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

Abstract

Background: Child 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.

Methods: We 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).

Findings: The 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.

Interpretation: Excess 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.

Funding: The 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).

Figure 1

Development of comparable and representative birth cohorts in England and Sweden For each exclusion criterion, the percentages of all livebirths and all deaths are shown in brackets. Crude mortality rates at age 2 days to 4 years per 100 000 person-years are presented for each country before and after applying all exclusion criteria.

Figure 2

Mortality at 2 days to 4 years in England and Sweden, overall and by selected risk factors at birth We calculated excess deaths at 1 year and 5 years by multiplying the number of births in the English cohort based on all births (n=6 100 404) by the difference in proportion of children who died by their first or fifth birthday in England and Sweden. Probability of death is only presented for one risk factor at a time. ED=excess death.

Figure 3

Survival at 2 days to 4 years by socioeconomic factors in England and in Sweden Q1 denotes the most deprived 20% of pregnant women. Q5 represents the least deprived 20% of pregnant women. Probability of death is only presented for one risk factor at a time. Q=quintile.