Infant Mortality
Trends, causes,
and responses in a
changing world
Megan Brown
Children’s Defense Fund Minnesota
“Children who
get a healthy start
in life are more
likely to reach
their full
potential, with
benefits for
themselves, their
families and
society as a
whole.”
-State of the World’s Mothers
Save the Children, 2007
Infant Mortality
Every day, 28,000 children under 5 die
10 million children annually
40% of those are newborns in their first month
2 million die on the day they are born
“Using existing tools and
knowledge, we could save more
than 6 million of the 10 million
children who die every year
from easily preventable or
treatable causes.”
Infant Mortality
• Trends
– Historical
– Geographical
• Less Developed
Countries
– Causes
– Responses
• More Developed
Countries: U.S.
– Causes
– Responses
Historical Trends
• Prior to 1900, infant mortality
rates of two and three hundred per
1,000 births
• Fluctuated sharply
–
–
–
–
Weather
Harvest
War
Epidemic disease
• Anthropologists have found
groups that do not name children
until they have survived a year.
Historical Trends
• 1900 – Industrial Revolution
• New attitudes, behaviors and advancements
brought shift in infant mortality rates
• Geographic, economic disparities persist
Infant Mortality Rates, 1900
Infant Mortality Rates, 1930
Infant Mortality Rates, 1960
Infant Mortality Rates, 1996
Global Regional Variation
1960s
East Asia & Pacific
1970s
1980s
1990s
Absolute
Change
Percent
Change
94
65
48
39
-55
-58.6
n.a.
n.a.
35
26
n.a.
n.a.
Latin America & Caribbean
95
73
52
35
-60
-62.9
Middle East & North Africa
153
117
76
54
-100
-64.9
South Asia
151
132
106
81
-70
-46.2
Sub-Saharan Africa
151
126
107
96
-55
-36.3
26
16
10
7
-19
-73.7
Europe & Central Asia
High Income
• Nine of the 10 countries with the highest IMR are in SubSaharan Africa
– Afghanistan is the tenth
• IMR sky-rocketing in the Middle East
– Iraq: 1990 (50); 2005 (125)
Global Infant Mortality
• 198 in 1960; 83 in 2001
• Significant disparity between Less
Developed Countries (LDC) and More
Developed Countries (MDC)
– LDC (91); MDC (8)
– 10X higher for LDC than MDC
– 17X higher for Least Developed Countries than
MDC
– Reductions overall, but more for MDC
Per Capita Income and Infant Mortality
Two Sides of Infant Mortality
Less/Least Developed
Countries v. More
Developed Countries
Our responses depend
on the causes, and the
causes depend on the
nation…
Infant Mortality in Less
Developed Countries
Violence
• Due to armed conflicts over
the past decade,
– two million children were
killed,
– six million were seriously
injured or permanently
disabled,
– 12 million were left homeless,
– millions more orphaned.
• Refugee camps
– disrupt home life
– affect nutritional intake
– expose children to infections
Poverty
• Children born in the developing world have
a 4 in 10 chance of living in extreme
poverty.
• In 1998 over half a billion children lived on
less than $1 a day.
Total world population living off less than US$1 per day
by region 1981-2001
1600
1400
Total population (m)
1200
Sub-Saharan Africa
1000
800
South Asia
Middle East and N.
Africa
600
400
Latin America and
Caribbean
East Asia
200
0
1981
1984
1987
1990
1993
Source: Economic and Social Research Council
1996
1999
2001
Eastern Europe &
Central Asia
Family Size
• Children in larger families receive smaller share of
family resources.
– More likely to be malnourished.
• Girls are often given fewer family resources,
including medical care and food, than boys.
Mother’s Educational Level
• Adult female literacy rate
– In countries where the adult female literacy rate is
higher, the IMR is consistently lower.
• Mozambique: female literacy rate (23 percent), IMR (130)
• Tanzania: female literacy rate (57 percent), IMR (92)
• Delayed marriage and first birth
– Babies born to women in their 20s and 30s have a lower
risk than those born to women younger than 20.
• Family planning and smaller families
– Reproductive health care for themselves
– Take better care of their children’s health needs.
