中介分析阐释早产在母亲教育与婴儿死亡关联中的作用
创作:Epi汪 审核:Epi汪 2019年06月28日
  • 纳入199万余名单胎妊娠的数据,随访婴儿出生后一年之内的死亡情况;
  • 相较于受到高等水平教育的母亲,低、中等教育的母亲的婴儿总死亡风险分别高出1.63、1.19倍;
  • 上述两个关联是通过早产和胎儿限制性生长(SGA)中介作用的比例分别占55%、60%;
  • 如果只消除早产因素,其可降低的婴儿死亡比例大于只消除SGA因素带来的获益;
  • 若同时消除早产和SGA因素,可减少75%-81%的新生儿27天内死亡,21-23%的一年内死亡。
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Epi汪
母亲的教育程度越低,其婴儿在一年内死亡的风险也较高,但是其中的原因是复杂的,多元的。本文通过中介效应分析,认为早产、胎儿限制性生长(SGA)在二者的关联中扮演重要的角色。或许降低早产和SGA便可以减少由于母亲教育程度低带来的婴儿死亡风险。
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PLoS Medicine [IF:11.069]

Mediating roles of preterm birth and restricted fetal growth in the relationship between maternal education and infant mortality: A Danish population-based cohort study

早产和胎儿限制性生长在母亲教育和婴儿死亡的关联之间的中介作用:一项丹麦人群队列研究

10.1371/journal.pmed.1002831

2019-06-14, Article

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BACKGROUND: Socioeconomic disparities in infant mortality have persisted for decades in high-income countries and may have become stronger in some populations. Therefore, new understandings of the mechanisms that underlie socioeconomic differences in infant deaths are essential for creating and implementing health initiatives to reduce these deaths. We aimed to explore whether and the extent to which preterm birth (PTB) and small for gestational age (SGA) at birth mediate the association between maternal education and infant mortality.
METHODS AND FINDINGS:: We developed a population-based cohort study to include all 1,994,618 live singletons born in Denmark in 1981-2015. Infants were followed from birth until death, emigration, or the day before the first birthday, whichever came first. Maternal education at childbirth was categorized as low, medium, or high. An inverse probability weighting of marginal structural models was used to estimate the controlled direct effect (CDE) of maternal education on offspring infant mortality, further split into neonatal (0-27 days) and postneonatal (28-364 days) deaths, and portion eliminated (PE) by eliminating mediation by PTB and SGA. The proportion eliminated by eliminating mediation by PTB and SGA was reported if the mortality rate ratios (MRRs) of CDE and PE were in the same direction. The MRRs between maternal education and infant mortality were 1.63 (95% CI 1.48-1.80, P < 0.001) and 1.19 (95% CI 1.08-1.31, P < 0.001) for low and medium versus high education, respectively. The estimated proportions of these total associations eliminated by reducing PTB and SGA together were 55% (MRRPE = 1.27, 95% CI 1.15-1.40, P < 0.001) for low and 60% (MRRPE = 1.11, 95% CI 1.01-1.22, P = 0.037) for medium versus high education. The proportions eliminated by eliminating PTB and SGA separately were, respectively, 46% and 11% for low education (versus high education) and 48% and 13% for medium education (versus high education). PTB and SGA together contributed more to the association of maternal educational disparities with neonatal mortality (proportion eliminated: 75%-81%) than with postneonatal mortality (proportion eliminated: 21%-23%). Limitations of the study include the untestable assumption of no unmeasured confounders for the causal mediation analysis, and the limited generalizability of the findings to other countries with varying disparities in access and quality of perinatal healthcare.
CONCLUSIONS: PTB and SGA may play substantial roles in the relationship between low maternal education and infant mortality, especially for neonatal mortality. The mediating role of PTB appeared to be much stronger than that of SGA. Public health strategies aimed at reducing neonatal mortality in high-income countries may need to address socially related prenatal risk factors of PTB and impaired fetal growth. The substantial association of maternal education with postneonatal mortality not accounted for by PTB or SGA could reflect unaddressed educational disparities in infant care or other factors.

First Authors:
Yongfu Yu

Correspondence Authors:
Bo Fu,Jiong Li

All Authors:
Yongfu Yu,Zeyan Liew,Aolin Wang,Onyebuchi A Arah,Jialiang Li,Jørn Olsen,Sven Cnattingius,Guoyou Qin,Carsten Obel,Bo Fu,Jiong Li

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