Relationships between pregnancy spacing,sex of infants,maternal age,and birth order,and neonatal and post‐neonatal mortality in Bangladesh

Abstract

The relationships between length of the interpregnancy interval, outcome of the pregnancy preceding the interval, sex of the infants, pregnancy order, maternal age, and maternal history of previous child deaths and neonatal and postneonatal mortality were explored in a rural Bangladeshi population using a multiple regression analysis. Specific interactions between the interpregnancy interval, outcome of the pregnancy preceding the interval, sex of the infants, and history of previous child deaths were examined. An inverse relationship was observed between postneonatal mortality and the length of the interpregnancy interval when the pregnancy preceding the interval was a surviving infant. No such trend was observed for neonatal mortality. Post‐neonatal mortality rates among children whose mothers had experienced two or more previous child deaths were essentially the same as that for infants whose mothers had experienced 0–1 child deaths when the interpregnancy intervals were more than 24 months. Although female infants have a lower neonatal mortality than male infants, the neonatal mortality rate for female infants conceived less than twelve months following a male infant birth was higher than for a male infant conceived less than twelve months following another male infant birth. Post‐neonatal mortality is consistently higher for female compared to male infants in all interval categories.     

Deaths in a desert baboon troop

Over a 4-year period, three of 22 infants born in a desert-dwelling chacma baboon troop (Papio ursinus) survived to more than 6 months of age. Tick infestation and infant kidnapping by adult females were the main causes of infant death. The high neonatal mortality resulted in a rapid birth rate through a decrease in duration of interbirth intervals for mature females. There were more adult male deaths in the troop than adult female deaths. Males died from canine inflicted wounds sustained during fights.     

The Bourgeois-Pichat's biometric method and the influence of climate: new evidences from late 19th-century Italy

This paper examines to which extent seasonal and climatic conditions might affect the reliability of the Bourgeois-Pichat's method. Other scholars have already argued on this issue, but although climate has often been claimed to explain part of the differentials in mortality figures among Italian regions, to date its impact has not actually been recognized and quantitatively evaluated. To test such hypothesis data at the regional level from late 19th-century Italy have been analyzed. Our analysis of the biometric components revealed a strong bias in the estimates of the endogenous and exogenous components in the first month of life. Variations in infant mortality among Italian regions correlated with variations in the endogenous levels rather than in the exogenous levels of infant (neonatal) mortality, as it was expected owing to the infective nature of the diseases climate might induce. Specifically, Northern and colder regions featured high figures for both neonatal mortality and the endogenous component, while the opposite scheme applied to the Southern, more temperate regions. Finally, the reasons for such misleading results were investigated. It emerged that the model's assumption of a constant and invariant proportion of neonatal exogenous deaths to the total amount of exogenous deaths was not matched by the Italian data. This situation caused the excess neonatal exogenous mortality, especially that induced by cold climate in Northern regions, to be wrongly counted in the endogenous component.     

Using Health Extension Workers for Monitoring Child Mortality in Real-Time: Validation against Household Survey Data in Rural Ethiopia

Background

Ethiopia has scaled up its community-based programs over the past decade by training and deploying health extension workers (HEWs) in rural communities throughout the country. Consequently, child mortality has declined substantially, placing Ethiopia among the few countries that have achieved the United Nations’ fourth Millennium Development Goal. As Ethiopia continues its efforts, results must be assessed regularly to provide timely feedback for improvement and to generate further support for programs. More specifically the expansion of HEWs at the community level provides a unique opportunity to build a system for real-time monitoring of births and deaths, linked to a civil registration and vital statistics system that Ethiopia is also developing. We tested the accuracy and completeness of births and deaths reported by trained HEWs for monitoring child mortality over 15 -month periods.

