Evidence makes it clear that exposure to adversity and stress has vast potential to negatively influence the trajectory of a person’s health and wellbeing throughout their life. In this blog, Professor Pamela Qualter and Dr Anna Sanders present the key findings of a Child of the North report, co-authored with colleagues from Newcastle, Bradford, Sheffield, and Leeds, discussing the impacts of the COVID-19 pandemic on new mothers and their children across the UK.

• Pregnancy inequalities pre-date COVID-19, with children in the north dying almost a decade earlier than their peers in the south of England.
• Inequalities have been exacerbated by lockdown restrictions, with a greater impact on ethnic minorities and migrant communities.
• Early years investment is needed to counter the effects of lost schooling and poor maternity care during the COVID-19 pandemic.

Regional inequalities in infant and child health were pervasive before COVID-19, with infants and children living in the north having worse outcomes than those living elsewhere in England. The 2014 Due North report showed that worse child health is a key driver of the north-south divide in adult health and life expectancy, with those born in the most deprived areas of the north on average living almost 10 years less than those born in the least deprived areas in the south. COVID-19 highlighted and exacerbated these inequalities.

Perinatal and infant mortality among women from ethnic minority communities

Perinatal and infant mortality in the UK affects ethnic minority populations at a higher rate. The Office for National Statistics’ analysis of 2017 births shows infant mortality and low birth rates were highest among babies identified as an ethnic minority.

Some migrant women are exposed to particular stress during pregnancy and childbirth as immigration rules can enforce family separation, leaving women alone. This lack of social support is likely to increase poor birth outcomes, and family separation has a detrimental impact on children. Studies document dissatisfaction with migrant care, poor communication, and discriminatory treatment, as well as a failure to respond appropriately to particular needs. A shortage of midwives from ethnic minority backgrounds in the north has been identified as a particular concern, as well as the poor experiences of ethnic minority staff.

Widening health inequalities during COVID-19

The lockdown response to COVID-19 had unintended effects, exacerbating health inequalities across the UK, and increasing financial and food insecurity and poor mental health. Services for pregnancy changed significantly during COVID-19: midwife and health visitor appointments became remote, women had to attend antenatal appointments alone, and partners were restricted in time allowed in hospital before and after birth.

A significant proportion of new mothers in the UK reported feeling low (56%), lonely (59%), irritable (62%), and worried (71%) during COVID-19 and initial lockdown, considerably more than pre-pandemic. Figures are likely to be worse in the north, which spent far longer in lockdown than the rest of England. Clinical depression increased in mothers from 11% before COVID-19 to 19% during the first lockdown, and anxiety increased from 10% to 16%.

Emerging evidence suggests the move to online care by midwives and health visitors disproportionately impacted ethnic minority women because interpretation services were not well-integrated, and poor access to digital technologies and overcrowded housing compromised consultations. The hostile environment towards migrants also intensified, with an increase of over 50% to the Immigration Health Surcharge, and heightened rhetoric around the ‘migrant crisis’. These trends raise concerns about increased prenatal stress and risks of miscarriage and prematurity.

The cost of poor perinatal mental health is estimated to be £8.1billion for each year’s birth cohort. There is a lack of national data on perinatal mental health so it is not possible to comment on regional differences or the impact of COVID-19; good quality data are needed as a matter of priority. Given the consequences of mental illness on the physical and psychological wellbeing of mother and baby, there is an urgent need to provide support.

Health visiting and early years’ services during COVID-19

Health visitors play a key role in ensuring all children get the best possible start in life. Before COVID-19, the distribution of health visiting services was uneven across England, with a 19% decrease in the number of health visitors between September 2015 and June 2019. In the UK, in response to the first wave of the pandemic, up to 63% of health visitors were redeployed. Staffing and capacity must be aligned to areas of greatest need, and funding is needed to reduce the heightened risks and vulnerabilities in families who had a baby during COVID-19.

In the pre-COVID-19 decade, mean Local Authority spending per child on early years’ services, including Sure Start children’s centres, which provide community-based services for children and their parents, decreased by 53% in real terms between 2010/2011 and 2016/2017. This reduction in investment is likely to have affected school readiness and has been linked to increased obesity by the time a child starts school.

School readiness and COVID-19

COVID-19 interrupted schooling with periods of remote learning alongside problems with digital access and literacy. During the first lockdown, only 7% of children who had previously attended formal early education and childcare services continued to do so. Access to early education has a range of benefits for children’s educational, cognitive, and socio-emotional development. Because attendance is particularly beneficial to more deprived children, inequalities will increase, disproportionally affecting children in the north. Evidence suggests the enrolment of all low-income children in high quality early education programmes could close the gap in educational outcomes by 20–50%.

Research highlights the negative impact on children who did not attend early years settings during COVID-19. Parents reported negative impacts on social and emotional development, and service providers noted consequences for physical development of children in deprived homes. In 2020, a national Ofsted survey of 208 providers found 53% of providers believed children had fallen behind in personal, social and emotional development, whilst 29% believed children had fallen behind in communication and language. Of particular concern were children living in poverty, children with English as an additional language and those with special educational needs and disabilities. COVID-19 will have further widened the learning gap, and will impact them throughout their lives.

Missed learning has long-term cost implications: OECD data shows a loss of one-third of a school years’ worth of learning reduces the earned income of pupils by approximately 3%. A less skilled workforce also lowers rates of national economic growth. Early investment is key to mitigating economic impacts, which can help to reduce inequalities and prevent achievement gaps more cost-effectively than tackling them in later life. There are still gaps in our understanding from a regional perspective.

Conclusion

Mothers and their children growing up in disadvantaged regions and in already vulnerable households, particularly in the north, are amongst those who have experienced the most negative consequences of COVID-19. The longer-term impacts on maternal and child health and wellbeing need to be closely monitored. Investment in the early years must be prioritised, with additional investment in priority areas. Only through serious investment can we start to reduce health inequalities and break the cycle of inequality seen across the north. There is a clear need to take a long-term approach to tackling inequalities, ensuring every child has a good start in life, reducing early years adversity and leading to improvements in health for all.

Insight for policymakers

• Government must develop a monitoring system for understanding long-term impacts of COVID-19 on maternal and child health and wellbeing.
• Government must provide rapid, focussed investment through the early years to ameliorate negative impacts of COVID-19.
• Government must recognise specific challenges of intergenerational inequality across the north and invest to level out opportunities.
• Commissioners of maternity and early years services to consider the impact on inequalities of service changes during COVID-19 to determine the shape of services moving forwards.

This is an abridged version of the Pregnancy and Early Years chapter from the Child of the North report, published in 2022 by the Northern Health Science Alliance. The original piece was co-authored by Judith Rankin, Sally Bridges, Sunil Bhopal, Pamela Qualter, Josie Dickerson, Anna Sanders, Calum Webb, Sarah Salway and Ghazala Mir.