1 Running head: THE STATUS OF INFANT MORTALITY Huong Dang Ofelia Gonzalez Lucien J.

Leyes HSC 420I: International Health Thursday, 12:30pm-3:15pm

The Status of Infant Mortality in Developing Nations Huong Dang, Ofelia Gonzalez, and Lucien J. Leyes California State University, Long Beach

2 The Status of Infant Mortality in Developing Nations Introduction: How has infant mortality affected people around the world? The rate of infant mortality in a country is one of the crucial indicators of a countrys overall health. If a country has a low infant mortality rate, it reflects the overall good health of the country, while a high infant mortality rate means the countrys overall health is influenced poorly. Infant mortality rate is the ratio of the number of deaths among children less than one year old during a given year to the number of live births during the same year. Different countries all over the world have different infant mortality rates. We will be examining different countries that have either high or fairly high infant mortality rates. The countries that we will be discussing about infant mortality are Nepal, Afghanistan, Brazil, and Iraq. Moreover, we will assess the cause and effect of infant mortality in these countries. At the same time, we will be examining a few of the reasons or causes of infant mortality rates globally overall. In addition, we will also be discussing the causes of infant mortality which are low birth weight, violence, maternal complications, congenital defects, and diarrhea. We aim to inform our peers about the condition of infant mortality in some of the worlds poorest countries and in assessing it, we hope to bring about the understanding that a countrys health status affects other countries as well. Throughout this paper we will analyze death rates in different countries and the different causes for these deaths. Main Points and Analysis - High IMR Countries: Nepal Nepal is one of the countries with a fairly high Infant Mortality Rate (IMR). According to the Central Intelligence Agency, Nepal is rated fifty sixth from the highest mortality rate which

3 is held by the country of Angola with an IMR of 178.13 infant deaths of every thousand live birth, while Nepal IMR is forty-six infant deaths out of a thousand live births (http://cia.org). One might ask, what are the causes for these infant deaths in the country of Nepal? According to the research study, Risk Factors For Early Infant Mortality In Sarlahi District, Nepal, researcher Katz with other colleagues assesses and discusses a broad variety of causes that found to cause infant deaths in Nepal. The article also attempts to gather the findings of risk factors that are linked to infant mortality and construct possible intervention strategies to reduce infant mortality overall. The research methods of this article are based on the 15,469 babies in the Sarlahi district of Nepal that were born during the study and data were taken from the families of these babies by tallied convenience sample of the possible risks factors that they experienced. As a result, the convenience sample produced the ratings of risks factors associated with early infant mortality as represented in the diagram data and the following description. Based on the methods and results that the research article gathered, among the 15,469 infants that were born alive during the research study, a hypothesized variety of risks factors associated with infant mortality resulted in some not being factors, while others were (Katz). The risk factors that the research identified not to be associated with infant mortality were smoking, drinking, and socioeconomic factors. On the other hand, the risk factors that the research found to be associated with early infant mortality were maternal mortality, maternal morbidity, anthropometric characteristics (birth weight), parity (previous pregnancies), and gestational age (Katz). The causes that were discussed in the research were maternal mortality, maternal morbidity, anthropometric characteristics (birth weight), parity (previous pregnancies), and gestational age. The article discusses that maternal mortality was one of the factors associated

4 strongly with infant mortality, due to the fact that they discovered that the death of the mother was caused by the birth of their infants who were likely to be weak or small from birth complications (Katz). This means when the mothers die due to complications after giving birth, there is a likelihood of the infant dying within weeks or months because of it. Morbidity or illness is another factor associated with infant deaths, in which the research reveals that serious illness during the last three months of the pregnancy increases the likelihood of mortality during the fourteen to twenty-eight days of the neonatal period (Katz). This means that illnesses and quite commonly as fevers may carry infections to the fetus and create complications during the fourteen to twenty-eight days of life. Also discussed as one of the risk factors of infant deaths is anthropometric characteristics (birth weight), which is to maintain the mothers birth weight at normalcy where they do not lack the fat or lean body mass that can affect the infants health and its staying alive or not during the first week of life (Katz). More specifically, the anthropometric characteristics or birth weight of pregnant women can be detected through the circumference of the upper arm during the second and third trimester to assess the normalcy or correct weight for pregnant women (Katz). Parity or previous pregnancies is also found to be associated with infant mortality, where Katz discussed from the research of infant mortality in the country of Nepal that the deaths of infants is associated strongest in the first week of life. The means that infants were most likely to die from mothers who have been pregnant once or more before. In addition, miscarriage of previous pregnancy was reported as a risk factor for infant mortality (Katz). Moreover, the risk factor of infant deaths due to miscarriage explains the association that many women from Nepal in the research study reported to a major cause for IMR. A last cause of infant mortality that was discussed from the research reporting Nepals infant mortality, is gestational age was strongly associated with infant mortality in the first week of life and after

