Social disadvantage has been linked to a twofold risk of death in children with congenital anomalies.

Children with severe congenital anomalies growing up in the most socially disadvantaged families have significantly worse chances of survival, with the social gap becoming more pronounced after the first year of life. In a new study from the European EUROlinkCAT project, the risk of death among infants from the most disadvantaged socioeconomic groups was approximately 47% higher than among those from the most advantaged groups, and by the age of 1 to 10 years, it was approximately twice as high. The study was published on August 5, 2026, in PLOS ONE.

For the main socioeconomic analysis, the researchers linked medical and social data on 47,134 liveborn children with major congenital anomalies from eight regional registries across Europe. The broader EUROlinkCAT database contained mortality data on 95,584 children with such anomalies from ten registries. The children were born between approximately 1995-1996 and 2014, and mortality follow-up continued until age 10 or until the end of 2015.

In the first year of life, the hazard ratio for death in the most disadvantaged group compared to the most advantaged group was 1.47, 95% confidence interval 1.19-1.83. For the intermediate socioeconomic group, the ratio was 1.29. However, among children who survived the first year, the differences became even greater: for children aged 1 to 10 years, the hazard ratio reached 2.00, 95% confidence interval 1.32-3.02, and in the intermediate group it was 1.65.

The authors believe that the increase in the gap after infancy is particularly important. In the first months of life, a child with a severe defect is typically under intensive care in a specialized hospital, where access to surgeries and treatment is less dependent on the family's financial resources. After discharge, housing conditions, nutrition, access to primary care and rehabilitation, the family's ability to regularly visit specialists, and other social resources become increasingly important. The study does not prove that any one of these mechanisms causes the increased mortality, but the age-related dynamics found are consistent with this hypothesis.

The main indicator	Result
Total number of children with major congenital anomalies in the available mortality database	95,584
Children with data for socioeconomic status analysis	47,134
Registers in the common database	10
Registers in the main analysis of socio-economic status	8
European countries	7
Period of births	approximately 1995/1996-2014
The most disadvantaged group, death before 1 year	HR 1.47
95% confidence interval	1.19-1.83
Intermediate group, up to 1 year	HR 1.29
The most disadvantaged group, ages 1-10	HR 2.00
95% confidence interval	1.32-3.02
Intermediate group, ages 1-10 years	HR 1.65
Countries with the most consistent statistically significant social gradient	Ukraine and Wales

HR is the odds ratio over time; an HR of 2.00 does not mean that half of the children will die or that the individual probability of death doubles for each child. It is a relative characteristic of the frequency of an event between groups. [1]

What was the EUROlinkCAT study?

The study is a population-based cohort study, pooling administrative medical data rather than an experiment. EUROlinkCAT was created using the European EUROCAT network, which maintains specialized registries of congenital anomalies. The researchers took data on live births with major congenital anomalies and linked them to national mortality records and maternal social characteristics.

Standardized EUROCAT criteria were used to identify major congenital anomalies. All diagnoses in the participating registries were verified and coded by specialists, and death information was obtained from official regional or national statistical systems, not from parental reports. This reduces the risk of recall errors and missed deaths due to incomplete medical questionnaires.

Instead of transferring children's personal data to a single international center, each registry analyzed related data locally using a common statistical script. Aggregated results were then transferred to a central repository and combined using random-effects meta-analysis. This approach allowed for compliance with national privacy regulations while simultaneously comparing different European regions using a single analytical protocol.

The quality of registry linkage varied, with the proportion of matched records ranging from 86% in Wessex, England, to 100% in Funen, Denmark. Regions and birth years where more than 15% of records could not be linked to mortality information were excluded. However, the authors acknowledge an important potential bias: among children who could not be linked to national databases, deaths in the first week of life were disproportionately common.

Research element	How it was organized
Design	Population cohort, administrative data linkage
Main network	EUROCAT / EUROlinkCAT
Population	Liveborn children with major congenital anomalies
Source of diagnoses	Specialized registers
Source of mortality	National/regional official registers
Age intervals	0-364 days and 365-3651 days
Maximum observation	Before the 10th anniversary
Statistics	Cox proportional hazards models and random effects meta-analysis
Transfer of personal data between countries	No
Analysis	General standardized STATA script

[2]

What did researchers mean by socioeconomic status?

