Gender Inequalities in Publications about COVID-19 in Spain: Authorship and Sex-Disaggregated Data.

Gender inequalities in biomedical literature have been widely reported in authorship as well as the scarcity of results that are stratified by sex in the studies. We conducted a bibliometric review of articles on COVID-19 published in the main Spanish medical journals between April 2020 and May 2021. The purpose of this study was to analyse differences in authorship order and composition by sex and their evolution over time, as well as the frequency of sex-disaggregated empirical results and its relationship with the author sex in articles on COVID-19 in the main Spanish biomedical journals. We identified 914 articles and 4921 authors, 57.5% men and 42.5% women. Women accounted for 36.7% of first authors and for 33.7% of last authors. Monthly variation in authorship over the course of the pandemic indicates that women were always less likely to publish as first authors. Only 1.0% of the articles broke down empirical results by sex. Disaggregation of results by sex was significantly more frequent when women were first authors and when women were the majority in the authorship. It is important to make gender inequalities visible in scientific dissemination and to promote gender-sensitive research, which can help to reduce gender bias in clinical studies as well as to design public policies for post-pandemic recovery that are more gender-equitable.

[Socioeconomic inequalities and COVID-19 in Spain. SESPAS Report 2022]. / Desigualdades socioeconómicas y COVID-19 en España. Informe SESPAS 2022.

The COVID-19 pandemic has shown its syndemic nature where the contagion by coronavirus joins the high prevalence of chronic diseases in a context of great social inequality and a clear gradient of those pathologies. The objectives of this article are: 1) to show a conceptual framework of the determinants of social inequality in the COVID-19; 2) to review the available literature on socioeconomic inequalities in various aspects related to COVID-19 in Spain; and 3) propose recommendations to monitor, intervene with policies and communication guides to reduce social inequalities in COVID-19, showing examples developed in Spain. The conceptual framework includes structural and intermediate determinants reflecting the different axes of inequality that characterize the syndemic nature of COVID-19. The literature review published up to July 2021 in Spain describes a socioeconomic gradient of COVID-19, not always consistent among studies, as well as an uneven impact of many measures to control the pandemic. Finally, the proposals for reducing social inequalities in COVID-19 include: 1) to guarantee information systems and research with an equity perspective; 2) to reduce inequalities in COVID-19 through its intermediate, and economic and political determinants; and 3) to design communication models and understanding frameworks that break with hegemonies that hide the relevance of social inequality in the pandemic. Given the syndemic nature of COVID-19 and accumulated knowledge, surveillance systems, interventions and communication must include a clear perspective of health equity.

Socioeconomic Inequalities in Small-for-Gestational-Age Births Before and During the Economic Crisis: An Ecologic Study of Trends in 13 Spanish Cities.

Economic recessions can increase socioeconomic inequalities in health. The objective of this study was to analyze socioeconomic inequalities in small-for-gestational-age (SGA) births before and during the Spanish economic crisis. We conducted an ecological study of trends based on 2 periods before the crisis (1999-2003 and 2004-2008) and another during the crisis (2009-2013). The study population was Spanish women resident in 13 cities who had given birth during 1999-2013. The prevalence of SGA was calculated for each census tract. A hierarchical Bayesian model was used to obtain the prevalence ratio (PR) and 95% credible intervals (CI). We analyzed the association between SGA and socioeconomic deprivation in each period for each city and for 3 age groups. The PR was above 1 and statistically significant for all 3 time periods in most of the 13 cities. The differences in PR between periods were only statistically significant for Madrid (PR = 1.56, 95% CI 1.48-1.65 for 1999-2003; PR = 1.28, 95% CI 1.19-1.38 for 2004-2008) and Barcelona (PR = 0.99, 95% CI 0.87-1.12 for 2004-2008; PR = 1.20, 95% CI 1.05-1.36 for 2009-2013). Socioeconomic inequalities in SGA births in small areas (census tracts) of most Spanish cities studied remained stable before and during the economic crisis.

[COVID-19 and gender: certainties and uncertainties in monitoring the pandemic.] / COVID-19 y género: certezas e incertidumbres en la monitori-zación de la pandemia.

