Infant Mortality in Bristol An Updated Epidemiological Needs Assessment, 2nd September 2014 Dr Darshana Bhattacharjee, Registrar in Paediatrics. Dr Julie Mytton, Consultant in Child Public Health. Department of Public Health, Bristol City Council.

Contents Key summary points

Page

Abbreviations Executive summary Introduction Trends in infant mortality Trends in births in Bristol Factors affecting infant mortality 1. Individual factors i. Prematurity ii. Low birth weight iii. Immunisations 2. Family factors i. Maternal age ii. Maternal ethnicity iii. Maternal weight iv. Maternal smoking v. Maternal immunisations vi. Antenatal care vii. Breastfeeding 3. Community factors i. Child poverty ii. Overcrowding iii. Sudden Infant deaths iv. Unintentional injuries Summary Conclusion Appendices

3 4 5 6 7

9 10 12 14 17 18 19 22 22 27 31 32 33 34 35 37 38-40

Infant Mortality Needs Assessment Bristol/ 2nd September 2014 2

Abbreviations BCC BME BMI BNSSG CCG CDOP CHIMAT CI CO HSCIC IMD JSNA MMR NICE NBT NHS ONS PCT PHIU SIDS SUI SW TPU UHB WAHT

Bristol City Council Black and Minority Ethnic Body Mass Index Bristol/North Somerset/South Gloucestershire Clinical Commissioning Group Child Death Overview Panel Child and Maternal Health Intelligence Network Confidence Interval Carbon Monoxide Health and Social Care Information Centre Index of Multiple Deprivation Joint Strategic Needs Assessment Mumps, Measles and Rubella National Institute for Health and Care Excellence North Bristol NHS Trust National Health Service Office for National Statistics Primary Care Trust Public Health Intelligence Unit Sudden Infant Death Syndrome Serious Untoward Incident South West Teenage Pregnancy Unit University Hospitals Bristol NHS Foundation Trust Weston Acute Hospitals NHS Trust

Infant Mortality Needs Assessment Bristol/ 2nd September 2014 3

Executive summary Introduction The infant mortality rate is the number of deaths in the first year of life per 1000 live born children. Infant mortality rates in Bristol have been falling steadily over the last 10 years and have consistently remained below the England average for the last 6 years.

Method The information provided in this report has been collated from a variety of sources. It is structured using the socio-economic model for health, which considers the individual, maternal/family and community factors influencing infant mortality.

Findings The rising birth rate in Bristol, together with the falling infant mortality rate, is an important contributory factor in the increasing child population of Bristol. This is likely to put increasing pressure on primary care and antenatal services. Individual factors, such as prematurity and low birth weight, have the highest risk for infant mortality due to the direct negative impact on the health of the infant. Maternal factors related to lifestyle choices, in particular smoking, can also increase the vulnerability of infants to poor health, and can increase the risk that an infant is born prematurely or with low birth weight. Smoking has shown a reversing trend in recent years, with more mothers smoking at delivery. The reasons behind this are likely to be multifactorial and require further exploration. Further information looking at the health-seeking behaviours of women from different ethnic groups is required, in particular with regards to booking for antenatal care. This is to ascertain whether more culturally appropriate services need to be developed, and whether specific targeted activity is needed to support more vulnerable women.

Implications Actions aimed at reducing premature births are likely to result in reductions of infant mortality. Encouraging healthy behaviours in pregnant women and mothers may reduce the negative health consequences on their infants, and lessen the risk of death. Information on births by income deprivation could facilitate support for families living in poverty. Healthcare professionals need to maintain their awareness of the most recent evidence for Sudden Infant Death Syndrome to enable them to support and help educate parents.

Recommendations This report aims to support the CCG in helping to inform the Infant Mortality Action Plan by the implications gathered from the data.

Infant Mortality Needs Assessment Bristol/ 2nd September 2014 4

Introduction In 2009 a baseline needs assessment on infant mortality (the death of a live born baby less than one year of age) was conducted at Bristol City Council. At this time, Bristol had a lower rate of infant mortality than the national rate for England, although inequalities existed with a higher likelihood of dying as an infant if the family lived in the most deprived areas of the city, compared to families living in the least deprived areas. Living in an area of deprivation has been shown to be associated with a range of different inequalities in health and accessing healthcare services. Since 2009 there has been a marked change in the population of Bristol. There has been inward migration to the city from a number of countries as well as an increase in the birth rate. Therefore we have updated the information available on infant mortality in Bristol and present in this report a summary of information on factors that can affect the infant mortality rate. This report has been written using a socio-economic model of health, that is, we have described the individual, family and community factors that can influence infant mortality. More information on this model is found in Appendix 1.