Methods and Findings

HEWs were trained in 93 randomly selected rural kebeles in Jimma and West Hararghe zones of the Oromia region to report births and deaths over a 15-month period from January, 2012 to March, 2013. Completeness of number of births and deaths, age distribution of deaths, and accuracy of resulting under-five, infant, and neonatal mortality rates were assessed against data from a large household survey with full birth history from women aged 15–49. Although, in general HEWs, were able to accurately report events that they identified, the completeness of number of births and deaths reported over twelve-month periods was very low and variable across the two zones. Compared to household survey estimates, HEWs reported only about 30% of births and 21% of under-five deaths occurring in their communities over a twelve-month period. The under-five mortality rate was under-estimated by around 30%, infant mortality rate by 23% and neonatal mortality by 17%. HEWs reported disproportionately higher number of deaths among the very young infants than among the older children.

Conclusion

Birth and death data reported by HEWs are not complete enough to support the monitoring of changes in childhood mortality. HEWs can significantly contribute to the success of a CRVS in Ethiopia, but cannot be relied upon as the sole source for identification of vital events. Further studies are needed to understand how to increase the level of completeness.     

The bourgeois‐pichat's biometric method and the influence of climate: New evidences from late 19th‐century Italy

Abstract

This paper examines to which extent seasonal and climatic conditions might affect the reliability of the Bourgeois‐Pichat's method. Other scholars have already argued on this issue, but although climate has often been claimed to explain part of the differentials in mortality figures among Italian regions, to date its impact has not actually been recognized and quantitatively evaluated. To test such hypothesis data at the regional level from late 19^th‐century Italy have been analyzed.

Our analysis of the biometric components revealed a strong bias in the estimates of the endogenous and exogenous components in the first month of life. Variations in infant mortality among Italian regions correlated with variations in the endogenous levels rather than in the exogenous levels of infant (neonatal) mortality, as it was expected owing to the infective nature of the diseases climate might induce. Specifically, Northern and colder regions featured high figures for both neonatal mortality and the endogenous component, while the opposite scheme applied to the Southern, more temperate regions.

Finally, the reasons for such misleading results were investigated. It emerged that the model's assumption of a constant and invariant proportion of neonatal exogenous deaths to the total amount of exogenous deaths was not matched by the Italian data. This situation caused the excess neonatal exogenous mortality, especially that induced by cold climate in Northern regions, to be wrongly counted in the endogenous component.     

A study of infant mortality and causes of death in a rural north-east Brazilian community

In 1984 a prospective study of 1645 women and 1677 births in a rural community in north-eastern Brazil showed the infant mortality rate to be 65 per 1000 live births. Neonatal, post-neonatal and infant mortality are analysed to determine the most important risk factors for each period. Post-neonatal survival depends largely on factors relating to child care, while neonatal deaths are more likely to be associated with biological factors. The principal cause of death, diarrhoeal disease, was responsible for a third of the deaths.     

The mortality of two groups of infants in Spanish rural region

In this study the structure of the mortality of two groups of infants settled in the same environmental context is analysed: the comarca (a typical Spanish sub-division of territory) of La Cabrera (province of León, Spain) between the years 1880 and 1932. In this geographical region of the northwest of Spain two communities of infants from different origins are found in this time period. On the one hand, an autochthonous infant population from the births of the legitimately constituted families settled in this territory. On the other, an infant population represented by a group of children who were abandoned in a foundling hospital situated in a nearby city (Ponferrada) and who were sent to this rural "comarca" to be breast-fed by wet-nurses being paid certain quantities of money. The mortality rates and the seasonality of the deaths have been analysed for both the autochthonous and non-autochthonous children. Thus we have been able to test whether differences in the structure of mortality exist. Throughout the study, the possibility that these differences in mortality could be attributed to discriminative cultural factors, expressed through preferential care and/or attention and which show in the different models of infant mortality, is considered.     