One of the challenges of the European study was that there was no universal measure of socioeconomic status available in all countries. Therefore, the researchers used two different types of indicators: maternal education and regional indices of multiple deprivation. In four countries, maternal education was the primary indicator, while in two others, national indices of deprivation were used.

Maternal education was divided into roughly three levels: primary or compulsory education only, secondary education, and higher education. For British indices of deprivation, three categories were also created: the most deprived, intermediate, and most advantaged. The index's central categories were combined to ensure a sufficient number of children and deaths for statistical analysis.

The area index is a much broader indicator than simply family income. For example, the English Index of Multiple Deprivation includes income, employment, education, health and disability, crime, access to housing and services, and environmental conditions. The Welsh index additionally considers community safety and access to services. Thus, social disadvantage in this study reflects several components of a child's environment.

But this also creates a methodological problem: "low socioeconomic status" in Ukraine, Wales, Italy, or England does not represent the same absolute material level. Socioeconomic categories were defined relative to the population of each specific register. Consequently, the result should be understood as a within-country social gradient, not a direct comparison of the incomes of specific families in different countries.

The indicator used	What does it reflect?
Mother's education	Individual socio-educational position
Index of Multiple Deprivation	Socio-economic characteristics of the area
Low level	The most disadvantaged third/category
Intermediate	Middle social groups
High	The most prosperous category
Family income directly	Not measured uniformly
Father's education	It was not available
One universal European index	Not used

[3]

Already in the first year of life, poverty was associated with higher mortality

To analyze infant mortality, socioeconomic data were linked to records of 47,134 children from eight registries. Death in infancy was defined as an event within the first 364 days after birth. On average, the most disadvantaged group had a HR of 1.47, meaning the death rate over time was approximately 47% higher than the most advantaged group.

Interestingly, an intermediate social gradient was also present. For children in the middle socioeconomic group, the HR was 1.29, with a 95% confidence interval of 1.15–1.43. In other words, the result wasn't limited to the contrast between the poorest and the richest—the intermediate group, on average, occupied an intermediate position in risk.

However, the results varied greatly across regions. The most consistent statistically significant differences for both poorer categories were observed in Ukraine and Wales. In some English regions, individual comparisons also reached statistical significance, while in Denmark, no significant social gradient in infant mortality was found. In Tuscany, the magnitude of the difference appeared large, but the number of deaths was too small, so the confidence intervals were wide and the result did not reach statistical significance.

In Malta, the situation even appeared to be the opposite—infant mortality was lower in the less affluent group, but the difference was also not statistically significant. The authors caution against overinterpreting these regional exceptions: the rarity of deaths following individual congenital anomalies means that one or two additional deaths could significantly alter the relative estimates in a small registry.

Comparison in the first year of life	HR	95% CI
The most prosperous	1.00	Reference
Intermediate socio-economic level	1.29	1.15-1.43
The most unfavorable level	1.47	1.19-1.83

[4]

After the first year of life, the social gap became even greater

The study's key finding emerged from an analysis of children who survived infancy. For ages one to ten, the most disadvantaged group had a mortality hazard ratio of 2.00, with a confidence interval of 1.32–3.02. Thus, in the pooled analysis, the mortality rate was approximately twice that of children with similar major congenital anomalies from the most advantaged families or neighborhoods.

In the middle socioeconomic group, the HR was 1.65, 95% confidence interval 1.10–2.49. As in infancy, a gradient was found: the most advantaged children had the best indicators, the intermediate group had worse ones, and the most socially disadvantaged had the highest mortality.

This does not mean that the absolute mortality rate after the first year was enormous. In most participating countries, approximately 1-2% of live-born children with major congenital anomalies died between the first birthday and age 10. Ukraine was an exception, where this rate was significantly higher. Therefore, a two-fold risk ratio may correspond to a relatively small absolute number of excess deaths.

However, it was childhood, not infancy, that proved to be the most sensitive to social status. The authors believe this is particularly important from a healthcare perspective: successful surgery or intensive treatment immediately after birth does not guarantee the same long-term outcome if subsequent rehabilitation, outpatient care, and living conditions vary significantly.

