Disparities in Neonatal Outcomes: Past, Present, and Our Future?

Neonatal outcomes and infant mortality rates have improved significantly in the past century. However, the disparities in outcomes linked to racial and ethnic variations have persisted and actually increased. Those differences in outcomes have been acknowledged for years as care providers strive to improve care for all of our most vulnerable and youngest individuals. Trends in neonatal outcomes are summarized.

Revisiting the effect of time of birth on neonatal, infant, and child mortality in rural Spain, 1830-1929.

OBJECTIVES: This article aims to determine whether different patterns of mortality occurred among children born during the day and the night respectively, between 1830 and 1929. METHODS: The data include the time of birth and death of 9814 individuals from 10 villages in rural Spain between 1830 and 1929, within a context of natural births at home with little medical support. These data were subjected to a comparative analysis relating to the time of birth and the age at death. RESULTS: Neonatal, infant, and child mortality was higher for children born during daytime. The day-to-night mortality pattern diverged until children were at least 5 years old. CONCLUSIONS: The results confirm that the mortality patterns differed according to the time of birth. Possibly some of these children experienced longer or problematic deliveries that, in the absence of good medical assistance, had health consequences during the following days and years of life.

The Relationship between Birth Weight Discordance and Adverse Infant Mortality among Monozygotic and Dizygotic Twins in Japan, 1995-2008.

Using vital statistics in Japan (1995-2008), 154,578 live-born twin pairs (128,236 monozygotic [MZ] and 180,920 dizygotic [DZ]) were identified. The proportion of severe discordance among live-born twin births was twice as high in Japanese than Caucasian infants. There were 1858 MZ and 1620 DZ infant deaths. Computation of the relationship between infant mortality rate and birth weight discordance among the twins was performed. Discordance levels were classified into seven groups: <5%, five groups from 5-9% to 25-29%, and ≥30%.The mortality rate was significantly higher in MZ than DZ twins for discordances except at 5-9% and 10-14%. The lowest rate for MZ twins was at 5-9% (7.5 per 1000 live twins) and significantly increased from 10-14% (9.4) to ≥30% (83.4), while the lowest rate for DZ twins was at <5% (6.7), which significantly increased at 10-14% (8.0) and from 25-29% (12.1) to ≥30% (35.5). The relationship was also computed in two gestational age groups (<28 and ≥28 weeks). For births at <28 weeks, three discordances (after 20-24%) in MZ twins were associated with adverse mortality rate. For births at ≥28 weeks, the same relationship was obtained after 10-14% in MZ and after 20-24% in DZ twins. The relationship from 2002 to 2008 showed that the mortality rates significantly increased after 10-14% for both types of twins. In conclusion, five discordance levels in MZ and three levels in DZ twins were associated with adverse mortality rates.

Sun Smoke in Sweden: Perinatal Implications of the Laki Volcanic Eruptions, 1783-1784.

BACKGROUND: The Icelandic volcano Laki erupted from June 1783 through January 1784. It produced 122 megatons of sulfur dioxide, particulate matter, and acid rain and contributed to one of the coldest winters on record in Western Europe. Although uncontrollable volcanic eruptions continue, few studies have investigated their perinatal health implications. METHODS: Using the Human Mortality Database, we assessed the association between the Laki event and the secondary sex ratio, infant mortality rates, and the number of births from 1751 to 1800 with time-series models that controlled for temporal trends. RESULTS: The secondary sex ratio decreased 3% below expected levels in 1784 (95% CI = -4%, -1%). Both female and male infant mortality rates exceeded expectation in 1785, by 54% (95% CI = 25%, 83%) and 37% (-1%, 74%), respectively. We observed little change in female live births but a reduction in male live births in 1784. CONCLUSIONS: Our findings are consistent with the hypothesis that the large-scale Laki volcanic eruptions of 1783-1784 resulted in adverse perinatal health outcomes in Sweden.

Learning From History About Reducing Infant Mortality: Contrasting the Centrality of Structural Interventions to Early 20th-Century Successes in the United States to Their Neglect in Current Global Initiatives.

