Related Terms

• Acquired immune deficiency syndrome, AIDS, alcohol, amniocentesis, anemia, anencephaly, antenatal, Apgar Scale, asphyxia, baby, bacteria, birth, Brazelton Scale, breastfeeding, calcium, child, childbirth, chorionic villus sampling, chromosome, colostrum, congenital, CVS, death, defects, diarrhea, diet, diphtheria, Down syndrome, drugs, exercise, fetal, fluoride, folate, folic acid, healthcare, heart, hepatitis, HIV, human immunodeficiency virus, hygiene, immunization, infant gestation, influenza, malaria, malnutrition, maternal, measles, Medicaid, mortality, mumps, neonatal, neural tube, nutrition, offspring, omega-3 fatty acids, omphalocele, perinatal, pertussis, pneumonia, polio, postnatal, pregnancy, premature, prenatal, preterm, race, rubella, sexually transmitted diseases, SCHIP, SIDS, spina bifida, State Children's Health Insurance Program, STDs, stillborn, sudden infant death syndrome, syphilis, testing, tetanus, UNICEF, United Nations Children's Fund, vaccinations, vitamin B.

Background

• The terminology used to describe different stages of life varies among national and international government agencies, countries, states, hospitals, and research institutions. This lack of standardization makes comparison of infant mortality data, or the number of infant deaths, difficult. Also, multiple terms may be used in reference to the same stage in life.

• Although these definitions may vary, most organizations use the term "infant" to describe a human that is between one month and one year old. Neonates are one day to one month old. Gestation is the period of time that a fetus is developing in the mother's womb. The duration of gestation period in humans is about nine months. Live birth is the birth of an offspring with the ability to move its muscles, breathe on its own, and whose heart is beating. The offspring is also called live born.

• The most common definition of neonatal death refers to the death of a baby in the first four weeks of life. Early neonatal death occurs within the first seven days. Infant death is the death of a baby after the neonatal period and up to one year of age. Late neonatal death occurs between seven and 28 days of life. Post-neonatal death occurs between 29 days and one year of life. Child death usually refers to the death of a child between one year and five years of age.

• The most common definition of the perinatal period begins at 154 days of gestation of the fetus and ends seven days after birth. Perinatal mortality is a measure of fetal deaths and the deaths of babies within the first week of life. The most common definition of fetal death or stillbirth is a death that occurs at any time during the pregnancy, and occurs when the baby dies before birth.

• According to the World Health Organization (WHO), eight million babies worldwide die in their first year of life, and 10 million children die before they are five years old. An estimated 130 million babies are born worldwide every year.

• The risk of child mortality, or the death of children under the age of five years, is now half what it was in the middle of the 20th Century, according to recent studies. This reduction affects children over the age of one month. The risk of death for neonates, or babies one day to one month old, has changed very little, due in part to ineffective or absent care for mothers and neonates. WHO estimates that 3.3 million babies are stillborn annually, though these deaths are largely preventable with improvement to maternal, prenatal, and neonatal care, and 98% of these deaths occur in developing countries.

• Neonatal death risk is highest in sub-Saharan regions of Africa (42-49 deaths per 1,000 live births) and south-central Asia (43 deaths per 1,000 live births). More than 40% of neonatal deaths globally occur in south-central Asia. In these areas, in about one third of births, a skilled birth attendant is present. About 70% of these deaths could be prevented with improved health services.

• According to WHO, the first month of a child's life is the most precarious. Nearly four million babies die in the first month. This accounts worldwide for 36% of childhood deaths. Three million babies die in the early neonatal period, or the first week of life.

• Most newborn deaths could be prevented if women had access to basic healthcare and understood the importance of vaccinations, breast feeding, treatment of infections, and proper newborn hygiene. Most newborn deaths internationally are attributed to birth before nine months of gestation (preterm birth), perinatal asphyxia (the fetus receiving too little oxygen during labor or birth), and infections.

• The first week of a baby's life often represents a gap in the formal healthcare the mother and infant receive in developing countries. Babies in these countries may be born at home with no follow-up doctor or hospital visits. This may be due to ineffective, absent, or difficult-to-access healthcare systems. Contact with the healthcare system reinforces the importance of behaviors that may improve maternal and neonatal health, including breastfeeding.

• In developing countries, healthcare services are generally inadequate or do not reach communities in need, resulting in perinatal deaths that are usually preventable. Cultural perceptions and attitudes, economic instability, war, poverty, and famine may make implementation of certain healthcare practices challenging.

• Post-neonatal death may be caused by a variety of factors, including injury and homicide. Past the age of one month and until the age of five years, malnutrition is a contributing factor in more than half of deaths of children. Most child deaths in this age range are due to HIV, measles, pneumonia, malaria, and diarrhea.

• In developed countries, research into the causes of infant and child mortality generally focuses on medical advances in the understanding of birth defects, prematurity, and life-threatening diseases. Multiple healthcare programs offering pre- and postnatal care usually exist and are generally successful in reaching communities, although racial disparities may remain.

