UK child survival in a European context: recommendations for a national Countdown Collaboration

Ingrid Wolfe; Angela Donkin; Michael Marmot; Alison Macfarlane; Hilary Cass; Russell Viner

doi:10.1136/archdischild-2014-306752

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UK child survival in a European context: recommendations for a national Countdown Collaboration

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Re: Where do the differences in childhood mortality rates between England & Wales and Sweden originate?
Ingrid Wolfe
Published on: 22 March 2016
Re: Pickled Red Herrings
Ingrid Wolfe
Published on: 22 March 2016
Pickled Red Herrings
Michael A. Colvin
Published on: 22 March 2016
Where do the differences in childhood mortality rates between England & Wales and Sweden originate?
Anna M. Zylbersztejn
Published on: 22 March 2016

Published on: 22 March 2016
Re: Where do the differences in childhood mortality rates between England & Wales and Sweden originate?
- Ingrid Wolfe, Dr
- Other Contributors:
  Angela Donkin, Michael Marmot, Alison Macfarlane, Hilary Cass and Russell Viner
We thank Zylbersztejn, et al for their constructive letter and for their support for the Countdown initiative. Their data suggests that high rates of preterm birth and thresholds for reporting preterm birth [1] in the UK were one of the most likely explanations for the disparities seen between the UK and European countries such as Sweden, and we agree this is likely (as outlined in our recent Lancet paper [2]. We agree en...
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We thank Zylbersztejn, et al for their constructive letter and for their support for the Countdown initiative. Their data suggests that high rates of preterm birth and thresholds for reporting preterm birth [1] in the UK were one of the most likely explanations for the disparities seen between the UK and European countries such as Sweden, and we agree this is likely (as outlined in our recent Lancet paper [2]. We agree entirely that it is important to know where to target policy, and their data moves us on considerably in determining priorities. This is precisely the sort of approach needed on the Countdown technical committee and we look forward to further collaboration.
Ingrid Wolfe, Angela Donkin, Michael Marmot, Alison Macfarlane, Hilary Cass, Russell Viner
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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Published on: 22 March 2016
Re: Pickled Red Herrings
- Ingrid Wolfe, Dr
- Other Contributors:
  Angela Donkin, Michael Marmot, Alison Macfarlane, Hilary Cass and Russell Viner
Colvin correctly notes that we are interested in solution-focused research, and expresses some anxiety about our recommendations for improving child survival. There are two issues to consider in addressing his concerns: determining causality, and the burden of proof required to take action.
First, Bradford Hill's criteria for considering causality are helpful in demonstrating why the association between poverty...
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Colvin correctly notes that we are interested in solution-focused research, and expresses some anxiety about our recommendations for improving child survival. There are two issues to consider in addressing his concerns: determining causality, and the burden of proof required to take action.
First, Bradford Hill's criteria for considering causality are helpful in demonstrating why the association between poverty and social inequalities, and many child health outcomes including mortality, is convincing[3]. The correlation between poverty and mortality is strong and consistent, and there is a clear gradient; poor children are more likely to die, and the greater the gap between rich and poor, the greater the risk[4]. Most of the other criteria are either self-evident (temporality) or are more relevant and appropriate to simpler questions of causality, (specificity, experiment). However Colvin also questions the plausibility and coherence of the associations, focusing on low birth weight, preterm birth, and teenage pregnancy as intermediary factors. The links between poverty, social inequalities, and adverse child health outcomes are more of a causal web than simple chain, so examination from multiple perspectives is helpful and indeed the associations are plausible, supported by epidemiological association, and other studies including intervention [5, 6].