Policy Points Current efforts to reduce infant mortality and improve infant health in low- and middle-income countries (LMICs) can benefit from awareness of the history of successful early 20th-century initiatives to reduce infant mortality in high-income countries, which occurred before widespread use of vaccination and medical technologies. Improvements in sanitation, civil registration, milk purification, and institutional structures to monitor and reduce infant mortality played a crucial role in the decline in infant mortality seen in the United States in the early 1900s. The commitment to sanitation and civil registration has not been fulfilled in many LMICs. Structural investments in sanitation and water purification as well as in civil registration systems should be central, not peripheral, to the goal of infant mortality reduction in LMICs. CONTEXT: Between 1915 and 1950, the infant mortality rate (IMR) in the United States declined from 100 to fewer than 30 deaths per 1,000 live births, prior to the widespread use of medical technologies and vaccination. In 2015 the IMR in low- and middle-income countries (LMICs) was 53.2 deaths per 1,000 live births, which is comparable to the United States in 1935 when IMR was 55.7 deaths per 1,000 live births. We contrast the role of public health institutions and interventions for IMR reduction in past versus present efforts to reduce infant mortality in LMICs to critically examine the current evidence base for reducing infant mortality and to propose ways in which lessons from history can inform efforts to address the current burden of infant mortality. METHODS: We searched the peer-reviewed and gray literature on the causes and explanations behind the decline in infant mortality in the United States between 1850 and 1950 and in LMICs after 2000. We included historical analyses, empirical research, policy documents, and global strategies. For each key source, we assessed the factors considered by their authors to be salient in reducing infant mortality. FINDINGS: Public health programs that played a central role in the decline in infant mortality in the United States in the early 1900s emphasized large structural interventions like filtering and chlorinating water supplies, building sanitation systems, developing the birth and death registration area, pasteurizing milk, and also educating mothers on infant care and hygiene. The creation of new institutions and policies for infant health additionally provided technical expertise, mobilized resources, and engaged women's groups and public health professionals. In contrast, contemporary literature and global policy documents on reducing infant mortality in LMICs have primarily focused on interventions at the individual, household, and health facility level, and on the widespread adoption of cheap, ostensibly accessible, and simple technologies, often at the cost of leaving the structural conditions that determine child survival largely untouched. CONCLUSIONS: Current discourses on infant mortality are not informed by lessons from history. Although structural interventions were central to the decline in infant mortality in the United States, current interventions in LMICs that receive the most global endorsement do not address these structural determinants of infant mortality. Using a historical lens to examine the continued problem of infant mortality in LMICs suggests that structural interventions, especially regarding sanitation and civil registration, should again become core to a public health approach to addressing infant mortality.

Revising Infant Mortality Rates for the Early Twentieth Century United States.

Accurate vital statistics are required to understand the evolution of racial disparities in infant health and the causes of rapid secular decline in infant mortality during the early twentieth century. Unfortunately, U.S. infant mortality rates prior to 1950 suffer from an upward bias stemming from a severe underregistration of births. At one extreme, African American births in southern states went unregistered at the rate of 15 % to 25 %. In this study, we construct improved estimates of births and infant mortality in the United States for 1915-1940 using recently released complete count decennial census microdata combined with the counts of infant deaths from published sources. We check the veracity of our estimates with a major birth registration study completed in conjunction with the 1940 decennial census and find that the largest adjustments occur in states with less-complete birth registration systems. An additional advantage of our census-based estimation method is the extension backward of the birth and infant mortality series for years prior to published estimates of registered births, enabling previously impossible comparisons and estimations. Finally, we show that underregistration can bias effect estimates even in a panel setting with specifications that include location fixed effects and place-specific linear time trends.

Under-5 mortality in 2851 Chinese counties, 1996-2012: a subnational assessment of achieving MDG 4 goals in China.

