title_full_unstemmed Mediation of socioeconomic inequalities in preterm birth. A cohort analysis of Welsh linked data
title_sort Mediation of socioeconomic inequalities in preterm birth. A cohort analysis of Welsh linked data
author_id_str_mv 93dd7e747f3118a99566c68592a3ddcc
aa1b025ec0243f708bb5eb0a93d6fb52
author_id_fullname_str_mv 93dd7e747f3118a99566c68592a3ddcc_***_Hoda Abbasizanjani
aa1b025ec0243f708bb5eb0a93d6fb52_***_Ashley Akbari
author Hoda Abbasizanjani
Ashley Akbari
author2 Philip McHale
Daniela K. Schlüter
Hoda Abbasizanjani
Ashley Akbari
Ben Barr
David Taylor‐Robinson
format Journal article
container_title Acta Obstetricia et Gynecologica Scandinavica
container_volume 104
container_issue 6
container_start_page 1081
publishDate 2025
institution Swansea University
issn 0001-6349
1600-0412
doi_str_mv 10.1111/aogs.15101
publisher Wiley
college_str Faculty of Medicine, Health and Life Sciences
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hierarchy_top_id facultyofmedicinehealthandlifesciences
hierarchy_top_title Faculty of Medicine, Health and Life Sciences
hierarchy_parent_id facultyofmedicinehealthandlifesciences
hierarchy_parent_title Faculty of Medicine, Health and Life Sciences
department_str Swansea University Medical School - Health Data Science{{{_:::_}}}Faculty of Medicine, Health and Life Sciences{{{_:::_}}}Swansea University Medical School - Health Data Science
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description IntroductionConsistent socioeconomic inequalities in preterm birth prevalence are seen internationally. Understanding the pathways to inequalities in preterm birth and the mediators that contribute to these inequalities is essential to inform policies and interventions to reduce health inequalities across the life course.Material and MethodsWe conducted a causal mediation analysis using routinely collected, anonymised population-scale, individual-level linked data within the SAIL Databank on all singleton live births in Wales between 1 January, 2000 and 30 September, 2019. Our outcome was preterm birth, and exposure was area-based deprivation. Mediators were smoking during pregnancy, maternal mental health, hospitalisation due to maternal physical health and obstetric conditions. We calculated inequalities in preterm birth (dichotomised as before or after 37 weeks) and estimated two measures of mediation: proportion eliminated, the percentage of the effect of deprivation on preterm birth eliminated by removing the mediators, through the Controlled Direct Effects; and proportion mediated, the percentage of the inequality removed by equalising the distribution of the mediators across socioeconomic strata. Multiple multivariate imputations by chained equations were used to deal with missing data.ResultsThe final sample included 609 610 live births with 6.1% preterm. Socioeconomic gradients were seen in preterm birth and exposure to mediators, with a higher occurrence in mothers residing in the most compared to the least deprived quintiles. Compared with the least deprived quintile, the odds ratio for preterm births in the most deprived quintile was 1.26 (95% confidence interval 1.22–1.31). The proportion eliminated by the removal of all mediators at the same time was 21%. The proportion mediated by maternal smoking during pregnancy was 26%, and less than 10% for other mediators.DiscussionSmoking during pregnancy is a significant mediator of preterm birth inequalities. Maternal mental and physical health during pregnancy and obstetric conditions also lie on the pathway from socioeconomic status to preterm birth but mediate the relationship to a lesser extent. Significant socioeconomic inequalities remained after the effect of mediators was removed. These findings suggest that there is a need to reduce inequalities in smoking during pregnancy and direct action on socioeconomic status during pregnancy.
published_date 2025-06-01T06:01:53Z
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