González-Rabago Y et al.

1. Yolanda González-Rábago, Elena Rodriguez-Alvarez,
Luisa N. Borrell and Unai Martín
Research 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

2. 2
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

3. 3
Index
• Background
• Methods
• Results
• Conclusions

4. 4
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

5. 5
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)

6. 6
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

7. 7
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

8. 8
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

9. 9
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

10. 10
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

11. 11
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

12. 12
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

13. 13
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

14. 14
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

15. 15
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

16. 16
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

17. 17
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

18. Thank you for your attention!
yolanda.gonzalezr@ehu.eus
www.ehu.eus/opik
@Opik_ikerketa
@YolandaGRabago
@unaimr