BACKGROUND: In the past two decades, the under-5 mortality rate in China has fallen substantially, but progress with regards to the Millennium Development Goal (MDG) 4 at the subnational level has not been quantified. We aimed to estimate under-5 mortality rates in mainland China for the years 1970 to 2012. METHODS: We estimated the under-5 mortality rate for 31 provinces in mainland China between 1970 and 2013 with data from censuses, surveys, surveillance sites, and disease surveillance points. We estimated under-5 mortality rates for 2851 counties in China from 1996 to 2012 with the reported child mortality numbers from the Annual Report System on Maternal and Child Health. We used a small area mortality estimation model, spatiotemporal smoothing, and Gaussian process regression to synthesise data and generate consistent provincial and county-level estimates. We compared progress at the county level with what was expected on the basis of income and educational attainment using an econometric model. We computed Gini coefficients to study the inequality of under-5 mortality rates across counties. FINDINGS: In 2012, the lowest provincial level under-5 mortality rate in China was about five per 1000 livebirths, lower than in Canada, New Zealand, and the USA. The highest provincial level under-5 mortality rate in China was higher than that of Bangladesh. 29 provinces achieved a decrease in under-5 mortality rates twice as fast as the MDG 4 target rate; only two provinces will not achieve MDG 4 by 2015. Although some counties in China have under-5 mortality rates similar to those in the most developed nations in 2012, some have similar rates to those recorded in Burkina Faso and Cameroon. Despite wide differences, the inter-county Gini coefficient has been decreasing. Improvement in maternal education and the economic boom have contributed to the fall in child mortality; more than 60% of the counties in China had rates of decline in under-5 mortality rates significantly faster than expected. Fast reduction in under-5 mortality rates have been recorded not only in the Han population, the dominant ethnic majority in China, but also in the minority populations. All top ten minority groups in terms of population sizes have experienced annual reductions in under-5 mortality rates faster than the MDG 4 target at 4.4%. INTERPRETATION: The reduction of under-5 mortality rates in China at the country, provincial, and county level is an extraordinary success story. Reductions of under-5 mortality rates faster than 8.8% (twice MDG 4 pace) are possible. Extremely rapid declines seem to be related to public policy in addition to socioeconomic progress. Lessons from successful counties should prove valuable for China to intensify efforts for those with unacceptably high under-5 mortality rates. FUNDING: National "Twelfth Five-Year" Plan for Science and Technology Support, National Health and Family Planning Commission of The People's Republic of China, Program for Changjiang Scholars and Innovative Research Team in University, the National Institute on Aging, and the Bill & Melinda Gates Foundation.

The impact of water supply and sanitation on infant mortality: Individual-level evidence from Tartu, Estonia, 1897-1900.

Evidence from a number of historical studies has demonstrated a strong impact of the provision of clean water on mortality risks, while no clear effect has been reported in others. We investigated the relationship between water supply, sanitation, and infant survival in Tartu, a university town in Estonia, 1897-1900. Based on data from parish registers, which were linked to the first census of the Russian Empire, the analysis reveals a clear disadvantage for infants in households using surface water, compared with families that acquired water from groundwater or artesian wells. The impact is stronger in the later stages of infancy. Competing-risk analysis shows that the effect is more pronounced for deaths caused by diseases of the digestive system. Our findings suggest that it may have been possible to improve the water supply, and consequently reduce infant mortality, before the introduction of piped water and sewage systems.

A lost family-planning regime in eighteenth-century Ceylon.

Based on Dutch colonial registers (thombos), this paper reconstructs fertility for two districts in Ceylon, 1756-68. It overcomes challenges in data quality by establishing the outer bounds of plausible estimates in a series of scenarios. Among these, total fertility rates (TFRs) averaged 5.5 in one district, but only 2.7 in the other. These figures exclude the victims of infanticide, a custom noted in European travelogues between about 1660 and 1820. Sex ratios among children differed depending on the number of older siblings, and overall, 27 per cent of girls are missing in one district and 57 per cent in the other. There was little significant variation either in the TFR or the sex ratio by socio-economic status, suggesting that poverty was not a key factor in motivating infanticides. Instead, we argue that at least parts of Ceylon had a forward-looking culture of family planning in the eighteenth century, which was lost in subsequent decades.

Change of Self-recognition about the Accuracy of Data on Okinawa in the Mizushima Prefectural Life Table: Influence of His "Pre-publication of the 1921-25 Prefectural Life Table".

We examined the change in the self-recognition about the accuracy of data on Okinawa in the Mizushima Prefectural Life Table, and discussed:its relationship to the "Okinawa Is a Traditional Longevity Prefecture" theory. In the Prefectural Life Table made before WWII, Mizushima had suspended his judgment as to the reliability of infant mortality data in Okinawa. However, after the production of the "Proto-'1921-25' Life Table" in 1952-1954, Mizushima asserted that infant mortality data in Okinawa was incomplete and unreliable, and excluded Okinawa in his analysis in two times of the life table. On the other hand, the "Pre-publication of the 1921-25 Prefectural Life Table" was, in a way that ignores Mizushima's own interpretation, used as the basis of the "Okinawa Is a Traditional Longevity Prefecture" thesis used by the Ryukyu government in its occupation era, and in recent years by other commentators.

Specifying the Date when Mizushima Haruo Calculated His "Pre-publication of the 1921-25 Prefectural Life Table," Based on Circumstances of Publication and Changes of Methods.

