International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

Infant mortality and migrant health in a Pakistani Muslim community in the UK. Professor Neil Small University of Bradford, UK

Background Bradford, a city in northern England with a population of about half a million people, is one of the most deprived cities in the United Kingdom. It has a wide-range of public health problems that are associated with socioeconomic deprivation, including a particularly high rate of infant mortality.1 Twenty three percent of the Metropolitan District of Bradford‟s residents are of South Asian origin, almost all being from the Mirpur region of Pakistan, a predominantly rural region in the province of Azad Kashmir. This figure increases to 62% in the inner city. Bradford has attracted migrants from Pakistan since the late 1950‟s. A first wave of male workers was followed by the migration of family members and by a continuing inflow ever since. The original migrant population of Pakistani origin has now matured into a three generational community. Bradford‟s Pakistani community retains close links with its homeland. Marriage between UK and Pakistan based members of the same extended families and travel for lengthy visits in both directions are common. Many of the traditional practices of Pakistan are evident in Bradford and there is evidence of the impact of these long-term connections with Bradford in Mirpur, branches of Bradford businesses and homes built by people based in Bradford for example. These are migrants and British born descendants of This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

migrants who are part of a community in the UK but are also a member of a community defined by identity not geography, one community across two continents. Such a hybrid is a world-wide phenomenon, a feature of the coming together of the dispersal of families and neighbourhood communities and of modern communication possibilities. Bradford‟s population is younger than the national average, and mothers of Pakistani origin have a higher than average birth rate. Almost half the babies born in Bradford have parents of Pakistani origin (50% white; 44% Pakistani; 4% Bangladeshi; 2% other) 1. Between 1996 and 2003 infant mortality in Bradford was 9.1 deaths per 1000 live births, almost double that for England and Wales as a whole (5.3/1000).1 Mortality was higher for babies of Pakistani-origin (12.9/1000), than for those of UK origin (7.1/1000) although the figures for babies of UK origin are still significantly higher than national averages. The highest mortality figures were for babies of mothers born in Pakistan who had moved to the UK. Rates improved in babies born to mothers who were of Pakistani origin but who had themselves been born in the UK, but these rates were still higher than national averages 2. As well as higher infant mortality children of Pakistani origin also have a greater prevalence of low birth weight

1

Infant mortality is defined as the death of live born infants before age 1 and is presented per 1000 live births.

2

In much official literature mothers who were born in the UK but had parents who were born in Pakistan are identified as “second generation”. This is inaccurate, if they were born in the UK they are not migrants. It is not a semantic issue but one of citizenship status. These “second generation” mothers are born in the UK and hence are UK citizens in the same way as all born in the UK. Identifying them as second generation potentially marks them out as belonging to a group, “immigrants”, and such groups have been and continue to be subject to stigmatisation. I have used more precise language, “women of Pakistani origin who were born in the UK” unless I am quoting direct from published material where the “second generation” terminology is used. I am grateful for guidance from Professor Raj Bhopal, University of Edinburgh. This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

(generally considered to be predictive of subsequent health problems). Morbidity including levels of obesity, an indicator of later diabetes and heart disease, and genetic disorders 2, 3 was also highest in children of Pakistani origin. There is concern in the city about likely high levels of morbidity in South Asian adults as the population ages. Of particular concern is a high prevalence of indications of prediabetes and of diabetes in South Asian adults, 40% of adults of Pakistani origin either have diabetes or indicators of pre-diabetes. Bradford‟s Pakistani community constitute a vulnerable group, here identified by some of the most profound measures of vulnerability, the rates of death of children and the burden of disease. But it is also a community typical of many. Ethnically and religiously defined, geographically concentrated, socio-economically disadvantaged, communities are a major feature of the twenty first century city. Bradford provides an advantageous setting for research to explore the pathways linking socioeconomic deprivation with infant deaths, ill-health and impaired development, and for exploring differences between people of European and Pakistani origin in their experience of health and wellbeing. It also provides a context for considering the impact of migration on health and in particular the changes in infant health in the British born children of migrants and children born to mothers of Pakistani origin who were themselves born in the UK. While there is a strong research imperative to investigate why death and illness are so high that research has to engage with the ethics and accepted practices of the vulnerable community. Without that engagement it is unlikely that the most useful questions will be asked and it is unlikely that This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

