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Maternal Education and Stillbirth: Estimating Gestational-age-specific and Cause-specific Associations

Auger, Nathaliea,b,c; Delézire, Paulined; Harper, Same; Platt, Robert W.e

doi: 10.1097/EDE.0b013e31824587bc

Background: Associations between risk factors and perinatal outcomes may be biased at preterm gestational ages, if preterm delivery behaves as an effect modifier due to other unmeasured factors in the causal pathway. We evaluated whether fetuses-at-risk denominators could be used in regression models instead of conventional denominators to obtain less biased estimates of the association between maternal education and stillbirth at preterm gestational intervals.

Methods: Data included 2,143,134 live-born and 8946 stillborn singletons from 1981 through 2006 in Québec, Canada. Odds ratios and 95% confidence intervals were estimated for the relationship between education and stillbirth according to cause of fetal death, adjusting for maternal age, marital status, home language, parity, and period. We examined associations for 4 gestational intervals (<28, 28–31, 32–36, and ≥37 completed weeks), using both conventional denominators (ie, preterm live births) and fetuses-at-risk denominators.

Results: Stillbirth rates were greater for mothers with fewer years of education at all gestational intervals. Using conventional denominators, low education (relative to high education) was more strongly associated with term than preterm stillbirth and was apparently protective at <28 weeks. Using fetuses-at-risk denominators, low education was more strongly associated with preterm stillbirth than term stillbirth, even at <28 weeks. Low education was most strongly associated with diabetic-related stillbirth at ≥28 weeks (odds ratio = 5.04) relative to high education.

Conclusions: Low education is associated with stillbirth throughout gestation, especially diabetic-related stillbirth. Use of fetuses-at-risk denominators in regression models can avoid potentially biased estimates obtained with conventional denominators at preterm gestational ages.

Supplemental Digital Content is available in the text.

From the aInstitut national de santé publique du Québec, Montréal, Québec, Canada; bResearch Centre of the University of Montréal Hospital Centre, Montréal, Québec, Canada; cDepartment of Social and Preventive Medicine, University of Montréal, Montréal, Québec, Canada; dInstitut de Santé Publique, d'Épidémiologie et de Développement, Université Victor Segalen Bordeaux 2, Bordeaux, France; and eDepartment of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada.

Submitted 21 January 2011; accepted 5 October 2011.

Supported by the Canadian Institutes for Health Research (CIHR grant 225924). The authors reported no other financial interests related to this research.

Supplemental digital content is available through direct URL citations in the HTML and PDF versions of this article ( This content is not peer-reviewed or copy-edited; it is the sole responsibility of the author.

Editors' note: A commentary on this article appears on page 255.

Correspondence: Nathalie Auger, Institut national de santé publique du Québec, 190, boulevard Crémazie Est, Montréal, Québec H2P 1E2, Canada. E-mail:

© 2012 Lippincott Williams & Wilkins, Inc.