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

Lethality of Birth Defects in Live Born Infants Categorized by Gestational Age and Birth Weight

OBJECTIVE

This study aimed to describe lethality of birth defects (BDs) in newborns categorized by gestational age and birth weight and to identify BDs associated with prematurity.

STUDY DESIGN

Live born infants (n = 16,452) with isolated BDs classified by severity, and 42,511 healthy controls were assigned to categories: adequate growth, preterm, or small for gestational age (SGA). Proportion of cases and BDs' lethality rates were obtained by category and compared with controls.

RESULTS

Overall fewer malformed than nonmalformed infants were of adequate growth, while the opposite occurred in the preterm and SGA categories where gastroschisis and esophageal atresia were among the most outstanding defects. For most severe BDs, the early neonatal death rate was higher than control values in all categories; for mild defects, except cleft lip in the preterm category, they did not differ. Diaphragmatic hernia showed the highest lethality values, while those of spina bifida were among the lowest. Talipes, hypospadias, and septal heart defects were mild defects significantly associated with prematurity.

CONCLUSION

Although reasons, such as induced preterm delivery of fetuses with certain anomalies, could partially account for their high prematurity rates, susceptibility to preterm birth might exist through underlying mechanisms related with the defects. The identification of BDs associated with prematurity should serve to improve measures that prevent preterm birth especially of fetuses at risk.

KEY POINTS

· Some BDs predispose to prematurity.. · Prematurity is an additional risk factor for mortality in infants with mild defects.. · Lethality values should be adjusted by gestational age and birth weight..

Gender, education expansion and intergenerational educational mobility around the world

The extent to which people's social status is associated with their parents' status has far-reaching implications for the openness of and stratification in society. Whereas most research focused on the father-child association in advanced economies, less is known about the role mothers play in intergenerational mobility, particularly in a global context. We assembled a dataset of 1.79 million individuals born in 1956-1990 across 106 societies to examine the global patterns of intergenerational educational mobility and how they vary with education expansion and changes in parents' educational pairing. With education expansion, father-child associations in educational status become weaker and mother-child associations become stronger. With the prevalence of hypogamous parents (mother more educated), mother-child associations are stronger, but father-child associations are weaker. With the prevalence of hypergamous parents (father more educated), mother-daughter associations are weaker. Our global evidence calls for a gender-sensitive understanding of how education expansion matters for intergenerational mobility.

Health disparities in past influenza pandemics: A scoping review of the literature

Objective

The COVID-19 pandemic has exacerbated existing health disparities. To provide a historical perspective on health disparities for pandemic acute respiratory viruses, we conducted a scoping review of the public health literature of health disparities in influenza outcomes during the 1918, 1957, 1968, and 2009 influenza pandemics.

Methods

We searched for articles examining socioeconomic or racial/ethnic disparities in any population, examining any influenza-related outcome (e.g., incidence, hospitalizations, mortality), during the 1918, 1957, 1968, and 2009 influenza pandemics. We conducted a structured search of English-written articles in PubMed supplemented by a snowball of articles meeting inclusion criteria.

Results

A total of 29 articles met inclusion criteria, all but one focusing exclusively on the 1918 or 2009 pandemics. Individuals of low socioeconomic status, or living in low socioeconomic status areas, experienced higher incidence, hospitalizations, and mortality in the 1918 and 2009 pandemics. There were conflicting results regarding racial/ethnic disparities during the 1918 pandemic, with differences in magnitude and direction by outcome, potentially due to issues in data quality by race/ethnicity. Racial/ethnic minorities had generally higher incidence, mortality, and hospitalization rates in the 1957 and 2009 pandemics.

Conclusion

Individuals of low socioeconomic status and racial/ethnic minorities have historically experienced worse influenza outcomes during pandemics. These historical patterns can inform current research to understand disparities in the ongoing COVID-19 pandemic and future pandemics.

A Qualitative Inquiry of Women's Perspective of Antenatal Education Services in Oman

Introduction

Antenatal care (ANC) provides an opportunity for systematic assessment and follow-up of pregnant women to ensure positive outcomes for mother and foetus. Pregnant women should be offered evidence-based information with support to enable them to make informed decisions.

