Health outcomes of experiencing poverty in the early years: evidence review

Chapter 3: The health outcomes of experiencing poverty in the early years

As mentioned in Chapter 1 (Introduction and context), the life-course perspective highlights the profound impact of early experiences, including those in the pre-birth period, on a child’s future health and development. These early experiences can shape gene expression through epigenetic adaptations, determining whether, when, and how genes activate their instructions to build future capacities for health, skills, and resilience^[116]. This highlights how deeply the foundations of lifelong health are intertwined with conditions experienced during the earliest stages of life and why strategic focus is needed in this area.

Good health in childhood should be valued not only for its critical role in shaping future development and prosperity but also for its intrinsic worth and immediate benefits for children^[117]. Prioritising children's health for its own sake ensures children can thrive in the present and fully experience and enjoy their childhood through learning, playing, exploring, and growing at their own pace^[118]. These experiences are time-sensitive and irreplaceable, which means that they cannot be compensated for later in life. In this context, addressing child poverty and investing in good early years health is fundamental to securing the health and wellbeing of children both now and into the future.

It is important to note that the outcomes presented below are not unavoidable. Instead, the literature highlights a clear association between early childhood poverty and a higher risk of health issues for children in the early years or prior to birth. Findings highlight that reducing the transgenerational transmission of health risks is possible through implementing a whole-family strategy focusing on enhancing parental health before and after birth, supporting infant health and development after birth and optimising nurturing care^[119]. Key interventions should target behavioural, individual, and environmental risk factors linked to adverse outcomes for mothers and children, such as poor nutrition, parental mental health challenges, and substance use, including alcohol and tobacco^[120]. Poverty is not experienced in the same way by every child; equally interventions for change can have an important impact on the health and wellbeing of children at higher risk.

This chapter sets out the health outcomes associated with child poverty in the early years. It follows a clear structure: first, a discussion of each indicator; second, a discussion of existing inequalities; and third, a discussion of the impacts on parental and child health, and the suggested actions for improvement derived from the literature and closely linked to the indicators underpinning this review. Chapter 4 (Moving forward: overarching evidence) will build on these findings, presenting other overarching evidence and broader actions.

It is worth noting that data around health – for example data on diet-related inequalities as outlined below – often focuses on adults. However, much of the existing literature on data improvement around child health highlights the need for child-specific measures (see Monitoring and Evaluation section in Chapter 5) to strengthen understanding of the health and wellbeing of children generally, and children living in poverty specifically. Additionally, there is a noticeable lack of literature that captures the perspectives of children and young people regarding the values and goals underpinning initiatives directly impacting them and their families. Moreover, existing evidence does not always clearly define what constitutes targeted support or specify the optimal timing for interventions. More work is required in these areas to address these gaps.

Parental nutrition, weight, and supplement use

Optimal nutrition before and during pregnancy, as well as in early childhood, is critical for children’s long-term health, as these stages lay the foundations for future outcomes (see Chapter 1: Introduction and context for more detail). Pregnant women require increased nutritional intake to support the dietary needs of the developing foetus^[121], including balanced intake of essential nutrients and specific supplements, such as Vitamin D to prevent calcium deficiencies and folic acid^[122] to help prevent birth defects, while avoiding excessive Vitamin A^[123]. However, the literature suggests that maintaining a healthy weight and nutrient intake during pregnancy is particularly challenging for families experiencing poverty and deprivation, which increases the risk of poor health outcomes for children.

Diet-related inequalities

Evidence highlights inequalities in nutrient intake and health outcomes among pregnant women, with those in more deprived areas experiencing higher rates of obesity and diabetes. For example, in 2023/24, 20% of women from the least deprived areas in Scotland (SIMD Quintile 5) had a body mass index (BMI) in the range classified as obese at their first antenatal appointment, compared to 32% of women from the most deprived areas (SIMD Quintile 1)^[124]. Similarly, among those living in the most deprived areas (SIMD Quintile 1), nearly 12% had a recorded diagnosis of any type of diabetes compared to 7% in the least deprived areas (SIMD Quintile 5)^[125].

Findings on supplement use among women show similar inequalities, however routine reporting on maternal supplementation uptake remains challenging due to small sample sizes. The 2017 Scottish Maternal and Infant Nutrition Survey^[126] showed that 41% of respondents in the most deprived areas (SIMD Quintile 1) reported taking folic acid before pregnancy, compared to 67% in the least deprived areas (SIMD Quintile 5) ^[127]. Similarly, in 2021, individuals in the most deprived areas (SIMD Quintile 1) were less likely to report taking vitamin D supplements compared to those in the least deprived areas (SIMD Quintile 5)^[128].

Food insecurity

The literature highlights the importance of examining nutrition and diet in the context of food insecurity^[129]. Ensuring parents can eat well is vital to supporting the healthiest possible development for children, yet households experiencing food insecurity face challenges in accessing sufficient, diverse, and nutritious food^[130]. Various factors can disproportionately impact individuals' capacity to prepare and eat healthy meals, including the availability of stores offering a wide range of nutritious options, reliable transportation to reach them, and adequate time to prepare healthy meals^[131]. Income is a key factor in this context; findings show that households in the lowest income quintile in the UK and Scotland allocate a larger proportion of their income to food compared to higher-income households^[132]. Rising food costs can further exacerbate financial strain on these families^[133], which can impact parental nutrition and by extension, access to nutritious food for children.

In Scotland, 2023 Scottish Health Survey (SHeS) data^[134] show a significant rise in food insecurity compared to 2017-2021 figures. In particular, 14% of adults were concerned about running out of food, an increase from the 8-9% range recorded in previous years and the highest figure in the time series. Additionally, 11% had eaten less in the previous 12 months due to financial constraints, an increase from 6-7% in previous years. Finally, 6% reported that they had run out of food in the past year, compared to 3% in 2021. Adults in food-insecure households also reported lower average life satisfaction and significantly poorer mental wellbeing^[135]. There is evidence that food insecurity is linked to poor psychological and social outcomes, particularly around the limited ability of low-income households to have choice over the food they purchase^[136].

Cross-sectional data from the Dietary Intake in Scotland’s CHildren (DISH^[137]) survey, which assesses the diet of children and young people specifically, highlight significant differences in food insecurity across SIMD quintiles (Table 1)^[138]. Notably, 44% of parents in the most deprived areas (SIMD Quintile 1) reported having worried about running out of food compared to 6% in the least deprived areas (SIMD Quintile 5). Seventeen percent in the most deprived areas (SIMD Quintile 1) had eaten less to leave more for their child or children, compared to 1% in the least deprived areas (SIMD Quintile 5).