research findings would be welcomed and acted upon by the community being studied. The challenge for improving migrant health is how to engage with communities to build on their health sustaining practices and encourage change where practices are detrimental per se, or detrimental in their new environment. For example infant feeding that had been established over generations in Pakistan may need to change as families move from resource poor to resource rich countries 4. Additionally those responsible for planning and delivering public health, medical care and social provision have to offer services sensitive to the practices and priorities of different communities. This paper will introduce the Born in Bradford birth cohort study 5, 6. It will explore infant mortality in more detail by looking at deprivation, ethnicity and migration effects. It will take areas of health related practice and consider how they are differentially present in the two main ethnic communities included in Born in Bradford. The value of considering approaches by migrant communities and by the children of migrants to health and health services as a hybrid of attitudes and approaches from both country of residence and country of origin will be considered. Understanding health inequalities, conventionally pursued via examining economic inequality, is made more complex both descriptively and in terms of seeking to identify causal relationship when one considers the added dimension of ethnicity. This paper will explore the limitations of engaging with inequalities in health via utilising simple constructs based either on economics or race. Cultural and religious identify, specifically the significance of Islam; the importance of migration effects; complexities of health related behaviours; engagement of different groups with their localities and the local state including health services all contribute to the complex lived experience of migrant communities and all This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

these factors, as well as those of economics and race need to be included when we seek ways of theorising health inequalities. The Born in Bradford Study. The Born in Bradford study is a birth cohort study that is designed to examine how genetic, nutritional, environmental and social factors impact on health and development during childhood, and subsequently adult life. As well as social class and ethnicity the study will examine health relevant behaviours, diet, smoking, alcohol and drug use, patterns of infant and child care, use of antenatal and child care services, and social capital. The intention is to test hypotheses about the developmental origins of disease in the context of migration, to examine social class and parental behaviours as predictive of health status in minority ethnic communities and to consider if, how and why successive generations of migrants shift towards host community health norms. The ultimate aim will be to develop hypotheses, which can then be evaluated and tested, for health and social interventions to improve childhood and adult health. Cohort studies have proved to be a powerful way of examining the complex interplay between biological, environmental, social and economic factors impinging upon health and well being. A series of UK national birth cohort studies recruiting in 1946, 1958, 1970 and 2000/01 (www.cls.ioe.ac.uk) , and locally based studies, notably a 1991 cohort in the Avon Region in the South-West of England ( www.bristol.ac.uk/alspac/ ), have made major contributions to studying patterns of heath in the context of changing circumstances over time. The studies are characterized by broad recruitment, large This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

numbers and long follow up. As well as these UK studies there are many birth cohort studies in existence across the world (for example in Germany, Norway, Netherlands, Denmark) and major new national studies are developing the USA and in France. Other cohort studies recruit children postbirth. These include studies in Ireland, Australia and Canada. Born in Bradford began to recruit pregnant women attending hospital outpatient services in March 2007. The study aims to recruit 13,000 mothers and babies. All fathers will be invited to join the study but previous birth cohorts, and early indications in Born in Bradford, suggest numbers will be considerably less. Approximately half the babies Born in Bradford have parents of South Asian origin, primarily from Pakistan. Initial estimates informed by other cohort studies, was of a likely 80% uptake for the women and children, with 75% retention over five years. It was not anticipated that there would be particular difficulties in recruiting South Asian families if study material and interviews were available in the appropriate community languages. All women planning to have their baby at the Bradford Royal Infirmary, the only maternity hospital in a city with a very low number of home births, are invited to participate in the Born in Bradford cohort when they are between 26 and 28 weeks of their pregnancy. If they agree, they complete a baseline questionnaire with a trained project worker, have anthropometric measurements taken of height, weight and skinfold thickness and give a blood sample. Consent from the woman also includes permission to access routine health data collected by NHS organizations for mother and baby and that permission is assumed to be ongoing, that is it relates to all subsequent contacts with the NHS. The intention is to follow the babies recruited to the cohort throughout their childhood. This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

