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Effects of Health Inequalities on Infant Mortality

Health and social policy assignment



Longest (2002), the Health Policy Institute Director at the University of Pittsburgh in the United States, states that ”Public policies are authoritative decisions made at the legislative, executive or judicial branches of government … (which are) … intended to direct or influence the action, behaviors, or decisions of others…” He continues, “When public policies pertain to or influence our pursuit of health … then … they become health policies.” (Longest, 2002). Longest vision of health policy is seen in United Kingdom as well as Europe in the same manner as “… view of public health activism that sees little distinction between health policy and public policy as a whole” (Randall, 2000, p. 8). Petersen and Lupton (1996, p. xii) describe the new public health as “… at its core a moral enterprise, in that it involves prescriptions about how we should live our lives individually and collectively”, which represent an approach that is much like Monnet’s plans for Europe (Fontaine, 1994, p. 12), which explains the European health policy as it exists today.

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As a unitary state, the United Kingdom’s central government directs most activity representing government functions. Social policy applies to those policies that governments utilize for welfare as well as social protection, the manner and ways via which welfare is devised and developed, and the academic study of social policy (Robert Gordon University, 2006). Social policy, in its primary sense is concerned with the welfare state and social services, and in its broader context represents the range of issues that extended beyond governmental actions, including the means that welfare is promoted as well as the economic and social conditions shaping its development (Robert Gordon University, 2006). William Beveridge offered the citizens of the United Kingdom “… a blueprint for social advance and a modern caring state …” which would provide for citizens “… from cradle to grave” (Randall, 2000, p. 5) which were foundations of the welfare state that Britain briefly embarked on after World War II that offered full employment, a minimum national safety net, free and equal access to health and education, and a state provision for welfare. The Beveridge Report aimed at the elimination what was termed the ‘five giants’ of want, ignorance, idleness, squalor and disease, which he believed “… construed an investment to facilitate a healthier workforce that would be able to promote productivity” (Gormley, 1999, p. 31). Beveridge’s vision helped to serve as the foundation for the later development of the National Health Service.

The National Health Service came into being in 1946 by the UK Minister of Health and enacted through the National Health Service Act 1946, the National Health Service “… was created by a national consensus within Britain” (Rintala, 2003, p. 3). Prior to its creation patients in the United Kingdom generally were responsible for paying for their health care services with free treatment sometimes available at hospital that taught as well as charitiable hospitals (Gormley, 1999, pp. 14 – 21). As a country, the United Kingdom “… has a long history of offering some form of assistance for the sick, destitute and poverty-stricken” (Gormley, 1999, p. 13). Evidence of the foregoing is found under the National Insurance Act of 1911 a small deduction was taken from wage payments, 4d, that was also aided by employer contributions, 3d, and the government of the UK contributed 2d (Spartacus Educational, 2007). Workers received free medical service as well as being guaranteed a payment of 7s per week for a term of fifteen weeks when unemployed that were paid at Labour Exchanges that also posted notices regarding job vacancies (Spartacus Educational, 2007). Aneurin Bevan is credited as being the architect of the “… successful implementation of the National Health Service …” as a result of his “… personal political skills” (Gormley, 1999, p. 36). The NHS today is Britain’s largest employer, and is managed by the Department of Health, controlling the ten Strategic Health Authorities which have the responsibility for overseeing National Health Service activities in specific areas (Bevan, 2006). The Strategic Health Authorities have the responsibility for the strategic supervision of the 302 Primary Care Trusts that oversee the general practioners and dentists, 29,000 and 18,000 respectively, along with the commissioning of acute services from the private sector and other NHS Trusts (Bevan, 2006). The National Health Services Trusts number 290, representing 1,600 hospitals, and also falling under the supervision of the Strategic Health Authorities are the NHS Ambulance Services, Care Trusts and Mental Health Services Trusts (Bevan, 2006). The National Health Services broad and comprehensive program(s) includes Special Health Authorities, Blood and Transplant, Business Services Authority, National Treatment Agency, National Patient Safety Agency as well as the National Insitute for Health and Clinical Excellence (Bevan, 2006).

