Public Health Wales
How are current and future population health needs likely to impact on the use of maternity, neonatal, gynaecology and paediatric services in North Wales? – A population profile.
Author:Siobhan Jones, Specialty Registrar Public Health,Rachel Andrew, Specialty Registrar Public Health, Claire Jones, Public Health Intelligence Specialist, Siwan Jones, Principal Practitioner Public Health, Gill Richardson, Executive Director Public Health Aneurin Bevan Health Board, Andrew Jones, Executive Director of Public Health BCU HB
Date:July 2011 / Version:1 (Final)
Intended Audience:
  • North Wales Maternity and Child Health Review Project Team
  • North Wales Maternity and Child Health Review Key Stakeholders
  • Public Health Wales

Purpose and Summary of Document:
  • To describe the population of North Wales and health status of the population in relation to maternal and child health
  • To provide information on population health need to support the North Wales review of maternity, neonatal, gynaecology and paediatric services

Publication/Distribution:
  • Internet

Contents

KEY MESSAGES / 4
1 / BACKGROUND / 6
2 / DEMOGRAPHY / 7
2.1 / Population estimates / 7
2.2 / Females population of childbearing age / 7
2.3 / Population structure / 8
2.4 / Population aged under 18 years / 8
2.5 / Population projections / 11
2.6 / Population density / 13
3 / DEPRIVATION / 17
3.1 / Economy and Income / 17
3.1.1 / Welsh Index of Multiple Deprivation 2008 / 17
3.2 / Impacts of deprivation / 20
3.3 / Deprivation and maternal/neonatal health / 22
3.4 / Deprivation and child health / 23
3.5 / Deprivation and lifestyle factors / 26
4 / LIFESTYLE FACTORS IMPACTING ON MATERNAL AND CHILD HEALTH / 27
4.1 / Tobacco / 27
4.1.1 / Smoking in pregnancy / 27
4.1.2 / Exposure to second hand smoke in childhood / 28
4.1.3 / Smoking in teenagers / 28
4.2 / Overweight & obesity / 30
4.2.1 / Obesity in pregnancy / 30
4.2.2 / Childhood obesity / 32
4.3 / Substance misuse: alcohol / 34
4.3.1 / Alcohol in pregnancy / 35
4.3.2 / Alcohol use and young people / 35
4.4 / Substance misuse: illicit drugs / 36
4.4.1 / Use of illicit drugs in pregnancy / 37
5 / DATA ANALYSIS / 39
5.1 / Maternal and neonatal factors / 39
5.1.1 / Fertility and birth rates / 40
5.1.2 / Birth rate projections / 40
5.1.3 / Total Fertility Rate / 40
5.1.4 / General Fertility Rate / 41
5.1.5 / Conception and abortion rates / 44
5.1.6 / Maternal mortality / 45
5.1.7 / Neonatal and infant mortality / 46
5.1.8 / Stillbirth / 48
5.1.9 / Perinatal mortality / 50
5.1.10 / Neonatal mortality / 50
5.1.11 / Infant mortality / 52
5.1.12 / Low birth weight / 53
5.2 / Women’s health and impacts on gynaecology
Services / 56
5.2.1 / Sexually transmitted infections / 56
5.2.2 / Cervical screening / 57
5.2.3 / Cervical cancer / 58
5.2.4 / Human Papillomavirus / 59
5.2.5 / Human Papillomavirus vaccine uptake / 59
5.3 / Child health factors / 60
5.3.1 / Child mortality / 60
5.3.2 / Teenage conceptions / 62
5.3.3 / Immunisation / 64
5.3.4 / Injuries / 68
5.3.5 / Breastfeeding / 72
5.3.6 / Childhood physical and learning disabilities / 73
5.3.7 / Congenital anomalies / 75
5.3.8 / Child Protection / 76
6 / REFERENCES / 77
7
8 / APPENDIX ONE:Super Output Areas
APPENDIX TWO: Middle Super Output Areas/Electoral Divisions / 84
85
Key Messages
  • The pre-pregnancy, pregnancy and early year’s phases of life are key in terms of influencing the future health and development of children and young people.
  • Deprivation impacts significantly on maternal health and neonatal care. Rates of stillbirth, preterm birth,low birth weight, neonatal deaths and admission to neonatal units have been shown to be significantly higher in areas with high levels of deprivation.
  • Deprivation impacts significantly on child health. Rates of infant mortality, child mortality, injuries and teenage pregnancy have been shown to be significantly higher in areas with high levels of deprivation.
  • A proportion of the North Wales population resides in areas of deprivation. 12% of lower super output areas within North Wales are in the most deprived fifth in Wales.
  • Denbighshire has the highest percentage of lower super output areas in the most deprived fifth in Wales, and contains three out of the top five most deprived areas in Wales.
  • Wrexham contains the second highest percentage of lower super output areas in the most deprived fifth in Wales.
  • Lifestyle factors are linked to deprivation and are an important contribution to health inequalities. Rates of smoking and obesity levels have been shown to be higher in areas with high levels of deprivation. Consumption of fruit and vegetables and levels of physical activity have been shown to be lower in areas with high level of deprivation.
  • Smoking, obesity and substance misuse during pregnancy are preventable causes of a significant proportion of morbidity and mortality for mothers and babies. Smoking and obesity in particular have a high prevalence in the population and can impact on rates of miscarriage, still birth, maternal death, neonatal deaths, admission to neonatal care and low birth weight. The impacts on the use of maternity and neonatal servicesare significant.
  • Lifestyle factors including smoking and obesity are important risk factors for some gynaecological cancers.
  • Exposure to second hand tobacco smoke is an important cause of morbidity in childhood. It increases risks of asthma, ear infections, respiratory infections, bacterial meningitis and sudden infant death. The cost to the health service from exposure to second hand smoke in childhood is significant.
  • Rising levels of childhood obesity, high levels of smoking among teenage girls and alcohol use are important factors in the future health of the next generation of mothers and could have a large impact on the future use of maternity and neonatal services.
  • The total number of registrable births to mothers resident in North Wales has risen for the seventh consecutive year, an increase of 20% since 2002. By 2030/2031 the total fertility rate is predicted to be higher in every Local Authority in Wales compared to 2005/2006.
  • Across Wales there are no significant differences in stillbirth, perinatal mortality, neonatal mortality and infant mortality rates.
  • Cervical screening and Human Papillomavirus vaccination are important preventative interventions, the uptake of which can have a direct influence on the demand for gynaecological services.
  • Wales has a higher rate of conception in females aged 15-17 years compared to England.
  • Rates of admission for childhood injuries are significantly higher in Gwynedd and Anglesey than the Wales average. Most injuries in 0 to five year olds occur in the home. Injuries are a largely preventable cause of ill health, are linked closely to deprivation and impact greatly on health service use by children and young people.
  • Immunisation is a highly effective and cost effective health care intervention. Rates in parts of North Wales currently fall below the 95% uptake rate required to protect the population from outbreaks of serious infectious diseases.
  • Interventions to promote breastfeeding are cost effective and can reduce demand on health care services.
Future Maternal and child health services should seek to ensure:
•a whole systems approach ensuring preventable causes of ill health are addressed at every opportunity;
•interventions are targeted to reduce health inequality & inequities;
•evidence based interventions to prevent ill health are systematically introduced as part of clinical practice;
•health care delivered as part of the wider system;
•NHS and partner agencies identify and agree key priorities for health prevention and early intervention.