Both the cohort study itself and other studies that ask specific questions from sub-sets of the cohort, are approved by the Bradford Local Research Ethics Committee and necessary research governance permissions have been obtained. Born in Bradford has an Advocacy and Scrutiny Group made up of parents from the study, members of the local community and people with specific areas of interest and expertise (for example in the law) who are not involved in other aspects of the study. This group review and advise on all proposed new studies and on the overall direction of Born in Bradford, including issues of cultural sensitivity and of any potential excessive burden that joining Born in Bradford may impose on study participants. Any person recruited to the study is free to withdraw at any stage with no detriment to the health services they receive. Fathers who agree to take part and sign the consent form have height and weight recorded, and are asked to complete a self administered questionnaire and to provide a saliva sample. As of October 2009 there are 9400 mothers recruited, 8194 babies and 2149 fathers. Summary of patterns of infant mortality in Bradford.3 Infant mortality, death in the first year for life for babies born alive, was 5.06 per 1000 live births in England and Wales in 2005. For Bradford it was 7.21 per 1000 live births, this represent a decline from over 9 per 1000 in 2000/2. Figure 1 illustrates a steady trajectory of decline in infant mortality rates for England and Wales but a more varied picture for Bradford. Given that overall Bradford is one of the 3

The four tables presented in this section have been developed by the informatics team of Bradford and Airedale Teaching Primary Care Trust headed by Helen Brown. The data up to the year 2003 is presented in the Bradford Infant Mortality Commission Report (see reference 1) and subsequent years updates are from data made available by this team to the Trust – see www.bradfordairedale-pct.nhs.uk This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

UKs most deprived districts it is not surprising that the Bradford infant mortality rate is always greater than that for England and Wales, the relationship between deprivation and infant mortality is well established. What is of note is both the extent of the gap, which is greater than cities with comparable levels of deprivation, and the upwards trajectory evident for a part of the time period. Fig 1.

10 9 Rate per 1000 live births

8 7 6 5 4 3 2 1 0 1996-1998

1997-1999

1998-2000 Bradford Rate

1999-2001

2000-2002

2001-2003

2002-2004

2003-2005

2004-2006

England & Wales Rate

Infant Mortality Rate, Bradford and England and Wales

Fig 2 breaks down the infant mortality rate according to deprivation quintiles. I will say more about the way deprivation is classified and its relevance for minority ethnic communities below. Suffice to say here that this is a geographic measure that divides the England and Wales into five bands according to This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

a combination of income, health and disability, education, skills and training, barriers to housing and services, living environment and crime. It is used to identify pockets of deprivation but not everyone in an area is deprived and not all deprived people live in deprived areas. In 2005/07 Bradford births according to the quintile the mother was in were as follows: 32% of babies were born into the most deprived quintile; 26% in quintile 2; 16% in quintile 3; 14% in quintile 4; and 11% in least deprived quintile. While fig 2 shows a clear differences between most and least deprived sections of the population there is some need for caution in interpreting the figures. Analyses by quintiles means that in less deprived quintiles numbers of births are small. Specifically, increasing rates in the least deprived group between 2001 and 2005 are not significant, numbers are small and a change over one time period does not, with any degree of certainty, indicate a trend. If we ignore the apparent jump in the least deprived category in the most recent time period we can see a difference of the order of 5 between least and most deprived groups, that is you are more than 5 times as likely to have an infant death if you are in the most deprived group compared to the least deprived. At its widest (1999-2003) this gap has been more than 6 times as many.

This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

Figure 2.

14

Rate per 1000 live births

12

Most deprived

10 2nd most deprived

8 3rd most deprived

6 4

2nd least deprived

2

Least deprived

2001-2005

2000-2004

1999-2003

1998-2002

1997-2001

1996-2000

1995-1999

1994-1998

1993-1997

0

Infant Mortality by Deprivation Quintile within Bradford 1993-97 to 2001-05

Figure 3 considers deprivation, ethnicity and migration status. It presents figures for births for the whole period 1996-2005. Infant mortality decreases in the white population as deprivation decreases, although in the most affluent groups there is not a significant difference. Infant mortality rates for first and second generation Pakistanis do not appear to improve as deprivation decreases. As noted above numbers are very small in the more affluent categories, particularly for Pakistani‟s.

