Maternal education and age: inequalities in neonatal death

Fonseca, Sandra Costa; Flores, Patricia Viana Guimarães; Camargo Jr., Kenneth Rochel; Pinheiro, Rejane Sobrino; Coeli, Claudia Medina

doi:10.11606/S1518-8787.2017051007013

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Original Articles • Rev. Saúde Pública 51 • 2017 • https://doi.org/10.11606/S1518-8787.2017051007013 copy

Maternal education and age: inequalities in neonatal death

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

Evaluate the interaction between maternal age and education level in neonatal mortality, as well as investigate the temporal evolution of neonatal mortality in each stratum formed by the combination of these two risk factors.

METHODS

A nonconcurrent cohort study, resulting from a probabilistic relationship between the Mortality Information System and the Live Birth Information System. To investigate the risk of neonatal death we performed a logistic regression, with an odds ratio estimate for the combined variable of maternal education and age, as well as the evaluation of additive and multiplicative interaction. The neonatal mortality rate time series, according to maternal education and age, was estimated by the Joinpoint Regression program.

RESULTS

The neonatal mortality rate in the period was 8.09‰ and it was higher in newborns of mothers with low education levels: 12.7‰ (adolescent mothers) and 12.4‰ (mother 35 years old or older). Low level of education, without the age effect, increased the chance of neonatal death by 25% (OR = 1.25, 95%CI 1.14–1.36). The isolated effect of age on neonatal death was higher for adolescent mothers (OR = 1.39, 95%CI 1.33–1.46) than for mothers aged ≥ 35 years (OR = 1.16, 95%CI 1.09–1.23). In the time-trend analysis, no age group of women with low education levels presented a reduction in the neonatal mortality rate for the period, as opposed to women with intermediate or high levels of education, where the reduction was significant, around 4% annually.

CONCLUSIONS

Two more vulnerable groups – adolescents with low levels of education and older women with low levels of education – were identified in relation to the risk of neonatal death and inequality in reducing the mortality rate.

Infant Mortality, trends; Socioeconomic Factors; Mothers; Educational Status; Maternal Age; Health Inequalities

Variable	Education
Maternal age (years)	Low	Intermediate and high
	(< 4 years)	(≥ 4 years)
	(n = 91,973)	(n = 1,353,369)

	NMR (95%CI)	NMR (95%CI)
11–19	12.71 (10.94–14.67)	10.13 (9.74–10.52)
20–34	9.07 (8.35–9.83)	7.29 (7.12–7.46)
35 or older	12.47 (10.68–14.46)	8.44 (7.97–8.92)

Variable	Maternal age group (years)						OR (95%CI) for maternal age (10–19 years), within the maternal education strata	OR (95%CI) for maternal age (≥ 35 years), within the maternal education strata

	20-34		10-19		≥ 35

	# of deaths/ survivors	OR (95%CI)	# of deaths/ survivors	OR (95%CI)	# of deaths/ survivors	OR (95%CI)
Maternal education
≥ 4 years	6,927/943,409	Reference	2,601/254,274	1.39 (1.33–1.46)	1,233/144,925	1.16 (1.09–1.23)	1.39 (1.33–1.46)	1.16 (1.09–1.23)
≥ 4 years				p = 0.000		p = 0.000	p = 0.000	p = 0.000
< 4 years	578/63,161	1.25 (1.14–1.36)	183/14,257	1.74 (1.51–2.03)	172/13,622	1.72 (1.48–2.00)	1.40 (1.19–1.66);	1.38 (1.16–1.64)
< 4 years		p = 0.000		p = 0.000		p = 0.000	p = 0.000	p = 0.000

OR (95%CI) for education within the maternal age strata

		1.25 (1.14–1.36)		1.25 (1.08–1.46)		1.48 (1.26–1.74)
		p = 0.000		p = 0.003		p = 0.000
Interaction measure on the additive scale
RERI (95%CI)			0.11 (-0.17–0.39); p = 0.45		0.32 (0.10–0.53); p = 0.003
AP (95%CI)			0.06 (-0.09–0.21); p = 0.42		0.18 (0.06–0.31); p = 0.004
S (95%CI)			1.17 (0.79–1.72); p = 043		1.78 (1.05–3.00);p = 0.032
Interaction measure on the multiplicative scale OR (95%CI)			1.01 (0.85–1.20); p = 0.94		1.19 (0.99–1.43); p = 0.06

Maternal category/Education and age	Neonatal mortality rate							Annual percentage change

	2004	2005	2006	2007	2008	2009	2010	(95%CI)
Low education
(1) 11 to 19 years	16.0	11.9	6.8	14.4	10.9	10.2	18.9	2.3% (-10.1–16.3)
(2) 20 to 34 years	10.3	8.7	8.2	9.5	8.8	8.9	7.7	-2.4% (-5.8–1.1)
(3) ≥ 35 years	13.3	16.0	10.2	10.1	13.1	12.9	9.5	-3.8 % (-10.5–3.4)
Intermediate or high education
(4) 11 to 19 years	11.3	11.2	10.8	9.4	9.3	9.5	9.1	-4.0% (-5.8– -2.2)^*
(5) 20 to 34 years	8.1	8.1	7.5	7.3	6.7	6.7	6.6	-4.1% (-4.9– -3.2)^*
(6) ≥ 35 years	10.1	9.3	8.4	8.8	7.9	7.4	7.3	-5.2% (-6.3– -4.0)^*

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[1] Correspondence: Sandra Costa Fonseca. Departamento de Epidemiologia e Bioestatística Instituto de Saúde Coletiva. Universidade Federal Fluminense R. Marquês de Paraná, 303 Anexo 3ª andar Sala 6 24033-900 Niterói, RJ, Brasil E-mail: sandracfonseca@yahoo.com.br