There is specific data for England and Wales, based on individual parents' social status, demonstrating a clear social gradient in preterm birth rates of 6.8 per cent for babies with at least one parent in a managerial or professional occupation, compared with 7.8 per cent of babies with parents in routine or manual occupations[7]. Socio-economic adversity during pregnancy is also associated with an increased risk of having a low birth weight baby [6, 8]. Plausibility is supported by other associations and evidence too. For example, families from lower socio-economic backgrounds are likely to be more stressed[9] and acute and chronic antenatal maternal stress and poor maternal mental health are linked with preterm births and low birth weight [10, 11] Depression may also lead to negative maternal behaviours, and poor prenatal care, substance abuse, poor nutrition during pregnancy and smoking are associated with both socio-economic disadvantage, and with lower birth weight [12-15]. Young women from social disadvantaged backgrounds and low educational attainment are more likely to have a teenage pregnancy; teenage pregnancy rates are higher in more disadvantaged areas, approximately twice as high for women living in the most deprived areas compared with least deprived. Teenage pregnancy is associated with an increased risk of preterm birth compared with women in their 20 and 30s; in 2013, the overall rate of preterm births was 7.4 per cent, but among women under 20 years the rate was 8.0 per cent [16-19]. Infant mortality rates among babies born preterm to mothers under 20 years are higher (22.4 per thousand preterm births among mothers under 20 years) than among older mothers (15.1 per thousand among mothers aged 35-39)[7, 16-18, 20]. Colvin's suggestion that differences in teenage pregnancy rates are an alternative explanation ignores the strong association between teenage pregnancy rates and deprivation on both an individual and an area level, and the ample evidence that social disadvantage contributes to poor outcome at birth and in childhood.
The second issue relates to the burden of proof required before taking action. Epidemiology and health systems research are important tools in the search for explanations and solutions, and there are different methods and standards according to the questions asked[21]. Applying an epidemiological standard to a health systems or social policy question is neither always sufficient nor appropriate.The logical consequence of Colvin's argument is that a randomised controlled trial would be necessary before taking action to reduce social inequalities. There has never, to our knowledge, been any evidence published suggesting detrimental health effects of reducing poverty, narrowing the gap between rich and poor, or introducing policies promoting social protection. By contrast, there is plenty of evidence demonstrating good. It would seem remiss to wait for a purported but misguided epidemiological standard of evidence. The burden of proof suggests that our recommendations are likely to be safe and do more good than harm.
Ingrid Wolfe, Angela Donkin, Michael Marmot, Alison Macfarlane, Hilary Cass, Russell Viner
1. EURO-PERISTAT Project with SCPE and EUROCAT, European Perinatal Health Report. The health and care of pregnant women and babies in Europe in 2010,. 2013.
2. Viner, R., et al., Deaths in young people aged 0-24 years in the UK compared with the EU15+ countries, 1970-2008: analysis of the WHO Mortality Database. . Lancet. , 2014 384(9946): p. 880-92.
3. Bradford Hill, A., The environment and disease: association or causation? Proceedings of the Royal Society of Medicine, 1965. 58(5): p. 295-300.
4. Marmot, M., WHO European review of social determinants of health and the health divide. . The Lancet. , 2012. 380: p. 1011-1029.
5. Cattaneo, A., et al., Child Health in the European Union
2012, European Commission: Luxembourg.
6. Ohlsson, A. and Shah P, Determinants and prevention of low birth weight: a synopsis of the evidence. 2008, Institute of Health Economics Alberta, Canada
7. Office for National Statistics. Gestation-specific infant mortality in England and Wales, 2013. 2015; Available from: http://www.ons.gov.uk/ons/publications/re-reference- tables.html?edition=tcm%3A77-39593 http://www.ons.gov.uk/ons/dcp171778_419800.pdf.
8. Dibben, C., M. Sigala, and A. Macfarlane, Area deprivation, individual factors and low birth weight in England: is there evidence of an "area effect"? J Epidemiol Community Health, 2006. 60(12): p. 1053-9.
9. Duncan, G.J., J. Brooks-Gunn, and P.K. Klebanov, Economic deprivation and early childhood development. Child Dev, 1994. 65(2 Spec No): p. 296-318.
10. Talge, N.M., et al., Antenatal maternal stress and long-term effects on child neurodevelopment: how and why? J Child Psychol Psychiatry, 2007. 48(3-4): p. 245-61.
