Infant mortality trends and differences between American Indian/Alaska Native infants and white infants in the United States, 1989-1991 and 1998-2000

Population-based birth cohort study on diabetes in pregnancy and infant hospitalisations in Cree, other First Nations and non-Indigenous communities in Quebec

OBJECTIVES

Diabetes in pregnancy, whether pre-gestational (chronic) or gestational (de novo hyperglycaemia), increases the risk of adverse birth outcomes. It is unclear whether gestational diabetes increases the risk of postnatal morbidity in infants. Cree First Nations in Quebec are at high risk for diabetes in pregnancy. We assessed whether pre-gestational or gestational diabetes may increase infant hospitalisation (an infant morbidity indicator) incidence, and whether this may be related to more frequent infant hospitalisations in Cree and other First Nations in Quebec.

DESIGN

Population-based birth cohort study through administrative health data linkage.

SETTING AND PARTICIPANTS

Singleton infants (≤1 year) born to mothers in Cree (n=5070), other First Nations (9910) and non-Indigenous (48 200) communities in rural Quebec.

RESULTS

Both diabetes in pregnancy and infant hospitalisation rates were much higher comparing Cree (23.7% and 29.0%) and other First Nations (12.4% and 34.1%) to non-Indigenous (5.9% and 15.5%) communities. Compared with non-diabetes, pre-gestational diabetes was associated with an increased risk of any infant hospitalisation to a greater extent in Cree and other First Nations (relative risk (RR) 1.56 (95% CI 1.28 to 1.91)) than non-Indigenous (RR 1.26 (1.15 to 1.39)) communities. Pre-gestational diabetes was associated with increased risks of infant hospitalisation due to diseases of multiple systems in all communities. There were no significant associations between gestational diabetes and risks of infant hospitalisation in all communities. The population attributable risk fraction of infant hospitalisations (overall) for pre-gestational diabetes was 6.2% in Cree, 1.6% in other First Nations and 0.3% in non-Indigenous communities.

CONCLUSIONS

The study is the first to demonstrate that pre-gestational diabetes increases the risk of infant hospitalisation overall and due to diseases of multiple systems, but gestational diabetes does not. High prevalence of pre-gestational diabetes may partly account for the excess infant hospitalisations in Cree and other First Nations communities in Quebec.

American Indian/Alaska Native Birth and Maternal Health Outcomes in Louisiana: Investigating Regional Disparities

OBJECTIVES

To report regional maternal and infant health characteristics in the Louisiana American Indian/Alaska Native (AIAN) population.

METHODS

This was a cross-sectional descriptive analysis using 2016-2019 Louisiana birth certificate data (N = 242,359; 3205 AIAN births). Prevalence of health characteristics and disparities from population averages were calculated. Health characteristics included low birth weight, preterm birth, very low birth weight, very preterm birth, high birth weight, NICU admission, breastfeeding at discharge, rurality, cesarean section, inadequate prenatal care, and maternal smoking.

RESULTS

Low birth weight prevalence ranged from 5.7% in central Louisiana to 20.7% in northeast Louisiana. Most other infant outcomes followed a similar pattern. Disparities from regional averages also varied. AIAN infants had 8% higher risk of LBW than the northeast Louisiana average and 4% lower risk in central Louisiana. Maternal smoking was most prevalent in northern and western Louisiana. Across Louisiana, maternal smoking was as or more prevalent in mothers of AIAN infants compared to regional averages.

CONCLUSIONS FOR PRACTICE

There is substantial regional variability in maternal and infant health characteristics in Louisiana AIAN populations, motivating emphasis on locally focused epidemiology to better serve Indigenous communities.

Incidence of infant mortality and its predictors in East Africa using Gompertz gamma shared frailty model

Background

Globally, infant mortality is a major public health concern and a sensitive indicator of countries' socio-economic and health status. Despite the substantial reduction of under-five mortality in sub-Saharan African countries specifically in East Africa, the infant mortality rate remains highest and too far below to achieve the WHO target. As to our search of the literature is concerned, there is a dearth of evidence on the incidence and predictors of infant mortality in East Africa. Therefore, this study investigated the incidence of infant mortality and its predictors in East Africa.

Methods

The present study has utilized 138,803 weighted samples from Demographic and Health Surveys (DHSs) of 12 East African countries. Considering the hierarchical nature of DHS data shared frailty parametric survival models were fitted and compared based on deviance (-2LLR), AIC, and BIC. Gompertz gamma shared frailty model was the best-fitted model for the data since it had the lowest deviance, AIC, and BIC values. Variables with a p-value < 0.2 in the bi-variable analysis were considered for the multivariable analysis. In the multivariable Gompertz gamma shared analysis, the Adjusted Hazard Ratio (AHR) with 95% Confidence Interval (CI) was reported to declare the significant predictors of infant mortality.

Results

The infant mortality rate in East Africa was 41.41 per 1000 live births. Mothers aged 25–34 years, wanted birth, health facility delivery, 1–3 ANC visit, being 2nd- 4th birth order, 5th and above, the birth interval of 24–48 months, and birth interval of 49 months and above were significantly associated with lower risk of infant mortality. Whereas women who didn’t have formal education, women who didn't participate in making health care decisions making, being male children, cesarean delivery, small size at birth, and large size at birth were significantly associated with a higher risk of infant mortality.

Conclusion

Despite the substantial progress in improving maternal and child health, this study showed that infant mortality is still a major public health concern in East Africa. Maternal age, place of delivery, maternal education, birth size, sex of the child, mode of delivery, women's autonomy, birth order, birth interval, and ANC visit were found to be significant predictors of infant mortality. Therefore, public health interventions enhancing health facility delivery, ANC visit, maternal education, birth spacing, and empowering women are crucial for reducing the incidence of infant mortality in East Africa.

Trends of infant mortality and its determinants in Ethiopia: mixed-effect binary logistic regression and multivariate decomposition analysis

BACKGROUND

Infant mortality remains a serious global public health problem. The global infant mortality rate has decreased significantly over time, but the rate of decline in most African countries, including Ethiopia, is far below the rate expected to meet the SDG targets. Therefore, this study aimed to investigate the trends of infant mortality and its determinants in Ethiopia based on the four consecutive Ethiopian Demographic and Health Surveys (EDHSs).

METHODS

This analysis was based on the data from four EDHSs (EDHS 2000, 2005, 2011, and 2016). A total weighted sample of 46,317 live births was included for the final analysis. The logit-based multivariate decomposition analysis was used to identify significantly contributing factors for the decrease in infant mortality in Ethiopia over the last 16 years. To identify determinants, a mixed-effect logistic regression model was fitted. The Intra-class Correlation Coefficient (ICC) and Likelihood Ratio (LR) test were used to assess the presence of a significant clustering effect. Deviance, Akaike Information Criteria (AIC), and Bayesian Information Criteria (BIC) were used for model comparison. Variables with a p-value of less than 0.2 in the bi-variable analysis were considered for the multivariable analysis. In the multivariable analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to identify the statistically significant determinants of infant mortality.

