Figure 1 shows the results of the literature search; 14 studies met the inclusion criteria.
Characteristics of studies and exposure measures
Table 1 spells out the characteristics of included studies: study design (cross-sectional, trends over time, before-after approach, cohort study, or qualitative study), country (individual country, or the number of countries analysed), exposure (type of austerity measure and source of data), outcome (SDCH and/or CHO), and the risk of bias. Nine studies report time trend analyses of cross-sectional repeated data and two studies report before-after analyses following the implementation of austerity measures. The level of austerity measures was assessed by methods proposed by the International Monetary Fund (IMF),16 the European Union’s Maastricht criteria,17 or by analysing spending on families/children social protection in specific periods of time.18, 19
A before-after approach was used to compare Italy, Greece, France and the UK,20 in terms of the ability of social benefits to reduce child poverty. One cross-sectional study collected information on a survey to families of disabled children and professionals from 32 European countries,17 while a follow-up of a cohort of children from Ireland reported on the consequences of reported reductions on welfare benefits,21 and a qualitative study from Scotland provided information on the impact of austerity measures on families with disabled children.22
Risk of bias
Seven out of 14 studies showed a low risk of bias according to STROBE (average score = 72.1%; median= 75.6%), 2 studies showed high risk of bias, while the qualitative study showed intermediate risk of bias on the EPICURE assessment.
Social determinants of child health (SDCH) (Table 2)
The study analysing indicators of child poverty and material deprivation in 16 European countries according to the extent of austerity implemented by governments found that material deprivation increased in the period 2012-2015 in countries with high austerity level (interaction austerity*period 2012–15= B: 5.62: p<0.001).16 Children were significantly less likely to be poor in countries with higher levels of social protection spending in 2008–2013 in 30 EU countries.18 Spending on in-kind benefits was more effective in reducing child poverty (B= -1.6) than for cash benefits (B= -1.2), although a gradual downward trend in the efficacy of both coefficients over time was reported.19 Child and family poverty rates increased in Spain and Portugal following the crisis partly due to low levels of social protection; social transfers in both countries only reduced poverty and social exclusion by 7.4%.23, 24
Shares of the social benefits devoted to family/children in the UK and France were approximately double those in Italy and Greece and the UK was the only one of these countries in which deterioration in some of the measures of well-being analysed in the study from D’Agostino et al was avoided.20 Both children’s deprivation and economic vulnerability were measured at higher levels in 2014 than in 2009 in Iceland, though only the change in the latter was statistically significant.25 Rates of deprivation and vulnerability were low and the overlap very limited, which may be indicative of low deprivation rates.25, 26
Child health outcomes (CHO)
Results on CHO are summarised in Table 3. Increasing rates of low birth weight (LBW) were associated to high level of austerity in the study of 16 countries (interaction austerity*period 2012–15, B: 0.25; p=0.004).16 Preterm birth and LBW increased by 37% and 7% respectively in Greece the years 2011-14. 27 In Iceland, small for gestational age increased from 2% to 3.4%.26
Absolute inequalities in infant mortality rates (IMR) in England increased in 1990-1999 (annual changes between the most deprived local authorities and the rest of England: 0.03), decreased during the welfare strategy period 2000-2010 (-0.11) and increased in 2011-2017 (0.04) after the end of this strategy. 28 The study Growing Up in Ireland (GUI) found that 48% of participating families in 2011 (2y old children) and 60% in 2013 (4y olds) reported a reduction in welfare benefits, and it was associated with an increased risk of reporting asthma and atopy symptoms in the latter period.21
Healthcare services, and preventive services
In the study of 32 European countries, families from countries with high austerity level reported more difficulties in access to healthcare services and benefits for children with disability; professionals reported worse quality of services provided and increasing waiting time for visits.17
The study from Scotland showed a reduction or withdrawal of services in a wide range of provision—social work, education, voluntary organisations, health and professions allied to medicine.22 Voluntary sector survey showed a shift from preventative work to crisis intervention and an increase in unmet needs. Some families waited between one and three years for assessments on child mental health services for diagnosis, equipment and/or home extensions. Difficulty meeting the needs of children on the autistic spectrum was a recurring theme.22
An annual reduction of 1% in public health expenditure (PHE) was associated to 0.5% reduction in Measles-Mumps-Rubella (MMR) vaccination coverage by region in Italy. 29