Table 1. Household Food Insecurity (weighted percentage) by SIMD in Children Aged 2–15, Scotland, 2024 (unweighted sample size 1,700), DISH^[139]

In the previous 12 months…	Overall	1st (Most Deprived)	2nd	3rd	4th	5th (Least Deprived)
Worried about running out of food	22%	44%	30%	16%	13%	6%
Had smaller meals than usual or skipped meals	17%	38%	21%	14%	9%	4%
Ran out of food	7%	17%	8%	3%	3%	1%
Ate less to leave more for your child / children	7%	17%	8%	3%	3%	1%

Families on low-income and single-parent families are at a higher risk of experiencing food insecurity^[140]. Some of the factors that drive food insecurity for lone-parent families include lower incomes, limited savings, high childcare and housing costs, reduced employment opportunities, and rising food and energy prices^[141]. For example, parents participating in a qualitative study reported ‘losing weight due to not being able to afford to eat enough’ and having to keep the heating off and ‘using small heaters and blanket, hot water bottle’ to manage competing financial priorities^[142].

Health outcomes and suggestions for action

Globally, a poor diet is a significant risk factor for various health issues, and eating habits developed during childhood can have a lasting impact on behaviour and health outcomes in later years^[143]. Evidence highlights the importance of pre-pregnancy weight status and its connection to child health. Among children of mothers with a healthy pre-pregnancy weight, higher vitamin D levels were associated with reduced rates of childhood overweight^[144]. Additionally, research in Scotland found that children born to mothers living with obesity (BMI ≥30 kg/m²) or overweight (BMI 25–29.9 kg/m²) had a higher risk of developing type 2 diabetes compared to those born to mothers with a BMI not indicating obesity or overweight^[145]. Maternal obesity increases risks such as miscarriage, gestational diabetes, preterm births^[146], stillbirths^[147] and perinatal deaths; poorer perinatal mental health; lower breastfeeding rates, metabolic and developmental issues for the foetus; and obesity and diabetes in childhood and into adulthood^[148]. On the other hand, maternal underweight has been linked to miscarriage, preterm birth and low birth weight^[149].

While maternal nutrition and its effects on child health are widely studied, research on the impact of paternal dietary patterns and lifestyle choices on child health outcomes is notably lacking. Emerging evidence suggests that both parents' nutrition and lifestyle are crucial at conception, with higher paternal Body Mass Index (BMI) being associated with an increased risk of higher birth weight, obesity, and chronic disease in offspring^[150]. While the exact mechanisms remain complex and not fully understood, it is believed that a combination of genetic and epigenetic factors contribute to this effect^[151].

As stated earlier in the report, poverty and poor health – in this case, malnutrition and micronutrient deficiencies, also referred to as ‘hidden hunger’ – exist in a mutually reinforcing cycle where each drives the other. Evidence shows that poverty increases food insecurity and hidden hunger, leading to nutritional imbalances that impair work capacity and economic prosperity^[152]. At the same time, malnutrition negatively impacts physical and mental development, cognitive function and productivity, limiting an individual's economic potential and increasing the risk of poverty. Addressing these interconnected challenges requires coordinated action that tackles poverty and health inequalities in tandem, recognising that strategies aiming at poverty reduction not only influence but are also directly influenced by health outcomes.

Evidence emphasises that there is no single most important intervention to improve healthy weight^[153]. Tackling the structural and systemic factors contributing to poor diets is key to shifting the focus from individual responsibility to healthier food environments^[154]. Recognising this need for system-wide change, Nesta has published a blueprint toolkit outlining a high-impact, low-cost, and equitable approach to tackling obesity. This approach prioritises structural interventions, including mandatory healthiness targets for large retailers, advertising and promotion restrictions, improved food labelling, expanded access to effective treatments, and mandated data collection of sales and nutritional information for large businesses^[155]. These strategies aim to ensure that healthier choices become more accessible to all, reducing focus on individual responsibility and addressing the drivers of existing inequalities – ultimately fostering supportive food environments where healthier behaviours can be adopted and sustained^[156].

Promoting preconception health as a critical window of opportunity is important to support good health in the early years and throughout the life course^[157]. Professionals play a key role in promoting preconception health; ensuring that they are skilled in addressing healthy weight related issues and providing the necessary support and signposting would be a key component in integrating preconception health across different services^[158].

Other key areas where health professionals can provide valuable support include discussing the importance of vitamin supplements before and during pregnancy, ensuring expectant and new mothers understand their role in maternal and infant health. Providing guidance on healthy eating before and during pregnancy while considering affordability and individual resources helps ensure practical and accessible advice for women from low-income backgrounds. Additionally, exploring ways for women planning a pregnancy, pregnant women and mothers to integrate supplements into their daily routines can make it easier to maintain nutritional balance in a way that suits their lifestyle^[159]. Furthermore, community-based nutrition programmes can help improve access to healthy food options for low-income families^[160].

It is important to note that strategies to improve nutrition also need to account for the challenges posed by climate change. Climate change disrupts food systems both directly and indirectly – through reducing nutrient availability and compromising nutrition – and these effects disproportionately impact certain population groups^[161]. Research in Scotland shows that higher-quality, lower-emission diets are often more expensive than lower-quality, higher-emission diets^[162], making healthy food less accessible for those experiencing poverty and/or deprivation. Adapting diets to meet climate goals – such as through actions highlighted in the most recent UK Carbon Budget^[163] – is therefore vital not only for reducing emissions but also for improving public health and addressing inequalities. A more detailed exploration of these issues falls beyond the scope of this review.

Infant-feeding practices, nutrition and weight

Healthy eating in the early years is highlighted as a key priority within healthy weight delivery plans in Scotland^[164] and the wider UK^[165] in the context of giving every child the best start in life. Both global and UK guidelines advise that infants should be exclusively breastfed for the first six months. After that, breastfeeding should continue alongside a mixed diet until at least the age of two and beyond^[166]. These recommendations are backed by strong evidence of the positive effects of breastfeeding on both parental and child health. For example, for children, studies suggest breastfeeding supports healthy weight gain^[167], reduces the likelihood of dental disease^[168], and decreases the risk of obesity and Type 2 diabetes later in life^[169]. For the parent, breastfeeding has been linked to a lower risk of cardiovascular disease^[170], as well as reduced incidences of breast and ovarian cancer^[171].

Beyond breastfeeding, when children start to eat solid food, a nutritious diet remains significant to health outcomes. In Scotland, guidance emphasises a balanced diet rich in fruits, vegetables, whole grains, and protein sources while limiting sugar, salt, and saturated fats^[172]. Encouraging healthy eating habits early can support health across the lifespan.

Breastfeeding-related inequalities

There are clear differences in breastfeeding rates by deprivation, with the incidence of breastfeeding reducing as deprivation levels rise^[173]. In 2023/24, 65% of babies born to mothers living in Scotland's least deprived areas (SIMD Quintile 5) were breastfed (exclusive or mixed) by their 6-8-week review, compared to 36% in the most deprived areas (SIMD Quintile 1)^[174]. However, over the past decade, the proportion of babies being breastfed at both the First Visit and 6-8-week reviews has consistently increased among those in more deprived areas, narrowing the gap in socioeconomic inequality in breastfeeding. In the least deprived areas (SIMD Quintile 5), rates of exclusive breastfeeding at the First Visit have remained stable, but overall breastfeeding rates have risen^[175]. These findings may be understood within a wider context of sustained Scottish Government efforts to increase breastfeeding rates through targeted funding and breastfeeding support^[176].

