Joaquín Salvador

Socioeconomic inequalities in unintended pregnancy and abortion decision.

Pregnancy planning allows women to better control their life trajectory and contributes to the future child’s health and development. Many studies that have analyzed socioeconomic inequalities in unintended pregnancy only took into account those pregnancies ending in births. Few of them that analyzed unintended pregnancy, including both induced abortion and births, and its socioeconomic determinants, concluded that unintended pregnancy is more frequent in young, poor, or unmarried women. These inequalities have been poorly studied in Europe, especially in the southern European context. The aim of the present study is to describe socioeconomic inequalities in unintended pregnancy and in abortion decision in Barcelona, Spain. The major findings are that unintended pregnancies accounted for 41% of total pregnancy and of these, 60% ended in abortion. From all pregnancies, the proportion of induced abortion reached 25.6%. Compared to women with university studies, those with primary education uncompleted had more unintended pregnancies (OR = 7.22). When facing an unintended pregnancy, women of lower socioeconomic position are more likely to choose induced abortion, although this is not the case among young or single women. This study reveals deep socioeconomic inequalities in unintended pregnancies and abortion decision in Barcelona, Spain, where the birth rate is very low and the abortion rate is rising. Women in low socioeconomic positions have many more unintended pregnancies than better educated women. Except for young or single women, the lower the socioeconomic position, the higher the proportion of women who choose an induced abortion when facing an unintended pregnancy.

Desigualdades socioeconómicas relacionadas con el cuidado y el control del embarazo

Objetivo: Describir las desigualdades socioeconomicas relacionadas con el cuidado y el control del embarazo de las gestantes de Barcelona durante 1994-2003. Metodos: Diseno transversal de las gestantes de Barcelona que tuvieron un hijo sin anomalias congenitas. La informacion se obtuvo de las historias hospitalarias y una encuesta realizada a las madres del Registro de Defectos Congenitos de Barcelona, que recoge una muestra aleatoria del 2% del total de nacimientos de esta ciudad (n = 2.299). Se estudiaron las siguientes variables dependientes: visitas al obstetra, trimestre de la primera visita, numero de ecografias, ecografia del quinto mes, realizacion de una prueba invasiva, consumir acido folico, planificacion del embarazo, consumo y abandono del tabaco. Las variables independientes fueron la edad y la clase social. Se ajustaron modelos de regresion logistica para cada variable dependiente. Resultados: Las gestantes de clases sociales con ocupaciones manuales realizan, en mayor proporcion, menos de 6 visitas y la primera visita despues del primer trimestre; ademas, tienen menor probabilidad de realizar alguna prueba invasiva, tomar acido folico, planificar el embarazo, no fumar y abandonar el consumo de tabaco. Y las gestantes de clases no manuales realizan, en mayor proporcion, mas de 12 visitas y mas de 3 ecografias. Conclusiones: Hay desigualdades socioeconomicas relacionadas con el cuidado y el control del embarazo en Barcelona. Las gestantes de las clases sociales mas favorecidas realizan un mejor cuidado y control del embarazo, pero en todas se observa una excesiva medicalizacion. Una racionalizacion del uso de recursos sanitarios y una reduccion de la medicalizacion podria disminuir las desigualdades relacionadas con el cuidado y el control de la gestacion en Barcelona.

Recent Immigration and Adverse Pregnancy Outcomes in an Urban Setting in Spain

To describe social and economic inequalities in non-fatal pregnancy outcomes (low birth weight, preterm birth and small for gestational age births) in the neighbourhoods of the city of Barcelona (Spain), according to maternal age and maternal country of origin, between 1991 and 2005. A cross-sectional ecological study was carried out using the 38 neighbourhoods of Barcelona as the unit of analysis. The study population comprises the 192,921 live births to resident women aged 12–49 residing from 1991 to 2005. Information was gathered from births registry. Prevalence of low birth-weight, preterm birth and small for gestational age, was calculated for each of the 38 neighbourhoods of mothers’ residence, stratifying results by maternal age and country of origin. The indicator of neighbourhood socio-economic level was the unemployment rate. Quartile maps along with Spearman correlation coefficients and linear regression were performed between indicators. The present study reports socio-economic inequalities in pregnancy outcomes among neighbourhoods in Barcelona (Spain): the more disadvantaged neighbourhoods have worse pregnancy outcomes (low birth weight, preterm birth and small for gestational age births) in all women age groups. These inequalities do not exist among immigrant women, and some groups of foreign mothers even have lower rates of low birth weight, pretem birth, and small for gestational age births than autochthonous women. The existing inequalities suggest that policy efforts to reduce these inequalities are not entirely successful and should focus on improving pregnancy and delivery care in less privileged women in a country with universal access to health care.

