Infant mortality
Infant mortality is the death of an infant before the infant's first birthday.[1] The occurrence of infant mortality in a population can be described by the infant mortality rate (IMR), which is the number of deaths of infants under one year of age per 1,000 live births.[1] 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.[2]
In 2013, the leading cause of infant mortality in the United States was birth defects.
In 1990, 8.8 million infants younger than one-year-old died globally[9] out of 12.6 million child deaths under the age of five.[10] More than 60% of the deaths of children under-five are seen as avoidable with low-cost measures such as continuous breastfeeding, vaccinations, and improved nutrition.[11] The global under-five mortality rate in 1950 was 22.5%, which dropped to 4.5% in 2015.[10] Over the same period, the infant mortality rate declined from 65 deaths per 1,000 live births to 29 deaths per 1,000.[12] Globally, 5.4 million children died before their fifth birthday in 2017;[13] by 2021 that number had dropped to 5 million children.[14]
The child mortality rate (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 was established as a target in the Sustainable Development Goals—Goal Number 3: Ensure healthy lives and promote well-being for all at all ages.[15] As of January 2022[update], an analysis of 200 countries found 133 already meeting the SDG target, with 13 others trending towards meeting the target by 2030.[16] Throughout the world, the infant mortality rate (IMR) fluctuates drastically, and according to Biotechnology and Health Sciences, education and life expectancy in a country are the leading indicators of IMR.[17] 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.[17]
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.[18]
Forms of infant mortality:
- Perinatal mortality is late fetal death (22 weeks gestation to birth) or death of a newborn up to one week postpartum.[18]
- Neonatal mortality is 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.[19]
- Postneonatal mortality is the death of children aged 29 days to one year. The major contributors to postneonatal death are malnutrition, infectious disease, pregnancy complications, sudden infant death syndrome, and problems in the home environment.[1]
Causes
Causes of infant mortality, or direct causes of death, differ from contributions to the IMR, as contributing factors raise the risk of death, but do not directly cause death.
Main causes
There are three main leading causes of infant mortality: conditions related to preterm birth, congenital anomalies, and SIDS (sudden infant death syndrome).[24] In North Carolina between 1980 and 1984, 37.5% of infant deaths were due to prematurity, congenital anomalies accounted for 17.4% and SIDS accounted for 12.9%.[24]
Premature birth
Premature, or preterm birth (PTB), is defined as birth before a gestational age of 37 weeks, as opposed to full term birth at 40 weeks. This can be further sub-divided in various ways, one being: "mild preterm (32–36 weeks), very preterm (28–31 weeks) and extremely preterm (<28 weeks)".[25] A lower gestational age increases the risk of infant mortality.[26]
Between 1990 and 2010 prematurity was the second leading cause of worldwide mortality for neonates and children under the age of five.[27] 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.[27][failed verification] 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.[28] In the United States, the period from 1980 to 2000 saw a decrease in the total number of infant mortality cases, despite a significant increase in premature births.[29]
Based on distinct clinical presentations, there are three main subgroups of preterm births: those that occur due to spontaneous premature labor, those that occur due to spontaneous membrane (
Infant mortality caused by premature birth is mainly attributed to developmental immaturity, which impacts multiple organ systems in the infant's body.
Understanding the biological causes and predictors of PTB 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 <1,000 g or at <28 to 30 weeks of gestation" have been associated with inflammation.[citation needed] 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 understanding the pathology of preterm birth, but they are not always useful if not acquired at the appropriate gestational time-frame. For example, biomarkers such as fibronectin are accurate predictors of premature birth at over 24 weeks of gestation but have poor predictive values before then.[34] Additionally, understanding the risks associated with different gestational ages is a helpful determiner of Gestational age-specific mortality.[29]
Sudden infant death syndrome (SIDS)
Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant less than one year of age with no cause detected after a thorough investigation. SIDS is more common in Western countries.