• Global mortality trends indicate that the mortality rate of children under five years of age is decreasing in almost all countries, although fetal and neonatal deaths remain the same or may be increasing. Child mortality may not have changed or is increasing in countries affected by the HIV/AIDS epidemic.

• Sierra Leone, in Africa, has the highest infant mortality rate, at 160.3 deaths per 1,000 infants. The United States has 6.3 deaths per 1,000 infants. Iceland has the lowest infant mortality rate, at 2.9 deaths per 1,000 infants.

Technique

• General: The healthy development of a fetus is closely linked to the health of the mother. Proper prenatal and maternal care reduces the likelihood of a fetus developing birth defects, being born prematurely, or having a low birth weight or other conditions that negatively affect health, such as infections. Maternal nutrition greatly affects the health of the fetus. After birth, preventing infection with proper vaccinations and feeding habits is important to an infant's healthy development.

• Pregnancy:

• General: Lack of medical care during pregnancy, poor management of pregnancy and delivery complications, and poor hygiene may lead to fetal and neonatal death. Human pregnancy takes about 40 weeks. If contractions cause the cervix to open between the 20th and 37th week, labor may be premature. This may result in the birth of a premature baby. Babies born before the 37th week may have trouble breathing, eating, and keeping warm.

• Maternal nutrition: Pregnant women are encouraged to consult their obstetricians for specific advice. According to The U.S. Department of Health and Human Services (HHS), to meet the nutritional needs of both the fetus and mother, a pregnant woman should have 300 more calories daily (from 2,500 to 2,700 calories total daily) from different healthy foods. HHS recommends that pregnant women eat at least seven servings of fruits and vegetables, six to nine servings of whole grains, four servings of low-fat dairy products, and 60 grams of lean protein every day. Daily water intake is six eight-ounce glasses each day and an additional eight ounces for every hour of physical activity.

• Folic acid: Folic acid (called folate when it occurs naturally), or vitamin B9, is strongly recommended by healthcare professionals at the start of pregnancy and even before conception. Folic acid plays an important role in development of the central nervous system. In the developing fetus, the neural tube is the precursor to the central nervous system, which includes the brain and spinal cord. Folic acid has been shown to help prevent neural tube defects, including spina bifida and anencephaly. Folate is abundant in spinach (fresh, frozen, or canned) and is also found in green vegetables, salads, melon, and eggs. In the United States and Canada, most wheat products (such as flour or noodles) are fortified with folic acid. HHS recommends that pregnant women or women who may get pregnant take 400 micrograms of folate daily from foods or in supplement form if the diet is insufficient. Women who may be deficient in folate include those with type 2 diabetes, epilepsy, rheumatoid arthritis, psoriasis, inflammatory bowel disease, kidney disease, liver disease, celiac disease (nutritional disorder wherein the body can't properly breakdown gluten), or alcohol abusers.

• Calciumand iron: The Centers for Disease Control and Prevention (CDC) recommends that pregnant women consume 30 grams of iron daily from vitamin supplements or iron-rich foods such as iron-fortified cereals, red meat, fish, poultry, and whole grains. Doctors may prescribe iron supplements if pregnant women develop anemia, a condition that causes low levels of iron in the blood. A pregnant woman between the ages of 19 and 50 requires 1,000 micrograms of calcium daily. Calcium-rich foods include low-fat dairy products, leafy greens, and calcium-fortified foods.

• Calcium is effective only if women also obtain enough vitamin D, because vitamin D facilitates the absorption of calcium. Foods fortified with vitamin D and fatty fish, such as salmon, are good sources of vitamin D.

• Omega-3 fatty acids: Oils from salmon, trout, tuna, herring, sardine, mackerel, and some chicken eggs contain omega-3 fatty acids that are needed to build membranes in the nervous system. Fatty fish intake during pregnancy may provide nutrition for proper brain and eye development of the fetus. However, large fish such as shark, swordfish, king mackerel, and tilefish may contain high levels of toxic mercury. HHS recommends that pregnant women avoid these fish during their pregnancies and consume only six ounces of albacore tuna or tuna steak each week. In total, HHS recommends that pregnant women consume two 12-ounce portions of fish each week. Low-mercury fish include shrimp, salmon, catfish, and "light" tuna. Omega-3 fatty acids are also present in walnuts, flaxseed, and marine algae.

• Bacteria: Dangerous bacteria or parasites, particularly listeria and toxoplasma, may contaminate foods. To avoid those two hazards, fruits and raw vegetables should be washed and meats cooked to temperatures recommended by the U.S. Food and Drug Administration (FDA). For example, it is recommended that ground beef be cooked to 160ºF to kill harmful bacteria and chicken breasts to 170ºF. Raw-milk cheeses (which may contain listeria) and cat feces (which may contain toxoplasma) should be avoided. Toxoplasmosis is a parasitic blood infection that can be passed to the fetus during pregnancy. Listeria is a bacterium that can contribute to miscarriage, premature delivery, neonatal death, and fetal infection. It is suggested refrigerators be cleaned with diluted bleach (then rinsed).