OBJECTIVE: Highlighting gender inequalities during the pandemic and its relationship with other axes of social inequality will be decisive for its adequate monitoring. The aim of this study was to assess the differences between men and women in the main measures of infection and mortality by COVID-19, considering its temporal evolution, raising awareness about the weaknesses and contradictions between sources of information. METHODS: Cross-sectional analysis based on the microdata on COVID cases notified by the National Epidemiological Surveillance Network (RENAVE), the Death Statistics of the National Statistical Institute (INE) and the estimates of excess mortality from the INE and the Daily Mortality Monitoring System (MoMo) microdata. Standardized rates, prevalences and and ratios by sex were calculated for each indicator. The percentage of excess mortality without COVID-19 diagnosis in each sex was calculated. Male/female ratios for symptoms and risk factors of COVID-19 were also calculated. RESULTS: The rate of infection by COVID-19 was higher in women in the three waves of the pandemic, reaching 65% of infections during April and May 2020. Complications were between 1.5 and 2.5 times higher in men, especially in ICU admissions, which were 2.5 times more frequent than in women. Although mortality rates and excess mortality were also higher in men (around 1.8 times), the percentage of excess mortality without COVID-19 diagnosis was higher in women (44% in men vs. 52% in women the first wave). With regard to the symptoms of COVID-19, fever, cough, and dyspnoea were more frequent in men (20%, 10% and 19% more, respectively) compared to sore throat, vomiting or diarrhea that were more prevalent in women (90%, 40% and 10% more, respectively). CONCLUSIONS: The analysis disaggregated by sex has made it possible to identify differences between men and women in the diagnosis, presentation and severity of the COVID-19 that can help a better clinical and epidemiological approach to the disease. However, official sources present important gaps when presenting information disaggregated by sex. It is therefore necessary to advance in the inclusion of a gender perspective in the statistics on COVID-19, starting with a necessary but not sufficient condition such as the disaggregation by sex of the data.

OBJETIVO: Visibilizar las desigualdades de género durante la pandemia y su relación con otros ejes de desigualdad social resultará decisivo para su adecuada monitorización. El objetivo de este estudio fue analizar las diferencias entre hombres y mujeres en las principales medidas de contagio, complicaciones y mortalidad por la COVID-19 teniendo en cuenta la evolución temporal de las mismas a lo largo de la pandemia en el estado español, visibilizando las aportaciones y carencias entre fuentes de información. METODOS: Análisis transversal en base a los casos COVID notificados por la Red Nacional de Vigilancia Epidemiológica (RENAVE); las estimaciones de mortalidad del Instituto Nacional de Estadística (INE) y las estimaciones de exceso de mortalidad del INE y los microdatos del Sistema de Monitorización de la Mortalidad diaria (MoMo). Se calcularon tasas, prevalencias y ratios por sexo de cada indicador. Se calculó el porcentaje de exceso de mortalidad sin diagnóstico COVID-19 en cada sexo. Se calcularon, así mismo, las ratios hombres/mujeres para los síntomas y factores de riesgo de la COVID-19 recogidos. RESULTADOS: La tasa de infección por la COVID-19 fue superior en mujeres en las tres olas de la pandemia, llegando a constituir un 65% de las infecciones durante abril y mayo de 2020. Las complicaciones por coronavirus fueron entre 1,5 y 2,5 veces mayores en hombres de manera constante especialmente en las admisiones en UCI que llegaron a ser 2,5 veces más frecuentes que en mujeres. Si bien las tasas de mortalidad y el exceso de mortalidad fueron también superiores en hombres (en torno a 1,8 veces), el porcentaje de exceso de mortalidad sin diagnóstico COVID-19 fue superior en mujeres (44% en hombres frente a 52% en mujeres en la primera ola). Con respecto a los síntomas de la COVID-19, la fiebre, la tos y la disnea fueron más frecuentes en hombres (un 20%, 10% y 19% más, respectivamente) frente al dolor de garganta, vómitos o diarrea que se presentó más en mujeres (90%, 40% y 10% más, respectivamente). CONCLUSIONES: El análisis desagregado por sexo ha permitido identificar diferencias entre hombres y mujeres en el diagnóstico, presentación y gravedad de la COVID-19 que ayudarán a un mejor abordaje clínico y epidemiológico de la enfermedad. Sin embargo, las fuentes oficiales presentan importantes lagunas a la hora de presentar la información desagregada por sexo. Es por ello necesario avanzar en la inclusión de la perspectiva de género en la estadística sobre el COVID-19, empezando por una condición necesaria, pero no suficiente, como la desagregación por sexo de los datos.

Social Inequalities in Health Determinants in Spanish Children during the COVID-19 Lockdown.

