Adjei, Nicholas Kofi

Esan, Oluwaseun B

Hill, Ruaraidh

Lee, Paris

Maden, Michelle

McHale, Philip

McIntosh, Mikhailia

Saberian, Samira

Taylor-Robinson, David

University of Liverpool Repository

Intersecting ethnic and socio-economic inequalities in infant mortality in England, 2007-2019Oluwaseun B Esan1,2, Dougal Hargreaves, Hanna Creese2,3, Paul Norman4, Philip McHale1, G.J Melendez-Tores 2,5, and David Taylor-Robinson1,2Correspondence to Dr Oluwaseun B Esan, Department of Public Health Policy and Systems, University of Liverpool, Liverpool; oluwaseun.esan@liverpool.ac.ukDepartment of Public Health Policy and Systems, University of Liverpool NIHR School for Public Health Research, Children Young People and Families ProgrammeSchool of Public Health, Imperial College, London, UKSchool of Geography, University of Leeds, Leeds, UKUniversity of Exeter Medical School, University of Exeter, Exeter, UKThere are stark socio-economic and ethnic inequalities in infant mortality in the UK.1 Previously, we have demonstrated that rising child poverty led to an increase in the infant mortality rate (IMR) in England following a period of sustained decline.2 Recent estimates show stagnation in improvements in IMR and increasing inequalities over the last decade in UK nations.3 This study aims to determine if previously observed social patterning of IMR is consistent across all ethnic groups.In this analysis, we used publicly available data on births and deaths, ethnicity of mothers, and the Index of Multiple Deprivation (IMD) from 2007 to 2019. We calculated IMR by IMD quintile (ONS IMD deciles collapsed to quintiles) and broad ethnic categories of Black (Black African, Black Caribbean, Any other Black background), Asian (Bangladeshi, Pakistani, Indian, Chinese, Any other Asian background), Mixed background, White (White British, White Other) and any Other ethnic background.2 In keeping with ONS methods, we used deaths registered in a year as the numerator and births registered in a year as the denominator, pooling over year bands. We present the results graphically for year trends (Figure 1) and show results for the most recent period to compare social gradients within and across ethnic groups (Figure 2).Figure 1 shows a clear deprivation gradient and rising inequalities over time across most ethnic groups except for the Black ethnic category for each of the year bands, with the highest IMR observed amongst those living in the most deprived quintile. There are clear SES gradients for Asian, Mixed, and White ethnicity categories, while for the Black ethnicity category, there is no clear SES gradient with a high IMR across all SES levels (Figure 2). On average, IMR for this category was nearly double the England rate across all IMD quintiles (average of 7.1 per 1,000 births), although with large confidence intervals for the most affluent groups.There are large and intersecting SES and ethnic inequalities in IMR in England, which vary across ethnic categories. IMR is particularly high for infants of the Black ethnic category regardless of deprivation, indicating that other factors beyond SES may contribute to poor outcomes and it is consistent with reported poorer maternal outcomes reported for Black women.4 However, the findings are limited by using broad ethnic categories which mask heterogeneity within groups and homogenise experiences. The current data availability limits the use of granular categories. It will lead to a loss of confidentiality due to small cell counts, imprecise estimates, and large confidence intervals. Moreover, the use of crude descriptive statistics without data on known risk factors for IMR limits inference on causal explanations. These findings highlight the necessity for granular, multi-level quantitative intersectional analyses to reveal how certain ethnic groups may experience multiplicative adverse health outcomes due to the impacts of intersecting socioeconomic and ethnic inequalities. Such comprehensive analyses can capture heterogeneity across and within ethnic groups, informing clinicians on tailoring care to address the intersectional effects of these inequalities that may not follow expected social patterns.Funding: OE and DTR are funded by the National Institute for Health and Care Research(NIHR) School for Public Health Research SPHR, (Grant Reference Number NIHR204000). DTR  is also supported by the NIHR on a Research Professorship (NIHR 302438). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.Conflicts of interest: The authors have no conflicts of interest to disclose.Contributorship statement: OE and DTR conceived the study. OE analysed the data. PN, PM, DH, HC, GJMT provided input on presenting the results. All authors contributed to the manuscript.Word count: 499References1. 	Robinson. dated 21 September 2023 UK Covid-19 Inquiry Archives [Internet]. UK Covid-19 Inquiry. [cited 2023 Oct 23]. Available from: https://covid19.public-inquiry.uk/documents/inq000280060-expert-report-titled-child-health-inequalities-by-professor-david-taylor-robinson-dated-21-september-2023/2. 	Taylor-Robinson D, Lai ETC, Wickham S, Rose T, Norman P, Bambra C, et al. Assessing the impact of rising child poverty on the unprecedented rise in infant mortality in England, 2000–2017: time trend analysis. BMJ Open [Internet]. 2019 Oct 1 [cited 2023 Jun 13];9(10):e029424. Available from: https://bmjopen.bmj.com/content/9/10/e0294243. 	Births and infant mortality by ethnicity in England and Wales - Office for National Statistics [Internet]. [cited 2023 Oct 12]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/childhealth/articles/birthsandinfantmortalitybyethnicityinenglandandwales/2007to20194. 	Esan O, Adjei NK, Saberian S, Christianson L, McHale P, Pennington A, et al. Mapping existing policy interventions to tackle ethnic health inequalities in maternal and neonatal health in England: A systematic scoping review with stakeholder engagement [Internet]. 2022 Dec [cited 2023 Feb 8]. Available from: https://www.doi.org/10.17638/03166498 Figure Figure 1. Four to five yearly infant mortality rate by index of multiple deprivation and ethnicity in England, 2007-2019Figure 1 shows four-five yearly infant mortality rate by ethnic categories and index of multiple deprivation (IMD) quintiles in England for the period 2007-2019. Footnote: Index of multiple deprivation (IMD) is a relative area-level measure of deprivation based on income, employment, education, health, housing, crime, and the living environment of approximately 1000-1500 households. ONS published IMD deciles were collapsed to IMD-quintiles due to small numbers for some ethnic groups. IMD Quintiles: 1 – most deprived and 5 – least deprived. Error bars show corresponding 95% confidence intervals.Figure 2: Four year infant mortality rate by Index of Multiple Deprivation (IMD) and ethnicity in England, 2016-2019Figure 2 shows the infant mortality rate by ethnic categories and IMD quintiles for the most recent period (2016-2019). Footnote: Year groups were based on the Index of Multiple Deprivation (IMD) applied to the year in question (2016-2019 uses IMD-2019). IMD deciles were collapsed to IMD-quintiles due to small numbers for some ethnic groups. Error bars show corresponding 95% confidence intervals. 2

Equity in Medical Devices: a Rapid Review of Potential Biases for Informing Patient Pathways in Pregnancy – Preprint

https://livrepository.liverpool.ac.uk/3182591/1/Intersecting%20Ethnic%20and%20Socioeconomic_Archdischild-2023-326619_V2_20May2024_Final_Deposited.docx

Equity in Medical Devices: a Rapid Review of Potential Biases for Informing Patient Pathways in Pregnancy – Preprint

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