Ability of municipality-level deprivation indices to capture social inequalities in perinatal health in France: A nationwide study using preterm birth and small for gestational age to illustrate their relevance

Abstract

Background: Evidence-based policy-making to reduce perinatal health inequalities requires an accurate measure of social disparities. We aimed to evaluate the relevance of two municipality-level deprivation indices (DIs), the French-Deprivation-Index (FDep) and the French-European-Deprivation-Index (FEDI) in perinatal health through two key perinatal outcomes: preterm birth (PTB) and small-for-gestational-age (SGA).

Methods: We used two data sources: The French National Perinatal Surveys (NPS) and the French national health data system (SNDS). Using the former, we compared the gradients of the associations between individual socioeconomic characteristics (educational level and income) and "PTB and SGA" and associations between municipality-level DIs (Q1:least deprived; Q5:most deprived) and "PTB and SGA". Using the SNDS, we then studied the association between each component of the two DIs (census data, 2015) and "PTB and SGA". Adjusted odds ratios (aOR) were estimated using multilevel logistic regression with random intercept at the municipality level.

Results: In the NPS (N = 26,238), PTB and SGA were associated with two individual socioeconomic characteristics: maternal educational level (≤ lower secondary school vs. ≥ Bachelor's degree or equivalent, PTB: aOR = 1.43 [1.22-1.68], SGA: (1.31 [1.61-1.49]) and household income (< 1000 € vs. ≥ 3000 €, PTB: 1.55 [1.25-1.92], SGA: 1.69 [1.45-1.98]). For both FDep and FEDI, PTB and SGA were more frequent in deprived municipalities (Q5: 7.8% vs. Q1: 6.3% and 9.0% vs. 5.9% for PTB, respectively, and 12.0% vs. 10.3% and 11.9% vs. 10.2% for SGA, respectively). However, after adjustment, neither FDep nor FEDI showed a significant gradient with PTB or SGA. In the SNDS (N = 726,497), no FDep component, and only three FEDI components were significantly associated (specifically, the % of the population with ≤ lower secondary level of education with both outcomes (PTB: 1.5 [1.15-1.96]); SGA: 1.25 [1.03-1.51]), the % of overcrowded (i.e., > 1 person per room) houses (1.63 [1.15-2.32]) with PTB only, and unskilled farm workers with SGA only (1.52 [1.29-1.79]).

Conclusion: Some components of FDep and FEDI were less relevant than others for capturing ecological inequalities in PTB and SGA. Results varied for each DI and perinatal outcome studied. These findings highlight the importance of testing DI relevance prior to examining perinatal health inequalities, and suggest the need to develop DIs that are suitable for pregnant women. .

Keywords: Deprivation indices; Preterm birth; Small for gestational age; Social inequalities in health; Socioeconomic factors.

Fig. 1

Flow chart of the study

Fig. 2

Multivariate multilevel analyses for the NPS: Association between PTB and individual socioeconomic status, and the quintiles of both DIs (FDep, FEDI) (Fig. 2a). Association between SGA and individual socioeconomic status, and the quintiles of the DIs (FDep, FEDI) (Fig. 2 b). aOR (95% CI) = adjusted odds ratio (95% confidence interval) from multilevel logistic regression models. Educational level categorized into four classes: ISCED 0–2 (lower secondary education or less), ISCED 3 (upper secondary education), ISCED 4–5 (post-secondary non-tertiary education, short-cycle tertiary education), ISCED 6–8 (university Bachelors’ degree or equivalent or higher). Individual social deprivation index categorized into in four classes: ISDI-0: zero factor, ISDI-1: one factor, ISDI-2: two factors, ISDI ≥ 3 factors. FDep/FEDI: Q1: least-deprived quintile (reference); Q5: most-deprived quintile. a Preterm Birth. b Small for gestational age

Fig. 3

Multivariate multilevel analysis for both FDep and FEDI components in the SNDS: Association between FDep and FEDI components and preterm birth (Fig. 3a) and small for gestational age (Fig. 3b) which were significant in Appendices 4 and 5. aOR (95% CI) = adjusted odds ratio (95% confidence interval) from multilevel analyses. All FDep and FEDI significant components adjusted for individual mother’s characteristics in the same model. a Preterm birth. b Small for gestational age