The COVID-19 lockdown was imposed in a context of notable inequalities in the distribution of the social determinants of health. It is possible that the housing conditions in which children and their families experienced the confinement, and the adoption of healthy behaviors, may have followed unequal patterns. The aim was to describe social inequalities in housing conditions and in health-related behaviors among children during the lockdown in Spain. This cross-sectional study was based on data from an online survey collecting information on the child population (3-12 years) living in Spain (n = 10,765). The outcome variables used were several housing conditions and health-related behaviors. The socioeconomic variables used were financial difficulties and parents' educational level. Crude prevalence and prevalence ratios estimated using Poisson models were calculated. During lockdown, children from families with low educational levels and financial difficulties not only tended to live in poor housing conditions, but were also exposed to negative health determinants such as noise and tobacco smoke; they took less physical exercise, had a poorer diet, spent more time in front of screens and had less social contact. A notable social gradient was found in most of the variables analyzed. The results point to the need to incorporate the perspective of equity in the adoption of policies in order to avoid the increase of pre-existing social inequalities in the context of a pandemic.

Gender inequalities in depression/anxiety and the consumption of psychotropic drugs: Are we medicalising women's mental health?

Aims: Clinical studies show that women are more likely to be diagnosed with depression and anxiety, and to consume prescribed psychotropic drugs. Applying an intersectional perspective that considers age, education and social class, the present study assesses gender inequalities in the diagnosis of depression/anxiety and in psychotropic consumption. Methods: We analysed data from the 2018 Basque Country Health Survey (Spain; n=8014). Prevalence rates of poor mental health, diagnosis of depression/anxiety and psychotropic consumption were calculated for each sex by age and socio-economic status. Poisson regression models were calculated to estimate PRs of these variables in women, adjusted for age, mental health status and health-care visits, and for diagnosis of depression/anxiety in the case of psychotropic drug consumption. Results: Women were 2.48 times more likely than men to be diagnosed with depression or anxiety, and this difference remained significant after adjustments (prevalence ratio (PR)=1.86; 95% confidence interval (CI) 1.40-2.47). Women also took significantly more prescribed psychotropic drugs, even controlling for their poorer mental health, their higher prevalence of diagnosis and their more frequent health-care visits (PR=1.52; 95% CI 1.28-1.82). No gender inequalities were observed in those younger than 45 or with the highest level of education. Conclusions: Gender inequalities in the diagnosis and prescription of psychotropic drugs exist, and these cannot be explained by differences in mental-health status or health-care visit frequency. It seems, then, that medicalisation of mental health is occurring among women. Further evidence about the mechanisms that underlie the results is crucial to design truly gender-sensitive health policies that reduce medicalisation of women's mental health.

Diagnosis and Treatment of Depression in Spain: Are There Gender Inequalities?

It is well known that women are more likely than men to be diagnosed with depression and to consume antidepressants. The factors related to the medicalisation of depression and their social distribution remain unclear. The aim of this study was to analyse gender inequalities in the medicalisation of depression from an intersectional perspective. This was a cross-sectional study based on data from the European Health Survey relating to Spain. Gender inequalities were calculated using prevalence ratios of women compared to men with a diagnosis of depression and antidepressant use, adjusted for age, depressive symptoms, primary care visits and diagnosis of depression in the case of antidepressant use. After adjustments, the diagnosis of depression and the use of antidepressants were more prevalent in women, especially of lower socioeconomic levels. Gender inequalities in the diagnosis of depression also increased with decreasing level of education. Regarding the use of antidepressants, gender inequalities were not significant in university graduates and people of higher social. The gender inequalities found in the diagnosis and treatment of depression cannot be completely attributed to a higher level of depressive symptoms in women or their greater frequency of visits to primary care. Inequalities are greater in more vulnerable social groups.

[Gender as a determinant of mental health and its medicalization. SESPAS Report 2020]. / El género como determinante de la salud mental y su medicalización. Informe SESPAS 2020.

Women's worse mental health has been shown using both health survey and clinical-based data. Considering that the hypothesis about a greater biological vulnerability of women is inconsistent, unequal living conditions between men and women, together with hegemonic models of hegemonic masculinity and femininity emerge as explain factors of these gender inequalities in mental health. The article shows that gender inequalities in mental health, the intersection of different axes of inequality, and the existence of a possible process of medicalization of women's mental health, by which health professionals are labeling women more frequently as depressed and anxious given similar mental health status in men and women. Prescription of psychotropic drugs is also of greater intensity in women, given equal need. This reality, moreover, seems to be unequal depending on the age and socioeconomic level of the patients. In recent years, different experiences are being developed aimed at addressing the growing medicalization of mental health from a gender perspective. Given that the phenomenon of medicalization is complex, it is necessary to act and promote changes at political-structural, cultural and health care levels that ultimately reverse gender inequalities in societies and promote non gender-biased healthcare.