11. Hoffman, S. and M.C. Hatch, Stress, social support and pregnancy outcome: a reassessment based on recent research. Paediatr Perinat Epidemiol, 1996. 10(4): p. 380-405.
12. Bradley, R.H. and R.F. Corwyn, Socioeconomic status and child development. Annu Rev Psychol, 2002. 53: p. 371-99.
13. Brooks-Gunn, J., et al., Enhancing the cognitive outcomes of low birth weight, premature infants: for whom is the intervention most effective? Pediatrics, 1992. 89(6 Pt 2): p. 1209-15.
14. Korenman, S.M., JE. Sjaastas J., Long term poverty and child development in the United States: results from the NLSY. Institute for research on Poverty Discussion paper, . 1994, Institute for research on Poverty.
15. Marmot, M., Marmot M. Fair Society, Healthy Lives: the Marmot Review. Strategic review of health inequalities in England post 2010. 2010.
16. Office for National Statistics. Teenage pregnancies at lowest level since records began. 2013 [cited 2015 April]; Available from: http://www.ons.gov.uk/ons/rel/vsob1/conception-statistics--england-and- wales/2011/sty-conception-estimates-2011.html.
17. Office for National Statistics. Teenage pregnancies at record low: how does your local area compare? 2014 [cited 2015 April]; Available from: http://www.ons.gov.uk/ons/rel/vsob1/conception-statistics--england- and-wales/2012/sty-conception-rates.html.
18. Office for National Statistics. Conception statistics, England and Wales, 2013. . 2015; Available from: http://www.ons.gov.uk/ons/rel/regional-trends/area-based- analysis/conceptions-deprivation-analysis-toolkit/conceptions-deprivation- measures--2009-11.html.
19. Right Care, Atlas of Variation: Children. 2012.
20. Office for National Statistics, Teenage conceptions are highest in the most deprived areas. 2014.
21. Ghaffar, A., et al., Changing mindsets in health policy and systems research. Lancet, 2013. 381(9865): p. 436-7.
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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Published on: 22 March 2016
Pickled Red Herrings
- Michael A. Colvin, Paediatrician
Wolfe et al heighten my anxiety about solution- focussed epidemiological research with their recommendations for improving child survival in the UK (1). The correlation of lower socio- economic inequality with better child health outcomes in Sweden is clear enough but correlation does not equal causation, as we never tire of hearing. The assertion that "child survival in Britain would be improved through macroeconomic po...
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Wolfe et al heighten my anxiety about solution- focussed epidemiological research with their recommendations for improving child survival in the UK (1). The correlation of lower socio- economic inequality with better child health outcomes in Sweden is clear enough but correlation does not equal causation, as we never tire of hearing. The assertion that "child survival in Britain would be improved through macroeconomic policies to redistribute wealth and narrow the income gap between rich and poor people" is barely plausible and not demonstrable.
The relevant papers in October's ADC demand a solution to fundamental puzzles of pathophysiology- What causes intra-uterine growth restriction and premature birth; and what part is played by their social determinants? The association of preterm birth with poverty is modest (2). The suggestion that a comparison of your income with your wealthy compatriots can cause death goes too far.
One reason that Sweden has lower infant mortality rates is that they have very few births to teenage women. This in turn is due to high abortion ratios for teenagers, rather than having particularly low rates of teenage pregnancy (3). Of course we can't rationally propose more abortion as a solution to infant mortality when it is associated with increased rates of premature birth in subsequent pregnancies (4).
Teenage maternity is a biological norm, and is not universally associated with preterm birth. We must consider why preterm birth is commoner in young mothers in the UK and many other countries. Pre- conception stressful life events are associated with a four-fold increase in preterm birth for teenage mothers in the USA (5). Pre-conception stress provides us with a plausible pathophysiological model for causes of prematurity and a potential focus for research. Its causes reach far beyond family income and a protective effect against childhood stress of certain family structures might explain their association with infant survival and reduced risk of preterm birth(6).