Age	Intermediate group	The most disadvantaged group
0-1 year	HR 1.29	HR 1.47
1-10 years	HR 1.65	HR 2.00
Severity of social gradient	Moderate	Stronger after 1 year

[5]

Why social status may have a greater impact after hospital discharge

In the first weeks and months of life, children with severe congenital defects are often treated in large, specialized medical centers. Decisions regarding surgery, intensive care, and diagnostics in such an environment are determined primarily by the severity of the disease. The physical conditions within a single hospital for a wealthy and a poor patient differ significantly less than their living conditions after returning home.

After the first year, children typically spend much less time in hospital and rely more on primary care, outpatient specialists, rehabilitation, and family resources. The authors point out that this may be where so-called social capital—knowledge, resources, support, and the family's ability to access necessary services—may come into play.

In addition to medical care, differences in the material environment return after discharge: housing quality, heating, nutrition, exposure to tobacco smoke, and other household factors. For a healthy child, some of these impacts may be moderate, but for a child with a congenital heart condition, neurological defect, or chronic respiratory problems, the additional burden potentially becomes much more significant.

Researchers call this a potential "double jeopardy": a congenital anomaly already makes a child medically vulnerable, and social deprivation adds a second layer of vulnerability. For example, children with congenital anomalies are more likely to experience respiratory illnesses and injuries, and these outcomes are themselves associated with housing quality and social disadvantage. However, the new analysis did not directly determine how many additional deaths were associated with each specific cause.

Ukraine and Wales showed the most consistent social gradient

The association between socioeconomic status and mortality was not consistent across Europe. Only in Ukraine and Wales were statistically significant differences consistently present across all four main comparisons—for the most disadvantaged and intermediate groups, both in infancy and later childhood.

Notably, among the participating regions, Ukraine and Wales had relatively low gross domestic product per capita, but not the highest income inequality rates. The authors therefore cautiously suggest that not only the relative differences between the richest and poorest may be significant, but also the absolute amount of resources available to families and the healthcare system. However, the statistical relationship between gross domestic product and the magnitude of social inequality in this study did not reach significance.

In Denmark, by contrast, socioeconomic status had virtually no impact on infant mortality in Funen. The authors note that Denmark, among the included countries, had a high gross domestic product per capita and low income inequality. However, based on a single regional sample, it is impossible to conclude that state wealth or the social protection structure completely eliminated the social effect.

Three English registries showed no statistically significant overall association with mortality between one and 10 years. The authors emphasize that these registries covered only specific regions of England, and none of them were among the most deprived areas of the country. Therefore, the results cannot be generalized to England as a whole.

Region/Country	What was observed
Ukraine	Consistent association of low socioeconomic status with mortality
Wales	Serial communication in infancy and childhood
Funen, Denmark	No significant effect on infant mortality was found.
Malta	No convincing social gradient was found.
Tuscany	Large point difference, but few deaths and wide uncertainty
English regions	Individual cues in infancy, but no overall significant effect 1–10 years

Ukraine also differed significantly in absolute infant mortality.

Across the ten registries, infant mortality rates among children with major congenital anomalies ranged from 2.9% in Tuscany to 7.9% in Malta. These figures apply to all social categories combined and demonstrate the wide variation in baseline rates between the participating regions.

Among children followed further, in most countries, approximately 1-2% of additional deaths occurred between the first and tenth years of life. However, Ukraine was a notable exception: approximately 9% of deaths were recorded after infancy. The cumulative mortality rate by age ten in the Ukrainian registry reached 13.5%, with a 95% confidence interval of 12.5-14.6%.

By comparison, the minimum mortality rate at this age in Tuscany was approximately 3.7%, with a 95% confidence interval of 3.1–4.4%. Moreover, the largest registries by population size—Finland and Wales—demonstrated lower absolute mortality rates than Ukraine.

These cross-country differences cannot be automatically explained solely by the quality of medical care. The results are influenced by the structure of the registries, the severity of the registered defects, the availability of abortion for severe anomalies, the social structure of the population, and many other factors. The authors explicitly warn that international comparisons in this study are less reliable than comparisons of social groups within the same registry.

Children who require complex surgery and long-term rehabilitation appeared particularly vulnerable.

When researchers attempted to disaggregate the data by specific congenital anomalies, the most pronounced social disparities were more often observed for conditions requiring complex and lengthy treatment. These included congenital heart defects, severe heart defects, hydrocephalus, severe microcephaly, limb defects, craniosynostosis, and gastroschisis.