HIV/AIDS
• Increasing impact on children of all ages
– 4.3 million children under age 15 had died of AIDS (12/03)
– In 2000, 1.4 million children under 15 years of age were
living with HIV/AIDS, up from 830,000 in 1996.
• One million live in sub-Saharan Africa
• 1,600 children infected each day.
• Mother-to-child transmission of HIV during pregnancy, birth, or
breastfeeding accounts for more than 90 percent of all infections in
children.
– One-third of infants born to HIV-infected mothers become infected.
• Children orphaned by AIDS
– More than 13 million children lost either their mother or
both parents by the end of 1999.
• Ninety percent in sub-Saharan Africa
– Likely to be malnourished
Illness & Disease
• 70% caused by preventable,
treatable diseases
–
–
–
–
Respiratory infections
Diarrhea
Malaria
Measles
• The physical environment is
responsible for one-fourth of all
preventable disease
– Water supply
– Sanitation
– Urban versus rural resources
Physical Environment
• Safe drinking water and sanitation
– Over one billion people lacked access to safe drinking
water in 2000
– Inadequate sanitation, unsafe drinking water, air
pollution and crowding
 malnutrition, diarrhea and acute respiratory infections
• Urban versus rural resources
– Urban residents have greater access to medical surveys
and educational campaigns
• Large-scale campaigns have constituted the most recent child
health initiatives
• In Bolivia the child mortality rate in rural areas in 1998 was
134, versus 72 in urban areas.
Responses
• Ensure the well-being of mothers
• Invest in basic, low-cost solutions to save
children’s lives
• Expand the availability of health care
• Increase the use of basic, lifesaving services
• Increase government support for proven
solutions
-State of the World’s Mothers, Save the Children, 2007
Ensure the well-being of mothers
• Nutrition
– Stronger mothers
– Fewer birth complications
– Healthier babies
• Skilled care during
childbirth
• Family planning
Family Planning
• Could prevent one in four of
the deaths in children under
five by helping women to
space births at least two
years apart.
– Can also improve the survival
of the next sibling.
• Helps women to have
children during their
healthiest reproductive years
• Enables couples to have their
desired number of children
The United States, through
the U.S. Agency for
International Development
(USAID), provides voluntary
family planning and
reproductive health services
in over 60 developing
countries. According to
USAID, 50 million couples in
the developing world use
family planning directly as a
result of its efforts.
Invest in basic, low-cost solutions
• Antibiotics
– Newborn sepsis
– Pneumonia
• Insecticide-treated mosquito nets
• Oral rehydration therapy
• Breastfeeding
“Recent analysis has shown that nearly 3 million
of…newborn deaths could be prevented annually by
improving access to basic, cost-effective interventions
that are not yet reaching those who need them most.”
-State of the World’s Mothers
Save the Children, 2007
Oral rehydration Therapy (ORT)
• Low-cost, lowtechnology method to
control diarrhea
• Prepackaged mixture
of salts and sugars
combined with water
– Replaces fluid and salts
lost through diarrhea
• Throughout the 1990s,
it was used in 80
percent of all episodes.
Increased Breastfeeding
• One of the most cost-effective interventions
– Saves the lives of six million infants every year
Increased Breastfeeding
• If a child is breastfed for six months, she is
significantly less likely to contract or die
from diarrhea and acute respiratory
infections.
• Beyond 6 months, breastfed alongside ageappropriate feeding
– Almost one-fifth of all child deaths
– Save an additional two million children each
year
Expand the availability of health care
• Trained health workers
– Urban and rural
• Basic newborn care
– Home visits
• Mass media, public education campaigns
– Promote healthy behaviors
– Raise awareness
Increase use of basic, lifesaving
services
• Community case management linked to
local health facilities
• Community education and mobilization
Encourage family members to use lifesaving,
home-based practices to care for their infant.
Increase government support for
proven solutions
• Basic education
• HIV/AIDS awareness
• Family planning
– Funding
– Policies
•
U.S. Cuts in International Family
Planning
Funding
– Level- funded since 2001
– President Bush’s 2007 budget: 18 percent reduction
• $357 million, well below the 2006 level of $440 million
– Highest levels in 1995 ($541 million)
• With inflation, 30 percent reduction
• Funding should be $865 million
• "Mexico City Policy" / “Global gag rule”
– Denies USAID funds to overseas clinics that perform
abortions, provide abortion counseling and referral, or
lobby to make abortion legal.
