Infant Mortality
Infant mortality is the death of young children
under the age of 1. This death toll is measured by the infant
mortality rate (IMR), which is the probability of deaths of children under
one year of age per 1000 live births. Similarly, the child mortality rate,
also known as the under-five mortality rate compares the death
rate of children up to the age of five.
In 2013, the leading cause of infant mortality in the United
States was birth defects. Other leading causes of infant mortality
include birth asphyxia, pneumonia, congenital malformations, term birth complications such as abnormal presentation of the fetus umbilical cord prolapse, or prolonged labor, neonatal infection, diarrhea, malaria, measles, and malnutrition. One of the most
common preventable causes of infant mortality is smoking during pregnancy. Lack of prenatal care, alcohol consumption during
pregnancy, and drug use also cause complications which may result in infant
mortality. Many situational factors lead to infant mortality, such as the
pregnant woman's level of education, environmental conditions, political
infrastructure, and level of medical support. Improving sanitation, access to clean drinking water, immunization against infectious
diseases, and
other public health measures can help reduce high rates of infant
mortality.
In 1990, 8.8 million infants younger than 1-year-old died globally out of 12.6 million child deaths under the age of five. More than 60% of the deaths of children under-five are seen as being avoidable with low-cost measures such as continuous breastfeeding, vaccinations, and improved nutrition. The global mortality rate in 1950 was 22.5% which dropped to 4.5% in 2015. Over the same period, the infant mortality rate declined from 65 deaths per 1,000 live births to 29 deaths per 1,000. Globally, 5.4 million children died before their fifth birthday in 2017.
The child mortality rate, but not the infant mortality rate, was an indicator used to monitor progress towards the Fourth Goal of the Millennium Development Goals of the United Nations for the year 2015. A reduction in child mortality is now a target in the Sustainable Development Goals—Goal Number 3: Ensure healthy lives and promote well-being for all at all ages. Throughout the world, the infant mortality rate (IMR) fluctuates drastically, and according to Biotechnology and Health Sciences, education and life expectancy in the country is the leading indicators of IMR. This study was conducted across 135 countries over the course of 11 years, with the continent of Africa having the highest infant mortality rate of any region studied, with 68 deaths per 1,000 live births.
Classification
Infant mortality rate (IMR) is the number of deaths per 1,000 live births of children under one year of age. The rate for a given region is the number of children dying under one year of age, divided by the number of live births during the year, multiplied by 1,000.
Forms of infant mortality:
·
Perinatal mortality is late fetal death weeks gestation to birth)
or death of a newborn up to one week postpartum.
· Neonatal mortality is newborn death occurring within 28 days postpartum. Neonatal death is often attributed to inadequate access to basic medical care, during pregnancy and after delivery. This accounts for 40–60% of infant mortality in developing countries.
· Postneonatal mortality is the death of children aged 29 days to one year. The major contributors to postneonatal death are malnutrition, infectious disease, troubled pregnancy, sudden infant death syndrome, and problems with the home environment.
Causes
Causes of infant mortality directly lead to the death. Environmental and social barriers prevent access to basic medical resources and thus contribute to an increasing infant mortality rate; 99% of infant deaths occur in developing countries, and 86% of these deaths are due to infections, premature births, complications during delivery, and perinatal asphyxia and birth injuries. Greatest percentage reduction of infant mortality occurs in countries that already have low rates of infant mortality. Common causes are preventable with low-cost measures. In the United States, a primary determinant of infant mortality risk is infant birth weight with lower birth weights increasing the risk of infant mortality. The determinants of low birth weight include socioeconomic, psychological, behavioral and environmental factors.
Main causes
There are three main leading causes of infant mortality;
namely Premature-related conditions, Congenital anomalies and Sudden Infant
Death Syndrome. In North Carolina,Premature-related conditions ranked first,
with a percentage of 37.5%, followed by congenital anomalies which accounted
for 17.4% of the total infant deaths, while Sudden Infant Death Syndrome
accounted for 12.9%.
Premature birth
A Premature
Baby in a ventilator
Premature, or preterm birth (PTB) is defined as birth before 37 weeks of gestation and can be
further sub-classified as extremely PTB (occurring at less than 28 weeks
gestation), very preterm birth (occurring between 28 and 32 weeks gestation),
and moderate to late PTB (occurring from 32 through 36 weeks gestation). Lower
gestational age increases the risk of infant mortality.
Over the last decade, prematurity has been the leading
cause of worldwide mortality for neonates and children under the age of five.
The overall PTB mortality rate in 2010 was 11.1% (15 million deaths) worldwide
and was highest in low to middle-income countries in sub-Saharan Africa and south
Asia (60% of all PTBs), compared with high-income countries in Europe, or the
United States.Low-income countries also have limited resources to
care for the needs of preterm infants, which increases the risk of infant
mortality. The survival rate in these countries, for infants born before 28
weeks of gestation is 10%, compared with a 90% survival rate in high-income
countries. In the United States, the
past two decades of the 20th century has seen a significant increase in
Premature births, despite a decrease in the total number of infant mortality
cases.
Based on distinct clinical presentation, there are three
main subgroups of preterm births; those that occur due to spontaneous premature
labor, those that occur due to spontaneous membrane (Amniotic sac) rapture, and those that are medically induced. Both spontaneous factors are viewed to be a result
of similar causes, hence two ma in classifications remain: spontaneous and
medically induced causes. The risk of spontaneous PTB increases with
"extremes of maternal age (both young and old), short inter-pregnancy
interval, multiple gestation, assisted reproductive technology, prior PTB,
family history, substance abuse, cigarette use, low maternal socioeconomic
status, late or no prenatal care, low maternal prepregnancy weight, bacterial
vaginosis, periodontal disease, and poor pregnancy weight gain. Medically
induced PTB is often conducted when continued pregnancy poses significant risks
to the pregnant parent or fetus. The most common attributing factors for
medically induced PTB include preeclampsia, diabetes, maternal medical
conditions, fetal distress, or developmental problems. Despite these risk
factors, the underlying causes of premature infant death are often unknown and
approximately 65% of all cases are not associated with any known risk factor.