• Physical activity and weight: Pregnant women should talk to their doctors to determine what types of exercise and how much physical activity is safe during pregnancy. According to the CDC, physical activity during pregnancy can relieve discomfort. Light to moderate exercise, such as swimming, yoga, and riding a stationary bike, is generally safe during pregnancy. In general, the American College of Obstetricians and Gynecologists (ACOG) recommends that pregnant women gain an average of 25 to 30 pounds during pregnancy. During the first trimester, pregnant women gain about two to four pounds. During the second and third trimesters, in general, pregnant women gain three to four pounds every month.

• Prenatal care:

• General: Getting early and regular prenatal care is one of the most effective ways to ensure a healthy pregnancy. Prenatal care includes education and counseling about how to handle different aspects of pregnancy, such as nutrition and physical activity, what to expect from the birth itself, and basic skills needed to properly care for the infant.

• Doctors' visits: Prenatal visits also give the woman and her family a chance to talk to a healthcare provider about any questions or concerns related to pregnancy, birth, or parenthood. A doctor may schedule monthly visits during the first two trimesters (from week one to week 28 of pregnancy), every two weeks from weeks 28-36 of pregnancy, and weekly after week 36 (until the day of delivery, which could be between weeks 38-40).

• Monitoring: The objective of prenatal care is to monitor the health of the pregnant mother and fetus. It is important for a woman to visit the doctor as soon as she suspects she is pregnant. At each visit, a doctor examines the woman to make sure that the baby and the mother are healthy. This examination includes: monitoring weight gain or loss, blood pressure, circumference of the abdomen, position of the fetus, and fetal heartbeat either by physical exam, ultrasound, or another technique. Such variables are closely followed during the course of the pregnancy.

• Postnatal care:

• Neonatal testing: Two scales are used to assess the health of newborns immediately after birth and up to several hours later.

• The Apgar Scale is used within the first five minutes after birth; the infant's heart rate, respiratory effort, muscle tone, body color, and reflexes are analyzed. The infant receives a score of zero, one, or two for each of the above mentioned health signs. This is performed by an obstetrician or nurse. Results fall into three ranges: 7-10 = normal or good condition; five = may have developmental difficulties; three or below = high or increased risk of death.

• The Brazelton Scale is used to assess the newborn hours after birth and includes neurological development, various reflexes, and reactions to people in different circumstances. Results are categorized by terms such as: "worrisome," "normal," or "superior."

• Normal indicators: Normal newborn weights and measurements include: normal weight, 7-8 pounds; normal length, 19-21 inches; and normal vision, 20/40, which means that vision is clear at a 12-inch distance.

• Vaccines: Vaccines work by stimulating the body's immune system. Vaccines contain small amounts of inactivated, disease-causing organisms. This allows the immune system to produce antibodies to the foreign invader. Once antibodies are developed, the immune system is able to respond quickly to the infection if the disease-causing organism ever enters the body. After receiving a vaccine, the patient may become immune to the specific illness.

• Healthcare professionals recommend that parents immunize children according to healthcare authorities in their area. For some of the most deadly childhood diseases, such as measles, vaccines are available in developed and many developing countries, and timely completion of immunization may protect a child from death. Since babies have underdeveloped immune systems, they are more vulnerable to infections and diseases than adults, even with the passive immunity they gain through their mothers. Thus, several vaccines are given to babies to help protect them against illnesses.

• Babies typically receive vaccines for diphtheria, tetanus, hepatitis, pertussis (whooping cough), polio, measles, rubella (German measles), mumps, and a type of flu called hemophilus B influenza. Some vaccines are given when the baby reaches two months old because this is when the high level of antibodies passed on by the mother begins to decline. Many vaccines require more than one shot. These additional shots, also called booster shots, ensure that enough antibodies are produced to make the vaccine effective. Vaccines against the seasonal flu are given yearly to babies over six months old.

• Immune system development:

• Fetal immunity: A specific type of immunoglobulin, called immunoglobulin G (IgG), is the only antibody that crosses the placenta to the fetus during pregnancy. This is called passive immunity because the mother is "passing" her antibodies to her child, helping protect the baby from diseases and infections. IgG antibodies are the smallest but most abundant antibodies, making up 75-80% of all the antibodies in the body. They are present in all body fluids, and they are considered to be the most important antibodies for fighting against bacterial and viral infections. These antibodies help protect the fetus from developing an infection inside the womb. Immunoglobulins identify and bind to harmful substances that enter the body, such as bacteria, viruses, and fungi. The antibodies then trigger other immune cells to destroy the foreign substance and prevent infection and disease.

• Infantimmunity: Immediately after birth, the newborn has high levels of the mother's antibodies in the bloodstream. During the first few days after pregnancy, the mother secretes a fluid from her breasts called colostrum, which contains high levels of antibodies and nutrients. Mature breast milk contains all five types of antibodies, including immunoglobulin A (IgA), immunoglobulin D (IgD), immunoglobulin E (IgE), immunoglobulin G (IgG), and immunoglobulin M (IgM).

• The amount of antibodies in the breast milk decreases over the course of several months. Initially, the infant produces antibodies at a much slower rate than adults. When healthy babies are about 2-3 months old, the immune system will start producing its own antibodies. Once healthy babies reach six months of age, their antibodies are produced at a normal rate.

