Women’s participation in the workforce has increased remarkably in recent years, both globally and in Turkey. The female labor force participation rate in Turkey, which was 25.3% in 2002, has risen to 35.2% in 2023. The number of employed women, which was 4.8 million in 2005, has nearly doubled to 9.9 million by 2023 (1). Women are now participating in the labor force at historically unprecedented rates. Many of them balance their roles as wives and mothers with their working lives (2).

Before the 1960s, social norms often forced pregnant women to leave work. From the 1960s, workforce participation increased and maternity leave policies were introduced. These changes affected employment patterns during pregnancy (3). Pregnant women may continue working for several reasons, including self-fulfillment and financial necessity. Maintaining a professional identity is another important factor. The increase in the number of women continuing to work during pregnancy has necessitated careful examination of the potential effects of employment on pregnancy. The impact of this situation on pre- and postnatal health indicators has become an important issue requiring careful consideration in the field of public health (4)

Prenatal, neonatal, and postnatal mortality rates are key indicators of societal health. Neonatal deaths (first 28 days) are linked to birth complications and maternal health, while post-neonatal deaths (28 days–1 year) relate to infections, environment, and healthcare access. Perinatal deaths (stillbirths and deaths within the first 7 days) are related to the level of equipment at the place of birth and the quality of healthcare services received by the mother during pregnancy, providing important insights into maternal and infant health (5).

Obstetricians pay close attention to the mother's nutrition and environmental conditions during prenatal care, but the mother's work situation is often overlooked. Many employed women balance work responsibilities with domestic duties. This can create additional physical and psychological stress during pregnancy and pose potential risks for pregnancy-related complications (6). Many women who work in paid employment continue to work throughout their pregnancy, which can lead to adverse outcomes such as abortion, preterm birth, low birth weight (SGA), or babies with fetal abnormalities. It can also cause pregnancy complications in mothers, such as hypertension and eclampsia (7).

However, some studies have shown that women who work during pregnancy generally have higher socioeconomic and educational levels, which allows them to access healthcare more easily, and this may be associated with positive pregnancy outcomes (8). According to the World Health Organization, approximately 800 women worldwide die every day due to pregnancy or childbirth-related complications, and the majority of these deaths are preventable (9). The United Nations International Children's Emergency Fund (UNICEF) reported that approximately 2.3 million newborns died worldwide in 2023, most of which were preventable. UNICEF reports emphasize that the economic empowerment of women and increased participation in the workforce are critical factors for improving maternal and child health outcomes, as they positively affect access to health services and quality of care (10, 11). Health inequalities begin in the prenatal period, as poverty before and during pregnancy negatively affects the physical and mental health of mothers. This can disrupt fetal development, increasing the risk of low birth weight or premature birth. Measures that improve living conditions in the early stages play a critical role in breaking the cycle of social inequality in the health sector (12). Therefore, increasing women's employment rates is important for public health.

As the number of women continuing to work during pregnancy increases, the importance of pre- and postnatal support policies offered by workplaces has also grown. Paid maternity leave, parental leave, and flexible working hours which help women stay in the workforce not only support women's employment but also directly impact maternal and infant health (13). Workplace policies aimed at protecting women during pregnancy and the postpartum period are of great importance for improving maternal and infant health outcomes and making workplace conditions more sustainable and equitable (14).

This study aimed to examine the relationship between female employment rates and prenatal, neonatal, and postnatal mortality rates in different regions of Turkey. Women's participation in the labor force not only contributes to economic development but can also have a direct impact on infant health through factors such as access to healthcare services and quality of care. Therefore, this study aims to analyze the effect of female employment rates on infant mortality rates using quantitative data, considering regional differences.

The findings are expected to guide the development of women's employment policies and the determination of strategies aimed at improving access to healthcare services and the quality of care for expectant mothers during pregnancy.

Turkey consists of 81 provinces. To facilitate sample selection and analysis in demographic research, five basic regions have been defined in the country. These regions are the Western, Southern, Central, Northern, and Eastern regions, which were formed by bringing together neighboring provinces with similar social, economic, cultural, and demographic characteristics. This classification is an important tool that enables a more accurate analysis of socioeconomic inequalities and demographic differences between regions.

As an alternative to the traditional seven geographical region system, the IBBS, developed by TÜİK and the State Planning Organisation (DPT) in collaboration with the European Union's harmonization process, is used in Turkey. The IBBS is compatible with the European Union NUTS .

The IBBS consists of three levels: Level 1 divides Turkey into 12 broad regions, and Level 2 covers 26 sub-regions. Level 3, the most detailed level, is based on 81 provinces in Turkey. This classification enables the analysis of regional development disparities and comparative assessments in areas such as health and employment, thereby providing a reliable and standardized data foundation for scientific research and public policies (15, 16).

The female employment rates used in our study were obtained from the TÜİK data and are presented according to NUTS Level 2 (17). In contrast, the perinatal mortality rate per 1,000 births and the neonatal and post-neonatal mortality rates per 1,000 live births were published by the Ministry of Health based on NUTS Level 1. Owing to this difference in data source levels, TÜİK data were converted to NUTS Level 1 for ease of analysis (16).

In this study, regional differences in the level of access to healthcare services were analyzed using the average number of visits to a doctor per person per year, as published by the Ministry of Health according to the IBBS Level 1 (16). The level of education was evaluated using the average years of education data published by TÜİK for each province, and these data were presented according to NUTS Level 3 (1). The data were grouped appropriately, averaged, and converted to the NUTS Level 1.

Since TÜİK reports female employment rates for nine out of the 12 regions at NUTS Level 1, our study focused on these nine regions.

