Effects of maternal education on maternal and perinatal outcomes: An individual participant data meta-analysis of 2 356 402 pregnancies.

Abstract

Background: Maternal and perinatal mortality remain critical indicators of global health inequity. In 2020, an estimated 287 000 women died from preventable causes related to pregnancy, and in 2021, approximately 2.3 million neonatal deaths occurred within the first 28 days of life. A recently defined risk group, small vulnerable newborns (SVNs, including preterm, low birth weight, and small-for-gestational-age infants), highlights the compounded vulnerability of certain newborns. Maternal education is a key social determinant of health, yet its effect on maternal and perinatal outcomes across global settings remains insufficiently quantified.

Aims: The primary aim of this study was to quantify the association between maternal education level and adverse maternal and perinatal outcomes. The secondary aim was to evaluate whether these associations vary by country income level.

Methods: We conducted an individual participant data (IPD) meta-analysis using data from the International Prediction of Pregnancy Complications (IPPIC) Network. Eligible studies included those reporting maternal and perinatal outcomes stratified by at least two levels of maternal education (informal/primary, secondary, tertiary). Primary outcomes were maternal mortality, preeclampsia, stillbirth, and SVNs. Associations were estimated using a two-step random-effects IPD meta-analysis adjusted for maternal age and ethnicity. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported.

Results: Compared to tertiary education, women with secondary education had a 27% higher risk of maternal death (OR 1.27, 95% CI 0.38; 4.30), and those with informal or primary education had approximately double the risk (OR 2.51, 95% CI 0.23; 26.95). Risk of stillbirth was also twofold higher in lower education groups. These association remained significant in analyses restricted to high-income countries.

Discussion: Women with lower levels of education are at substantially greater risk of adverse maternal and perinatal outcomes. These findings reinforce the need for education-focused policy and health system strategies to reduce maternal and neonatal mortality, particularly in settings with high educational inequality.