Infant mortality: a reflection of the quality of health.

********** It is often said that the infant mortality rate (IMR) is an indicator of a country's civilization (Brosco, 1999; Gortmaker & Wise, 1997; McCloskey et al, 1999). If this is true, how well are we doing? The United States claims to have the best and most technologically advanced health care system in the world. Our infant mortality would suggest another conclusion. In 1996 the United States ranked 26th in the world for infant mortality (Center for Disease Control and Prevention [CDC], 2001), behind many developing countries. Infant mortality has been subdivided into three major categories to clarify understanding of risk factors. Infant mortality encompasses two subgroups: neonatal (birth to 27 days) and postneonatal (28 days to 364 days). Child mortality applies to one-to-18 years olds. A thorough discussion of each category would exceed the limits of this column. In this article, I review the status of infant mortality in the United States, including a discussion of key issues and future agendas. HISTORICAL CONTEXT Rates of infant mortality have shown significant improvement since the early 1900s ("Healthier Mother and Babies," 1999; Sable W Zylke, 1989). In 1915 the rate of infant death was 100 infants per 1,000 live births, declining to 7.2 per 1,000 live births by 1997. This translated into a decline of almost 90 percent. Much of the decline in the IMR has been attributed to improvements related to urban living (for example, sanitation, pasteurization, improved water and sewage, reduced fertility rates, and improved economic and educational levels) followed by technological and public health strategies ("Healthier," 1999). Three distinct periods of technological advancements in health care treatment have been noted: The period from 1930 to 1950 witnessed the development of antibiotics and fluid replacement techniques (for example, electrolyte replacement and blood transfusions); the 1970s saw the expansion of neonatal intensive care units to treat birth complications. In the 1980s, artificial pulmonar y surfactant treatment was introduced to treat respiratory distress, common to low birthweight (LBW) (less than 2,500 grams) infants. Access to care improved with the enactment of Medicaid legislation in the 1960s and the regionalization of perinatal services in the 1970s. Public health initiatives also share in the success. Two campaigns are of significant note:(1) efforts to improve immunization rates for children, and (2) the reduction of sudden infant death syndrome (SIDS) by placing babies on their backs to sleep. MAJOR THEMES Several themes emerge from a review of the abundant research and scholarly work on infant mortality. Although much of the research is inconclusive, several factors continue to be identified with poor birth outcomes: low birthweight, preterm delivery, smoking, substance abuse, maternal age, pregnancy intent, attitudes about pregnancy, stress, poverty, and domestic violence. A thorough discussion of risk factors is beyond the scope of this column, although I highlight several in the following discussion. Most of these factors fall within the psychosocial domain, highlighting the important role social work has and will continue to play. Statistical Reporting Statistical analysis for infant mortality often is based on population data, primarily collected from birth and death records. Consequently, how indices are defined influences comparative analysis, particularly when gross indicators such as IMR are used. Countries, states, counties, and health care personnel may use different criteria for determining a live birth. For some, if the infant takes one breath, it is considered a live birth; for others, a predetermined period of time must elapse before a determination of a live birth is established. Sowards (1999) pointed out that this presents specific problems to the study of prematurity. Petrini and colleagues (1989) uncovered a similar concern in relation to racial and ethnic factors. …