Socioeconomic differences in food purchasing behaviour and suggested implications for diet-related health promotion

Background The relationship between socioeconomic position (SEP) and diet has been examined mainly on the basis of food and nutrient intake. As a complement to this work, we focused on the socioeconomic patterning of food purchasing, as many educational dietary messages emphasize behaviours such as food choice when shopping. Also, the type of food people buy influences the quality of their nutrient intake. Methods A probability sample of households in Brisbane City, Australia (n = 1003, 66.4% response rate). Data were collected using face‐to‐face interviews. SEP was measured using education, occupation and household income. Food purchasing was examined on the basis of grocery items (including meat and chicken) and fruit and vegetables. Results Significant associations were found between each socioeconomic indicator and food purchasing. Persons from socioeconomically disadvantaged backgrounds were less likely to purchase grocery foods that were comparatively high in fibre and low in fat, salt and sugar. The least educated, those employed in blue‐collar (manual) occupations and residents of low income households purchased fewer types of fruit and vegetables, and less regularly, than their higher status counterparts. Conclusions Health promotion efforts aimed at narrowing socioeconomic differences in food purchasing need to be designed and implemented with an understanding of, and a sensitivity to, the barriers to nutritional improvement that difficult life circumstances can impose.     

Socioeconomic inequalities in food purchasing: the contribution of respondent-perceived and actual (objectively measured) price and availability of foods

BACKGROUND: Research has shown that lower socioeconomic groups purchase foods that are less consistent with dietary recommendations. The price and availability of foods are thought to be important mediating factors between socioeconomic position and food purchasing. OBJECTIVES: We examined the relative contribution of the perceived and objectively measured price and availability of recommended foods to household income differences in food purchasing. METHODS: Using a face-to-face interview, a random sample of Brisbane residents (n=812) were asked about their food purchasing choices in 2000. They were also asked about their perceptions of the price and availability of 'recommended' foods (i.e. choices lower in fat, saturated fat, sugar, salt or higher in fibre) in the supermarkets where they usually shopped. Audits measuring the actual availability and price of identical foods were conducted in the same supermarkets. RESULTS: Lower socioeconomic groups were less likely to make food purchasing choices consistent with dietary guideline recommendations. Objective availability and price differences were not associated with purchasing choices, nor did they contribute to socioeconomic inequalities in food purchasing choices. Perceived availability and price differences were associated with the purchase of recommended foods. Perceived availability made a small contribution to inequalities in food purchasing, however perceived price differences did not. CONCLUSION: Socioeconomic inequalities in food purchasing are not mediated by differential availability of recommended foods and differences in price between recommended and regular foods in supermarkets, or by perceptions of their relative price. However, differential perceptions of the availability of recommended foods may play a small role in food purchasing inequalities.     

Food store availability and neighborhood characteristics in the United States

OBJECTIVE: This study provides a multivariate analysis of the availability of food store outlets in the US and associations with neighborhood characteristics on race, ethnicity and socioeconomic status (SES). METHOD: Commercial food store outlet data are linked across 28,050 zip codes to Census 2000 data. Multivariate regression analyses are used to examine associations between the availability of chain supermarkets, non-chain supermarkets, grocery stores and convenience stores and neighborhood characteristics on race, ethnicity and SES including additional controls for population size, urbanization and region. RESULTS: Low-income neighborhoods have fewer chain supermarkets with only 75% (p<0.01) of that available in middle-income neighborhoods. Even after controlling for income and other covariates, the availability of chain supermarkets in African American neighborhoods is only 52% (p<0.01) of that in White neighborhoods with even less relative availability in urban areas. Hispanic neighborhoods have only 32% (p<0.01) as many chain supermarkets compared to non-Hispanic neighborhoods. Non-chain supermarkets and grocery stores are more prevalent in low-income and minority neighborhoods. CONCLUSION: The study results highlight the importance of various potential public policy measures for improving access to supermarkets that may serve to reduce systematic local area barriers that are shown to exist by race, ethnicity and income.     