We examined the first appearing papers of a series of the Mizushima Prefectural Life Table and checked its publication history and the transition of manufacturing methods as a first step in order to examine the theory that life expectancy in Okinawa has been long from a long time ago. However, the Prefectural Life Table of 1921-25 was first published in 1960, and its original form (as the "Pre-publication of the 1921-25 Prefectural Life Table") was estimated to have been started after WWII and completed in 1952-1954, based on the publication history and the transition of the manufacturing methods. In our next publication we will examine the change in the self-recognition about the accuracy of data from Okinawa in the Mizushima Prefectural Life Table, and discuss its relationship to the "Okinawa Is a Traditional Longevity Prefecture" theory.

State constitutional commitment to health and health care and population health outcomes: evidence from historical US data.

OBJECTIVES: I investigated whether the introduction of health and health care provisions in US state constitutions can make health systems more equitable and improve health outcomes by urging state policymakers and administrative agencies to uphold their human rights obligations at state level. METHODS: I constructed a panel of infant mortality rates from 50 US states over the period 1929 through 2000 to examine their association with the timing and details of introducing a constitutional right to health and health care provisions. RESULTS: The introduction of a stronger constitutional commitment that obligates state legislature to provide health care was associated with a subsequent reduction in the infant mortality rate of approximately 7.8%. The introduction of provisions explicitly targeting the poor was also associated with a reduction in the infant mortality rate of 6.5%. These health benefits are primarily evident in non-White populations. CONCLUSIONS: This empirical result supports Elizabeth Leonard's view that although state constitutional rights have been poorly enforced through the judiciary, a constitutional expression of health care duties has fueled the political and social process, ultimately allowing states to identify the best way to address citizens' health inequality concerns.

Infant mortality and isotopic complexity: New approaches to stress, maternal health, and weaning.

OBJECTIVES: Studies of the carbon and nitrogen stable isotope ratios (δ(13) C and δ(15) N) of modern tissues with a fast turnover, such as hair and fingernails, have established the relationship between these values in mothers and their infants during breastfeeding and weaning. Using collagen from high-resolution dentine sections of teeth, which form in the perinatal period we investigate the relationship between diet and physiology in this pivotal stage of life. MATERIALS AND METHODS: Childhood dentine collagen δ(13) C and δ(15) N profiles were produced from horizontal sections of permanent and deciduous teeth following the direction of development. These were from two 19th-century sites (n = 24) and a small number (n = 5) of prehistoric samples from Great Britain and Ireland. RESULTS: These high-resolution data exhibit marked differences between those who survived childhood and those who did not, the former varying little and the latter fluctuating widely. DISCUSSION: Breastfeeding and weaning behavior have a significant impact on the morbidity and mortality of infants and the adults they become. In the absence of documentary evidence, archaeological studies of bone collagen of adults and juveniles have been used to infer the prevalence and duration of breastfeeding. These interpretations rely on certain assumptions about the relationship between isotope ratios in the bone collagen of the adult females and the infants who have died. The data from this study suggest a more complex situation than previously proposed and the potential for a new approach to the study of maternal and infant health in past populations.

Why was Infant Mortality so High in Eastern England in the mid Nineteenth Century?

This paper re-examines the high rates of infant mortality observed in rural areas of eastern England in the early years of civil registration. Infant mortality rates in some rural registration districts in the East Riding of Yorkshire, Cambridgeshire and Norfolk were higher than those in the mill towns of Lancashire. After describing the areas affected, this paper considers three potential explanations: environmental factors, poor-quality child care associated with the employment of women in agriculture, and the possibility that the high rates were the artefactual consequence of migrant women workers bringing their children to these areas. These explanations are then assessed using a range of evidence. In the absence of reliable cause of death data, recourse is had to three alternative approaches. The first involves the use of the exceptionally detailed tabulations of ages at death within the first year of life provided in the Registrar General's Annual Reports for the 1840s to assess whether the 'excess' infant deaths in rural areas of eastern England happened in the immediate post-natal period or later in the first year of life. Second, data on the seasonality of mortality in the 1840s are examined to see whether the zone of 'excess' infant mortality manifested a distinctive seasonal pattern. Finally, a regression approach is employed involving the addition of covariates to regression models. The conclusion is that no single factor was responsible for the 'excess' infant mortality, but a plausible account can be constructed which blends elements of all three of the potential explanations mentioned above with the specific historical context of these areas of eastern England.