This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

Figure 3.

Infant mortality rate by deprivation quintile and ethnicity, 1996 - 2005 30.0

25.0

Rate per 1000

20.0

15.0

10.0

5.0

0.0 Most deprived White

2nd most deprived

Pakistani 1st generation

3rd most deprived Pakistani 2nd generation

2nd least deprived Total Pakistani

Other

Over the period from 1996 Bradford births to white mothers have reduced from 59% to 53%, and the percentage of South Asian origin mothers has increased from 34% to 40% . About half of births to Asian families are to first generation mothers, that is to mothers who were themselves born in Pakistan. This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

Overall, first generation Pakistani births increased from 21% to 22.5% of Bradford totals. Births to women of Pakistani origin who were born in the UK increased from 10.2% to 15 %. Babies born to first generation mothers of Pakistani origin had a rate of infant mortality that, in the years 1996 to 2005 , peaked at 15.35 per 1000 in 2000, in 2005 it was 9.74, second generation mothers had a steady decline from 14.68 in 1996/8 to 7.56 in 2002/4. White Mothers figures were rising up to 2002 when they were 7.96, then have gone down to 5.30 in 2005. The infant mortality rate also shows a difference in terms of the gender of the baby who dies. There is a higher female than male mortality, particularly in first generation Pakistani mothers (F=14.5, M=11.6). This is less pronounced for 2nd generation Pakistani‟s (F=10.6, M=9.7). With white mothers a higher male to female death rate is found, which is in keeping with England and Wales and with other European countries (F=5.9, M=7.4) Figure 4 identifies cause of death analyzed by ethnicity, gender of the baby and migration history. As with some of the other figures and trends presented above there is a need for caution in interpretation. Cause of death ascertained from death certification can underestimate complexity, that is a single cause is identified when a combination of factors is a better way to characterize the death. Some indications of difference are however evident, deaths from congenital abnormalities in male second generation Pakistani babies account for the excess over deaths on white babies for example.

This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

Cause of Death, 1996 - 2005 16.0 14.0 12.0

Rate

10.0 8.0 6.0 4.0 2.0 0.0

White

Pakistani 1st generation

Other specific conditions Antepartum infections

Other conditions Sudden infant deaths

Pakistani 2nd generation

Male

White

Pakistani 1st generation

Pakistani 2nd generation

Female External conditions Infections

Immaturity related conditions Congenital anomalies

Asphyxia, anoxia or trauma

As well as infant mortality, figures for low birth weight are collected – low birth weight is an indicator for likely health problems in infancy and beyond. 10% of Bradford's live births are less than 2500g (this is classified as low birth weight) compared to 7.6% in England and Wales. 1.5% of Bradford's live births are less than 1500g (very low birth weight), compared to 1.2% in England and Wales. This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

Proximal and distal causes of infant mortality: how inequality gets under the skin. In the conventional language of epidemiology (and of public health) we can distinguish between sorts of causes; proximal are those causes located in the body as organism; distal are those situated away from the centre of the body – here understood as a compendium of the economic, social and behavioural 7. The challenge is to understand the mechanism whereby the distal is transmitted to the body. How does economic disadvantage impact on the body such that illness and death result? How do particular circumstances of your life or particular behaviours stop your heart beating? What about those distal factors that are positive for health in one way, or in one place, but negative in another? It is in longitudinal studies such as Born in Bradford that the mysteries of excess mortality and morbidity can be most effectively scrutinised in the context of detailed data about a wide range of social circumstances and behavioural patterns. In this section I will consider what is evident from the literature as contributing to excess infant mortality and then will link this to some observations about the Bradford population. The UK‟s National Perinatal Epidemiology Unit in 2003 concluded that three main factors, the direct effects of poverty, variations in behaviour and differential access to services, combine to cause the persistent and wide inequalities in pregnancy outcomes and in the health of babies. 8 More specifically, infant mortality rates in the general population are strongly associated with the social position of women.9 Women‟s levels of education and literacy, their socio-economic status and the level of relative deprivation in their area of residence are all correlated with the risk that their baby will die in its first This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

