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Why child mortality is 1.5 times higher in England than Sweden

4 May 2018

Premature births, low birth weight and birth anomalies explain why England has a higher death rate than Sweden among children under 5 years old, according to a new study led by UCL.



The study, published today in The Lancet, compared more than 3.9 million English births and 1 million Swedish births to understand factors driving higher rates of child mortality in England. 

Researchers found the difference is largely due to children in England typically weighing less at birth, being born earlier, and having more birth anomalies (such as congenital heart defects) than in Sweden.

"While child deaths are still rare, the UK has one of the highest child mortality rates in western Europe," says lead author Dr Ania Zylbersztejn (UCL Great Ormond Street Institute of Child Health).

"Babies born prematurely or with low birth weight have an increased risk of early death, and those who survive are more likely to have chronic ill health or disability. Families need to be better supported before and during pregnancy to improve maternal health, and in turn to give all children a healthy start in life."

With the UK and Sweden having similar levels of economic development and universal healthcare, the authors say that Sweden's lower mortality rates should be achievable within the UK. However, the UK's more unequal wealth distribution leads to poorer maternal health during pregnancy, which in turn causes more babies to be born prematurely and with a low birthweight.

The authors say that public health interventions to help improve the health of mothers before and during pregnancy, as well as reducing socioeconomic disadvantage overall, will be important to improve the health of babies at birth and increase their survival.

The study used routinely collected medical data from the English NHS and Swedish health services to compare births from 2003 to 2012, and track the children's health and death records up to their fifth birthday. These records included information on the mother's age, family's socioeconomic position, as well as length of pregnancy, the child's birthweight, gender, and whether they had any birth anomalies.

Between the ages of two days to four years old, the child mortality rate for England was one and a half times higher than for Sweden (29 deaths per 10,000 children in England, vs 19 deaths per 100,000 children in Sweden). If the child mortality rate was the same in England as in Sweden 607 fewer child deaths per year would have occurred in England, equivalent to 6,073 fewer child deaths in total from 2003-2012. These differences were mainly driven by differences in mortality among children aged under 1 year old.

The higher frequency of adverse birth characteristics such as low birth weight, preterm birth or congenital anomalies in England largely explained the excess risk of death compared to Sweden (accounting for 77% of the excess risk for newborns, 68% for under-1 year olds). Socioeconomic factors also contributed to the differences between the two countries (explaining a further 3% of excess risk in newborns, and further 11% in under-1 year olds). Combined, these factors fully explained the difference in survival for 1-4 year olds in England and Sweden.

Good maternal health (including maintaining a healthy weight, avoiding chronic illnesses such as diabetes, high blood pressure, psychological stress and infections) and health behaviours (such as a healthy diet, avoiding smoking, drugs and alcohol during pregnancy) are associated with healthy fetal development during pregnancy. However, many adverse maternal characteristics are more common in England than in Sweden.

The UK also has one of the most unequal distributions of wealth of all western countries. In 2003-2005, the most deprived 20% of the UK's population had a seven-fold lower income than the least deprived 20%, while the gap in Sweden was only four-times. Socioeconomic disadvantages are associated with preterm birth, low birthweight, birth anomalies and poor maternal health, reflecting circumstances and behaviours that are linked to poverty and stress.

Co-author of the study, Professor Anders Hjern, Karolinksa Institute, Sweden, says: "This study shows that the main explanations for the differences in child mortality rates between England and Sweden are systemic, and beyond the reach of healthcare services alone. The key factors here are likely to include Sweden's broader welfare programs that have provided families with an economic safety net for over 50 years, the free and accessible educational system, including early child care, and public health policies for many lifestyle issues such as obesity, smoking and alcohol use."

The authors note some limitations, including that the quality of data in England was poorer than in Sweden, meaning that the study was restricted to 64.5% of English births between 2003-2012, compared to 99.8% of all Swedish births.



  • The Lancet


Credit: abhijit chendvankar  source: flickr 

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