Infant mortality caused by premature birth is mainly
attributed to the various complications of preterm births. A key characteristic
of preterm birth is developmental immaturity, which directly impacts different
organ systems of the infant's body. The main body systems affected include
the respiratory system, which, due to failure of fetal breathing movement, may
result in pulmonary
hypoplasia, respiratory distress syndrome, bronchopulmonary dysplasia (chronic lung disease), and apnea. Other body systems that rely on later gestational
age to fully develop include the gastrointestinal system, the skin, the immune system, the cardiovascular
system, and the hematologic system. Poor development of these systems increases
the risk of infant mortality.
Understanding the biological causes and predictors is
important for identifying and preventing premature birth and infant mortality.
While the exact mechanisms responsible for inducing premature birth are often
unknown, many of the underlying risk factors are associated with inflammation.
Approximately 80% of preterm births that
occur at <1000 g or at <28 to 30 weeks of gestation" have been associated
with inflammation. Biomarkers of inflammation, including C-reactive protein,
ferritin, various interleukins, chemokines, cytokines, defensins and bacteria
have been shown to be associated with increased risks of infection or
inflammation-related preterm birth. Biological fluids have been utilized to
analyze these markers in hopes of understand the pathology of preterm birth,
but are not always useful if not acquired at the appropriate gestational
time-frame. For example, biomarkers such as fibronectihn are accurate
predictors of premature birth at over 24 weeks gestation, but have a poor
predictive values before then. Additionally, understanding the risks associated
with different gestational ages is a helpful determiner of Gestational
age-specific mortality. This way, the rate of infant mortality in preterm births of
gestational age above 26-31weeks are significantly lower compared to those
under the same age.
Sudden infant death
syndrome (SIDS)
Main
article: Sudden infant death syndrome
Sudden infant death syndrome (SIDS) is a syndrome where
an infant dies in their sleep for no known reason. Even with a complete
autopsy, no one has been able to figure out what causes this disease. This
disease is more common in Western countries. The United States Center for Disease Control
reports SIDS to be the leading cause of death in infants age 1 month to 1 year
of life. Even though researchers are not sure what causes
this disease, they have discovered that it is healthier for babies to sleep on
their backs instead of their stomachs. This discovery saved many families from the tragedy that this disease
causes. Scientists have also discovered three causes within a model they
created called "the contemporary triple risk model". This model
states that three conditions such as the pregnant parent smoking while
pregnant, the age of the infant, and stress referring to conditions such as
overheating, prone sleeping, co-sleeping, and head covering. In the early
1990s, it was argued immunizations could attribute to an increased risk of SIDS;
however, studies since then have proven otherwise and in fact support the idea
that vaccinations provide protective properties by reducing the risk of SIDS.
In the United States, approximately 3,500 infants deaths
are attributed to sleep-related deaths included in this category is
SIDS. For this reason, the American Academy of Pediatrics recommends
providing infants with safe-sleeping environments; additionally for the
reductions of these sleep-related mortalities, they recommend the prevention of
the following, respectively, while pregnant or around infants: exposure to
smoke, alcohol, and illicit drugs—this includes second hand smoking. They recommend the following do's: do breastfeed,
do schedule immunizations according to proper immunization scheduling, and do
use a pacifier.
Congenital
malformations
Congenital malformations are birth defects that babies
are born with, such as cleft lip and palate, Down Syndrome, and heart defects.
Some congenital malformations may be more likely when the mother consumes
alcohol, but can also be caused by genetics or unknown factors. Congenital malformations have had a significant
impact on infant mortality. Malnutrition and infectious diseases were the main
cause of death in more undeveloped countries. In the Caribbean and Latin
America, congenital malformations only accounted for 5% of infant deaths, while
malnutrition and infectious diseases accounted for 7% to 27% of infants deaths
in the 1980s. In more developed countries such as the United States, there
was a rise in infant deaths due to congenital malformations. These birth
defects were mostly due to heart and central nervous system problems. In the
19th century, there was a decrease in the number of infant deaths from heart
diseases. From 1979 to 1997, there was a 39% decline in infant mortality due to
heart problems.
Medicine and biology
Causes of infant mortality and deaths that are related to
medical conditions include: low birth weight, sudden infant death syndrome, malnutrition, congenital malformations and infectious
diseases, and low income for health care including neglected tropical diseases.
The American Academy of Pediatrics recommends that
infants need multiple doses of vaccines such as diphtheria–tetanus–acellular
pertussis vaccine, Haemophilus influenzae type b (Hib) vaccine, hepatitis B (HepB) vaccine, inactivated polio vaccine (IPV), and pneumococcal vaccine (PCV). Research conducted by the Institute of
Medicine's Immunization Safety Review Committee concluded that there is no relationship between
these vaccines and the risk of SIDS in infants.
Low birth weight
Main
article: Low birth
weight
Low birth weight makes up 60–80% of the infant mortality rate in developing countries. The New England Journal of Medicine stated that "The lowest mortality rates occur among infants weighing 3,000 to 3,500 g (6.6 to 7.7 lb). For infants born weighing 2,500 g (5.5 lb) or less, the mortality rate rapidly increases with decreasing weight, and most of the infants weighing 1,000 g (2.2 lb) or less die. As compared with normal-birth-weight infants, those with low weight at birth are almost 40 times more likely to die in the neonatal period; for infants with very low weight at birth the relative risk of neonatal death is almost 200 times greater." Infant mortality due to low birth weight is usually a direct cause stemming from other medical complications such as preterm birth, poor maternal nutritional status, lack of prenatal care, maternal sickness during pregnancy, and an unhygienic home environments. Along with birth weight, period of gestation makes up the two most important predictors of an infant's chances of survival and their overall health.
