Do biomass fuel use and consumption of unsafe water mediate educational inequalities in stillbirth risk? An analysis of the 2007 Ghana Maternal Health Survey

Background: Numerous studies have explored the association between educational inequalities and stillbirth but most have failed to elaborate how low educational attainment leads to an increased risk of stillbirth. We hypothesised that use of biomass fuels and consumption of unsafe water related to low educational attainment could explain the stillbirth burden in Ghana attributable to socioeconomic disadvantage. Methods: Data from the 2007 Ghana Maternal Health Survey, a nationally representative population-based survey were analysed for this study. Of the 10 370 women aged 15-49 years interviewed via structured questionnaires for the survey, 7183 primiparous and multiparous women qualified for inclusion in the present study. Results: In a logistic regression analysis that adjusted for age, area of residence, marital status and ethnicity of women, lower maternal primary education was associated with a 62% (OR= 1.62; 95% CI 1.04 to 2.52) increased lifetime risk of stillbirth. Biomass fuel use and consumption of unsafe water mediated 18% and 8% of the observed effects, respectively. Jointly these two exposures explained 24% of the observed effects. The generalised additive modelling revealed a very flat inverted spoon-shaped smoothed curve which peaked at low levels of schooling (2-3 years) and confirms the findings from the logistic regression analysis. Conclusions: Our results show that biomass fuel use and unsafe water consumption could be important pathways through which low maternal educational attainment leads to stillbirths in Ghana and similar developing countries. Addressing educational inequalities in developing countries is thus essential for ensuring household choices that curtail environmental exposures and help improve pregnancy outcomes.