Inequalities in participation in colorectal cancer screening programmes: a systematic review.

BACKGROUND: Colorectal cancer (CRC) is a major public health problem due to its incidence and mortality. Screening programmes help decrease its impact on the population through early detection. However, the uneven distribution of social determinants of health can cause inequalities. The aim of this study is to identify the social inequalities in the participation in CRC screening programmes. METHODS: A systematic review of the literature was carried out, searching in both health and social databases for papers published since 2000 in English, Spanish, Portuguese and French. The search strategies combined terms regarding screening, CRC, participation and social inequalities. Included papers were quantitative or qualitative primary studies analyzing gender and socioeconomic inequalities in the participation in CRC screening programmes implemented by public and private health-care providers and addressing 45- to 75-year-old population. RESULTS: A total of 96 studies, described in 102 articles, were included. Most were quantitative observational studies and analyzed population-based screening programmes. They were carried out mainly in the UK (n=29) and the USA (n=18). Participation in screening programmes varied from 1.1% to 82.8% using several methods. A total of 87 studies assessed participation by sex and one focussed on men, but only two provided an analysis from a gender perspective. Although men are at a higher risk of developing CRC, they generally were less likely to participate in screening programmes. Screening attendance was higher among the least deprived areas. CONCLUSIONS: Gender and socioeconomic inequalities in CRC screening participation should be addressed through the design of tailored interventions with a multidimensional focus.

Educational Inequalities in Life and Healthy Life Expectancies among the 50-Plus in Spain.

This study computes educational inequalities in life expectancy (LE), healthy life expectancy (HLE), and unhealthy life expectancy (ULE) by gender and education level in Spain in 2012. Death registrations and vital status by level of education were obtained from Spain's National Institute of Statistics. Health prevalences were estimated from the National Health Survey for Spain. We used Sullivan's method to compute HLE, ULE, and the proportion of time lived with health problems. Our results reveal that Spanish women live longer than men in all education groups, but a higher proportion of women report poor health. We detect substantial differences in unhealthy life by gender and education, with higher effect for women and for those with low levels of education. Poor self-perceived health shows the largest educational gradient; chronic diseases present the lowest. This is the first work that provides evidence on health inequalities by education level in Spain. Our findings seem to be in line with reports of the smaller social inequalities experienced in Southern Europe and highlight the importance of education level on extending the proportion of years spent in good health in a Mediterranean country.

[Social inequalities in health among the elderly population: review of indicators used in Spain]. / Desigualdades sociales en salud en población mayor: revisión de los indicadores empleados en España.

OBJECTIVE: To identify the indicators of social position used to evaluate inequalities in health among the population aged 65 and over in Spain. METHOD: A systematic search of the literature published in English and Spanish since 2000 in health and social databases was carried out. Primary and secondary studies analyzing these inequalities in Spain were included. The indicators used were identified, as well as the advantages and limitations pointed out by the authors. The main findings were synthesized in a review of the literature. RESULTS: We included 87 studies, described in 89 articles. The socioeconomic indicators employed were both individual and ecological. Among the former, educational level was the most analyzed socioeconomic variable (n=73). Other individual variables used were occupation (n=17), objective economic level (n=16), subjective economic level (n=4), housing and household material wealth (n=6), relationship with work activity (n=5), and mixed measures (n=5). Among the ecological indicators, simple (n=3) and complex indices (n=7) were identified. The latter had been constructed based on several indicators, such as educational level and unemployment. Inequalities in multiple health indicators were analyzed, self-perceived health being the only indicator assessed according to all the socioeconomic indicators described. CONCLUSIONS: A wide variety of indicators is identified for the evaluation of social inequalities in health among the elderly population. There have not been sufficiently assessed from a gender perspective; this is a line of interest for future research.

Decline in fertility induced by economic recession in Spain.

