CHILD & FAMILY HEALTH Infant Mortality Module 1 of 2 Grace E CHILD & FAMILY HEALTH Infant Mortality Module 1 of 2 Grace E. Foege Holmes, MD OVERVIEW: Infant Mortality–Module 1 Trends over time of a country’s infant mortality rates provide a great deal of information regarding the overall well-being of that population. Dr. Grace E. Foege Holmes, MD Professor of Pediatrics and Preventive Medicine University of Kansas School of Medicine Kansas City, Kansas (USA)

Learning Objectives: To understand the medical and non-medical factors that affect the infant mortality rate of a country or region. To view the infant mortality rate (IMR) as a sensitive barometer to the general health and well-being of a country’s population. To recognize problems associated with the measurement of the IMR. To appreciate that a high IMR can occur even in a wealthy country, while a low IMR may occur in a developing country.

Performance Objectives: To understand the medical and non-medical factors that affect the infant mortality rate of a country or region. To view the infant mortality rate (IMR) as a sensitive barometer to the general health and well-being of a country’s population. To recognize problems associated with the measurement of the IMR. To appreciate that a high IMR can occur even in a wealthy country, while a low IMR may occur in a developing country.

Dr. Grace Holmes reads to grandson, Quentin Grace E. Foege Holmes, MD The author loves to be and has been surrounded by children: as a child herself surrounded by five siblings, as a mother by six children, and as a grandmother by twelve grandchildren. Likewise, professionally, she loves to be surrounded by children who need her helpespecially those with problems of growth and development. Dr. Grace Holmes reads to grandson, Quentin

Copyright  1994, Christopher Wee In addition to a long career at the University of Kansas School of Medicine, she practiced medicine in Malaysia (1959-1963) and at the Kilimanjaro Christian Medical Centre in Moshi, Tanzania (1970-1972). Copyright  1994, Christopher Wee Mount Kilimanjaro

Dr. Grace Holmes with patient in Malaysia, 1959 INFANT MORTALITY is measured by the Infant Mortality Rate (IMR) as the number of babies who die before they reach the age of one year per 1,000 babies born alive that year. REMEMBER, THIS IS A RATE, NOT A PERCENTAGE. What can we do to reduce IMR? First, we need to take a close look at the causes of infant death. GEFH Dr. Grace Holmes with patient in Malaysia, 1959

Mother with Newborn Child SurvivalWorld Development INFANT MORTALITY is measured by the Infant Mortality Rate (IMR) as the number of babies who die before they reach the age of one year per 1,000 babies born alive that year. Mother with Newborn Child SurvivalWorld Development

DIRECT Causes of Infant Death Immediate Immaturity Birth injury Genetic disease Congenital anomaly Chronic Malnutrition Infection Direct causes of infant deaths are immediate/acute and chronic problems that require medical attention. In privileged societies Direct/ immediate causes (immaturity, birth, injury, congenital abnormalities) may be responsible for 1/3 of infant deaths. In deprived societies for only 1.5%. Direct/chronic medical problems (malnutrition; infection) are so much more common in deprived countries and are more important than acute causes.

INDIRECT Causes of Infant Death Social Economic Environmental Indirect causes are non-medical conditions that make infants more vulnerable to Direct causes.

Crowding among gypsies in Greece, 1959 GEFH Crowding among gypsies in Greece, 1959

Child begging in Karachi, Pakistan, 1959 GEFH Indirect–Social Discrimination High fertility Crowding Ignorance Educational level

Coffee trees in Tanzania, East Africa, 1972 Fishermen in Penang, Malaysia, 1959 GEFH Indirect–Economic Family income Country’s resources (coffee, usually a high income resource) Family income is closely related to country’s resources.

Mother washing baby... Knowledge of basic sanitation is extremely important. Indirect–Environmental Lack of sanitation Exposure to toxic substances

Historical Perspective on IMR

Europe–19th Century IMRs fluctuated with wars, famines, epidemics, and social turmoil of the Industrial Revolution. In 1870, one Bavarian city had an infant mortality rate of 449. In 1900, there was a fall in the infant mortality rate with modern sanitation, increased income of working classes, and better understanding of disease control. By 1940, most of Europe had an infant mortality rate around 100. In post-World War II there was a continued steady decline in infant mortality rates because of public health measures, antibiotics, and more available medical care.

Death is usually due to: Countries with High IMR Death is usually due to: Chronic DIRECT medical causes (malnutrition; infection) INDIRECT causes (social/economic/environmental) These countries often have: Social problems Environmental contamination Lack of education Discrimination against women Poor health services

A rising IMR indicates that something is wrong with the country’s developmental process. A low IMR usually reflects that infant death is mostly within the first month of life due to direct/immediate medical conditions, (immaturity, congenital abnormalities, etc.). A rapidly declining IMR indicates that there is probable improvement generally in social and environmental conditions.

Remember that poor countries may have a low IMR. Likewise, rich countries may have a high IMR. In 1965 Chile had an IMR of 100. After instituting programs to extend basic health services throughout the country, this improved, so that by 1991 the IMR was reduced to 40. Oftentimes, favorable health status indicators are due less to sophisticated medical technology and excellent tertiary care services, or, for that matter, even to primary care services, but may be due more to the result of improved housing and education.

As general welfare of a society improves, the IMR declines. Add specific medical programs to reduce it even further.

Barefoot Doctors in China Barefoot doctors in China (often with minimal education) provided widespread basic services to all the people during 1949-1970.

Declining Deaths–China 200 Infant mortality rate (IMR) China 200 150 139 National Average IMR/1000 Live Births 100 71 Rural 50 32 25 13 22 13 1949 ‘54 ‘57 ‘63 ‘75 ‘82 Preliberation Child Survival–World Development

Rockefeller Foundation Study A Rockefeller Foundation study called, “Good Health at Low Cost,” deliberated on why some countries--China, Costa Rica, Sri Lanka, and Kerala State in India--had achieved high levels of health and child survival in spite of low economic status. They found these societies to have strong social and political commitments. They provided comprehensive health services for all, universal primary education, and availability of adequate nutrition at all levels of society.

A quick look at the decline in IMR in the United States over 100+ years

Infant Mortality Rate 1851 to 1974 in US 175 Infant Mortality Rate 1851 to 1974 in US 150 125 100 75 50 In spite of a decline in IMR in the US, this graph shows there is still room for improvement. 25 1865 1895 1920 1955 1985 1880 1910 1940 1970

Problems with Measurement of IMR Different criteria used in different countries Variation of data collection Estimates and unreliable data In many societies, deaths may be unrecorded up to 40 days or longer after birth. It is during that time, however, that many deaths are actually likely to occur. The infant mortality rate is considered the most sensitive index of the level of living and sanitary conditions of a country or region.

Which is basically what Florence Nightingale said in 1893: “The life duration of babies is the most delicate test of health conditions.”