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The magnitude and population burden of educational inequalities in adverse birth outcomes
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  • Published: 11 February 2026

The magnitude and population burden of educational inequalities in adverse birth outcomes

  • Anton Schreuder1,2 na1,
  • David van Klaveren1,
  • Richard M. K. van Dijk2,
  • Jasper V. Been1,3,4,
  • Lisa Broeders5,
  • Ageeth N. Rosman5,6,
  • Wessel Kraaij2,7 &
  • …
  • Tanja A. J. Houweling1 na1 

Scientific Reports , Article number:  (2026) Cite this article

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Subjects

  • Diseases
  • Health care
  • Medical research
  • Risk factors

Abstract

We aimed to describe the magnitude and population burden of inequality in adverse birth outcomes by maternal education (five categories). Data from 639,007 singleton births of gestational age ≥ 24 weeks or, if missing, birthweight ≥ 500 g were included from the National registry of the Netherlands, 2016–2019. One in six Dutch births had an adverse outcome. Each step down the educational ladder was associated with higher adverse outcome rates. Inequalities in stillbirth and neonatal mortality rates were large between the highest (Master’s or higher) and lowest (primary) educated groups (rate ratio [RR] = 2.94 [95%CI: 2.33–3.55] and 2.25 [1.71–2.79], respectively). Inequalities were smaller for preterm birth, small-for-gestational-age, low Apgar score, neonatal intensive care unit admission, and severe congenital anomalies (RR range = 1.32–1.77; PAF range = 13.8–17.7%). Mortality would reduce by a third if the entire population had the mortality rates of the highest educated (population attributable fraction [PAF]stillbirth=35.0% [24.4–45.6%]; PAFneonatal mortality=27.1% [14.4–39.7%]). The middle education category (higher secondary) was the largest group, contributing most to the population burden of inequality despite only having a moderately elevated risk of adverse outcomes. Population health gains would be largest if addressed through preventive approaches targeting the entire health gradient rather than by only focussing on those at highest risk.

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Data availability

The data that has been used is confidential. Access to the DIAPER linked data-infrastructure can be requested by contacting [diaper@rivm.nl] , access to Perined data can be requested by contacting [info@perined.nl] , and access to the CBS microdata can be requested by following the instructions at [https://www.cbs.nl/en-gb/our-services/customised-services-microdata/microdata-conducting-your-own-research/applying-for-access-to-microdata] .

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Acknowledgements

We thank Jeroen Struijs and Anouk Klootwijk for granting access to their DIAPER linked data-infrastructure (29).

Funding

This work was funded by a grant from the Dutch Research Council (NWO grant number NWA.1238.18.001).

Author information

Author notes

  1. These authors contributed equally: Anton Schreuder and Tanja A. J. Houweling.

Authors and Affiliations

  1. Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, 3000, CA, Netherlands

    Anton Schreuder, David van Klaveren, Jasper V. Been & Tanja A. J. Houweling

  2. Leiden Institute of Advanced Computer Science, Leiden University, Leiden, the Netherlands

    Anton Schreuder, Richard M. K. van Dijk & Wessel Kraaij

  3. Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands

    Jasper V. Been

  4. Department of Obstetrics and Gynaecology, Erasmus MC Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands

    Jasper V. Been

  5. Perined, Utrecht, Netherlands

    Lisa Broeders & Ageeth N. Rosman

  6. Department of Health Innovations, Rotterdam University of Applied Sciences, Rotterdam, Netherlands

    Ageeth N. Rosman

  7. Netherlands Organisation for Applied Scientific Research, Leiden, Netherlands

    Wessel Kraaij

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Contributions

A.S., W.K., and T.A.J.H. conceptualized and designed the study, A.S. and R.M.K.D. prepared the data, D.K., L.B., A.N.R., W.K. and T.A.J.H. supervised data preparation and analyses, A.S. carried out the analyses, A.S. and T.A.J.H. drafted the initial manuscript, and all authors critically reviewed, revised, and approved the manuscript as submitted and agree to be accountable for all aspects of the work.

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Correspondence to Anton Schreuder.

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The proposal for this study was reviewed by the Medical Ethics Committee (METC) of Erasmus MC, Rotterdam, The Netherlands.

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Schreuder, A., van Klaveren, D., van Dijk, R.M.K. et al. The magnitude and population burden of educational inequalities in adverse birth outcomes. Sci Rep (2026). https://doi.org/10.1038/s41598-026-37601-z

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  • Received: 28 September 2025

  • Accepted: 23 January 2026

  • Published: 11 February 2026

  • DOI: https://doi.org/10.1038/s41598-026-37601-z

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Keywords

  • Epidemiology
  • Parturition
  • Public health
  • Educational status
  • Health equity
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