A range of individual, socioeconomic, and societal factors influence infant-feeding choices. Challenges such as pain, concerns about milk production, embarrassment about breastfeeding in public, negative societal attitudes, and insufficient professional and social support often prevent mothers from breastfeeding^[177]. For families experiencing poverty, these challenges are further compounded by poverty-specific factors. Research from the Food Foundation highlights common obstacles, including inadequate support, work-related pressures, practical difficulties, and financial strain^[178]. Maternity Action's 2023 findings illustrate this with 58% of mothers surveyed reported having to shorten their maternity leave and return to work earlier than desired due to financial pressures^[179]. This often resulted in a switch to formula feeding, as expressing milk at work proved difficult. Therefore, though breastfeeding may be understood to be a positive decision for child (and parent) health it is often not practically possible, and these wider factors should be taken into account in any intervention to increase uptake of breastfeeding.

Diet-related inequalities

Beyond breastfeeding, high quality, nutritious food remains significant to the health and wellbeing of children in the early years, as set out above. However, the Public Health Nutrition Strategy 2023 (Food Standards Scotland) highlights that dietary inequalities are a significant concern, with children in deprived areas being more likely to experience poor diet and related health issues^[180]. The DISH study found that children and young people living in the most deprived areas of Scotland (SIMD Quintile 1) generally had less healthy diets than those living in the least deprived areas (SIMD Quintile 5). Their diets were higher in energy density, saturated fat, free sugars, and salt, while being lower in fibre, fruit, vegetables, and oily fish^[181]. Fruit and vegetable intake in the least deprived areas averaged one portion more per day (5.7 portions versus 4.5 portions) than in the most deprived areas^[182].

Information about infant weight and growth in Scotland is collected at Primary 1 health reviews, where height and weight measurements are recorded to assess body mass index (BMI). In the school year 2023/24, socioeconomic inequalities in child healthy weight persisted, particularly in the risk of obesity, with 14% of children in the most deprived areas at risk, compared to over 6% in the least deprived areas^[183]. Although this data pertains to 5-year-olds, which is beyond the review's scope, it shows that healthy weight issues start early and may already be apparent before the age of 5. This highlights the need for early intervention to address these inequalities prior to the transition to school.

Food insecurity

As mentioned earlier, living in a food-insecure household can have adverse health effects for children and hinder their potential for growth at a critical stage of their lives. This is relevant in the context of child poverty in Scotland, as findings from 2021-24 show that children in poverty were less likely to have high food security. During this period, 22% of children were estimated to live in households with marginal, low, or very low food security^[184]. The financial strain faced by these families is indicated by qualitative findings, which highlight the challenges of affording formula milk. Parents in low-income households reported that money provided through vouchers 'disappears', frequently failing to cover the full cost, further exacerbating the financial strain on families^[185].

This negative impact on sufficient nutritional intake^[186] and the inability to meet nutritional needs can heighten health risks for children^[187]. Children experiencing food insecurity are at greater risk of being admitted to hospital, being underweight or overweight, and experiencing developmental delays, anaemia, and asthma compared to children who are not affected by food insecurity^[188]. These health risks are compounded by the broader concerns parents frequently express, such as the impact of inadequate food on their children's physical and mental health, social development, and relationships^[189].

However, evidence suggests that not everyone in a food insecure household experiences it directly. Parents’ strategies to protect their children (e.g., lowering food intake themselves) from the impacts of food insecurity can be effective in ensuring that children are not affected directly^[190], though evidences the consequences of poverty on the wider family unit.

Health outcomes and suggestions for action

Evidence suggests that living in more deprived areas is linked with a higher risk of low birth weight^[191], and both low birth weight and prematurity are closely linked to poverty^[192]. A poor diet during early childhood is associated with child malnutrition^[193] and can have other negative effects including low energy, frequent illnesses, poor growth and cognitive and behavioural challenges^[194]. Over time, it can lead to developmental delays, chronic health conditions like obesity and diabetes, and long-term oral health issues^[195].

A study in Scotland found that by age 14, higher obesity rates were more likely among children from deprived areas, single-parent households, families with lower maternal education, maternal unemployment, or not owning the family home. The risk was greatest for children facing both area deprivation and low household income^[196]. Additionally, the same study found that food insecurity played a central role in childhood obesity. Notably, children that had experienced food insecurity at age 2 had a much higher likelihood of remaining at a weight classed as obese at both ages 4 and 14 compared to their peers who did not experience food insecurity at age 2^[197].

Evidence emphasises the need to support parents and caregivers in safely and sustainably providing appropriate nutrition for infants, tailored to their developmental needs, whether they are breastfed, formula-fed, or both^[198]. Beyond milk feeding, holistic support needs to be provided to families who choose to formula feed. This includes guidance on selecting and safely preparing infant formula, preventing overfeeding, and fostering closeness between parents and babies to support brain development and emotional well-being. Helping families lower the costs associated with formula feeding is also crucial and this can be supported through clear, accessible, and evidence-based information on the nutritional comparability of different formulas and the dietary needs of infants as they begin eating solid foods^[199]. Essentially, a key priority is to foster healthier food environments rather than focusing solely on individual responsibility^[200].

In addition to this, focusing on equipping health professionals who support children and young people to be able to advise on healthy lifestyles (covering weight management, diet, and physical activity) is important to create a supportive environment where parents and caregivers feel confident and capable of making informed decisions about their children's health^[201]. Qualitative evidence shows that mothers are open to receiving advice from healthcare professionals, especially during weaning. One mother described healthcare professionals as being ‘very supportive’, explaining that sharing details about her child's eating habits had resulted in practical and encouraging suggestions, such as, ‘Try this, try that.’^[202].

At universal level, suggested actions include establishing breastfeeding support groups and peer networks, which can offer assistance with breastfeeding, provide advice, facilitate early diagnosis of issues, and support formula feeding when appropriate^[203]. This has been incorporated into the Becoming Breastfeeding Friendly (BBF) Scotland scheme^[204]. However, by building on these existing actions and addressing key gaps - such as improving mothers’ awareness of their rights, strengthening legislative protections, and offering robust support for women returning to employment - the Scottish context can be further strengthened as an enabling environment for breastfeeding^[205]. This would promote better health outcomes for both mothers and children, ensuring a strong foundation for early development and lifelong wellbeing.

On more targeted support, UK survey data emphasise the need to remove barriers faced by mothers in poverty, including insufficient support from healthcare professionals, lack of financial and social resources, and limited public spaces for feeding their babies, to help extend breastfeeding duration^[206]. Evidence further highlights the importance of tackling food insecurity and its financial drivers^[207]; focusing on measures to increase spending on fruit and vegetables, address hunger, and promote healthy eating^[208]; and encouraging diet changes to achieve higher fibre intake through foods such as bread, breakfast cereals, pasta, rice, vegetables (including beans), and fruit^[209]. Furthermore, ensuring better representation of deprived and lower-income population groups in research could help strengthen the voices of people in poverty and ensure initiatives meet their needs^[210]. Finally, regular monitoring of infants for signs of malnutrition is important to ensure risks are addressed early^[211] and addressing evidence gaps is needed to improve nutrition and health during the first years of life^[212].