1Background

The purpose of this report is to provide information to support the North Wales Review of Maternity, Neonatal, and Gynaecology and Child Health services. The aim of the review is to describe the optimum service delivery model that will ensure safe, sustainable and efficient maternity, neonatal, gynaecology and paediatric health services are provided for the population of North Wales.The future model of service delivery will seek to improve population health and optimise health and well-being outcomes for women and children.

The following principles will be used to guide and underpin the work of the Project.

Future health services for women and children will seek to:

  1. Take a whole systems approach to ensure preventable causes of ill health are addressed at every opportunity.
  2. Use an early intervention/primary prevention approach.
  3. Provide as much clinical care in community settings as is reasonably possible.
  4. Provide safe, sustainable, efficient and affordable health services.

It is vital that the options generated must:

  • be based on assessment of population need;
  • maximise the health and wellbeing of women, children and families;
  • seek to reduce inequality and inequity in provision of healthcare and related services.

This report describes:

  • the demography of North Wales;
  • deprivation and its impacts;including lifestyle factors that impact on maternal and child health;and
  • data on health status factors that impact on the use of health care services for women and children.

2Demography

North Waleshas a geographical area of approximately 2,500 square miles. There are six unitary authorities (UA’s) within this region – Isle of Anglesey, Gwynedd, Conwy, Denbighshire, Flintshire and Wrexham. The population is served by one Health Board (HB) – Betsi Cadwaladr University Health Board (BCU HB)(Public Health Wales 2010a).