¿Qué pasa en La Inclusa? The role of press scandals, doctors and public authorities in the evolution of La Inclusa de Madrid, 1890-1935.

Traditionally, infants abandoned at foundling hospitals were identified as "bastards" and "children of vice" whose health, to all intents and purposes, reflected the moral sins of their parents and thus, led to unavoidable mortality. By late 19th century, several changes challenged that consideration: a growing emphasis on the importance of fighting infant mortality, the appearance of a new, medicalized, ideal of motherhood, the spread of new medical theories, the appearance of disciplines like Child Health, the construction of pediatric wards, and maternity hospitals. The consequences of these changes had their greatest impact at La Inclusa due to its location in the capital city, close to the decision-making centres and as focus of the interest of the national media. This article examines the role of the press and the medical profession in successively denouncing La Inclusa's excess mortality during the period 1890-1935. By looking at daily press and medical publications, it sheds light on the uneven consequences of the press scandals denouncing foundlings' extreme mortality in the period. The first scandal (1899-1900) faded without acknowledging any excess foundling mortality; the second (1918) was initiated by the doctors in charge but only produced some changes. The third scandal (1927) was instrumental in bringing about the changes that would turn a century-old institution in a state-of-the art medicalized centre and the change from debris of society to healthy children of foundlings. The effects of the press coverage were not restricted locally to foundlings in Madrid, and had a wider impact: by making the public aware of the dire situation of foundlings, they contributed to the development of legislation related to the fight against infant mortality and the control of mercenary breastfeeding.

Main characteristics of Hungarian twin and multiple births in official statistics.

Since 1876, statistical data on twin and multiple (TAM) births and deliveries have been registered in Hungary. Although there were some years during this 138-year period when twin births and deliveries were left out of the statistics, the trends can be followed, except for the period of World War II. The trends of twinning over the past four decades are summarized in this article, relying on official statistical data since 1970. Notably, the TAM birth rate rose following the Act CLIV of 1997 on Health. The Act provided state support for assisted reproductive treatments (ART), which spectacularly increased the ratio of twins - and especially of triplets - among live births. The trend has turned around since 2009-2010, and a decreasing era of TAM births seems to have begun. This article discusses some of the main and most interesting findings connected with TAM births, including twinning rates associated with different age groups, educational level, and actual place of residence by mothers, and the number of previous pregnancies of the mother. Ratios of live born males compared with live born females, lengths and weights at birth both among twins and singletons, and infant mortality rates have been calculated from the data. Twinning rates are higher in the western counties, the capital and its suburbs, and lower in the eastern counties.

Lessons in community health activism: the maternity care coalition, 1970-1990.

This study employed historical methodologies to explore the means through which the Maternity Care Coalition used grassroots activism to dismantle the power structures and other obstacles that contributed to high infant mortality rates in Philadelphia's health districts 5 and 6 during the 1980s. Infant mortality within the black community has been a persistent phenomenon in the United States. Refusing to accept poverty as a major determinant of infant mortality within marginalized populations of women, activists during the 1980s harnessed momentum from a postcivil rights context and sought alternative methods toward change and improvement of infant mortality rates.

Mortality among sons of female dental personnel--a national cohort study.

AIMS: Dental personnel are exposed to mercury when using dental amalgam. This exposure constitutes a potential hazard to offspring of women working in dentistry. The present study examined increased mortality risk in offspring of mothers working in dentistry. METHODS: Mortality was compared between sons of dental personnel and sons of nondental health-care personnel. Hazard ratios were calculated for three decades (1960s-1980s), when the magnitude of mercury exposure in dentistry was likely to have varied. RESULTS: During the 1960s, there was a statistically significant increase in the risk of neonatal mortality for sons of dental nurses when compared with sons of assistant nurses: hazard ratio (HR) 1.82 (95% confidence interval, CI: 1.04-3.22). There was no increased risk in the subsequent decades, but a trend test demonstrated a consistent decrease in the risk over the three decades: HR for trend 0.63 (95% CI: 0.44-0.90). The raised mortality risk was limited to neonatal mortality. The comparison between dentists and physicians had insufficient statistical power. CONCLUSIONS: There is no increased mortality risk among sons of female dentists after the 1960s. Although the results should be interpreted with caution, they suggest a modestly raised risk of neonatal mortality, during the 1960s, when exposure to mercury was thought to be highest.