Parental tobacco, alcohol and drug use

Smoking, alcohol, and drug use are known to pose health risks throughout an individual’s life, but the periods before, during, and after pregnancy are particularly sensitive times when these behaviors can have heightened impacts on the wellbeing of both mother and child. In Scotland, it is recommended that women trying to conceive or who are pregnant avoid smoking, alcohol and recreational drug use^[213]. The NHS emphasises that second-hand smoke exposure is particularly harmful to pregnant women and children^[214]. Evidence shows that these issues are particularly prevalent in families facing poverty and deprivation, which heightens the health risks for these children^[215].

Inequalities in tobacco, alcohol and drug use

Tobacco, alcohol, and drug use are major public health challenges in the Scottish context, disproportionately affecting individuals living in deprived areas. From a pre-conception perspective, in 2023, smoking prevalence among adults was significantly higher in the most deprived areas (SIMD Quintile 1 – 26%) compared to the least deprived areas (SIMD Quintile 5 – 6%). Although the percentage of children exposed to second-hand smoke has decreased from 12% in 2012 to 4% in 2023, specific data by deprivation is unavailable^[216].

In relation to alcohol consumption, variation across deprivation levels was less pronounced for average weekly intake, binge drinking, and hazardous/harmful drinking. In 2023, the mean alcohol consumption was 13.2 units per week in the most deprived areas (SIMD Quintile 1) and 11.8 units per week in the least deprived areas (SIMD Quintile 5) ^[217]. Binge drinking (defined as consuming over 6 units for women or 8 units for men in a single day) had an equal prevalence (15%) in both the most and least deprived areas^[218]. However, hazardous/harmful drinking (exceeding 14 units per week) was more prevalent in the least deprived areas (23%) than in the most deprived areas (17%)^[219].

Greater variation was observed in alcohol-related health outcomes. In 2023/24, the rate of alcohol-related hospital admissions was 1,140.4 per 100,000 population in the most deprived areas, compared to 217.7 per 100,000 in the least deprived areas^[220]. Alcohol-specific deaths (using a 5 year rolling average between 2019 and 2023) occurred at a rate of 43.3 per 100,000 in the most deprived quintile, compared to 9.0 per 100,000 in the least deprived quintile^[221].

Regarding drug use, in 2023, there were no significant variations with regards to the adult prevalence of any drug use in the past 12 months by area deprivation^[222]. However, drug-misuse deaths^[223] were disproportionately higher in the most deprived areas. In 2023, there were 53.7 drug misuse deaths for every 100,000 people in Scotland, compared to 3.5 for every 100,000 in the least deprived areas^[224].

Inequalities are also evident among expectant mothers in Scotland. In 2023, women living in the most deprived areas (SIMD Quintile 1) were reported as current smokers in 20.4% of pregnancies where smoking status was known (5,502 pregnancies booked where women reported smoking), compared to 2.4% in the least deprived areas (SIMD Quintile 5) ^[225]. In 2023-24, the rate of recorded drug use among maternities in Scotland was 18.8 per 1,000. However, notable inequalities exist by deprivation level. In the most deprived areas (SIMD Quintile 1), the rate was considerably higher at 31.2 per 1,000 maternities, compared to 5.5 per 1,000 in the least deprived areas (SIMD Quintile 5). This marks the highest recorded rate of drug use during pregnancy in the most deprived areas since 2011-12 (32.3 per 1,000 maternities)^[226].

With regards to maternal alcohol consumption, data is currently collected at a woman's antenatal booking appointment^[227] and is not available by deprivation. The data that is available suggests that, in 2023/24, around 25% of women consumed alcohol in the 3 months prior to their pregnancy (a figure that is relatively stable over the previous 4 years), but this data is self-reported and, given the known lack of reliability of self-reported alcohol data, should be treated with caution^[228].

Several factors may contribute to these inequalities. Deprived areas are often characterised by higher numbers of people with complex, overlapping needs and a lack of sufficient services to support them^[229]. Additionally, evidence from Scotland suggests an environmental influence, as deprived areas tend to have a higher density of tobacco and alcohol retail outlets, often located in close proximity, compared to less deprived areas^[230]. These environmental and systemic factors need to be taken into consideration when considering impacts throughout the life course and suggestions for action.

Health outcomes and suggestions for action

Smoking, alcohol, and drug use have far-reaching outcomes for parental and child health. Smoking is associated with fertility problems in men^[231] and a range of perinatal complications, such as miscarriage, stillbirth, premature birth, and low birth weight^[232]. Children exposed to tobacco smoke are at higher risk of sudden infant death syndrome (SIDS), respiratory infections, asthma, and middle ear disease^[233]. Moreover, these children are twice as likely to become smokers themselves and therefore more likely to experience the longer-term health harms associated with smoking^[234]. Longitudinal data from the GUS study highlight that, by age 12, children in the most deprived areas (SIMD Quintile 1) were more likely than those in the least deprived areas (SIMD Quintile 5) to have tried cigarettes (8% compared with 1%) and e-cigarettes (13% compared with 3%)^[235]. It is clear that children living in poverty are at higher risk of experiencing the negative health outcomes that come with smoking and vaping, in both the short and longer-term.

Exposure to alcohol during pregnancy can lead to foetal alcohol spectrum disorders (FASD)^[236] and drug use during pregnancy can result in neonatal abstinence syndrome (NAS), where newborns experience withdrawal symptoms. Drug use is also associated with giving birth prematurely and having underweight babies, along with feeding and breathing problems, infections and developmental and growth issues in babies^[237]. Additionally, issues with drug use can disrupt the home environment and create circumstances that are less conducive to nurturing care, which can jeopardise children’s development, health, and wellbeing^[238].

To address alcohol-related harms, the evidence points to the importance of the Minimum Unit Pricing policy^[239] in Scotland and providing information to help people make informed decisions^[240]. Additionally, raising tobacco taxes and levying tobacco companies are also important measures to reduce the harms caused by tobacco use^[241]. The recent passing of the legislative consent motion in the Scottish Parliament is also a step towards a ‘smoke-free generation’.

The literature highlights pre-conception as a key phase to reduce tobacco, alcohol and drug-use related harms in line with primary prevention principles. Findings suggest prioritising vulnerable women who smoke or use substances before, during and after pregnancy^[242]. Insights emphasise the importance of healthcare providers asking all pregnant women about their past and present substance use as early as possible and at every antenatal visit. They also stress the need for risk evaluations to reflect the type and quantity of substances used and their impact on daily life, and highlight that early brief interventions by non-specialists in primary care can be effective^[243]. Cross-service collaboration is crucial to support information sharing and continuity of support. One way to achieve this is by developing multi-agency safeguarding arrangements through local joint protocols between alcohol and drug treatment services as well as children and family services^[244].