This document shall critically analyse the inequalities in health care services as it relates to infant morality in Northern Ireland. As of 2006, the infant morality rate for all of Ireland stood at 5.3, and in Northern Ireland stood at just under 6 in 2001 (Bureau for Vital Statistics, 2001) which is higher than the 5.1 for the United Kingdom, and a number of other European Countries (infroplease.com, 2007). The problem lies in the infant morality rate for children from the highly deprived areas who are fifty percent more likely to die in their first year than are babies from more affluent areas (BBC News, 2000). This is problematic in light of the provision for equal health care for all as mandated under the United Kingdom’s National Health Service. This examination of the health care system in Northern Ireland shall take into account why the infant morality rates are high as well as whether there are inequalities in the system and if so what they are and why they exist. The reason is to reach a determinatation as to the causes, and reasons for the higher infant morality rate as well as what is being done to reverse the occurance.

The figures for infant morality in Northern Ireland have been showing a downward trend, yet the morality rates for infants from deprived areas indicates a mortality rate that is 50% higher than the overall average during the first year (BBC News, 2000). The signifacne of Tables 1 through 4 is to provide a foundational frameowrk from which to make comparisons of underlying reasons and facets attributing to higher infant mortality rates as a factor of inequalities to be discussed utilizing varied class, income, and other correlations.

Table 1 – Neonatal Morality in Northern Ireland 1988 – 2003

(dhsspsni.gov.uk. 2004)

Year Number Rate
1988 149 5.4
1989 104 4.0
1990 106 4.0
1991 121 4.6
1992 104 4.1
1993 123 4.9
1994 101 4.2
1995 131 5.5
1996 92 3.7
1997 102 4.2
1998 93 3.9
1999 112 4.8
2000 82 3.8
2001 98 4.4
2002 73 3.4
2003 87 4.0

Table 2 – Post-Neonatal Mortality in Northern Ireland 1988 – 2003

(dhsspsni.gov.uk. 2004)

Year Number Rate
1988 99 3.6
1989 76 2.9
1990 92 3.5
1991 73 2.8
1992 49 1.9
1993 53 2.1
1994 46 1.9
1995 38 1.6
1996 50 2.0
1997 35 1.4
1998 41 1.7
1999 36 1.6
2000 27 1.2
2001 36 1.6
2002 27 1.2
2003 28 1.3

Table 3 – Infant Mortality in Northern Ireland 1988 – 2003

(dhsspsni.gov.uk. 2004)

Year Number Rate
1988 248 8.9
1989 180 6.9
1990 198 7.5
1991 194 7.4
1992 153 6.0
1993 176 7.1
1994 147 6.1
1995 169 7.1
1996 142 5.8
1997 137 5.6
1998 134 5.6
1999 148 6.4
2000 109 5.0
2001 134 6.0
2002 100 4.6
2003 115 5.3

The preceding figures take on increased importance with regard to the nature of this examination when viewed in comparison to figures from other regions.

Table 4 – Live Births, Stillbirths and Infant Deaths by Mother’s Country of Birth, 2005

(National Statistics, 2006)

Live Still- Early Neonatal Post- Infants
births births neonatal neonatal
All 5.4 7.9 3.4 1.5 4.9 3,188
United Kingdom 5.1 7.6 3.3 1.5 4.8 2,452
England and Wales 5.1 7.6 3.3 1.5 4.8 2,395
Scotland 4.6 7.5 3.8 2.2 6.0 44
Northern Ireland 6.1 8.2 3.1 2.2 5.2 12
Elsewhere 12.9 16.2 3.3 3.3 1

These figures represent the Northern Ireland population as a whole. An important facet in this examination is represented by economics. The region has a higher proportion of people that are receiving benefits for being out of work, large numbers who are not working and a larger population of low pay wage earners (Joseph Roundtree Foundation, 2006). In finding conducted by a study it was found that infants of lone mothers as well as those that belong to parents in manual social classes are of the highest risk regarding infant morality (Whitehead and Drever, 1999). They also found that the lives of babies has at the highest risk in lower income groups as tabulated by the numbers of live births, stillbirths, early neonatal, late neonatal and postnatal deaths for babies in all types of marriage and non-marriage circumstances (Whitehead and Drever, 1999).