For congenital and severe congenital heart defects, the association with socioeconomic status was, on average, stronger after one year of age than during infancy. This was particularly evident in the British data among the most deprived children. In Southern European countries, the pattern was less clear, but the number of individual deaths there was significantly lower.

In infancy, high risk ratios were also observed in some countries for spina bifida, hydrocephalus, congenital cataracts, gastroschisis, hydronephrosis, limb reduction defects, and craniosynostosis. However, the authors strongly caution that the numbers of deaths for individual diagnoses were too small to draw firm conclusions.

In contrast, no convincing association between deprivation and infant mortality was found for facial clefts, multicystic dysplasia of the kidney, and hypospadias. The authors suggest that one explanation may be a lesser need for long-term, complex rehabilitation after initial treatment. This remains an interpretation, not a proven causal mechanism.

Anomalies in which the social effect was more noticeable	Possible common feature
Congenital heart defects	Complex operations and long-term observation
Severe congenital heart defects	Intensive specialized treatment
Hydrocephalus	Neurosurgery and long-term observation
Severe microcephaly	High need for support and rehabilitation
Limb defects	Rehabilitation and assistive technologies
Craniosynostosis	Surgical and specialized observation
Gastroschisis	Complex early surgical treatment
Facial clefts/hypospadias	No convincing overall effect was found in infancy.

[6]

Children from families outside the European Union also appeared to be more vulnerable

The researchers separately examined the ethnicity of the mother and child. Such data were available for 48,450 mothers and children from Finland and the Italian region of Emilia-Romagna. This is a separate analysis and should not be combined with the main sample of 47,134 children used to assess socioeconomic status.

If the mother or child was a citizen of another European Union country, their survival rates did not differ significantly from those of citizens of their country of birth. In other words, intra-European migration itself, in the available data, was not associated with a significant increase in child mortality.

In contrast, citizens of countries outside the European Union had higher mortality rates, with the difference being particularly pronounced after the first year of life. Due to the relatively small number of deaths, the authors do not draw firm conclusions about the underlying mechanism or attribute the results to ethnicity. Ethnicity here can be an indicator of a variety of factors, including migration status, language, access to services, and socioeconomic status.

Interestingly, single parenthood did not provide a similar signal. In Finland and Emilia-Romagna, there was no evidence that children of single mothers with congenital anomalies died more often. However, the number of widowed mothers was so small that this category could not be analyzed separately.

Why single motherhood and poverty cannot be considered the same factor

At the everyday level, social disadvantage is often associated primarily with single-parent families, but the results of this study show that this model is too simplistic. In two registers where marital status could be analyzed, single motherhood itself was not associated with higher child mortality.

This doesn't mean that family structure never affects health. Rather, socioeconomic status includes many more components—education level, income, housing quality, access to transportation and healthcare, social connections, and the ability to manage complex treatment. A single mother may have a high level of resources, while a two-parent family may live in profound deprivation.

On the other hand, data on marital status were available only in Finland and Emilia-Romagna. Therefore, the lack of an effect in two relatively prosperous European regions does not guarantee that a similar pattern will be observed in countries with different social security systems.

The authors therefore use marital status only as an additional social indicator and do not consider it a full-fledged substitute for socioeconomic status. The main indicator of the study remains the gradient of deprivation or maternal education, rather than family composition per se.

The study raises the question: is inequality more important than the total amount of resources?

The authors examined whether the difference in mortality between rich and poor families was related to the Gini coefficient, a measure of a country's economic inequality. No convincing correlation was found: countries with less income inequality did not necessarily exhibit a smaller social gap in the survival of children with congenital anomalies.

At the same time, the graphs showed slightly stronger social disparities in regions with lower per capita gross domestic product. However, the number of countries was too small, the confidence intervals were too wide, and this trend did not reach statistical significance. Therefore, it cannot be claimed that the study has proven a direct correlation between survival and national wealth.

The authors discuss the hypothesis that for a seriously ill child, not only the family's relative position within society matters, but also the absolute availability of resources. If resources are scarce, it is more difficult for the family to compensate for poor housing, transportation costs, special diets, the need to miss work for medical appointments, or long-term rehabilitation.

But the healthcare system can also significantly alter this relationship. Universal insurance, free medications, transportation assistance, home care, and accessible rehabilitation potentially reduce the impact of family income. The new analysis did not have sufficiently detailed data on specific healthcare systems to disentangle these effects.