year10. This pattern is observed world wide11. Infant mortality is also consistently associated with birth weight and pre-term birth, mother‟s age, birth spacing, with access to a range of maternal health technologies and with lifestyle characteristics of the mother and her household. Most notable „behavioural‟ risk factors that will affect significant numbers of women are smoking during pregnancy and poor nutritional status, the rates of which are affected by her socio-economic position 12, 13, 14. Smoking rates during pregnancy are higher in more socio-economically deprived women. Any successful intervention to reduce smoking in these groups would impact on overall patterns of health inequalities for England and Wales 15 .4 As well as general structural and behavioural factors there are additional powerful influences on infant mortality rates that are most evident in specific sections of the population. For example maternal diabetes or HIV positive status, or the use of non-prescribed drugs during pregnancy, exert a high risk for the babies of women with these characteristics. The genetic contribution to infant mortality, introduced above, is evident in all sections of the population but it is considered to affect the Pakistani population of England and Wales to a greater extent than the general population

16,17,18.

If we take some of these key determining factors and re-examine them using ethnicity and migration status as variables we encounter conceptual, category and measurement difficulties. We also encounter relationships between the structural and the behavioural that are very different, low levels of 4

This paragraphs and the next précis points made in two papers presented to the Bradford Infant Mortality Commission, Alison Macfarlane, Inequalities in the outcome of pregnancy. Implications for policy and recommendations for research and Ann Hobbiss, Background literature on the public health aspects of infant mortality. Both are available online – see reference 1. This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

smoking in deprived Pakistani women for example. Data from the West of Scotland Twenty-07 cohort study underlines how complex identifying social class gradients in health in British South Asians (here defined as those with ancestry in the Indian subcontinent) can be. This study facilitated an examination of the relationship between class structure, standard of living and class lifestyle, that is changes to patterns of health behaviour or activities relevant to health risk. Williams et al‟s report on the Scottish cohort data illustrates how sections of the South Asian population are forced into an “underclass” position, that is into either unemployment or a separate and disadvantaged labour market, with the result that their standard of living is lower than that of the corresponding sections of the general population. Those who do not fall into this underclass characteristically set up small businesses and achieve a standard of living equivalent with their non-South Asian counterparts. However, who falls into which group does not seem predicted by education level and the consequence is a disruption of intergenerational class position. In the short term health behaviour does not change in response to the observed change in standard of living, but over time there does seem a reversion to the more general correlation of social class and health related behaviour 19. In considering people of South Asian origin in the UK we have difficulty then in utilising prevailing models of social class and deprivation 20, 21. If we extrapolate from Williams et al‟s insights we have to differentiate between structures and lifestyle. At the least we have to consider that education level or past professional status may be reflected in the latter even when they are not evident in the sorts of occupation or income level that can be achieved in the UK. But there is a temporal effect, over time consistent disadvantage in terms of structural position may impact on lifestyle. Further, we have to This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

consider if within the same deprivation quintile there is a quality or a degree to the deprivation experienced by Pakistani families, and particularly by mothers, that can help explain higher mortality rates in their children than those evident with white families/mothers who are ostensibly equally deprived. This is a pressing challenge made more important by the counter-indicators evident in some major behavioural predictors of likely infant mortality, smoking and alcohol use in pregnant mothers. It may also be that measures used to identify deprivation are not sensitive to South Asian cultural practices. For example the prevailing understanding identifies sources of financial and other support for mothers with babies as being located in the nuclear family. This may not be illuminating in families with more multi-generational households and close familial and community networks. If we look at measures of family and individual deprivation as opposed to the geographic definition used in identifying deprivation quintiles above we can see that deprivation is now defined by a composite measure that includes income, welfare benefit support, a subjective assessment about economic well-being and a consideration of the access a person has to consumer goods that one might assume to be in common use, two pairs of shoes, funds for a holiday and so on. Each component of these is complex when we wish to develop cross-ethnic comparison. For example subjective measures include a question about how well off you feel compared to a year ago. Answering for anyone involves complex reasoning as to what subjectively one includes in making such as assessment. It may well be that different world-views perhaps enshrined in a mix of ethnicity, religion and migration history prompt the different weighing of factors that go into making such an assessment. Further, understandings and attitudes to consumer goods vary considerably. There is then in measures of individual and family deprivation a challenge in This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