OBJECTIVE: To describe trends in fertility in Spain before (pre-recession; 1998-2008) and during (recession period; 2009-2013) the economic crisis of 2008, taking into account women's age and regional unemployment in 2010. METHOD: The study consisted of a panel design including cross-sectional ecological data for the 17 regions of Spain. We describe fertility trends in Spain in two time periods, pre-recession (1998-2008) and recession (2009-2013). We used a cross-sectional, ecological study of Spanish-born women to calculate changes in fertility rates for each period using a linear regression model adjusted for year, period, and interaction between them. RESULTS: We found that compared to the pre-recession period, the fertility rate in Spain generally decreased during the economic recession. However, in some regions, such as the Canary Islands, this decrease began before the onset of the recession, while in other regions, such as the Basque country, the fertility rate continued to grow until 2011. The effects of the recession on the fertility rate are clearly observed in women aged 30-34 years. CONCLUSIONS: The current economic recession has disrupted the positive trend in fertility that began at the start of this century. Since Spain already had very low fertility rates, the further decline caused by the economic recession could jeopardize the sustainability of welfare-state systems.

[Socioeconomic inequalities in health among the elderly population in Spain]. / Desigualdades socioeconómicas en la salud de la población mayor en España.

OBJECTIVE: To examine socioeconomic inequalities in health in the older population in Spain. METHOD: A systematic search and review of the literature published between 2000 and 2017 in English and Spanish was conducted in Social Science Citation Index, Sociology Database, Scopus, PubMed and Embase. Primary and secondary studies analysing these inequalities in Spain were included. Two researchers were responsible for the selection of the studies and the extraction of the information (first author, year of publication, region, design, population/sample, socioeconomic and health indicators used, and main results). RESULTS: A total of 89 articles were included, corresponding to 87 studies. Of the studies, 81.6% were cross-sectional, 88.5% included only non-institutionalised population and 35.6% were carried out at a national level. The studies analysed social inequalities in the following health indicators: functional status (n=29), morbidity (n=19), self-perceived health (n=18), mental and emotional health (n=10), cognitive status (n=7), quality of life (n=9), mortality (n=15) and life expectancy (n=2). Socioeconomic inequalities were detected in all of them, although the magnitude varied depending on the socioeconomic and health indicator used. The educational level and the ecological indexes were the indicators that detected more inequalities in health. The impact of inequalities by sex was different in functional status, morbidity, self-perceived health, mental and emotional health and mortality. CONCLUSION: There are socioeconomic inequalities in health among the elderly population and their magnitude varies by sex in some of the health indicators. The increase in educational level and the maintenance of sufficient pensions can be key policies that contribute to the reduction of inequalities in this population group.

[Health and determinants of health in second generations of international immigrants: Social inequalities in health since childhood?] / Salud y determinantes sociales de la salud en hijos e hijas de personas inmigrantes internacionales: ¿desigualdades sociales en salud desde la infancia?

OBJECTIVE: To analyse the social inequalities in health between children and youth population of an immigrant origin from low-income countries and those of native origin in the Basque Country. METHOD: Cross-sectional descriptive study using data from the Basque Country Health Survey 2013. Variables of health, behaviours and life conditions were used as the outcome variables. Prevalence ratios were calculated using robust Poisson models. RESULTS: The children with immigrant parents had poorer self-rated health, a higher prevalence of obesity, spent more hours in sedentary activities and lived in households with greater economic difficulties. The differences persisted even after adjusting for social class and educational level of parents. CONCLUSIONS: A migrant background is a highly relevant axis of health inequalities and has an influence beyond a generation. Given this reality, it is necessary to implement effective and suitable measures to ensure life with good health conditions and to reduce social inequalities in health, not only in childhood but through the entire life cycle.

[Social inequalities in health in the older population: an insight into the debate on delayed retirement age in Spain from a public health perspective]. / Desigualdades sociales en salud en población mayor: una aportación desde la salud pública al debate sobre el retraso de la edad de jubilación en España.

OBJECTIVE: To analyse the inequalities in life expectancy in the Spanish population over the age of 65 according to educational level. METHOD: Cross sectional study on the Spanish population aged 65 years and over. Life expectancy and healthy life expectancy were calculated combining mortality, health and population data. RESULTS: People aged 65 and over with a lower educational level had shorter lives, with fewer years of good health and more years of poor health. Women lived longer, but with proportionally more years of poor health. DISCUSSION: Social inequalities in health must be considered in the current debate on delaying the age of retirement.

Bayesian smoothed small-areas analysis of urban inequalities in fertility across 1999-2013.