2.1 Population Estimates

Table 1 shows the midyear population estimates for North Wales. In 2009, the approximate population was 678,800. Flintshire in the North East has the largest population of 149,900 and Anglesey in the North West has the smallest population, 68,800 (Public Health Wales 2010a).

Table 1: Midyear population estimates, 2009

Thousands
Wales / 2999.3
North Wales / 678.8
Isle of Anglesey / 68.8
Gwynedd / 118.8
Conwy / 111.4
Denbighshire / 96.7
Flintshire / 149.9
Wrexham / 133.2

Source: ONS

2.2 Female population of childbearing age

Table 2 shows the number of females of childbearing age in the population. Flintshire has the largest population of females aged 15 to 44 years. The Isle of Anglesey has the lowest population of females aged 15 to 44 years.

Table 2: Females aged 15 to 44 years,

North Wales, 2009

Thousands
North Wales / 121.3
Isle of Anglesey / 11.6
Gwynedd / 22.4
Conwy / 17.6
Denbighshire / 16.3
Flintshire / 27.8
Wrexham / 25.4

Source: ONS

2.3 Population Structure

It can be seen in Figure 1that the population structure of North Wales is similar but not identical to that of all Wales. There is a notably lower proportion of the population in younger age groups compared to the Wales average.

This could reflect young people from North Wales moving out of the region for education or employment. For each of the age bands of 55 years and over, the proportion is higher than the Wales average; this could reflect an ageing population and older people moving into North Wales for retirement (Public Health Wales 2010a).

Figure 1:

2.4 Population aged under 18 years

Data shows that 20.8% of the population of North Wales is under the age of 18, compared with 21.2% in Wales as a whole. Figures 2and 3show how this varies across North Wales, with the highest proportion of under 18s in Flintshire, 21.6%, and the lowest proportion of under 18s residing in Conwy, 20.0% (Public Health Wales Observatory 2010).

Figure 2: Percentage of population aged under 18 in BetsiCadwaladrUniversity Health Board area, 2008

Produced by Public Health Wales Observatory, using data from ONS (ADDE, MYE)

Figure 3: Proportion of the population aged under 18 years, 2008

Table 3 shows Flintshire has the highest number of children aged 0 to 18 years and the Isle of Anglesey has the smallest number.

Table 3: All Children aged 0 to 18 years,

North Wales, 2009

Thousands
North Wales / 149.4
Isle of Anglesey / 15.0
Gwynedd / 25.6
Conwy / 23.5
Denbighshire / 21.1
Flintshire / 34.1
Wrexham / 29.9

Source: ONS

2.5 Projected changes in total population from 2008 to 2033

The population of North Wales is predicted to increase to over 700,000 by 2033. Figure 4shows that while the population projections show that the number of children and young people in the population will remain fairly constant, it is anticipated that in 2033, young people will account for a smaller proportion of the total population than in 2008, while older people will account for a higher proportion. Despite the fact that in the future children and young people may account for a smaller proportion of the total population, actual numbers of children and young people may rise due to the projected rise in both birth rates and total fertility rates. It is important to note that population projections provide estimates of the size of the future population, and are based on assumptions about births, deaths and migration. The assumptions are based on past trends. Projections only indicate what may happen should the recent trends continue. Projections done in this way do not make allowances for the effects of local or central government policies on future population levels, distribution and change (National Public Health Service & Wales Centre for Health 2009).

Figure 4: 2008-based population projections for North Wales population groups 0 to 14 years, 15 to 24 years and 25 to 44 years: 2008 to 2033

Data source: Statistical Directorate, Welsh Assembly Government / ONS

As the process of demographic change is cumulative, projections become increasingly uncertain the further they are carried forward. Demographic changes affect some populations more rapidly than others (Welsh Assembly Government 2008a).It is projected that across local authorities in Wales the number of men will increase by up to 30% and the number of women will increase by up to 19%; the average increase in the number of women in any local authority in Wales by mid-2031 is 13%(Welsh Assembly Government 2008a).

Any increase in the population is likely to cause an increase in the demand for health services. Measures to prevent ill health through primary prevention and early intervention techniques can play an important part in managing future demand for health services.

