High infant mortality rates in disadvantaged groups make the latest inequalities targets tough to hit. But there has been some progress in this area, as Andy Cowper found out.
The higher number of infant deaths among disadvantaged groups is a particularly poignant illustration of how health inequalities work. Yet this is how socio-economic differences are translated. The infant mortality rates for routine and manual occupational groups are 17 per cent higher than for the whole population and 70 per cent higher than for managerial and professional groups. This makes the infant mortality aspect of the 2010 health inequalities target particularly challenging.
The Review of the Health Inequalities Infant Mortality PSA Target (2007) highlighted several groups that had significantly higher infant mortality rates compared with the whole population. These included mothers:
born in Pakistan - 10.2 per 1,000 live births for 2002-04 was double the overall infant mortality ratio;
born in the Caribbean - 8.3 per 1,000 live births was 63 per cent higher than the national average;
aged under 20 - 7.9 per 1,000 live births was 60 per cent higher than for older mothers aged 20-39;
who were the sole parent to register the birth - 6.7 per 1,000 live births was 36 per cent higher than among all births inside or outside marriage or jointly registered by both parents.
National clinical director for children, young people and maternity services Sheila Shribman welcomes the Health Inequalities: progress and next steps document's "multiple references" to children. "I'm pleased to see an enormous focus on the health of children in general," she says.
Does Dr Shribman think the bigger impact is to be made on infant mortality in healthcare interventions or in the wider determinants of health? "Both: wider determinants are very important and infant mortality is a good general marker of the health of a society. On health and healthcare, specific evidence-based interventions can make a real difference.
"Our challenge is to ensure these interventions get to families who are not receiving the help they need. So it's very good news that the number of babies dying is going down, but health inequalities in infant mortality remain unacceptable."
Of course, she adds, the determinants of infant mortality are by no means all healthcare related or within the boundaries of the Department of Health. How optimistic is she about progress towards the 2010 target?
Dr Shribman admits that up to a couple of years ago, the trend was "not encouraging, although there has been some improvement recently and we must sustain this momentum.
She goes on to say: "The groups at highest risk must be the priority and they include teenagers and smokers. Other issues such as obesity are newer; the rise in obesity, particularly among girls and women, is a worrying trend. Many of these women need continuous encouragement to achieve and maintain a healthy weight.
"But we've had lots of successes, like the enormous reduction in babies dying from sudden unexpected deaths in infancy, which was known as 'cot death' - most people now know that young babies should sleep on their backs."
How does she perceive progress on reducing health inequalities in infant mortality?
"It's the usual questions: where are we now, what does our data show? While the figures are small in absolute numbers, we need to look at neonatal/infant mortality rates over a three-year period, look at trends and compare with populations with similar demographics," she says. "Are we doing all the evidence-based things like smoking cessation, cot death and teen pregnancy rates? These are the risk areas. We're very keen to promote early antenatal booking among disadvantaged groups, using the new national indicator for booking by 12 weeks.
"So step one is to see where we are now. Step two what can we do: can we learn new ways to tackle the issue that will be locally owned? The DH national support teams are available for people to consult about how to address these issues. The differences in infant mortality between social groups aren't acceptable. We must challenge the NHS and ask 'what are you doing in your area?'"
Has commissioning made an impact? "How services are commissioned is important and PCTs working with local authorities in terms of children's trusts are doing some good work. This is a new opportunity and we see innovations like the Sure Start children's centres, where services have provided for easy access for disadvantaged communities. We published Maternity Matters in 2007 and it emphasised the importance of early access as well as early booking."
Dr Shribman argues that health inequalities in infant mortality remain "a major challenge for child health and children's services, across a range of issues".
She says: "Road traffic accidents might seem an unexpected area, but there are big differences between social groups. It's about action on these wider public health issues as much as health service interventions - it's about both."
Annette Williamson is director of cross-city partnership on health inequalities for Heart of Birmingham primary care trust. Birmingham has the highest number of infant deaths of any local authority in the country and a very diverse population, including a large Pakistani population. The infant mortality implementation plan programme began in 2006 in response to the target action plan for the city.
"We were viewed as a failing spearhead local authority, as infant mortality rates were so high, set against the rest of England and Wales," says Ms Williamson.
Birmingham developed a whole-systems approach for a complete revamp of its maternity services, she explains. "We mapped existing provision and gaps, from which it was clearly a very medicalised model of care. The gap between service provision and social need is the key to many outcomes, especially in infant mortality, but it wasn't being addressed. Partly, this was due to capacity and training needs and in the way midwives responded to these needs," she says.
"We ran a tender for pregnancy outreach workers and commissioned 20 from the Gateway Family Services social enterprise. The levels of need these workers found were huge: much bigger than anticipated. Midwives will refer pregnant women to outreach workers for simple housing, benefit or other social needs as well as smoking cessation and healthy eating advice. This is a big improvement on what went before, when women had no single point of reference to get their needs met."
The outreach worker scheme not only supports hard-to-reach pregnant women but also helps to support the local economy and employment, by employing local women with career opportunities. The entry qualification is NVQ3, but already 11 have started a foundation degree.
Because of the social and economic needs of these disadvantaged groups, as part of the programme's links with the local authority and children's trust, Ms Williamson and colleagues are suggesting joint commissioning across the board.
"I would see it as an ideal piece of work - a good opportunity to commission for a reduction in infant mortality," she says. "The big issue for me has been uncovering social need and managing it on a whole-system basis. The systems just weren't there to cope with the amount of need with the existing professionals. The midwives found issues of boundaries and there's clear evidence that some of them had to work across boundaries to help their clients."
Ms Williamson says Birmingham has focused on hard-end child protection for some time, having been a zero-star local authority for a number of years. Nowadays, with the parameters to access social care set very high, women and their families can fall into grey areas. Pregnancy outreach workers are picking up their needs.
She adds: "The other lesson is that you can never underestimate resistance to transformational change. Some midwives and GPs found our use of outreach workers hugely challenging and there was a lot of hostility to the new concept of bringing in a social enterprise. We try to help them use our social risk assessment tool being piloted across the city. But some midwives were uneasy about the risk assessment questions in the tool, as they didn't know how to use the information in the answers.
"That shows huge training needs in the PCT-commissioned maternity services: very acute-based, with acute allegiances and never really fully embedded within community centres.
"We also use children's centres for antenatal care: there are now 13 across the city and a reason to embed maternity services within a wider social context of care - free childcare, benefits advice, family support worker.
"After two years, independent evaluation shows that both midwives and children found these to be acceptable venues. Birmingham has a lot of single-handed GPs and, mapping services, we found that while women's medical needs were met, there was less attention to - and little knowledge of - their other needs."
Ms Williamson emphasises that for her and Heart of Birmingham director of public health Jacky Chambers, it has become a "lifetime's work, born out of concerns about infant mortality and the impact of migration and issues around the Pakistani population".