Confidence to Cook Vegetables and the Buying Habits of Australian Households

Cooking skills are emphasized in nutrition promotion but their distribution among population subgroups and relationship to dietary behavior is researched by few population-based studies. This study examined the relationships between confidence to cook, sociodemographic characteristics, and household vegetable purchasing. This cross-sectional study of 426 randomly selected households in Brisbane, Australia, used a validated questionnaire to assess household vegetable purchasing habits and the confidence to cook of the person who most often prepares food for these households. The mutually adjusted odds ratios (ORs) of lacking confidence to cook were assessed across a range of demographic subgroups using multiple logistic regression models. Similarly, mutually adjusted mean vegetable purchasing scores were calculated using multiple linear regression for different population groups and for respondents with varying confidence levels. Lacking confidence to cook using a variety of techniques was more common among respondents with less education (OR 3.30; 95% confidence interval [CI] 1.01 to 10.75) and was less common among respondents who lived with minors (OR 0.22; 95% CI 0.09 to 0.53) and other adults (OR 0.43; 95% CI 0.24 to 0.78). Lack of confidence to prepare vegetables was associated with being male (OR 2.25; 95% CI 1.24 to 4.08), low education (OR 6.60; 95% CI 2.08 to 20.91), lower household income (OR 2.98; 95% CI 1.02 to 8.72) and living with other adults (OR 0.53; 95% CI 0.29 to 0.98). Households bought a greater variety of vegetables on a regular basis when the main chef was confident to prepare them (difference: 18.60; 95% CI 14.66 to 22.54), older (difference: 8.69; 95% CI 4.92 to 12.47), lived with at least one other adult (difference: 5.47; 95% CI 2.82 to 8.12) or at least one minor (difference: 2.86; 95% CI 0.17 to 5.55). Cooking skills may contribute to socioeconomic dietary differences, and may be a useful strategy for promoting fruit and vegetable consumption, particularly among socioeconomically disadvantaged groups.     

Socioeconomic disadvantage and the purchase of takeaway food: a multilevel analysis

This study examined relationships between individual-level socioeconomic position, area-level disadvantage, characteristics of the takeaway food environment, and the purchase of takeaway food. 'Takeaway' is conceptualised as foods or meals that are prepared and purchased outside of the home, and ready for immediate consumption either at the place of purchase or elsewhere. The analytic sample comprised 1001 households and 50 small areas in Brisbane, Australia. Takeaway food was purchased more regularly by high-income householders and those with higher levels of education. Residents of advantaged areas purchased takeaway food more regularly, although area differences attenuated to the null after adjustment for individual-level compositional factors. Number of takeaway shops in the local food environment, and road distance to the closest takeaway shop, were largely unrelated to the purchase of takeaway food. We conclude that there is little evidence that takeaway food purchasing in Brisbane is influenced by area-level socioeconomic disadvantage or features of the takeaway food environment. Rather, it seems that what matters most in terms of influencing the decision or capacity of Brisbane residents to purchase takeaway food are the socioeconomic characteristics of individuals and their households. The findings of this and previous analyses of the Brisbane Food Study data suggest that policy and health promotion aimed at improving the diets of residents and reducing dietary inequalities between socioeconomic groups should focus on people more so than places.     

Associations of neighborhood characteristics with the location and type of food stores

OBJECTIVES: We investigated associations between local food environment and neighborhood racial/ethnic and socioeconomic composition. METHODS: Poisson regression was used to examine the association of food stores and liquor stores with racial/ethnic composition and income in selected census tracts in North Carolina, Maryland, and New York. RESULTS: Predominantly minority and racially mixed neighborhoods had more than twice as many grocery stores as predominantly White neighborhoods (for predominantly Black tracts, adjusted stores per population ratio [SR]=2.7; 95% confidence interval [CI]=2.2, 3.2; and for mixed tracts, SR=2.2; 95% CI=1.9, 2.7) and half as many supermarkets (for predominantly Black tracts, SR=0.5; 95% CI=0.3, 0.7; and for mixed tracts, SR=0.7; 95% CI=0.5, 1.0, respectively). Low-income neighborhoods had 4 times as many grocery stores as the wealthiest neighborhoods (SR=4.3; 95% CI=3.6, 5.2) and half as many supermarkets (SR=0.5; 95% CI=0.3, 0.8). In general, poorer areas and non-White areas also tended to have fewer fruit and vegetable markets, bakeries, specialty stores, and natural food stores. Liquor stores were more common in poorer than in richer areas (SR=1.3; 95% CI=1.0, 1.6). CONCLUSIONS: Local food environments vary substantially by neighborhood racial/ethnic and socioeconomic composition and may contribute to disparities in health.     