Theory/Evidence

• Inconsistent data reporting:

• General: According to the World Health Organization (WHO), inconsistency in terminology, underreporting, cultural differences, and lack of understanding affect the numbers of deaths recorded in a country or region. This, in turn, can lead to a significant gap between published mortality rates and actual numbers of deaths. According to WHO, perinatal deaths are less likely to be reported than live births. Fetal deaths are the most likely to be underreported. Underreporting can range between 20%-40%, depending on the region.

• The reporting of births and deaths are vital statistics and differ among countries and states. Fetal and infant mortality rates compiled by international or national agencies are based on the country or state's legal definitions of terms such as live birth or infant death. If births are not recorded, then deaths early in life, during the neonatal period, for example, will not likely be recorded. This is especially true of stillborn or fetal deaths, which are often underreported. Vital statistics often include data from surveys of communities and hospitals.

• Measurement: Fetal and neonatal mortality is often not recorded in the same manner from one country to another or even within the same country. WHO recommends countries record the deaths of all fetuses and infants weighing 500 grams or more. Deaths of fetuses and infants weighing 500-1,000 grams are recorded for national statistics; deaths of fetuses and infants past 28 weeks of gestation are recorded for international statistics.

• Classifications: Agencies such as the United Nations (UN) and WHO include data related to fetal, neonatal, infant, and child mortality from various countries in their mortality calculations only when the data are considered reliable. Definitions of reliability differ. WHO considers 85% of deaths in a country or region being recorded as reliable. The UN requires 90% mortality reporting. Reliable vital statistics exist for only a third of the international population.

• Data collection: Countries or regions often calculate mortality based on data collected from surveys and hospitals. According to WHO, community surveys are incomplete when the information from sources is incomplete. Women are usually interviewed at the time of the survey, not when they are pregnant or give birth. The lapse of time from their pregnancy to the interview can affect the accuracy of the data given. This inaccuracy is compounded by the fact that there may be no records of birth weight, gestational age, or menstruation cycle (which may indicate the date of conception). The cultural sensitivity of the interviewer can also affect what information is collected and its accuracy. According to WHO, hospital data cannot be considered reliable unless all births are recorded there, which they often are not. If it is not considered reliable, it may not be included in national or international statistics.

• Underreporting and misclassification: Neonatal deaths remain unchanged, and many agencies such as WHO believe that neonatal and fetal deaths are largely underreported. Factors that contribute to fetal and early neonatal deaths are similar, and therefore fetal deaths or stillbirths should equal or exceed early neonatal deaths. This is demonstrated by data from developed countries, according to WHO. However, according to WHO, stillbirths make up one-half to one-third of early neonatal deaths in developing countries. Underreporting of early neonatal and fetal deaths may be due to ignorance or avoidance of the process of registration, according to WHO. Registration fees may deter death registration. Live births and deaths may be misclassified by the registrar or the person registering due to the inconsistency in definitions or lack of knowledge.

• Invisibility: In many developing countries, fetal and neonatal deaths are widespread. This often leads to a fatalistic mentality, wherein perinatal deaths are not even recorded, according to some studies. Newborn babies may remain at home and unnamed for several weeks, as family members fear they will succumb to death in poorer countries. This contributes to the global invisibility of perinatal mortality, with many governments not concerned with the extent of the problem, according to some studies.

• Reducing fetal, neonatal, and infant mortality:

• General: Although infant and child mortality is decreasing globally, neonatal mortality, or the number of children who die within the first month of life, remains unchanged or may be increasing in some countries. WHO and the international community have made reducing neonatal mortality a priority.

• Although developed countries may focus on technological advances in neonatal care to reduce mortality, the most significant reductions have been achieved with the introduction of pre- and postnatal care. Neonatal mortality rate in England dropped more than 60% between 1940 and 1979 due to such interventions, according to some studies. The use and availability of antibiotics, immunizations, and trained healthcare professionals during birth has also reduced neonatal mortality in some countries. Successful healthcare programs that reduce perinatal and infant mortalities often consider both the mother and infant's health and provide continuity between the two, according to some studies.

• The first weeks of a baby's life are often the most precarious because in many developing nations during this time, little to no adequate care is provided. Several reports indicate that quality healthcare systems and services are lacking in developing countries, and this is contributing to preventable fetal and neonatal deaths. Also, in some countries, cultural practices, such as not washing a newborn, may dictate maternal and infant care, which may be in opposition to sound healthcare. These practices may not be clearly understood by healthcare workers or researchers.

• Healthcare: Healthcare systems vary greatly from country to country in what services they offer, how effective they are at reaching different populations, and the skills of those implementing the programs. Access to pre- and postnatal healthcare services may greatly improve an offspring's chance of survival. Prenatal care may identify maternal behaviors or conditions that may contribute to prematurity or other complications. According to the U.S. Department of Health and Human Services (HHS), three times as many babies are likely to be born with a low birth weight and five times as many are likely to die when their mother receives no prenatal care in the United States. Several programs exist in the United States to promote access to pre- and postnatal care.