RESULTS

Infant mortality rate has decreased from 96.9 per 1000 births in 2000 to 48 per 1000 births in 2016, with an annual rate of reduction of 4.2%. According to the logit based multivariate decomposition analysis, about 18.1% of the overall decrease in infant mortality was due to the difference in composition of the respondents with respect to residence, maternal age, type of birth, and parity across the surveys, while the remaining 81.9% was due to the difference in the effect of residence, parity, type of birth and parity across the surveys. In the mixed-effect binary logistic regression analysis; preceding interval <  24 months (AOR = 1.79, 95% CI; 1.46, 2.19), small size at birth (AOR = 1.55, 95% CI; 1.25, 1.92), large size at birth (AOR = 1.26, 95% CI; 1.01, 1.57), BMI <  18.5 kg/m² (AOR = 1.22, 95% CI; 1.05, 1.50), and twins (AOR = 4.25, 95% CI; 3.01, 6.01), parity> 6 (1.51, 95% CI; 1.01, 2.26), maternal age and male sex (AOR = 1.50, 95% CI: 1.25, 1.79) were significantly associated with increased odds of infant mortality.

CONCLUSION

This study found that the infant mortality rate has declined over time in Ethiopia since 2000. Preceding birth interval, child-size at birth, BMI, type of birth, parity, maternal age, and sex of child were significant predictors of infant mortality. Public health programs aimed at rural communities, and multiparous mothers through enhancing health facility delivery would help maintain Ethiopia's declining infant mortality rate. Furthermore, improving the use of ANC services and maternal nutrition is crucial to reducing infant mortality and achieving the SDG targets in Ethiopia.

Residential inequality and spatial patterns of infant mortality in Ethiopia: evidence from Ethiopian Demographic and Health Surveys

Background

Despite the remarkable decrease in infant mortality rate in most countries, the rate of decline is slow and it remains unacceptably high in Sub-Saharan Africa. The progress in infant mortality in Ethiopia is far below the rate needed to achieve the Sustainable Development Goal. Understanding the residential inequality and spatiotemporal clusters of infant mortality is essential to prioritize areas and guide public health interventions. Therefore, this study aimed to investigate the residential inequality and spatial patterns of infant mortality in Ethiopia.

Methods

A secondary data analysis was done based on the Ethiopian demographic and health surveys conducted in 2000, 2005, 2011, and 2016. A total weighted sample of 46,317 live births was included for the final analysis. The residential inequality was assessed by calculating the risk difference in infant mortality rates between urban and rural live births and presented using a forest plot. For the spatial patterns of infant mortality, the SaTScan version 9.6 and ArcGIS version 10.6 statistical software were used to identify the spatial patterns of infant mortality.

Results

The study revealed that the infant mortality rate significantly declined from 96.9 per 1000 live births [95% CI 93.6, 104.2] in 2000 to 48.0 per 1000 live births [95% CI 44.2, 52.2] in 2016 with an annual rate of reduction of 3.2%. The infant mortality rate has substantial residential inequality over time, which is concentrated in the rural area. The spatial distribution of infant mortality was significantly clustered at the national level in survey periods (global Moran’s I, 0.04–0.081, p value < 0.05). In 2000, the most likely clusters were found in east Afar and at the border areas of south Amhara and north Oromia regions (LLR = 7.61, p value < 0.05); in 2005, at the border areas of Southern Nations Nationalities and People and in the entire Amhara region (LLR = 10.78, p value< 0.05); in 2011, at Southern Nations Nationalities and People and Gambella regions (LLR = 6.63, p value< 0.05); and in 2016, at east Oromia and northeast Somali regions (LLR = 8.38, p value < 0.05).

Conclusion

In this study, though infant mortality has shown remarkable reduction, infant mortality remains a major health care concern and had significant spatial variation across regions. Besides, the study found that infant mortality was highly concentrated in rural areas. Identifying the hotspot areas of infant mortality would help in designing effective interventions to reduce the incidence of infant mortality in these areas. Therefore, the findings highlighted that public health interventions should target rural areas and identified hotspot areas to reduce the incidence of infant mortality.

Mortalidade infantil segundo cor ou raça com base no Censo Demográfico de 2010 e nos sistemas nacionais de informação em saúde no Brasil

O objetivo deste estudo é investigar as informações sobre mortalidade infantil no Brasil, de acordo com a cor ou raça com foco nos indígenas, baseando-se nos dados do Censo Demográfico de 2010 e daqueles oriundos do Sistema de Informação sobre Mortalidade (SIM) e do Sistema de Informações sobre Nascidos Vivos (SINASC). Em ambas as fontes, as taxas de mortalidade infantil (TMI) de indígenas foram as mais elevadas dentre os diversos segmentos populacionais. Apesar dos dados censitários indicarem desigualdades de cor ou raça, as TMI para indígenas e pretos foram inferiores às derivadas do SIM/SINASC. Particularidades metodológicas quanto à coleta dos dados em ambas as fontes devem ser consideradas. A redução da TMI no Brasil nas últimas décadas é em larga medida atribuída à prioridade da saúde infantil na agenda política. Os achados deste trabalho são indicativos de que o impacto das políticas públicas não alcançou os indígenas em mesma escala que o restante da população. Novas fontes de dados relativos à ocorrência de óbitos nos domicílios, de abrangência nacional, como é o caso do Censo de 2010, podem contribuir para uma melhor compreensão das desigualdades segundo cor ou raça no Brasil.

Disparities in infant hospitalizations in Indigenous and non-Indigenous populations in Quebec, Canada

BACKGROUND

Infant mortality is higher in Indigenous than non-Indigenous populations, but comparable data on infant morbidity are lacking in Canada. We evaluated disparities in infant morbidities experienced by Indigenous populations in Canada.

METHODS

We used linked population-based birth and health administrative data from Quebec, Canada, to compare hospitalization rates, an indicator of severe morbidity, in First Nations, Inuit and non-Indigenous singleton infants (< 1 year) born between 1996 and 2010.

RESULTS

Our cohort included 19 770 First Nations, 3930 Inuit and 225 380 non-Indigenous infants. Compared with non-Indigenous infants, all-cause hospitalization rates were higher in First Nations infants (unadjusted risk ratio [RR] 2.05, 95% confidence interval [CI] 1.99-2.11; fully adjusted RR 1.43, 95% CI 1.37-1.50) and in Inuit infants (unadjusted RR 1.96, 95% CI 1.87-2.05; fully adjusted RR 1.37, 95% CI 1.24-1.52). Higher risks of hospitalization (accounting for multiple comparisons) were observed for First Nations infants in 12 of 16 disease categories and for Inuit infants in 7 of 16 disease categories. Maternal characteristics (age, education, marital status, parity, rural residence and Northern residence) partly explained the risk elevations, but maternal chronic illnesses and gestational complications had negligible influence overall. Acute bronchiolitis (risk difference v. non-Indigenous infants, First Nations 37.0 per 1000, Inuit 39.6 per 1000) and pneumonia (risk difference v. non-Indigenous infants, First Nations 41.2 per 1000, Inuit 61.3 per 1000) were the 2 leading causes of excess hospitalizations in Indigenous infants.

INTERPRETATION

First Nations and Inuit infants had substantially elevated burdens of hospitalizations as a result of diseases of multiple systems. The findings identify substantial unmet needs in disease prevention and medical care for Indigenous infants.