In the United States, approximately 3,500 infant deaths are sleep-related, a category that includes SIDS.[39] To reduce sleep-related infant deaths, the American Academy of Pediatrics recommends providing infants with safe-sleeping environments, breastfeeding, and immunizing according to the recommended immunization schedule. They recommend against the use of a pacifier and recommend avoiding exposure to smoke, alcohol, and illicit drugs during and after pregnancy.[39]
Congenital malformations
Congenital malformations are present at birth and include conditions such as cleft lip and palate, Down Syndrome, and heart defects. Some congenital malformations may be more likely when the mother consumes alcohol, but they can also be caused by genetics or unknown factors.[40] Congenital malformations have had a significant impact on infant mortality, but alnutrition and infectious diseases remain the main causes of death in less developed countries. For example, in the Caribbean and Latin America in the 1980s, congenital malformations only accounted for 5% of infant deaths, while malnutrition and infectious diseases accounted for 7% to 27% of infant deaths.[41] In more developed countries, such as the United States, there was a rise in infant deaths due to congenital malformations, mostly heart and central nervous system problems. In the 20th century, there was a decrease in the number of infant deaths from heart conditions, from 1979 to 1997, there was a 39% decline.[42]
Medicine and biology
Causes of infant mortality and deaths that are related to medical conditions include: low birth weight,
The American Academy of Pediatrics recommends that infants need multiple doses of vaccines such as
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."[This quote needs a citation] 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, a lack of prenatal care, maternal sickness during pregnancy, and unhygienic home environments.[18] Birth weight and the length of gestation are the two most important predictors of an infant's chances of survival and their overall health.[44]
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."[This quote needs a citation] The rate of low birth weights among African Americans remains twice as high as the rate for white people. Low birth weight, the leading cause of infant deaths, is preventable by effective programs to help prevent low birth weight are a combination of health care, education, the environment,mental modification,[clarify] and public policy.[45] Preterm birth is the leading cause of newborn deaths worldwide.[46] Even though America has a higher survival rate for premature infants, the percentage of Americans who deliver prematurely is comparable to those in developing countries. Reasons for this include teenage pregnancy, an increase in pregnancy after the age of 35, an increase in the use of in vitro fertilisation (which increases the risk of multiple births), obesity, and diabetes. Also, pregnant people who do not have access to health care are less likely to visit a doctor, therefore increasing their risk of delivering prematurely.[47]
Malnutrition
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.[48] It is especially prevalent during pregnancy and in infants and children under 5 who live in developing countries within the poorer regions of Africa, Asia, and Latin America.[49] Children are especially vulnerable as they have yet to fully develop a strong immune system and are dependent on their 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.[50] Socioeconomic and environmental factors contribute to malnutrition, as do gender, location, and cultural practices surrounding breastfeeding.[51] It is difficult to assess the most pressing factor as they can intertwine and vary among regions.
Children suffering from malnutrition can become underweight, and experience stunting or wasting. In Africa, the number of stunted children has risen, while Asia has the most children under 5 suffering from wasting.[52] Inadequate nutrients adversely affect physical and cognitive development, increasing susceptibility to severe health problems. Micronutrient deficiency has been linked to anemia, fatigue, blindness, goiter, poor brain development, and death.[53] Malnutrition also decreases the immune system's ability to fight infections, resulting in higher rates of death from diseases such as malaria, respiratory disease, and diarrhea.[54]
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 (
Seven out of ten childhood deaths are due to infectious diseases like
Environmental
The infant mortality rate is one measure of a nation's health and social conditions. Its causes are a composite of a number rates that each have their own separate relationships with each other and with various other social factors. As such, IMR can often be seen as an indicator to measure the level of socioeconomic disparity within a country.[44][58]
Organic
The burning of inefficient fuels doubles the rate of acute respiratory tract infections in children under 5 years old.
A key pollutant in infant mortality rates is carbon monoxide. Carbon monoxide is a colorless, odorless gas that can kill, and is especially dangerous to infants because of their immature respiratory systems.[63] Another major pollutant that can have detrimental effects on a fetus is second-hand smoke.
[I]n 2006, more than 42,000 Americans died of secondhand 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 black, as were 28% of those dying of respiratory distress syndrome, 25% dying of other respiratory conditions, and 24% dying of sudden infant death syndrome.
— American Journal of Public Health
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.