According to the New England Journal of Medicine, "in the past two decades, the infant mortality rate (deaths under one year of age per thousand live births) in the United States has declined sharply." Low birth weights from African American pregnant parent's remain twice as high as that of white people. LBW may be the leading cause of infant deaths, and it is greatly preventable. Although it is preventable, the solutions may not be the easiest but effective programs to help prevent LBW are a combination of health care, education, environment, mental modification and public policy, influencing a culture supporting lifestyle. Preterm birth is the leading cause of newborn deaths worldwide. Even though America excels past many other countries in the care and saving of premature infants, the percentage of American pregnant parent's who deliver prematurely is comparable to those in developing countries. Reasons for this include teenage pregnancy, increase in pregnant parent's over the age of thirty-five, increase in the use of in-vitro fertilization which increases the risk of multiple births, obesity and diabetes. Also, pregnant parent's who do not have access to health care are less likely to visit a doctor, therefore increasing their risk of delivering prematurely.
Malnutrition
Main article: Undernutrition in children
Percentage of population suffering from hunger, World Food 2020 Programm22 2,5%
2,5–5,0%
5,0–14,9%
15,0–24,9%
25,0–34,9%
> 35,0%
No data
Malnutrition or undernutrition is defined as inadequate
intake of nourishment, such as proteins and vitamins, which adversely affects
the growth, energy and development of people all over the world. It is
especially prevalent in pregnant parent's and infants under 5 who live in
developing countries within the poorer regions of Africa, Asia, and Latin
America. Children are most vulnerable as they have yet to fully develop a
strong immune system, as well as being dependent upon parents to provide the
necessary food and nutritional intake. It is estimated that about 3.5 million
children die each year as a result of childhood or maternal malnutrition, with
stunted growth, low body weight and low birth weight accounting for about 2.2
million associated deaths. Factors which contribute to malnutrition are
socioeconomic, environmental, gender status, regional location, and
breastfeeding cultural practices. It is difficult to assess the most
pressing factor as they can intertwine and vary among regions.
Adverse effects of
malnutrition
Children suffering from malnutrition face adverse
physical effects such as stunting, wasting, or being overweight. Such characteristics entail difference in
weight-and-height ratios for age in comparison to adequate standards. In Africa
the number of stunted children has risen, while Asia holds the most children
under 5 suffering from wasting. The number of overweight children has
increased among all regions of the globe. Inadequate nutrients adversely
effect physical and cognitive developments, increasing susceptibility The
outcome of malnutrition in children results in decreased ability of the immune
system to fight infections, resulting in higher rates of death from diseases
such as malaria, respiratory disease and diarrhea.
Infectious diseases
Babies born in low to middle income countries in
sub-Saharan Africa and southern Asia are at the highest risk of neonatal death.
Bacterial infections of the bloodstream, lungs, and the brain's covering
(meningitis) are responsible for 25% of neonatal deaths. Newborns can acquire infections
during birth from bacteria that are present in their pregnant parent's
reproductive tract. The pregnant parent may not be aware of the infection, or
they may have an untreated pelvic inflammatory disease or sexually transmitted disease. These bacteria can move up the vaginal canal into the
amniotic sac surrounding the baby. Maternal blood-borne infection is another
route of bacterial infection from pregnant parent to baby. Neonatal infection
is also more likely with the premature rupture of the membranes (PROM) of the
amniotic
Seven out of ten childhood deaths are due to infectious
diseases: acute respiratory infection, diarrhea, measles, and malaria. Acute respiratory infection such as pneumonia, bronchitis, and bronchiolitis account for 30% of childhood deaths; 95% of
pneumonia cases occur in the developing world. Diarrhea is the second-largest
cause of childhood mortality in the world, while malaria causes 11% of
childhood deaths. Measles is the fifth-largest cause of childhood
mortality. Folic acid f.or pregnant parents is one way to combat iron
deficiency. A few public health measures used to lower levels of iron deficiency
anemia include iodize salt or drinking water, and include vitamin A and
multivitamin supplements into a pregnant parent's diet.] A deficiency of this vitamin causes certain types
of anemia (low red blood cell count).
Environmental
Infant mortality rate can be a measure of a nation's health and social condition. It is a composite of a number of component rates which have their separate relationship with various social factors and can often be seen as an indicator to measure the level of socioeconomic disparity within a country.
Organic water pollution is a better indicator of infant mortality than health expenditures
per capita. Water contaminated with various pathogens houses a host of parasitic and microbial infections. Infectious disease and parasites are
carried via water pollution from animal wastes. Areas of low socioeconomic status are more prone to inadequate plumbing
infrastructure, and poorly maintained facilities. The burning of inefficient fuels doubles the rate
of children under 5 years old with acute respiratory tract infections. Climate and geography often play a role in
sanitation conditions. For example, the inaccessibility of clean water
exacerbates poor sanitation conditions.
People who live in areas where particulate matter (PM) air pollution is higher tend to have more health problems across the board. Short-term and long-term effects of ambient air pollution are associated with an increased mortality rate, including infant mortality. Air pollution is consistently associated with post neonatal mortality due to respiratory effects and sudden infant death syndrome (SIDS). Specifically, air pollution is highly associated with SIDS in the United States during the post-neonatal stage. High infant mortality is exacerbated because newborns are a vulnerable subgroup that is affected by air pollution. Newborns who were born into these environments are no exception. People with uterus' who are exposed to greater air pollution on a daily basis who are pregnant should be closely watched by their doctors, as well as after the baby is born. Babies who live in areas with less air pollution have a greater chance of living until their first birthday. As expected, babies who live in environments with more air pollution are at greater risk for infant mortality. Areas that have higher air pollution also have a greater chance of having a higher population density, higher crime rates and lower income levels, all of which can lead to higher infant mortality rates.