Infant and child mortality in Pakistan--some trends and differentials

Data from reproductive histories collected in the Population, Labor Force and Migration Survey (PLM) of 1979 are used to analyze trends and differentials in infant and child mortality in Pakistan. Comparisons with the Pakistan Fertility Survey (PFS) findings are also presented. The main concern is to provide from the latest national data, the PLM, direct measures of infant and child mortality and to demonstrate the relatively static and low chances of survival for children in Pakistan. The apparent trends from the PLM and the PFS are similar and seem to confirm that infant and childhood mortality has ceased to decline, at least rapidly, since 1965-69. Neonatal mortality is higher at levels of 70-85 deaths/1000 compared to postneonatal mortality of 40-60 deaths/1000. Improvements in neonatal rates from 1950 until 1975 are only approximately 1/2 of those for postneonatal rates for that period. The relationship between maternal age and mortality in the PLM data confirms that children of youngest mothers experienced the highest rates of infant mortality; mortality is again higher for children of oldest mothers aged 35 and above. The pattern of mortality in the 2 surveys is similar except that in the PFS there was little variation among births higher than 5th order. Sex differentials in mortality are very clear in both surveys. Boys have higher chances of dying in the 1st month of life but then the probability of their surviving from age 1 to 5 years is higher, reflecting the behavioral preference for the male sex in this society. The data also demonstrate an almost monotonic decline in infant and child mortality associated with longer birth intervals. Childhood mortality shows a less clear association with preceding birth interval than does infant mortality. While neonatal mortality is much higher in rural than in urban areas, there are negligible differences in the postneonatal rate. The urban-rural differential continues into childhood, reflecting lower health care and nutrition of children in rural areas. The data confirm the importance of parental education, particularly that of mothers, as a contributor to the health and mortality of infants. Mortality between age 1 and 5 years for children of the rural educated group is lower than that for the urban uneducated indicating the strong influence that education of mothers can have in preventing child loss. The combined evidence from the PFS and PLM data stresses the importance of improving health facilities in the rural areas, in aneffort to reduce the differences in mortality by area of residence. The data from both surveys also suggest the need to restrict motherhood to between the ages of 20 and 34, when obstetrical and health risks are minimal, and indicate the definite advantages of increasing the spacing between children.     

Confidential paediatric inquiry into neonatal deaths in Wessex, 1981 and 1982.

From 1 January 1981 to 31 December 1982, 66 256 births and 386 neonatal deaths were recorded in the Wessex Regional Health Authority, giving a neonatal mortality of 5.8/1000 live births. An experienced consultant paediatrician undertook a confidential inquiry into each death shortly after it had been reported. One hundred and forty four deaths (37%) were found to be due to lethal or severe malformations, an incidence of 2.2/1000 births. Of the 242 normally formed infants, 111 (46%) died within 24 hours of birth. Seventy seven (32%) weighed over 2500 g at birth. Factors operating before delivery accounted for 104 (43%) of the deaths of normally formed infants. The commonest factors were short gestation and low birth weight, and intrauterine hypoxia and birth injury. Factors after delivery accounted for 81 deaths (33%), the commonest being infections and sudden infant deaths. In the remaining 57 deaths (24%) it seemed that a combination of factors before and after birth had led to the death. Factors before birth thus played a part in two thirds of all deaths. Possible adverse factors in medical care were sought in 154 potentially viable babies and were identified in 38--that is, 10% of all neonatal deaths. Better provision and training of district staff in immediate care at birth would achieve more in lowering neonatal mortality in Wessex than the setting up of a regional unit specializing in advanced neonatal intensive care. Moreover, the greatest scope for improving the outcome of childbirth in Wessex would be offered if there were further advances in obstetric rather than neonatal care.     

Transport of dead infant mountain gorillas by mothers and unrelated females

This report describes prolonged carriage of the corpses of two mountain gorilla infants by both related and unrelated adult females. Two hypotheses regarding this transport are considered: 1) that maternal behavior toward unrelated infants may be a by‐product of the hormonal condition of pregnancy, and 2) that the animals may be “learning to mother,” as nulliparous females could benefit from the experience of handling an infant that is no longer alive. Some factors pertinent to the event of infant deaths in captivity are considered. Zoo Biol 23:375–378, 2004. © 2004 Wiley‐Liss, Inc.     