Data on perinatal, neonatal, and post-neonatal mortality rates were last published by the Ministry of Health for 2023, and all comparisons in our study were based on data from this year.

In this context, based on data from the TÜİK and the Ministry of Health, female employment rates and prenatal, neonatal, and postnatal mortality rates will be examined at the regional level. By analyzing the correlations and possible causal relationships between these indicators, we aimed to establish a scientific basis for more effective planning of regional health policies.

The female employment rates, employment levels, and perinatal, neonatal, and post-neonatal mortality rates for each region are summarized in Table 1.

Southeast Anatolia has the lowest female employment rate, while the Mediterranean has the highest. Perinatal and neonatal mortality rates were the lowest in the East Black Sea region, whereas post-neonatal mortality was the lowest in the Istanbul region. The highest perinatal mortality was observed in the Central Anatolia region, whereas neonatal and post-neonatal mortality were highest in the Southeast Anatolia region (Table 1, Fig. 1).

The region with the highest education duration is Istanbul, while that with the lowest is Northeastern Anatolia. The number of visits to doctors, which is accepted as an indicator of the level of access to health services, was the highest in the Western Black Sea region and the lowest in Central Anatolia (Table 2).

Correlation analyses revealed negative, high-level, and statistically significant relationships between the female employment rate and perinatal and neonatal mortality rates (p = 0.007 and p = 0.018, respectively). No significant relationship was found between the female employment rate and post-neonatal mortality rate (p > 0.05).

A statistically significant, high-level positive relationship was found between the female employment rate and the level of access to health services (r = 0.81; p = 0.005). This result shows that as the female employment rate increases, the number of visits to doctors increases (Table 3).

One-way analysis of variance (One-Way ANOVA) revealed significant differences between female employment levels and mortality rates (p < 0.05). The Tukey HSD post-hoc test results showed a statistically significant difference in perinatal mortality rates between regions with low female employment levels and medium female employment levels. The perinatal mortality rate was higher in regions with low employment levels (p = 0.048). The effect size of this difference was calculated as 2.52 using Cohen's d, indicating a large effect.

Additionally, significant differences were observed between regions in terms of the number of visits to physicians according to female employment levels; in particular, the difference between regions with low and high employment levels was significant (p = 0.043). The effect size of Cohen's d was − 3.33, indicating a very large effect in favor of the high employment group (Table 4).

Female employment rates show a marked increase in western regions, and access to healthcare services also shows a parallel upward trend. However, the increase in access to healthcare services is more limited and follows a horizontal trend compared with female employment rates (Fig. 2).

A regional correlation analysis between female employment rates and education levels revealed no significant relationships (p > 0.05).

This study found a significant negative correlation between female employment and perinatal and neonatal mortality rates in Turkey. Women’s participation in the workforce is believed to have a protective effect on infant health during early pregnancy and the postpartum period. Economic independence and easier access to healthcare drive these positive outcomes. Improved quality of antenatal care also contributes.

Similarly, the literature shows that the risk of preterm birth and low birth weight is reduced in mothers with a higher socioeconomic status and education levels (12, 20). There is evidence that social support for low-income and low-education mothers reduces the infant mortality rate.

However, no significant relationship was found between female employment rates and post-neonatal mortality. Post-neonatal mortality (28 days–1 year) is generally less influenced by economic factors such as maternal employment. During this period, deaths are primarily associated with infections, environmental conditions, quality of home care, and nutrition. Consequently, the impact of female employment on post-neonatal mortality appears to be limited. Existing literature emphasizes the role of environmental and social determinants during this period; for instance, adequate hygiene, proper nutrition, and regular health check-ups are critical in reducing post-neonatal mortality (21, 22).

A strong and positive relationship was observed between female employment rates and access to healthcare services (r = 0.81, p < 0.05). This indicates that economic independence increases the regular use of healthcare services. The literature also reports that female employment positively affects infant health through access to healthcare services, education, and social support (23, 24).

Some studies have also shown that working during pregnancy does not directly pose a health risk and may even provide social benefits (25, 26). These findings support the notion that women's employment is effective through indirect means via socioeconomic and healthcare system access factors.

Women’s employment is both an economic and public health determinant. Policies should support workforce participation and prenatal care to reduce perinatal and neonatal mortality.

The regional scope of the study limits the detailed analysis of socioeconomic and health conditions on an individual basis. In addition, the conversion of female employment data from NUTS Level 2 to Level 1 carries the risk of not fully reflecting local differences in the data.

The number of visits to doctors per capita, used as an indicator of access to health services, does not provide information on the quality and effectiveness of services. Educational level was assessed only in terms of average years of education, and factors such as educational quality and health literacy were disregarded.

Moreover, the cross-sectional design restricts the ability to infer causality, and the study does not account for potential confounding variables at the individual level. Longitudinal studies using individual-level data, including detailed assessments of occupational conditions, healthcare utilization, and maternal lifestyle factors, are recommended to provide more robust evidence.

Despite these limitations, this study reveals important relationships between female employment and perinatal and neonatal mortality in Turkey.

A significant negative correlation was observed between female employment and prenatal and neonatal mortality rates in different regions of Turkey; as female employment increased, these mortality rates decreased. No significant correlation was found between post-neonatal mortality and female employment.

Women's participation in the workforce increases access to healthcare services and positively impacts infant health by improving the quality of prenatal care. Women's employment should be considered a strategic social determinant of public health, alongside economic development.

Therefore, legal regulations supporting women’s workforce participation, social support mechanisms, and the integration of healthcare services will contribute to reducing perinatal and neonatal mortality.

In the future, it is recommended that studies be conducted to examine the impact of women's working conditions on the pregnancy process at the individual level.