BACKGROUND: A healthy start to life is a major priority in efforts to reduce health inequalities across Europe, with important implications for the health of future generations. There is limited combined evidence on inequalities in health among newborns across a range of European countries. METHODS: Prospective cohort data of 75 296 newborns from 12 European countries were used. Maternal education, preterm and small for gestational age births were determined at baseline along with covariate data. Regression models were estimated within each cohort and meta-analyses were conducted to compare and measure heterogeneity between cohorts. RESULTS: Mother's education was linked to an appreciable risk of preterm and small for gestational age (SGA) births across 12 European countries. The excess risk of preterm births associated with low maternal education was 1.48 (1.29 to 1.69) and 1.84 (0.99 to 2.69) in relative and absolute terms (Relative/Slope Index of Inequality, RII/SII) for all cohorts combined. Similar effects were found for SGA births, but absolute inequalities were greater, with an SII score of 3.64 (1.74 to 5.54). Inequalities at birth were strong in the Netherlands, the UK, Sweden and Spain and marginal in other countries studied. CONCLUSIONS: This study highlights the value of comparative cohort analysis to better understand the relationship between maternal education and markers of fetal growth in different settings across Europe.

1st Department of Paediatrics University of Athens Aghia Sophia Children's Hospital Athens Greece

Biocenter Oulu University of Oulu Oulu Finland

Center for Global Health University of Illinois College of Medicine Chicago Illinois USA

Center for Research in Environmental Epidemiology Barcelona Spain

Department of Clinical Epidemiology Predictive Medicine and Public Health University of Porto Medical School Porto Portugal EPIUnit Institute of Public Health University of Porto Porto Portugal

Department of Epidemiology and Biostatistics MRC Health Protection Agency Centre for Environment and Health School of Public Health Imperial College London London UK Unit of Primary Care Oulu University Hospital Oulu Finland Center for Life Course Epidemiology Faculty of Medicine University of Oulu Oulu Finland Institute of Health Sciences University of Oulu Oulu Finland

Department of Epidemiology and Health Promotion Public Health Service of Amsterdam Amsterdam The Netherlands

Department of Epidemiology of the Lazio Regional Health System Rome Italy

Department of Genes and Environment Norwegian Institute of Public Health Oslo Norway

Department of Medicine and Health Sciences Linköping University Linköping Sweden

Department of Public Health Academic Medical Center University of Amsterdam Amsterdam The Netherlands

Division of Pediatrics Department of Clinical and Experimental Medicine Linköping University Linköping Sweden

Faculty of Science Research Centre for Toxic Compounds in the Environment Masaryk University Brno Czech Republic

Faculty of Science Research Centre for Toxic Compounds in the Environment Masaryk University Brno Czech Republic Faculty of Medicine Institute of Biostatistics and Analyses Masaryk University Brno Czech Republic

Institut National de la Santé et de la Recherche Médicale Center for Epidemiology and Statistics Sorbonne Paris Cité DHU Risks in Pregnancy Paris Descartes University Paris France

Institut National de la Santé et de la Recherche Médicale Center for Epidemiology and Statistics Sorbonne Paris Cité Paris Descartes University Paris France

Institute of Pediatrics Obstetrics and Gynecology Kyiv Ukraine

Public Health Department of Gipuzkoa Gipuzkoa Spain BIODONOSTIA Health Research Institute San Sebastian Spain

Research Department of Epidemiology and Public Health UCL Institute of Health Equity University College London London UK

Research Department of Epidemiology and Public Health University College London London UK

Research Department of Epidemiology and Public Health University College London London UK Research Department of Epidemiology and Public Health UCL Institute of Health Equity University College London London UK

Spanish Consortium for Research on Epidemiology and Public Health Barcelona Spain Departamento de Medicina Universitat Jaume 1 Castellon Spain

Spanish Consortium for Research on Epidemiology and Public Health Barcelona Spain IB Salut Menorca Health Area Balearic Islands Spain

J Epidemiol Community Health. 2015 Sep;69(9):821-2. doi: 10.1136/jech-2015-205625. PubMed

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