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Reducing Infant Mortality

Introduction

Infant mortality is the term used to describe any deaths arising in children who are born alive but who die before their first birthday. “Infant mortality is a sensitive measure of the overall health of a population. It reflects the apparent association between the causes of infant mortality and other factors that are likely to influence the health status of whole populations, such as their economic development, general living conditions, social well being, rates of illness and the quality of the environment.” (see footnote 1).

There are many factors that impact on the infant mortality rate. The diagram below (see footnote 1) outlines interventions that would be most effective in reducing the gap in infant mortality.

A larger image of the above is available on the Department of Health website (external link). Download and view page 36 of the "Review of the health inequalities infant mortality PSA target" document.

Links with Maternity; Teenage Pregnancy; Smoking and Obesity sections

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Key issues and gaps

While the infant mortality rate for England is at an all time low, rates in Haringey are higher than those for England and London although the gap has closed in recent years. In 1997-99, there were 63 infant deaths in Haringey which gradually rose to a peak of 96 deaths in 2003-05. After this period, the number of deaths fell to 62 deaths in 2007-09, the lowest rate since 1997-9.

Figure 2: Infant Mortality, Under 1 year in England, London and Haringey, 3 year rolling average, 1997/99 – 2008/10

Source: NCHOD

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Who is at risk and why

See data section below and Maternity section.

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The level of need in the population

See Maternity section.

Although more recent data exists for infant deaths in Haringey, national and local comparative data is only currently available for 2007-2009.

The charts below compare the infant mortality rate in Haringey with England and London. The infant mortality rate in Haringey for 2008-2010 is 4.8 per 1000 live births (n=62 deaths). Rates in Haringey are slightly higher than for England and London, however, there is no statistical difference, except for stillbirths where Haringey is statistically higher than England. (Stillbirths are not included in the infant mortality rate but are included in perinatal mortality rates)

Figure 3: Infant Mortality Rate 2008-2010

Source: NCHOD

Figure 4: Infant Mortality Rate (2008-2010)

Source: NCHOD

As the numbers of infant deaths are small, it is worth looking at trends and data aggregated to three year totals. Neonatal deaths, deaths under 28 days, are slightly higher in Haringey than in London and England, although the gap has closed from a peak in 2004-6.

Figure 5: Infant mortality, under 28 days, 3 year rolling average, 1997/99-2008/10

Source: NCHOD

A similar trend is evident for deaths under 7 days, with the gap closing from a peak in 2003-5 and 2004-6.

Figure 6: Infant mortality, under 7 days, 3 year rolling average, 1997/99-2008/10

Source: NCHOD

The chart below describes the perinatal mortality rate in England, London and Haringey. The perinatal mortality rate includes stillbirths, which explains why the rate in Haringey is higher than in England and London, due to a higher stillbirth rate in Haringey in 2008-10.

Figure 7: Perinatal mortality, 3 year rolling average, 1997/99-2008/10

Source: NCHOD

The chart below compares the trend in infant mortality between Haringey and its statistical neighbours. These boroughs are statistical neighbours because they have a similar population demographic and one would therefore expect them to have similar health outcomes. In 2007-09, there is no statistical difference between Haringey and the other boroughs; however, Haringey has the lowest infant mortality rate among this group.

Figure 8: Infant mortality rate 2008-10, Haringey statistical neighbours

Source: NCHOD

Between 2007 and 2009, there were 62 deaths in infants under one in Haringey which are described in the following charts and maps. As numbers of deaths are very small, it is not possible to identify wards where there were fewer than five deaths due to data protection issues.

The table below describes infant deaths by cause and age. The majority of deaths occur within the first 7 days of life, 50% (n=31). Prematurity related conditions account for the highest number of neonatal deaths (under 28 days), 40% (n=25), followed by congenital anomalies, 26% (n=11). Nationally, three quarters of neonatal deaths are due to immaturity related conditions and congenital anomalies, suggesting that the deaths in Haringey reflect the national picture. Across all ages, prematurity and congenital anomalies account for the highest proportion of deaths, 52% (n=32) and 18% (n=11) respectively.

Other causes of death during this period include complications at birth (complications include for example, acute asphyxia in labour, hypoxic ischaemic encepathalopathy brain damage), infections and sudden unexpected death in infancy (SUDI). SUDI refers to deaths previously known as “cot deaths”. The term cot death does not adequately reflect that many babies do not die in cots, but rather on sofas, in car seats or co-sleeping in the parental bed.