Infant Mortality Needs Assessment Bristol/ 2nd September 2014 5

Trends in infant mortality Between 2010 and 2012, there were 57 infant deaths in Bristol, which equates to a rate of 2.9 per 1000 live births in the same 3-year period. The rate of infant mortality has fallen over the preceding 5 years. The current rate is now lower than the England average of 4.3 per 1000 live births. The following graph (Figure 1) illustrates the trends in infant mortality rate compared to England for pooled years (due to the random year-on-year variation that occurs with relatively rare events, these data have been presented as a rolling three year average of deaths per 1000 live births). Figure 1: Trend in infant mortality rate, 2001 to 2012.

crude infant mortality rate

8 7 6 5 4 3

Bristol

2

England

1 0 2001 - 2002 - 2003 - 2004 - 2005 - 2006 - 2007 - 2008 - 2009 - 2010 03 04 05 06 07 08 09 10 11 12

Time Period Source: Public Health Intelligence Unit, Bristol City Council

The following table (Figure 2) shows trends by locality in Bristol. The rates of infant mortality are shown together with their 95% confidence intervals (CI), that is, the range within which we can be 95% confident that the true rate for that locality lies. The infant mortality rates for Inner City & East and Bristol South appear to be on a downward trend, which may suggest that inequality in relation to infant mortality is improving.

Infant Mortality Needs Assessment Bristol/ 2nd September 2014 6

Figure 2: Trends in infant mortality by Bristol locality, 2005-2012. Infant Mortality Rate (deaths aged under 1 per 1000 births) by year with 95% CIs Locality

2005-2007

2006-2008

2007-2009

2008-2010

2009-2011

2010-2012

Inner City & East

6.2

7.4

6.7

5.5

3.3

3.9

(4.1-8.2)

(5.2-9.6)

(4.6-8.8)

(3.7-7.3)

(1.9-4.7)

(2.4-5.4)

4.0

3.9

3.2

2.1

1.8

2.2

(2.4-5.6)

(2.3-5.4)

(1.8-4.5)

(1.0-3.3)

(0.8-2.8)

(1.1-3.3)

3.7

3.9

4.1

3.9

3.6

3.5

(2.1- 5.3)

(2.3-5.5)

(2.5-5.7)

(2.3-5.4)

(2.1-5.1)

(2.1-5.0)

Bristol South Bristol North & West

Source: Public Health Mortality File and Public Health Birth File

Trends in births in Bristol Between 2002 and 2012, the total number of births to Bristol resident mothers has been steadily increasing (Figure 3). The vast majority of these births have been to UK born mothers. However, there are proportionally more births to non-UK mothers (Figure 4), which reflects a rise in the migrant population of Bristol. Further information on maternal ethnicity can be found in section 2(ii). Figure 3: Trends in births in Bristol, 2002-2012. 8,000 7,000

Number of births

6,000 5,000 4,000 3,000 2,000 1,000 2002

2003

2004

2005

Births to UK born mothers

2006

2007

2008

2009

2010

2011

2012

Births to non-UK born mothers

Source: ONS Annual District Birth data Infant Mortality Needs Assessment Bristol/ 2nd September 2014 7

Figure 4: Births to UK and non-UK born mothers, 2002-2012. Total live births Number 2002 4,708 2003 5,023 2004 5,278 2005 5,440 2006 5,708 2007 5,931 2008 6,318 2009 6,202 2010 6,486 2011 6,718 2012 6,781 Source: ONS Annual District Birth data

Births to UK born mothers Number % 3,947 83.8 4,108 81.8 4,248 80.5 4,312 79.3 4,396 77.0 4,453 75.1 4,722 74.7 4,626 74.6 4,745 73.2 4,973 74.0 4,895 72.2

Births to non-UK born mothers Number % 761 16.2 915 18.2 1,030 19.5 1,128 20.7 1,312 23.0 1,478 24.9 1,596 25.3 1,576 25.4 1,741 26.8 1,745 26.0 1,886 27.8

Implications for action plan: A rising birth rate will continue to put pressure on primary care and antenatal services.

Infant Mortality Needs Assessment Bristol/ 2nd September 2014 8

Factors affecting infant mortality 1. Individual factors i. Prematurity A premature baby is one born before 37 completed weeks of pregnancy, or more than 3 weeks before their due date. Premature babies are at increased risk of death due to immature physical development, increased risk of infections, and increased associations with congenital abnormalities. Local NHS maternity providers record the gestation of new babies on the Avon Child Health System. Over the past 3 years, 6.9% of babies in Bristol have been born premature, compared to 7.2% in England and Wales in 2011 (ONS). There has been no significant change in the percentage of babies born before 37 weeks to Bristol residents (Figure 5). Mothers at either end of the age spectrum are more likely to have preterm births; 9.7% of pregnancies to women under 19 years old and 8.0% of pregnancies to women over 40 years old resulted in premature births. The lowest rate of pre-term labour is seen in mothers aged 30 – 34 years old (Figure 6). Figure 5: Percentage of births of Bristol residents born prior to 37 weeks gestation (shown annually from 2009 to 2011, with the 3-year average for 2009-2011). 10%

5% 7.0%

6.7%

7.0%

6.9%

2009

2010

2011

2009-2011

0%

Source: Compilation of maternity data from Child Health System and local NHS maternity providers

Figure 6: Percentage of births of Bristol residents born prior to 37 weeks gestation by maternal age-group (3-year averages 2009-2011 shown).

Infant Mortality Needs Assessment Bristol/ 2nd September 2014 9

20%

10%

9.7%

7.3%

6.9%

6.1%

6.8%

19-24yrs

25-29yrs

30-34yrs

35-39yrs

8.9%

0%