Objective

To identify the gap between the current practices and the recommended guidelines for antenatal education services in Oman.

Methods

A qualitative inquiry was implemented through semistructured in-depth interviews guided by open-ended questions and probes. A purposive non-probability sampling technique was used to select 13 pregnant women who had completed 30 weeks of gestation. The women were selected from 9 antenatal healthcare facilities among them: 7 primary health centers, one polyclinic and one, tertiary hospital.

Results

Antenatal education focused on four thematic areas of safe pregnancy; safe labor and birth; postpartum care; and new-born care. Regarding antenatal education for safe pregnancy, the findings indicate that most healthcare workers provided pregnant women adequate information to promote healthy dietary habits; cope with pregnancy symptoms; recognize and manage medical conditions, and to adhere to dietary supplements and medication. In addition, the findings revealed that the healthcare team did not provide the required antenatal education to meet the pregnant women's needs to ensure they had safe labor and birth, postpartum care, and new-born care.

Conclusion

This study is the first of its kind in Oman to provide baseline data regarding the current antenatal education services from the perspective of pregnant women. These findings will help in developing strategies to improve maternal and neonatal outcomes in the country.

The Influence of Maternal Factors on Neonatal Intensive Care Unit Admission and In-Hospital Mortality in Premature Newborns from Western Romania: A Population-Based Study

Background and Objectives: Neonatal mortality is a global public health issue, disproportionately affecting low- and middle-income nations. Although Romania is a high-income nation, according to the European Union’s most recent demographic data, it had the second-highest infant death rate in 2019. Although significant progress has been made in the last three decades in lowering newborn mortality, more initiatives to accelerate progress are required to meet the 2030 Sustainable Development Goals (SDG) objective. Therefore, we aimed to develop an observational study to determine the influence of maternal factors on in-hospital neonatal intensive care unit admission and mortality in premature infants born in western Romania. While newborn mortality has decreased globally, the pace of decline is far less than what is desired. Materials and Methods: A retrospective study comprising 328 premature patients and 422 full-term newborns, was developed at a tertiary obstetrics and gynecology clinic in western Romania, comprising the period of the last 24 months before the COVID-19 pandemic and the first 24 months of the pandemic. Results: The following variables were identified as statistically significant risk factors for neonatal intensive care unit admission: age > 35 years, OR = 1.59; twin births, OR = 1.14; low gestational age, OR = 1.66; preeclampsia, OR = 2.33; and peripartum infection, OR = 2.25. The same risk factors, with the exception of twin births, were significantly associated with in-hospital neonatal mortality. Except for a longer duration of maternal hospitalization and neonatal therapy with surfactant, steroids, and antibiotics, the COVID-19 pandemic did not cause significant differences in the evolution and outcomes of preterm newborns. Conclusions: The major maternal risk factors for NICU admission were advanced age, twin pregnancy, low gestational age, preeclampsia, and peripartum infection. Additionally, these characteristics contributed to a high likelihood of death, despite adequate access to medical care and advanced life support for the neonates. Understanding the causes of morbidity and death in neonates admitted to the neonatal intensive care unit enables better prioritization and planning of health services, resource reallocation, and care quality improvement.

The Political Realignment of Health: How Partisan Power Shaped Infant Health in the United States, 1915-2017

The US two-party system was transformed in the 1960s when the Democratic Party abandoned its Jim Crow protectionism to incorporate the policy agenda fostered by the civil rights movement, and the Republican Party redirected its platform toward socioeconomic and racial conservatism. The authors argue that the policy agendas promoted by the two parties through presidents and state legislatures codify a racially patterned access to resources and power detrimental to the health of all. To test the hypothesis that fluctuations in overall and race-specific infant mortality rates (IMRs) shift between the parties in power before and after the political realignment (PR), the authors apply panel data analysis methods to state-level data from the National Center for Health Statistics for the period 1915 through 2017. Net of trend, overall, and race-specific IMRs were not statistically different between presidential parties before the PR. This pattern, however, changed after the PR, with Republican administrations consistently underperforming Democratic ones. Net of trend, non-Southern state legislatures controlled by Republicans underperform Democratic ones in overall and racial IMRs in both periods.

