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Child health unravelling in UK

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l963 (Published 05 March 2019) Cite this as: BMJ 2019;364:l963

Rapid Response:

Re: Child health unravelling in UK

We strongly support the call for action to reduce child poverty and address social determinants of child and adolescent health in England from David Taylor-Robinson and colleagues.[1] The authors present recent increases in infant deaths to illustrate broader declines in health of English children and widening inequalities. Trends in infant mortality, however, need to be interpreted with caution as the patterns could be partially explained by changes in stillbirth rates.

According to Office for National Statistics (ONS), infant mortality increased from 3.6 deaths per 1000 live births in 2014, to 3.7/1000 in 2015 and 3.8/1000 in 2016 in England and Wales.[2] Breakdown by age at death shows that this increase was primarily driven by changes in early neonatal mortality (defined as deaths at age 0-6 days per 1000 live births), which increased from 2.0/1000 in 2014, to 2.1/1000 in 2015 and 2.2/1000 in 2016 (mortality beyond the first week of life remained constant over time). At the same time, we observed declines in stillbirth rates (from 4.7 stillbirths per 1000 total births in 2014, to 4.5/1000 in 2015 and 4.4/1000 in 2016). These changes in early neonatal mortality and stillbirth rates could reflect improved care for mothers at high risk of pregnancy complications (which may prevent a stillbirth by deferring death to the neonatal period), or changes to recording of these first week deaths versus stillbirths. Perinatal mortality rate (calculated as the number of stillbirths and deaths in first week of life per 1000 total births) can provide a more complete overview of trends in maternal and infant health. Indeed, this rate remained stable over the past few years (6.6 stillbirths or deaths /1000 total births in 2014, 6.5/1000 in 2015 and 6.6/1000 in 2016).

The authors show that increases in infant mortality mainly affected the most deprived areas, with the rates remaining constant in the least deprived areas.[1] These inequalities reflect patterns observed for neonatal mortality (that is, mortality at age 0-27 days).[3–5] Stillbirth rates and perinatal mortality, however, show a less negative picture. Stillbirth rates declined across all quintiles of deprivation, changing from 5.5/1000 in 2014, to 5.7/1000 in 2015 and 5.3/1000 in 2016 in the most deprived areas, and from 3.7/1000 in 2014, to 3.3/1000 in 2015 and 3.4/1000 in 2016 in the least deprived areas. Perinatal mortality (calculated as neonatal deaths and stillbirths per 1000 total births – more detailed data by age at death was not available by quintile of deprivation from ONS) remained constant in the most deprived areas (8.9/1000 in 2014, 9.2/1000 in 2015 and 8.9/1000 in 2016) and decreased in children from the least deprived areas (from 5.7/1000 in 2014, to 5.3/1000 in 2015 and 5.4/1000 in 2016). Further action is needed to achieve comparable reductions in the most deprived areas, where perinatal mortality remains approximately 40% higher compared to the least deprived areas. Many recommendations on the need to invest in health of women before and during pregnancy to reduce inequalities in child mortality and other health outcomes, have already been published. We are yet to see them implemented to ensure healthy future for children in England.

1 Taylor-Robinson DC, Lai ET, Whitehead M, et al. Child health unravelling in UK. BMJ 2019;364:l963. doi:10.1136/bmj.l963
2 Office for National Statistics. Child and infant mortality in England and Wales: 2016. 2018. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri... (accessed 20 Mar 2019).
3 Office for National Statistics. Live births, stillbirths, neonatal deaths and infant deaths, age of mother, and index of multiple deprivation, England 2016. 2018. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri... (accessed 20 Mar 2019).
4 Office for National Statistics. Live births, stillbirths, neonatal deaths and infant deaths, by local authority, age of mother and index of multiple deprivation, England, 2015. 2017.https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri... (accessed 20 Mar 2019).
5 Office for National Statistics. Births and infant deaths, England: 2012 to 2014. 2016. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri... (accessed 20 Mar 2019).

Competing interests: No competing interests

21 March 2019
Ania Zylbersztejn
Research Associate
Ruth Gilbert, Pia Hardelid
UCL Great Ormond Street Institute of Child Health
30 Guilford St, London WC1N 1EH