Influence of birth weight on differences in infant mortality by social class and legitimacy.

OBJECTIVE--To investigate the influence of birth weight on the pronounced social class differences in infant mortality in Britain. DESIGN--Analysis of routine data on births and infant deaths. SETTING--England and Wales. SUBJECTS--All live births and infant deaths, 1983-5. MAIN OUTCOME MEASURE--Mortality in infants by social class, birth weight, and legitimacy according to birth and death certificates. RESULTS--Neonatal and postneonatal mortality (deaths/1000 births) increased with social class. Neonatal and postneonatal mortality was 4.2/1000 and 2.3/1000 respectively for social class I and 6.8/1000 and 5.6/1000 respectively for social class V. Mortality was lower among births registered within marriage (postneonatal 3.5/1000; neonatal 5.2/1000) than among those jointly registered outside marriage (5.1/1000; 6.4/1000); mortality was highest in those solely registered outside marriage (7.2/1000; 7.0/1000). For neonatal mortality the effect of social class varied with birth weight. Social class had little effect on neonatal mortality in low birthweight babies and increasing effect in heavier babies. For postneonatal mortality the effect of social class was similar for all birth weights and was almost as steep as for all birth weights combined. CONCLUSION--Birth weight mediates little of the effect of social class on postneonatal mortality.     

The Apgar Score and Infant Mortality

Objective

To evaluate if the Apgar score remains pertinent in contemporary practice after more than 50 years of wide use, and to assess the value of the Apgar score in predicting infant survival, expanding from the neonatal to the post-neonatal period.

Methods

The U.S. linked live birth and infant death dataset was used, which included 25,168,052 singleton births and 768,305 twin births. The outcome of interest was infant death within 1 year after birth. Cox proportional hazard-model was used to estimate risk ratio of infant mortality with different Apgar scores.

Results

Among births with a very low Apgar score at five minutes (1–3), the neonatal and post-neonatal mortality rates remained high until term (≥ 37 weeks). On the other hand, among births with a high Apgar score (≥7), neonatal and post-neonatal mortality rate decreased progressively with gestational age. Non-Hispanic White had a consistently higher neonatal mortality than non-Hispanic Black in both preterm and term births. However, for post-neonatal mortality, Black had significantly higher rate than White. The pattern of changes in neonatal and post-neonatal mortality by Apgar score in twin births is essentially the same as that in singleton births.

Conclusions

The Apgar score system has continuing value for predicting neonatal and post-neonatal adverse outcomes in term as well as preterm infants, and is applicable to twins and in various race/ethnic groups.     

The effect of divorce on infant mortality in a remote area of Bangladesh

The process of divorce is usually lengthy and hazardous, and can start quarrels that can lead to the abuse of women and their children. This study examines the effects of divorce on neonatal and postneonatal mortality of babies born before and after divorce in Teknaf, a remote area of Bangladesh. The longitudinal demographic surveillance system (DSS) followed 1,762 Muslim marriages in 1982-83 for 5 years to record divorce, deaths of spouse, emigration and births. It recorded 2,696 live births during the follow-up period, and their survival status during infancy. Logistic regression models were used to estimate the effect of divorce on neonatal and postneonatal mortality, controlling for maternal age at birth, parity, sex of the child and household economic status. The odds of neonatal and postneonatal deaths among babies born after divorce or less than 12 months before mothers were divorced were more than double the odds of those born to mothers of intact marriages. The odds of postneonatal deaths were two times higher among babies born more than 12 months before divorce happens than their peers. The high mortality of infants born before and after mothers were divorced may reflect how abusive marriage and divorce increase the vulnerability of women and children in rural Bangladesh. Divorce and abuse of women are difficult and intractable social and health problems that must be addressed.     