You are where you shop: grocery store locations, weight, and neighborhoods

BACKGROUND: Residents in poor neighborhoods have higher body mass index (BMI) and eat less healthfully. One possible reason might be the quality of available foods in their area. Location of grocery stores where individuals shop and its association with BMI were examined. METHODS: The 2000 U.S. Census data were linked with the Los Angeles Family and Neighborhood Study (L.A.FANS) database, which consists of 2620 adults sampled from 65 neighborhoods in Los Angeles County between 2000 and 2002. In 2005, multilevel linear regressions were used to estimate the associations between BMI and socioeconomic characteristics of grocery store locations after adjustment for individual-level factors and socioeconomic characteristics of residential neighborhoods. RESULTS: Individuals have higher BMI if they reside in disadvantaged areas and in areas where the average person frequents grocery stores located in more disadvantaged neighborhoods. Those who own cars and travel farther to their grocery stores also have higher BMI. When controlling for grocery store census tract socioeconomic status (SES), the association between residential census tract SES and BMI becomes stronger. CONCLUSIONS: Where people shop for groceries and distance traveled to grocery stores are independently associated with BMI. Exposure to grocery store mediates and suppresses the association of residential neighborhoods with BMI and could explain why previous studies may not have found robust associations between residential neighborhood predictors and BMI.     

Socioeconomic status in relation to selected birth defects in a large multicentered US case-control study

This study examined individual and household socioeconomic status (SES) in relation to phenotypes of neural tube defects, orafacial clefts, and conotruncal heart defects using data from the National Birth Defects Prevention Study with 2,551 nonmalformed liveborn controls and 1,841 cases delivered in 1997-2000. The individual SES was measured by maternal and paternal education, occupation, and household income. All individual SES measures were combined to create a household SES index. Elevated risks were found for maternal low education in association with anencephaly and dextrotransposition of the great arteries (dTGA) (adjusted odds ratios (AORs) > or = 1.4); paternal low education in association with anencephaly, cleft palate, tetralogy of Fallot (TOF), and dTGA (AORs > or = 1.4); low household income in association with TOF (AOR = 1.4, 95% confidence interval (CI): 0.8, 2.5); maternal operator/laborer occupation in association with cleft palate, TOF, and dTGA (AORs > or = 1.4); paternal operator/laborer occupation in association with spina bifida (AOR = 1.4, 95% CI: 1.0, 2.0); and either parent's unemployment in association with dTGA (AOR > or = 1.4). Subjects with the lowest household SES index had the greatest risks of all selected birth defects except TOF. This study reveals consistently increased risks of selected birth defects in association with household SES index but not individual SES measures.     

Socio-economic distribution of environmental risk factors for childhood injury

OBJECTIVE: Childhood injury remains the single most important cause of mortality in children aged between 1-14 years in many countries. It has been proposed that lower socio-economic status (SES) and poorer housing contribute to potential hazards in the home environment. This study sought to establish whether the prevalence of observed hazards in and around the home was differentially distributed by SES, in order to identify opportunities for injury prevention. METHODS: This study was a cross-sectional, random sample survey of primary school children from 32 schools in Brisbane. Interviews and house audits were conducted between July 2000 and April 2003 to collect information on SES (income, employment and education) and previously identified household hazards. RESULTS: There was evidence of a relationship between prevalence of household environmental hazards and household SES; however, the magnitude and direction of this relationship appeared to be hazard-specific. Household income was related to play equipment characteristics, with higher SES groups being more likely to be exposed to risk. All three SES indicators were associated with differences in the home safety characteristics, with the lower SES groups more likely to be exposed to risk. CONCLUSION: The differential distribution of environmental risk factors by SES of household may help explain the SES differential in the burden of injury and provides opportunities for focusing efforts to address the problem.     