Access to healthcare in the perinatal period

As mentioned earlier, the literature indicates that many health behaviours and risk factors for adverse birth outcomes are established before pregnancy. Women in good health at the time of conception are more likely to conceive, experience a safe and healthy pregnancy, and deliver a healthy baby. Conversely, poor preconception health is linked to increased concerns about the safety of pregnancy and childbirth^[245].

Access to pregnancy planning services during the antenatal period, as well as healthcare in the perinatal and postnatal periods, is essential to protecting the health of children and families. It is advised that women have their initial appointment by 10 weeks of pregnancy^[246]. After birth, access to support services is crucial for supporting parents to provide responsive care, improving the quality of caregiving, child attachment, and development^[247]. Findings show that families experiencing poverty and deprivation face barriers to accessing care, which increases health risks for children.

Inequalities in access to healthcare

In 2023, 86.5% of pregnant women from the most deprived areas of Scotland (SIMD Quintile 1) accessed antenatal care by 12 weeks, compared to 94.9% from the least deprived areas (SIMD Quintile 5), with this disparity widening over time^[248]. Analysis of the Scottish Maternity Care Survey also found that women living in the most deprived areas booked for their antenatal care significantly later than women living in the least deprived areas and were less involved in aspects of decision making about their care^[249].

Neonatal care^[250] data from 2023/24 indicate that babies from the most deprived areas (SIMD Quintile 1) in Scotland required the highest levels of neonatal care. When comparing babies from the most deprived areas (SIMD Quintile 1) with those from the least deprived areas (SIMD Quintile 5), the differences are important to note. Babies from the most deprived areas accounted for 36% of all intensive care cases (814 in total), compared to 9.5% from the least deprived areas. High dependency care figures (1,272 in total) for babies from the most deprived areas were just over 31%, compared to nearly 14% from the least deprived areas, and special care figures (2,340 in total) were 26% compared to 15%, respectively. Transitional care^[251] was less common overall.

Accessing healthcare can prove challenging for parents and families experiencing complex social factors and deprivation. Families in deprived areas face greater barriers to accessing healthcare, including fewer or lower-quality services in more deprived areas and high costs to travel to healthcare facilities^[252]. Pregnant women living in deprived areas are more likely to face barriers to accessing healthcare in a timely manner or engaging effectively with it^[253]. These barriers to accessing healthcare can contribute to poorer health outcomes for children in both the short and medium term, while also increasing the risk of chronic health issues that may persist throughout their lives.

Health outcomes and suggestions for action

Limited access to healthcare services before, during, and after pregnancy is associated with reduced ability to manage conditions that could affect pregnancy, resulting in unmet medical needs and increased risks for both mother and child^[254]. Women from low-income households are also more likely to enter pregnancy with pre-existing conditions such as obesity and diabetes, leading to higher risks for both maternal and child health and requiring increased and/or specialist care^[255].

A study in Scotland found that women who reported having poorer general health also reported consistently poorer experiences of care^[256]. Lack of preventive care and early detection of arising issues may result in major postpartum haemorrhage and the need for intervention in the perinatal period^[257]. Inadequate care can also lead to other complications including increased risks of preterm birth and stillbirth^[258]. Poverty exacerbates these issues and increases health risks, including the risk of infant mortality^[259] and maternal mortality^[260].

Raising awareness of preconception health, ensuring continuity of care across various life stages and improving equity of access to healthcare provision across inequalities are key for preventing or mitigating these impacts^[261]. The evidence highlights the importance of providing integrated, one-stop-shop early years services that serve as a central point of contact for every family and make the system easier to navigate^[262]. In this context, creating spaces for people supporting families to come together and share best practice and ideas, as well as to receive support and advice, can help develop a greater understanding of each other’s roles and build resilience^[263].

The literature notes that access to services is particularly challenging for women in deprived areas and notes strategies such as decentralising services to local areas with good transport links and childcare provision^[264]. As previously mentioned, place-based systems approaches, currently implemented in Scotland, can support strategies aimed at improving health outcomes and addressing poverty through integrated, locally tailored actions^[265]. Other key takeaways focusing on service design and delivery include: identifying leaders who can champion the needs of families, monitor the effective delivery of early years services and ensure continuous improvement; developing parent and carer panels where professionals and parents can work collaboratively to co-design and provide feedback on services; establishing key contacts for families and ensuring empathy is central to the support provided; utilising diverse service delivery methods, with a focus on flexibility and accessibility for families and children in poverty; undertaking further work to understand barriers to accessing services and tackle the stigma associated with seeking help^[266]. Stigma could potentially be pervasive across a number of issues explored in this report and needs further investigation and consideration when tackling health and child poverty.

Additionally, all staff should be trained to recognise and support vulnerable women during routine maternity care, and access to specialist care should be provided to those facing complex social factors^[267], along with more time to discuss complex needs^[268]. There is also evidence suggesting that NHS trusts and boards should assess the diversity of their local populations to tailor their services to meet the specific needs of the people they serve^[269].

In relation to paternal support methods, the literature highlights that healthcare professionals need to have a good understanding of the challenges new fathers face^[270] and that services need to be inclusive for dads and other partners^[271].

Parental mental health

The evidence base suggests that parent and child mental health are deeply interconnected, with each influencing the other. A parent's emotional health is crucial to a child's development, while a child's emotional health can, in turn, impact parental mental health and wellbeing. Various external factors can affect both, with poverty being a significant contributor.

Poverty-related stress can create a difficult home environment, leading to psychological distress for both parents and children. This distress may not only stem from financial hardship but can also worsen its effects^[272], creating a cycle where poor mental health and economic hardship reinforce each other^[273]. Research using GUS data highlights the importance of childhood experiences of poverty, showing that prolonged exposure significantly affects child mental wellbeing, and that persistent poverty also has a lasting impact on parental mental health, exacerbating stress over time^[274]. This cycle of financial hardship and psychological distress can limit parents' ability to provide a nurturing environment, influencing children's development and future opportunities. Addressing these challenges is essential to breaking this cycle and promoting family wellbeing.

Mental health-related inequalities

The literature shows significant inequalities in mental health between adults living in the most and least deprived areas. In Scotland, adults in deprived areas are more likely to report higher levels of psychosocial stress and mental ill health compared to adults in less deprived areas^[275]. For example, survey data from SHeS showed that in 2023 25% of adults living in Scotland’s most deprived areas (SIMD Quintile 1) had questionnaire responses indicating a possible psychiatric disorder, compared to 18% in the least deprived areas (SIMD Quintile 5)^[276]. Moreover, 14% of adults in the most deprived areas reported having felt lonely "most" or "all of the time" in the past week, compared to 5% in the least deprived areas, and 10% in the overall population^[277]. However, this data is not disaggregated to specifically identify parents of children as a subset, meaning the unique challenges faced by this group may not be fully represented.

