Background

Removal from family of origin to state care can be a highly challenging childhood experience and is itself linked to an array of unfavourable outcomes in adult life. We aim to synthetise evidence on the risk of adult mortality in people with a history of state care in early life, and assess the association according to different contexts.

Methods

In this systematic review and meta-analysis, we focused on four health outcomes hypothesised to be associated with exposure to early state care: total mortality, cardiovascular disease, cancer, and suicide. We searched the electronic databases PubMed and Embase from inception to Jan 21, 2022, for studies fulfilling the following criteria: it was a prospective study in which the assessment of care was made up to 18 years of age; it included an unexposed comparator group; the focus of the study was temporary out-of-home care and not adoption; mortality surveillance was extended into adulthood; standard estimates of association (eg, relative risk, odds ratios, or hazard ratios) and variance (eg, CIs and SE) were provided; the study appeared in a peer-reviewed journal; and the study was published in English. An adapted Cochrane Risk of Bias Tool was used to assess study quality. We extracted estimates of association and variance from qualifying studies and augmented these findings with analyses of unpublished data from individual participants in two UK birth cohorts—ie, the 1958 and 1970 studies (total n=21 936). We computed hazard ratios with accompanying 95% CIs for care and each health outcome separately for each study, and then pooled the results using a random-effects meta-analysis. This review is registered at PROSPERO, CRD42021254665.

Findings

We identified 210 potentially eligible published articles, of which 14 met our inclusion criteria (two studies were unpublished). Of 3 223 580 individuals drawn from 13 studies, those who were exposed to care in childhood had twice the risk of total mortality in adulthood relative to those without a history of care in childhood (summary risk ratio 2·21 [95% CI 1·62–3·02]), with study-specific estimates varying between 1·04 and 5·77 (I² =98%). Despite some attenuation, this association remained following adjustment for other measures of early-life adversity; extended into middle and older age; was stronger in higher-quality studies; and was of equal magnitude according to sex, geographical region, and birth year. There was some suggestion of sensitive periods of exposure to care, whereby individuals who entered state care for the first time in adolescence (2·47 [0·98–6·52]) had greater rates of mortality than those doing so early in the life course (1·75 [1·25–2·45]). In four studies including 534 890 people, children in care had more than three times the risk of completed suicide in adulthood relative to their unexposed peers (3·35 [2·41–4·68]), with study-specific estimates ranging between 2·42 and 5·85 (I²=72%). The magnitude of this association was weaker after adjustment for multiple covariates; in men than in women; and in lower-quality studies.

Interpretation

Our results for adult mortality suggest child protection systems, social policy, and health services following care graduation are insufficient to mitigate the adverse experiences that might have preceded placement into care and those that might accompany it.

Funding

None.

中文翻译：

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国家对儿童和成人死亡率的护理：前瞻性队列研究的系统回顾和荟萃分析

 背景

从原生家庭转移到国家照顾可能是一种极具挑战性的童年经历，并且本身与成年生活中的一系列不利结果有关。我们的目标是综合有关早年接受过国家护理的人的成人死亡风险的证据，并根据不同的情况评估这种关联。

 方法

在这项系统回顾和荟萃分析中，我们重点关注了四种被认为与早期国家护理相关的健康结果：总死亡率、心血管疾病、癌症和自杀。我们检索了 PubMed 和 Embase 电子数据库，从成立到 2022 年 1 月 21 日，寻找满足以下标准的研究：这是一项前瞻性研究，其中对 18 岁以下的护理进行评估；它包括一个未暴露的比较组；研究的重点是临时的家庭外护理而不是收养；死亡率监测延伸至成年期；提供了关联性（例如相对风险、比值比或风险比）和方差（例如 CI 和 SE）的标准估计；该研究发表在同行评审期刊上；该研究以英文发表。使用经过修改的 Cochrane 偏差风险工具来评估研究质量。我们从合格研究中提取了关联性和方差的估计值，并通过对两个英国出生队列（即 1958 年和 1970 年研究（总计 n=21 936））的个体参与者的未发表数据进行分析来增强这些发现。我们针对每项研究分别计算了护理和每种健康结果的风险比以及伴随的 95% CI，然后使用随机效应荟萃分析汇总结果。该评论已在 PROSPERO 注册，CRD42021254665。

 发现

我们确定了 210 篇可能符合资格的已发表文章，其中 14 篇符合我们的纳入标准（两项研究未发表）。在 13 项研究中抽取的 3 223 580 名个体中，那些在童年时期接受过护理的人在成年后的总死亡率风险是那些没有童年护理史的人的两倍（总风险比 2·21 [95% CI 1· 62–3·02]），具体研究的估计值在 1·04 和 5·77 之间变化（ I ² =98%）。尽管有所减弱，但在对早期生活逆境的其他衡量标准进行调整后，这种关联仍然存在。延伸至中老年；在更高质量的研究中表现更强；根据性别、地理区域和出生年份，其大小相同。有人建议，暴露于护理的敏感时期，在青春期首次进入国家护理的个体 (2·47 [0·98–6·52]) 的死亡率高于在青春期早期进入国家护理的个体。生命历程（1·75 [1·25–2·45]）。在涵盖 534 890 人的四项研究中，与未接触过自杀的同龄人相比，接受照料的儿童成年后完成自杀的风险是其三倍多 (3·35 [2·41–4·68])，具体研究估计范围为2·42和5·85（ I ² =72%）。对多个协变量进行调整后，这种关联的程度较弱；男性多于女性；以及低质量的研究。

 解释

我们的成人死亡率结果表明，儿童保护系统、社会政策和护理毕业后的卫生服务不足以减轻在进入护理机构之前以及可能伴随的不良经历。

 资金

 没有任何。