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Exploring the major causes for the rising cases of prenatal and infant mortality

Advanced Search It is quite fitting for a symposium reviewing progress in infant nutrition in the 20th century to start with a review of infant mortality rates during that time period.

Indeed, it has been a truism in public health that, within limits, the infant mortality rate of any community, large or small, reflected its general state of health better than any other single indicator.

Although no longer valid for the wealthier countries, it is still the norm for most countries in the world, where the diseases that kill most babies, i. Interrelation of infection and nutrition was appreciated early, as documented persuasively in Scrimshaw's classic 1975 review 1.

At the beginning of the 20th century, infant mortality was at such heights that organized attempts to attack it began more or less simultaneously throughout what is now called the developed world. In the forefront was western Europe, a major effort having come from the French, stung by the loss of the Franco-Prussian War in 1870 and the realization that population dynamics favored a newly united Germany.

A landmark step in the United States came when more or less isolated efforts in many cities led to organization in 1909 of the American Association for the Study and Prevention of Infant Mortality, instrumental in promoting the White House Conferences on Children and Youth and stimulating the establishment of the Children's Bureau.

Almost 100 years later, decline in infant mortality has occurred worldwide, dramatically in the industrialized nations, less so and unevenly in many population groups in those nations and worldwide. Sources of data Community-wide data used to track infant mortality are routinely collected by government for societal reasons other than health, for example, to establish identity, residence and citizenship. Indeed, in many countries, collection of birth and death statistics is a responsibility of the police or a central statistical agency.

But those needs require the same high degree of completeness as that required for vital statistics; thus, the data collected for these purposes are well adapted for analysis in relation to health conditions. This report will concentrate chiefly on our own country, for which information on the completeness and accuracy of the data is readily available.

Some international comparisons will be made later. In the United States, countrywide information gathering and analysis on population, births and deaths has been the responsibility of a succession of Federal agencies.

In 1900, it was the Bureau of the Census in the U. Department of Health and Human Services. Crucial to the study of infant mortality was acceptance of a uniform definition of a live birth. A live birth is any product of conception which, after complete expulsion or extraction from its mother, irrespective of the duration of pregnancy, breathes or shows any other evidence of life such as beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached.

Each product of such a birth is considered live born.

  1. Previous comparisons of neonatal and postneonatal mortality in aggregate data such as Kleinman and Kiely 1990 are diffcult to interpret given the differential reporting concern.
  2. First, a well-recognized problem is that countries vary in their reporting of births near the threshold of viability.
  3. Although no longer valid for the wealthier countries, it is still the norm for most countries in the world, where the diseases that kill most babies, i.

The infant mortality rate is a ratio of all deaths in y 1 of life to the total number of live births as defined above. Completeness of birth registration is thus crucial to accuracy.

  • Disturbingly, furthermore, the difference has been growing in recent years;
  • We begin in this paper by relaxing this data constraint;
  • To be consistent, however, this discussion will begin with the establishment of the BRA and deal primarily with the period 1915 to the present;
  • In the United States today, almost all births take place in hospitals, making registration a relatively straightforward routine; early in the century, however, many, if not most, births took place in homes 3 and were not officially registered;
  • We begin in this paper by relaxing this data constraint.

In the United States today, almost all births take place in hospitals, making registration a relatively straightforward routine; early in the century, however, many, if not most, births took place in homes 3 and were not officially registered.

In those years, a new health officer in a rural area promptly learned that the quickest way to reduce his jurisdiction's infant mortality figures was merely to increase birth registration! The years 1900, 1915 and 1933 In 1900, when the republic's population was 75 million, only a few states and cities had essentially complete birth reporting. Other states qualified in short order and, by 1933, with admission of Texas to the BRA, the entire country was covered. Thus, because of the different denominators, we have no representative national infant mortality figures, as such, for the first decade and a half of the century.

