What can be done to reduce the number of Lancashire children dying before their first birthday?
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That was the message from the region’s director of public health as he welcomed a commitment from health and social care bosses to adopt a plan to reduce the number of children under the age of one who die every year in the region.
Dr. Sakthi Karunanithi says that poverty plays “a major part” in the health and wellbeing of all residents - including the youngest children, whose vulnerability can be heightened as a result.
The lives of 179 infants came to an end in the Lancashire County Council area between 2016 and 2018, giving the county an infant mortality ratio of 4.7 deaths for every 1,000 live births, excluding stillborn babies. That is slightly above the North West average, but significantly higher than the England average of 3.9 deaths for every one thousand children born.
The county is the second worst-performing authority by that measure out of 16 statistically-similar counterparts across the country.
Lancashire's "infant mortality action plan" will focus on known risk factors such as smoking and obesity in pregnant women and the failure to implement safe sleeping practices once a baby is born.
But Dr. Karunanithi says the county must not shy away from the effect of inequality on the life chances - and even the chance of life - for its youngest citizens.
“The first 1,000 days from conception are very important and [public] services play a part, but it’s also about the environment in homes, the learning and stimulation that we give to our babies as soon as they’re born - as well as things like vaccinations and disposable income.
“Infant mortality is a marker not just of the health of our infants, but the health of our communities at large.
“Our plan is a sign that we’re starting to come together to work on all the determinants that affect the health and wellbeing of our infants,” he said.
Statistics show a correlation between poverty levels and infant deaths both nationally and in Lancashire. The highest infant mortality rates and numbers of individual fatalities are found in the 20 percent most deprived localities.
Similarly, low birth weights - another known risk factor - are also more prevalent in the least well-off parts of the county.
However, there are some anomalies locally, with Chorley and Fylde - both in the lower half of Lancashire’s deprivation rankings overall - recording above average levels of infant mortality between 2015 and 2017.
Lancashire’s annual public health report claims that the new contract between the county council and Virgin Care to deliver health visitor and school nursing services - which launched last year - will “transform” how the system operates. It cites new ways of working as an opportunity to free staff “to spend more time in the community and [provide] extra help for the most vulnerable".
While describing the so-called ‘healthy child programme’ as a “key service”, Dr. Karunanidhi warns that its interventions are not necessarily a panacea.
“It is a universal [service] and helps identify issues early. But what needs to happen when those issues are identified is probably already too late [to make a difference].
“So we need to get in earlier on - register mums when they are pregnant and try and solve all the other issues like poverty, housing and skills throughout the pregnancy and up to three years of age.”
There are also indications that deprivation can have an effect on later development - as well as health.
A recent meeting of Lancashire County Council’s education scrutiny committee, heard that there is evidence to suggest that the attainment gap for pupils identified as ‘disadvantaged’ has its roots in their experiences long before they walk through the school gates.
“It starts before birth, with alcohol and smoking during pregnancy. It starts with a lack of breastfeeding - all these things are statistically linked to disadvantage”, said senior education adviser Paul Dyson-Knight, referring to research by the Education Policy Institute thinktank.
“It goes into parenting and the influences on the child and whether there are clear expectations - or if children are allowed to develop as they will.
"Most of those factors are very difficult for a teacher or headteacher to tackle in a secondary school. Most of [them] are about the wider society and that’s where we need to be working with other services,” said Mr. Dyson-Knight.
Lancashire’s plan to tackle infant mortality - as approved by the county’s health and wellbeing board in January - will target areas of inequality, while setting targets designed to improve health outcomes more widely.
Board members heard that there is already “a strong network of organisations and programmes in Lancashire that are supporting healthy pregnancy and the first years of a baby’s life” - on whose work the plan can draw.
But pressed on whether an overarching ambition to eradicate child poverty is realistic in the short term, Dr. Karunanithi admitted that it would not be easy.
“There is no single magic bullet - we need good political will and [that of] wider civic society to address the inequalities.
“But we need to keep our hopes high.”
WHAT NEEDS TO CHANGE?
A report presented to health and social care bosses in Lancashire lists a series of so-called “modifiable factors” which increase the risk of infant mortality - and which the county intends to tackle as part of its plan to reduce the number of babies dying under the age of one.
Smoking in pregnancy is known to be the single biggest risk factor for infant mortality.
Obesity during pregnancy, substance misuse while pregnant and teenage pregnancy are also identified as inflating that risk.
But the infant mortality plan acknowledges that some of the issues which it seeks to tackle - including unsafe sleeping practices and low birth weight - are the result of wider socioeconomic factors such as poverty and poor housing.
So-called “protective factors” - including breastfeeding and flu vaccinations during pregnancy - are also identified in the report.
The Lullaby Trust charity found in a survey last year that 40% of parents are not following safe sleeping practices for their baby, which increases the risk of sudden infant death syndrome (SIDS). The NHS advises:
***Place your baby on their back to sleep, in a cot in the same room as you, for the first six months.
***Don't smoke during pregnancy or breastfeeding and don't let anyone smoke in the same room as your baby.
***Don't share a bed with your baby if you have been drinking alcohol, if you take drugs, or you're a smoker.
***Never sleep with your baby on a sofa or armchair (The Lullaby Trust says this can increase the risk of SIDS by 50 times).
***Don't let your baby get too hot or cold.
***Keep your baby's head uncovered. Their blanket should be tucked in no higher than their shoulders.
***Place your baby in the "feet to foot" position, with their feet at the end of the cot or moses basket.
For more detailed guidance, search “Lancashire safe sleeping advice”.
WHAT THE EXPERTS SAY
An NSPCC spokesperson said: “The first 1,000 days of a child’s life are the most important in terms of its health, development and life chances. Research shows that one in five mums and one in ten dads experience mental health problems, and this could negatively affect their children during that time.
“Our Fight For A Fair Start campaign calls for a radical review of the way support is provided to parents during that crucial period, and urges the government to guarantee the funding, workforce and accountability to ensure parents receive strong support from the very first check-up.
“Locally, the NSPCC’s Blackpool Better Start centre offers our Baby Steps service to new parents. The programme starts in the seventh month of pregnancy and uses home visits and group work to support new parents to build strong relationships with their children - and to build confidence and communication skills, so parents know how to seek further support if needed.”
Elsewhere in Lancashire, mums-to-be can access the Bump to Birth and Beyond programme - a free ante-natal course available at children’s centres in the county. Attendance is recommended from the 28th week of pregnancy.
FACTS AND STATS
179 - number of children under one to die in Lancashire (2016-2018)
13.4 percent - proportion of Lancashire mothers who smoke during pregnancy (2018/19)
51 percent - proportion of Lancashire women who were obese while pregnant (2017)