Infant mortality

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.

What do we know?

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).

Facts, Figures, Trends

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).

Figure 1: Infant, neonatal and post-neonatal mortality rates, 1983 to 2013

Graph shows category of death for all child death reviews completed in 2012-2013. Source: Department for Education

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.

Infant mortality

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.

Figure 2. Infant Mortality in Slough

Map shows percentage of births that are a low birth weight by Middle Super Output Area (MSOA). Source: Local Health (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.

Table 1. Rates of risk factors for infant mortality

Risk factors Date Slough England
Teenage pregnancy
(under 18 conceptions)
2013 19 per 1000 24 per 1000
Smoking in pregnancy
(smoking at time of delivery)
2014/15 8.7% 11.4%
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

National & Local Strategies (Current best practices)

National

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:

Local

The Berkshire wide actions required agreed with the local safeguarding board are:

  • Improve the health of women prior to pregnancy to reduce pre term births focussing on nutrition as well as smoking
  • Promote consistency in the measurement of fundal height
  • Adopt a consistent referral pathway to tertiary centres for very underweight babies and babies with congenital heart problems
  • More work is needed to cascade cultural change through education regarding congenital anomalies. Deliver the PSHE programme created in 2014 across all secondary schools in Slough to increase awareness of consanguinity related deaths in particular ethnic groups.
  • Continue to promote safe sleeping advice consistently.
  • Promote the viral wheeze information on the parental version of the www.puffell.com website for parents to improve self-care and early reconition of sick children
  • Continue to promote advice from the Health and Safety Executive to prevent drowning accidents
    Two deaths by drowning in 2013-14 led to the promotion of Health and Safety Executive advice i.e the 10:20 rule which states that the adult supervising the child should scan every 10 seconds and not be more than 20 seconds away from the child
  • Promote cancer network advice on culturally appropriate ways of marking a child’s death

Other work areas include:

  • Address language barriers: particularly through early access to health services, and to emergency services if required. Slough has the highest ethnic proportion of the population in Berkshire and the lowest rates of access to primary care (based on 2014 data from the patient access survey. Data is expected from July 2015 which will show whether changes have occurred as a result of additional GP and out of hours sessions).
  • Raise awareness about the risks of consanguinity: Panels nationally remain concerned that inter-family couples do not have a sufficient understanding of the increased risks of having a child with a disability or of having a child die under the age of 5. Due to the infrequency in which consanguinity is recorded on discharge summaries, it is suspected a significant number of child deaths may be related to consanguineous partnerships. However, due to shortcomings in how this data is recorded it is difficult to quantity accurately. There is scope to improve the data collection.
  • Reduce the risk of harm from domestic abuse:
    In 3% of the deaths reviewed nationally domestic abuse may have contributed to vulnerability, ill-health or death. Only one case in Slough in 2013-14 had a history of DA and this was not considered a modifiable factor in the actual death
  • Promote recognition of sepsis:
    South Central Ambulance Trust have reviewed their procedures in 2014-15 in relation to a sepsis case and this revised pathway has been shared with local GPs and hospitals
  • Ensure adequate parental supervision:
    A number of panels reported that parental supervision was a factor in accident related deaths (mainly in older children) and actions were being taken to address this. There were two drowning deaths in 2013-14 and HSE advice has been circulated.

What is this telling us?

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.

What are the key inequalities?

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.

What are the unmet needs/ service gaps?

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:

  1. There is a need for further education of primary care and midwifery staff on features of pre conception and early pregnancy care highlighting the need for; aspirin, high dose folic acid and good diabetes care. There should be discussion on how this can be provided in 2015.
  2. The measurement of symphisio-fundal height should be standardised across Thames Valley and recorded at each antenatal visit.
  3. Each Trust should consider whether women who are having serial scans should have either additional scans or the timing of routine scans altered such that late pregnancy is covered.
  4. Every professional should be aware of the need for good communication and ensure a full history is available where a woman is moving between providers. Each discharge summary after pregnancy should contain specific advice about the need for any special measures in any subsequent pregnancy and should be provided to the mother.
  5. Each Trust should examine how post mortem consent is sought and by whom in order to improve the uptake of post mortem after stillbirth.

Recommendations for consideration by other key organisations:

  • The Local Safeguarding Children’s Board and child death panel for Berkshire have oversight of the work underway to reduce child deaths
  • Thames Valley Children’s and Maternity network and the Oxford Academic Health Sciences Network for Maternity have a coordinating role in improving acute care in the antenatal period
  • Slough CCG will continue to promote best practice in reducing child deaths from asthma and viral wheeze through a paediatric service as part of the Better Care Fund programme
  • Secondary schools in Slough have agreed to roll out the genetics programme developed in Herschel Grammar School
  • Public health are piloting a bespoke smoking cessation service to promote improvements in the health of the mother

Related pages