社区老年人社会经济地位与轻度认知功能障碍的相关性研究

目的  探讨老年人社会经济地位(socioeconomic status,SES)与轻度认知功能障碍(mild cognitive impairment,MCI)患病的关联。方法  数据来源于湖北老年记忆队列(the Hubei Memory and Aging Cohort Study,HMACS);共纳入7 887名≥65岁老年人,他们完成了3全套神经心理评估和临床体格检查。SES通过受教育程度、职业性质和家庭人均月收入综合评定;MCI由专家组根据Petersen标准和中国痴呆与认知障碍诊治指南进行诊断;多因素logistic回归分析模型分析老年人SES与MCI患病的关联。结果  共纳入7 887名调查对象,平均年龄(71.74±5.58)岁,MCI检出率为23.00%(95% CI: 22.07%~23.93%);低SES组MCI检出率(44.65%)高于中SES组MCI检出率(16.89%)和高SES组MCI检出率(9.18%);女性高于男性;农村高于城市。分层分析发现：城市男性低SES组MCI患病风险为高SES组的6.276倍(OR=6.276, 95% CI: 4.017~9.805),城市女性低SES组MCI患病风险为高SES组的3.978倍(OR=3.978, 95% CI: 2.943~5.376);依据现有SES标准,农村女性老年人SES分布不均匀。结论  低SES组老年人MCI检出率较高,认知功能障碍的防控要密切关注低SES组老年人,特别是社区低收入、低教育程度的老年人。     

Food Waste and Its Association with Diet Quality of Foods Purchased in South Florida

The objective of this study was to explore the associations between food waste and the diet quality of foods purchased and with grocery purchasing behaviors. This was a cross-sectional study among 109 primary household food providers conducting primary shopping. Participants were recruited outside of local grocery stores and were asked to complete a survey assessing amounts of avoidable food waste and grocery purchasing behaviors. The diet quality of the foods purchased was assessed from grocery receipts using the Grocery Purchase Quality Index-2016 (GPQI-2016). Variables were associated using linear regression, analysis of covariance, and point biserial correlations. We found that fresh fruits (63%) and leafy greens (70%) were the foods that were the most wasted. The GPQI-2016 total score was significantly inversely associated with the total amount of food wasted (β  =  −0.63; 95% CI: −1.14,−0.12) after adjusting for important confounders. The reason “food past the date printed on the package” was directly correlated with food wasted (r = 0.40; p < 0.01) but inversely correlated with GPQI-2016 score (r = −0.21; p = 0.04). Food wasted, but not the GPQI-2016 score, was significantly higher among those who grocery shop 2–4 times per week compared to 1 time every 1–2 weeks (p = 0.02). In conclusion, food waste is inversely associated with diet quality and directly associated with grocery purchasing frequency.     

Socioeconomic differences in purchases of more vs. less healthy foods and beverages: Analysis of over 25,000 British households in 2010

Socioeconomic inequalities in diet-related health outcomes are well-recognised, but are not fully explained by observational studies of consumption. We provide a novel analysis to identify purchasing patterns more precisely, based on data for take-home food and beverage purchases from 25,674 British households in 2010. To examine socioeconomic differences (measured by occupation), we conducted regression analyses on the proportion of energy purchased from (a) each of 43 food or beverage categories and (b) major nutrients. Results showed numerous small category-level socioeconomic differences. Aggregation of the categories showed lower SES groups generally purchased a greater proportion of energy from less healthy foods and beverages than those in higher SES groups (65% and 60%, respectively), while higher SES groups purchased a greater proportion of energy from healthier food and beverages (28% vs. 24%). At the nutrient-level, socioeconomic differences were less marked, although higher SES was associated with purchasing greater proportions of fibre, protein and total sugars, and smaller proportions of sodium. The observed pattern of purchasing across SES groups contributes to the explanation of observed health differences between groups and highlights targets for interventions to reduce health inequalities.     

Socio-demographic influences on food purchasing among Canadian households

OBJECTIVE: To characterize the relationships between selected socio-demographic factors and food selection among Canadian households. DESIGN: A secondary analysis of data from the 1996 Family Food Expenditure survey was conducted (n=10,924). Household food purchases were classified into one of the five food groups from Canada's Food Guide to Healthy Eating. Parametric and non-parametric modelling techniques were employed to analyse the effects of household size, composition, income and education on the proportion of income spent on each food group and the quantity purchased from each food group. RESULTS: Household size, composition, income and education together explained 21-29% of the variation in food purchasing. Households with older adults spent a greater share of their income on vegetables and fruit (P<0.0001), whereas households with children purchased greater quantities of milk products (P<0.0001). Higher income was associated with purchasing more of all food groups (P<0.0001), but the associations were nonlinear, with the strongest effects at lower income levels. Households where the reference person had a university degree purchased significantly more vegetables and fruit, and less meat and alternatives and 'other' foods (P<0.0001), relative to households with the lowest education level. CONCLUSIONS: Household socio-demographic characteristics have a strong influence on food purchasing, with the purchase of vegetables and fruit being particularly sensitive. Results reinforce concerns about constraints on food purchasing among lower income households. Furthermore, the differential effects of income and education on food choice need to be considered in the design of public health interventions aimed at altering dietary behaviour.     

Density and type of food retailers surrounding Canadian schools: Variations across socioeconomic status

Lower socioeconomic status (SES) neighbourhoods may have differential access to food retailers, potentially explaining the varying area-level obesity rates. The food retail environment around 188 schools across Canada was examined, including full-service restaurants, fast food restaurants, sub/sandwich retailers, donut/coffee shops, convenience stores, and grocery stores. School addresses were linked to census data to obtain area-level SES measures. Access to food retailers was generally not associated with the neighbourhood SES in the immediate proximity. Within the broader neighbourhood, lower SES neighbourhoods had access to fewer food retailers of all types. This effect was diminished after taking population density into account.     

Socioeconomic status and health outcomes in a developing country

Although the relationship between socioeconomic status (SES) and health is well documented for developed countries, less evidence has been presented for developing countries. The aim of this paper is to analyse this relationship at the household level for Fiji, a developing country in the South Pacific, using original household survey data. To allow for the endogeneity of SES status in the household health production function, we utilize a simultaneous equation approach where estimates are achieved by full information maximum likelihood. By restricting our sample to one, relatively small island, and including area and district hospital effects, physical geography effects are unpacked from income effects. We measure SES, as permanent income which is constructed using principal components analysis. An alternative specification considers transitory household income. We find that a 1% increase in wealth (our measure of permanent income) would lead to a 15% decrease in the probability of an incapacitating illness occurring intra-household. Although the presence of a strong relationship indicates that relatively small improvements in SES status can significantly improve health at the household level, it is argued that the design of appropriate policy would also require an understanding of the various mechanisms through which the relationship operates.     

Geographic Socioeconomic Status, Race, and Advanced-Stage Breast Cancer in New York City

OBJECTIVES: This study examined the association between a residential area' socioeconomic status (SES), race, and advanced-stage breast cancer in New York City. METHODS: The cross-sectional study design used breast cancer information for 37 921 cases diagnosed in New York City from 1986 to 1995. Residential education and income levels were based on the 1990 census and ascribed to each case by zip code. Associations between race, area SES, and advanced-stage breast cancer stage, and the interaction between race and SES, were evaluated in bivariate and multivariate analyses. RESULTS: After adjusting for age and year at diagnosis, living in areas with lower levels of education and income increased the odds of presenting with advanced-stage breast cancer by 50% for Black women and by 75% for White women. No significant qualitative interaction was present between area SES and race. CONCLUSIONS: This study confirmed independent racial and socioeconomic differences in the risk of advanced-stage breast cancer in a large and diverse population. The results emphasize the need to improve screening practices and clinical treatment in both high-risk populations and high-risk geographic areas.     

Stillbirth outcome capture and classification in population-based surveys: EN-INDEPTH study

Area-level measures are often used to approximate socioeconomic status (SES) when individual-level data are not available. However, no national studies have examined the validity of these measures in approximating individual-level SES. Data came from ~ 3,471,000 participants in the Mortality Disparities in American Communities study, which links data from 2008 American Community Survey to National Death Index (through 2015). We calculated correlations, specificity, sensitivity, and odds ratios to summarize the concordance between individual-, census tract-, and county-level SES indicators (e.g., household income, college degree, unemployment). We estimated the association between each SES measure and mortality to illustrate the implications of misclassification for estimates of the SES-mortality association. Participants with high individual-level SES were more likely than other participants to live in high-SES areas. For example, individuals with high household incomes were more likely to live in census tracts (r = 0.232; odds ratio [OR] = 2.284) or counties (r = 0.157; OR = 1.325) whose median household income was above the US median. Across indicators, mortality was higher among low-SES groups (all p < .0001). Compared to county-level, census tract-level measures more closely approximated individual-level associations with mortality. Moderate agreement emerged among binary indicators of SES across individual, census tract, and county levels, with increased precision for census tract compared to county measures when approximating individual-level values. When area level measures were used as proxies for individual SES, the SES-mortality associations were systematically underestimated. Studies using area-level SES proxies should use caution when selecting, analyzing, and interpreting associations with health outcomes.     

