The social construction of infant mortality: From grassroots to medicalization

Infant mortality as a problematic situation has been recognized for some 130 years in one form or another. It has undergone various changes in its empirical dimensions relative to whom we study within the population, what we study--low birth-weight vs. pre-term births--and how we study it--whether demographically or medically. An analysis of the process by which the condition was raised by claims makers as an intolerable situation among America's urban residents reveals that demographic and medical data were sparse. Nonetheless, a judgement about the meaning and significance of the condition was made, and that interpretation led to the promulgation of systems to both document and address the condition as it has come to be defined.^ This investigation depicts the historical context and natural history of infant mortality as one of a number of social problems that came to be defined through the interplay among groups and individuals making claims and how their claims came to the public policy agenda as worthy of collective resources--who won, who lost and why. The process of social definition focuses attention on the claims makers and the ways they contrast the meaning, origins and remedies for this troubling condition. The historical context becomes the frame of reference for understanding the actions of the claims makers and the meaning and significance they attached to the problem.^ We purport that "context" provides a closer reality than disjoined "value free" accounts. Context provides the evidence for the definition, who participated in the process, why and by what means.^ The role of women in the definitional process reveals the differences in approaches utilized by the women of the settlement house reform movement and African-American women working at the grass-roots. Much of the work done by these two groups provided options to the problem's remedy; however, their differences paved the way to our current (principally medically-oriented) definition and its inherent limitations. ^

Non-nutritive sucking and the preterm infant

Background. Preterm birth is major public health problem. Preterm infants face a post-natal environment that their under developed systems are inapt to manage. Developmentally supportive individualized care has demonstrated positive outcomes in minimizing resulting negative effects. Non-nutritive sucking (NNS) interventions are thought to promote the development of the suck-swallow-breathe mechanism and a calming tool. It is hypothesized that growth and development is maintained by strengthened sucking skills and stable behavioral states.^ Objective. To determine the importance of non-nutritive sucking (NNS) on outcomes that are clinically relevant to the preterm infant population.^ Methods. A computerized search of MEDLINE and PUBMED databases during the period of 1975 and May 2011 was conducted. Relevant articles were selected using published criteria for detecting clinically validated studies. The search yielded 10 randomized controlled studies relative to the outcomes of interest: weight gain, time to full feeds, time to discharge from hospital, and pain response.^ Results. NNS was found to decrease significantly the length of hospitalization in preterm infants. Although positive results were reported in some of the studies, the results did not show a consistent benefit of NNS with respect to other major clinical variables. NNS was shown to reduce distress following painful stimuli.^ Conclusion. Although NNS shows promise for the development of preterm infants, there is lack of agreement concerning some of the outcomes of interest. Evidence does support NNS's positive contribution to early hospital discharge and pain relief. Future research should focus on long-term, comparable outcomes. ^

Infant breastfeeding patterns by sex: Do males feed more?

Background: Most studies have looked at breastfeeding practices from the point of view of the maternal behavior only, however in counseling women who choose to breastfeed it is important to be aware of general infant feeding patterns in order to adequately provide information about what to expect. Available literature on the differences in infant breastfeeding behavior by sex is minimal and therefore requires further investigation. Objectives: This study determined if at the age of 2 months there were differences in the amount of breast milk consumed, duration of breastfeeding, and infant satiety by infant sex. It also assessed whether infant sex is an independent predictor of initiation of breastfeeding. Methods: This is a secondary analysis of data obtained from the Infant Feeding Practices Survey II (IFPS II) which was a longitudinal study carried out from May 2005 through June 2007 by the Food and Drug Administration and the Centers for Disease Control and Prevention. The questionnaires asked about demography, prenatal care, mode of delivery, birth weight, infant sex, and breastfeeding patterns. A total of 3,033 and 2,552 mothers completed the neonatal and post-neonatal questionnaires respectively. ^ Results: There was no significant difference in the initiation of breastfeeding by infant sex. About 85% of the male infants initiated breastfeeding compared with 84% of female infants. The odds ratio of ever initiating breastfeeding by male infants was 0.93 but the difference was not significant with a p-value of 0.49. None of the other infant feeding patterns differed by infant gender. ^ Conclusion: This study found no evidence that male infants feed more or that their mothers are more likely to initiate breastfeeding. Each baby is an individual and therefore will have a unique feeding pattern. Based on these findings, the major determining factors for breastfeeding continue to be maternal factors therefore more effort should be invested in promoting breastfeeding among mothers of all ethnic groups and social classes.^

