Infant mortality rate is the term used to describe the rate of death of infants under the age of 1 year per 1000 live births. Where an infant dies before the age of 28 days this is called a ‘neonatal’ death and ‘early neonatal’ deaths is the name used to describe deaths before the age of 7 days.
Infant mortality rate is an important indicator of the health of a population and factors associated with a higher risk of infant death are also indicators for poor health of the wider family e.g. smoking, obesity and deprivation.
Though stillbirths are not included in the definition of infant deaths and often a clear cause of stillbirth is not evident, risk factors for stillbirth and early neonatal deaths overlap significantly which is why this group of events are often analysed together, considered as “perinatal deaths”.
Each Local Safeguarding Children Board (LSCB) in England has a statutory duty to review the circumstances of death, not only for all infant deaths but for all deaths in children aged 0-18 years through convening Child Death Overview Panels (CDOP).
In Berkshire, the CDOP represents the LSCBs of all six unitary authorities. According to the Department of Education’s Working Together guidance, which was updated in 2013, Child Death Overview Panels must consider every child death aged 0-18 to review the both professionals’ responses to each death of a child as well as, importantly, relevant environmental, social, health and cultural aspects of each death and ensure a thorough consideration of how such deaths might be prevented in the future.
The majority of deaths in childhood occur in the first year of life (infant mortality) and are most commonly due to conditions related to premature birth and congenital anomalies. In those aged 1-16, rate of death is lower and the commonest causes include congenital related conditions and cancers.
Infant mortality rates vary according to age, socioeconomic status and ethnicity of the mother with the highest risks in babies of mothers aged under 20 years of age, from deprived backgrounds, and from minority ethnic groups specifically mothers born outside the UK. Lifestyle factors that increase risk of infant mortality include smoking in pregnancy and maternal obesity.
Infant mortality is also related to birth weight. In 2013, the risk of mortality in low birth weight babies (under 2.5kg) was eight times higher than average and for very low birth weight babies (under 1.5kg) the risk was over forty fold higher. Mortality rates are higher for multiple births, which are also associated with low birth weight.
A further risk factor relevant to Slough is the mothers country of origin and the predominance of deaths among certain Asian groups from Pakistan as discussed in the Born in Bradford report http://www.borninbradford.nhs.uk/research-scientific/ which highlighted excess risks associated with consanguineous births (i.e marrying a first or second cousin or other close relative).
Nationally, total infant mortality rates in England have reduced significantly over the last thirty years (Figure 1). Between 1983 and 2013 a 63% reduction in infant deaths occurred. There were 2,686 infant deaths in 2013, resulting in an infant mortality rate of 3.8 deaths per 1,000 live births which is the lowest rate ever recorded in England and Wales (Figure 1).
Over the same period, there has been a similar fall in national neonatal mortality rates (deaths under 28 days) and post-neonatal mortality rates (deaths between 28 days and 1 year). The neonatal mortality rate fell by 54%, from 5.9 deaths per 1,000 live births in 1983, to 2.7 deaths per 1,000 live births in 2013.
Rates of infant mortality are pooled over three years when shown in national statistics. The Slough Health profile for 2015 cites an infant mortality rate of 5.9 per 1000 live births for 2011-2013 which was significantly higher than the national average. It is important to note that due to time lag in releasing these national statistics, these data are significantly out of date and much work has been done to investigate risk of genetic conditions due to consanguineous births in Slough since 2013.
Data for 2013-14 shows that 13 infant deaths occurred in Slough in 2013-14. Half were born under the weight of viability at birth. A significant proportion of neonatal deaths locally are due to chromosomal, genetic, and congenital anomalies which are among the categories with the fewest modifiable factors.
The table below illustrates risk factors for infant mortality and stillbirths in Slough compared to the national average.
(under 18 conceptions)
|2013||19 per 1000||24 per 1000|
|Smoking in pregnancy
(smoking at time of delivery)
|Low birthweight rate||2013||8.9%||7.4%|
|Premature births||2010/12||84 per 1000||76 per 1000|
|Deprivation score (IMD)||2015||22.9||21.8|
The Department for Education's annual child death reviews cites modifiable factors in child death for which action should be taken (DfE 2013). Many of these identifed actions have been addressed locally already either through the adoption of NICE guidance or through local action via the Slough safeguarding children board.
The Oxford Academic Health Science network for maternity have prioritised improvements in maternal health covering the topics below for which NICE Guidelines are currently available:
The Berkshire wide actions required agreed with the local safeguarding board are:
Other work areas include:
The risk of infant mortality is reducing nationally but not as fast in Slough due to the higher proportion of infant deaths among younger mothers from BME communities who access the antenatal pathway late and are at higher risk of their children being born with low birth weights or with congenital anomalies due to consanguinity, smoking and other risk factors.
As highlighted above, increased risk of infant mortality is associated with very young age of mother, low socioeconomic status and mothers from minority ethnic groups particularly those born outside of the UK.
The key challenges remain the reduction of pre-term births and hence low birth-weight and this work will be supported at a regional level by the new Oxford Academic Health Sciences network (OAHSN) for maternity services and the existing Thames Valley Childrens and Maternity network.
Further work is required on promoting the many recommendations in the Scientific Advisory Committee on Nutrition report (2011), Early Life Nutrition, prior to and during pregnancy and NICE guidance on maternal and child health
Apart from further action on the risk factors for infant deaths there is a gap on work locally around reducing stillbirths which will be addressed by the Thames Valley Children’s and Maternity Network. Their recent audit recommended that: