My original research on infant mortality rate in 2007

Introduction

 In the 21^st century more than 10 million children under 5 years old die each year.  Most of these deaths are from preventable and treatable conditions, and almost all deaths are in poor countries.  Of these 10 million deaths, eight million are infants, half of who are newborns in their first month of life.  A high proportion (40%) of deaths in children under 5 years occur in the first month of life, and 30% during their first week ¹.  Infant and child mortality rates vary among world regions, and these differences are large and increasing.  In 1990, in Sub-Saharan Africa (SSA) there were 180 deaths per 1000 live births, and only 9 deaths per 1000 live births in industrialized countries, that is a 20-fold difference.  In 2000, SSA had a mortality rate of 175 deaths per 1000 children and 6 deaths per 1000 children in industrialized countries, an increase to 29-fold diffrence.²

For the past three decades, significant progress has been made towards the reduction of infant mortality rates in third world countries.  As a result between 1960 and 1993 in the Arab states infant mortality rates declined from 167 to 66 per 1000 live births, in South East Asia from 146 to 42 per 1000 live births, in Latin America from 107 to 45 per 1000 live births, and in SSA from 167 to 97 per 1000 live births.  Although SSA experienced a decline it still retains more than five times the rate for East Asia (excluding China; UNDP, 1996).  Also, in most developing countries mortality rate among children under the age of five years decreased from 243 to less than 100 and once more, SSA lags behind with a rate of 174 per 1000 live births when compared with the Arab States (73 per 1000). ³ At present the high infant mortality rate in SSA are attracting international, national and individual researchers seeking effective and definitive health programs or methodology to implement sustainable measures or solutions towards reduction of infant mortality rates⁴.

Objective

This paper will focus on a SSA country-Nigeria, where there is an urgent need of intervention for reduction of infant mortality rate.  The main objective being two fold: (i) to lay out some determinants of high infant mortality rate in Nigeria within a historical context and (ii) suggest some strategic interventions towards reduction of high infant mortality rate using “theories on change in communities and communal action for change.”⁵

Nigeria and Numbers

Nigeria is the most populous country in the African continent.  It has a population of 140 million people and per capita GDP: $840 (ELCA.org, 2006).   Nigeria is said to be a major contributor to infant mortality rate globally, and also a major contributor to the estimated stillbirths of 32.2 per 1000 deliveries in SSA, which is the highest globally.⁶   In contrast, stillbirth rate in developing countries is 25.5 per 1000 deliveries, and 5.3 per 1000 deliveries for developed countries.  Thus, estimated global total stillbirths is said to be 3.2 million (uncertainty range 2.5-4.1 million), a conservative data.¹ 

In Nigeria the stillbirths for the period in 2005, translates to a crude rate of 158.6 per 1000 deliveries.  This figure is perhaps not unusual for Nigeria, being the fourth largest contributor to global neonatal deaths, at a rate of 247 per 1000 births ⁷.  In 1993 the perinatal mortality rate among teenage mothers in northern Nigeria (Sokoto), was 375 deaths per 1000 live births, making age specific difference in mortality statistically significant in this study⁸.

In 2005 Nigeria infant mortality rate was 98.8 deaths per 1000 live births (CIA Word Factbook).  In “goggle” it is 72.5 deaths per 1000 live births (www.nigeria.com).  And in the country itself in December 2006, News Papers put the figure between 200-300 per 1000 live births.  In spite of the inconsistency in reporting accurate infant mortality rate, it is widely accepted and acknowledged that Nigeria has a high unacceptable infant mortality rate and some scientists even argue that above figures are still underestimated.⁶

There are various epidemiological, programmatic, and cultural reasons for the void in vital statistics in infant mortality rate in Nigeria.  First, counting all births-dead or alive increases the probability of correctly recording all the important outcomes, including livebirths, stillbirths, and early neonatal deaths.  Second, babies who die very soon are less likely to be registered than are older babies who die.  Third, live-born babies who die early might be misclassified for several reasons: lack of information, lack of knowledge, avoidance of extra work, or blame, or audit, ill assessment for signs of life, and cultural reasons of perceived gain or loss for the family¹.

Because of the substantial variations in reporting mortality data, a global initiative is imperative in establishing a definitive measuring tool.  In view of this difficulty and scarcity of timely and accurate vital registration data especially in SSA with high mortality rates, world health organization (WHO) and Global Statistical groups are working on establishing a systematic, transparent, peer-reviewed accessible databases procedure for vital statistics¹.  Nigeria needs such a measure because census, population and statistical data have always been fraught with angst since the country’s inception coupled with its ill-funded health system.

Health care

 Health-care services in Nigeria are inadequate and unevenly distributed.  Obtaining health-care commodities are problematic.  A quarter of the people have no access to a pharmacy.  “Some-

times services have expired products or have run out altogether, probably 90% of reproductive health commodities are imported, supply and distribution is very challenging”, said Dr Arbayeru of  Federal Ministry of Health (FMoH) to Lancet in 2003.  Fewer than half of primary health facilities offer antenatal care, delivery, and postnatal services.  36% of births have no antenatal care and more than half of childbirth are not supervised by skilled attendants. Nigeria has one of the lowest levels of modern family planning use in the world, with contraceptive prevalence rate of less than 10 %.   After many years of mismanagement and military rule, 66% of the population live below the poverty level on less than US $1 a day, only 40% of households have access to portable water, and corruption is endemic⁹.

Nigeria

In 1990 the World Summit for Children pledged each nation to reduce child mortality to below 70 deaths per 1000 livebirths.  As part of the pledge Nigeria FMoH set reproductive health targets for 2006 to reduce infant mortality rate; neonatal morbidity by 30%, maternal mortality and morbidity by 50%, unwanted pregnancies by 50% and sexually transmitted infections by 50%.  Due to inadequate investments in the health system and lack of interventions, regrettably the above reductions were not met.  Funding for such projects has been vulnerable, especially with the US administration’s constant promotion of abstinence-based family planning and IMF insistence on third world countries cut social services in order to repay dept of 40 years in the past.  Increasing levels of foreign debt are associated with substantial excess mortality burden, and, without addressing high levels of foreign debt it may be difficult to improve child mortality across SSA (Mogford L).

In 2002 as part of the UN millennium development goals (MDGs-4), nations pledged a two-thirds reduction in child mortality by 2015, so in December 2006, the Federal Education Commission (FEC) of Nigeria approved 60 billion niara (approximately $60 million) to reduce infant and mother mortality rates in the country by two-thirds by 2015.  The money has not yet been utilized due to disagreements among states (ethnic groups) on plan of action.   Such is Nigeria’s dilemma, for equitable division of resources and power, due to the fact that population, census and data collection has been complicated and contentious in the country.   As is widely accepted population size and composition is an important asset as resource for development, and has far reaching implications for change and progress, thus a prime beneficiary for quality of life in any society.¹⁰

Historical trends

To understand the lack of accurate vital data for statistical usage in Nigeria is to understand that Nigeria distrusts itself due to its composition and formation.  The map of Nigeria is a product of the continent (Africa) redrawing during the precolonial period (Berlin Conference, 1847).  This brought about different tribes with different identities and cultures being grouped together.  So in light of the country’s 250 ethnic groups (4 dominant and politically influential ones; Hausa and Fulani 29%, Yoruba 21%, Igbo (Ibo) 18%)¹⁰ with their own languages and cultures, population has been a rather sensitive issue because of its implications for shaping regional, state and tribal relations and balance of power.

This has been responsible for the chequered history and census controversies the country has been associated with previously (PAN, 1990; Ottong JG, 1983).  “It is however salutary to note that the phenomenon now appears to be a thing of the past, especially with the successful conduct of the 1991 census”.   However, population growth, balance of power and distribution of resources between state and ethnic groups is influenced by the interplay of three main demographic processes of fertility, mortality (infant and maternal) and migration that inevitably affects vital statistics.¹⁰

Determinants of Infant Morality rate

Infant mortality rate is an accepted global indicator of the health and socioeconomic status of a given population (WHO; 1981, 1990).  Neonatal health is said to be dependent on healthcare services, and postneonatal health is dependent on environmental factors.  Hence, a high infant mortality rate is an indicator of unmet health care needs and unfavorable environmental factors.¹¹ Even though there is a dearth of information regarding direct causes of neonatal deaths in SSA, it is estimated that 29% are caused by birth asphyxia, 24% by severe infections, 24% by complications of prematurity, and 7% by tetanus.²    

A five-year retrospective study of childhood mortality (n = 12,522) at the University College Hospital, Ibadan found that neonatal deaths accounted for 50.8% of the total number of deaths and were preventable.  The leading causes of death were neonatal tetanus, prematurity/low birth weight, neonatal septicaemia, severe birth asphyxia, meningitis, severe malaria, pneumonia, severe malnutrition and measles.¹²  

Another 4-year study of pediatric deaths in the University of Calabar Teaching Hospital observed that newborns accounted for 47% of the deaths. Major causes of death were: tetanus, low birthweight and birth asphyxia in the newborn; malnutrition, pneumonia and measles in the pre-school age children.  Neonatal tetanus and malnutrition were leading causes in the overall mortality rate.¹³

In a prospective study in a rural community in southwestern Nigeria, population 3,308, infant mortality rate resulted in neonatal death rate accounting for 55.1% of all infant deaths, while postneonatal deaths accounted for 44.9% of the deaths.  44.4% of all neonatal deaths occurred within 24 hours of delivery while 74.1% of all neonatal deaths occurred in the first week of life and were perinatal deaths.  In the study significantly more deaths occurred during the rainy season than in the dry season, suggesting environmental factors play a role in neonatal deaths.  The commonest cause of death in the neonatal period was due to complications of low birth weight, while in the postnatal period it was due to infection.¹¹

Hence, the high infant morality rate in Nigeria is systemic and endemic stemming from exposure of certain environmental risk factors in contextual sites (household and community levels) in which mothers are forced to give birth and raise their children².  From the literature review infections (environmental factors), low birthweight-prematurity, birth asphyxia, tetanus and malnutrition were leading factors of infant mortality rate, indicating an urgent need for efficient prenatal care and public health services in the country.  

The root causes of persistent high infant mortality rate in developing countries have been explored.  Caldwell (1979) described a model, “the classical determinant” of childhood mortality.  He suggested that maternal education is the most significant determinant in child survival rates.  In other words there is a direct relationship between child survival and mothers’ education.  “The pathways by which maternal education enhances child survival are interwoven with decisions and actions mothers take in health situations as their educational qualifications improve” (Caldwell & Caldwell, 1988).   Consequently, the relationship between maternal education and child survival was advocated as a strategy and a measure to reduce infant morbidity and mortality rate. 

The problem with the above findings is that, in SSA it failed to materialize.  There was no observed strong correlation between maternal education and child survival in SSA.  At best the relationship was weak.  An increasing number of surveys began to reveal inconsistencies in the relationship between mothers’ education and childhood mortality rates  (Stewart & Sommerfelt, 1991), indicating that mother’s educational status yields no advantage in reducing infant mortality rate.  In addition, studies by UN and the World Bank stated that “the role of maternal education in child survival is least striking in SSA.   The impact of mother’s education has not been found to be statistically significant for infant mortality in some of the research projects conducted in SSA in the 1980s and 1990s.  Some scholars found contradictory relationships between child survival and mother’s education (Federal Office of Statistics (FOS), Nigeria, 1990; Sandifford et al., 1997; UNICEF, 1994).  

The irony out of the above contradictory findings between mothers’ education and child mortality were evidence of environmental conditions; lack of clean water, lack of portable water, poor hygiene and health care services and possession index under which children are reared (Cleland & van Ginneken, 1988; Defo, 1996).  In areas where living conditions are lowest, infant mortality rate were found to “peak” (Millard, Ferguson & Khalia, 1990).  Environmental or behavioral risk factors such as poor sanitation, insufficient waste disposal; poor domestic and human waste disposal, streams polluted with human wastes, an open toilet system, bushes littered with domestic wastes, no water drainage system (breeding grounds for mosquitoes), overcrowding in homes,  poor basic health facilities or no breastfeeding in infancy leads to increased exposure to infections. Such synergisms are leading risk factors of high infant mortality rate.

 Current theoretical perspectives suggest embracing an ecological perspective in other to understand the complexities behind child survival.^2,3   Researchers are stressing the impact of environment on child survival which has uped the ante in the face of the on-going economic crises in many African countries whereby cities, towns and villages are not able to maintain basic social amenities such as safe water supply and sanitation for the increasing population.  As the government acknowledged, “Nigeria would have to double its entire infrastructure for food production, health services, education, water supply, housing, energy, and services just to maintain today’s low standard of living.”

Intervention strategy

Mosley and Chen (1984) identified determinants that directly increase the risks of infant mortality and morbidity to include maternal factors, environmental conditions and nutrient deficiency.  These factors are physical and socio-cultural.  They are also associated with the community, regional ecology and household environmental characteristics.  If the ecological hypothesis³ of infant mortality rate in SSA is the exposure of infants to certain environmental risk factors and susceptibility to infectious diseases in households and surrounding communities in which mothers are forced to bring their babies into this world, then it is incumbent on the nation as a whole to significantly improve the said environment towards reduction of infant mortality rate. 

Nigeria needs thorough epidemiological information to plan and implement public health interventions.  The importance of public health interventions in improving infant survival has been confirmed with studies in developing countries (Muhuri PK).  There are multiple ways for Nigeria to improve infant survival.  A reduction in the aforementioned environmental risk factors will surely reduce babies dying from infections. Improving household sanitation and personal hygiene will improve infant survival.  Provision of public toilets, safe water, primary health care centers and health education will add to the improvement of health status in the country. 

The health policy should include increase coverage with appropriate services for prenatal care, increase number of midwives and obstetric staff to include traditional birthing attendants, repeated in-service training of existing staff in maternity and prenatal issues and problems, strengthening community services, culture-specific educational approaches using existing value system, educational campaigns to discourage harmful practices and behavior and incorporate native customs into government programs.  Post trained midwives in villages to attend to home deliveries, detect and manage infant and mother complications at onset and accompany patients requiring referral for higher-level of care to hospitals.  Immunization of children and their mothers in addition to nutrition and breastfeeding education will reduce neonatal risk factors that lead to death.  Interventions must be done through a participatory community organization and community building based strategy.

 Proposed Intervention: a three-year plan in 3 strategic phases [a pyramid format]

Phase 1:  Health Education Fair in a sample town- Nnewi in Eastern region of Nigeria

The town met all inclusion criteria. Fair conducted in churches, town halls, market places and hosted by individuals with big homes-compounds. 

8 by 11 flyer will include: babies pictures, [in native languages]

Traditional practices of reproductive health; breastfeeding picture, spacing children every 2 to 3 years, mother visiting midwife-doctor in a hospital for care.

Basic hygiene; drink clean water, wash hands, bed with mosquito nets, no littering of domestic waste, do not use open toilet.

Prenatal care: signs of pregnancy or stomach discomfort go to the doctor-Midwife.  pregnant woman eating fruits/vegetables-good nutrition.  Immunization education.

Fair to be done once a month for a12 month period.

Phase 2:  Training medical staff  -to begin 6 months after phase I began.

                Train doctors-midwives-traditional birthing attendants in prenatal care and hygiene.

                 Repeat training every 3 months. Evaluate training with a mock pregnancy event.

Train community- by holding training sessions in churches, town halls, and individual            compounds. Community training includes basic hygiene and clean environment.

                 Training to last for a 12-month period

    

 Phase 3:  Policy Formation – to begin 12 months after phase 1

Management team (physicians, public health officials, policy makers, scholars) from        state level to supervise, monitor and evaluate by collecting data.

Government to build-rebuild infrastructure; better sanitation system, sewage system, institute waste management, furnish hospitals and pharmacies with tools to function.

NGO and private grantors and donors represented.

Program to be evaluated every year and fine tuned seeking the ultimate goal of reduction in infant morality rate, thus may be implemented nation wide. 