Características de las gestantes y control del embarazo en Barcelona, 1994-1999

Resumen Objetivo Analizar aspectos sociodemograficos y de control del embarazo de las gestantes residentes en Barcelona y su evolucion durante el periodo 1994-1999, utilizando los controles del Registro Poblacional de Defectos Congenitos de la ciudad. Metodo La informacion se recogio mediante encuesta a la madre y revision de las historias hospitalarias. El analisis de tendencias se efectuo utilizando la prueba de Mantel-Haenszel de asociacion lineal. Para la comparacion de proporciones de las variables de control del embarazo entre centros publicos y privados se ha utilizado la prueba de la c2. Resultados Se recogio informacion de 1.337 gestantes. Se observa un incremento de la proporcion de mujeres mayores de 34 anos, pasando del 19% en 1994-1995 al 25% en 1998- 1999. Se aprecia un incremento en la clase social y una disminucion de las amas de casa. El 40% de las gestaciones no fueron planificadas, y la mitad de estas acabaron en una interrupcion voluntaria del embarazo. Estas proporciones se incrementan en gestantes menores de 25 y mayores de 39 anos. El 97% de las gestantes se visitaron por primera vez durante el primer trimestre del embarazo, practicamente todas se sometieron a alguna ecografia obstetrica, con una media de 5,2, aunque una cuarta parte no se hicieron ninguna en el quinto mes. Se registra un incremento de pruebas invasivas y de cesareas. El control medico del embarazo es mas acentuado entre las gestaciones que acaban naciendo en centros privados (un 55% del total). Conclusiones Existe una elevada falta de planificacion de los embarazos, asi como una creciente medicalizacion de la gestacion, con aspectos positivos (visita en el primer trimestre) y otros objeto de debate (ecografia obstetrica, cesareas y pruebas invasivas).

Socioeconomic inequalities in the provision and uptake of prenatal care

OBJECTIVE To describe socioeconomic inequalities in the provision and uptake of prenatal care among women in Barcelona (Spain) between 1994 and 2003. METHODS Cross-sectional study of women in Barcelona who delivered a child without birth defects. Information was obtained from hospital medical records and a personal interview with women included in the Barcelona Birth Defects Registry, containing a random sample of 2% of all pregnant women in the city (n = 2299). DEPENDENT VARIABLES number of obstetric visits, the trimester of the first visit, the number of obstetric ultrasound scans, the fifth-month diagnostic ultrasound scan, invasive procedures, prenatal folic acid intake, pregnancy planning, smoking and smoking cessation. The independent variables were maternal age and social class. Logistic regression models were filted for each dependent variable. RESULTS In social classes with manual occupations, there was a higher proportion of pregnant women who attended less than six obstetric visits and who attended the first obstetric visit after the first trimester. Moreover, these women were less likely to have undergone an invasive procedure, to have taken folic acid supplements, to have planned the pregnancy, to be non-smokers and to stop smoking. In the more privileged classes, there was a higher proportion of women who attended more than 12 obstetric visits and who underwent more than three ultrasound scans. CONCLUSIONS Socioeconomic inequalities were found in the provision and uptake of prenatal care in Barcelona. Uptake was greater in the more advantaged social classes but excessive medicalization was found in all classes. Rationalizing the use of healthcare resources and reducing excessive medicalization would reduce inequalities in prenatal care in Barcelona.

Tendencias en la exposición al tabaquismo durante la gestación: Barcelona, 1994–2001

Antecedentes La exposicion al tabaco durante la gestacion es un importante factor de riesgo para la salud infantil. En las ultimas decadas se ha incrementado la prevalencia del tabaquismo entre las mujeres en edad fertil en Espana Objetivos Valorar la exposicion fetal al tabaquismo y sus tendencias en una muestra representativa de las gestantes Metodos Se analiza la prevalencia del tabaquismo al inicio del embarazo y su abandono a partir de una muestra de las mujeres que dan a luz en la ciudad de Barcelona, extraida de los controles de un registro poblacional de defectos congenitos. La muestra es de 1.801 mujeres y abarca el periodo 1994-2001 Resultados El 43,4 % de las gestantes son fumadoras antes del embarazo y, de ellas, el 42,2 % abandona el consumo. Al final del embarazo, el 25,2 % de las mujeres consume tabaco. Durante el periodo se aprecia un claro descenso en la prevalencia del tabaquismo en las gestantes. Aunque la proporcion de cesaciones no muestra cambios significativos, disminuye la exposicion fetal al tabaco Conclusiones La prevalencia del tabaquismo entre las gestantes es elevada, aunque muchas abandonan el consumo durante el embarazo. Durante el periodo estudiado, disminuye la exposicion fetal al tabaco. Deberian desarrollarse esfuerzos mas sistematicos de intervencion

Erratum to: Neighborhood Inequalities in Adverse Pregnancy Outcomes in an Urban Setting in Spain: A Multilevel Approach