People living in poverty are more likely to experience higher levels of stress and have less access to mental health services, thereby increasing the risk of adverse outcomes for both parents and children^[278]. Evidence shows that women living in deprived areas are at a higher risk of experiencing poor mental health compared to those from less deprived areas, with this disparity widening as maternal age increases^[279]. Scottish Government analysis suggests that poverty is the single biggest driver of poor mental health^[280], with women living in deprived areas being particularly vulnerable to perinatal mental health issues^[281].

Financial hardship and repeated crises (for example the COVID-19 pandemic and the cost-of-living crisis) over the past five years have potentially placed additional strain on families, worsening mental health outcomes and widening health inequalities due to the disproportionate impact of these adversities^[282]. Qualitative evidence from the Mental Health Foundation highlights that these events brought to the surface a wide range of concerns, including increased uncertainty for the future and heightened awareness of risks faced by vulnerable groups. As one individual expressed it: ‘we don’t know where we’re going, and that’s really uncertain’^[283].

Health outcomes and suggestions for action

Socioeconomic disadvantage increases mental health symptoms in both parents and children^[284]. Cohort study findings show that children whose mothers had more positive mental health during pregnancy were less likely to develop mental and behavioural disorders^[285]. It is suggested that factors affecting parents’ capacity to promote positive development, in combination with financial challenges, can contribute to variations in child behaviour^[286].

Maternal mental health issues have been strongly linked to child behavioural problems^[287]. Findings from GUS indicate that children tend to have stronger social, emotional, and behavioral growth if their mothers maintain good emotional health in their first four years. Children of mothers who experienced brief mental health challenges faced some difficulties but generally experienced better outcomes than children whose mothers experienced ongoing mental health issues. These patterns persisted across different socio-economic backgrounds and were still evident by age seven, reinforcing the lasting impact of maternal health on child wellbeing^[288].

Parental mental illness is associated with poor foetal and child growth, malnutrition, and increased risks of childhood accidents, injuries, and asthma; however, the evidence suggests that the mechanisms of these effects are complex and need further exploration^[289]. Stress during pregnancy is also broadly linked to various cognitive, emotional, and health outcomes in offspring, including adverse birth outcomes such as preterm birth and low birth weight^[290]. Additionally, higher average maternal stress during pregnancy has been found to affect children's diet and food preferences, leading to less healthy food choices in later life^[291].

Evidence suggests that addressing poverty is essential for improving the mental health of both parents and children. Financial strain within the household can significantly affect parental mental health which, in turn, creates negative pressures on children’s mental health and wellbeing as per the family stress model^[292]. Research shows that interventions aimed at improving mothers’ mental health can have a positive impact on infants’ health and development, while efforts to promote infants’ health and development can improve mothers’ mood^[293].

The literature highlights the need to increase attention on parental mental health and parenting from the earliest stages of a child's life^[294] and focus on early detection and effective management of arising issues to improve women's quality of life during pregnancy and the postnatal period^[295]. During this period, supporting a sustainable balance between work and childcare is crucial in reducing depression risk^[296].

The role of maternity services^[297] and health visitors^[298] is emphasised, focusing on targeted, intensive support for families with high needs to protect the mental health of both children and mothers. Training and education are also important, particularly in ensuring all maternity professionals and health visitors are trained to identify maternal mental health problems^[299], as well as paternal mental health problems and their impact upon the child^[300]. Finally, providing father-friendly parenting groups, resources, and inclusive services around mental health are highlighted as useful ways to foster a supportive environment for all parents^[301].

Evidence further highlights the importance of strengthening protective factors to support mental health before, during, and after pregnancy, along with addressing the risk factors mentioned above. These include fostering strong social networks through family, friends, and communities; ensuring access to high-quality maternal and child healthcare; promoting educational opportunities to help women complete their schooling; creating income-generating opportunities to afford essentials; and enabling positive childbirth experiences where women feel informed and empowered^[302]. For women in poverty, strong social support, accessible healthcare and access to community-based services (i.e., housing services and local support groups) are important for addressing additional needs and priorities^[303].

Infant mental health

A child's early interactions with primary caregivers are crucial in shaping attachment, emotional regulation, resilience, and mental health. Secure attachment and a safe and stimulating environment, established through consistent, responsive interactions between the caregiver and infant, support the development of resilience, the ability to regulate and express emotions and the ability to form relationships and explore the environment^[304]. However, when these interactions are absent, harmful or inconsistent, it can disrupt brain development, potentially increasing the risk of long-term health and behavioural challenges. When this persists over time, it can deprive the brain of essential positive stimuli and trigger the body’s toxic stress response, exposing the developing brain to harmful hormones that interfere with healthy development^[305].

The latest PHS statistics^[306] indicate that, while social, emotional, and behavioural developmental issues are evident across all ages in child health review data, they become the most prevalent concern at the 4-5-year child health review. This highlights the importance of addressing the factors that precede their emergence, during the early years of 0-3, before they become more ingrained and harder to address.

Measuring outcomes and reporting on the prevalence of infant mental health issues in the early years and across sociodemographic groups is highlighted as a key challenge in the literature. Data on infant mental health often reflects parents’ perceptions of their own and their child’s wellbeing and development, rather than capturing the infants' perspectives directly. In this context, the tools that are used to assess mental health in this age group include parent-reported questionnaires and observational assessment methods administered by practitioners or researchers. While insights provided through parent-reported observations are valuable, they may not fully encompass the infants' own experiences or provide a complete picture of their mental health^[307]. Research shows that incorporating less conventional, participatory, and ethnographic approaches – such as involving children and their caregivers in creative activities, like taking photos of what matters to them – can help ensure that babies’, children’s and families’ voices are strengthened, and their priorities are better understood^[308]. This would address an important data gap.

Health outcomes and suggestions for action

Persistent poverty has been linked with childhood mental health problems^[309]. Analysis from the UK Millennium Cohort Study found that prolonged exposure to maternal distress was associated with an increased risk of child mental health problems at age three^[310]. Findings from the Millenium Cohort Study show that children born into poverty score significantly lower on cognitive tests at ages three, five, and seven^[311]. Persistent poverty was found to have a cumulative negative effect, and by age seven, the children included in this study scored lower than their peers who had never experienced poverty, even after accounting for family and parental factors^[312].

Further evidence indicates that early risk factors, measured by age three, account for about two-thirds of the social inequality in adolescent mental health^[313]. Longitudinal findings from the UK Millennium Cohort Study show that persistent poverty was associated with the greatest increase in the probability of behavioural problems at age 11, compared with never experiencing poverty^[314]. Findings from the GUS study also suggest that 12-year-olds living in the most deprived areas (SIMD Quintile 1) were more likely to have reported involvement in anti-social behaviour than their peers living in the least deprived areas (SIMD Quintile 5)^[315].Lastly, other research shows that socioeconomic advantage during childhood is significant for mental wellbeing in mid-to-later life^[316].

