Inequalities in neonatal unit mortality in England and Wales between 2012 and 2022: a retrospective cohort study

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BACKGROUND: Babies born to mothers living in more deprived areas and from ethnic minority groups are at a higher risk of dying during the neonatal period. Preterm and unwell term babies are cared for in neonatal units, and this population contributes substantially to the child mortality rate. The extent of and reasons for socioeconomic and ethnic inequalities in neonatal unit outcomes are unclear. We aimed to evaluate socioeconomic and ethnic inequalities in characteristics and mortality of babies admitted to National Health Service (NHS) neonatal units in England and Wales. METHODS: In this retrospective cohort study, any baby that was born at or after 22 weeks' gestation and admitted to an NHS neonatal unit in England and Wales, received neonatal care, and had clinical data registered in the National Neonatal Research Database was eligible for inclusion. Our primary exposures of interest were index of multiple deprivation (IMD) and maternal ethnicity. We assessed inequalities in in-unit mortality before discharge using nested logistic regression models, estimating crude, confounder-adjusted, and case-mix adjusted odds of mortality. Case-mix variables on admission were gestational age, birthweight, sex, maternal age, smoking during pregnancy, the presence of any congenital anomaly, obstetric problem, and previous medical problem in the mother. FINDINGS: Between Jan 1, 2012, and Dec 31, 2022, 709 569 babies were included in the analysis and there were 11 257 (1·6%) neonatal unit deaths. Of the 678 550 babies with complete IMD information, 649 180 (95·7%) babies were born to mothers living in England and 29 308 (4·3%) to mothers living in Wales. 561 621 (79·1%) babies had complete information on exposures and case-mix variables on admission used for logistic regression. More babies in neonatal units were born to women from the most deprived decile (102 419 [15·1%]) compared with the least deprived decile (43 882 [6·5%]). Babies born to women from the most deprived decile were at increased risk of mortality (odds ratio [OR] 1·63 [95% CI 1·48-1·81]) than babies born to women from the least deprived decile. After adjusting for ethnicity, the OR was 1·52 (1·38-1·69), and after adjusting for case-mix, the OR was 1·23 (1·10-1·37). Babies born to mothers who were Black had an OR for mortality of 1·81 (1·67-1·95) compared with mothers who were White, attenuated to 1·68 (1·55-1·81) after adjusting for deprivation, and 1·14 (1·05-1·24) in the case-mix adjusted model. Babies born to mothers who were Asian had an OR for mortality of 1·48 (1·39-1·57) compared with mothers who were White, attenuated to 1·40 (1·32-1·49) after adjusting for deprivation, and 1·36 (1·27-1·45) in the case-mix adjusted model. INTERPRETATION: There are stark socioeconomic and ethnic inequalities in babies admitted to and who die in neonatal units in England and Wales. Mortality inequalities are partly explained by case-mix on entry to the neonatal unit, suggesting in-unit factors such as care practices explaining residual inequalities. Further work to investigate the role of care practices is required, as well as policies and practices to address upstream drivers of these inequalities. FUNDING: Hugh Greenwood Legacy Fund, University of Liverpool, and National Institute for Health and Care Research.

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