Causes and temporal changes in nationally collected stillbirth audit data in high-resource settings

Few high-income countries have an active national programme of stillbirth audit. From the three national programmes identified (UK, New Zealand, and the Netherlands) steady declines in annual stillbirth rates have been observed over the audit period between 1993 and 2014. Unexplained stillbirth remains the largest group in the classification of stillbirths, with a decline in intrapartum-related stillbirths, which could represent improvements in intrapartum care. All three national audits of stillbirths suggest that up to half of all reviewed stillbirths have elements of care that failed to follow standards and guidance. Variation in the classification of stillbirth, cause of death and frequency of risk factor groups limit our ability to draw meaningful conclusions as to the true scale of the burden and the changing epidemiology of stillbirths in high-income countries. International standardization of these would facilitate direct comparisons between countries. The observed declines in stillbirth rates over the period of perinatal audit, a possible consequence of recommendations for improved antenatal care, should serve to incentivise other countries to implement similar audit programmes.

Carnitine palmitoyltransferase 1A P479L and infant death: policy implications of emerging data

Carnitine palmitoyltransferase 1 isoform A (CPT1A) is a crucial enzyme for the transport of long-chain fatty acids into the mitochondria. The CPT1A p.P479L variant is found in high frequencies among indigenous populations residing on the west and north coasts of Alaska and Canada and in northeast Siberia and Greenland. Epidemiological studies have reported a statistical association between P479L homozygosity and infant death in Alaska Native and Canadian Inuit populations. Here, we review the available evidence about the P479L variant and apply to these data the epidemiological criteria for assessing causal associations. We found insufficient evidence to support a causal association with infant death and, further, that if a causal association is present, then the genotype is likely to be only one of a complex set of factors contributing to an increased risk of infant death. We conclude that additional research is needed to clarify the observed association and to inform effective preventative measures for infant death. In light of these findings, we discuss the policy implications for public health efforts because policies based on the observed association between P479L homozygosity and infant death data are premature.Genet Med advance online publication 26 January 2017.

Racial and Ethnic Infant Mortality Gaps and the Role of Socio-Economic Status

We assess the extent to which differences in socio-economic status are associated with racial and ethnic gaps in a fundamental measure of population health: the rate at which infants die. Using micro-level Vital Statistics data from 2000 to 2004, we examine mortality gaps of infants born to white, black, Mexican, Puerto Rican, Asian, and Native American mothers. We find that between-group mortality gaps are strongly and consistently (except for Mexican infants) associated with maternal marital status, education, and age, and that these same characteristics are powerful predictors of income and poverty for new mothers in U.S. Census data. Despite these similarities, we document a fundamental difference in the mortality gap for the three high mortality groups: whereas the black-white and Puerto Rican-white mortality gaps mainly occur at low birth weights, the Native American-white gap occurs almost exclusively at higher birth weights. We further examine the one group whose IMR is anomalous compared to the other groups: infants of Mexican mothers die at relatively low rates given their socio-economic disadvantage. We find that this anomaly is driven by lower infant mortality among foreign-born mothers, a pattern found within many racial/ethnic groups. Overall, we conclude that the infant mortality gaps for our six racial/ethnic groups exhibit many commonalities, and these commonalities suggest a prominent role for socio-economic differences.

Evidence for an association between infant mortality and homozygosity for the arctic variant of carnitine palmitoyltransferase 1A

PURPOSE

Infant mortality in Alaska is highest among Alaska Native people from western/northern Alaska, a population with a high prevalence of a genetic variant (c.1436C>T; the arctic variant) of carnitine palmitoyltransferase 1A (CPT1A).

METHODS

We performed an unmatched case-control study to determine the relationship between the arctic variant and infant mortality. The cases were 110 Alaska Native infant deaths from 2006 to 2010 and the controls were 395 Alaska Native births from the same time period. In addition to the overall analysis, we conducted two subanalyses, one limited to subjects from western/northern Alaska and one limited to infants heterozygous or homozygous for the arctic variant.

RESULTS

Among western/northern Alaska residents, 66% of cases and 61% of controls were homozygous (adjusted odds ratio (aOR): 2.5; 95% confidence interval (CI): 1.3, 5.0). Among homozygous or heterozygous infants, 58% of cases and 44% of controls were homozygous (aOR: 2.3; 95% CI: 1.3, 4.0). Deaths associated with infection were more likely to be homozygous (OR: 2.9; 95% CI: 1.0-8.0). Homozygosity was strongly associated with a premorbid history of pneumonia, sepsis, or meningitis.

CONCLUSION

Homozygosity for the arctic variant is associated with increased risk of infant mortality, which may be mediated in part by an increase in infectious disease risk. Further studies are needed to determine whether the association we report represents a causal association between the CPT1A arctic variant and infectious disease-specific mortality.Genet Med 18 9, 933-939.

Macrosomia, Perinatal and Infant Mortality in Cree Communities in Quebec, 1996-2010

BACKGROUND

Cree births in Quebec are characterized by the highest reported prevalence of macrosomia (~35%) in the world. It is unclear whether Cree births are at greater elevated risk of perinatal and infant mortality than other First Nations relative to non-Aboriginal births in Quebec, and if macrosomia may be related.

METHODS

This was a population-based retrospective birth cohort study using the linked birth-infant death database for singleton births to mothers from Cree (n = 5,340), other First Nations (n = 10,810) and non-Aboriginal (n = 229,960) communities in Quebec, 1996-2010. Community type was ascertained by residential postal code and municipality name. The primary outcomes were perinatal and infant mortality.

RESULTS

Macrosomia (birth weight for gestational age >90th percentile) was substantially more frequent in Cree (38.0%) and other First Nations (21.9%) vs non-Aboriginal (9.4%) communities. Comparing Cree and other First Nations vs non-Aboriginal communities, perinatal mortality rates were 1.52 (95% confidence intervals 1.17, 1.98) and 1.34 (1.10, 1.64) times higher, and infant mortality rates 2.27 (1.71, 3.02) and 1.49 (1.16, 1.91) times higher, respectively. The risk elevations in perinatal and infant death in Cree communities attenuated after adjusting for maternal characteristics (age, education, marital status, parity), but became greater after further adjustment for birth weight (small, appropriate, or large for gestational age).

CONCLUSIONS

Cree communities had greater risk elevations in perinatal and infant mortality than other First Nations relative to non-Aboriginal communities in Quebec. High prevalence of macrosomia did not explain the elevated risk of perinatal and infant mortality in Cree communities.

Fatores associados à pneumonia em crianças Yanomami internadas por condições sensíveis à atenção primária na região norte do Brasil

Resumo Em países em desenvolvimento, a pneumonia é a principal causa de adoecimento e morte na infância, principalmente em grupos vulneráveis. O objetivo deste estudo foi analisar os fatores associados à pneumonia em crianças Yanomami internadas por condições sensíveis à atenção primária (ICSAP). As internações foram divididas em dois grupos: i) pneumonias e ii) demais causas, de acordo com a lista brasileira de ICSAP. Foram estimadas taxas ajustadas de ICSAP e utilizou-se a regressão logística não condicional para analisar fatores associados. Mais de 90% dos registros foram considerados ICSAP. A taxa padronizada de ICSAP foi 18,6/1.000. As chances de internação por pneumonia foram 2,7 (IC: 1,3-5,4) vezes maiores em crianças de 0,1 a 5,9 meses; 1,9 (IC: 1,1-3,3) vezes maiores nas crianças que tiveram a duração da hospitalização variando de 8 a 14 dias; e 3,0 (IC: 1,2-7,5) vezes maiores nas crianças com diagnóstico secundário de desnutrição. O excesso de internações evitáveis é um forte indício da baixa qualidade das ações em terras indígenas e do limitado acesso à atenção primária, contrariando o modelo assistencial proposto pelo subsistema de saúde indígena no Brasil que, em tese, deveria privilegiar tecnologias assistenciais ancoradas na atenção primária.