— The American Journal of Epidemiology
Modern research in the United States into racial disparities in infant mortality suggests a link between
It is important to note that infant mortality rates do not decline among African Americans if their socio-economic status improves. Parker Dominguez at the University of Southern California[64] has made some headway in determining the reasons behind this, claiming black women in the US are more prone to psychological stress than women of other races. Stress is a leading factor in the start of labor, and therefore, high levels of stress during pregnancy could lead to premature births that have the potential to be fatal for the infant.[65]
Early childhood trauma
There is a direct relationship between the age at which maltreatment or injury occurs and the risk of death. The younger an infant is, the more dangerous the maltreatment.[68][failed verification]
Family configuration,
Socio-economic factors
While infant mortality is normally negatively correlated with GDP, there may be some beneficial short-term effects from a recession. A 2009 study in
Social class dictates which medical services are available to an individual. Disparities due to
Developing nations with democratic governments tend to be more responsive to public opinion,
Levels of socioeconomic development and global integration are inversely related to a nation's infant mortality rate, meaning that as they increase, IMR decreases.
These economic factors present challenges to governments' public health policies.[59] If the nation's ability to raise its own revenues is compromised, governments will lose funding for their health service programs, including those that aim to decrease infant mortality rates.[75] Less developed countries face higher levels of vulnerability to the possible negative effects of globalization and trade in relation to more developed countries.[59]
Even with a strong economy and economic growth (measured by a country's
War
Infant mortality rates correlate with
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, and obtaining 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 epidemics during war.[79]
Many developing countries rely on foreign aid for basic nutrition, and transport of aid becomes significantly more difficult in times of war. In most situations, the average weight of a population will drop substantially.[80] Expectant mothers are affected even more by a 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.[79]
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.[81][82][83] Causes of infant mortality after abuse during pregnancy range from physical side effects of the initial trauma to psychological effects that lead to poor adjustment to society.[84] Many people who became pregnant by rape in Bosnia were isolated from their hometowns, making life after childbirth exponentially more difficult.[citation needed]
Culture
High rates of infant mortality occur in developing countries where financial and material resources are scarce, and where there is a high tolerance for infant deaths. There are a number of developing countries where certain cultural situations, such as favoring male babies over female babies, are the norm.[18] In developing countries such as Brazil, infant mortality rates are commonly not recorded due to not registering for death certificates.[85] 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."[86] This makes it even more difficult for pregnant women and newborns to get the needed treatment that is available to them.
In the United States cultural influences and lifestyle habits can account for some infant deaths. Examples include teenage pregnancy, obesity, diabetes, and smoking. All are possible causes of premature births, which constitute the second-highest cause of infant mortality.[47] 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 non-Hispanic babies. Ethnic differences are accompanied by a higher prevalence of behavioral risk factors and sociodemographic challenges that each ethnic group faces.[44]
Male sex favoritism
Historically, males have had higher infant mortality rates than females, with the difference being 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 infections and chronic degenerative diseases. However, since 1970, male sex favoritism in certain cultures has led to a decrease in the infant mortality gap between males and females. Also, medical advances have resulted in a greater effect on the survival rate of male infants than female infants, due to the initial high infant mortality rate of males.[87]
Genetic components result in newborn females being at a biological advantage when it comes to surviving their first birthday, versus newborn males, who have lower chances of surviving infancy. As infant mortality rates decreased globally, the gender ratios changed from males being at a biological disadvantage to females facing a societal disadvantage.[87] Some developing nations have social and cultural patterns that favor boys over girls for their future earning potential. A country's ethnic composition, homogeneous or heterogeneous, can explain social attitudes and practices. Heterogeneous levels are a strong predictor of infant mortality.[76][verification needed]
Birth spacing
Birth spacing is the time between births. Births spaced at least three years apart are associated with the lowest rate of mortality. The longer the interval between births, the lower the risk of having complications at birth, or of infant, childhood, or
Unplanned pregnancies and birth intervals of less than twenty-four months are known to correlate with low birth weights and delivery complications. Also, mothers who are already small in stature tend to deliver smaller than average babies, perpetuating a cycle of being underweight.[18][19][88]
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 the development of human resources, strengthening health information systems, health service delivery, etc. Improvements in such areas aim to increase regional health systems and aid efforts to reduce mortality rates.
Policy
Reductions in infant mortality are possible at any stage of a country's development.