Inequality and child health: dynamic population health interventions

PURPOSE OF REVIEW

Established social gradients across a wide range of child health issues including obesity, anxiety, infectious diseases, injuries, prematurity and low birth weight suggest that much illness is avoidable and there is an imperative to intervene in this whole of society issue. This review examines recent advances in understanding of the pathways to health and health inequalities and their application to interventions to improve health equity.

RECENT FINDINGS

Children's health develops over the life course in ways that are profoundly influenced by their entire developmental ecosystem including individual, family, community and system-level factors. Interventions to address child health inequalities must include action on the structural determinants of health, a greater focus on family and community health development, and attention to the acquisition of developmental capabilities. Nascent dynamic population health initiatives that address whole developmental ecosystems such as All Children Thrive, Better Start Bradford and Generation V, hold real promise for achieving child health equity.

SUMMARY

Pathways to health inequalities are driven by social and structural determinants of health. Interventions to address inequalities need to be driven less by older biomedical models, and more by prevailing ecological and complex systems models incorporating a life course health development approach.

Breastfeeding Insufficiencies: Common and Preventable Harm to Neonates

Insufficient milk intake in breastfed neonates is common, frequently missed, and causes preventable hospitalizations for jaundice/hyperbilirubinemia, hypernatremia/dehydration, and hypoglycemia - accounting for most U.S. neonatal readmissions. These and other consequences of neonatal starvation and deprivation may substantially contribute to fully preventable morbidity and mortality in previously healthy neonates worldwide. Previous advanced civilizations recognized this problem of breastfeeding insufficiencies and had an infrastructure to solve it: Wetnursing, shared nursing, and prelacteal feeding traditions used to be well-organized and widespread. Modern societies accidentally destroyed that infrastructure. Then, modern reformers missing a few generations of direct knowledge transmission about safe breastfeeding invented a new, historically anomalous conception of breastfeeding defined in terms of exclusivity. As that new intervention has become increasingly widespread, so too have researchers widely reported associated possible harms of the longer neonatal starvation/deprivation and later infant under-nutrition periods that it creates when breastfeeding is insufficient. Early insufficient nutrition/hydration has possible long-term effects including neurodevelopmental consequences such as attention deficit hyperactivity disorder, autism, cerebral palsy, cognitive and developmental delay, epilepsy, hearing impairment, kernicterus, language disorder, mood disorders, lower IQ, and specific learning disorder. Current early infant feeding guidelines conflict with the available evidence. Recent reform efforts have tended to focus on using more technology and measurement to harm fewer neonates instead of proposing the indicated paradigm shift in early infant feeding to prevent more harm. The scientific evidence is already sufficient to mandate application of the precautionary principle to feed neonates early, adequate, and often milk before mothers' milk comes in and whenever signs of hunger persist, mitigating possible risks including death or disability. In most contexts, the formula is the best supplementary milk for infants at risk from breastfeeding insufficiencies. National-level reviews of scientific evidence, health policy, and research methods and ethics are needed to initiate the early infant feeding paradigm shift that the data already support. Policy experiments and related legislative initiatives might also contribute to the shift, as insurers might decline or be required by law to decline reimbursing hospitals for costs of this type of preventable hospitalization, which otherwise generates profit.

Disparities in infant mortality by payment source for delivery in the United States