Investigating the Decline of Fetal and Infant Mortality Rates in Alaska During 2010 and 2011

INTRODUCTION

The U.S. infant mortality rate has been steadily declining since 2007. Although the downward trend has been notable in Alaska since 2006 when the rate was 6.9 infant deaths per 1000 live births, a dramatic drop in infant mortality occurred in 2010 and 2011 when the infant mortality rate fell to 3.8 infant deaths per 1000 live births during both years. The purpose of this study was to investigate the sudden decrease in fetal and infant mortality rates (FIMR) using the perinatal periods of risk (PPOR) method, an approach that has not been used previously in Alaska.

METHODS

The study was conducted for 251 fetal and infant deaths in 2004-2006, 265 deaths in 2007-2009, and 129 deaths in 2010-2011. Data were stratified by Alaska Native (AN) and White maternal race and urban/rural residence.

RESULTS

Among both urban and rural White women, the rate ratios (RR) for FIMRs between the earlier and later time periods were not significantly different. The postneonatal mortality rate (PNMR) among AN infants living in rural areas decreased significantly (RR 0.40; 95 % confidence interval 0.21-0.76) between 2007-2009 and 2010-2011. An unexplained increase in sudden unexplained infant death was noted in 2009, followed by a precipitous decrease in 2010-2011. No other unusual distribution of the cause specific mortality rates was observed.

DISCUSSION

The decrease in the Alaska Native FIMR might have been due to focused efforts for preventing postneonatal sleep associated deaths. Education for prevention of sleep related deaths, particularly in rural communities, is necessary to maintain Alaska's low PNMR.

Disparities and Trends in Birth Outcomes, Perinatal and Infant Mortality in Aboriginal vs. Non-Aboriginal Populations: A Population-Based Study in Quebec, Canada 1996-2010

BACKGROUND

Aboriginal populations are at substantially higher risks of adverse birth outcomes, perinatal and infant mortality than their non-Aboriginal counterparts even in developed countries including Australia, U.S. and Canada. There is a lack of data on recent trends in Canada.

METHODS

We conducted a population-based retrospective cohort study (n = 254,410) using the linked vital events registry databases for singleton births in Quebec 1996-2010. Aboriginal (First Nations, Inuit) births were identified by mother tongue, place of residence and Indian Registration System membership. Outcomes included preterm birth, small-for-gestational-age, large-for-gestational-age, low birth weight, high birth weight, stillbirth, neonatal death, postneonatal death, perinatal death and infant death.

RESULTS

Perinatal and infant mortality rates were 1.47 and 1.80 times higher in First Nations (10.1 and 7.3 per 1000, respectively), and 2.37 and 4.46 times higher in Inuit (16.3 and 18.1 per 1000, respectively) relative to non-Aboriginal (6.9 and 4.1 per 1000, respectively) births (all p<0.001). Compared to non-Aboriginal births, preterm birth rates were persistently (1.7-1.8 times) higher in Inuit, large-for-gestational-age birth rates were persistently (2.7-3.0 times) higher in First Nations births over the study period. Between 1996-2000 and 2006-2010, as compared to non-Aboriginal infants, the relative risk disparities increased for infant mortality (from 4.10 to 5.19 times) in Inuit, and for postneonatal mortality in Inuit (from 6.97 to 12.33 times) or First Nations (from 3.76 to 4.25 times) infants. Adjusting for maternal characteristics (age, marital status, parity, education and rural vs. urban residence) attenuated the risk differences, but significantly elevated risks remained in both Inuit and First Nations births for the risks of perinatal mortality (1.70 and 1.28 times, respectively), infant mortality (3.66 and 1.47 times, respectively) and postneonatal mortality (6.01 and 2.28 times, respectively) in Inuit and First Nations infants (all p<0.001).

CONCLUSIONS

Aboriginal vs. non-Aboriginal disparities in adverse birth outcomes, perinatal and infant mortality are persistent or worsening over the recent decade in Quebec, strongly suggesting the needs for interventions to improve perinatal and infant health in Aboriginal populations, and for monitoring the trends in other regions in Canada.

Disparities in mortality rates among US infants born late preterm or early term, 2003-2005

The purpose of this study was to identify disparities in neonatal, post-neonatal, and overall infant mortality rates among infants born late preterm (34-36 weeks gestation) and early term (37-38 weeks gestation) by race/ethnicity, maternal age, and plurality. In analyses of 2003-2005 data from US period linked birth/infant death datasets, we compared infant mortality rates by race/ethnicity, maternal age, and plurality among infants born late preterm or early term and also determined the leading causes of death among these infants. Among infants born late preterm, infants born to American Indian/Alaskan Native, non-Hispanic black, or teenage mothers had the highest infant mortality rates per 1,000 live births (14.85, 9.90, and 11.88 respectively). Among infants born early term, corresponding mortality rates were 5.69, 4.49, and 4.82, respectively. Among infants born late preterm, singletons had a higher infant mortality rate than twins (8.59 vs. 5.62), whereas among infants born early term, the rate was higher among twins (3.67 vs. 3.15). Congenital malformations and sudden infant death syndrome were the leading causes of death among both late preterm and early term infants. Infant mortality rates among infants born late preterm or early term varied substantially by maternal race/ethnicity, maternal age, and plurality. Information about these disparities may help in the development of clinical practice and prevention strategies targeting infants at highest risk.

American Indian and Alaska Native infant and pediatric mortality, United States, 1999-2009

OBJECTIVES

We described American Indian/Alaska Native (AI/AN) infant and pediatric death rates and leading causes of death.

METHODS

We adjusted National Vital Statistics System mortality data for AI/AN racial misclassification by linkage with Indian Health Service (IHS) registration records. We determined average annual death rates and leading causes of death for 1999 to 2009 for AI/AN versus White infants and children. We limited the analysis to IHS Contract Health Service Delivery Area counties.

RESULTS

The AI/AN infant death rate was 914 (rate ratio [RR] = 1.61; 95% confidence interval [CI] = 1.55, 1.67). Sudden infant death syndrome, unintentional injuries, and influenza or pneumonia were more common in AI/AN versus White infants. The overall AI/AN pediatric death rates were 69.6 for ages 1 to 4 years (RR = 2.56; 95% CI = 2.38, 2.75), 28.9 for ages 5 to 9 years (RR = 2.12; 95% CI = 1.92, 2.34), 37.3 for ages 10 to 14 years (RR = 2.22; 95% CI = 2.04, 2.40), and 158.4 for ages 15 to 19 years (RR = 2.71; 95% CI = 2.60, 2.82). Unintentional injuries and suicide occurred at higher rates among AI/AN youths versus White youths.