Conclusion

 It is of interest to note that in the 21^st century, we are able to transport man to the moon and stay for days, we are able to do stem cell research for diseases, and we are able to sequence the human genome, yet we seem incapable of counting infant mortality rate in developing countries. “The health status of populations in developing countries will never be understood until the void in vital statistics is addressed”.   Some suggest that better counting of infant mortality rate and improved cause of death rate are means to advocate and prioritise policy action.   Infant survival should be a major policy goal for Nigeria, because of the multiple short-term and long-term effects on human and economic development for the progress of a society.   A global initiative is imperative in the wider context of the required progress towards relevant Millennium Development Goals (MDGs) for SSA by 2015.

REFERENCE:

1. Stanton C, Lawn JE, Rahman H, Wilczynska-Ketende K, Hill K. Stillbirth rates: delivering estimates in 190 countries. Lancet 2006; 367:1487-94.

2. Black RE, Morris SS, Bryce J, Where and why are 10 million children dying every year? Lancet. 2003; 361: 2226- 2234.

3. Folasade IB. Environmental factors, situation of women and child mortality in southwestern Nigeria. Social Science & Medicine 51 (2000) 1473-1489 [Dept of Pan African Studies, University of Louisville, Louisville, KY 40292, USA].

4. Bulletin World Health Organization v.81 n.3 Genebra 2003.  WHO 2006 Neonatal and Perinatal Mortality Country, Regional and Global Estimates. Adebayo SB & Fahrmeir L. Analyzing child mortality in Nigeria with geoadditive discrete-time survival models. Statistics in Medicine 2005; 24:709-728. Black RE, Morris SS, Bryce J, Where and why are 10 million children dying every year? Lancet 2003; 361:2226-2234.

5. Nutbeam D & Harris E. Theory in a Nutshell, Apractical guide to health promotion theories. 2^nd Edition, The McGraw-Hill Australia Pty Ltd. 2004.

6.  Bolajoko O Olusannya, Olumuyiwa A Solanke, Angela A Okolo. Institute of Child Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria (BOO); Institute of Child Health and Great Ormond Street Hospital for Children NHS Trust, University College London, 30 Guilford Street, London WC1N 1EH, UK (BOO); Lagos Island Maternity Hospital, Lagos, Nigeria (OAS); and Department of Pediatrics and Community Child Health, University of Benin Teaching Hospital, Benin City, Nigeria (AAO).

7. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891-900.

8. Akpala CO. Perinatal mortality in northern Nigeria rural community. Journal of Royal Society for the Promotion of Health. 1993; 113(3): 124-7.

9. Roberts H. Reproductive health struggles in Nigeria. Lancet 2003; 361 p. 1966.

10. http://www.nigeria-planet.com/population-of-nigeria.html

11. Lawoyin TO, Risk factors for infant mortality in a rural community in Nigeria. The Journal of The Royal Society for the Promotion of Health. 2001; 121(2): 114-118.

12. Ayoola OO et al, A five-year review of childhood mortality at the University College Hospital, Ibadan, Nigeria. West Africa Journal of Med. 2005; 24(2): 175-9.

13. Asindi AA, Ibia EO, Udo JJ. Mortality pattern among Nigerian children in the 1980s. Journal of Tropical Medical hygiene. 1991; 94(3): 152-5.

14. Save the Children. http://www.savethechildren.org/mothers/newborn  (accessed 3/14/07

15. ECLA.org; Evangelical Lutheran Church in America, 2007 (www.ecla.org )

16. Pradip K. Muhuri. Health Programs, Maternal Education and Differential Child Mortality in Matlab, Bangladesh. Population and Development Review, vol. 21, 1995.

17. Mogford, L. Structural determinants of child mortality in sub-Saharan Africa: A cross-national study of economic and social influences from 1970 to 1997. Social Biology.  2004; 51(3-4): 94-120.

                                                University of California Los Angeles

                                  SCHOOL OF PUBLIC HEALTH-MPH           

                                           COMMUNITY HEALTH SCIENCES 100

                                      Winter Quarter 2007- Dr. Bonnie Taub

            Infant Mortality Rate in Nigeria

“Is the life of a child worth less to those with political

 power than the life of a child in a high-income country?”

   Final project

          By

                                Mukosolu N.C. Onwughalu- March 16, 2007