BACKGROUND: Since the 2008 economic crisis in Spain, overall fertility has continued to decrease, while urban inequalities have increased. There is a general lack of studies of fertility patterns in small-areas of Spanish cities. We explored the effects of the economic crisis on fertility during three time periods in urban settings in Spain. METHODS: We studied the distribution of fertility rates among women (15-49 years) from Spain and low-middle income countries (LIC) who were living in 13 Spanish cities. We mapped fertility and the MEDEA socioeconomic deprivation index in small-areas, and analyzed age-related trends in fertility rates. We performed an ecological regression analysis of fertility and the deprivation index in two pre-crisis periods (1999-2003 and 2004-2008) and one crisis period (2009-2013). Fertility rates were calculated and smoothed using the hierarchical Bayesian model (BYM). RESULTS: Higher fertility was generally associated with socioeconomic deprivation, with adjustment for the mothers' age and nationality. While Spanish citizens tended to delay childbearing throughout the three study periods, fertility increased among Spanish adolescents from deprived urban areas during the economic crisis. There was a general decline in fertility among immigrants after the crisis, especially in southern cities. Overall, fertility appeared to be stable, with higher fertility in more deprived areas. CONCLUSION: Increased unemployment and changes to government family policies may have contributed to delayed childbearing in Spain. For immigrants, more restrictive immigration policies may have played a crucial role in decreasing fertility rates. Reforming such policies will be key for better reproductive rights and improved fertility rates across all population cohorts in Spain.

Inequalities in Health Services Usage in a National Health System Scheme: The Case of a Southern Social European Region.

BACKGROUND: Health services can reduce inequalities caused by other determinants of health or increase them due to the effect of the inverse care law-the principle that the availability of good quality care tends to vary inversely with the need for it in the population served. OBJECTIVE: The purpose of the research was to describe inequalities in the use of nursing services, medical services in primary care, specialist care, and services not fully covered by the Basque public health system in Spain. METHODS: A cross-sectional study of adults aged at least 25 years who completed the 2013 Basque Health Survey (N = 10,454) was conducted. Age-standardized prevalence and prevalence ratios for use of services that are covered and noncovered in the health system were computed. The association of health services usage with socioeconomic variables was estimated using a Poisson regression model with robust variance. The relative index of inequality (RII) was used to measure the magnitude of socioeconomic status inequalities in health service use. All analyses were carried out separately for men and women. RESULTS: Individuals with lower socioeconomic status were more likely to use primary care (RII = 0.87, 95% CI [0.79, 0.97]) and less likely to use specialist services (RII = 0.82, 95% CI [0.75, 0.89]). Across noncovered health services, inequalities between the highest and lowest social groups were significant in all cases and especially marked in men's use of physiotherapists (RII = 0.46, 95% CI [0.35, 0.61]) and podiatrists (RII = 0.24, 95%CI [0.15, 0.38]). DISCUSSION: There are significant inequalities in primary and specialist health service use based on individual socioeconomic status, particularly for services that are not provided free of charge within the existing health system. This suggests that health service systems that are not explicitly designed to provide universal access may actually amplify preexisting social and health inequalities within their target populations.

The role of birthplace and educational attainment on induced abortion inequalities.

BACKGROUND: Induced abortion (IA) has shown social inequality related to birthplace and education with higher rates of IAs in immigrant and in less educated women relative to their native and highly educated counterparts. This study examined the independent and joint effects of birthplace and education on IA, repeated and IA performed during the 2nd trimester of pregnancy among women residing in the Basque Country, Spain. METHODS: We conducted a cross-sectional population-based study of IA among women aged 25-49 years residing in the Basque Country, Spain, between 2011 and 2013. Log-binomial regression was used to quantify the independent and joint effects of birthplace and education attainment on all outcomes. RESULTS: Immigrant women exhibited higher probability of having an IAs (PR: 5.31), a repeated (PR: 7.23) or a 2nd trimester IAs (PR: 4.07) than women born in Spain. We observed higher probabilities for all outcomes among women with a primary or less education relative to those with a graduate education (All IAs PR: 2.51; repeated PR: 6.00; 2nd trimester PR: 3.08). However, no significant heterogeneity was observed for the effect of education on the association of birthplace with IAs, repeated or 2nd trimester IAs. CONCLUSIONS: Birthplace and education are key factors to explain not only an IA decision but also having a repeated or a 2nd trimester IA. However, the effects of birthplace and education may be independent from each other on these outcomes. A better understanding of these factors on IAs is needed when designing programs for sexual and reproductive health aimed to reduce inequalities among women.