In this study, we hypothesized that infant mortality varies among health insurance status. Furthermore, we examined whether there are racial and ethnic disparities in the association between infant death and payment source for delivery. Our study used US national linked birth and infant death data for 2013 and 2017 collected by the National Center for Health Statistics and included 3,311,504 and 3,218,168 live births for each year. The principal source of payment for delivery was classified into three groups: Medicaid, private insurance, and self-payment. The outcome measures were infant mortality, neonatal mortality, and postneonatal mortality. Subgroup analysis for race and ethnicity was also performed. Overall infant mortality was lower in mothers who paid with private insurance than in those who paid with Medicaid insurance (RR = 0.87, 95% CI 0.84-0.90 in 2013; RR = 0.91, 95% CI 0.87-0.94 in 2017), but it was higher in self-paid women than in Medicaid-insured women at delivery (RR = 1.25, 95% CI 1.17-1.33 in 2013; RR = 1.16, 95% CI 1.08-1.24 in 2017). Non-Hispanic black (RR = 1.67, 95% CI 1.47-1.90 in 2013; RR = 1.16, 95% CI 1.00-1.35 in 2017) and Hispanic (RR = 1.30, 95% CI 1.17-1.44 in 2013; RR = 1.22, 95% CI 1.09-1.36 in 2017) mothers with self-payment had a higher risk for infant mortality than those with Medicaid at delivery. Newborns whose mothers have no health insurance would be more vulnerable to infant mortality than Medicaid beneficiaries, and non-white ethnic groups with self-payment would have an elevated risk of infant mortality among other racial and ethnic groups.

Changing speed of reduction in under-5 mortality rates over the 20th century

BACKGROUND

Declines from high levels of under-5 mortality rate (U5MR) first occurred in Western Europe. Knowledge and technologies gained from early mortality reductions could accelerate the U5MR decline for countries that followed. We explored whether average annual reduction (AAR) in U5MR increased between countries over time in the 20th century.

METHODS

We used U5MR time series from the Human Mortality Database and United Nations for 110 countries experiencing a decline from 100 to 50 under-5 deaths per 1000 live births during the 20th century.

RESULTS

Between 1907 and 1938, the AAR was 2.61 (95% CI 2.09, 3.13) deaths per 1000 live births per year on average and increased by 0.06 (95% CI 0.02, 0.10) deaths for each year that passed before the decline started. Countries going through the decline in 1938-1968 and 1968-1999 showed an AAR of 3.96 and 3.67 (95% CI 3.37, 4.54 and 3.26, 4.07), respectively, with no increase in AAR.

CONCLUSIONS

Acceleration in U5MR reduction was apparent in today's high-income countries, indicating that greater similarities and capacity may have facilitated the adaptation of mortality reducing knowledge and technologies. Greater emphasis on simple and individual-level interventions or more difficult circumstances may also explain the lack of acceleration in mortality reduction after 1950.

The effect of the National Birth Defects Intervention Project on the prevention of congenital disabilities among children in China: a natural experiment

Most childhood disabilities are caused by congenital factors such as birth defects. The present study aims to evaluate the effect of periconceptional nutrition intervention on the prevention of congenital disability among Chinese children using the National Birth Defects Intervention Project as a natural experiment. We obtained individual-level data from the Second National Sample Survey on Disability, a nationally representative survey, and 110 365 children born between September 1999 and August 2003 were included for analysis. Difference-in-differences estimates of the project effects on congenital disability were captured by exploiting temporal variation in the timing of project exposure across four birth cohorts along with geographical variation in project category at the province level. The findings contribute to an emerging body of evidence showing that prenatal micronutrient intervention before and during early pregnancy could substantially reduce the risk of congenital disability in childhood (OR 0·73; 95 % CI 0·57, 0·94). The National Birth Defects Intervention Project improved the awareness of reproductive health and disability prevention in the population. It highlights the need for a potential policy change focusing on early-life health investment in China.

Association of Poor Sanitation With Growth Measurements Among Children in India

Importance

Much research on sanitation and linear growth in low- and middle-income countries focuses on children younger than 5 years. However, poor sanitation may be associated with growth faltering during middle and late childhood to a greater extent than previously recognized.

Objective

To characterize the association of poor sanitation with height-for-age z (HAZ) scores in children and adolescents in India aged 0 to 18 years.

Design, Setting, and Participants

This cross-sectional study examined 134 882 children and adolescents aged 0 to 18 years who were surveyed in the fourth round of India's District Level Household and Facilities Survey (survey conducted August 2012 to February 2014). Data were analyzed from June 1, 2019, to August 20, 2019.

Exposures

Proportion of households reporting open defecation at the village level (to account for its high negative externality) and household-level access to boiled or filtered drinking water.