The key pollutant for infant mortality rates is carbon
monoxide. Carbon
monoxide is a colorless, odorless gas that does great harm especially to
infants because of their immature respiratory system. Another major pollutant is second-hand smoke, which
is a pollutant that can have detrimental effects on a fetus. According to
the American Journal of Public Health, "in 2006, more than 42
000 Americans died of second hand smoke-attributable diseases, including more
than 41 000 adults and nearly 900 infants ... fully 36% of the infants who
died of low birth weight caused by exposure to maternal smoking in utero were
Blacks, as were 28% of those dying of respiratory distress syndrome, 25% dying
of other respiratory conditions, and 24% dying of sudden infant death
syndrome." The American Journal of Epidemiology also
stated that "Compared with nonsmoking women having their first birth,
women who smoked less than one pack of cigarettes per day had a 25% greater
risk of mortality, and those who smoked one or more packs per day had a 56%
greater risk. Among women having their second or higher birth, smokers
experienced 30% greater mortality than nonsmokers."
Modern research in the United States on racial disparities in infant mortality suggests a link between the institutionalized racism that pervades the environment and high rates of African American infant mortality. In synthesis of this research, it has been observed that "African American infant mortality remains elevated due to the social arrangements that exist between groups and the lifelong experienced responding to the resultant power dynamics of these arrangements."
It is important to note that infant mortality rates do
not decline among African Americans even if their socio-economic status does
improve. Parker Dominguez at the University of Southern California has made
some headway in determining the reasoning behind this, claiming black women are
more prone to psychological stress than other women of different races in the
United States. Stress is a lead factor in inducing labor in pregnant women, and
therefore high levels of stress during pregnancy could lead to premature births
that have the potential to be fatal for the infant.
Early childhood
trauma
Early childhood trauma includes physical, sexual, and psychological abuse
of a child ages zero to five years-old. Trauma in early development has extreme impact over the
course of a lifetime and is a significant contributor to infant mortality.
Developing organs are fragile. When an infant is shaken, beaten, strangled, or
raped the impact is exponentially more destructive than when the same abuse
occurs in a fully developed body. Studies estimate that 1–2 per 100,000 U.S.
children annually are fatally injured. Unfortunately, it is reasonable to
assume that these statistics underrepresent actual mortality.. Three-quarters (70.6 percent) of child fatalities
in FFY 2018 involved children younger than 3 years, and children younger than 1
year accounted for 49.4 percent of all fatalities. In particular, correctly identifying deaths due to
neglect is problematic, and children with sudden unexpected death or those with
what appear to be unintentional causes on the surface often have preventable
risk factors which are substantially similar to those in families with
maltreatment.
There is a direct relationship between age of
maltreatment/injury and risk for death. The younger an infant is, the more
dangerous the maltreatment.
Family configuration, child gender, social isolation, lack of support,
maternal youth, marital status, poverty,
parental ACES, and parenting practices are thought to contribute to increased risk.
Socio-economic factors
Infant mortality rates are higher in countries with higher economic inequality.
Social class is a major factor in infant mortality, both historically and today. Between 1912 and 1915, the Children's Bureau in the United States examined data across eight cities and nearly 23,000 live births. They discovered that lower incomes tend to correlate with higher infant mortality. In cases where the father had no income,
the rate of infant mortality was 357% more than that for the highest income earners ($1,250+). Differences between races were also apparent. African-American mothers experience infant mortality at a rate 44% higher than average; however, research indicates that socio-economic factors do not totally account for the racial disparities in infant mortality.
While infant mortality is normally negatively correlated with GDP, there may indeed be some opposing short-term effects from a recession. A recent study by The Economist showed that economic slowdowns reduce the amount of air pollution, which results in a lower infant mortality rate. In the late 1970s and early 1980s, the recession's impact on air quality is estimated to have saved around 1,300 US babies It is only during deep recessions that infant mortality increases. According to Norbert Schady and Marc-François Smitz, recessions when GDP per capita drops by 15% or more increase infant mortality.
Social class dictates which medical services are available to an individual. Disparities due to socioeconomic factors have been exacerbated by advances in medical technology. Developed countries, most notably the United States, have seen a divergence between those living in poverty who cannot afford medical advanced resources, leading to an increased chance of infant mortality, and others.
Countries by
Political modernization perspective, the neo-classical
economic theory that scarce goods are most effectively distributed to the
market, say that the level of political democracy influences the rate of infant mortality. Developing nations with
democratic governments tend to be more responsive to public opinion, social
movements, and special interest groups for issues like infant mortality. In contrast,
non-democratic governments are more interested in corporate issues and less so
in health issues. Democratic status effects the dependency a nation has towards
its economic state via export, investments from multinational corporations and
international lending institutions.
Levels of socioeconomic development and global
integration are inversely related to a nation's infant mortality rate. Dependency perspective occurs in a global capital
system. A nation's internal impact is highly influenced by its position in the
global economy and has adverse effects on the survival of children in
developing countries. Countries can experience disproportionate effects
from its trade and stratification within the global system. It aids in the global division of
labor, distorting
the domestic of developing nations. The dependency of developing
nations can lead to a reduce rate of economic growth, increase income
inequality inter- and intra-national, and adversely affects the wellbeing of a
nation's population. A collective cooperation between economic countries plays
a role in development policies in the poorer, peripheral, countries of the
world.