The aim of the present study was to describe socioeconomic inequalities in low birth weight (LBW), premature birth (PM) and small size for gestational age at birth (SGA) between 2000 and 2005 in Barcelona, Spain, jointly evaluating the effect of mother’s country of origin, and neighborhood of residence socioeconomic level measured using unemployment and educational level. We performed a cross-sectional study of births to mothers aged 12–49 years who were residents in the city of Barcelona in 2000–2005, analyzing adverse pregnancy outcomes (n = 61,676). Weighted multilevel logistic regression models were fitted with individual data on level 1 and neighborhood data on level 2, to obtain adjusted odds ratios (aOR) with 95% confidence intervals and residual variance. Individually, pregnancy outcomes are more favorable in births to older mothers and to mothers from Maghrib and Central and South America than from developed countries (including Spain) or from other developing countries. After adjusting for individual variables, poor pregnancy outcomes were associated with poor neighborhoods (more unemployment was associated to LBW: aOR = 1.56; PM aOR = 1.51; SGA aOR = 1.66). The same trend was observed for associations with illiteracy rate. The present study shows that there are socioeconomic inequalities in adverse pregnancy outcomes in the city of Barcelona. One of the main challenges in perinatal health continues to be the reduction of adverse pregnancy outcomes in the city.

Evolución de las desigualdades según la clase social en el control del embarazo en Barcelona (1994-97 frente a 2000-03)

Objetivo: Describir y comparar las desigualdades segun la clase social en el control del embarazo en Barcelona durante 2 periodos. Metodos: Se comparan 2 cuatrienios: 1994-1997 y 2000-2003. La poblacion de estudio son las gestantes de Barcelona y la muestra los controles del Registro de Defectos Congenitos de Barcelona (n = 905 en 1994-1997; n = 927 en 2000-2003). Las fuentes de informacion son las historias hospitalarias y una encuesta realizada a las madres. Las variables dependientes son: planificacion del embarazo, ingesta de acido folico antes del embarazo, consumo de tabaco, numero de visitas al obstetra, trimestre de primera visita, numero de ecografias, ecografia del quinto mes, prueba invasiva y abandono del tabaco. Las variables independientes son la edad y la clase social. Se ajustaron modelos de regresion logistica para cada variable dependiente segun la clase social y se compararon los resultados entre cuatrienios. Resultados: Tanto las gestantes de clases de ocupacion manual como las de no manual presentan mejorias en el segundo cuatrienio en 7 de los 10 indicadores (no son exactamente los mismos en ambas clases). Sin embargo, cuando comparamos las variaciones interclase entre los 2 cuatrienios se registran diferencias en 8 de los 10 indicadores, 7 a favor de las clases mas favorecidas y uno a favor de las menos favorecidas. Conclusiones: Excepto para una de las situaciones analizadas (hacer mas de 3 ecografias), las clases menos favorecidas presentan peores resultados que las mas favorecidas al comparar la tendencia de los indicadores entre los 2 periodos. La distancia entre clases en el ambito del control de la gestacion se acentua con el tiempo.

Evolution of prenatal detection of neural tube defects in the pregnant population of the city of Barcelona from 1992 to 2006

To assess the prenatal ultrasound detection rates (DR) of neural tube defects (NTDs) and its evolution over the 1992 to 2006 period in the pregnant population of the city of Barcelona.

Determinantes del retraso de la interrupción voluntaria del embarazo

BACKGROUND In induced abortion, the method, the risk of complications and the economic cost of the abortion are determined by gestational age. The aim of this study was to describe the determinants of induced abortion delay until the second trimester of pregnancy in Barcelona. METHODS We performed a cross-sectional study of induced abortions due to the physical or mental health of the woman (Barcelona, 2004-2005; N=9,175). The citys induced abortion register provided data on gestational age at abortion (dependent variable), educational level, age, cohabitation with the partner, number of children previous abortions, and type of center. Adjusted prevalence ratios (aPR) were calculated with log-binomial regression models. RESULTS A total of 7.7% of induced abortions were second-trimester abortions and 99.3% were performed in private centers. Compared with women with a university education, those with primary education or less had an aPR of 1.8 (95% confidence interval [95%CI]: 1.4-2.2) of delaying the abortion until the second trimester. A higher proportion of second-trimester abortions were also recorded in women aged less than 18 years old (aPR=2.6; 95%CI: 2.0-3.4), women not cohabiting with their partners (aRP=1.4; 95% CI: 1.2-1.6) and in public centers (aPR=2.8; 95% CI: 2.2-3.7). No differences were found in induced abortion delay among women with previous abortions and those without. CONCLUSION Induced abortion delay until the second trimester of pregnancy was associated with low educational level, young ages, not cohabiting with a partner, and public centers. This study demonstrates the existence of socioeconomic inequalities in access conditions to abortion services.