Reducing the chances of babies being born at low birth weights and contracting pneumonia can be accomplished by improving air quality.[
Promoting
Focusing on preventing preterm and low birth weight deliveries throughout all populations can help eliminate cases of infant mortality and decrease health care disparities within communities. In the United States, these two goals have decreased regional infant mortality rates, but there has yet to be further progress on a national level.[44]
Increasing human resources such as
In certain parts of the US, specific programs aim to reduce levels of infant mortality. One such program is the "Best Babies Zone" (BBZ), based at the
Prenatal care and maternal health
Certain steps can help to reduce the chance of complications during pregnancy. Attending regular
Abstinence from alcohol can also decrease the chances of harm to the fetus as drinking any amount of alcohol during pregnancy may lead to fetal alcohol spectrum disorders (FASD) or other alcohol related birth defects.[97] 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.[98] Pregnant women should consult with their doctors to best manage any pre-existing health conditions to avoid complications to both their health as well as the fetus's. 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.[99][96]
Nutrition
Appropriate nutrition for newborns and infants can help keep them healthy, and can help avoid health complications during early childhood. The American Academy of Pediatrics recommends exclusively breastfeeding infants for the first 6 months of life, and continuing breastfeeding as other sources of food are introduced through the next 6 months of life (up to 1 year of age).[100] Infants under 6 months of age who are exclusively breastfed have a lower risk of mortality compared to infants who are breastfed part of the time or not at all.[101] 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.[102] 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).[103] 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.[103]
The efficacy of these vaccinations can be seen immediately following their introduction to society.
As mentioned in a previous section,[c] sudden infant death syndrome (SIDS) is the leading cause of infant mortality between 1 month and 1 year of age.[36] Immunizations, when given in accordance to proper guidelines, have shown to reduce the risk of SIDS by 50%.[39][105] For this reason, the American Academy of Pediatrics (AAP) and the Center for Disease Control (CDC) both recommend immunizations in accordance to their guidelines.[39][106]
Socio-economic factors
It has been well documented that increased education among mothers, communities, and local health workers results in better
A decrease in
Differences in measurement
The infant mortality rate correlates very strongly with the likelihood of
The method of calculating IMR often varies widely between countries, as it is based on how they define a live birth and how many premature infants are born in the country. Depending on a nation's live birth criterion, vital registration system, and reporting practices, reporting may be inconsistent or understated.[113] The reported IMR provides one statistic which reflects the standard of living in each nation. Changes in the infant mortality rate "reflect enduring social and technical capacities that become attached to a population".[21] 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.[114] This definition is used in Austria,[115] and is also used in Germany, but with one slight modification: muscle movement is not considered to be a sign of life.[116] Many countries, including certain European states (e.g. France) and Japan, only count cases where an infant breathes at birth as a live birth, which makes their reported IMR numbers somewhat lower and increases their rates of perinatal mortality.[117] In other countries, the Czech Republic and Bulgaria, for instance, requirements for live birth are even higher.[118]
Although many countries have
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.[119]
Another challenge in comparing infant mortality rates is the practice of counting frail or premature infants who die before the normal due date as miscarriages, or counting those who die during or immediately after childbirth as stillbirths. Therefore, the quality of a country's documentation of perinatal mortality can greatly affect the accuracy of its infant mortality statistics. This point is reinforced by the demographer Ansley Coale, who finds the high ratios of reported stillbirths to infant deaths in Hong Kong and Japan in the first 24 hours after birth dubious. As this pattern is consistent with the high male to female sex ratios recorded at birth in those countries it suggests two things: that many female infants who die in the first 24 hours are misreported as stillbirths rather than infant deaths; and that those countries do not follow WHO recommendations for the reporting of live births versus infant deaths.[120]
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.[citation needed]
The country-to-country variation in child mortality rates is huge, and growing wider despite progress in decreasing the overall IMR. Among the world's roughly 200 nations, only Somalia showed no decrease in the under-5 mortality rate over the past two decades. In 2011 the global rate of under-5 deaths was 51 deaths per 1,000 births. Singapore had the lowest rate at 2.6, while Sierra Leone had the highest at 185 child deaths per 1,000 births. In the U.S., the rate was 8 under-5 deaths per 1,000 births.[121]