These economic factors present challenges to governments' public health policies. If the nation's ability to raise its own revenues is compromised, governments will lose funding for its health service programs, including services that aim in decreasing infant mortality rates. Peripheral countries face higher levels of vulnerability to the possible negative effects of globalization and trade in relation to key countries in the global market.
Even with a strong economy and economic growth (measured
by a country's gross national product), the advances of medical technologies may not be felt by everyone,
lending itself to increasing social disparities. In England from 2014 to
2017 a rise in infant mortality was experienced disproportionately in the most
deprived local authorities where the previously declining trend in infant
mortality was reversed with an additional 24 infant deaths per 100,000 live
births per year relative to the previous trend
War
In policy, there is a lag time between realization of a
problem's possible solution and actual implementation of policy. Infant mortality rates correlate with war, political unrest, and government corruption.
In most cases, war-affected areas will experience a
significant increase in infant mortality rates. Having a war taking place where
a person is planning on having a baby is not only stressful on the pregnant
person and foetus, but also has several detrimental effects.
However, many other significant factors influence infant mortality rates in war-torn areas. Health care systems in developing countries in the midst of war often collapse. Attaining basic medical supplies and care becomes increasingly difficult. During the Yugoslav Wars in the 1990s Bosnia experienced a 60% decrease in child immunizations. Preventable diseases can quickly become epidemic given the medical conditions during war.
Many developing countries rely on foreign aid for basic nutrition. Transport of aid becomes significantly more difficult in times of war. In most situations the average weight of a population will drop substantially. Expecting mothers are affected even more by lack of access to food and water. During the Yugoslav Wars in Bosnia the number of premature babies born increased and the average birth weight decreased.
There have been several instances in recent years of systematic rape as a weapon of war. People who become pregnant as a result of war rape face even more significant challenges in bearing a healthy child. Studies suggest that people who experience sexual violence before or during pregnancy are more likely to experience infant death in their children. Causes of infant mortality in abused pregnant people range from physical side effects of the initial trauma to psychological effects that lead to poor adjustment to society. Many people who became pregnant by rape in Bosnia were isolated from their hometowns making life after childbirth exponentially more difficult.
Culture
High rates of infant mortality occur in developing countries where financial and material resources are scarce and there is a high tolerance to high number of infant deaths. There are circumstances where a number of developing countries to breed a culture where situations of infant mortality such as favoring male babies over female babies are the norm. In developing countries such as Brazil, infant mortality rates are commonly not recorded due to failure to register for death certificates. Failure to register is mainly due to the potential loss of time and money and other indirect costs to the family. Even with resource opportunities such as the 1973 Public Registry Law 6015, which allowed free registration for low-income families, the requirements to qualify hold back individuals who are not contracted workers.
Another cultural reason for infant mortality, such as
what is happening in Ghana, is that "besides the obvious, like rutted
roads, there are prejudices against wives or newborns leaving the house." Because of this it is making it even more difficult
for the pregnant people and newborns to get the treatment that is available to
them and that is needed.
Cultural influences and lifestyle habits in the United States can account for some deaths in infants throughout the years. According to the Journal of the American Medical Association "the post neonatal mortality risk (28 to 364 days) was highest among continental Puerto Ricans" compared to babies of the non-Hispanic race. Examples of this include teenage pregnancy, obesity, diabetes and smoking. All are possible causes of premature births, which constitute the second highest cause of infant mortality. Ethnic differences experienced in the United States are accompanied by higher prevalence of behavioral risk factors and sociodemographic challenges that each ethnic group faces.
Male sex favoritism
Historically, males have had higher infant mortality rates than females. The difference between male and female infant mortality rates have been dependent on environmental, social, and economic conditions. More specifically, males are biologically more vulnerable to infections and conditions associated with prematurity and development. Before 1970, the reasons for male infant mortality were due to infections, and chronic degenerative diseases. However, since 1970, certain cultures emphasizing males has led to a decrease in the infant mortality gap between males and females. Also, medical advances have resulted in a growing number of male infants surviving at higher rates than females due to the initial high infant mortality rate of males. Genetic components results in newborn female being biologically advantaged when it comes to surviving their first birthday. Males, biologically, have lower chances of surviving infancy in comparison to female babies. As infant mortality rates saw a decrease on a global scale, the gender most affected by infant mortality changed from males experiences a biological disadvantage, to females facing a societal disadvantage. Some developing nations have social and cultural patterns that reflects adult discrimination to favor boys over girls for their future potential to contribute to the household production level. A country's ethnic composition, homogeneous versus heterogeneous, can explain social attitudes and practices. Heterogeneous level is a strong predictor in explaining infant mortality.
Birth spacing
Map of
countries by fertility rate (2020), according to the Population Reference Bureau
Birth spacing is the time between births. Births spaced
at least three years apart from one another are associated with the lowest rate
of mortality. The longer the interval between births, the lower the risk for
having any birthing complications, and infant, childhood and maternal mortality. Higher rates of pre-term births, and low birth
weight are associated with birth to conception intervals of less than six
months and abortion to pregnancy interval of less than six months. Shorter
intervals between births increase the chances of chronic and general under-nutrition; 57% of pregnant people
in 55 developing countries reported birth spaces shorter than three years; 26%
report birth spacing of less than two years. Only 20% of post-partum people
report wanting another birth within two years; however, only 40% are taking
necessary steps such as family planning to achieve the birth intervals they want.
Unplanned pregnancies and birth intervals of less than
twenty-four months are known to correlate with low birth weights and delivery
complications. Also, pregnant parent's who are already small in stature tend to
deliver smaller than average babies, perpetuating a cycle of being underweight.
Prevention and outcomes
To reduce infant mortality rates across the world, health
practitioners, governments, and non-governmental organizations have worked to
create institutions, programs and policies to generate better health outcomes.
