Infant mortality

Neonatal mortality accounts for 70-80% of deaths in the first year of life, largely due to perinatal causes, which can be prevented through healthy behaviours before and during pregnancy.

Background

  • Infant mortality rate is an important marker of the overall health of a society,1 which is used as a key international indicator used in the United Nation’s Sustainable Development Goals2 and in UNICEF international comparisons.3
  • Infant mortality rates across all UK countries have declined markedly over the past 40 years. However, progress has slowed over the past 20 years, particularly compared to other European nations.4
  • Most deaths during childhood occur during the first year of life, particularly the first month of life (the neonatal period). Neonatal mortality accounts for between 70% and 80% of infant deaths.
  • The great majority of neonatal deaths are due to perinatal causes, particularly preterm birth, and are strongly related to maternal health, as well as congenital malformations. The remainder of infant deaths are post-neonatal, due to a broad range of causes, including sudden unexplained death in infancy (SUDI).

Key findings

  • Infant mortality has stalled in both the UK and England since 2014, at 3.9 deaths per 1,000 livebirths. There was a slight rise to 4.0 per 1,000 livebirths in England between 2016 and 2017, which returned to 3.9 per 1,000 in 2018.9 However small, rises in infant mortality among high-income countries is extremely unusual, and should be a cause for concern.5 Since 2014, there has been reductions in Northern Ireland (4.8 to 4.2 per 1,000 livebirths), Scotland (3.6 to 3.2 per 1,000 livebirths) and Wales (3.7 to 3.5 per 1,000 livebirths).9
  • Data classification issues may partially explain the change. Increases in deaths around the first day of life have a large impact on infant mortality; as stillbirths are reducing, there is a suggestion that rises in infant mortality may partly be explained by deaths of babies particularly at the extremes of viability now being classified as neonatal deaths when formerly they were classified as stillbirths.6
  • Social inequalities continue to have a marked impact on infant mortality. The risk of infant death increases with greater levels of maternal deprivation, reflecting the social gradient that exists across underlying risk factors such as preterm delivery, maternal health during pregnancy and uptake of recommended practices such as breastfeeding and safe infant sleeping positions. Infant mortality trends also show widening health inequalities, since 2010 there has been a rise in rates for the poorest children, compared to falling rates for more advantaged infants.7,5,8

The infant mortality rate is defined as deaths under one year of age, per 1,000 live births.

Fluctuations within mortality data from Northern Ireland, Scotland and Wales should be read with caution, due to small numbers of registered deaths.

Index of Multiple Deprivation used is based on the English Indices of Deprivation 2019.

The neonatal mortality rate is defined as deaths between 0 and 27 days, per 1,000 live births.

Fluctuations within mortality data from Northern Ireland, Scotland and Wales should be read with caution, due to small numbers of registered deaths.

The post-neonatal mortality rate is defined as deaths between 28 and 365 days of age, per 1,000 live births.

The post-neonatal rate was calculated by subtracting the number of neonatal deaths from the number of infant deaths, divided by the number of live births for that year, multiplied by 1,000.

Fluctuations within mortality data from Northern Ireland, Scotland and Wales should be read with caution, due to small numbers of registered deaths.

What does good look like?

A focus on tackling poverty and inequalities. Deaths during infancy are strongly associated with preterm birth, fetal growth restriction and congenital abnormalities, which disproportionately affect the most disadvantaged families in society.10 Government efforts to reduce child poverty remain crucial to improving infant survival.11

Improved pre-conception care, including maternal health and education. A life course approach to infant mortality must include maximising physical and mental health and wellbeing of women pre-conception and during pregnancy, including pregnancy planning.12 This is particularly important for younger mothers whose premature or low birthweight babies have the highest mortality risk. Smoking, alcohol and substance misuse, poor nutrition and obesity –both before and during pregnancy – are all associated with adverse child health outcomes. Folate supplementation to prevent birth defects is a key part of high quality pre-conception care.

Infant feeding and care. Breastfeeding is a protective factor for infant survival, particularly for infants born preterm; therefore, it is vital that women are supported to breastfeed.13 Universal midwifery and health visiting services are one of the key ways in which new mothers receive education and support in managing their new baby, including supporting breastfeeding and safe sleeping positions.14

Meeting Government targets to halve rates of stillbirths and neonatal deaths by 2025.15 This requires further investment in Operational Delivery Networks for maternity and neonatal care, to ensure that all babies are born in the right place and when unexpected problems arise post birth, services are set up to ensure timely transfer to appropriate neonatal units.