CONCLUSIONS

Death rates for AI/AN infants and children were higher than for Whites, with regional disparities. Several leading causes of death in the AI/AN pediatric population are potentially preventable.

Age distribution of infection and hospitalization among Canadian First Nations populations during the 2009 H1N1 pandemic

OBJECTIVES

We estimated age-standardized ratios of infection and hospitalization among Canadian First Nations (FN) populations and compared their distributions with those estimated for non-FN populations in Manitoba, Canada.

METHODS

For the spring and fall 2009 waves of the H1N1 pandemic, we obtained daily numbers of laboratory-confirmed and hospitalized cases of H1N1 infection, stratified by 5-year age groups and FN status. We calculated age-standardized ratios with confidence intervals for each wave and compared ratios between age groups in each ethnic group and between the 2 waves for FN and non-FN populations.

RESULTS

Incidence and hospitalization ratios in all FN age groups during the first wave were significantly higher than those in non-FN age groups (P < .001). The highest ratios were observed in FN young children aged 0 to 4 years. During the second wave, these ratios tended to decrease in FN populations and increase in non-FN populations, especially among groups younger than 30 years.

CONCLUSIONS

Incidence and hospitalization ratios in FN populations were higher than or equivalent to ratios in non-FN populations. Our findings support the need to develop targeted prevention and control strategies specifically for vulnerable FN and remote communities.

Temporal trends in Inuit, First Nations and non-Aboriginal birth outcomes in rural and northern Quebec

Objectives

The objective was to assess trends in Inuit, First Nations and non-Aboriginal birth outcomes in the rural and northern regions of Quebec.

Study design and methods

In a birth cohort-based study of all births to residents of rural and northern Quebec from 1991 through 2000 (n = 177,193), we analyzed birth outcomes and infant mortality for births classified by maternal mother tongue (Inuit, First Nations or non-Aboriginal) and by community type (predominantly First Nations, Inuit or non-Aboriginal).

Results

From 1991–1995 to 1996–2000, there was a trend of increasing rates of preterm birth for all 6 study groups. In all rural and northern areas, low birth weight rates increased significantly only for the Inuit mother tongue group [RR1.45 (95% CI 1.05–2.01)]. Stillbirth rates showed a non-significant increase for the Inuit mother tongue group [RR1.76 (0.64–4.83)]. Neonatal mortality rates decreased significantly in the predominantly non-Aboriginal communities and in the non-Aboriginal mother tongue group [RR0.78 (0.66–0.92)], and increased non-significantly for the First Nations mother tongue group [RR2.17 (0.71–6.62)]. Perinatal death rates increased for the First Nations mother tongue grouping in northern areas [RR2.19 (0.99–4.85)].

Conclusion

There was a disconcerting rise of some mortality outcomes for births to First Nations and Inuit mother tongue women and to women in predominantly First Nations and Inuit communities, in contrast to some improvements for births to non-Aboriginal mother tongue women and to women in predominantly non-Aboriginal communities in rural or northern Quebec, indicating a need for improving perinatal and neonatal health for Aboriginal populations in rural and northern regions.

Geographical disparities of infant mortality in rural China

OBJECTIVE

The purpose of the study was to investigate the trends and causes of regional disparities of infant mortality rate (IMR) in rural China from 1996 to 2008.

DESIGN

A population-based, longitudinal study.

SETTING

The national child mortality surveillance network.

POPULATION

Population of the 79 surveillance counties.

MAIN OUTCOME MEASURE

IMR, leading causes of infant death and the RR of IMR.

RESULTS

The IMR in coastal, inland and remote regions declined by 72.4%, 62.9% and 58.2%, respectively, from 1996 to 2008. Compared with the coastal region, the RR of IMR were 1.7 (95% CI 1.6 to 1.9), 1.9 (95% CI 1.7 to 2.0) and 1.8 (95% CI 1.6 to 2.0) for inland region and 2.6 (95% CI 2.4 to 2.7), 3.2 (95% CI 3.0 to 3.5) and 3.1 (95% CI 2.7 to 3.4) for the remote region during 1996-2000, 2001-2005 and 2006-2008, respectively. The regional disparities existed for both male and female IMRs. The postneonatal mortality showed the highest regional disparities. Pneumonia, birth asphyxia, prematurity/low birth weight, injuries and diarrhoea were the main contributors to the regional disparities. There were significantly more infants who did not seek healthcare services before death in the remote region relative to the inland and coastal regions.

CONCLUSION

The results indicated persistent existence of regional disparities in IMR in rural China. It is worth noting that regional disparities in IMR increased in the remote and coastal regions during 2001-2005 in rural China. These disparities remained unchanged during 2006-2008. The results indicate that strategies to reduce mortality caused by pneumonia, birth asphyxia and diarrhoea are keys to reducing IMR.

Disparities in infant mortality and effective, equitable care: are infants suffering from benign neglect?

Quality care for infant mortality disparity elimination requires services that improve health status at both the individual and the population level. We examine disparity reduction due to effective care and ask the following question: Has clinical care ameliorated factors that make some populations more likely to have higher rates of infant mortality compared with other populations? Disparities in postneonatal mortality due to birth defects have emerged for non-Hispanic black and Hispanic infants. Surfactant and antenatal steroid therapy have been accompanied by growing disparities in respiratory distress syndrome mortality for black infants. Progesterone therapy has not reduced early preterm birth, the major contributor to mortality disparities among non-Hispanic black and Puerto Rican infants. The Back to Sleep campaign has minimally reduced SIDS disparities among American Indian/Alaska Native infants, but it has not reduced disparities among non-Hispanic black infants. In general, clinical care is not equitable and contributes to increasing disparities.

Neonatal mortality due to preterm birth at 28-36 weeks' gestation in China, 2003-2008

Almost all (99%) neonatal deaths occur in developing countries, where the progress in reducing neonatal mortality rates (NMR) has been small; the Millennium Development Goal for child survival cannot be met if this situation continues. China is among the 10 countries that have the largest numbers of neonatal deaths. In order to provide effective interventions to reduce the national NMR for government policy makers, we analyse the trends, causes and characteristics of the neonatal deaths of preterm babies in different regions of China during the period 2003-2008. The data for this retrospective study were retrieved from the population-based Maternal and Child Health Surveillance System of China. The Cochran-Armitage trend test was used to analyse the trend of NMRs due to immaturity. The national NMR due to immaturity has decreased by 38.7% in 6 years. However, the proportion of preterm births among the causes of neonatal death has increased significantly from 33.6% in 2003 to 40.9% in 2008. The relative risk of neonatal death among preterm babies has shown significant regional disparity. In 2008, the adjusted relative risk was 1.30 [95% confidence interval (CI) 0.95, 1.78] in the inland regions and 2.37 [95% CI 1.56, 3.60] in the remote regions, both compared with the coastal regions. The proportion of neonatal deaths with a gestational age <32 weeks or a birthweight <1500 g was highest among the coastal regions. Most neonatal deaths of preterm babies in remote areas were born at home and were not treated before death. Our study suggests that preterm birth is the leading cause of neonatal death in China and neonatal mortality due to immaturity displayed regional differences. The Chinese government should implement major effective strategies for reducing the mortality of preterm infants to further decrease the total NMR. Priority interventions should be region-specific, depending on the availability of economic and health care resources.