– Clinics have closed or cut staff and services, including
HIV screening, voluntary counseling and education.
– USAID has stopped shipment of condoms to 16 countries
because the sole recipients – local family planning
organizations – have refused to sign on to the gag rule.
More Developed Countries
IMR and the Industrial Revolution
• Rates have been
steadily decreasing
• Major decline in 20th
century
• Attributed to
–
–
–
–
–
–
–
–
Cleanliness
Sewage systems
Central heating
Clean drinking water
More food
Cheaper clothing
Use of hospitals
Antibiotics and vaccines
Infant Mortality in the U.S.
• 2004
– 27,936 infant deaths
– More than all child/teen
deaths combined (25,325)
– 42nd in the world (2005)
• 36th (2002)
• 28th (1998)
The U.S. spends more on health care
than any other country, but our infant
survival rate is lower than that of
most other industrialized nations.
1
Singapore
2.3
2
Sweden
2.76
3
Japan
2.80
4
Hong Kong
2.94
5
Iceland
3.27
6
France
3.41
7
Finland
3.52
8
Norway
3.64
9
Malta
3.82
10
Czech Rep.
3.86
11
Andorra
4.03
12
Germany
4.08
23
Canada
4.63
29
U.K.
5.01
42
U.S.
6.37
The United States
has the second
worst newborn
mortality rate in the
developed world.
U.S. Infant Mortality Rates, 2004
Racial Disparities: U.S.
Infant Deaths, by Race
Births, by Race
7%
4%
19%
23%
Non-Hispanic White
Non-Hispanic Black
48%
56%
Hispanic
Other
29%
•
•
•
•
•
2004 Rates
Non-Hispanic white: 5.7
Non-Hispanic black: 13.8
Hispanic: 5.6
American Indian: 8.9
Asian/Pacific Islander: 3.6
14%
At any age, and at any income,
education or socioeconomic level,
an African American mother is
twice as likely to lose her infant
than a white woman.
Causes: U.S.
Primary Causes of Infant Deaths, 2004
Congenital malformations, deformations and chromosomal abnormalities
20.1%
Disorders related to short gestation and low birth weight, not elsewhere classified
16.6%
Sudden Infant Death Syndrome (SIDS)
8.0%
Newborn affected by maternal complications of pregnancy
6.1%
Accidents (unintentional injuries)
3.8%
Newborn affected by complications of placenta, cord and membranes
3.7%
Respiratory distress of newborn
3.1%
Bacterial sepsis of newborn
3.0%
Neonatal hemorrhage
2.2%
Diseases of the circulatory system
2.1%
All other causes
31.2%
Each year, well over half of infant deaths from
all causes involve LBW babies.
Low Birth Weight Babies, 2004
Contributing Factors
• Health of Baby
– LBW
– Birth Defects
– Disease/Illness
• Health of Mother
– High-risk pregnancy
– Poor nutrition
– Obesity
• Poverty
• Health Insurance
– Reduced access to care
– Lack of insurance
Responses
•
•
•
•
Address Disparities in Infant Mortality
Provide Pre-Pregnancy Education and Counseling
Ensure Timely Prenatal Care for All Women
Expand Access to Medical Care for Infants in the
First Month of Life (Neonatal)
• Expand Access to Well-baby Care and Parenting
Education
• Expand Programs for the Prevention of Child
Abuse and Neglect
-Annie E. Casey Foundation
Address Disparities
• Support research on the medical,
socioeconomic and behavior factors that
affect infant mortality, esp. low birth weight
– African American and Puerto Rican babies most
severely affected
– Medical advances increase survival
– Incidences of LBW are the same
The cost of a premature baby's hospital care can
reach over a quarter-of-a-million dollars. A fullterm healthy newborn costs a few thousand dollars.
