Child Death Rate Study Finds Poverty Link for England

Peter Russell

May 08, 2018

High rates of child mortality in England compared with similar Western European countries may be explained by factors such as low birth rate, being born earlier, and more birth anomalies, research has concluded.

A study published in the Lancet compared deaths in children younger than 5 years in England and Sweden — countries with similar levels of economic development and universal healthcare — to try to understand why child mortality rates are higher in England.

Unequal Wealth Distribution

Researchers from the Farr Institute of Health Informatics Research, UCL Great Ormond Street Institute of Child Health, London; Stockholm University, Sweden; and the Karolinska Institutet, Sweden, found that a more unequal distribution of wealth in England was a key contributory factor.

The authors say that improving the health of mothers before and during pregnancy is key to improving the health of babies and increasing their chances of survival in the first few years of life. Also, tackling poverty hot spots could reduce child mortality levels, they say.

Dr Ronny Cheung, a consultant paediatrician and spokesman for the Royal College of Paediatrics and Child Health, said England's child death rates were "enormously related to social factors rather than actually how well we deliver our healthcare." These included deprivation and the birth condition of a child, he told Medscape News UK.

In 2013, death rates among children younger than 5 years was 4.9 per 1000 births in the United Kingdom, which was around 25% higher compared with France, Germany, Italy, and Spain. It was almost twice as high compared with Sweden, where child mortality rates were 2.7 per 1000 births.

Comparing Births and Deaths in England and Sweden

The study was based on 3,932,886 births and 11,392 deaths recorded by the National Health Service in England, and 1,013,360 births and 1927 deaths obtained from Sweden's health services.

These records included information on the mother's age, socioeconomic background, length of pregnancy, birthweight, sex, and whether the child had any birth anomalies, such as congenital heart defects.

The analysis revealed that at 2 to 27 days, 77% of excess child deaths in England relative to Sweden were a result of differences in birth characteristics, and a further 3% a result of socioeconomic factors.

When mortality rates at 28 to 364 days were looked at, these proportions were 68% for birth characteristics, with a further 11% for socioeconomic factors.

Between the ages of 2 days to 4 years, child death rates in England were 29 deaths per 10,000 children in England compared with 19 per 100,000 in Sweden.

The study authors say that if child mortality rates in England had been identical to those in Sweden, this would have accounted for 607 fewer child deaths in England per year, which is equivalent to 6073 fewer child deaths in total between 2003 and 2012.

The researchers note that the bulk of the differences in child death rates between the two countries were observed in infants younger than 1 year.

Dr Ania Zylbersztejn, a research associate at UCL Great Ormond Street Institute of Child Health, London, United Kingdom, who led the study, said in an accompanying press release: "While child deaths are still rare, the UK has one of the highest child mortality rates in western Europe. "Babies born prematurely or with low birth weight have an increased risk of early death, and those who survive are more likely to have chronic ill health or disability."

Poverty, Affluence, and Welfare

The United Kingdom has a higher proportion of children living in relative poverty (12.1% vs 7.3% in Sweden in 2009), the researchers say, or in deprived households (5.5% vs 1.3% in Sweden in 2009).

The Lancet study found that teenage mothers, who are more likely to come from deprived backgrounds, accounted for four times more births in England than in Sweden.

The researchers also found that prevalence of smoking during pregnancy is almost twice as high in England as in Sweden (12% vs 6.5% in 2010), whereas a higher proportion of women in England are obese.

"Families need to be better supported before and during pregnancy to improve maternal health, and in turn to give all children a healthy start in life," said Zylbersztejn in the news release.

According to Cheung, child death rates in England could be reduced by "better universal coverage of support services for women before they get pregnant, while they are pregnant, and during the time of delivery," and that this should be backed up by support for "breastfeeding, health visiting, and promotion of immunisation — all of these early-years public health interventions, which over the last 10 years or so in particular have started to get denuded over time with cuts to public health in general."

Although child death rates are worse in England compared with Sweden, Cheung said there are worse examples in comparable affluent countries. "Infant mortality is much higher in the United States than any other Western country in the world, and the difference between the poorest and the most affluent in the United States is much bigger than it is in England," he said.

The authors of the Lancet study point to some drawbacks to their findings. In particular, the quality of data in England was poorer than in Sweden, meaning that the study was restricted to 64.5% of English births between 2003 and 2012. Also, the 2 databases did not have comparable measures of socioeconomic status.

The study authors declared no competing interests. Funding for the study came from the Farr Institute of Health Informatics Research (through the Medical Research Council, Arthritis Research UK, British Heart Foundation, Cancer Research UK, Chief Scientist Office, Economic and Social Research Council, Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institute for Social Care and Health Research, and the Wellcome Trust). The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Lancet. Published online May 3, 2018. Full text

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