both factor and face validity, does each questions make sense and together do they seem to capture a recognisable reality for the person being questioned. As well as the possibilities of these subjective, attitudinal, differences there may be differences between Pakistani origin families and white families included in the same deprivation quintile in more practical domains. For example the availability, acceptability, uptake and compliance with ante-natal care and with other health and social care services may differ. There may be a difference in the sorts of housing occupied and the density of that occupation. Perhaps old, terraced inner city housing (predominantly occupied by Pakistani families) is a determining factor. The poorest white families are more typically evident in 1960‟s housing estates on the city‟s periphery. Perhaps there is a difference in income utilisation within families, that is similar absolute levels of income do not translate into equal amounts made available for maternal and child care? This latter factor needs to be scrutinised in terms of support for extended families including those still living overseas. These are complex questions best answered in the sorts of large scale, inclusive and longitudinal study that Born in Bradford provides. If we now consider some of the characteristics of the Born in Bradford study population in relation to factors that have been identified with enhanced risk for the health of babies we can see ways in which the complexities that have been identified above can be scrutinised. 5 An initial analysis of 5000 mothers recruited to Born in Bradford found significant differences in the prevalence of behavioural

5

The figures in this and the next paragraph are from an initial analysis of Born in Bradford data. That analysis has not been sufficiently verified to warrant quotation or publication at this point. Verification is under way and for any publication arising from this conference paper these figures would be re-presented. This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

characteristics when analysed by ethnicity. 54.1% of White British Mothers reported that they had at some point in their lives smoked cigarettes (at least one cigarette a day) whereas only 6.2% of Pakistani mothers answered yes to this. When asked if they drank alcohol during pregnancy or in the three months before pregnancy no Pakistani mothers said yes, 53.8.% of white mothers said yes. 76.2% of White mothers had ever had paid employment, the figure was 35.2% for Pakistani. Total number of people living in the same household was higher in Pakistani families. Levels of marriage within extended families was absent in white families but high in Pakistani families. When asked if they were related to the father of their baby (other than by marriage) 65% of Pakistani respondents said yes. These figures were similar when asked if their parents also married relatives, for example cousins, 56.4% of women said their parents were related. Discussion – questions not answers. I have presented details of a level of infant mortality in babies born in Bradford that is in excess of national averages and in excess of areas with similar levels of deprivation. The differences in infant mortality according to deprivation are very marked. Numbers are small in the least deprived quintiles but nevertheless differences of the order of 5 between most and least deprived indicate the importance of deprivation in identifying early life chances. In addition to these deprivation differences levels of infant mortality are particularly high in babies born to mothers of Pakistani origin, and highest in those mothers who were themselves born in Pakistan. If we discount the least deprived quintiles because there are so few Pakistanis in them then in each quintile Pakistanis have higher infant mortality than This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

white families and that level of mortality is highest in babies born to mothers who were born in Pakistan. There is then both an ethnicity dimension and an impact of migration effect within, or in addition to, the portmanteau concept of deprivation. Cause of death data is problematic because the way it is collected is likely to underestimate multiple causation. But it does show the impact of deaths due to congenital anomalies as a part explanation for ethnic difference, at least in male infants. Congenital anomalies of the sorts linked to excessive death rates are caused by the transmission of recessive genes, damaged genes that in one parent do not transmit a defect to the foetus but when both parents have the same damaged (recessive) gene then the defect is transmitted. If both parents are from the same family the chances of them each having the same defective recessive gene is increased. Thus the excessive infant mortality can be presented as, in part, consequent upon the high rate of first cousin marriage in Bradford Pakistani‟s and in their parents, irrespective of their living in the UK or in Pakistan. I have linked this examination of patterns of infant mortality in Bradford with what we know more generally about determinates of infant mortality. Extrapolating from this general picture to South Asian populations in the UK and to Bradford‟s Pakistani origin population in particular creates challenges because of different cultural understanding and assumptions and because of the complex experience of deprivation for these groups who are particularly disadvantaged. It might be that the “underclass” construct presented by Williams et al illuminates a level of disadvantage beyond the deprivation identified by epidemiological measures currently in use. While it is the way that wealth is distributed in society that is the crucial determinate in determining death rates 22,23 if our intention is to both This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