Policy recommendations

  • Recommendations from the National Maternity Review should be implemented in Local Maternity Systems by the end of 2021. NHS England should plan an impact assessment to minimise variation and inform quality improvement in 2022.
  • The National Strategy for Child Health and Wellbeing should include a specific focus for the first 1,000 days of life.
  • There should be renewed investment and resource to support the revision of the Healthy Child Programme.
    • The Programme should provide a universal preventative service for all infants, children and young people aged 0 to 24.
    • Every child should receive a minimum of five mandatory contacts from a health visitor.
    • Revision of the Programme should be aligned to the latest evidence-base, namely the 5th edition of ‘Health for All Children’ (2019).
  • NHS England should deliver commitments within the Long Term Plan on health promotion and early intervention services, including:
    • Universal midwifery and health visiting services for new mothers;
    • Increased provision of targeted support for younger mothers.
  • NHS England should implement the recommendations of the Neonatal Critical Care Review in England.
  • The National Child Mortality Database in England should be maintained and supported to improve local learning and national policymaking.
  • UK Government should implement the fortification of flour with folic acid across the UK, to ensure women have healthy blood folate levels during their pregnancy.
  • ‘The Best Start: A Five Year Forward Plan for Maternity and Neonatal Care (2017)’ should be implemented in full and regularly reviewed in Scotland. The Plan should prioritise the care of women during pre-conception and pregnancy, including smoking cessation programmes, promotion of breastfeeding and promoting heathy weight in women of childbearing age.
  • There should be renewed investment and resource to support a revision of the Child Health Programme. Revision of the programme should be aligned to the latest evidence base, namely the 5th edition of ‘Health for All Children’ (2019) published in February 2019.
  • We welcome the Scottish Government’s public health campaign informing pregnant women on three steps to reduce the risk of stillbirths. This campaign should be rolled out nationally.
  • Healthcare Improvement Scotland should publish data to demonstrate whether the Patient Safety Programme on Maternity Care has fulfilled its commitment to reduce stillbirths by 35% by 2019.
  • Prioritise the care of women during pre-conception and pregnancy, including smoking cessation programmes, promotion of breastfeeding and promoting heathy weight in women of childbearing age. Welsh Government should deliver in full ‘Maternity Care in Wales: A Five Year Vision’, including implementation of the Maternity and Neonatal Network.
    • The Maternity and Neonatal Network should set and monitor targets to reduce still birth rates. The Network should ensure all Health Boards are signed up to the National Perinatal Mortality Tool, which enables clinicians to identify causation of death and disseminate learning. We welcome the Network’s Safer Pregnancy Campaign.
  • We welcomed the evaluation of the Healthy Child Wales Programme in 2019, which identified barriers to implementing the programme in full across Wales. There should be renewed support to implement the recommendations identified within the evaluation report. Future evaluations of the programme should consider recommendations from the latest evidence-base, namely the 5th edition of ‘Health for All Children’ (2019).
  • Welsh Government should ensure all Health Boards implement Growth Assessment Protocol (GAP) and gestation related optimal weight (GROW), which is designed to monitor fetal growth during pregnancy and ensure optimum outcomes at birth.
  • Public Health Wales should maintain and monitor the Child Death Review Programme, which collects, analyses and interprets all infant, child and young person deaths. Welsh Government should consider whether legislation is required to give Public Health Wales powers to demand data and documents, as the National Child Mortality Database has in England.
  • NHS Wales must consider the recommendations from the Neonatal Critical Care Review (England) for implementation, if they have not yet already been implemented.
  • The Maternity Strategy for Northern Ireland 2012-2018 should be revised and implemented in Northern Ireland with appropriate linkage to the Tobacco Control Strategy and A Great Start Breastfeeding to ensure integrated and coherent reporting and targeted intervention.
  • There should be renewed investment and resource to support the revision of the Healthy Child, Healthy Future (Northern Ireland) Framework and associated Programme. Revision of the Programmes should be aligned to the latest evidencebase, namely the 5th edition of ‘Health for All Children’ (2019).
  • A service specification for neonatal care should be established to improve neonatal services, as recommended within the Department of Health’s ‘Strategy for Paediatric healthcare services provided in hospitals and in the community, 2016-2026’. The service specification should address issues in neonatal units which were highlighted in the report ‘Bliss and TinyLife: Northern Ireland Baby Report’.
  • We welcome the Public Health Agency’s ‘Weigh to a healthy pregnancy’ programme (2019), which offers targeted support for pregnant women with a BMI of 38 and over. Public Health Agency should continue funding for this programme. Similar enhanced support for pregnant mothers with lower BMI rates should be available.
  • A Child Death Overview Panel should be created and resourced in Northern Ireland, with meaningful ongoing consultation with key stakeholders.