5 (Katz). This means that during the gestational age of the infant which is when they are fetuses, their development up to full term which is thirty-six weeks gestational period is significantly important and determines if they are to survive during their first year of life after the womb. When fetuses develop too early within their gestational period thus they are born as premature, are not fully developed, and are most likely to die within the first week or not make to their first birthday. The research article also discusses possible intervention strategies to reduce early infant mortality. One of the strategies that were mentioned is to reduce the maternal morbidity in the third trimester by identifying the illnesses for early referral. The research article mentions another intervention strategy to reduce infant mortality by the improvement in mid upper arm circumference of women by increasing the intake of calories and protein (Katz). Afghanistan Afghanistan is one of the countries with the highest infant mortality rate (IMR). Afghanistan is rated the second country with the highest infant mortality rate out of 224 countries, with an IMR of 151.50 infant deaths out of a thousand live births (http://cia.org). According to the research article Casualties of War by Jane Salvage, a variety of infant mortality causes were assessed and discussed. The research overall discussed the main causes for Afghanistans high infant mortality rate was due to the war. Salvage reported that there were other causes of infant mortality that branched off from the war such as communicable diseases, malnutrition, and on top of that, poverty. In addition, Afghanistan has a strict culture that consists of great repression upon the women where they are banned from education and training (Salvage). The lack of education for women prevented them from receiving maternal care and how to care for themselves during their pregnancies that resulted in too many infants being born with infectious diseases and low birth rate because the infants were not treated well for growth

6 during the gestational period. The research also reported that nearly two-thirds of infant mortality in Afghanistan is caused by diarrhea, respiratory infections and vaccine-preventable diseases, and epidemics of tuberculosis, malaria and cholera (Salvage). The lack of resources due to the fact that a war was going on prevented many women from getting primary care when theyre pregnant and even when the infant is born were very crucial in the infant survival within the couple of months or even days of life. Overall the infant mortality in Afghanistan was very high compared to other countries because the women were restricted from education and training in maternal health because of the Taliban and culture, where women were not able to be treated by male physicians to get maternal care or to deliver their infants (Salvage). Thus, infants were delivered mainly at home with a midwife or unskilled individual in unsanitary environment, a lack of medical resources, and on top of that, the war made it more overwhelming to bear. The lack of medical resources such as basic drugs or infants shots to protect the infants from communicable diseases were also very crucial in their survival within the couple of days, weeks or even months of life. Brazil Brazil has a population of 182 million people and is South Americas largest country. The country has had numerous developments in health though disparities still exist among its different geographical regions (De Carvalho, Westphal, & Lima, 2007, p. 7). These developments include a higher life expectancy and a decrease in infant mortality (IMR), which De Carvalho et al. (2007) point out that the decline is not only due to technological advances but also attributable to the increase in the gross domestic product (GDP) and with the policies of expansion of essential public servicesbasic sanitation, health, and education (p. 7).

