Background
Cervical cancer is still a major public health problem despite the availability of effective prevention strategies. Although Europe has experienced substantial declines in mortality, recent evidence suggests unequal outcomes across socioeconomic strata, with women with low socioeconomic position bearing the greatest burden. Data comparing the magnitude and evolution of these inequalities within and between countries in Europe is rare. 

Objectives
We quantified educational inequalities in cervical cancer mortality and assessed temporal trends in age-standardized mortality rates (ASMR) by educational level. We further assessed the evolution of absolute and relative educational inequalities across Europe.

Methods
We collected and harmonised population-based mortality data from 17 European countries, for women aged 35–79 years between 1970 and 2022. Data were derived primarily from longitudinal mortality follow-up linked to administrative censuses. Educational level was classified according to the 2011 International Standard Classification of Education into primary (ISCED 0–2), secondary (ISCED 3–4), and tertiary (ISCED 5–8) levels. Individuals with missing information on education were excluded from the analyses. ASMRs per 100,000 women-years were calculated using the 2013 European Standard Population. Absolute and relative educational inequalities were computed directly as rate differences (primary-tertiary) and rate ratios (primary/tertiary). We restricted our analyses to 1980-2022 to ensure consistency of data across countries. Analyses were conducted by country and period using Stata version 17 and R version 4.3.2.

Results
Between 1980-2022, there was a general decline in cervical cancer mortality in Europe, with recent increasing trends among the most disadvantaged women in Finland, Sweden, Spain, Hungary, and Lithuania. Large educational inequalities were observed in almost all countries (except in Switzerland and Italy) with a clear social gradient; women with primary education consistently experienced the highest mortality rates compared to their secondary- and tertiary-educated counterparts. In the most recent period (2001-2022 depending on data availability by country), ASMRs for primary-educated women varied markedly from 2/100,000 (Switzerland) to 36/100,000 (Lithuania), whereas rates for tertiary-educated women were low and relatively homogenous (2–6/100,000) and intermediate for women with secondary education (2-17/100,000). Absolute inequalities were relatively stable with hints of increases in Finland, Sweden, Austria, Spain, Hungary and Lithuania in the last decade (2010-2020). Relative inequalities increased in most countries, with women with primary education facing up to 5 times the risk of cervical cancer death in some countries. ASMRs and absolute and relative inequalities were generally largest in Baltic/Central/Eastern Europe.

Conclusions and Implications
Despite overall reductions in cervical cancer mortality in Europe, educational inequalities persist and are widening even in some affluent nations. Rising trends in mortality among disadvantaged women highlights persistent health system- and individual-level barriers. Achieving cervical cancer elimination will require equity-focused policies and implementation of prevention strategies, with surveillance systems that monitor engagement and outcomes by socioeconomic position. Without targeted efforts, especially for underserved populations, technological advances in cervical cancer prevention risk exacerbating the existing inequalities.