However, earlier establishment of a Death Registration Area allowed calculation of an age-specific death rate for y 1 of life, approximating the infant mortality rate. The distinction between the two rates is largely academic, as shown in Figure 1a comparison covering the first 40 y of the century.

Clearly, a decline in infant deaths was already in progress when the BRA was established. To be consistent, however, this discussion will begin with the establishment of the BRA and deal primarily with the period 1915 to the present. This graph, like the subsequent ones dealing with time trends, is on a logarithmic scale, to allow direct comparison of speed of change for values of quite different magnitude. Figure 2 shows four curves on the same scale as follows: Up until World War II and the dawn of the chemotherapy era, this decline appears more closely related to improvement in the biologic environment, exploring the major causes for the rising cases of prenatal and infant mortality less crowded housing and the quality and quantity of water available to households for drinking, personal hygiene and sewage disposal.

In recent decades, that pattern has been repeated for d 1 mortality, coincident with improvements in medical management of the perinatal experience. Race and ethnicity Here is the down side of the pattern of decline in infant mortality. Substantial differences continue to exist for certain racial and ethnic groups.

To study these and other differences more closely, NCHS has created a special file linking infant death certificates with birth certificates, because the birth certificate contains so much more information about the parents and family 2.

The years 1900, 1915 and 1933

Using data from this file, Figure 3 compares 1997 rates by race and ethnicity for the standard classifications of the NCHS. As shown in Figure 4both Caucasian and African-American rates have declined more or less steadily over the century, but the African-American rate has remained consistently higher than the Caucasian rate.

  • To the best of our knowledge, cross-country micro-data has not previously been used to undertake this type of exercise;
  • This finding highlights the importance of conducting cross-country comparisons in a setting where reporting differences can be addressed, which is typically not possible in the types of aggregate statistics compiled by the World Health Organization and the World Development Indicators World Health Organization, 2006 ; World Bank, 2013;
  • In our comparably-reported sample, the US neonatal mortality disadvantage is quantitatively small and appears to be fully explained by differences in birth weight;
  • First, a well-recognized problem is that countries vary in their reporting of births near the threshold of viability;
  • Clearly, a decline in infant deaths was already in progress when the BRA was established.

Disturbingly, furthermore, the difference has been growing in recent years. This is not surprising, given the long history of discrimination and the looseness of racial definition, sometimes involving specious quantification of ancestry. Many scientists believe that there is only one human race, and distinctions dependent on skin color or facial characteristics cannot be handled uniformly enough for routine classification of an individual person.

Indeed, there are arguments in favor of discontinuing any separation of data by skin color or any such characteristic.

Why Is Infant Mortality Higher in the United States Than in Europe?

Classification of infant deaths by racial and ethnic group has become even more complicated with the growing number of births to couples in which one parent is Caucasian and the other African-American.

Because the mother's race is often better correlated with differences in facilities available to the child, NCHS has used the linked birth and death certificate files since 1980 to classify infant death rates by race of mother rather than by race of child.

  • In 1900, it was the Bureau of the Census in the U;
  • Moreover, even normal birth weight infants have a substantial IMR disadvantage - 2;
  • Interrelation of infection and nutrition was appreciated early, as documented persuasively in Scrimshaw's classic 1975 review 1;
  • Each product of such a birth is considered live born;
  • As a specific example, although a large literature has documented significant inequality in infant mortality outcomes across socioeconomic groups within the US i;
  • The infant mortality rate in the US is higher at all ages, but this difference accelerates after the first month of life.

Later, the trend in the two rates became more or less parallel again, until the recent increasing divergence. Parity has never been approached. As one example, a comprehensive study of 209,055 births in 1939—1940 in New York City 4found that 7. Similarly, in 1997 5among almost 4 million live births nationwide, 6. The high percentage of non-Hispanic African-American infants born at low birth weight translates into a much higher level of total infant loss because so many more are in the highly vulnerable weight range.