Infant mortality rate (IMR) is not only a statistic but also a reflection of socioeconomic development, as such it effectively represents the presence of medical services in a country. IMR is an effective resource for health departments making decisions on medical resource allocation, and also formulates global health strategies and helps evaluate their success. The use of IMR helps solve the inadequacies of other vital statistic systems for global health as most neglect infant mortality rates among the poor. There remains a certain amount of unrecorded infant death in rural area as they either do not have the concept of reporting early infant death, or they do not know about the importance of the IMR.[85]
Europe and US
Reporting requirement | Country |
---|---|
All live births | Austria, Denmark, England and Wales, Finland, Germany, Hungary, Italy, Northern Ireland, Portugal, Scotland, Slovak Republic, Spain, Sweden, United States |
Live births at 12 weeks of gestation or more | Norway |
Live births at 500 grams birthweight or more, and less than 500 grams if the infant survives for 24 hours | Czech Republic |
Live births at 22 weeks of gestation or more, or 500 grams birthweight or more | France |
All live births for civil registration, births at 500 grams birthweight or more for the national perinatal register | Ireland |
Live births at 22 weeks of gestation or more, 500 grams birthweight or more if gestational age is unknown | Netherlands |
Live births at 500 or more grams birthweight | Poland |
The inclusion or exclusion of high-risk neonates from the reported IMRs can cause problems in making comparisons. Many countries, including the United States, Sweden and Germany, count any birth exhibiting any sign of life as alive, no matter the month of gestation or neonatal size. All of the countries named in the table adopted the WHO definitions in the late 1980s or early 1990s,[124] and they are used throughout the European Union.[125] However, in 2009, the US CDC issued a report that stated that the American rates of infant mortality were affected by the high rates of premature babies in the United States 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 under 500 g and/or 22 weeks of gestation.[126][127][128] However, differences in reporting are unlikely to be the primary explanation for the high rate of infant mortality in the United States compared to countries at a similar level of economic development. Rather, the report concluded that the primary reason for the higher infant mortality rate in the US compared to Europe was the much higher number of preterm births.[128]
Until the 1990s, Russia and the Soviet Union did not count, either as a live birth or as an infant death, extremely premature infants that were born alive but failed to survive for at least seven days (infants born weighing less than 1,000 g, of less than 28 weeks gestational age, or less than 35 cm in length, who that breathed, had a heartbeat, or exhibited voluntary muscle movement).
Brazil
This section relies largely or entirely on a single source. (July 2023) |
In certain rural developing areas, such as northeastern Brazil, infant births are often not recorded, 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 produce broad disclaimers in the IMR reports that the information has not been properly reported, resulting in discrepancies. Little has been done to address the underlying structural problems with the vital registry systems regarding the lack of reporting in rural areas, which has created a gap between the official and popular meanings of child death.[85]
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. These systems can be an accurate representation of a region's socio-economic situation, if the statistics are valid, which is unfortunately not always the case. An alternate method of collecting and processing statistics on infant and child mortality is via "popular death reporters" who are culturally linked to infants and may be able to provide more accurate statistics.[85] 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.[85] Combining the methods of household surveys, vital registries, and asking "popular death reporters" can increase the validity of child mortality rates. However there remain barriers that affect the validity of statistics of infant mortality, including political economic decisions: numbers are exaggerated when international funds are being doled out; and underestimated during reelection.[85][failed verification]
The bureaucratic separation of vital death reporting and cultural death rituals stems, in part, from
In developing countries such as Brazil the deaths of impoverished infants are regularly not recorded into the countries vital registration system, which skews statistics. Culturally validity and contextual soundness can be used to ground the meaning of mortality from a statistical standpoint.[clarification needed] 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 data that will lead to a better portrayal of the IMR of a region.[85]
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.[85][relevant?]