2.6 Population Density

Population density provides a measure of the number of people living in an area. It is calculated by dividing the population by the geographical area in square kilometres. Population density varies across North Wales, with Flintshire and Wrexham being the most densely populated areas. Denbighshire, Conwy and Anglesey are more sparsely populated and Gwynedd has the most sparsely distributed population in North Wales. Table 4 shows the population density across the region (Public Health Wales 2010a).

Table 4: Population density: persons per square km, 2007

Persons per km2
Wales / 143.4
North Wales / 109.9
Isle of Anglesey / 96.9
Gwynedd / 46.4
Conwy / 98.9
Denbighshire / 115.7
Flintshire / 343.9
Wrexham / 261.8

Source: WAG StatsWales

North Wales has 62 areas which are classed as ‘urban’ (that is, an area with a minimum population of 1,500). Forty of these areas have populations of less than 5,000 people and 14 areas have populations of 10,000 people or more (Public Health Wales 2010a).Table 5 shows that the main urban areas in North Wales are Wrexham and Colwyn Bay, followed by Rhyl and Shotton.

Table 5: Main urban areas in North Wales, 2001

UA Area / Resident population
Wrexham, / Wrexham / 42,576
ColwynBay / Conwy / 30,269
Rhyl / Denbighshire / 25,390
Shotton (inc. Hawarden) / Flintshire / 24,751
Prestatyn / Denbighshire / 18,496
Buckley / Flintshire / 18,268
Brymbo/Gwersyllt / Wrexham / 17,912
Abergele / Conwy / 17,574
Connah’s Quay / Flintshire / 16,526
Bangor / Gwynedd / 15,280
Llandudno / Conwy / 14,872
Rhosllanerchrugog / Wrexham / 13,246
Flint / Flintshire / 11,936
Holyhead / Anglesey / 11,237

Source: ONS Census

Figure 5 shows the number of people resident per hectare in North Wales at Lower Super Output Area (LSOA) level. The numbers in brackets after each range show the total number of LSOAs in that range across the whole of Wales (Public Health Wales 2010a).

It is apparent that the few densely populated areas in this region are situated around urban centres, for example in Rhyl and Wrexham and that Flintshire followed by Wrexham are the UAs with the highest population density. The majority of LSOAs in Gwynedd and the Isle of Anglesey have a population of less than two people per hectare. It is important to note that there are pockets of higher density populations within Anglesey and Gwynedd, for example, Holyhead and the LleynPeninsula where access to health care services needs consideration(Public Health Wales 2010a).

Figure 5: Number of people resident per hectare, Lower Super Output Area, North Wales, 2001

Figure 6 shows the Office for National Statistics’ (ONS) urban and rural classification of electoral divisions (or wards) in the North Wales region. The numbers in brackets after each classification show the total number of electoral divisions in that group across the whole of Wales(Public Health Wales 2010a).

Many electoral divisions in Gwynedd, south Conwy and the Isle of Anglesey are classified as rural, characterised by villages, hamlets and isolated dwellings. However, highly urban electoral divisions can be found in Bangor and Wrexham, in addition to the coastal areas of Conwy, Denbighshire and Flintshire (Public Health Wales 2010a).

Figure 6: Urban and rural classification, electoral division, North Wales, 2001

3Deprivation

3.1 Economy and Income

A number of indicators are used to measure and report deprivation. The different indices use a variety of data and, as a consequence, can produce slightly different conclusions.On the whole however, the same communities will be identified as most deprived whichever indicator is used (Public Health Wales 2010a).

3.1.1 Welsh Index of Multiple Deprivation, 2008

The Welsh Index of Multiple Deprivation (WIMD) is a geographically based deprivation measure. WIMD 2008 is produced at the small area level of Lower Super Output Area (LSOA), and is derived from a broad range of factors, including income, employment, health, education, and access to services (Public Health Wales 2010a). It is well documented that areas of deprivation often have higher levels of need in relation to many different measures of health such as levels of smoking related diseases, injuries, alcohol and drug related diseases, teenage pregnancy and mental health issues (Public Health Wales 2010a).

In North Wales, 49 out of the 425 LSOAs are in the most deprived fifth in Wales(Public Health Wales 2010a).Figure 7illustrates the WIMD across North Wales at LSOA level. In 2008 the Rhyl West 2 LSOA was identified as the most deprived in the whole of Wales, with Queensferry 1 (Wrexham) and Rhyl West 1 and Rhyl South West 2 ranked third, fourthand fifth respectively (Public Health Wales 2010a).