Why the outcome is especially important for children after complex surgeries

Modern surgery is enabling an increasing number of infants with heart defects, gastrointestinal tract defects, skull defects, and other severe congenital disorders to survive. However, surgery is often only the first stage of treatment. Afterward, medications, growth monitoring, nutrition, physical therapy, speech therapy, repeat procedures, and visits to specialized centers may be required for years.

In the new study, it was precisely the illnesses with such a high need for follow-up care that more often demonstrated a social gradient. The authors consider this an indirect argument that the financial and organizational burdens on families after discharge may influence long-term outcomes.

For the healthcare system, this changes the definition of "successful treatment." It's not enough to perform a complex operation and discharge a child alive: if socially disadvantaged families systematically lose access to rehabilitation and preventive care after discharge, some of the benefits of high-tech medicine may be lost in subsequent years. This is the authors' interpretation, based on the stronger social gradient between the ages of 1 and 10.

Therefore, the researchers propose focusing additional resources specifically on the intersection of these two risk factors—severe congenital pathology and poverty. Such assistance could include more active coordination of care, transportation, access to rehabilitation, and family support, although this study did not test specific interventions.

But HR 2.00 does not mean that poverty itself "doubles the likelihood of dying."

This is a fundamentally important statistical limitation. The study used Cox proportional hazards models, and the primary outcome measure was the hazard ratio. An HR of 2.00 indicates approximately a twofold relative rate of death over time in the compared groups, not the absolute probability of death for a particular child.

Furthermore, the analyses were univariate: the models directly compared socioeconomic categories but did not perform a unified multivariate adjustment for all potential causes of differences. For example, prematurity, multiple pregnancies, maternal medical conditions, and certain child characteristics were not systematically accounted for.

Therefore, it cannot be said that low maternal income or education biologically caused the additional deaths. Socioeconomic status may be associated with other factors, such as disease severity, prenatal exposures, environmental factors, prematurity, smoking, nutrition, and access to healthcare.

Yet, the lack of full adjustment doesn't render the result unimportant. For public health, socioeconomic status itself is a useful marker of vulnerability. Even if it combines several different causes, identifying a group with a twice-higher mortality rate can help identify those who require additional support.

Environmental factors may have partially influenced the results of Ukraine and Wales

The authors specifically note that they were unable to adjust their analysis for environmental pollution levels. This is important because certain environmental exposures are both more common in socially disadvantaged areas and associated with increased rates of adverse pregnancy outcomes and congenital anomalies.

The article pays special attention to Ukraine. The researchers cite the persistent cesium-137 contamination following the Chernobyl nuclear power plant accident and note that the most contaminated areas have historically overlapped with socially disadvantaged regions. They admit that this could have contributed to the unusually high mortality rate, but the study did not measure individual radiation exposure and therefore cannot prove such a causal link.

In Wales, social deprivation may also correlate with certain types of environmental stress. Because the Welsh Index of Multiple Deprivation includes the physical state of the environment, some of its association with mortality may theoretically reflect factors other than purely economic ones.

This is another example of why "poverty" in epidemiological research cannot be viewed as a single molecule or a single impact. It represents a complex set of conditions that can include housing, pollution, nutrition, education, employment, transportation, and access to healthcare. The new study identifies an overall social signal but does not fully dissect it into its individual mechanisms.

The strength of the study is that it is not based on volunteers.

Many medical cohorts recruit volunteers. These participants often have a higher level of education, are more interested in health, and have easier access to medical care than the general population. EUROlinkCAT uses population-based registries, so this type of volunteer bias is significantly reduced.

An additional benefit is that congenital anomaly diagnoses were established and coded by specialists according to uniform European criteria. This reduces the likelihood of a child being classified into one group simply because parents misreported the diagnosis or medical documentation was insufficiently detailed.

Information on deaths was also obtained from official government sources, not questionnaires. Therefore, the key endpoint—survival—was measured reliably. This is especially important when studying rare events, where even a small number of missed deaths can alter the odds ratio.

Finally, the study covers regions with significantly different levels of wealth and healthcare delivery. This increases the external informativeness of the study, although most Eastern European countries were unable to participate, so its representativeness for Europe remains incomplete.

