Zylbersztejn, Anna Maria; (2018) Using administrative linked datasets to explain differences in child mortality between England and Sweden. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

BACKGROUND: Child mortality (under-5 years old) is almost twice as high in England as in Sweden. Policy makers need to know whether preventive strategies should address adverse birth characteristics (e.g., preterm birth, low birth weight), or focus on care after birth. This PhD used administrative linked datasets in England and Sweden to determine the contribution of birth characteristics and socio-economic factors to inter-country differences in child mortality. METHODS: I developed nationally-representative birth cohorts using an administrative hospital database in England, and a medical birth register in Sweden for births in 2003-2012, with longitudinal follow-up from linked hospitalisation and mortality records. I compared all-cause mortality, and mortality from potentially preventable causes in England relative to Sweden using Cox proportional hazards regression models. The models were adjusted for birth characteristics (gestational age, birth weight, sex, congenital anomalies), and socio-economic factors (maternal age and socio-economic status). RESULTS: Birth characteristics accounted for 77% and 68% of excess risk of death in England at 2-27 days and 28-364 days, respectively. Socio-economic factors contributed a further 3% and 11%, respectively. After adjustment for all risk factors, small but statistically significant differences in mortality remained in infancy; the differences were negligible, however, at 1-4 years. The risk of respiratory tract infection-related mortality at 31-364 days in England relative to Sweden decreased from 50% to 16% after adjusting for birth characteristics, and from 58% to 32% at 1-4 years. A third of the excess mortality from sudden unexpected infant deaths in England was explained by each birth characteristics and socio-economic factors. CONCLUSIONS: The biggest reductions in child mortality in England relative to Sweden could be achieved by reducing the prevalence of adverse birth characteristics. Policies to reduce child mortality in England should focus on improving the health of women and reducing socio-economic disadvantage before and during pregnancy.

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