Meanwhile, Sweden may be storing up its child mortality risk. Falling educational attainment and rising rates of reported stress in young Swedes should cause our Scandinavian colleagues some sleepless nights(3).
1 Wolfe I; ADC 2015 2 De Franco E; BMC Public Health 2008 3 Hjern A; Scand J Public Health 2012 4 Hardy G; J Obs Gynaecol Canada 2013 5 Witt W; AJPH 2014 6 Zeitlin JA; Paediatr Perinat Epidemiol 2002
Conflict of Interest:
None declared
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None declared.
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Published on: 22 March 2016
Where do the differences in childhood mortality rates between England & Wales and Sweden originate?
- Anna M. Zylbersztejn, PhD Student
- Other Contributors:
  Ruth Gilbert, Pia Hardelid, and Anders Hjern
We support the call for action by Wolfe et al. to address UK's high child mortality rates relative to some other European countries (e.g. Sweden) and we agree that preventive public health strategies are crucial for reducing child mortality in the UK. To put these aspirations into practice policy makers need to know which populations to target. In particular, whether the priority should be to focus on the health of women...
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We support the call for action by Wolfe et al. to address UK's high child mortality rates relative to some other European countries (e.g. Sweden) and we agree that preventive public health strategies are crucial for reducing child mortality in the UK. To put these aspirations into practice policy makers need to know which populations to target. In particular, whether the priority should be to focus on the health of women and girls, especially during pregnancy, or on the care of children and families after birth. We do not suggest either or, but our basic comparison of England & Wales and Sweden, using publicly available tabulated data, adds information about where the priorities might lie.
We compared mortality rates per 1000 live births by birth weight and age-at-death categories in England & Wales and Sweden for singleton pregnancies in 2006. We restrict these analyses to infants, because most deaths occur in the first year of life.
First, when we applied the Swedish infant mortality rate to the number of live births in England and Wales, and compared the result with the actual number of deaths that occurred in 2006, we obtained a difference of 1238 excess deaths. This result is consistent with the numbers cited in the paper (2000 excess deaths under the age of 14). We then applied Swedish birth weight specific infant mortality rates to the number of live births in England and Wales in each birth weight category and calculated the differences with the observed number of deaths. When we summed excess deaths over all categories, we obtained only 559 excess deaths. This substantial drop implies that the majority of excess deaths in 2006 were driven by the differences in the distribution of birth weights between England & Wales and Sweden. Field et al. (2009) show consistent results for gestational age - a higher proportion of children in the UK are born preterm compared to other European countries and this accounts for a substantial amount of the mortality difference. These results suggest that preventive strategies should focus on reducing prenatal risk factors and improving maternal health before and during pregnancy.
Amongst the remaining excess deaths our research has identified two groups most at risk. The greatest disparities were observed for extremely low birth weight babies (<1000g) dying in the first week of life, with 440 excess deaths. Differences in resuscitation policies, practices for the recording of live births and/or obstetric practices could explain disparities in the early deaths among these babies. Babies with normal birth weights (2500-3499g) had the second highest number of excess deaths (219), with the majority occurring in the post-neonatal period. Further investigation into causes of death and the impact of socio-economic factors is required to fully understand the mechanisms driving mortality in this group. Numbers of excess deaths in these two groups sum to more than 559 as some birth weight groups had lower rates in England & Wales than in Sweden.
These calculations are based on tabulations, but illustrate that if we take into account differences in characteristics of babies at birth, then the outlook for England and Wales is better than previously assumed. Comparability of the datasets to explore country differences related to reporting of live- and stillbirths, birth weight, and gestational age distributions, and timing of death registrations could be maximised by the use of individual-level data for such cross-country comparisons. Such analyses would enable better understanding of where the disparities originate from and more specifically what preventive strategies in the UK may have the greatest impact.
Field D, Draper ES, Fenton A, et al. Rates of very preterm birth in Europe and neonatal mortality rates. Arch Dis Child Fetal Neonatal Ed 2009;94:F253-6.
Conflict of Interest:
None declared
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