Key limitations: rare deaths, different definitions of poverty, and lack of data on associated factors

The first limitation is the small number of deaths, despite the large initial cohort. More than 97% of live-born children with major congenital anomalies in European registries survive their first year, and more than 96% reach age ten. Therefore, after stratification by country, diagnosis, and social status, some cells contain literally isolated events.

Second, different countries have measured socioeconomic status differently. Maternal education and the neighborhood deprivation index are correlated, but they are not interchangeable. A highly educated woman may live in a disadvantaged neighborhood, while a family with a low educational level may have a relatively high income.

Third, social status was measured around the time of birth and assumed to be virtually constant. However, over the course of ten years, a family may move, improve or worsen its financial situation, the mother may continue her education, and access to services may change. The study could not account for such dynamics.

Fourth, there was a lack of consistent data on a number of potential confounding factors: multiple pregnancies, maternal medical conditions, certain perinatal characteristics, and lifestyle. Smoking, alcohol, obesity, sleep, and other factors were recorded inconsistently across different systems.

Finally, the analysis included only live births. Terminations of pregnancy following diagnosis of a severe anomaly, miscarriages, and stillbirths were not analyzed. This is particularly important when comparing countries, as legislation and practices regarding termination of pregnancy in cases of severe anomalies vary significantly. The authors, for example, point out that a complete ban on termination of pregnancy in Malta may have contributed to the high reported infant mortality rate among children with severe anomalies.

Limitation	Why is it important?
A small number of deaths	Wide confidence intervals
Different SES indicators	They make direct comparisons between countries worse.
Single-factor models	Confounding factors are possible
There is no uniform data on concomitant maternal illnesses	Risk cannot be fully adjusted
There is no consistent data on smoking, alcohol and obesity.	Residual mixing
SES changes over time	The original measurement may be out of date.
Not all registries were able to link all records	Selection bias possible
Only live born	Miscarriages, stillbirths and terminations of pregnancy are not taken into account.
Few Eastern European countries	Limited general applicability
Environmental exposure was not taken into account	Possible additional mixing

[7]

What the study showed—and what it didn't prove

The most reliable finding is that among European children with major congenital anomalies, low socioeconomic status is statistically associated with higher mortality. This association is observed already in infancy and becomes stronger among those who survive the first year of life.

However, it cannot be claimed that poverty is directly responsible for every additional death. The study is observational, socioeconomic exposure was measured approximately, and the models were not fully adjusted for potential confounding factors.

It also cannot be concluded that the risk for a poor child with any specific defect is necessarily exactly twice as high. The HR of 2.00 is a pooled estimate for all major anomalies and several registries at ages 1-10 years. For individual diagnoses and countries, the effect size could be much higher, lower, or even absent.

Finally, the results do not indicate that the European healthcare system as a whole is unequal. The effect varied greatly across countries and regions, and in some places, there was no statistically significant social gradient. Rather, the study shows that equal access to intensive care at birth does not necessarily guarantee equal long-term survival after discharge.

Correct conclusion	Incorrect interpretation
Low SES is associated with a HR of 1.47 to 1 year	"Poverty increases the absolute risk of death by 47 percentage points."
HR 2.00 for ages 1-10 years	"Every poor child has exactly twice the chance of dying."
The social effect increases after infancy	Hospital treatment completely eliminates social differences
Ukraine and Wales showed the most consistent effect	The effect is the same throughout Europe.
Complex anomalies often showed a greater social gradient	For each individual vice, causality is proven
Non-EU nationality associated with worse survival in two registries	Migration itself causes mortality.
Single motherhood was not associated with risk in two registries	Family structure never affects health
Observational study	The results have no public health implications.

What the results mean for child welfare organizations

The authors believe that the most logical point of intervention is the transition from a specialized hospital to home life. It is during this period that the social gradient begins to become more pronounced. Therefore, discharge after successful surgery should not mark the end of active monitoring for families at high social risk.

For a child who requires regular cardiac examinations, physical therapy, special formulas, medications, or repeated surgeries, even relatively minor obstacles can accumulate. Distance to the center, transportation costs, the need for a parent to miss work, and difficulties organizing home care potentially add up to a more significant gap. The new study did not measure the specific contribution of these factors, but this is precisely the mechanism consistent with the authors' interpretation.

Researchers believe that additional medical and social resources should be focused not just on poor children or those with congenital anomalies, but specifically where these two types of vulnerability intersect. This could include more active support for families after discharge, simplified access to rehabilitation, and prevention of loss to follow-up.