Current efforts focus on development of human resources, strengthening health
information systems, health services delivery, etc. Improvements in such areas
aim to increase regional health systems and aided in efforts to reduce
mortality rates.
Policy
Reductions in infant mortality are possible in any stage of a country's development. Rate reductions are evidence that a country is advancing in human knowledge, social institutions and physical capital. Governments can reduce the mortality rates by addressing the combined need for education (such as universal primary education), nutrition, and access to basic maternal and infant health services. A policy focus has the potential to aid those most at risk for infant and childhood mortality allows rural, poor and migrant populations.
Reducing chances of babies being born at low birth weights and contracting pneumonia can be accomplished by improving air quality. Improving hygiene can prevent infant mortality. Home-based technology to chlorinate, filter, and solar disinfection for organic water pollution could reduce cases of diarrhea in children by up to 48%. Improvements in food supplies and sanitation has been shown to work in the United States' most vulnerable populations, one being African Americans.
Promoting behavioral changes, such as handwashing with soap, can significantly reduce the rate of infant mortality from respiratory and diarrheal diseases. According to UNICEF, hand washing with soap before eating and after using the toilet can save more lives of children by cutting deaths from diarrhea and acute respiratory infections.
Focusing on preventing preterm and low birth weight
deliveries throughout all populations can help to eliminate cases of infant
mortality and decrease health care disparities within communities. In the
United States, these two goals have decreased infant mortality rates on a
regional population, it has yet to see further progress on a national level.
Increasing human resources such as physicians, nurses, and other health professionals will increase the number of skilled attendants and the number of people able to give out immunized against diseases such as measles. Increasing the number of skilled professionals is negatively correlated with maternal, infant, and childhood mortality. With the addition of one physician per 10,000 people, there is a potential for 7.08 fewer infant deaths per 10,000.
In certain parts of the U.S., specific modern programs
aim to reduce levels of infant mortality. One such program that aims to reduce
infant mortality is the "Best Babies Zone" (BBZ) based at the University of California,
Berkeley. The BBZ uses
the life course approach to address the structural causes of poor birth
outcomes and toxic stress in three U.S. neighborhoods. By employing
community-generated solutions, the Best Babies Zone's ultimate goal is to
achieve health equity in communities that are disproportionately impacted by
infant death.
Prenatal care and maternal health
When a person becomes pregnant, certain steps can help to
reduce the chance of complications during the pregnancy. Attending
regular prenatal care check-ups will help improve the baby's chances of
being delivered in safer conditions and surviving. Additionally, taking supplementation,
including folic acid, can help reduce the chances of birth defects, a leading
cause of infant mortality. Many countries have instituted mandatory folic
acid supplementation in their food supply, which has significantly reduced the
occurrence of spina bifida, a birth defect, in newborns. Similarly, the fortification of salt with iodine,
salt iodization, has helped reduce adverse birth outcomes associated with low
iodine levels during pregnancy.
Abstinence from alcohol can also decrease the chances of harm to the fetus during pregnancy. Drinking any amount of alcohol during pregnancy may lead to fetal alcohol spectrum disorders (FASD) or alcohol related birth defects (ARBD). Tobacco use during pregnancy has also been shown to significantly increase the risk of a preterm or low birth weight birth, both of which are leading causes of infant mortality. Pregnant parent's should consult with their doctors to best manage any existing health conditions that they have to avoid complications of both their health as well as the fetus. Obese people are at an increased risk of developing complications during pregnancy, including gestational diabetes or pre-eclampsia. Additionally, they are more likely to experience a pre-term birth or have a child with birth defects.
Nutrition
Appropriate nutrition for newborns and infants can help
keep them healthy and avoid health complications during early childhood. The
American Academy of Pediatrics recommends exclusively breastfeeding infants for
the first 6 months of life, following by a combination of breastfeeding and
other sources of food through the next 6 months of life, up to 1 year of age. Infants under 6 months of age who are exclusively
breastfed have a lower risk of mortality compared to infants who receive a
combination of breast milk and other food, as well as no breast milk at all. For this reason, breast feeding is favored over
formula feeding by healthcare professionals.
Vaccinations
The Centers for Disease Control and Prevention (CDC) defines infants as those 1 month of age to 1 year of age. For these infants, the CDC recommends the following vaccinations: Hepatitis B (HepB), Rotavirus (RV), Haemophilus Influenzae type B (HIB), Pneumococcal Conjugate (PCV13), Inactivated Poliovirus (IPV < 18 yrs), Influenza, Varicella, Measles, Mumps, Rubella (MMR), and Diphtheria, tetanus, acellular pertussis (DTapP < 7yrs). Each of these vaccinations are given at particular age ranges depending on the vaccination and are required to be done in a series of 1 to 3 doses over time depending on the vaccination.
The efficacy of these vaccinations can be seen
immediately following their introduction to society. Following the advent of the Pneumococcal Conjugate vaccine (PCV13) in the United States in the year 2000,
the World Health Organization (WHO) reports studies done in 2004 had shown a 57% decline
invasive penicillin-resistant strains of diseases and a 59% reduction in
multiple antibiotic resistant strains that could lead to mortality among
infants. This reduction was even greater for children under 2 years of age with
studies finding an 81% reduction in those same strains.
As mentioned in a previous section, sudden infant
death syndrome (SIDS) is the leading cause of infant mortality for those 1 month of
age to 1 year of age. Immunizations, when given in accordance to proper
guidelines, have shown to reduce the risk of SIDS by 50%. For this reason, the American Academy of Pediatrics (AAP) and the Center for
Disease Control (CDC) both recommend immunizations in accordance to their guidelines.