Main Outcomes and Measures

Individual-level HAZ scores were measured in standard deviations. The association of exposures with outcomes was estimated using ordinary least-squares regression stratified by sex (boys and girls) and 4 age groups (≤1, >1 to ≤7, >7 to ≤12, >12 to ≤18 years). Models controlled for parental height and education, socioeconomic status, maternal age at birth, hemoglobin level, and indicators for state and birth year to adjust for regional (state) and temporal (birth year) fixed effects.

Results

The sample comprised 70 463 male (52.5%) and 64 419 female (47.8%) children and adolescents aged 0 to 18 years; 46 722 participants (34.6%) were aged older than 12 to 18 years. Open defecation was inversely associated with HAZ score among all age groups except boys aged 1 year and younger (>1 to ≤7 years: β, -0.22; 95% CI, -0.35 to -0.10; >7 to ≤12 years: β, -0.15; 95% CI, -0.24 to -0.06; >12 to ≤18 years: β, -0.10; 95% CI, -0.19 to -0.01) and among girls aged between 7 and 18 years (>7 to ≤12 years: β, -0.22; 95% CI, -0.33 to -0.12; >12 to ≤18 years: β, -0.16; 95% CI, -0.23 to -0.09). Boiled or filtered drinking water was positively associated with HAZ score among younger girls (≤1 year: β, 0.26; 95% CI, 0.07 to 0.45; >1 to ≤7 years: β, 0.07; 95% CI, 0.01 to 0.14) and across all age groups in boys (≤1 years: β, 0.19; 95% CI, 0.03 to 0.35; >1 to ≤7 years: β, 0.07; 95% CI, 0.00 to 0.14; >7 to ≤12 years: β, 0.08; 95% CI, 0.03 to 0.13; >12 to ≤18 years: β, 0.06; 95% CI, 0.01 to 0.11).

Conclusions and Relevance

In this study, open defecation and lack of boiled or filtered drinking water were inversely associated with height-for-age measures across all ages in children and adolescents in India. Improved sanitation may benefit growth among children and adolescents older than 5 years.

Maternal Mortality and Public Health Programs: Evidence from Florida

Policy Points US maternal mortality rates (MMRs) display considerable racial disparities and exceed those of other developed countries. While worldwide MMRs have dropped sharply since the 1990s, the US MMR appears to be rising. We provide strong evidence of the effectiveness of pregnancy-related public health spending on improvements in maternal health. Using longitudinal data from Florida counties, we found that spending on public health significantly reduced the MMR among black mothers and narrowed black-white outcome disparities. Each 10% increase in pregnancy-related public health expenditures was associated with a 13.5% decline in MMR among blacks and a 20.0% reduction in black-white disparities.

CONTEXT

Maternal mortality rates in the United States exceed those of other developed countries. Moreover, these rates show considerable racial disparities, in which black mothers are at three to four times the risk compared with their white counterparts. With more than half of all maternal deaths deemed to be preventable, public health interventions have the potential to improve maternal health along with other pregnancy outcomes. This rigorous longitudinal study examines the impact of a package of pregnancy-related public health programs on maternal mortality rates.

METHODS

We analyzed administrative data on pregnancy-related public health expenditures, maternal mortality rates, and sociodemographic factors from all 67 Florida counties between 2001 and 2014. Florida provides consistent counts of maternal deaths for the entire period of this analysis. We estimated both fixed-effects ordinary least squares regressions (OLS) and generalized method of moments (GMM) models. GMM enabled us to identify the impact of public health expenditures on maternal mortality rates while also addressing both potential endogeneity and serial correlation problems. We also provide a series of robustness and falsification tests.

FINDINGS

Overall, a 10% increase in targeted public health expenditures led to a weakly significant decline in overall maternal mortality rates of 3.9%. The estimated effect for white mothers was not statistically significant. However, we found statistically significant improvements for black mothers. Specifically, a 10% increase in pregnancy-related public health spending led to a 13.5% decline in maternal mortality rates among black mothers and a 20.0% reduction in the black-white maternal mortality gap.

CONCLUSIONS

Our analysis provides strong evidence of the effectiveness of public health programs in reducing maternal mortality rates and addressing racial disparities.