This strategy is also consistent with the broader goal of reducing preventable child mortality. The authors emphasize that achieving international sustainable development goals requires looking not only at average national mortality but also at groups where health and social vulnerabilities overlap.

Why this study goes beyond the usual conversation about "access to a doctor"

The results show that social disparities can persist even in countries with developed medical infrastructure. Therefore, the issue is not limited to the presence or absence of a single operation. Particularly after the first year of life, a continuous care pathway becomes important – from a specialized center to a family doctor, rehabilitation, social services, and home.

This is crucial for congenital anomalies, as many require lifelong medical care. Treatment success is determined not only by surgical technique but also by complication prevention, regular monitoring, and the family's ability to implement a complex care plan.

The authors also note that socially disadvantaged children are generally more likely to be born with congenital anomalies, according to previous studies. The new study adds a second level of inequality: after birth, they may have worse survival. Thus, adverse social conditions can have an impact both before and after birth.

The authors view this dual vulnerability as an important signal for public policy. If resources are allocated solely based on the medical severity of the diagnosis, without taking into account the family's social capacity to provide long-term care, the gap after discharge may persist even with high-quality, high-tech healthcare.

Funding and conflicts of interest

The study was part of the EUROlinkCAT project (Establishing a linked European Cohort of Children with Congenital Anomalies), funded by the European Union under the Horizon 2020 program. Grant number 733001, funding for the project ran from January 2017 to December 2021.

The authors indicate that the funding organization had no involvement in the study design, data collection, processing, or interpretation, manuscript preparation, or the decision to publish. Funding was provided to the project and the participating congenital anomaly registries.

The researchers declared no competing interests, and no commercial companies were involved in the study. This is especially important for a study whose results primarily relate to the organization of medical and social care, rather than the efficacy of a specific drug.

However, the data itself cannot be simply downloaded at the individual patient level due to national confidentiality requirements. The research team had access primarily to locally linked data and aggregated results, and use of the original administrative datasets requires separate permission from the relevant registries.

Results

A new European study shows that the medical severity of a birth defect is not the only factor associated with child survival. Among 47,134 children with major congenital anomalies for whom socioeconomic data were available, the most disadvantaged group had a roughly 47% higher relative incidence of death in the first year of life compared to the most affluent group.

After the first year of life, the social gap became even greater. For children aged 1 to 10 years, the odds ratio reached 2.00, while for the intermediate socioeconomic group, it was 1.65. This age-related dynamic is perhaps the most important finding of the study: the influence of social conditions becomes especially noticeable when a child moves from the protected environment of a specialized hospital into everyday life.

Europe, however, proved to be heterogeneous. The most consistent differences were found in Ukraine and Wales, while in several other regions, the social gradient was much weaker or statistically indeterminable. Children with defects requiring complex surgery and lengthy subsequent rehabilitation appeared particularly vulnerable.

The study doesn't prove that poverty directly causes death, and its risk ratios shouldn't be translated into individual predictions. However, it does demonstrate an important systemic effect: two children with a severe congenital disorder may have the same medical diagnosis, but their long-term chances may differ depending on the social environment in which treatment continues after discharge. This is why the authors consider social support to be part of a strategy for reducing mortality in children with congenital anomalies, rather than a problem separate from medical care.

News source

Jordan S., Tucker D., Scanlon I., Thayer D. S., Ballardini E., Cavero-Carbonell C., Damkjaer M., Gatt M., Gissler M., Ostapchuk L., Santoro M., Stevens S., Wellesley D., Wertelecki W., Given J., Loane M., et al. Mortality among European children with congenital anomalies: Associations with socio-economic status in the EUROLINKCAT cohort. PLOS ONE. 2026; 21(8):e0352025. This article was published on August 5, 2026; it is categorized as a Research Article.

The study is based on the European population-based linked cohort EUROlinkCAT and analyzes the survival of children with major congenital anomalies in infancy and up to 10 years of age according to socioeconomic status. The main pooled results were HR 1.47 (95% CI 1.19-1.83) up to 1 year and HR 2.00 (95% CI 1.32-3.02) at 1-10 years of age for the most disadvantaged compared with the most advantaged group.

DOI: 10.1371/journal.pone.0352025.