Socio-economic factors
It has been well documented that increased education
among mothers, communities, and local health workers results in better family
planning, improvement on children's health, and lower rates of children's
deaths. High-risk areas, such as Sub-Saharan Africa, have demonstrated that an
increase in women's education attainment leads to a reduction in infant
mortality by about 35%. Similarly, coordinated efforts to train community
health workers in diagnosis, treatment, malnutrition prevention, reporting and
referral services has reduced infant mortality in children under 5 as much as
38%. Public health campaigns centered around the
"First 1,000 Days" of conception have been successful in providing
cost-effective supplemental nutrition programs, as well as assisting young
post-partum parent's in sanitation, hygiene and breastfeeding promotion. Increased intake of nutrients and better sanitation
habits have a positive impact on health, especially developing children.
Educational attainment and public health campaigns provide the knowledge and
means to practice better habits and leads to better outcomes against infant
mortality rates.
Awareness of health services, education, and economic
opportunities provide means to sustain and increase chance of development and
survival. A decrease in GDP, for example, results in increased rates of infant
mortality./Negative effects on household income reduces amount being spent on
food and healthcare, affecting the quality of life and access to medical services
to ensure full development and survival. On the contrary, increased household
income translates to more access to nutrients and healthcare, reducing the
risks associated with malnutrition and infant mortality. Moreover, increased aggregate household incomes
will produce better health facilities, water and sewer infrastructures for the
entire community.
Differences in measurement
Infant mortality rate by region
birth by region
The infant mortality rate correlates very strongly with,
and is among the best predictors of, state. IMR is therefore also a useful indicator of a country's
level of health or development, and is a component of the physical quality of life index.
However, the method of calculating IMR often varies
widely between countries and is based on how they define a live birth and how
many premature infants are born in the country. Reporting of infant mortality
rates can be inconsistent, and may be understated, depending on a nation's live
birth criterion, vital registration system, and reporting practices. The
reported IMR provides one statistic which reflects the standard of living in
each nation. Changes in the infant mortality rate reflect social and technical
capacities. of a nation's population. The World Health Organization (WHO) defines a live birth as any infant born
demonstrating independent signs of life, including breathing, heartbeat,
umbilical cord pulsation or definite movement of voluntary muscles. This definition is used in Austria, for example. The
WHO definition is also used in Germany, but with one slight modification:
muscle movement is not considered to be a sign of life. Many countries, however, including certain European
states (e.g. France) and Japan, only count as live births cases where an infant
breathes at birth, which makes their reported IMR numbers somewhat lower and
increases their rates of perinatal mortality. In the Czech Republic and Bulgaria, for instance,
requirements for live birth are even higher.
Although many countries have vital registration systems
and certain reporting practices, there are many inaccuracies, particularly in
undeveloped nations, in the statistics of the number of infants dying. Studies
have shown that comparing three information sources (official registries,
household surveys, and popular reporters) that the "popular death
reporters" are the most accurate. Popular death reporters include
midwives, gravediggers, coffin builders, priests, and others—essentially people
who knew the most about the child's death. In developing nations, access to
vital registries, and other government-run systems which record births and
deaths, is difficult for poor families for several reasons. These struggles
force stress on families, and make them take drastic measures in unofficial death ceremonies for their deceased infants. As a
result, government statistics will inaccurately reflect a nation's infant
mortality rate. Popular death reporters have first-hand information, and
provided this information can be collected and collated, can provide reliable
data which provide a nation with accurate death counts and meaningful causes of
deaths that can be measured/studied.
UNICEF uses a statistical methodology to account for
reporting differences among countries:
UNICEF compiles
infant mortality country estimates derived from all sources and methods of
estimation obtained either from standard reports, direct estimation from micro
data sets, or from UNICEF's yearly exercise. In order to sort out differences
between estimates produced from different sources, with different methods,
UNICEF developed, in coordination with WHO, the WB and UNSD, an estimation
methodology that minimizes the errors embodied in each estimate and harmonize
trends along time. Since the estimates are not necessarily the exact values
used as input for the model, they are often not recognized as the official IMR
estimates used at the country level. However, as mentioned before, these estimates
minimize errors and maximize the consistency of trends along time.
Another challenge to comparability is the practice of
counting frail or premature infants who die before the normal due date as miscarriages (spontaneous abortions) or those who die during or
immediately after childbirth as stillborn. Therefore, the quality of a country's documentation of perinatal mortality can matter greatly to the accuracy of its infant
mortality statistics. This point is reinforced by the demographer Ansley Coale, who finds dubiously high ratios of reported stillbirths
to infant deaths in Hong Kong and Japan in the first 24 hours after birth, a
pattern that is consistent with the high recorded sex ratios at birth in those
countries. It suggests not only that many female infants who die in the first
24 hours are misreported as stillbirths rather than infant deaths, but also
that those countries do not follow WHO recommendations for the reporting of
live births and infant deaths.
Another seemingly paradoxical finding, is that when
countries with poor medical services introduce new medical centers and
services, instead of declining, the reported IMRs often increase for a time.
This is mainly because improvement in access to medical care is often
accompanied by improvement in the registration of births and deaths. Deaths
that might have occurred in a remote or rural area, and not been reported to
the government, might now be reported by the new medical personnel or facilities.
Thus, even if the new health services reduce the actual IMR, the reported IMR
may increase.
Collecting the accurate statistics of infant mortality
rate could be an issue in some rural communities in developing countries. In
those communities, some other alternative methods for calculating infant
mortality rate are emerged, for example, popular death reporting and household
survey. The country-to-country variation in child mortality
rates is huge, and growing wider despite the progress. Among the world's
roughly 200 nations, only Somalia showed no decrease in the under-5 mortality
rate over the past two decades. The lowest rate in 2011 was in Singapore, which
had 2.6 deaths of children under age 5 per 1,000 live births. The highest was
in Sierra Leone, which had 185 child deaths per 1,000 births. The global rate
is 51 deaths per 1,000 births. For the United States, the rate is eight per
1,000 births.