• Educational programs: The Healthy Start program is available in 100 communities in America that suffer from high infant mortality rates. The program is tailored to a community's unique needs. It involves reaching out to the community and providing health education. HHS also provides a toll-free hotline that parents can call if they have questions about prenatal care. The hotline offers healthcare referrals.

• The National Folic Acid Campaign provides outreach to communities regarding the importance of folic acid consumption to reduce certain birth defects, particularly neural tube defects. The Back to Sleep campaign educates the public about the risk factors for Sudden Infant Death Syndrome (SIDS), including stomach sleeping. SIDS deaths have decreased by 53% between 1992 and 2002, according to HHS. HHS also educates doctors about the importance of reducing transmission of HIV from mother to infant with the use of the HIV drug zidovudine (AZT) and different delivery options.

• Immunization programs: HHS's childhood immunization initiative offers immunizations, particularly those that are most critical, to children throughout the country. According to HHS, currently 90% of children under the age of two in the United States receive the most crucial immunizations. Due to the success of this program, preventable diseases (such as measles) and resulting deaths in children are, in some cases, at record lows.

• U.S. funding: Medicaid is a program in the United States that offers funding for healthcare for low-income families and may also be offered to pregnant women, depending on the state. The program may include well-child visits and parenting education. The State Children's Health Insurance Program (SCHIP) provides funding for healthcare of the 4.6 million children not covered under Medicaid or other programs. Prenatal care may also be offered through SCHIP. The Maternal and Child Health Services Block Grant offers grants to states that wish to provide prenatal care and reduce infant mortality. According to HHS, 60% of women who give birth annually participate in this program. HHS funds programs that aim to prevent teenage pregnancy. The program reaches 47% of communities throughout the country.

• International funding: Several international agencies fund programs around the world to improve the health and well-being of mothers, infants, and children. The U.S. Agency for International Development (USAID)'s Global Health Bureau offers grants to support various health programs in different countries. USAID has funded programs to treat diarrhea and malnutrition, provide immunizations, and fight HIV/AIDS and infectious diseases in children and mothers. WHO, an agency with the United Nations system, is an international public health organization that funds maternal and child health programs at the local, national, and international levels. WHO funds research of infectious diseases, chronic disease, and other health issues that affect mothers and children. Twenty-one percent of WHO's 2006-2007 budget was used to maintain support staff in various countries to assist local governments in improving the health and well-being of their citizens.

• Medical research: Several advances in medical research have contributed to reducing infant deaths, particularly in premature babies. Treatments that increase the survival rate of premature infants and reduce the occurrence of respiratory distress in infants are more widely used. The treatments include antenatal corticosteroids and surfactants, according to HHS. Research is also ongoing into preeclampsia (an increase in blood pressure during pregnancy that may reach dangerous levels and contributes to maternal and infant mortality).

Health Impact/Safety

• General: Generally, the factors contributing to fetal and neonatal deaths differ from those contributing to infant and child deaths. Stillbirths and deaths during the neonatal period, or first four weeks of life, are closely tied to maternal health.

• Risk factors:

• General: Certain maternal conditions and behaviors may contribute to premature birth, low birth weight, or other factors that may lead to prenatal, neonatal, or infant death. High-risk pregnancies are pregnancies that have an increased risk of complications that may lead to maternal or perinatal death. The mother's age, multiple births, previous premature births, sexually transmitted diseases (STDs), alcohol consumption, and nutrition are important in determining whether a pregnancy is high-risk. Complications associated with certain tests administered during pregnancy may also lead to prenatal mortality.

• Mother's age: Women older than age 35 have an increased risk of having children with certain chromosomal abnormalities, such as Down syndrome, as well as placental problems (such as placenta previa). Studies also suggest an increased risk of miscarriage and low birth weight in pregnant women in this age group. Teen mothers are more likely to give birth prematurely than women older than age 20.

• Multiple births: Women carrying two or more babies are at an increased risk for a number of complications, including premature labor and low birth weight. Babies born prematurely may have many complications, such as respiratory infection and bleeding or fluid buildup in the brain.

• Previous premature births: Women who have already delivered a premature baby are more likely to have pregnancy complications, including additional premature births.

• Sexually transmitted diseases (STDs): A number of STDs can be transmitted to a baby before, during, or after birth, resulting in medical complications. STDs include herpes, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), genital warts (caused by human papilloma virus, or HPV), hepatitis B, chlamydia, syphilis, gonorrhea, and trichomoniasis. Certain antiviral drugs may prevent the transmission of viruses from mother to fetus.

• Drugs: Women who were exposed to diethylstilbesterol (DES, a hormonal drug) when their mothers took the drug during pregnancy are at an increased risk for a number of complications, including ectopic pregnancy (when a fertilized egg does not attach to the uterus, but instead to another place, such as the fallopian tubes) and preterm delivery. DES was prescribed to women from 1938 to 1971 to prevent miscarriage. Women exposed to the drug may wish to contact their obstetricians. Physical or cognitive deficits, which can range from mild to severe, that a child experiences as the result of alcohol consumption by his or her mother during pregnancy include, but are not limited to, fetal alcohol syndrome (FAS). Symptoms include facial abnormalities, hyperactivity, poor coordination, and learning disabilities.