Increased influenza-related healthcare utilization by residents of an urban aboriginal community

Most studies describing high rates of acute respiratory illness in aboriginals have focused on rural or remote communities. Hypothesized causes include socioeconomic deprivation, limited access to healthcare, and a high prevalence of chronic disease. To assess influenza rates in an aboriginal community while accounting for healthcare access, deprivation and chronic disease prevalence, we compared rates of influenza-related outpatient and emergency-department visits in an urban Mohawk reserve (Kahnawá:ke) to rates in neighbouring regions with comparable living conditions and then restricted the analysis to a sub-population with a low chronic disease prevalence, i.e. those aged <20 years. Using medical billing claims from 1996 to 2006 we estimated age-sex standardized rate ratios. The rate in Kahnawá:ke was 58% greater than neighbouring regions and 98% greater in the analysis of those aged <20 years. Despite relatively favourable socioeconomic conditions and healthcare access, rates of influenza-related visits in Kahnawá:ke were elevated, particularly in the younger age groups.

Consent for autopsy research for unexpected death in early life

Research in sudden death in fetuses (stillbirth) and infants (sudden infant death syndrome [SIDS]) is urgently needed, particularly in high-risk populations involving socioeconomic disadvantaged families. Essential to such research is the analysis of fetal and infant tissues at autopsy. Obtaining consent for donating autopsy tissues for research is especially problematic in socioeconomically disadvantaged populations in which mistrust of the medical establishment often exists. In this article, we present communication strategies for obtaining consent for research in autopsy tissues of stillbirth and SIDS cases in socioeconomically disadvantaged populations. Recommendations are provided about preparation for and the timing, setting, and content of the consent interview. The same lines of open and transparent communication delineated in this article are applicable to obtaining consent for the autopsy and autopsy research. Although the grief responses to the untimely death of the fetus or infant are universal and the recommendations of this essay are widely applicable to the general population, the expression of this grief and feelings toward autopsy-based research in socioeconomically disadvantaged populations may raise special issues that health care workers should be aware of when obtaining consent for research on autopsy-derived tissues.

Birth outcomes and infant mortality among First Nations Inuit, and non-Indigenous women by northern versus southern residence, Quebec

BACKGROUND

In circumpolar countries such as Canada, northern regions represent a unique geographical entity climatically, socioeconomically and environmentally. There is a lack of comparative data on birth outcomes among Indigenous and non-Indigenous subpopulations within northern regions and compared with southern regions.

METHODS

A cohort study of all births by maternal mother tongue to residents of northern (2616 First Nations (North American Indians), 2388 Inuit and 5006 non-Indigenous) and southern (2563 First Nations, 810,643 non-Indigenous) Quebec, 1991-2000.

RESULTS

Compared with births to southern non-Indigenous mother tongue women, births to northern women of all three mother tongue groups were at substantially elevated risks of infant death (adjusted OR (aOR) 1.7-2.9), especially postneonatal death (aOR 2.2-4.4) after controlling for maternal education, age, marital status and parity. The risk elevation in perinatal death was greater for southern First Nations (aOR 1.6) than for northern First Nations (aOR 1.2). Infant macrosomia was highly prevalent among First Nations in Quebec, especially in the north (31% vs 24% in the south). Within northern regions, Inuit births were at highest risk of preterm delivery (aOR 1.4) and infant death (aOR 1.6).

CONCLUSION

All northern infants (First Nations, Inuit or non-Indigenous) were at substantially elevated risk of infant death in Quebec, despite a universal health insurance system. Southern First Nations newborns have not benefited from the more advanced perinatal care facilities in southern regions. Environmental influences may partly account for the very high prevalence of macrosomia among First Nations in northern Quebec.

Evidence for an association between infant mortality and a carnitine palmitoyltransferase 1A genetic variant

OBJECTIVE

Alaska Native and other circumpolar indigenous populations have historically experienced high infant mortality rates, for unknown reasons. Through routine newborn screening, Alaskan and Canadian indigenous infants have been found to have a high frequency of a single sequence variant (c.1436C→T) in the gene coding for carnitine palmitoyltransferase type 1A (CPT1A). We sought to determine whether these 2 findings were related.

METHODS

As part of a quality control exercise at the Alaskan Newborn Metabolic Screening Program, we conducted genotyping for 616 consecutively born, Alaska Native infants and reviewed their medical records. We conducted an ecological analysis comparing Census area-level variant CPT1A allele frequency and historical Alaska Native infant, postneonatal, and neonatal mortality rates.

RESULTS

Infant death was identified for 5 of 152 infants homozygous for the c.1436C→T sequence variant (33 deaths per 1000 live births), 2 of 219 heterozygous infants (9 deaths per 1000 live births), and 0 of 245 infants carrying no copies of the variant allele (χ(2) = 9.2; P = .01). All 7 cases of infant death had some evidence of an infectious process at the time of death, including 5 with respiratory infections. Census areas with the highest frequency of the variant allele had the highest historical infant, postneonatal, and neonatal mortality rates.

CONCLUSIONS

Our data provide preliminary evidence that a highly prevalent CPT1A variant found among Alaska Native and other indigenous circumpolar populations may help explain historically high infant mortality rates. Larger definitive studies are needed.

American Indian/Alaska Native uninsurance disparities: a comparison of 3 surveys

OBJECTIVES

We examined whether 3 nationally representative data sources produce consistent estimates of disparities and rates of uninsurance among the American Indian/Alaska Native (AIAN) population and to demonstrate how choice of data source impacts study conclusions.

METHODS

We estimated all-year and point-in-time uninsurance rates for AIANs and non-Hispanic Whites younger than 65 years using 3 surveys: Current Population Survey (CPS), National Health Interview Survey (NHIS), and Medical Expenditure Panel Survey (MEPS).

RESULTS

Sociodemographic differences across surveys suggest that national samples produce differing estimates of the AIAN population. AIAN all-year uninsurance rates varied across surveys (3%-23% for children and 18%-35% for adults). Measures of disparity also differed by survey. For all-year uninsurance, the unadjusted rate for AIAN children was 2.9 times higher than the rate for White children with the CPS, but there were no significant disparities with the NHIS or MEPS. Compared with White adults, AIAN adults had unadjusted rate ratios of 2.5 with the CPS and 2.2 with the NHIS or MEPS.

CONCLUSIONS

Different data sources produce substantially different estimates for the same population. Consequently, conclusions about health care disparities may be influenced by the data source used.

Birth outcomes and infant mortality by the degree of rural isolation among first nations and non-first nations in Manitoba, Canada

CONTEXT

It is unknown whether rural isolation may affect birth outcomes and infant mortality differentially for Indigenous versus non-Indigenous populations. We assessed birth outcomes and infant mortality by the degree of rural isolation among First Nations (North American Indians) and non-First Nations populations in Manitoba, Canada, a setting with universal health insurance.

METHODS

A geocoding-based birth cohort study of 25,143 First Nations and 125,729 non-First Nations live births to Manitoban residents, 1991-2000. Degree of rural isolation was defined by an indicator of urban influence (no, weak, moderate/strong) based on the percentage of the workforce commuting to urban areas.