7 Statistics from the Rede Interagencial de Informaes para Sade indicate that the north and the northeast regions have the highest infant mortality rates, with 23.35 and 31.61 per thousand, respectively, compared to the southeast, south, and central-west regions, with 14.20, 13.80, and 17.83 per thousand, respectively (as cited in Da Silva, et al., 2010, p. 4). The north and northeast portions of Brazil are the most impoverished in the country. It can be deduced that the higher north one is, the more IMR increases. Another prominent piece of the research shows that IMRs and low birth weight (LBW) were negatively correlated and that more developed states had higher LBW rates and lower IMRs (Da Silva, et al., 2010, p. 4). Da Silva et al. (2010) report that the phenomenon of increased LBW rates and decreased IMRs are due to increased medical interventions, which are also seen in the United States (p. 6). Costello and Osrin (2005) examine health care in Brazil and despite all the improvements for the past twenty years, they come to the conclusion that neonatal mortality rates have changed little (p. 825). Their data demonstrates that falling mortality in term infants (37 weeks gestation or more) has been offset by a rise in preterm births and deaths, resulting in little change in neonatal mortality (Costello & Osrin, 2005, p. 825). Tying it all together, Da Silva et al. (2010) assert that the ecological dissociation between LBW rate and IMR suggests that LBW rate can no longer be systematically considered an indicator of socioeconomic well-being (p. 6). A more recent study maintains that IMR in Brazil has plummeted but that ethnic disparities in infant mortality, which are well documented in many countries, have remained unchanged or have even increased over the past decades (Matijasevich, et al., 2008, p. 692). The statistics in this study show a marked improvement, from 112 deaths per 1000 live births in 1960 to an estimated 25 deaths per 1000 live births in 2002 (Matijasevich, et al., 2008, p. 692). Regardless of the overall developments, the study, which was done in the city of Pelotas in the

8 South of Brazil, revealed the pervasive and enduring effects of social and racial inequalities on IMR. Matijasevich et al. (2008) relate the many disparities that still exist, including fewer antenatal consultations and later onset of prenatal care for black and mixed race women compared to white women and gynecological diagnostic produces were made less available to black and mixed race women, and by the year 2004 IMR in infants born to black and mixed race mothers was double that of whites (pp. 694-695). Brazils ascension as one of the top countries poised to be a future superpower may be hindered by the widening gap among its socioeconomic and racial strata. This is a problem faced by many other developed and developing countries. This is of importance because one of the eight United Nations Millennium Development Goals is to reduce infant mortality. Ultimately, the aim is to decrease world poverty by the year 2015. IMR is used to determine the health and well-being of a population and at the earliest, interventions must be taken to improve IMR across the board and to accurately and fairly reflect Brazils condition. Iraq War-torn Iraq has shaken not only the Middle East but also the other countries involved in the war effort. In the coming years, we will undoubtedly see the lasting effects of war on Iraqs people and environment. The increased rates of cancer and birth defects have been blamed on the omnipresence of mutagenic and carcinogenic substances employed in warfare, spurring the increase of childhood leukemia cases in the city of Basrah and different cases of cancer and birth defects in Fallujah (Busby, Hamdan, & Ariabi, 2010, p. 2829). Busby et al. (2010) conducted a five-year study on infant mortality in Fallujah and found out that while there was no problem in confirming infant deaths, it was difficult to ascertain the cause of death due to an apparent stigma attached to it (p. 2831). Busby et al. (2010) found that

9 possible exposure to uranium and to low doses of ionizing radiation have a significant effect on IMR (p. 2832). The infant death rate per thousand births in Fallujah from 2006-2010 is 80, a considerable amount when compared with its neighboring countries of Kuwait, Egypt, and Jordan, with 9.7, 19.8, and 17 per thousand births, respectively (Busby et al., 2010, p. 2834). Fallujahs numbers is an increase of more than four times that of Egypt and Jordan and almost nine times that of Kuwait. Even though the Busby study on Fallujah was inconclusive as to what was the exact substance(s) causing the increase in infant mortality, history shows that the United States has actively left behind toxic wastes in military bases and stations. With Iraq as a recent example, these environmental pollutants have unquestionably contaminated the air and the groundwater. Evidence points strongly that intended (through firearms and artillery) casualties of war are compounded by unintended (through environmental stressors and environmental toxins) factors that directly affect IMR, among other things. Main Points and Analysis - Causes of Infant Mortality: The leading causes of infant death have not changed in the last several years, even though there has been advancement in technology and have increased their focus on prenatal care. Most people would expect the rate of infant death to be decreasing rapidly, but it has actually remained pretty stable since the year 2000. There are many causes of infant mortality. In richer countries they can provide the basic ingredients for infant survived which are clean water, sanitary surroundings, adequate food and shelter, and access to health care services (diarrhea-anddehydration). A large portion of infant mortality is due to infectious and communicable diseases (Hummer, Robert).