Since adult mental health, particularly during the pre- and post-pregnancy period is critical to the mental health of infants, focusing on caregivers’ capacity to provide nurturing care is vital for ensuring healthy child development. Evidence outlined in the parental mental health section highlights key protective factors and areas of focus in this context, including ensuring access to education, secure income-generating opportunities, and social support. Evidence emphasises that policies that support household income play a central role in improving the mental wellbeing of children in poverty^[317].

A key area of focus in the literature relates to increasing awareness of the mental health needs of infants, as these are often not fully recognised, leading to a lack of understanding about the importance of specialised services. Additionally, evidence suggests that integrating infant mental health into broader mental health strategies would be useful to ensure that babies are included from birth onwards^[318]. Evidence further highlights the need to expand the provision of infant mental health services^[319]. Progress has been made in this area in Scotland, including the creation of 14 new Infant Mental Health Services and the appointment of parent-infant therapists and peer support workers to enhance staffing in Mother and Baby Units^[320]. Other useful suggestions include embedding safeguarding support into wider services^[321], providing training for health professionals to recognise and address infants’ mental health needs, and ensuring mental health teams are multi-professional^[322]. Investment in spaces and activities for families living in deprived areas, along with addressing gaps in support for children showing early signs of difficulties, are also important for supporting families and children with more complex needs^[323].

Infant oral health

To promote good oral health from an early age, UK and Scottish guidelines advise parents and carers to start brushing teeth twice a day^[324] and register with a dentist from when the first tooth appears, continuing regular dental visits thereafter^[325].

Infant oral health is deeply connected to other aspects of parental and child health, including infant-feeding practices and nutrition. Good nutrition is crucial to oral development and resistance to dental decay, as well as to general health^[326].

Despite the significance of infant oral health and its connections to wider aspects of health, data is less available for the early years. This poses a gap in understanding child health and the impacts of poverty.

Inequalities in infant oral health

Significant inequalities exist in oral health outcomes between children living in the most and least deprived areas. Data on dental registration and participation show contrasting findings. In 2022, while 85.3% of children (aged 0-17 years) from the most deprived areas (SIMD Quintile 1) were registered with a dentist, compared to 88.3% in the least deprived areas (SIMD Quintile 5), actual participation rates show a large gap. Children in the most deprived areas of Scotland (SIMD Quintile 1) were less likely to visit a dentist within the previous two years compared to those in the least deprived areas (SIMD Quintile 5; 55.9% versus 75.8%, respectively). The disparity between these groups has increased over time, from a three-percentage point gap in 2008 to twenty percentage points in 2022 – the largest recorded difference^[327]. A review of health policies across 14 countries/regions found a 30 percentage point gap in experience of tooth decay among 5-year-olds in Scotland, with about 14% of children living in the least deprived areas having visible cavities, compared to 44% of children living in the most deprived areas^[328]. Systematic review data suggest that these impacts are shaped well before the age of 5, as in some of the UK's most deprived areas, nearly half of children have multiple teeth affected by decay by age 5. It was also noted as the main reason young children undergo general anaesthesia^[329].

Poverty and deprivation create significant barriers to addressing children’s oral health needs. These include barriers to health literacy, limited access to oral health information and care, financial constraints such as travel costs to healthcare facilities and poverty-related stigma, which can make it challenging for families to seek support^[330]. In addition, practical difficulties – such as long wait times for appointments and limited digital access to online services – further complicate access to care^[331].

Health outcomes and suggestions for action

Inequalities in access to nutritious food and dental care can increase the risk of poorer oral health outcomes for children in poverty^[332]. Poor oral health in children can lead to a range of adverse health outcomes, including pain; infection; difficulties in eating, speaking and socialising; treatment under general anaesthesia; tooth loss; the need for costly treatment; time off school and work to attend appointments; and overall reduced quality of life for both children and their families. Additionally, high levels of disease in primary teeth are associated with higher risk of disease in permanent teeth, which could have lifelong impacts^[333].

These inequalities and impacts highlight the need for action moving forward. Evidence suggests that oral health promotion should target both individuals and broader community change^[334]. Strengthening communities' ability to promote oral health requires practical education, leadership training, consideration of the local context and access to resources^[335].

Considerations at universal level include enhancing oral health training for the broader professional workforce; integrating oral health into targeted home visits by health and social care workers; implementing community-based fluoride varnish programs; and providing targeted distribution of toothbrushes and fluoride toothpaste (already implemented in Scotland^[336]) through postal services or health visitors^[337]. Additional strategies include supervising tooth brushing with fluoride toothpaste in childhood settings; promoting healthy food and drinks; supporting peer oral health groups; and advocating for oral health improvement^[338].

As discussed earlier, while universal support is useful, reaching children facing poverty and overlapping adversities often requires targeting. This can be achieved through extending coverage of universal health improvement programmes, as evidenced by the expansion of the Childsmile programme in Scotland^[339]. An evaluation of the programme indicates that supervised toothbrushing in nurseries is useful in improving the oral health of children in poverty. Based on the cohort of children included in the study, nursery-supervised toothbrushing had the greatest impact in reducing the likelihood of dental caries among children in high deprivation areas^[340]. Evidence notes that when developing preventive programs, children from deprived areas should be considered at higher risk for early childhood caries^[341].

Other targeted measures focus on community engagement and identifying individuals at risk who would benefit from information sharing and education. This includes low income communities and children who do not attend regular check-ups^[342].

Infant vaccination uptake

Childhood immunisation plays a key role in shielding children from infectious illnesses. In Scotland, the NHS sets out a programme of childhood immunisations from 8 weeks to 3 years and four months. These include, among others, the MenB vaccine, the Rotavirus vaccine and the 6-in-1 vaccine^[343]. These immunisations are fundamental to safeguarding children’s health and preventing serious illnesses.

However, inequalities in vaccine uptake persist, disproportionately affecting children experiencing poverty and deprivation. In this context, the recently established (2023) Scottish Vaccination and Immunisation Programme (SVIP) aims to provide oversight for immunisation and vaccination delivery in Scotland with the aim of both improving and addressing inequalities in uptake. The publication of a 5-year Vaccination and Immunisation Framework and Delivery Plan established clear and actionable deliverables for the Scottish context^[344]. These efforts reflect a commitment to addressing barriers to vaccination and ensuring equitable access for all families.

Inequalities in infant vaccination uptake

Despite a recent declining trend, immunisation uptake rates in Scotland have generally remained high. In 2023, 95.0% of children turning 12 months completed their primary course of the 6-in-1 vaccine. By 12 months, the uptake rates for the pneumococcal conjugate vaccine (PCV) and meningococcal serotype B (MenB) primary courses were 95.2% and 93.8%, respectively^[345].Despite these positive numbers overall, immunisation rates in Scotland were lower in the most deprived areas (SIMD Quintile 1) compared to the least deprived (SIMD Quintile 5)^[346]. By 24 months, for example, there was a 7.3 percentage point gap in the first MMR dose and a 7.5 percentage point gap for the MenB booster. By 5 years, these gaps increased to 9.3 percentage points for the 4-in-1 vaccine and 9.7 percentage points for the second MMR dose. Children in deprived areas are also more likely to receive vaccinations later, leading to increased vulnerability to infectious diseases^[347].