Epidemiology
Years | Rate | Years | Rate |
---|---|---|---|
1950–1955 | 152 | 2000–2005 | 52 |
1955–1960 | 136 | 2005–2010 | 47 |
1960–1965 | 116 | 2010–2015 | 43 |
1965–1970 | 100 | 2015–2020 | 40 |
1970–1975 | 91 | 2020–2025 | 37 |
1975–1980 | 83 | 2025–2030 | 34 |
1980–1985 | 74 | 2030–2035 | 31 |
1985–1990 | 65 | 2035–2040 | 28 |
1990–1995 | 61 | 2040–2045 | 25 |
1995–2000 | 57 | 2045–2050 | 23 |
Global IMR, as well as the IMR for both
However, IMR was, and remains, higher in LDCs. In 2001, the IMR for 91 LDCs was about 10 times as large as it was for 8 MDCs. On average, for LDCs, the IMR is 17 times higher than that of MDCs.[clarification needed] Also, while both LDCs and MDCs made significant reductions in IMR, the reduction rate has been lower in less developed countries than among the more developed countries. Among many low- and middle-income countries, there is also substantial variation in infant mortality rate at a subnational level.[136]
As the lowest rate, in Monaco, is 1.80, and the highest IMR, in Afghanistan, is 121.63, a factor of about 67 separates them.
Rank | Country | Infant mortality rate (deaths/1,000 live births) |
---|---|---|
1 | Afghanistan | 121.63 |
2 | Niger | 109.98 |
3 | Mali | 109.08 |
4 | Somalia | 103.72 |
5 | Central African Republic | 97.17 |
218 | Sweden | 2.74 |
219 | Singapore | 2.65 |
220 | Bermuda | 2.47 |
221 | Japan | 2.21 |
222 | Monaco | 1.80 |
United Kingdom
A study published in the
United States
Of the 27 most developed countries, the U.S. has the highest infant mortality rate, despite spending more on health care, per capita, than any other country.[139] Significant racial and socio-economic differences in the United States affect the IMR, in contrast with other developed countries with more homogeneous populations. In particular, IMR varies greatly by race in the US. The average IMR for the country as a whole is therefore not a fair representation of the wide variations that exist between segments of the population.[140] Many theories have been explored as to why these racial differences exist, with socio economic factors usually coming out as a reasonable explanation. However, more studies have been conducted around this matter, and the largest advancement is around the idea of stress and how it affects pregnancy.[citation needed]
In the 1850s, the infant mortality rate in the United States was estimated at 216.8 per 1,000 white babies and 340.0 per 1,000 African American babies,[
Economic expenditures on
Differences in measurement could play a substantial role in the disparity between the US and other nations. A non-viable birth in the US could be registered as a stillbirth in similarly developed nations like Japan, Sweden, Norway, Ireland, the Netherlands, and France, thereby reducing their IMR.[128] Neonatal intensive care is also more likely to be applied in the US to marginally viable infants, although such interventions have been found to increase both costs and disability. A study following the implementation of the Born Alive Infant Protection Act of 2002 found universal resuscitation of infants born between 20 and 23 weeks increased the neonatal spending burden by $313.3 million while simultaneously decreasing quality-adjusted life years by 329.3.[148]
The vast majority of research conducted in the late twentieth and early twenty-first century indicates that African-American infants are more than twice as likely to die in their first year of life than white infants. Although a decline occurred from 13.63 deaths in 2005 to 11.46 deaths per 1,000 live births in 2010, non-Hispanic black parents continued to report a rate 2.2 times as high as that for non-Hispanic white parents.[149]
Contemporary research findings have demonstrated that nationwide racial disparities in infant mortality are linked to the experiences of the postpartum parent and that these disparities cannot be totally accounted for by socio-economic, behavioral or genetic factors.[23] The Hispanic paradox, an effect observed in other health indicators, appears in the infant mortality rate, as well. Hispanic postpartum parents see an IMR comparable to non-Hispanic white postpartum parents, even with lower educational attainment and economic status.[150] According to Mustillo's CARDIA (Coronary Artery Risk Development in Young Adults) study, "self reported experiences of racial discrimination were associated with pre-term and low-birthweight deliveries, and such experiences may contribute to black-white disparities in prenatal outcomes."[151] A study in North Carolina, for example, concluded that "white women who did not complete high school have a lower infant mortality rate than black college graduates."[152] Likewise, dozens of population-based studies indicate that "the subjective, or perceived experience of racial discrimination is strongly associated with an increased risk of infant death and with poor health prospects for future generations of African Americans."[23]
African American
While earlier parts of this article have addressed racial differences in the infant death rate, a closer look into the effects of racial differences within the country is necessary to view discrepancies. Non-Hispanic Black women have the highest infant mortality rate with a rate of 11.3, while the IMR among white women is 5.1.[153]
While the popular argument is that due to the trend of black women being of a lower socio-economic status there is in an increased likelihood of a child suffering, and while this does correlate, the theory is not congruent with the data on Latino IMR in the United States. Latino people are almost as likely to experience poverty as blacks in the U.S., however, the infant mortality rate of Latinos is much closer to white women than it is to black women. The poverty rate for blacks is 24.1% and for Latinos it is 21.4%; if there is a direct correlation, then the IMR of these two groups should be rather similar, however, blacks have an IMR double that of Latinos.[154] Also, for black women who move out of poverty, or never experienced it in the first place, their IMR is not much lower than their counterparts experiencing higher levels of poverty.