10 Infant mortality is often caused by infectious diseases, such as pneumonia, tetanus and malaria. This occurs because they do not have adequate nutrition, especially breast milk, which provides babies with both the nourishment and the antibodies to fight infectious diseases (WHO). Mothers are not nourished adequately and therefore, they cannot provide adequate breast milk to their infants. With no adequate breast milk mothers use breast milk substitutes, like mixing formula with unclean water and/or diluting formula for cost saving reasons, and this has negative effects on the health of infants (WHO). Violence is another cause of infant mortality. Violence to infants happens in the form of head trauma, including shaken baby syndrome (SBS). Another cause is that men are more likely to be perpetrators of violence, where the biological fathers are most likely the ones to cause fatal head trauma to infants, followed by boyfriends. Another cause of infant mortality is malnutrition, and sudden infant death syndrome (SIDS). Malnutrition contributes to about one third of the 9.7million child deaths that occur each year (Hummer, Robert). The last cause mentioned, which was SIDS is the unexplained death, usually during sleep of a seemingly healthy baby. Most SIDS cases occur between two months and four months of age. Vulnerability, critical development period, and outside stressor, combined within the first six months of an infants life to form the triple-risk model for SIDS (Hummer, Robert). The most common cause of infant mortality rate is diarrhea. Diarrhea is the number one cause of infant mortality rate in the entire world because it causes dehydration. Diarrhea is the babys passing stools that are softer than usual. This actually kills more children than malaria, AIDS and tuberculosis all combined. Diarrhea is responsible for the deaths of 1.9 million deaths a year. This is very sad because all of this could be prevented. A very simple solution to this

11 particular cause is to drink water mixed with a pinch of salt and a fist full hand of sugar. Or you can just have frequent fluids and this can also be a solution. In infants under one year of age it is known as infantile diarrhea (diarrhea-and-dehydration). Congenital defects are another cause of infant deaths, also known as birth defects. This is a problem that occurs while a fetus is developing in the womb. These defects can affect the way the body looks or functions and range from mild to severe. Some of the defects include cleft lip or palate, these can be easily fixed or treated. Other congenital defects may need life-long treatment to manage, for example down syndrome, heart defects, and others. But the most severe congenital defects prove fatal and lead to infant death. In 2005, 5,571 infants died as a result of congenital defects (Hummer, Robert). Preterm birth and low birth weight are also causes of these deaths. Preterm birth, is also referred to as short gestation period, or a pregnancy less than 37 weeks. Low birth weight is when a baby weights less than 5 pounds and 8 ounces. In 2005, 4,698 infants died as a result of preterm birth or low birth weight (Hummer, Robert). Maternal complications of pregnancy are also a cause of death in infants. These are complications that occur with the mother during the gestation period. These include preeclampsia, placenta previa, and incompetent cervix among many others. In 2005, 1,769 infants died as a result of maternal complications (Hummer, Robert). Other complications that may also cause the death of an infant are complications of the umbilical cord, placenta and membranes. The placenta is an organ inside the womb that supplies the fetus with the blood supply and nutrients necessary for survival. The umbilical cord connects the mother with the growing fetus at the placenta. The umbilical cord brings oxygen and nutrients to the fetus and takes away waste such as carbon dioxide. Umbilical cord and placenta