What can health professionals do about this?

  • Child death review. Clinicians should engage with their nation’s child death review processes to maximise and disseminate learning, and implement changes in systems and care processes in order to prevent child deaths in future. For this age group, the Perinatal Mortality Review Tool is particularly important, providing a standardised way in which infant deaths can be reviewed.16
  • Strengthen neonatal data collection. Professionals and services should participate actively in the National Neonatal Audit Programme, and use the findings to understand what is being done well and how services could be improved.
  • Recognise impact of social determinants of health, and support families in need. Professionals must recognise that families living in difficult circumstances are at higher risk of infant deaths, as well as other poor outcomes. They can support and act as advocates for vulnerable families, and signpost referrals if appropriate to other agencies for help with poverty and adversity.

Contributing authors

  • Dr Ronny Cheung, RCPCH State of Child Health Clinical Lead
  • Rachael McKeown, RCPCH State of Child Health Project Manager
  • Dr Rakhee Shah, RCPCH State of Child Health Clinical Advisor

Royal College of Paediatrics and Child Health (2020) State of Child Health. London: RCPCH. [Available at: stateofchildhealth.rcpch.ac.uk]

References

(1)

Centers for Disease Control and Prevention (CDC) Infant Mortality. Available from CDC

(2)

United Nations. Sustainable development goal 3: Ensure healthy lives and promote wellbeing for all at all ages. Available from Sustainable Development Goals

(3)

United Nations Children’s Fund (2016) The state of the world’s children: A fair chance for every child. Available from Unicef (PDF)

(4)

Office for National Statistics (2017). UK drops in European child mortality rankings. Available from: ONS

(5)

Taylor-Robinson D, Lai ETC, Wickham S, et al (2019) Assessing the impact of rising child poverty on the unprecedented rise in infant mortality in England, 2000–2017: time trend analysis BMJ Open 9:e029424. doi: 10.1136/bmjopen-2019-029424.

(6)

Zylbersztejn, A., Gilbert, R., Hjern, A. et al. (2017) How can we make international comparisons of infant mortality in high income countries based on aggregate data more relevant to policy?. BMC Pregnancy Childbirth 17, 430 doi:10.1186/s12884-017-1622-z.

(7)

Taylor-Robinson, D., Whitehead, M. & Barr, B. (2014) ‘Great leap backwards’, BMJ, 2014, 349:g7350.

(8)

Taylor-Robinson, D. (2017) ‘Death rate now rising in UK’s poorest infants’, BMJ, 2017, 357:j2258.

(10)

Tennant, P.W., Rankin, J., Bell, R. (2011) ‘Maternal body mass index and the risk of fetal infant death: a cohort study from the north of England’, Human Reproduction, 26(6), pp.1501-1511.

(11)

Aune, D., Saugstad, O.D., Henriksen, T. et al. (2014) ‘Maternal body mass index and the risk of fetal death, stillbirth, and infant death: a systematic review and meta-analysis’, Journal of the American Medical Association, 311(15), pp.1536-1546.

(12)

Royal College of Obestetricians and Gynaecologists (2019). Better for Women. Available from RCOG (pdf)

(13)

Lucas, A., Cole, T. (1990) ‘Breast milk and neonatal necrotising enterocolitis’, The Lancet, 336(8730), pp.1519-1523.

(14)

UNICEF Baby Friendly Initiative. Available from Unicef

(15)

Department for Health and Social Care (2017). New maternity strategy to reduce the number of stillbirths. Available from GOV.UK

(16)

Perinatal Mortality Review Tool. Available from NPEU