Assessing and applying evidence-based interventions at the community level in India as a model policy to reduce neonatal mortality rates in Nigeria

Background. The United Nations' Millennium Development Goal (MDG) 4 aims for a two-thirds reduction in death rates for children under the age of five by 2015. The greatest risk of death is in the first week of life, yet most of these deaths can be prevented by such simple interventions as improved hygiene, exclusive breastfeeding, and thermal care. The percentage of deaths in Nigeria that occur in the first month of life make up 28% of all deaths under five years, a statistic that has remained unchanged despite various child health policies. This paper will address the challenges of reducing the neonatal mortality rate in Nigeria by examining the literature regarding efficacy of home-based, newborn care interventions and policies that have been implemented successfully in India. ^ Methods. I compared similarities and differences between India and Nigeria using qualitative descriptions and available quantitative data of various health indicators. The analysis included identifying policy-related factors and community approaches contributing to India's newborn survival rates. Databases and reference lists of articles were searched for randomized controlled trials of community health worker interventions shown to reduce neonatal mortality rates. ^ Results. While it appears that Nigeria spends more money than India on health per capita ($136 vs. $132, respectively) and as percent GDP (5.8% vs. 4.2%, respectively), it still lags behind India in its neonatal, infant, and under five mortality rates (40 vs. 32 deaths/1000 live births, 88 vs. 48 deaths/1000 live births, 143 vs. 63 deaths/1000 live births, respectively). Both countries have comparably low numbers of healthcare providers. Unlike their counterparts in Nigeria, Indian community health workers receive training on how to deliver postnatal care in the home setting and are monetarily compensated. Gender-related power differences still play a role in the societal structure of both countries. A search of randomized controlled trials of home-based newborn care strategies yielded three relevant articles. Community health workers trained to educate mothers and provide a preventive package of interventions involving clean cord care, thermal care, breastfeeding promotion, and danger sign recognition during multiple postnatal visits in rural India, Bangladesh, and Pakistan reduced neonatal mortality rates by 54%, 34%, and 15–20%, respectively. ^ Conclusion. Access to advanced technology is not necessary to reduce neonatal mortality rates in resource-limited countries. To address the urgency of neonatal mortality, countries with weak health systems need to start at the community level and invest in cost-effective, evidence-based newborn care interventions that utilize available human resources. While more randomized controlled studies are urgently needed, the current available evidence of models of postnatal care provision demonstrates that home-based care and health education provided by community health workers can reduce neonatal mortality rates in the immediate future.^

Regression with autocorrelated data: A study of time trend of global infant mortality rate

The infant mortality rate (IMR) is considered to be one of the most important indices of a country's well-being. Countries around the world and other health organizations like the World Health Organization are dedicating their resources, knowledge and energy to reduce the infant mortality rates. The well-known Millennium Development Goal 4 (MDG 4), whose aim is to archive a two thirds reduction of the under-five mortality rate between 1990 and 2015, is an example of the commitment. ^ In this study our goal is to model the trends of IMR between the 1950s to 2010s for selected countries. We would like to know how the IMR is changing overtime and how it differs across countries. ^ IMR data collected over time forms a time series. The repeated observations of IMR time series are not statistically independent. So in modeling the trend of IMR, it is necessary to account for these correlations. We proposed to use the generalized least squares method in general linear models setting to deal with the variance-covariance structure in our model. In order to estimate the variance-covariance matrix, we referred to the time-series models, especially the autoregressive and moving average models. Furthermore, we will compared results from general linear model with correlation structure to that from ordinary least squares method without taking into account the correlation structure to check how significantly the estimates change.^

