1.  Most babies are born healthy requiring little or no medical intervention. Every year, however, around 10% of babies are born prematurely or suffer from an illness or condition which requires specialist care. There are three levels of progressively more complex specialist care; a local special care baby unit; a high dependency unit, and a highly specialised neonatal intensive care department. A baby needing neonatal care can move between these three levels of care as his or her condition changes.[3]

2.  The overall birthrate in England has been rising since 2001 and the Department, using Office for National Statistics projections, acknowledges that this rising trend is likely to continue.[4] The trend in low birth weight babies and other risk factors associated with prematurity (such as maternal obesity, high and low maternal age, ethnic origin, deprivation and assisted conception) are also increasing, and the number of newborn babies needing specialist care rose by 5% between 2005-06 and 2006-07 to 62,471.[5]

3.  Survival rates for premature or low birth weight babies have improved significantly. In 1975 half of babies born prematurely with a birth weight of 1,500 grams or less died and many others were stillborn. By 1985 a quarter died and by 1995 only a sixth of very small premature babies died. Improved survival rates have led to increased expectations that very small babies will survive. Infant mortality as a whole has fallen from 7.3 deaths per 1,000 live births in 1991 to five deaths in 2005. The neonatal period has one of the highest mortality rates of any period of life, with some 70% of infant mortality occurring in the first 28 days of life. Although prematurity and low birth weights are most closely associated with infant mortality, other factors such as congenital abnormalities also have a significant impact.[6] Of all babies who die before their first birthday, two thirds die because they are premature. There is also a correlation between high neonatal death rates and lower socio-economic groups.[7]

4.  In 2002, the Department set an overall Public Service Agreement target to reduce by at least 10% the gap in infant mortality between the 'routine and manual' group and the population as a whole by 2010.[8] By 2007, although infant mortality rates in the 'routine and manual' group were improving, the gap between this group and the population as a whole had widened. The Department is still working to meet the target, but acknowledges that the target is challenging and may not be met by 2010. The Department is redoubling its efforts including issuing a practical guide for Primary Care Trusts and health communities, and is also reviewing its health inequalities strategy.[9]

5.  England's neonatal mortality rate of an average 3.4 deaths per 1,000 is below that of Northern Ireland but above those of Scotland and Wales. It is also lower than neonatal mortality rates in the USA and Canada but above those in Australia and Sweden. The Department consider that part of the reason for an apparently better performance in Scotland and Wales is that, as smaller countries, they have smaller numbers of births (about a tenth of the number in England). More detailed statistical analysis indicates that rates in Scotland and England are broadly the same, but there does appear to be a difference in Wales, possibly because Wales has fewer low birth weight babies. When the incidence of low birth weight is taken into account England compares well internationally.[10]

6.  There are wide variations in mortality at network level (Figure 1) with Midlands South having the highest mortality (4.8 deaths per 1,000 live births compared to 1.8 in Surrey and Sussex and Essex).[11] Identifying the reasons for such variations is made difficult because of a lack of data on neonatal mortality rates at neonatal unit level. Analysing variations in neonatal mortality would require a sophisticated risk adjustment to reflect the complex combination of factors that occur at the local level.[12] As neonatal networks were expected to reduce many of the local differences in mortality rates, a review of network neonatal mortality rates could provide an indication of the quality of care provided.[13]

7.  The Department is unable to confirm whether variations in outcomes were due to socio-economic or other factors affecting the population, or related to the quality of neonatal service delivery.[14] The Healthcare Commission's National Neonatal Audit being undertaken in 2007-08 should provide better comparative data on outcomes, including outcomes of babies at two years.[15]

8.  Early intervention can improve neonatal mortality rates. Good communication and education can help by encouraging pregnant women to book early to see their midwife or General Practitioner. But there is also a need for interventions that help mitigate risk factors, such as smoking during pregnancy.[16] The Department is exploring the impact of premature labour on premature births and the actions that might help avoid premature births.[17]

Key: Dark shading indicates those networks whose neonatal mortality rates are significantly different from the average.