12 complications were the cause of death of 1,095 infants in 2005 (Hummer, Robert). Going over all of these infant death causes lets us realize that this is the reason why so many infants die every year. There are a lot of causes for these deaths, and these are only a few of them, there is actually a lot more that we did not mention. While developed countries cases of infant mortality are caused by infectious diseases, developing and underdeveloped countries are more impacted by infant mortality owing to a variety of different causes. The underlying aspect of most of these causes, whether they occur in wealthy or impoverished nations, is that they are avoidable. Though resources are not always available, proper nourishment of mother and baby can be reinforced through education. The same can be said for violence, manifested most commonly in shaken baby syndrome, which can be avoided if the parents are taught about proper care for an infant. Diarrhea is another significant cause of infant mortality. One of the biggest reasons why populations succumb to diarrhea is because clean water is not available to them. People share drinking water with animals or obtain water from murky ponds teeming with bacteria, viruses or protozoans. Diarrhea, a symptom of various waterborne diseases, can be eliminated if water purification techniques or potable water sources are introduced. Conclusion: By examining the causes that were assessed for the reasons of infant deaths, this indicates the severity of the overall countries health. Where the causes of infant mortality that were discussed such as lack of education, poverty, malnutrition, and low birth weight explains the overall health of the countries high infant mortality rates. All of the countries that were discussed had one thing in common, which is that they all share the overall causes of infant mortality in some way. This comparison is very important because it gives a sense of awareness

13 that other countries predicaments may be addressed, precautions taken and intervention strategies constructed in reducing infant mortality like the research that was done for Nepal. Some of the causes that were reported in the articles that were discussed were poverty, lack of resources, lack of education, malnutrition and low birth weight. These were the main comparisons that Nepal, Afghanistan, Brazil, and Iraq all shared. The causes that these countries shared along with other specific causes that each country has address the issue of infant mortality. In addition, the assessment of these causes of infant mortality may raise possible causes for other countries as well who are affected with high infant mortality and have not found the reasons for their countrys infants deaths. Special attention should be paid to the people, governments, and policymakers of these countries and to other countries suffering from high IMR in order to bridge gaps. Moreover, the overall causes that were discussed at the end of the main points summarize all the main causes of infant deaths at a global overview. Where other intervention strategies to reduce infant mortality that were not introduced from the main points could be constructed in the near future in the hopes of eradicating infant deaths in countries who are tremendously affected around the world.

14 References Busby, C., Hamdan, M., and Ariabi, E. (2010). Cancer, infant mortality and birth-sex ratio in Fallujah, Iraq 2005-2009. International Journal of Environmental Research and Public Health, 7, 2828-2837. De Carvalho, A. I., Westphal, M. F., and Lima V. L. G. P. (2007). Health promotion in Brazil. Promotion & Education, Supplement(1), 7-12. Costello, A. and Osrin, D. (2005). Epidemiological transition, medicalisation of childbirth, and neonatal mortality: Three Brazilian birth-cohorts. The Lancet, 365(9462), 825. Country Comparison Infant Mortality Rate. (2010). The World Fact Book. Central Intelligence Agency (CIA). Retrieved from Web. http://cia.org/. Diarrhea and DehydrationThe Grim Reaper of Children. (2008). All-About-Drinkingwater.com. Retrieved from Web. http://www.all-about-water-filters.com/diarrhea-anddehydration.html. Hummer, Robert A. Race/Ethnicity Nativity, and Infant Mortality in the United States. Social Forces 77 (1999): 1083-1118. Katz, J., West Jr, K., Khatry, S., Christian, P., LeClerq, S., Pradhan, E., et al. (2003). Risk factors for early infant mortality in Sarlahi district, Nepal. Bulletin of the World Health Organization, 81(10), 717-725. Retrieved from Academic Search Complete database. Matijasevich, A., Victoria, C. G., Barros, A. J. D., Santos, I. S., Marco, P. L., Albernaz, E. P., and Barros, F. C. (2008). Widening ethnic disparities in infant mortality in Southern Brazil. American Journal of Public Health, 98(4), 692-698.

15 Salvage, J. (2007). Casualties of war. Nursing Standard, 21(50), 20-22. Retrieved from Academic Search Complete database. Da Silva, A. A. M., Da Silva, L. M., Barbieri, M. A., Bettiol, H., De Carvalho, L. M., Ribeiro, V. S., and Goldani, M. Z. (2010). The epidemiologic paradox of low birth weight in Brazil. Revista de Sade Pblica (Journal of Public Health), 44(5), 767-775. World Health Organization Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of Breastfeeding on Infant and Child Mortality Due to Infectious Diseases in Less Developed Countried: A Pooled Analysis. Lancet 355 (2000): 451-455.