Figure 9: Infant deaths by cause 2008-2010

Source: PHMF

The table below compares infant mortality in Haringey with England by age. Haringey has a slightly lower proportion of deaths under 7 days than England, but a slightly higher proportion between 7 and 28 days.

Figure 10: Comparison of Haringey Infant Mortality with England by age 2008-2010

Source: PHMF

Age of mother

Nationally, there is a higher rate of infant deaths in women aged under 20 and over 40. In 2007-09, the highest rates of infant mortality were to mothers aged over 40, 6.3 per 1000 births (n= 5 deaths). The lowest rate was for women aged 35-39, 2.7 per 1000 births (n= 7). The rate for women under 20 was 3.5 per 1000 births (n=2) and 4.5 per 1000 births to women aged 20-34 (n=39). The age of mother was not known for 9 out of the 62 deaths.

Additional information on age of mother was not available for deaths in 2008-10.

Ethnicity of mother

Reducing infant mortality in BME groups could have an important impact on the target group. This is because some BME groups are at particular risk of poverty and socioeconomic disadvantage, including Pakistani, Bangladeshi, Black Caribbean and Black African families (see footnote 1). It is important to provide services that take account of the different circumstances of mothers, for example between women and their partners from well-established communities and women who have recently migrated to the UK. Furthermore, women who are refugees or asylum seekers may have difficulty accessing maternity care and may be more reluctant to do so due to concerns about their citizenship status.

Ethnicity is not recorded on Public Health birth or mortality files. Ethnicities for deaths described here were obtained from the local Child Health Department and from the Haringey Child Death Overview panel. A breakdown of all births by ethnicity is not available so it is not possible to calculate an infant mortality rate by ethnicity. However, the figure below describes the number of infant deaths by mother’s ethnicity. Between 2007 and 2009, the ethnicity of the mother was known for 51 out of the 62 deaths. Of these, 29% of the mothers were Black African (n=18); 11% were White other (n=7) and 6% were Black Caribbean (n=4).

Figure 11: Infant deaths by ethnicity 2007-2009

Source: PHMF

*It is currently not possible to present ethnicity data for 2008-2010 due to data quality issues.

Haringey Public Health department has recently undertaken Health Equity Audits into women who book for antenatal care before 12 completed weeks of pregnancy and after 22 weeks of pregnancy at the North Middlesex and Whittington hospitals. The aim of these audits is to identify if any inequities exist in those who access maternity care late in terms of age, ethnicity and deprivation. Initial findings suggest that Black African women and those aged under 20 tend to book late for maternity care and therefore it is recommended that targeted outreach work is undertaken to improve early booking for antenatal care for these groups. See maternity section for more information.

Infant deaths by deprivation decile

The chart below describes infant deaths by deprivation decile. All of the 62 deaths were to mothers who lived in the 50% most deprived Super Output Areas (SOA) in the country. 42% (n=26) of the deaths were in the 10% most deprived postcodes in the country, suggesting a strong link between deprivation and infant mortality.

Figure12: Infant deaths by deprivation decile (2007-2009)

Source: PHMF

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Current services in relation to need

See maternity section

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Projected service use in 3-5 years and 5-10 years

See maternity section

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Expert opinion and evidence base

The Department of Health undertook a review of the infant mortality aspect of the life expectancy target during 2006, which aimed to identify the current position and develop a strategy for delivering the target. Review of the health inequalities infant mortality PSA target (external link) The review gained a clear understanding of the infant mortality target and the challenges faced in terms of local delivery.

The review identified five key barriers to delivery:

No recognition of the target or widening gap
Services not fully delivering to the target group
Lack of leadership and systems to support delivery
Lack of knowledge and understanding of the target
Poor handling and use of data and gaps in the evidence base.

It also identified key principles or “high impact changes” that could achieve change at a local level and help deliver the target. These are listed below:

Know the target, know your gap
Make the target part of everyday business – integrate it into commissioning plans and provider contracts
Take responsibility, engage communities and families in this work
Match resources to need
Focus on what can be done

The Department of Health published an Implementation Plan for Reducing Health Inequalities in Infant Mortality at the end of 2007 Implementation plan for reducing health inequalities in infant mortality: a good practice guide (external link) This offered further guidance for local areas in terms of what works and what would make a difference. The implementation plan highlighted interventions that will have a demonstrable impact on the gap; likely to have an impact and likely to reduce Infant Mortality overall.

Interventions that have a demonstrable impact on the gap: