Child mortality in England compared with Sweden: a birth cohort study

Abstract

SummaryBackgroundChild mortality is almost twice as high in England compared with Sweden. We aimed to establish the extent to which adverse birth characteristics and socioeconomic factors explain this difference.MethodsWe developed nationally representative cohorts of singleton livebirths between Jan 1, 2003, and Dec 31, 2012, using the Hospital Episode Statistics in England, and the Swedish Medical Birth Register in Sweden, with longitudinal follow-up from linked hospital admissions and mortality records. We analysed mortality as the outcome, based on deaths from any cause at age 2–27 days, 28–364 days, and 1–4 years. We fitted Cox proportional hazard regression models to estimate the hazard ratios (HRs) for England compared with Sweden in all three age groups. The models were adjusted for birth characteristics (gestational age, birthweight, sex, and congenital anomalies), and for socioeconomic factors (maternal age and socioeconomic status).FindingsThe English cohort comprised 3 932 886 births and 11 392 deaths and the Swedish cohort comprised 1 013 360 births and 1927 deaths. The unadjusted HRs for England compared with Sweden were 1·66 (95% CI 1·53–1·81) at 2–27 days, 1·59 (1·47–1·71) at 28–364 days, and 1·27 (1·15–1·40) at 1–4 years. At 2–27 days, 77% of the excess risk of death in England was explained by birth characteristics and a further 3% by socioeconomic factors. At 28–364 days, 68% of the excess risk of death in England was explained by birth characteristics and a further 11% by socioeconomic factors. At 1–4 years, the adjusted HR did not indicate a significant difference between countries.InterpretationExcess child mortality in England compared with Sweden was largely explained by the unfavourable distribution of birth characteristics in England. Socioeconomic factors contributed to these differences through associations with adverse birth characteristics and increased mortality after 1 month of age. Policies to reduce child mortality in England could have most impact by reducing adverse birth characteristics through improving the health of women before and during pregnancy and reducing socioeconomic disadvantage.FundingThe Farr Institute of Health Informatics Research (through the Medical Research Council, Arthritis Research UK, British Heart Foundation, Cancer Research UK, Chief Scientist Office, Economic and Social Research Council, Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institute for Social Care and Health Research, and the Wellcome Trust).

Medical diagnoses among infants at entry in out‐of‐home care: A Swedish population‐register study

“…This pattern was, however, less pronounced for infants associated with SBS/AHT criteria, who, surprisingly, had parents who scored better for education, living together, and smoking. Biological risk factors such as smoking, SGA, obesity, and prematurity are known to be more prevalent among socioeconomically disadvantaged individuals, and socioeconomic factors are also associated with child morbidity and child mortality . SGA and prematurity are associated with SDH, and in addition to these, obesity is associated with infant metabolic bone disease .…”

Sweden wins over England in child health championship

“…Other factors identified by Zylbersztejn et al 1 were that smoking during pregnancy was much less common in Sweden than in England (6.5% vs 12%, 2010), although there are some worries that the popular use of oral tobacco, or snus, in Sweden may have similar negative effects. Obesity is also more common among pregnant women in England.…”

“…Zylbersztejn et al 1 also reported that deaths due to congenital malformations were more common in England than Sweden (43 vs 29/100 000 singleton live births). This could partially be due to the higher smoking and obesity rates in England.…”

“…Child mortality is almost twice as high in England as Sweden, according to a study by Zylbersztejn et al 1 that covered 2003–2012. This is a little difficult to understand given the many similarities between the two countries and the fact that Sweden essentially copied the model for the UK National Health Service.…”

“…The Zylbersztejn et al study comprised nearly four million singleton births from England and just over one million births in Sweden, which represented about 65% and 99.8% of the live births, respectively, during the study period 1. The highest mortality rates, and the main differences between England and Sweden, were at 2–27 days of age, when 77% of the excess risk of death in England seemed to be due to birth characteristics, and to a lesser extent to socioeconomic factors (3%).…”