Infant mortality is technical speak for babies who die before their first birthday, something that is unspeakably tragic.
A decade ago, Sheffield wasn't doing very well. The rate in Sheffield was much higher than the England average. We set out to refresh our strategy, we refreshed our view of the evidence and the risks, what would work best in Sheffield and really put our energies into this.
In 2010 stakeholders across the city made a commitment to reducing the infant mortality rate below the national average by 2020 and to reduce inequalities between the different communities in the city.
It was based on eight programmes of work: breastfeeding, maternal smoking, recessive genetic conditions, child poverty, maternal weight, early access to maternity care, teenage conception, safer sleep.
What did we “do”
It was the whole of the strategy that made the difference, but to illustrate I will focus on a few of the specifics.
Smoking in pregnancy is one of the things the city does amazingly well by providing support advice and encouragement to mum's and dad's to stop during and after pregnancy. We have a comprehensive plan in place and have stuck at it for a long time. The plan includes implementing a smoke free hospital policy, midwifery stop smoking provision, significant support from consultants, relapse prevention, carbon monoxide monitoring. There are also brief interventions and relapse prevention across the health visiting service with significant efforts made on communications and campaigns. The results speak for themselves, we have almost the lowest smoking in pregnancy rate in Yorkshire.
We have also put huge effort into breastfeeding. Sheffield is a WHO accredited breastfeeding friendly city with support from many partners including midwifery, health visiting service, councillors and many others. Sheffield one of the first to develop and deliver a Doula peer support programme this within the council. This involves volunteers supporting vulnerable women supporting breastfeeding initiation and maintenance. Again the results speak for themselves, our breastfeeding initiation and continuation rates are much higher than England and Yorkshire average.
We have put effort into reducing teenage conceptions. Our teenage pregnancy rates have fallen since 2006 from 49.0 to 19.3. The work to achieve this has improved access to contraception including emergency contraception, more sexual health service referrals, focus on community provision, schools, colleges and GP lead services.
We worked hard to reduce the impact of recessive genetic conditions and consanguinity. There was a sheffield wide programme. We aimed to improve understanding of genetic inheritance, equity of access to services and cultural competency of staff. To enable this we employed a community genetics awareness worker co-ordinating community based activities to bring knowledge TO our communities (as opposed to expecting our communities to come to services)
It isnt all going perfectly. We haven’t done as well as I would have hoped on healthy weight in pregnancy. Whilst we have worked hard on this through training and development of the right pathways and services, there is a long way to go. It is hard, as anyone who has ever tried to loose weight knows; the interventions that we readily have aren’t terribly effective and we really need to flip our thinking on weight towards the environment in which we make choices rather than the choices individuals make.
Did it work
Quietly and doggedly in the background we got on with implementing what we set out to do. The data speaks for itself we are now consistently below the England average, and again compete with places considerably more affluent than Sheffield.
Looking back further in time, in 2001–03 there were 116 babies that died before their first birthday. for the last time we have good data – 2018–20 there were 62. This hugely positive change hasn't happened by magic, it's happened because we've continuously and relentlessly implemented effective and evidence-based interventions over a long period.
There are obviously worries for the future and I worry a lot about the immediate trend and giving austerity and the offcuts to many public services over the decade. We are noticing that sudden infant death rates are beginning to rise again, despite our interventions. I have seen some worrying signs in national data that the inequality in infant mortality rates is now beginning to widen again, we haven’t done the local analysis yet but there is no reason to think this wont also happen locally.
You never know about the dog that doesn’t bark
Why have you never heard of this story, and why does this matter? We have quietly got on with implementing it. Like most of my world it is like the dog that doesn't bark, we just quietly get on in the background doing the best it can on with the evidence and resources that are available to us.
Nobody is ever really able to count and quantify the benefits of prevention, welcome to my world. We talked a lot about outcomes-based commissioning and outcomes based delivery. This area is about as “sharp” as outcomes get. Here is a cast-iron example of success in prevention and public health with real outcomes. You never read about the children that don’t die from meningococcal infection, or the disability avoided in account of fewer lower birthweight babies or zero measles, or greater attachment on account of stupendously good breastfeeding rates. These benefits will have a ripple effect through communities and generations.
Just a little story of a success in day to day public health practice to illustrate there ARE successes and that public health isn’t only covid.