• Other contributing factors:

• Maternal anemia: Maternal anemia (low number of red blood cells), which is defined by WHO as a hemoglobin count of less than 11 grams/deciliter, may affect a pregnancy's outcome. Studies have found that material anemia may lead to increased risk of premature birth.

• Labor complications: Some studies have examined the incidence of perinatal and infant deaths in different countries. In general, most deaths occur during the perinatal period, are associated with complications from labor, and are preventable. Hypertensive disease (high blood pressure) has been found to contribute to labor complications. Other factors that may affect labor complications are the mother's age, multiple births, or maternal health. Maternal health is impaired by anemia, urinary infection, hypertension, and toxemia. Premature babies may suffer from syphilis, uteroplacental pathology, congenital malformations, or nutritional problems.

• Complications during labor and delivery may contribute to health problems or possibly death of the mother or baby. Untrained healthcare professionals who do not know how to respond to labor complications may also contribute to mortality. Prolonged labor may also compromise the health of the baby. A fatal lack of oxygen, or birth asphyxia, may occur if the baby does not receive enough oxygen during labor and delivery. Some studies have examined the effect of birth asphyxia on fetal and neonatal mortality and have found that birth asphyxia contributes to perinatal mortality. Proper hygiene during delivery also helps prevent neonatal infections.

• Caesarean delivery: A Caesarean delivery (C-section) is a surgical procedure where a cut is made in the abdominal area and the baby is delivered through this opening instead of vaginally. A C-section may be necessary for several reasons, including prolonged or difficult labor, the baby being in the wrong position, the baby being very large, the umbilical cord or placenta being in the wrong position, or when the health of the baby or the mother is impaired. There are more complications associated with C-section than with vaginal births. Babies born from C-sections are more likely to develop transient tachypnea (fast breathing) for the first few days after birth. There is also an increased risk (four times greater) of the mother developing blood clots during or after surgery that may be fatal.

• Newborn care: Lack of newborn care, including proper hygiene and feeding, may lead to neonatal death. The first hours after birth are a critical time for newborns. Good hygiene includes keeping the baby, clean, warm, and dry. After delivery, the umbilical cord is cut, with a stump about an inch long left behind. To prevent infection, the stump is kept clean and dry. The stump will usually fall off on its own within two weeks. Care for illnesses in infants and neonates is also important, as young children are more susceptible to illnesses than adults. Sick young infants require the immediate attention of a trained healthcare provider.

• Feeding: The first milk a mother produces, called colostrum, is rich in antibodies, which help the baby's body fight off infections. Feeding other food instead of colostrum and breast milk may compromise the baby's immune system.

• Sudden infant death syndrome (SIDS):

• General: Sudden Infant Death Syndrome (SIDS) is the leading cause of death among infants who are one month to one year old; it claims the lives of about 2,500 infants each year in the United States. Most SIDS deaths are associated with sleep (hence the common reference to "crib death"). Infants who die of SIDS show no signs of suffering.

• SIDS risk: When considering which babies could be most at risk, no single risk factor is likely to be sufficient to cause a SIDS death. Rather, several risk factors combined cause an at-risk infant to die of SIDS. Most deaths due to SIDS occur between two and four months of age, and incidence increases during cold weather. African-American infants are twice as likely and Native American infants are about three times more likely to die of SIDS than Caucasian infants. More boys than girls fall victim to SIDS. Other potential risk factors include: smoking, drinking, or drug use during pregnancy; poor prenatal care; prematurity or low birth-weight; mothers younger than 20; smoke exposure following birth; overheating from excessive sleepwear and bedding; and sleeping on the stomach.

• SIDS diagnosis: While most conditions or diseases usually are diagnosed by the presence of specific symptoms, most sudden infant death syndrome (SIDS) diagnoses come only after all other possible causes of death have been ruled out through a review of the infant's medical history and environment. This review helps distinguish true SIDS deaths from those resulting from accidents, abuse, and previously undiagnosed conditions, such as cardiac or metabolic disorders.

• Stomach sleeping: The most common risk factor for SIDS is stomach sleeping. Numerous studies have found a higher incidence of SIDS among babies placed on their stomachs to sleep than among those sleeping on their backs or sides. Some researchers have hypothesized that stomach sleeping puts pressure on a child's jaw, thereby narrowing the airway and hampering breathing. Another theory is that stomach sleeping may increase an infant's risk of "re-breathing" his or her own exhaled air, particularly if the infant is sleeping on a soft mattress or with bedding, stuffed toys, or a pillow near the face. In that scenario, the soft surface could create a small enclosure around the baby's mouth and trap exhaled air. As the baby breathes exhaled air, the oxygen level in the body drops and carbon dioxide accumulates. Eventually, this lack of oxygen could contribute to SIDS.