Infant mortality rate (IMR) is not only a group of
statistic but instead it is a reflection of the socioeconomic development and
effectively represents the presence of medical services in the countries. IMR
is an effective resource for the health department to make decision on medical
resources reallocation. IMR also formulates the global health strategies and
help evaluate the program success. The existence of IMR helps solve the
inadequacies of the other vital statistic systems for global health as most of
the vital statistic systems usually neglect the infant mortality statistic
number from the poor. There are certain amounts of unrecorded infant deaths in
the rural area as they do not have information about infant mortality rate
statistic or do not have the concept about reporting early infant death.
Europe and US.
The exclusion of any high-risk infants from the denominator or numerator in reported IMRs can cause problems in making comparisons. Many countries, including the United States, Sweden and Germany, count an infant exhibiting any sign of life as alive, no matter the month of gestation or the size, but according to United States some other countries differ in these practices. All of the countries named adopted the WHO definitions in the late 1980s or early 1990s, which are used throughout the European Union. However, in 2009, the US CDC issued a report that stated that the American rates of infant mortality were affected by the United States' high rates of premature babies compared to European countries. It also outlined the differences in reporting requirements between the United States and Europe, noting that France, the Czech Republic, Ireland, the Netherlands, and Poland do not report all live births of babies under 500 g and/or 22 weeks of gestation. However, the differences in reporting are unlikely to be the primary explanation for the high rate of infant mortality in the United States' compared with its peer countries at a similar level of economic development. Rather, the report concluded that the primary reason for the United States' higher infant mortality rate when compared with Europe was the United States' much higher percentage of preterm births.
Until the 1990s, Russia and the Soviet Union did not count, as a live birth or as an infant death, extremely premature infants (less than 1,000 g, less than 28 weeks gestational age, or less than 35 cm in length) that were born alive (breathed, had a heartbeat, or exhibited voluntary muscle movement) but failed to survive for at least seven days. Although such extremely premature infants typically accounted for only about 0.5% of all live-born children, their exclusion from both the numerator and the denominator in the reported IMR led to an estimated 22%–25% lower reported IMR. In some cases, too, perhaps because hospitals or regional health departments were held accountable for lowering the IMR in their catchment area, infant deaths that occurred in the 12th month were "transferred" statistically to the 13th month (i.e., the second year of life), and thus no longer classified as an infant death.
Brazil
In certain rural developing areas, such as northeastern
Brazil, infant births are often not recorded in the first place, resulting in
the discrepancies between the infant mortality rate (IMR) and the actual number
of infant deaths. Access to vital registry systems for infant births and deaths
is an extremely difficult and expensive task for poor parents living in rural
areas. Government and bureaucracies tend to show an insensitivity to these
parents and their recent suffering from a deceased child and produce broad
disclaimers in the IMR reports that the information has not been properly
reported, resulting in these discrepancies. Little has been done to address the
underlying structural problems of the vital registry systems in respect to the
lack of reporting from parents in rural areas, and in turn has created a gap
between the official and popular meanings of child death. It is also argued that the bureaucratic separation
of vital death recording from cultural death rituals is to blame for the
inaccuracy of the infant mortality rate (IMR). Vital death registries often
fail to recognize the cultural implications and importance of infant deaths. It
is not to be said that vital registry systems are not an accurate
representation of a region's socio-economic situation, but this is only the
case if these statistics are valid, which is unfortunately not always the
circumstance. "Popular death reporters" is an alternative method for
collecting and processing statistics on infant and child mortality. Many
regions may benefit from "popular death reporters" who are culturally
linked to infants may be able to provide more accurate statistics on the
incidence of infant mortality. According to ethnographic data, "popular death
reporters" refers to people who had inside knowledge of anjinhos,
including the grave-digger, gatekeeper, midwife, popular healers etc.—all key
participants in mortuary rituals. By combining the methods of household surveys,
vital registries, and asking "popular death reporters" this can
increase the validity of child mortality rates, but there are many barriers
that can reflect the validity of our statistics of infant mortality. One of
these barriers are political economic decisions. Numbers are exaggerated when
international funds are being doled out; and underestimated during reelection.
The bureaucratic separation of vital death reporting and cultural death rituals stems in part due to structural violence. Individuals living in rural areas of Brazil need to invest large capital for lodging and travel in order to report infant birth to a Brazilian Assistance League office. The negative financial aspects deters registration, as often individuals are of lower income and cannot afford such expenses. Similar to the lack of birth reporting, families in rural Brazil face difficult choices based on already existing structural arrangements when choosing to report infant mortality. Financial constraints such as reliance on food supplementations may also lead to skewed infant mortality data.
In developing countries such as Brazil the deaths of
impoverished infants are regularly unrecorded into the countries vital
registration system; this causes a skew statistically. Culturally validity and
contextual soundness can be used to ground the meaning of mortality from a
statistical standpoint. In northeast Brazil they have accomplished this
standpoint while conducting an ethnographic study combined with an alternative
method to survey infant mortality. These types of techniques can develop quality
ethnographic data that will ultimately lead to a better portrayal of the
magnitude of infant mortality in the region. Political economic reasons have
been seen to skew the infant mortality data in the past when governor Ceara
devised his presidency campaign on reducing the infant mortality rate during
his term in office. By using this new way of surveying, these instances can be
minimized and removed, overall creating accurate and sound data.
Jan Ricks Jennings, MHA, LFACHE
Senior Consultant
Senior Management Resources, LLC
412.913.0636 Cell
724.733.0509 Office
JanJenningsBlog.Blogspot.com
412.913.0636 Cell
724.733.0509 Office
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