understand and develop responses to combat inequality we have to look at the work at the interface between structure and behaviour and at ethnicity and migration history, dimensions that can make significant differences even within an overall social class differential in mortality. Conclusions: ethnicity, migration and hybrid health systems. The lived experience of health and of ill health is one characterised by a number of domains: a popular; a professional; and a domain structured around cultural practices specific to ones own community. Each individual negotiates both the choices they make relevant to health and their contact with health services within and between these domains. The result is the existence of cultural hybridity in health .24 Arguing for the existence of domains of experience and hybridity allows us to consider the social organisation of health care systems and the reflexivity of personal engagement with them. Kleinman has described how, like religion, language or kinship we have to consider health care as a special cultural system, “a system of symbolic meanings anchored in particular arrangements of social institutions and patterns of interpersonal interactions” 25 (p24). Cultural systems overlap – any one action or experience may have different symbolic meanings in different systems. For example feeding patterns for infants may reflect popular images of what is desirable food and what is a desirable weight for babies. It may reflect professional advice and it may reflect a set of cultural practices developed in another country and another time, for example via the support and advice of grandparents whose own childrearing occurred in Pakistan. A mother will have to exercise a personal reflexivity amidst what might be competing advice. Further, those the person interacts with in the family and in the health care This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

system may be neither aware of, or have any understanding about, alternative meanings of what might seem to them an uncontentious activity. The existence of different cultural systems can also help in understanding decisions to marry first cousins even when the increased risk of recessive gene disorders in any children is understood and accepted. Understanding health related behaviour requires a consideration of a plurality of discourses and practices and a series of hybrid configurations that look to varied institutions, interaction settings and sources of social legitimacy. 26 (p250-1). It is this sort of behaviour that presents evidence of hybridity. Hybridity here is encompassed by the sense that individuals; “juxtapose and fuse objects, languages and signifying practices from different and normally separated domains”. 27 Neither the boundaries nor the domains are immutable, “they are continually being contested and redefined in an ideological struggle over what are „correct‟ beliefs and practices”.25 (p 254) It is a contest that illuminates the danger of an essentialising construct of ethnicity and of illness. It also is resonant of reflexivity, in that individuals make informed excursions into different domains to meet different needs and satisfy different expectations. Hybridity is not restricted to minority ethnic communities but in the data presented here it is a particularly rich tool for conceptualising behaviour that is both endogenous and exogenous to that community. Specifically, we are considering the Pakistani Muslim population but in so doing we are in danger of conflating two distinct categories, ethnicity (Pakistani) and religion (Muslim). However, a feature of our data is that some of the material highlights the continuing importance of social networks in Pakistan and characteristic patterns of community responses there. Other features resonate with a This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

cosmology characteristic of being a Muslim. Living with hybridity is evident in the coming together of constructs shaped by place and by belief system within the Pakistani community. It is also evident in encounters with individuals - employers, colleagues, shopkeepers, the general public – and organisation like the National Health Service (NHS) and other service providers from outside the minority community 24. References 1.Bradford Infant Mortality Commission 2006. www.nhs.uk/ebm/BDIMC/Documents/_Infant_Mortality_Report.pdf 2.Whincup, PH, Gilg JA, Papacosta, O, Seymour C, Miller GJ, Alberti, KG, Cook DG: Early evidence of ethnic differences in cardiovascular risk: cross sectional comparison of British South Asian and white children. BMJ (Clinical research ed) 2002, 324(7338): 635 3.Corry PC: Intellectual disability and cerebral palsy in a UK community. Community Genetics 2002, 5(3): 201-4 4.Lawlor DA, Chaturvedi N: Treatment and prevention of obesity – are there critical periods for intervention? International journal of epidemiology 2006, 35 (1): 3-9 5.For more details of Born in Bradford see study website : www.borninbradford.nhs.uk