• Brain abnormality: Infants who succumb to SIDS may have an abnormality in the arcuate nucleus, a part of the brain that may help control breathing and waking during sleep. If a baby is breathing stale air and not getting enough oxygen, the brain usually triggers the baby to wake up and cry. That movement changes the breathing and heart rate, making up for the lack of oxygen. But a problem with the arcuate nucleus could deprive the baby of this involuntary reaction and put him or her at greater risk for SIDS.

• SIDS prevention: Individuals can take steps to help reduce the risk of SIDS in the infant. First and foremost, infants younger than one year old should be put to sleep on their back. Healthcare professionals suggest the following measures to help reduce the risk of SIDS: place the baby on a firm mattress to sleep, never on a pillow, waterbed, sheepskin, or other soft surface. To prevent re-breathing, do not put blankets, comforters, stuffed toys, or pillows near the baby. Make sure the baby does not get too warm while sleeping. Keep the room at a temperature that feels comfortable for an adult in a short-sleeve shirt. Some healthcare professionals suggest that a baby who gets too warm could go into a deeper sleep, making it more difficult to awaken.

• Smoking: It is recommended not to smoke, drink alcoholic beverages, or use drugs (unless prescribed by a doctor) while pregnant. Pregnant mothers and newborns are cautioned not be exposed to secondhand smoke. Infants of mothers who smoked during pregnancy are three times more likely to die of SIDS than those whose mothers were smoke-free, and exposure to secondhand smoke doubles a baby's risk of SIDS. Smoking may affect the central nervous system, starting prenatally and continuing after birth, which could place the baby at an increased risk.

• Cribs and pacifiers: While infants can be brought into a parent's bed for nursing or comforting, returning babies to their cribs or bassinets when they are ready to sleep may help prevent SIDS. Placing the crib in the parents' bedroom has been linked with a lower risk of SIDS. Putting the baby to sleep with a pacifier during the first year of life may reduce SIDS risk.

• Congenital abnormalities:

• General: According to WHO, about one percent of babies suffer from a serious congenital abnormality, or a defect or damage to a part or whole of the body that occurs during development of the fetus and has major medical or cosmetic consequences. Diseases such as syphilis or lack of certain nutrients such as folic acid can cause problems during development of the fetus. According to the U.S. Centers for Disease Control and Prevention (CDC), most abnormalities occur during the first three months of fetal development and are discovered in the first year of life. Abnormalities may appear obvious or may not be uncovered until tests are performed. Some anomalies (deviations from normal, defects, malformations) require medical attention for healthy development. Others may cause death in the womb or after birth. If a developing fetus has a severe developmental abnormality, the mother may have a miscarriage (the pregnancy ends spontaneously before 20 weeks of gestation).

• Types of defects: Severe developmental defects can affect a part of the body or an organ. Heart defects are the most common and, according to the CDC, are responsible for about 50% of deaths due to birth defects in babies under one year of age. Other defects affect the developing spinal column and are collectively called neural tube defects. They are often serious, life-threatening conditions, and they occur in one out of every 1,000 pregnancies.

• Heart defects: Abnormalities of the heart often affect its structure and how it is able to function. Some defects can be corrected with surgery. Hypoplastic left heart syndrome (HLHS) is a defect that without correction may cause death. In this defect, the left side of the heart is not completely developed. The heart often cannot supply the body with the oxygen-rich blood it needs. Babies suffering from HLHS may look normal at birth but within days develop symptoms such as blue skin, trouble breathing, and insufficient eating. The CDC estimates that two out of every 10,000 babies are born with HLHS.

• Some studies found that multivitamin use could reduce the risk of heart defects. This reduction occurred only if the multivitamin was taken three months before conception and three months after conception. When taken a month after conception, no reduction was observed.

• Neural tube defects: Spina bifida occurs when the developing spinal column does not close properly and an opening is left in the neural tube. The condition can be fatal if the opening is large, not covered by skin, located in a more sensitive area, and has nerves protruding from opening. Anencephaly is an improper closing of the spinal column that would otherwise form the brain and surrounding tissue. Babies suffering from anencephaly will lack parts of their brain, skull, and scalp. One in 4,000 babies in the United States has anencephaly. According to several studies, babies with anencephaly cannot survive. Although the causes of anencephaly are not known, the defect may be linked to folic acid. Consumption of vitamin B or folic acid by the mothers before and during pregnancy appears to lower the risk of the defect.

• Some studies found that more than 80% of infants born with birth defects from 1995 to 1997 survived. Infants suffering from anencephaly died before the end of the first year.

• In 1998, the U.S. Food and Drug Administration (FDA) mandated that grain products be fortified with folic acid. According to one study, after the mandate, the occurrence of spina bifida was reduced by 31% and anencephaly by 16%.

• Some studies have examined the effect of folic acid consumption on neural tube defect reduction in different ethic groups. Between 1995 and 2002, the fortification of grain products with folic acid resulted in a decrease in neural tube defects in Hispanic and non-Hispanic white populations. Neural tube defects were most common in Hispanic births.