Tyan Parker Dominguez at the University of Southern California offers a theory to explain the disproportionally high IMR among black women in the United States. She says African American women experience stress at much higher rates than any other group in the country. Stress produces particular hormones that can induce labor and contribute to other pregnancy problems. Considering
Others believe black women are predisposed to a higher IMR, meaning ancestrally speaking, all women from African descent should experience an elevated rate. This theory is quickly disproven by looking at foreign-born African immigrants, these women come from a completely different social context and are not prone to the higher IMR experienced by American-born black women.[155] Arline Geronimus, a professor at the University of Michigan School of Public Health calls the phenomenon "weathering". She claims constantly dealing with disadvantages and racial prejudice causes black women's birth outcomes to deteriorate with age. Therefore, younger black women may experience stress with pregnancy due to social and economic factors, but older women experience stress at a compounding rate and therefore have pregnancy complications aside from economic factors.[156]
Mary O. Hearst, a professor in the Department of Public Health at Saint Catherine University, researched the effects of segregation on the African American community to see if it contributed to the high IMR in black children.[157] Hearst claims that residential segregation contributes to the high rates because of the political, economic, and health implications it poses on black mothers regardless of their socioeconomic status. Racism, economic disparities, and sexism in segregated communities are all examples of the daily stressors that pregnant black women face, and are risk factors for conditions that can affect their pregnancies such as pre-eclampsia and hypertension.[citation needed]
Studies have also shown that high IMR is due to the inadequate care that pregnant African Americans receive compared to other women in the country.[158] In another study, it was shown that Black patients were more likely to receive ibuprofen after surgery instead of oxycodone.[159] This unequal treatment stems from the idea that there are racial medical differences and is also rooted in racial biases and controlled images of black women. Because of this unequal treatment, research on maternal and prenatal care received by African American women and their infants,[160] finds that black women do not receive the same urgency in medical care; they are also not taken as seriously regarding pain they feel or complications they think they are having, as exemplified by the complications tennis-star Serena Williams faced during her delivery.[161]
Several peer-reviewed articles have documented a difference in the levels of care a black patient receives regardless of whether they have insurance. For white women IMR drops after age 20, and remains the same until she is in her 40s; for black women IMR does not decrease when accounting for higher education, nor change based on age, suggesting that there is a racial element.[162] There is another element that must be considered: the effect of the intersection of race and gender. Misogynoir is a commonly cited and overlooked issue.[163] Black feminists have often been cited as the backbone of numerous Civil Rights events, but they feel overlooked when it comes to meaningful change that positively changes the lives of Black women specifically.[164] During the June 2020 Black Lives Matter protests, many black feminists criticized the movement for excluding them.[165] When examined through this lens, the increased rates of IMR of African American women becomes a matter of equity and an issue of social justice.