This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

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6.Born in Bradford, a cohort study of babies born in Bradford and their parents: Protocol for the recruitment phase. Pauline Raynor and Born in Bradford Collaborative Group. BMC Public Health 2008, 8: 327 doi 10.1186/1471-2458-8-327 7 Nazroo, J. Ethnicity and Health Health Matters, 76: 16-18. 8 D'Souza L, Garcia J. Limiting the Impact of Poverty and Disadvantage on the Health and Well-being of Low-income Pregnant Women, New Mothers and Their Babies: Results of a Mapping Exercise. 2003. Oxford, NPEU & Maternity Alliance. 9 Maher J and Macfarlane A. Inequalities in infant mortality: trends by social class, registration status, mother‟s age and birthweight, England and Wales, 1976-2000. Health Statistics Quarterly Winter 2004. 10 See ONS series: Infant and perinatal mortality by social and biological factors www.statistics.gov.uk 11 The World Health Report 2005 http://www.who.inf/who/2005/annex/en/index.html accessed 29.11.05. 12 Department of Health 2003. Health Survey for England 2002 SO: London. 13 Kramer MS Socioeconomic determinants of intrauterine growth retardation European Journal of Clinical Nutrition (1998) 52 S1, S21-33. 14 Mwatsama M and Stewart L Food Poverty and Health Briefing Statement from the Faculty of Public Health May 2005. This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

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www.fphm.org.uk/policy_communication/publications/briefing_statements/default.asp#f 15 Bull, J., Mulvihill, C and Quigley R. 2003 Prevention of low birthweight: assessing the effectiveness of smoking cessation and nutritional interventions. Evidence briefing. London: Health Development Agency 16 Botting B and Physick N. Congenital Anomalies Chapter 11 in The health of children and young people ONS March 2004. www.statistics.gov.uk 17 Collingwood Bakeo A. Investigating variations in infant mortality in England and Wales by mother‟s country of birth, 1983-2001. Paediatric and Perinatal Epidemiology. 2006; 20 127-139. 18 ONS Figure 14 Stillbirth and infant mortality rates by cause, England and Wales. ONS birth statistics, Series FM1. www.statistics.gov.uk 19. Williams, R., Wright, W., Hunt, K. 1998. Social class and health: the puzzling counter-example of British South Asians. Soc Sci Med 47, 9, pp 1277-1288. 20 Nazroo, J. Y. 2001. The Health of Britain’s Ethnic Minorities. Policy Studies Institute, London. 21 Nazroo, J.Y, Williams, D R, 2005. The social determination of ethnic / racial inequalities in health. In, Marmot, M., Wilkinson, RG (eds) Social Determinants of Health (2nd Ed) Oxford, Oxford University Press. 238-266.

This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.

International Conference on Migration, Citizenship and Intercultural Relations 19 - 20 November 2009 Deakin University Australia

22. Wilkinson, R.G. 1992. Income distribution and life expectancy. BMJ. 304. (6820): 165-8. 23. Wilkinson, R.G. and Pickett, K. 2009. The Spirit Level. Why more equal societies almost always do better. London, Penguin. 24. Small, N., Ismail, H., Rhodes, P. Wright, J. 2005. Evidence of cultural hybridity in responses to epilepsy among Pakistani Muslims living in the UK. Chronic Illness. 1, 165-177. 25. Kleinman, A. (1980). Patients and Healers in the Context of Culture. Berkeley, University of California Press. 26. Eade, J. (1997). The power of the experts. In, Marks, L., Worboys, M. 1997. Migrants, Minorities and Health. London, Routledge, pp 250-71. p254 27. Werbner, P. (2000). The dialectics of cultural hybridity. In, Werbner, P., Modood, T. (Eds) Debating Cultural Hybridity. London, Zed Books. pp 1-26. p2.

This paper is for presentation at the International Conference on Migration, Citizenship and Intercultural Relations, 2009. Some data included is drawn from preliminary analysis of study data. It will need to be verified for publication. Please do not publish or quote from this paper without prior contact and permission from the author.