Social and Ethnic Inequalities in Infant Mortality: A Perspective from the United Kingdom

doi:10.1053/j.semperi.2011.02.021

Seminars in Perinatology

Volume 35, Issue 4, August 2011, Pages 240-244

https://doi.org/10.1053/j.semperi.2011.02.021 Get rights and content

Social inequalities in infant mortality can be clearly demonstrated in the countries of the United Kingdom with a social gradient between different groups. Marked variations in infant mortality between ethnic groups are also evident in England and Wales, with the highest rates seen in Pakistani and Caribbean infants and the lowest rates in the white and Bangladeshi groups. Although individual risk factors for infant mortality are well understood, the reasons why certain social and ethnic groups have higher rates remain to be fully elucidated. Policies and interventions to tackle these inequalities are likely to be most effective if they have both universal and targeted components to “level-up” rates to the rate of the most advantaged in society.

Section snippets

Infant Mortality

As illustrated in Fig. 1 the infant mortality rate in England and Wales has declined steadily during the past 3 decades, although the rate of decline from the early 1990s slowed markedly. The relative contribution of neonatal and postneonatal deaths has also changed during this period. In the 1980s, 58% of infant deaths occurred during the neonatal period (within the first 28 days after birth) with 42% in the postneonatal period (between 28 days and 1 year). From 1992 onwards, the distribution

Socioeconomic Inequalities in Infant Mortality

In many countries, including the countries of the United Kingdom, socioeconomic status is strongly associated with infant mortality. Socioeconomic status can be measured in various ways but a classification based on the father's occupation is commonly used in the United Kingdom. Data on births and deaths in the United Kingdom are classified using the National Statistics Socioeconomic Classification (NS-SEC). The NS-SEC has 17 categories, but many of these are small and hence are often

The Determinants of Infant Mortality and the Determinants of Inequalities in Infant Mortality Rates

Three of the main causes of infant mortality are immaturity-related conditions, congenital anomalies, and SIDS, with each related to social position, ethnic grouping, and social exclusion. How can we explain these inequalities? The epidemiologist Geoffrey Rose⁹ argued cogently that we should distinguish between the determinants of individual cases of disease and the determinants of incidence rates of disease in populations. Although his argument was framed in terms of hypertension, it can be

Acknowledgments

This article is loosely based on an oral presentation given by R.G. to a workshop on Disparities in Perinatal Medicine at the Eunice Kennedy Shriver National Institute of Child Health and Human Development August 5-6, 2010. R.G. thanks the participants for constructive feedback. The article draws on work carried out and ideas developed as part of the inequalities in infant mortality project funded by the Department of Health. This is an independent report from a study that is funded by the