Strides have been made, however, to combat this epidemic. In Los Angeles County, health officials have partnered with non-profits around the city to help black women after the delivery of their child. One non-profit that has made a large impact on many lives is Great Beginnings For Black Babies in Inglewood. The non-profit centers around helping women deal with stress by forming support networks, keeping an open dialogue around race and family life, and also finding these women a secure place in the workforce.[166]
Some research argues that to end the high infant mortality rate of black children, the country needs to fix the social and societal issues that plague African Americans,[167] such as institutional racism, mass incarceration, poverty, and health care disparities that are present amongst the African American population. Following this theory, if institutional inequalities are addressed and repaired by the United States Government, this will reduce daily stressors for African Americans, and African American women in particular, and lessen the risk of complications in pregnancy and infant mortality. Others argue that increasing diversity in the health care industry can help reduce the IMR as more representation can tackle deep-rooted racial biases and stereotypes that exist towards African American women.[168] Another attempt to reduce high IMR among black children is the use of doulas throughout pregnancy.[160]
History
It was in the early 1900s when countries around the world started to notice that there was a need for better child health care services; first in Europe, and then with the United States creating a campaign to decrease the infant mortality rate. With this program, they were able to lower the IMR from 100 deaths to 10 deaths per every 1,000 births.[169] When infant mortality began being noticed as a national problem it was viewed a social problem, and middle class American women with an educational background started to create a movement to provide housing for families of a lower social class. Through this movement they were able to establish public health care and government agencies, which in turn made more sanitary and healthier environments for infants. Medical professionals helped further the cause for infant health by creating the field of pediatrics, which is devoted to the medical care of children.[170]
United States
In the 20th century decreases in infant mortality around the world were linked to several common trends, including social programs, improved sanitation, improved access to healthcare, and improved education, as well as scientific advancements like the discovery of penicillin and the development of safer blood transfusions.[171]
In the United States, improving infant mortality in the early half of the 20th century meant tackling environmental factors. By improving sanitation, especially access to safe drinking water, the United States dramatically decreased infant mortality, which had been a growing concern in the United States since the 1850s.[172] During this time the United States also endeavored to increase education and awareness regarding infant mortality. Pasteurization of milk also helped the United States combat infant mortality in the early 1900s, as it helped curb disease in infants.[173] These factors, on top of a general increase in the standard of living in urban areas, helped the United States make dramatic improvements to their rates of infant mortality in the early 20th century.
Although the overall infant mortality rate was sharply dropping during this time, within the United States infant mortality varied greatly among racial and socio-economic groups. Between 1915 and 1933 the change in infant mortality per 1,000 births was, for the white population, 98.6 down to 52.8 per 1,000, and for the black population, 181.2 to 94.4 per 1,000 - studies imply that this has a direct correlation with relative economic conditions between these populations.[174] Additionally, infant mortality in southern states was consistently 2% higher than other regions in the US across a 20-year period starting in 1985. Southern states also tend to perform worse on predictors for higher infant mortality, such as per capita income and poverty rate.[175]
In the latter half of the 20th century, a focus on greater access to medical care for women spurred declines in infant mortality in the United States. The implementation of Medicaid, granting wider access to healthcare, contributed to a dramatic decrease in infant mortality, as did greater access to legal abortion and family-planning care, such the IUD and the birth control pill.[176]
By 1984, the United States' decreasing infant mortality slowed. Funding for the federally subsidized Medicaid and Maternal and Infant Care programs was reduced, and availability of prenatal care decreased for low-income parents.[177]
China
The growth of medical resources in the People's Republic of China's during the latter half of the 20th century partly explains its dramatic improvement regarding infant mortality during this time. The Rural Cooperative Medical System, which was founded in the 1950s, granted healthcare access to previously underserved rural populations, and is estimated to have covered 90% of China's rural population throughout the 1960s. The Cooperative Medical System achieved an infant mortality rate of 25.09 per 1,000; while it was later defunded, leaving many rural populations to rely on an expensive fee-for-service system, the rate continued to decline.[178] As the Cooperative Medical System was replaced, the change caused a socio-economic gap in accessibility to medical care in China, however this was not reflected in its declining infant mortality rate; prenatal care was increasingly used, and delivery assistance remained accessible.[179]
China's one-child policy, adopted in the 1980s, negatively impacted its infant mortality. Women carrying unapproved pregnancies faced state consequences and social stigma and were thus less likely to use prenatal care. Additionally, economic realities and long-held cultural factors incentivized male offspring, leading some families who already had sons to avoid prenatal care or professional delivery services, and causing China to have unusually high female infant mortality rates during this time.[180]
See also
- List of countries by infant mortality rate
- List of countries by maternal mortality ratio
- Maternal mortality
- Miscarriage
- Stillbirth
Related statistical categories:
- Perinatal mortality only includes deaths between the fetal viability (22 weeks gestation) and the end of the 7th day after delivery.
- Neonatal mortality only includes deaths in the first 28 days of life.
- Postneonatal mortality only includes deaths after 28 days of life but before one year.
- Child mortality includes deaths before the age of 5.
Notes
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