Discussion

To our knowledge, this is the first study exploring the impact of austerity imposed by governments in high-income countries on perinatal outcomes and SDCH above and beyond the impact of the economic crisis itself. The study provides some evidence to suggest that austerity measures themselves have had an impact on children’s health, independent of the economic crisis that led to austerity. The results support the hypothesis that those countries that have applied and maintained higher levels of austerity have experienced adverse consequences for children that will likely have implications for the future adult health of a generation.

The results of the present study corroborate other studies at the European general population level.25 According to the latter, although there are many differences between countries, the analysis suggests that the interaction of fiscal austerity with economic shocks and weak social protection ultimately seems to produce greater social crisis. In general, the initial response to the crisis was increasing public spending during the years immediately following the crisis, mainly in those countries with increasing needs in vulnerable population groups (ie, high unemployment rates). Afterwards, the Greek, Spanish and the UK governments modified public policy to reduce deficits by cutting public expenditure, particularly on welfare benefits, with adverse effects on SDCH. On the other hand, in other countries such as Iceland, besides its specific characteristics, governmental responses have attempted to give prominence to redistribution, and try to protect middle-income and low-income groups.19 This fact would explain, in part, the differences observed between the austerity group to which Iceland belongs and SDCH indicators.

A systematic review of the impact of the crisis on population health included a few studies on child health,13 one of which found increased odds of LBW deliveries during the crisis in Iceland.26 It is worth noting that other variables should be taken into account when analysing perinatal outcomes such as LBW. For example, age of mother at birth, origin, social class, rates of multiple births, etc, although our data do not allow us to go further into these mechanisms affecting maternal environment and birth outcomes, which should be the subject of future studies. In any case, the results of our study are consistent with the finding of the mentioned study, particularly in the countries that applied the most severe austerity measures. The studies included in the systematic review by Parmar et al are likely to have been too early to detect the full extent of the impact of the crisis and austerity measures on child health. Nevertheless, an increase in child mental health admissions and a high prevalence of mental health problems in children were described, and also poor well-being and an increase in the prevalence of overweight and obesity in poorest areas of the UK and among vulnerable children in Spain.27–30

A recent study showed that the rate of increase in life expectancy in 25 European countries slowed in 2011–2015 regarding 2006–2010.31 The relationship between high austerity and LBW but not IM in the present study could be associated to lag effects, as suggested by a recent rise in IM in the UK over last 2 years,32 and also the large numbers and much less power to detect changes in IM. These results reinforce the need for long-term monitoring of perinatal indicators such as IM.

This is one of the first studies to analyse trends in SDCH and perinatal indicators starting before the economic crisis. Although it is an observational study with ecological data from each country analysed, the findings provide credible evidence on the impact of austerity in childhood. The main strengths of our study include the use of nationally representative data with standardised and comparable definitions and methods, and a study design that allowed us to analyse time trends starting in 2005, 3 years before the economic crisis, through to 2015. Although the starting period, the extent and implementation of austerity measures might differ between countries and periods, the results are plausible and show a specific impact on SDCH and perinatal outcomes.

Some limitations of the study deserve comment. First of all, countries included in the study may not allow the results to be generalised. Nevertheless, European countries from the Euro and non-Euro areas were included. Future studies should extend the number of countries included to assess the influence of austerity in the remaining rich as well as middle-income and low-income countries. Second, those variables used to assess austerity, SDCH and perinatal outcomes may have limited ability to discriminate specific measures taken by governments. Moreover, validity and reliability of SDCH and perinatal indicators would be affected by country variability on data collection, etc. Nevertheless, both Eurostat and OECD make effort to continuously improve the quality of data collection (see http://ec.europa.eu/eurostat/en/web/products-statistical-working-papers/-/KS-RA-12-018 and https://data.oecd.org/healthstat/infant-mortality-rates.htm as examples). The austerity measure, the CAPB, used in this study to differentiate policy responses, although being a generally accepted economic measure of austerity, may not adequately reflect national policies which institute general economic stringency at the same time as attempting to protect the most vulnerable groups, such as children. This might explain why Iceland, although having a CAPB suggesting a high level of austerity, shows trends more consistent with those for countries with intermediate and low levels of austerity. Another limitation of these data is the absence of variables that allow inequalities in the SDCH and perinatal outcomes within countries to be analysed. It is well known that indicators analysed as averages often mask differences between population groups. Moreover, aggregate data do not allow adjusting LBW or IM by relevant variables such as parity, multiplicity or type of birth. In this sense, the sustained rise in multiple pregnancies associated with an increased access to assisted reproductive technology, a general deterioration in neonatal indicators such as LBW and a decrease in fertility since recession with changing socioeconomic status patterning, may underestimate the recession effect. For example, as previously mentioned, IM showed decreasing trends throughout the study period, but has been shown to have increased in the UK in recent years in the most disadvantaged social classes.33 Third, the difficulties establishing causal associations between exposure and outcomes is well known especially in the case of international comparisons over time. Finally, as a result of the study design, the ecological fallacy cannot be ruled out.

In summary, to our knowledge, this is the first study to attempt to distinguish the negative impact on perinatal outcomes and SDCH of austerity measures imposed by government in response to the economic crisis from the effects of the economic crisis itself.

In conclusion, our findings suggest that those governments that applied high levels of austerity have exacerbated the effects of 2008 economic crisis on children specifically increasing child poverty, material deprivation in families at most need and perinatal outcomes such as LBW. The findings suggest the need to urgently protect vulnerable groups of children from the impact of austerity.