Health outcomes and suggestions for action

Vaccine uptake is a complex process influenced by a series of personal, inter-personal and structural factors, including trust in healthcare providers, values and attitudes, perception of expected risks and benefits and socioeconomic status^[348]. These factors play a key role in shaping whether families access vaccinations, with evidence showing that vaccinated children are less likely to contract vaccine-preventable diseases such as measles, mumps, rubella, and whooping cough. Such illnesses can result in severe complications, including ear infections, pneumonia, and brain inflammation^[349]. These concerns are particularly relevant for children from low-income families, who appear to face more barriers to receiving vaccinations at recommended intervals and are therefore more vulnerable to infection^[350].

Beyond protecting against these immediate risks, vaccines also play a broader role in public health. By preventing diseases and conditions such as those mentioned above, vaccines reduce the need for antibiotics, lessening the chances of antibiotic overuse and resistance^[351]. Their impact on mortality rates is also documented. International modelling data estimate that between 2000 and 2030, vaccinations targeting ten key pathogens will have prevented 69 million deaths, with the most significant reductions seen among children under five years old, particularly in reducing deaths from measles^[352].

These findings highlight the importance of universal access to healthcare as a practical step to address health inequalities throughout childhood, adolescence, and the entire life course^[353]. This is particularly critical in the early years, as this is a time of rapid development when children are especially vulnerable to rapidly developing illnesses and are unable to advocate for their needs^[354].

In the context of poverty, raising awareness of the benefits of vaccination is key to boost vaccine coverage^[355]. PHS research indicates that to improve uptake, especially in socioeconomically deprived areas, useful strategies include addressing misinformation and providing clear, trustworthy information about vaccines, providing face-to-face information sessions and mobile vaccination units, and offering vaccinations in more accessible and convenient locations with flexible hours^[356].

Similarly, the Royal Society for Public Health suggests several actions in relation to ensuring children facing poverty and deprivation are vaccinated against infectious diseases. These include offering vaccinations in more convenient and diverse locations, particularly in areas with low uptake or difficult access to healthcare settings; engaging the wider public health workforce, such as health visitors, midwives, and school nurses, to provide vaccination information to parents; investing in positive social media campaigns to disseminate accurate messages about vaccinations, targeting groups with lower uptake; modifying school curriculums to include information on the value and importance of vaccinations; and working with the press to ensure the dissemination of accurate messages about vaccinations^[357].

Infant mortality

As a critical determinant of population health ^[358], infant mortality is widely studied. The literature distinguishes between different types of mortality based on when death takes place. Infant mortality refers to all deaths in the first year of life, including stillbirths^[359], perinatal^[360], neonatal^[361] and post-neonatal^[362] deaths^[363].

Evidence indicates a connection between infant mortality and maternal health. For example, a systematic review found that women with pre-existing mental health concerns before childbirth faced a higher risk of infant mortality compared to women without such concerns. These effects were consistent across various mental health concerns, including anxiety and depression^[364]. This highlights the need to take a holistic approach to addressing the interconnected health needs of parents and children, particularly within the context of poverty, where risks often accumulate and overlap.

Inequalities in infant mortality

Between October and December 2024, the infant mortality rate in Scotland was recorded at 4.4 per 1,000 live births^[365]. Additionally, according to MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) analysis, the stillbirth rate in Scotland for 2023 was 2.95 per 1,000 total births^[366], reflecting a decrease compared to 3.31 per 1,000 total births in 2022^[367]. Reductions in stillbirth rates were observed across all UK nations. The neonatal mortality rate in Scotland showed a slight increase, recorded at 1.61 per 1,000 live births in 2023^[368], compared to 1.59 per 1,000 births in 2022^[369].

While routinely available data on infant mortality is not broken down by deprivation in Scotland, across the UK, MBRRACE-UK data for births between 2019 and 2023 indicate that stillbirth rates remained highest among babies born to mothers in the most deprived areas, based on socio-economic deprivation quintiles of residence. Additionally, the gap in neonatal death rates widened, with rates increasing among the most deprived groups while declining for those in less deprived areas^[370].

Bespoke analysis by the Health Foundation found that there has been an increase in infant mortality rates in the most deprived areas of Scotland since 2015^[371], while another study by Harpur et al. (2021) also finds an upward trend in infant mortality rates among the most deprived areas in Scotland from 2016 onwards^[372].

Several studies indicate the correlation between socio-economic disadvantage and higher mortality rates among children^[373]. For example, a study^[374] in England found that the relative risk of death increased by 10% with each decile of increasing deprivation, reflecting a progressively higher risk for children in poverty. Similarly, findings in Scotland show that increasing deprivation (from least deprived SIMD Quintile 5 to most deprived SIMD Quintile 1) was accompanied by a 16% increase in the incidence rate of infant mortality^[375]. Modifiable factors^[376] in childhood death appear to exhibit a social pattern associated with deprivation, with this trend applying to, for example, financial difficulties, homelessness, and inadequate maternal nutrition^[377].

Health outcomes and suggestions for action

The loss of life is, in itself, the most profound health consequence. The death of a very young child has devastating effects not only on the child and the loss of their potential, but also on the bereaved and grieving parents^[378]. While these outcomes and their impacts are irreversible, it is critical to recognise that poverty and deprivation – key contributors to such losses – are not inevitable. Work to reduce them can protect, safeguard, and prevent the deaths of children in our society. Evidence shows that targeted interventions and policies can effectively reduce poverty and its associated impacts.

Improved data collection is essential to identify the populations most vulnerable to pregnancy loss and infant deaths in the Scottish context, uncover the causes of inequalities and develop effective strategies to address them^[379]. Furthermore, ensuring preparedness for pregnancy through a holistic approach that includes reproductive health care, preconception advice, and planning is key to support nurturing care before birth^[380]. Identifying vulnerability and risk in the pre-birth period is crucial for reducing harm to unborn children by providing a foundation for interventions that mitigate the risk of adverse outcomes. Midwives can play a central role in identifying risks by conducting comprehensive wellbeing assessments during antenatal bookings, which aim to capture a variety of risk factors. This includes poverty-related issues, such as financial difficulties, homelessness, housing issues, and mental health concerns^[381]. Identifying and mitigating deprivation-related risk factors for mothers that contribute to preterm births is also important, as evidence suggests that this is the main cause of death in the neonatal period^[382]. Finally, strengthening access to support during pregnancy and after the child is born is important for timely and appropriate care-seeking for sick children^[383].

The link between infant mortality and maternal health highlights the importance of improving women’s health prior to conception, during and after pregnancy

to reduce infant deaths^[384]. Reductions in infant mortality can be achieved by increasing support for caregivers and improving the environments in which infants are raised^[385].

The next chapter will present overarching findings that can help address the issues presented in this chapter.