inequalities in induced abortion according to birthplace and educational attainment in the basque...

Yolanda González-Rábago, Elena Rodriguez-Alvarez, Luisa N. Borrell and Unai MartínResearch Group on Social Determinants of Health and Demographic Change - OPIK

Inequalities in induced abortion according to birthplace and educational attainment in a Southern European region (Basque Country)

www.ehu.eus/opik@Opik_ikerketa

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Inequalities in induced abortion

• Research Group on Social Determinants of Health and Demographic Change – OPIK:

– Inequalities in health and use of health services between immigrant population and native population in the Basque Country (University of the Basque Country, EHU14/55)

– Crisis, health and social inequalities in health (Ministry of Economy and Competitiveness of Spain, CSO2013-44886-R)

Background

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Index

• Background• Methods• Results• Conclusions

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Inequalities in induced abortion

• Health inequalities by birthplace: unequal distribution of social determinants of health:- Socioeconomic status (SES)

- Discrimination

- Social support

• Health inequalities by level of education

• Intersection of axes of inequalities in different areas and also related to health

– Few in reproductive health (Downing et al. 2006; Eskild et al. 2007)

Background

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Inequalities in induced abortion

• Induced abortion (IA) as an indicator of reproductive health that has shown social inequalities:

• Repetition and 2nd trimester: risk to women’s health and adverse outcomes in future pregnancies (Jones and Finer 2012; Font-Ribera et al. 2009; Hardy et al. 2013; Brown et al. 2008)

• Last two decades tremendous growth of the immigrant population in Spain (12.6% 2015)– Some previous studies have shown inequalities in IA, but

any of them look at intersection of two axes

Background

Birthplace: higher rate of IA, repetition and 2nd trimester (Fisher et al. 2005; Helström et al. 2003; Loeber et al. 2008; Picavet et al. 2013)

Education: higher rate of IA, repetition and 2nd trimester (Perez et al. 2010; Jones and Finer 2012; Makenzius et al. 2011; Laanpere et al. 2014)

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Inequalities in induced abortion

Objective:

– Examine the independent and joint effects of birthplace and education on IA, repetition and IAs performed in the 2nd trimester among women residing in the Basque Country (Spain)

Background

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Inequalities in induced abortion

• Cross-sectional population-based study including IAs for women aged 25 to 49 years residing in the Basque Country. – Women 25 or more years to capture women who have

completed their education

• Data: – Registry of Induced Abortions. Department of Health of

Basque Government

– 2011, 2012 and 2013

• After exclusions: 7,211 records

Methods

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Inequalities in induced abortion

• Dependent variables: all IAs, repeat IAs and IAs conducted in the 2nd trimester among women who have an IA.

• Independent variables:– Birthplace: born in Spain vs. born in countries with a HDI<0.78

2011 low income countries

– Educational attainment: primary or less, secondary and graduate

• Covariates:– Year of intervention

– Age groups (25-29, 30-34, 35-49)

Methods

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Inequalities in induced abortion

• Prevalence estimates and associations

• Log-binomial regression to calculate prevalence ratios (PR) and 95% CI

• Final model: association for birthplace was adjusted for education and association for education was adjusted for birthplace

• Interaction terms were tested to determine joint effect of birthplace and education

Methods

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Inequalities in induced abortion

• Descriptive data:

– 2 in 3 IA among women younger than 34 years

– 1 in 2 IA among women with secondary studies

– 36.1% were repeat IAs and 4.2% performed in 2nd trimester

– Some differences. Immigrants:• More likely to be younger than 34 years

• Higher proportion of repeat IA

• Lower proportion of 2nd trimester IA

Results

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Inequalities in induced abortion Results

Table 1. Prevalence and prevalence ratios (PR) with their 95% confidence intervals (CI) associated with birthplace and educational attainment on all induced abortions: Basque Country, years 2011-2013

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Inequalities in induced abortion Results

Table 2. Prevalence and prevalence ratios (PR) with their 95% confidence intervals (CI) associated with birthplace and educational attainment on repeat induced abortions: Basque Country, years 2011-2013

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Inequalities in induced abortion Results

Table 3. Prevalence and prevalence ratios (PR) with their 95% confidence intervals (CI) associated with birthplace and educational attainment on second trimester induced abortions: Basque Country, years 2011-2013

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Inequalities in induced abortion

• No heterogeneity of the association of birthplace with each outcome according to education (p-interactions >0.50), but...

– Associations among women born in low income countries were stronger as level of education increased relative to women born in Spain, in repeat IAs and 2nd trimester IAs

Results

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Inequalities in induced abortion

• Immigrant women born in low income countries are more likely to have IAs as well as repeat and 2nd trimester IAs than those born in Spain, regardless of their level of education

• Having a graduate level may not play a protective role for all IAs in immigrant women as it does for native ones.

• Greater likelihood among immigrant women relative to native ones as education increases on repeat and 2nd trimester IAs

Conclusions

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Inequalities in induced abortion

• Two key moments:– Before the pregnancy:

• Lower sex education

• Less equal relationships with the partner

Importance of cultural factors in reproductive decisions (Eskild et al. 2007)

– After the pregnancy: • Lower socioeconomic position, regardless education

• Less social support in host societies

Education may be less important as an indicator of social position among immigrant women

Conclusions

Higher rate of unintended pregnancies

Higher rate of abortion

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Inequalities in induced abortion

• Understanding factors not only in IA but also in repetition and delay on IA– How social factors work independently and together

• Important when designing:– Programs for sexual and reproductive health

– Policies on access to IA

Conclusions

Thank you for your attention!

yolanda.gonzalezr@ehu.euswww.ehu.eus/opik@Opik_ikerketa@YolandaGRabago@unaimr