The ‘Black Report’ in 1980 presented the term ‘inequalities in health’ as a result of it uncovering the gap between the richest and the poorest concerning experiences in illness, life expectancy and accident rates (Unison, 2001). The broader context of inequality in health, which has bearing upon infant mortality rates is comprised of factors associated with access to quality services, along individual as well as group characteristics that can affect and or lead to unequal treatment and discrimination (Unison, 2001). The report by Unison (2001) also identified social and economic factors, broader economic and environmental societal conditions and risk factors that are a part of lower income lifestyles. These aspects directly affect not only the mothers, but also fathers of infants in that their personal health, choices before and during pregnancy may not constitute the best avenues to the development of healthy offspring. In addition the importance of prenatal care, treatments, diet, nutrition, exercise, abstinence from smoking, drinking, drugs and other damaging aspects is higher in the lower socioeconomic groups (Investing for Health, 2006). The report also drew attention to health inequalities as a factor of an individuals social class, gender, ethnic origin, religious beliefs, political opinion, marital status and sexual orientation that area aspects even though these discrimination potentials are addressed in Northern Ireland’s equality and human rights laws (Unison, 2001). The overall effects of the broader consideration, representing age as a facet in infant mortality rates is illustrated in the following Table:

Table 5 – Standardised Mortality Rates for People Aged Under 75

(Health, Social Services and Public Safety, 2004)

1997 – 2001 1998 – 2002

Area Males Females All


Males Females All


Deprived Wards 135 130 133 136 132 134
Non-deprived Wards 91 92 91 91 91 91

The preceding clearly indicates the differences in mortality rates as referred to in the Unison (2001) study, as well as the underlying health / lifestyle aspects of smoking, drinking, nutrition, exercise and allied factors indicated by Investing for Health (2006). The Health, Social Services and Public Safety (2004) report indicated that life expectancy for mean and females in deprived areas represented 72.0 and 77.9 years as compared to the non-deprived males and females of 75.2 and 80.2 years. The preceding also reveals itself in infant mortality rates, as shown by the following:

Table 6 – Infant Mortality Rates per 1,000 Live Births

(Health, Social Services and Public Safety, 2004)

Area 1997 – 2001 1998 – 2002
Deprived Wards 7.1 6.8
Non-deprived Wards 5.3 5.1

The foregoing clearly indicates the vast differences as uncovered in the Unison (2001) and Health, Social Services and Public Safety (2004) reports where the infant morality rate in deprived areas is a staggering 23% higher. A factor in the overall causes and reasons attributing to higher infant mortality rates is also shown by the higher incidences of teenage pregnancy:

Table 7 – Teenage Birth Rates per 1,000 Females Aged 13 – 19

(Health, Social Services and Public Safety, 2004)

Areas 2001 2002
Deprived Wards 28.9 28.6
Non-deprived Wards 12.9 12.7

The preceding indicates a 70% deferential in2001, and 71% differential in 2002. Another factor in the higher deprived area infant mortality rates is immunization.

Table 8 – Immunisation Uptake Rates, Children born in 1998

(Health, Social Services and Public Safety, 2004)

Areas DPT Pertussis Hb MenC MMR
Deprived Wards 95 93 94 79 90
Non-deprived Wards 98 97 98 86 94
Northern Ireland Average 97 96 97 84 93

Table 9 – Immunisation Uptake Rates, Children born in 2001

(Health, Social Services and Public Safety, 2004)

Areas DPT Pertussis Hb MenC MMR
Deprived Wards 97 96 97 96 88
Non-deprived Wards 97 97 97 96 89
Northern Ireland Average 97 97 97 96 88

In seeking to equate the causes and reasons for the higher incidence of infant mortality rates in Northern Ireland as a result of socioeconomic class, and inequalities in health care, the facet of overall general admission rates for non maternity reasons represents a valid area to be explored. The rationale for the preceding is to seek to determine, in a general fashion, if the inequalities in infant mortality rates represents more of a factor of lifestyle, health and personal choices as opposed to inequalities in the health system with regard to treatment, discrimination and related factors that are much harder to prove as well as seeming less likely to be a broader system wide occurrence.