Do area-based markers of poverty accurately measure personal poverty?

Area-based markers of deprivation (e.g., postal codes) are commonly used to identify groups of people with low socioeconomic status (SES); the validity of this approach, however, remains unknown. In this study, we determined the accuracy of using income quintile groups calculated on the basis of the median family income of each forward sortation area (1996 Canadian census) to identify those living in poverty (i.e., annual family income of < $12,620). The sensitivity and specificity of using the lowest income quintile to capture those in poverty were 26% and 83%, respectively (likelihood ratio (LR) of 1.49; 99% CI, 1.49 to 1.50). Among those in non-metropolitan and metropolitan areas, the LRs were 1.26 (99% CI, 1.26 to 1.27) and 2.01 (99% CI, 2.01 to 2.02), respectively. The use of postal codes as the only marker to identify people with low SES may result in substantial misclassification of personal poverty, particularly in non-metropolitan areas.     

Urban area disadvantage and physical activity: a multilevel study in Melbourne, Australia

OBJECTIVE: To estimate variation between small areas in the levels of walking, cycling, jogging, and swimming and overall physical activity and the importance of area level socioeconomic disadvantage in predicting physical activity participation. METHODS: All census collector districts (CCDs) in the 20 innermost local government areas in metropolitan Melbourne, Australia, were identified and ranked by the percentage of low income households (<400 dollars/week) living in the CCD. Fifty CCDs were randomly selected from the least, middle, and most disadvantaged septiles of the ranked CCDs and 2349 residents (58.7% participation rate) participated in a cross sectional postal survey about physical activity. Multilevel logistic regression (adjusted for extrabinomial variation) was used to estimate area level variation in walking, cycling, jogging, and swimming and in overall physical activity participation, and the importance of area level socioeconomic disadvantage in predicting physical activity participation. RESULTS: There were significant variations between CCDs in all activities and in overall physical participation in age and sex adjusted models; however, after adjustment for individual SES (income, occupation, education) and area level socioeconomic disadvantage, significant differences remained only for walking (p = 0.004), cycling (p = 0.003), and swimming (p = 0.024). Living in the most socioeconomically disadvantaged areas was associated with a decreased likelihood of jogging and of having overall physical activity levels that were sufficiently active for health; these effects remained after adjustment for individual socioeconomic status (sufficiently active: OR 0.70, 95% CI 0.55 to 0.90 and jogging: OR = 0.69, 95% CI 0.51 to 0.94). CONCLUSION: These research findings support the need to focus on improving local environments to increase physical activity participation.     

The Association Between Rural-Urban Continuum, Maternal Education and Adverse Birth Outcomes in Québec, Canada

ABSTRACT:  Context: Rural relative to urban area and low socioeconomic status (SES) are associated with adverse birth outcomes. Whether a graded association of increasing magnitude is present across the urban-rural continuum, accounting for SES, is unclear. We examined the association between rural-urban continuum, SES and adverse birth outcomes. Methods: Singleton births from 1999 to 2003 (n = 356,147) were linked to Québec municipalities ranked on a continuum of 3 urban and 4 rural areas based on population and economic base. Maternal education was used to represent SES. Odds ratios (OR) were calculated for preterm birth (PTB), low birth weight (LBW), and small-for-gestational-age (SGA) birth, accounting for municipality and individual-level covariates. We used stratified analyses to examine interaction between SES and rural-urban continuum. Findings: Relative to metropolitan area residence, living in small urban or rural areas was associated with adverse birth outcomes. Living in rural areas was associated with SGA birth (OR 1.11, 95% CI 1.05-1.17) and LBW (OR 1.15, 95% CI 1.05-1.26), and living in small urban areas was associated with PTB (OR 1.14, 95% CI 1.08-1.20). Upon stratification by education, living in remote rural relative to metropolitan areas was associated with adverse birth outcomes among university educated mothers only, and living in small urban areas was associated with adverse birth outcomes among mothers with lesser but not higher education. An SES gradient was present in all rural-urban areas, particularly for SGA birth. Conclusion: Differences in perinatal health exist across the rural-urban continuum, and maternal education has a modifying influence.