Address Disparities
• Promote breastfeeding, with an emphasis on
African American mothers
– African American
mothers only 40% as
likely to breastfeed as
other mothers
• Accounts for higher rates
of infant mortality
– Campaign
– Research
• Improve education
• Workplace policies
Pre-Pregnancy Counseling and
Education
• Health education and preconception counseling
– Expectant mothers
– Unplanned pregnancies
• Education about positive and negative behaviors that
impact health of baby
• Effective monitoring and treatment of chronic
diseases
– Hypertension, diabetes, renal disease, urogenital infactions
– Addresses disparities (African American women)
Prenatal Care
• Infant mortality is 50
percent higher for children
born into families in poverty
• Decreased access to prenatal
care
– Low-income women
– Segregated rural and urban
areas
– Racial/ethnic minorities
• First trimester
Prenatal Care
• Address barriers to prenatal care
– Medically underserved
areas
– Regular source of care
(Outpatient, ER)
– Culturally competent
providers
• Ensure that all eligible individuals receive
Medicaid and SCHIP services
– Covering All Families
(www.coveringallfamilies.org)
Infant Mortality in the 1990s
Infant Medical Care
• Expand access to neonatal intensive care
• Timely, appropriate treatment for congenital
anomalies
– Birth defects cause 1 in 4 deaths
• 1 in 3 are heart defects
– Improvements in surgical treatment
• Reduce the incidence of respiratory distress syndrome
– Preterm babies (less than 3 1/3 lbs, earlier than 32 wks)
• 40,000 develop it each year; 1,400 die
– Surfactant treatment
– Reduce LBW incidence
Well-baby Care and Parenting
Education
• SIDS public education campaign
– “Back to Sleep” campaign
– Target communities
• American Indian 2X higher than whites
• African American also higher than whites
• Well-baby and sick-baby care
– Early detection and treatment of influenza and
pneumonia
– Access through SCHIP or Medicaid
Accessing Health Insurance
• Covering All Families
• SCHIP Reauthorization
– Bush - $5 million
• Kick off 1 to 2 million currently covered kids
– Senate - $35 million
• Cover 3 to 4 million uninsured kids
“In 2004, Gov. Haley Barbour came to
office promising not to raise taxes and to
cut Medicaid. Face-to-face meetings were
required for annual re-enrollment in
Medicaid and CHIP, the children’s health
insurance program; locations and hours
for enrollment changed, and
documentation requirements became
more stringent.
As a result, the number of non-elderly
people, mainly children, covered by the
Medicaid and CHIP programs declined
by 54,000 in the 2005 and 2006 fiscal
years.
According to the Mississippi Health
Advocacy Program in Jackson, some
eligible pregnant women were deterred
by the new procedures from enrolling. “
-Erik Eckholm
New York Times
Accessing Health Insurance
• Legislation
– Children’s Health Security Act
• Cover 80,000 uninsured in MN, option for all kids
– All Healthy Children Act
• Cover 9 million uninsured kids, option for all kids
“The CHSA…[would] change the way we provide
health care coverage for children to a system
analogous to public education – all children would
have access to health care coverage just as all
children are guaranteed a public education.”
-Carole Specktor
CDF-MN
Expand Programs for the Prevention of Child
Abuse and Neglect
• SIDS decreasing, deaths from abuse increasing
– 1% to 5% of SIDS cases as infanticide
• Provide services to parents at risk for child abuse
and neglect
– Emergency services for distraught parents
– Education for teen parents and single mothers on babies’
needs and vulnerabilities
• Legal alternatives to desperate parents
– Abandonment
– Laws that allow parents to avoid prosecution for child
abandonment by leaving their babies in safe places such
as hospital emergency rooms
Summary
• 10 million children under 5 die
annually, 40% are newborns
• IMR decreasing through time
– Geographic, economic
disparities persist
• Less developed countries
– Easily preventable causes
– Health care, education, family
planning
Bottom line:
This is a solvable
problem!
• More developed countries
(U.S.)
– Worst outcomes for MDC
– Racial/ethnic disparities
– Low birth weight, maternal
health
“We should
expect more and
we should do
better, and we
need to look at
every aspect that
we can influence,
that we can
control, that
could help
improve the
chance that a
baby who is born
can live.”
`
Thank you for coming…