Table 10 – Standardised Admission Rates

(Health, Social Services and Public Safety, 2004)

2001 – 2002 2002 – 2003

  Area Males Females All Males Females All





127 123 125 127 120 123


93 94 93 93 95 94




137 129 133 134 126 130


90 92 91 91 93 92




109 111 110 110 109 110


98 97 97 97 97 97

From the preceding, the argument that inequalities in health care being available or offered to lower income or deprived individuals as a factor of race, martial status, or other discrimination aspects is not seemingly borne out by the above table. What this table does suggest is that there are increased health factors affecting this segment of the population that are more in keeping with poorer health lifestyle choices, nutrition, smoking, drinking and drugs. Further evidence of the preceding rational is supported by the waiting time for inpatient admissions that does not indicate a bias against lower income groups despite their higher incidence of health services utilization as shown in Table 11. And while the area of reference utilized for this aspect is not within the infant mortality confines, it does provide a general factor that does not seemingly support bias in treatment as a result of income, or social status.

Table 11 – Waiting Times for Inpatient Admission

Proportion of inpatient elective admission where the patient has waited more that 18 months, or 12 months for cardiac surgery

(Health, Social Services and Public Safety, 2004)

Areas 2001-2002 2002-2003


1.3% 1.7%


1.4% 2.1%



1.4% 2.0%

Further illustration that the health care system in Northern Ireland is not seemingly discriminating against individuals with a lower socioeconomic status, and or other facets of discrimination is indicated in the following Table:

Table 12 – Median Ambulance Response Times

(in minutes)

(Health, Social Services and Public Safety, 2004)

Areas September 2002 September 2004


6.8 7.3


8.2 8.6



7.6 8.1

In further analising factors representing potentially inequalities in health care that contribute to higher rates of infant mortality, the following Table indicates that there is a higher incidence of mortality in rural wards, which are more likely to also be lower income:

Table 13 – Infant Mortality Rates per 1,000 Live Births

(Health, Social Services and Public Safety, 2004)

Area 1997-2001 1998 2002


6.0 5.7


5.7 5.5

Further support for the contention that inequalities in infant mortality in Northern Ireland are seemingly more of a product of factors inherent in the lifestyles, living conditions, health choices and educational background of individuals from deprived wards as opposed to the NHS discriminating and or providing a lower quality of care was reported by the BBC (2000) which advised that the Institute of Public Health was holding a conference to examine ways in which the inequalities in health would be addressed, focusing on social circumstances to build more successful partnerships. One of the key aspects mentioned was that a survey found that babies born in deprived wards had a fifty percent higher incidence of death than those born in affluent areas (BBC, 2000). The report also indicated that males in the lower socioeconomic classifications have a higher incidence of dying younger and have higher chronic illnesses than males from managerial and or professional groups (BBC, 2000). The Institute of Public Health in Ireland (2005) in its ongoing concern regarding higher infant mortality rates in deprived wards has stated that poverty and educational levels of parents continues to represent the biggest threat in this area and that an improvement in poverty rates is an important area in reducing infant mortality.

The consultation also pointed out that diet, nutrition, understanding of child symptoms and seeking medical assistance at the onset of problems along with better pre and post natal care are factors attributed to higher infant mortality in lower socioeconomic groups. The updated report found that the government of Northern Ireland has not provided core funding to broaden educational outreach programs aimed at educating mothers and families in the lower socioeconomic groups to the symptoms and dangers facing infants. It points to the lack of the preceding as a clear indication that the government does not consider this a priority (Institute of Public Health in Ireland, (2005). The consultation also advised that monitoring with respect to birth outcomes, vaccination rates, infectious diseases, institution and other facets need budgets to enable the health system to perform better follow up on children identified as living in or subject to these aspects to lower infant mortality rates. It suggests that through increased partnership cooperation this could be obtained, however, that the commitment of addition funds and resources from the government is required in order to cause this to work.

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Internationally, the World Health Organization (2005) in its 56th Session held in New Caledonia stated that most child deaths could be avoided through the provision for more basic health care and detection, monitoring and follow up of pregnant mothers and newborns. The World Health Organization (2004) advises that to effectively reduce infant mortality, increased monitoring during the first month of life needs to be addressed as approximately 2/3rds of mortality occurs in the first month, with 2/3rd of that figure occurring in the first week. This holds implications for Northern Ireland in that an extended outreach, educational and monitoring program addressing the first month would effectively reduce infant mortality rates. Sweden, Norway and Demark provide an illustrat


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