FINDINGS

Preterm birth and low birth weight rates were somewhat lower in all rural areas regardless of the degree of isolation as compared to urban areas for both First Nations and non-First Nations. Infant mortality rates were not significantly different across areas for First Nations (10.7, 9.9, 7.9, and 9.7 per 1,000 in rural areas with no, weak, moderate/strong urban influence, and urban areas, respectively), but rates were significantly lower in less isolated areas for non-First Nations (7.4, 6.0, 5.6, and 4.6 per 1,000, respectively). Adjusted odds ratios showed similar patterns.

CONCLUSIONS

Living in less isolated areas was associated with lower infant mortality only among non-First Nations. First Nations infants do not seem to have similarly benefited from the better health care facilities in urban centers, suggesting a need to improve urban First Nations' infant care in meeting the challenges of increasing urban migration.

A review of Aboriginal infant mortality rates in Canada: striking and persistent Aboriginal/non-Aboriginal inequities

OBJECTIVE

The Joint Working Group on First Nations, Indian, Inuit, and Métis Infant Mortality of the Canadian Perinatal Surveillance System is a collaboration of national Aboriginal organizations and federal and provincial/territorial stakeholders. Our objective was to better understand what is currently known about Aboriginal infant mortality rates (IMR) in Canada.

METHODS

As part of a larger international systematic review of Indigenous IMR calculation, we searched the published literature for original research regarding the calculation of First Nations, Inuit, and Métis infant mortality rates at the national and provincial/territorial level.

SYNTHESIS

We identified major deficiencies in the coverage and quality of infant mortality data for Aboriginal populations in Canada. The review of provincial and territorial reporting of infant mortality for Aboriginal populations revealed substantial provincial and territorial variation in the way that birth and death data were collected. With respect to coverage, high-quality IMRs were available only for Status Indians and communities with a high proportion of Inuit residents. No rates were available for Métis or non-Status Indians.

CONCLUSION

Striking and persistent disparities persist in the IMRs for Status Indians and in communities with a high proportion of Inuit residents, compared to the general Canadian population. There is an urgent need to work in partnership with First Nations, Indian, Inuit, and Métis stakeholder groups to improve the quality and coverage of Aboriginal IMR information and to acquire information that would help to better understand and address the underlying causes of disparities in infant mortality between the Aboriginal and non-Aboriginal population in Canada.

Birth outcomes in the Inuit-inhabited areas of Canada

BACKGROUND

Information on health disparities between Aboriginal and non-Aboriginal populations is essential for developing public health programs aimed at reducing such disparities. The lack of data on disparities in birth outcomes between Inuit and non-Inuit populations in Canada prompted us to compare birth outcomes in Inuit-inhabited areas with those in the rest of the country and in other rural and northern areas of Canada.

METHODS

We conducted a cohort study of all births in Canada during 1990-2000 using linked vital data. We identified 13,642 births to residents of Inuit-inhabited areas and 4,054,489 births to residents of all other areas. The primary outcome measures were preterm birth, stillbirth and infant death.

RESULTS

Compared with the rest of Canada, Inuit-inhabited areas had substantially higher rates of preterm birth (risk ratio [RR] 1.45, 95% confidence interval [CI] 1.38-1.52), stillbirth (RR 1.68, 95% CI 1.38-2.04) and infant death (RR 3.61, 95% CI 3.17-4.12). The risk ratios and absolute differences in risk for these outcomes changed little over time. Excess mortality was observed for all major causes of infant death, including congenital anomalies (RR 1.64), immaturity-related conditions (RR 2.96), asphyxia (RR 2.43), sudden infant death syndrome (RR 7.15), infection (RR 8.32) and external causes (RR 7.30). Maternal characteristics accounted for only a small part of the risk disparities. Substantial risk ratios for preterm birth, stillbirth and infant death remained when the comparisons were restricted to other rural or northern areas of Canada.

INTERPRETATION

The Inuit-inhabited areas had much higher rates of preterm birth, stillbirth and infant death compared with the rest of Canada and with other rural and northern areas. There is an urgent need for more effective interventions to improve maternal and infant health in Inuit-inhabited areas.

Indigenous newborn care

Infant mortality and morbidity disparities occur between non-Indigenous and Indigenous populations of Australia, Canada, New Zealand, and the United States. Neonatal mortality is due to high-risk births, which vary according to prevalence of the maternal risk factors of smoking, alcohol consumption, infection, and disorders of nutritional status, whereas postneonatal mortality is predominantly influenced by environmental factors. Aside from changing socioeconomic conditions, a continuum of maternal and child health care is likely to be the most effective measure in reducing these health disparities.

Risk factors for lower respiratory tract infection death among infants in the United States, 1999-2004

OBJECTIVE

To describe maternal and birth-related risk factors associated with lower respiratory tract infection (LRTI) deaths among infants.

METHODS

Records for infants with LRTI as a cause of death were examined by using the linked birth/infant death database for 1999-2004. Singleton infants dying with LRTI and a random sample of surviving singleton infants were compared for selected characteristics.

RESULTS

A total of 5420 LRTI-associated infant deaths were documented in the United States during 1999-2004, for an LRTI-associated infant mortality rate of 22.3 per 100,000 live births. Rates varied according to race; the rate for American Indian/Alaska Native (AI/AN) infants was highest (53.2), followed by black (44.1), white (18.7), and Asian/Pacific Islander infants (12.3). Singleton infants with low birth weight (<2500 g) were at increased risk of dying with LRTI after controlling for other characteristics, especially black infants. Both AI/AN and black infants born with a birth weight of > or =2500 g were more likely to have died with LRTI than other infants of the same birth weight. Other risk factors associated with LRTI infant death included male gender, the third or more live birth, an Apgar score of <8, unmarried mother, mother with <12 years of education, mother <25 years of age, and mother using tobacco during pregnancy.

CONCLUSIONS

Low birth weight was associated with markedly increased risk for LRTI-associated death among all of the racial groups. Among infants with a birth weight of > or =2500 g, AI/AN and black infants were at higher risk of LRTI-associated death, even after controlling for maternal and birth-related factors. Additional studies and strategies should focus on the prevention of maternal and birth-related risk factors for postneonatal LRTI and on identifying additional risk factors that contribute to elevated mortality among AI/AN and black infants.

Effects of alcohol and smoking during pregnancy on infant autonomic control

Prenatal exposure to smoking and alcohol increases the risk for Sudden Infant Death Syndrome (SIDS). Physiological changes associated with these exposures are not well studied. Full-term infants were tested within the first 3 days of life. We hypothesized that maternal alcohol consumption and/or smoking during pregnancy would alter autonomic nervous system function. Newborns whose mothers smoked during pregnancy had lower beat-to-beat heart rate variability in quiet sleep. Infants whose mothers consumed alcohol had lower global heart rate variability, but only in active sleep. Unexposed infants demonstrated increases in heart rate with head-up tilt and decreases in heart rate with head-down tilt, but smoking and alcohol-exposed infants showed no significant responses. These results indicate that autonomic function is altered by prenatal exposure to alcohol and smoking. Such markers may provide early identification of infants at greatest risk for SIDS.