Parents' age at birth of their offspring and child survival

This study presents some new results on parental age as a risk factor for child survival. The study is based on individual registration forms for live births and infant deaths collected in Hungary from 1984 to 1988. Logistic regression models have been fitted for early neonatal and neonatal mortality on the one hand, and post-neonatal mortality on the other hand. Children of older males and females have significantly higher early neonatal and neonatal mortality rates compared to those of younger males and females. The impact of age of both parents remains, however, slighter than that of other biological characteristics such as previous number of fetal deaths, induced abortions, or live births. The authors discuss possible biological explanations.     

Contribution of twin pregnancy to perinatal mortality and fetal growth retardation; reversal of growth retardation after birth.

A survey of factors associated with perinatal mortality in 511 twins and fetal growth retardation and its reversal in 262 twins is presented. The incidence of stillbirth was almost 50% higher in twins than in singletons and the neonatal mortality was six times as high. Eighty percent of the neonatal deaths occurred in infants born prior to or at 30 weeks of gestation; 93% of the deaths were in infants weighing less than 1500 g and 75% occurred within 48 hours of birth. Fetal malnutrition was the main cause of stillbirth, and respiratory distress syndrome and asphyxia neonatorum were the main causes of neonatal death. One quarter of the twins had fetal growth retardation, a prevalence 10 times that in singletons. In almost all, the growth retardation was reversed by high-energy feedings. Although twins represented only 1% of all pregnancies and 2% of live births, they composed 12% of infants with early neonatal death and 17% of growth-retarded infants. A program is suggested for reduction of twin mortality and morbidity.     

Gestational age patterns of fetal and neonatal mortality in Europe: results from the Euro-Peristat project

Background

The first European Perinatal Health Report showed wide variability between European countries in fetal (2.6–9.1‰) and neonatal (1.6–5.7‰) mortality rates in 2004. We investigated gestational age patterns of fetal and neonatal mortality to improve our understanding of the differences between countries with low and high mortality.

Methodology/Principal Findings

Data on 29 countries/regions participating in the Euro-Peristat project were analyzed. Most European countries had no limits for the registration of live births, but substantial variations in limits for registration of stillbirths before 28 weeks of gestation existed. Country rankings changed markedly after excluding deaths most likely to be affected by registration differences (22–23 weeks for neonatal mortality and 22–27 weeks for fetal mortality). Countries with high fetal mortality ≥28 weeks had on average higher proportions of fetal deaths at and near term (≥37 weeks), while proportions of fetal deaths at earlier gestational ages (28–31 and 32–36 weeks) were higher in low fetal mortality countries. Countries with high neonatal mortality rates ≥24 weeks, all new member states of the European Union, had high gestational age-specific neonatal mortality rates for all gestational-age subgroups; they also had high fetal mortality, as well as high early and late neonatal mortality. In contrast, other countries with similar levels of neonatal mortality had varying levels of fetal mortality, and among these countries early and late neonatal mortality were negatively correlated.

Conclusions

For valid European comparisons, all countries should register births and deaths from at least 22 weeks of gestation and should be able to distinguish late terminations of pregnancy from stillbirths. After excluding deaths most likely to be influenced by existing registration differences, important variations in both levels and patterns of fetal and neonatal mortality rates were found. These disparities raise questions for future research about the effectiveness of medical policies and care in European countries.     

Reducing Neonatal Mortality in India: Critical Role of Access to Emergency Obstetric Care

Background

Neonatal mortality currently accounts for 41% of all global deaths among children below five years. Despite recording a 33% decline in neonatal deaths between 2000 and 2009, about 900,000 neonates died in India in 2009. The decline in neonatal mortality is slower than in the post-neonatal period, and neonatal mortality rates have increased as a proportion of under-five mortality rates. Neonatal mortality rates are higher among rural dwellers of India, who make up at least two-thirds of India''s population. Identifying the factors influencing neonatal mortality will significantly improve child survival outcomes in India.