Indigent care and infant mortality in Texas

Infant Mortality has been made a point of emphasis by the Department of Health and Human Services in the Healthy People 2000, 2010, and 2020 priorities. This study used the Behavioral Model for Vulnerable Populations to consider a number of factors which impact infant mortality in the indigent populations in the State of Texas. The primary focus of this study was the enabling factor of community resources, specifically the program used by each county to provide care to their indigent population. The Legislature of the State of Texas requires that each state have a program set up within a Hospital District, Public Hospital or develop a County Indigent Health Care Program (CIHCP) in order to provide the basic health care needs of their most vulnerable residents. We sought to determine whether the development of a CICHP without an appointed hospital to provide the care would have an adverse effect on residents seeking care and increase infant mortality. A Poisson Regression Analysis was used to analyze incidence rate ratios adjusting for race/ethnicity and wealth/poverty variables. Our study showed that counties using a CIHCP had significantly lower infant mortality rates when compared to counties using a hospital district and were statistically equivalent to counties using a public hospital program or a combination of service programs. This relationship was maintained when adjusted incidence rate ratios were calculated. This may give evidence that counties struggling to fund a public hospital or hospital district may be able to find a more cost-effective alternative in the CIHCP without adversely affecting the health status of their residents. More cost-benefit analysis and controlling analysis must be done to further characterize this relationship. ^

First -year mortality and survival among infants with selected congenital anomalies in Texas, 1995 to 1997

Congenital anomalies have been a leading cause of infant mortality for the past twenty years in the United States. Few registry-based studies have investigated the mortality experience of infants with congenital anomalies. Therefore, a registry-based mortality study was conducted of 2776 infants from the Texas Birth Defects Registry who were born January 1, 1995 to December 31, 1997, with selected congenital anomalies. Infants were matched to linked birth-infant death files from the Texas Department of Health, Bureau of Vital Statistics. One year Kaplan-Meier survival curves, and mortality estimates were generated for each of the 23 anomalies by maternal race/ethnicity, infant sex, birth weight, gestational age, number of life-threatening anomalies, prenatal diagnosis, hospital of birth and other variables. ^ There were 523 deaths within the first year of life (mortality rate = 191.0 per 1,000 infants). Infants with gastroschisis, trisomy 21, and cleft lip ± palate had the highest first year survival (92.91%, 92.32%, and 87.59%, respectively). Anomalies with the lowest survival were anencephaly (5.13%), trisomy 13 (7.41%), and trisomy 18 (10.29%). ^ Infants born to White, Non-Hispanic women had the highest first year survival (83.57%; 95% CI: 80.91, 85.88), followed by African-Americans (82.43%; 95% CI: 76.98, 86.70) and Hispanics (79.28%; 95% CI: 77.19, 81.21). Infants with birth weights ≥2500 grams and gestational ages ≥37 weeks also had the highest first year survival. First year mortality drastically increased as the number of life-threatening anomalies increased. Mortality was also higher for infants with anomalies that were prenatally diagnosed. Slight differences existed in survival based on infant's place of delivery. ^ In logistic regression analysis, birth weight (<1500 grams: OR = 7.48; 95% CI: 5.42, 10.33; 1500–2499 grams: OR = 3.48; 95% CI: 2.74, 4.42), prenatal diagnosis (OR = 1.92; 95% CI: 1.43, 2.58) and number of life-threatening anomalies (≥3: OR = 22.45; 95% CI: 11.67, 43.18) were the strongest predictors of death within the first year of life for all infants with selected congenital anomalies. To achieve further reduction in the infant mortality rate in the United States, additional research is needed to identify ways to reduce mortality among infants with congenital anomalies. ^