Associations of major congenital anomalies, long-term health conditions, and socioeconomic deprivation with educational attainment in Wales: A population-based data linkage study

Background Education outcomes are associated with life chances. However, deprivation, ill-health and disability are barriers to achievement. We aimed to investigate educational attainment of children with and without major congenital anomalies in state-funded mainstream schools at ages 11 and 16 (key stages [KS] 2 and 4), accounting for maternal and child socioeconomic deprivation, demographic factors, comorbidities, and special education needs (SEN) provision. Methods and findings We conducted a retrospective population-based cohort study using the Secure Anonymised Information Linkage (SAIL) Databank to link routinely collected electronic health and education records of children born in Wales between January 1st, 1998 and December 31st, 2007, who were followed up until December 31st, 2019. Education outcomes were explored using logistic regression, adjusting for: major congenital anomalies, maternal and child socioeconomic deprivation, medicated co-morbidities, hospitalisation, gestation length, child sex, year of birth, and SEN provision. Children with major congenital anomalies were less likely to achieve national academic standards, including those required for some professional courses: however, attainment was more strongly associated with socioeconomic deprivation. At age 11, 81.9% (7167/8754) with and 93.8% (232,450/247,814) without major congenital anomalies attained established standards (odds ratio [OR] 0.30; 95% confidence intervals [CI] [0.28,0.32]). At age 16, 46.8% (2070/4427) with and 56.1% (69,732/124,300) without major congenital anomalies achieved 5 General Certificates of Secondary Education (GCSEs) at grades C–A*, including English/Welsh, Maths and Science (EWMS) (OR 0.69; 95% CI [0.65,0.73]). Discrepancies narrowed in adjusted analyses, particularly when SEN provision was accounted: aOR 0.72; 95% CI [0.66,0.78] at KS2, age 11, and aOR 0.93; 95% CI [0.87,1.00] for 5 GCSEs C–A* with EWMS. These GCSEs were achieved by 29.7% (307/1034) children with major congenital anomalies and 38.4% (10,875/28,305) of unaffected children in the most deprived quintile (using maternal Welsh Index of Multiple Deprivation at birth): in the least deprived quintile, figures were 67.6% (547/810) and 75.0% (16,978/22,644), respectively. Children with major congenital anomalies, receiving maximum SEN support, and eligible for Free School Meals (FSM) were the least likely to achieve national academic standards: 5/192 (2.6%) obtained 5 GCSEs C–A* with EWMS, as did 37/354 (10.4%) ineligible for FSM. The strongest associations with 5 GCSEs C–A* with EWMS, were SEN statements (aOR 0.07; 95% CI [0.06,0.07]), FSM eligibility (aOR 0.39; 95% CI [0.37,0.41]), and epilepsy (aOR 0.60; 95% CI [0.45,0.80]). Study limitations included absence of data for 15%–18% of children, mainly those educated outside mainstream schools, and for some comorbidities; generalisation of findings to other settings or other countries is uncertain. Conclusions Many children with major congenital anomalies from least deprived quintiles attained national academic standards, including 5 GCSEs C–A* with EWMS. The children living in the most deprived quintiles or eligible for FSM and with ill-health from major congenital anomalies and/or epilepsy were two to four times less likely to attain these standards. SEN provision mitigated the associations with disadvantage, but children from socioeconomically deprived quintiles with major congenital anomalies were unlikely to achieve 5 GCSEs C–A* with EWMS.