Methods

Our analysis is based on household data from the nationally representative 2008 Indian District Level Household Survey (DLHS-3). We use probit regression techniques to analyse the links between neonatal mortality at the household level and households'' access to health facilities. The probability of the child dying in the first month of birth is our dependent variable.

Results

We found that 80% of neonatal deaths occurred within the first week of birth, and that the probability of neonatal mortality is significantly lower when the child''s village is closer to the district hospital (DH), suggesting the critical importance of specialist hospital care in the prevention of newborn deaths. Neonatal deaths were lower in regions where emergency obstetric care was available at the District Hospitals. We also found that parental schooling and household wealth status improved neonatal survival outcomes.

Conclusions

Addressing the main causes of neonatal deaths in India – preterm deliveries, asphyxia, and sepsis – requires adequacy of specialised workforce and facilities for delivery and neonatal intensive care and easy access by mothers and neonates. The slow decline in neonatal death rates reflects a limited attention to factors which contribute to neonatal deaths. The suboptimal quality and coverage of Emergency Obstetric Care facilities in India require urgent attention.     

Quantifying Spatial Disparities in Neonatal Mortality Using a Structured Additive Regression Model

Background

Neonatal mortality contributes a large proportion towards early childhood mortality in developing countries, with considerable geographical variation at small areas within countries.

Methods

A geo-additive logistic regression model is proposed for quantifying small-scale geographical variation in neonatal mortality, and to estimate risk factors of neonatal mortality. Random effects are introduced to capture spatial correlation and heterogeneity. The spatial correlation can be modelled using the Markov random fields (MRF) when data is aggregated, while the two dimensional P-splines apply when exact locations are available, whereas the unstructured spatial effects are assigned an independent Gaussian prior. Socio-economic and bio-demographic factors which may affect the risk of neonatal mortality are simultaneously estimated as fixed effects and as nonlinear effects for continuous covariates. The smooth effects of continuous covariates are modelled by second-order random walk priors. Modelling and inference use the empirical Bayesian approach via penalized likelihood technique. The methodology is applied to analyse the likelihood of neonatal deaths, using data from the 2000 Malawi demographic and health survey. The spatial effects are quantified through MRF and two dimensional P-splines priors.

Results

Findings indicate that both fixed and spatial effects are associated with neonatal mortality.

Conclusions

Our study, therefore, suggests that the challenge to reduce neonatal mortality goes beyond addressing individual factors, but also require to understanding unmeasured covariates for potential effective interventions.     

Perinatal mortality and adverse pregnancy outcomes in a low-income rural population of women who smoke

We describe adverse pregnancy outcomes, including congenital anomalies, fetal, neonatal, and infant mortality among a Missouri population of low-income, rural mothers who participated in two randomized smoking cessation trials. In the Baby BEEP (BB) trial, 695 rural women were recruited from 21 WIC clinics with 650 women's pregnancy outcomes known (93.5% retention rate). Following the BB trial, 298 women who had a live infant after November 2004 were recruited again into and completed the Baby Beep for Kids (BBK) trial. Simple statistics describing the population and perinatal and postneonatal mortality rates were calculated. Of the adverse pregnancy outcomes (n = 79), 29% were spontaneous abortions of less than 20 weeks' gestation, 23% were premature births, and 49% were identified birth defects. The perinatal mortality rate was 15.9 per 1000 births (BB study) compared with 8.6 per 1000 births (state of Missouri) and 8.5 per 1000 births (United States). The postneonatal infant mortality rate was 13.4 per 1000 live births (BBK) compared with 2.1 per 1000 live births (United States). The health disparity in this population of impoverished, rural, pregnant women who smoke, particularly in regard to perinatal and infant deaths, warrants attention.