Primary birthing attendants and birth outcomes in remote Inuit communities--a natural "experiment" in Nunavik, Canada

BACKGROUND

There is a lack of data on the safety of midwife-led maternity care in remote or indigenous communities. In a de facto natural "experiment", birth outcomes were assessed by primary birthing attendant in two sets of remote Inuit communities.

METHODS

A geocoding-based retrospective birth cohort study in 14 Inuit communities of Nunavik, Canada, 1989-2000: primary birth attendants were Inuit midwives in the Hudson Bay (1529 Inuit births) vs western physicians in Ungava Bay communities (1197 Inuit births). The primary outcome was perinatal death. Secondary outcomes included stillbirth, neonatal death, post-neonatal death, preterm, small-for-gestational-age and low birthweight birth. Multilevel logistic regression was used to obtain the adjusted odds ratios (aOR) controlling for maternal age, marital status, parity, education, infant sex and plurality, community size and community-level random effects.

RESULTS

The aORs (95% confidence interval) for perinatal death comparing the Hudson Bay vs Ungava Bay communities were 1.29 (0.63 to 2.64) for all Inuit births and 1.13 (0.48 to 2.47) for Inuit births at > or =28 weeks of gestation. There were no statistically significant differences in the crude or adjusted risks of any of the outcomes examined.

CONCLUSION

Risks of perinatal death were somewhat but not significantly higher in the Hudson Bay communities with midwife-led maternity care compared with the Ungava Bay communities with physician-led maternity care. These findings are inconclusive, although the results excluding extremely preterm births are more reassuring concerning the safety of midwife-led maternity care in remote indigenous communities.

Progress towards narrowing health disparities: first steps in sorting out infant mortality trend improvements among American Indians and Alaska Natives (AI/ANs) in the Pacific Northwest, 1984-1997

BACKGROUND

Most AI/AN infant mortality rates (IMRs) remain higher than white rates. The Northwest Portland Area Indian Health Board (NPAIHB), serving 43 tribes, CDC and the Washington, Oregon, and Idaho health departments investigated AI/AN infant survival.

METHODS

NPAIHB completed linking computerized birth certificate and birth-death files. We used death and birth cohorts, StatXact and SAS to compare 3-state resident, single and multi-year IMRs, basing infant race on mother's race, regardless of Hispanic origin. We used CDC's National Infant Mortality Surveillance ICD-9 categories for cause-specific rates.

RESULTS

From 1984 to 1997, about 2100-2800 AI/AN births occurred annually. From 1984 to 1990, AI/AN IMRs were 1.8-2.4 fold higher than white rates. Then aggregate-year IMRs significantly declined from 16.3 in 1984-1987 to 6.7 in 1994-1997 (P < 0.0001), approaching the 5.6 1994-1997 white rate. In 1998 the AI/AN IMR rate increased to 10.3. AI/AN SIDS and respiratory distress syndrome rates decreased significantly, respectively, from 8.1 in between 1984-1987 to 2.3 in 1994-1996 and from 1.8 in 1984-1987 to 0.3 in 1991-1993, then leveled off. Significant rate declines occurred among most demographic, risk behavior, birthweight, gestational-age, reproductive risk, birth spacing, and labor/delivery sub-groups. Among others, AI/AN residents in Idaho as well as those who received no prenatal care and who had 0-5 month birth spacing experienced no improvements.

CONCLUSIONS

These uncommon rate declines imply multi-factorial improvements among Northwest AI/ANs. Community-level surveillance and interventions before conception through post-partum may further improve health. Collaborative efforts need to be maintained to continue to monitor changes in AI/AN infant health and maternal characteristics.

Three maternal risk factors associated with elevated risk of postneonatal mortality among Alaska native population

OBJECTIVE

Compared to non-Natives in Alaska, the Alaska Native population has a postneonatal mortality rate 2.3 times higher (95% CI 1.9, 2.7). The objective of the study was to identify variables that account for this elevated risk.

METHODS

The dataset used included birth and death certificate records for all Alaska-resident live births and infant deaths occurring during 1992-2004. Race was defined as Alaska Native or non-Native. The association between race and postneonatal mortality was examined using univariate, stratified and regression analyses. Variables were considered confounding if they resulted in a change of at least 10% in the odds ratio between race and postneonatal mortality when added to a bivariate model, or when removed from a multivariate model.

RESULTS

In stratified analysis, race remained associated with postneonatal mortality within most categories of marital status, maternal education, maternal age, prenatal tobacco or alcohol use, prenatal care utilization, parity and residence. The odds ratio between race and postneonatal mortality was reduced to 1.3 (95% CI 1.0, 1.6) by controlling for education, a composite variable of marital status and the presence of father's name on the birth certificate, and prenatal tobacco or alcohol use.

CONCLUSIONS

A small number of potentially modifiable factors explain most of the postneonatal mortality disparity between Alaska Natives and non-Natives, leaving a relatively small increase in risk. These findings suggest that by targeting Alaska Native women who display these characteristics, the postneonatal mortality gap may be reduced.

Poverty as context for the parenting experience of low-income Lumbee Indian mothers with a medically fragile infant

PURPOSE

To explore the influence of poverty on the parenting experience and maternal developmental trajectory of Lumbee mothers with medically fragile infants.

DESIGN

A multiple-case study design using secondary data from a larger longitudinal study of parental role attainment with medically fragile infants.

SAMPLE

Five cases involving mothers who were Lumbee Indians and who had medically fragile infants.

RESULTS

The key features of the mothers' talk about their parenting experiences were organized into categories that fit into five inductively derived themes related to poverty.

IMPLICATIONS

Health care professionals need to be aware of how the context of living in poverty affects mothers of high-risk infants who are hospitalized in tertiary care units. In particular, low-income mothers, especially American Indians living in high-poverty areas, urgently need improved community resources such as access to birth control; early prenatal care; programs to help reduce drug, alcohol, and tobacco use both during and following pregnancy; and follow-up health and developmental services for their infants.

Sudden infant death syndrome: another year of new hope but no cure

PURPOSE OF REVIEW

Sudden infant death syndrome has inspired increasingly sophisticated studies at a time when rates are declining because of the Back-to-Sleep campaign, but ethnic disparities are widening. This review evaluates and discusses original, recent research in this area.

RECENT FINDINGS

The epidemiology of sudden infant death syndrome was evaluated, corroborating known risk factors and identifying new risk factors such as socioeconomic depression and air pollution. Deficits in our understanding of risk factors for this syndrome persist, suggesting a need for ethnicity-specific education, especially among the underserved. Both autopsy and genetic testing were found to improve diagnostic accuracy or identify other causes of death (e.g. long Q-T syndrome). Debate persists over counseling regarding pacifiers and co-sleeping within the context of breastfeeding. Support was found for a relationship between sudden infant death syndrome and autonomic dysregulation via the serotonergic pathway, but more research is needed.

SUMMARY

The cause of sudden infant death syndrome remains elusive. Recent studies, however, suggest that improved culturally sensitive educational programs, increased diagnostic specificity, and further clarification of the link between genetics and developmental stage might further decrease the number of infants lost to this devastating disease and elucidate the mechanism(s) responsible for this syndrome.