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However, factors important for one health outcome may not apply to another (Jayaweera & Quigley, 2010). In contrast to women born in Africa and the Indian subcontinent who tend to have higher rates of maternal and infant morbidity and mortality (Hollowell, Kurinczuk, Brocklehurst, & Gray, 2011; Knight, Kurinczuk, Spark, & Brocklehurst, 2009), women coming to the UK from European countries, including Accession countries, tend to have lower rates of poor outcome than UK-born women, and are more likely to have a normal birth (Gorman et al., 2014; Walsh et al., 2011). This has been partly ascribed to the ‘healthy migrant effect’ in which healthy women are more able and willing to migrate (Pendleton, 2015; Walsh et al., 2011).
In the UK, changes to legislation in 2003 regarding the free movement of people in the European Union resulted in an increase in immigration from countries that joined the EU since 2004, the Accession countries.
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Questionnaires asked about demographic characteristics, care during pregnancy, labour, birth and postnatally, about country of origin and, if not born in the UK, when they came to the UK. Country of origin was grouped into UK, Accession countries, and rest of the world. Recency of migration was grouped into recent arrivals (0–3 years), and earlier arrivals (4 or more years since arrival). Descriptive statistics and binary logistic regression were used to explore women's experiences of care. Stratified analyses were used to account for the strong correlation between recency of migration and region of origin.
Overall, 5332 women responded to the survey (a usable response rate of 54%). Seventy-nine percent of women were UK-born. Of the 21% born outside the UK, a third were born in Accession countries. All migrants reported a poorer experience of care than UK-born women. In particular, recent migrants from the Accession countries were significantly less likely to feel that they were spoken to so they could understand and treated with kindness and respect.
Given the rising population of non-UK-born women of childbearing age resident in the UK and the relatively high proportion from Accession countries, it is important that staff are able to communicate effectively, through interpreters if necessary.
The differences in clinical practice between women's home countries and the UK should be discussed so that women's expectations of care are informed about the options available to them.
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The risk of giving birth to a stillborn child or a child with severe congenital anomaly is higher for women who have immigrated to Europe as compared to the majority population in the receiving country. The literature, however, reveals great differences between migrant groups, even within migrants from low-income countries, although there is no clear pattern regarding refugee or non-refugee status. This heterogeneity argues against a particular migration-related explanation.
There are social disparities in stillbirth risk worldwide, and it has been suggested that the demonstrated ethnic disparity is a result of the socioeconomic disadvantage most migrants face. Consanguinity has been considered as another cause for the increased stillbirth risk and the high risk of congenital anomaly observed in many migrant groups. Utilization and quality of care during pregnancy and childbirth is the third major aspect. All three factors seem to contribute to stillbirth risk, and they should be considered in clinical practice and public health.
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These findings are in part because low birthweight, a risk factor associated with infant mortality (Maher and Macfarlane, 2004), is itself associated with area deprivation (Spencer et al., 1999; Dibben et al., 2006). Inequalities in both infant morbidity and mortality exist by ethnic group, influenced by the interplay between physiological, behavioural and cultural factors and the deprivation of the areas in which people live (Davey Smith et al., 2000; Hollowell et al., 2011; Small, 2012). Geodemographic classifications based on the sociodemographic characteristics of residents can provide insights about geographic patterns of health (Openshaw and Blake, 1995; Shelton et al., 2006; Abbas et al., 2009).
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The highest mortality rates are in infants and the greatest scope for further reductions might lie as much in reducing antenatal and perinatal risk factors as in technological improvements in perinatal care. Socioeconomic gradients in infant mortality persist, suggesting that wider social policy measures might be equally important for further reductions.96,97 Deaths from acquired natural disease occur throughout childhood.
In the past century, child mortality has fallen to very low rates in all developed countries. However, rates between and within countries vary widely, and factors can be identified that could be modified to reduce the risk of future deaths. An understanding of the nature and patterns of child death and of the factors contributing to child deaths is essential to drive preventive initiatives. We discuss the epidemiology of child deaths in England and Wales. We use available data, particularly that of death registration and other available datasets, and published literature to emphasise issues relevant to reduction of child deaths in developed countries. We examine the different patterns of mortality at different ages in five broad categories of death: perinatal causes, congenital abnormalities, acquired natural causes, external causes, and unexplained deaths. For each category, we explore what is known about the main causes of death and some of the contributory factors. We then explain how this knowledge might be used to help to drive prevention initiatives.
Risk factors for congenital anomaly in a multiethnic birth cohort: An analysis of the Born in Bradford study
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The increased risk associated with consanguinity was still apparent in the rates adjusted for deprivation: deprivation in mothers in consanguineous unions did not explain the increased rates of congenital anomaly in offspring. Poor access to prenatal screening in pregnancy and low rates of termination of severely affected fetuses have been suggested as a cause of the excess of infant mortality due to congenital anomaly in babies of Pakistani origin.26 Analysis of data for hospital activity for the period of the study showed that 132 terminations of pregnancy were done for fetal anomaly—59% in women of Pakistani origin and 32% in those of white British origin.
Congenital anomalies are a leading cause of infant death and disability and their incidence varies between ethnic groups in the UK. Rates of infant death are highest in children of Pakistani origin, and congenital anomalies are the most common cause of death in children younger than 12 in this ethnic group. We investigated the incidence of congenital anomalies in a large multiethnic birth cohort to identify the causes of the excess of congenital anomalies in this community.
We obtained questionnaire data from the mothers of children with one or more anomalies from the Born in Bradford study, a prospective birth cohort study of 13 776 babies and their families in which recruitment was undertaken between 2007 and 2011. Details of anomalies were prospectively reported to the study and we cross checked these details against medical records. We linked data for anomalies to maternal questionnaire and clinical data gathered as part of the Born in Bradford study. We calculated univariate and multivariate risk ratios (RRs) with 95% CIs for various maternal risk factors.
Of 11 396 babies for whom questionnaire data were available, 386 (3%) had a congenital anomaly. Rates for congenital anomaly were 305·74 per 10 000 livebirths, compared with a national rate of 165·90 per 10 000. The risk was greater for mothers of Pakistani origin than for those of white British origin (univariate RR 1·96, 95% CI 1·56–2·46). Overall, 2013 (18%) babies were the offspring of first-cousin unions. These babies were mainly of Pakistani origin—1922 (37%) of 5127 babies of Pakistani origin had parents in first-cousin unions. Consanguinity was associated with a doubling of risk for congenital anomaly (multivariate RR 2·19, 95% CI 1·67–2·85); we noted no association with increasing deprivation. 31% of all anomalies in children of Pakistani origin could be attributed to consanguinity. We noted a similar increase in risk for mothers of white British origin older than 34 years (multivariate RR 1·83, 95% CI 1·14–3·00). Maternal education to degree level was protective (0·53, 95% CI 0·38–0·75), irrespective of ethnic origin.
Consanguinity is a major risk factor for congenital anomaly. The risk remains even after adjustment for deprivation, and accounts for almost a third of anomalies in babies of Pakistani origin. High levels of educational attainment are associated with reduced risk in all ethnic groups. Our findings will be valuable in health promotion and public health, and to those commissioning antenatal, paediatric, and clinical genetic services. Sensitive advice about the risks should be provided to communities at increased risk, and to couples in consanguineous unions, to assist in reproductive decision making.
National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care programme.
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Social and Ethnic Inequalities in Infant Mortality: A Perspective from the United Kingdom

Section snippets

Infant Mortality

Socioeconomic Inequalities in Infant Mortality

The Determinants of Infant Mortality and the Determinants of Inequalities in Infant Mortality Rates

Acknowledgments

Drug Alcohol Depend

Drug Alcohol Depend

Am J Obstet Gynecol

Econ Hum Biol

Lancet

Lancet

Measuring health Inequalities

Sudden infant death syndrome: After the “back to sleep” campaign

BMJ

Inequalities in infant mortality briefing paper 1Infant Mortality: Overview and Context: National Perinatal Epidemiology Unit, Oxford 2009

Geographical trends in infant mortality: England and Wales, 1970-2006

Health Statistics Q