• Chromosomal defects: Chromosomes carry the genetic information or DNA that a baby inherits from its mother and father. A developing fetus receives 23 chromosomes from each parent. If a problem occurs during development, the fetus can inherit either too many, too few, or inappropriately paired chromosomes. Down syndrome is a chromosomal defect caused by either the sperm or egg containing an extra chromosome, i.e., the baby receives 47 instead of 46 chromosomes. This defect can cause a number of developmental and physical problems that can be life threatening in some cases. Risk factors for Down syndrome include maternal age and some types of prenatal testing.

• Some studies report that mortality of babies suffering from Down syndrome was associated with the presence of heart defects and low birth weight. Also, a racial disparity was found in the survival of babies with Down syndrome, with African-American babies more likely to die.

• Omphalocele: Omphalocele is a defect that causes the baby's internal organs, usually the intestines, to rupture into the umbilical cord. This defect occurs when the baby's abdominal wall does not close completely, and it is often found in conjunction with other birth defects. The causes of omphalocele are unknown, though in some cases it may be inherited. One in every 4,000 babies suffers from omphalocele. These babies usually die before the first year of life and are deaf and blind.

• Prenatal tests that carry health risks:

• Amniocentesis: Amniocentesis involves extracting and examining DNA and chromosomes from the amniotic sac surrounding the fetus in order to determine if the baby has a chromosomal disorder. In rare occasions, the woman may experience infection as a result of the procedure or even more severe complications that may lead to miscarriage. It has been estimated that amniocentesis may raise the risk of miscarriage by 0.5%. Amniocentesis is usually performed in women where inherited disorders are a concern at 14-20 weeks of pregnancy, although it may be repeated in the third trimester if an obstetrician deems it necessary.

• Chorionic villi sampling (CVS): CVS is the removal of a small piece of placenta tissue (chorionic villi) from the uterus during early pregnancy. It is done screen the baby for genetic defects, such as those that are known to cause Tay-Sachs, sickle-cell anemia, most types of cystic fibrosis, or Down syndrome. However, the procedure is slightly riskier than amniocentesis, with miscarriage as a possible side effect of the test.

Future Research or Applications

• Millennium Development Goal 4: According to the World Health Organization (WHO), reducing infant, neonatal, fetal, and maternal mortality are goals set by many countries and international conferences, such as the United National Special Session on Children (which met in 2002) and the United Nations (UN) Millennium Declaration. The UN's Millennium Development Goal 4 outlines goals for reducing the number of child deaths. It states that the mortality rate for children under five years of age should be reduced to 31 deaths per 1,000 live births. Currently, the rate of neonatal mortality alone is 31 deaths per 1,000 live births. The mortality rate for children under five was 68 deaths of every 1,000 births, according to United Nations Children's Fund (UNICEF).

• Meeting the goals: According to UNICEF, 90 countries should be able to reduce child mortality by two-thirds by 2015. Ninety-one countries are expected to not meet this goal, including those that have seen a rise in mortality, such as the former Soviet Union, Iraq, and sub-Saharan African countries. The biggest threats facing children are malaria and HIV/AIDS, which is expected to orphan 25 million children, most of who live in sub-Saharan Africa.

• Research: Most neonatal and infant deaths occur in developing countries. However, according to some studies, little research is available on the effectiveness of different health programs in these countries. To accomplish the research, countries may need to improve their registration systems, which allows for more comprehensive recording of infant mortality and understanding of the extent of the problem. Of specific concern is neonatal mortality, or death during the first four weeks of life, and fetal mortality, which may be underestimated as much as 40% in some cases.

• Also, neonatal and maternal health is linked and should be jointly considered when addressing child mortality. Educating the public about the extent of the problem and available healthcare options are important steps in reducing child and infant mortality.

• UNICEF's goals: According to UNICEF, newborn, infant, and child mortalities are due in large part to perinatal conditions such as premature birth, birth asphyxia, and neonatal infection. Other causes are malaria, diarrhea, and pneumonia. Lack of immunizations, internal conflict, HIV/AIDS, unsafe drinking water, poor sanitation, and malnutrition all contribute to infant and child mortality. UNICEF has set goals for reduction of infant and child mortality, including increasing vaccinations and continuing successful programs.

• Health and nutrition intervention: UNICEF's goal is to provide vaccinations to 90% of children nationally for every country and 80% at the district level. Global immunization rates are currently at 74%. UNICEF is working toward eradicating polio and making improvements in areas with minimal levels of vaccination and other immunization programs. UNICEF offers nutritional supplement to children and infants. Vitamin A supplements have reduced mortality from diarrhea and measles. By increasing the use of mosquito nets to 60%, UNICEF hopes to reduce malaria deaths, which account for 10% of child deaths in developing countries. UNICEF supports prenatal care programs and promotes breastfeeding to reduce neonatal mortality.

• Family care: UNICEF continues to support family care programs that educate expectant mothers and families about proper infant care. The programs support families in good infant feeding practices, breastfeeding, proper hygiene and sanitation, and feces disposal. UNICEF also supports healthcare workers in community outreach and proper treatment of conditions such as diarrhea and respiratory infections.

• Sanitation: Poor water quality can lead to disease. UNICEF works with governments to improve water quality and sanitation, and promote hygiene. It supports the construction of facilities for sanitation and fresh water.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

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