The UK has made less progress in reducing stillbirths and neonatal and infant deaths over the last two decades than many other developed countries, as our new explainer today shows.
Since 2013, the UK’s infant mortality rate has stalled at 3.9 deaths per 1,000 live births, with the neonatal death rate remaining static at 2.7 deaths per 1,000 live births – even increasing slightly to 2.8 deaths per 1,000 live births in 2016. A recent report by the Royal College of Paediatrics and Child Health found that if current trends continue, infant mortality in the UK would be more than double the median value for comparable countries by 2030.
Encouragingly, the government has recently repeated and even strengthened its ambitions to improve pregnancy outcomes. Last year, the Department of Health announced they were on track to meet their goal to reduce stillbirths and neonatal deaths in England by 20% by 2020.
Some progress was certainly made, as between 2010 and 2015 the stillbirth rate fell by 16%, but the neonatal death rate only dropped by 10%. They decided to reset the target, with an ambition to halve the rates of stillbirths and neonatal deaths in England by 2025. That would require England to reduce its stillbirth rate to 2.6 stillbirths per 1,000 births, and its neonatal mortality rate to 1.5 deaths per 1,000 live births. As it stands the government has no specific target for reducing overall infant mortality rates.
As illustrated by this chart, the required rate of decline would be much greater than it has been in recent years.
So is it realistic to expect the rapid improvements in outcomes that are needed for these targets to be met? Here we present five reasons why these reductions in mortality rates may be possible, alongside three challenges that may need to be overcome for that to be the case.
Reasons to be cheerful
- If very low rates of stillbirths and neonatal death can be achieved in other countries, there is no reason why the same can’t be true for the UK. There is no evidence that our relatively poor outcomes are due to unalterable genetic differences, a rainy climate or having a constitutional monarchy. They are probably due to factors that can be changed, including how health services are organised and delivered, preventable population factors such as maternal smoking and obesity, and social determinants of health.
- Neonatal care – one important factor in reducing neonatal deaths – is generally of a high quality. Outcomes for preterm infants are comparable to those of other high-income countries, and with appropriate attention and resources, there is no reason why antenatal and perinatal care in the NHS cannot equal or outperform services in other countries.
- While perinatal care has been an area for improvement (the Each Baby Counts report from 2015, for example, found that around three in four poor outcomes after full-term labour might have been avoided with better care), the Royal College of Obstetricians and Gynaecologists has launched a programme to improve labour care and outcomes. A strategy in the Netherlands with some parallels to this was introduced in 2009 and contributed to a huge 66% reduction in stillbirths between 2000 and 2015, showing that rapid reductions are possible.
- NHS England and NHS Improvement recently published a joined-up approach to improve the safety and outcomes of maternal and neonatal care. Well-resourced and coordinated plans with professional and public support have been shown to be successful in improving NHS services for children. For example, the Year of Care programme resulted in improved diabetes control, fewer emergency admissions and the narrowing of inequalities.
- The targets have been carefully chosen to maximise the chances of success – both in terms of timing (the start date was 2010 so significant improvements have already happened) and outcomes, with international experience suggesting it is easier to reduce stillbirths and neonatal deaths in a relatively short timeframe compared to infant mortality.
Cautions and challenges
- It is not yet clear whether there are sufficient resources and professional engagement for the strategy to be successful in improving health care quality. It is indicated in NHS England’s development of the long-term plan for the NHS, however, that reducing stillbirth and infant mortality will remain a key ambition. The question will be whether current staffing challenges can be overcome, and resources increased to a level that ensures successful implementation of the new strategy.
- A recent study found that differences in child mortality between England and Sweden were largely accounted for by higher rates of adverse birth characteristics. This suggests that interventions aiming to improve health services alone are unlikely to be sufficient for England to meet the targets. Wider public health measures that address pre-conception nutrition, obesity, smoking, mental and physical health are likely to be needed. In 2017/18, more than one in 10 mothers in England were known to be smokers at the time of delivery.
Reducing obesity in pregnancy will be an even bigger challenge. The UK was recently named the most obese country in Western Europe, and maternal obesity is on the rise. Population measures that reduce obesity and increase the level of physical activity will be important in reducing the number of obese women of childbearing age.
- Pregnancy outcomes for the most affluent section of the population match the best in the world, but wide social inequalities mean poor outcomes at a national level. With health inequalities widening in many areas, and the proportion of families with young children living in poverty projected to increase, it is not clear how the government’s strategy will reduce inequalities in pregnancy outcomes. Without doing so, it is difficult to believe that the targets will be met.
Wider challenges ahead
The ambitions of the current government targets are welcome. Many aspects of the strategy to achieve them are sensible, and there are reasons to be cheerful that pregnancy outcomes could improve rapidly with the right policies, professional engagement and adequate resources.
But improvements in health care quality alone are unlikely to be sufficient for these targets to be met. The wider challenges of population health and social inequalities will have to be addressed if we are to see lasting change.
Morris J and Hargreaves D (2018) "Are the government’s targets for reducing stillbirths and neonatal deaths achievable?", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/are-the-government-s-targets-for-reducing-stillbirths-and-neonatal-deaths-achievable