Community-Based Participatory Research Addressing Infant Mortality
STEVEN S. COUGHLIN, PHD AND SELINA A. SMITH, PHD, MDIV
This chapter considers community-based participatory research (CBPR) aimed at reducing infant mortality and improving maternal and child health. The topics discussed include global disparities in infant mortality, risk factors for infant mortality, and evidence-based approaches for preventing infant mortality in low- and middle-income countries and in higher-income countries such as the United States. The role of CBPR in addressing infant mortality is highlighted, including CBPR studies conducted in the United States that addressed infant mortality and closely related maternal and newborn health topics (e.g., smoking during pregnancy) that had a randomized controlled trial, quasi-experimental, or pre/post test design. Participatory studies conducted in developing countries are also considered. Additional CBPR studies are needed that have the potential to fill in gaps in the current evidence about what intervention strategies are effective in reducing infant mortality in population subgroups that are disproportionately affected by it. This includes dissemination and implementation research and studies that translate evidence-based interventions to new populations identified by age, race, ethnicity, culture, nativity, or geographic locality. In addition, participatory action cluster randomized controlled trials of women’s group interventions should be extended to additional low-resource, rural settings in sub-Saharan Africa and Latin America, as existing studies have primarily been conducted in Asia.
The infant mortality rate, an estimate of the number of infant deaths for every 1,000 live births, has long been recognized as a key indicator of the health and well-being of a nation or community. There is substantial international variation in infant mortality rates. In developed countries, infant mortality rates declined rapidly during the 1970s due to medical advances such as neonatal intensive care units for premature or seriously ill newborn infants.
About 98% of the almost 4 million deaths that occur each year among newborns during the first month of life occur in developing countries.1 The highest neonatal mortality rates occur in sub-Saharan Africa followed by Asia and Latin America.2
In countries that have the highest rates, almost 10% of infants die within the first month. Globally, most deaths of infants and children under the age of 5 occur at home, without any contact with the formal health system.3 Several factors contribute to high newborn mortality, including poverty, poor maternal reproductive health and nutrition, HIV/AIDS, infections (e.g., bacterial sepsis), low-quality delivery or antenatal care, lack of skilled attendance at birth, and lack of postnatal care.4 In regions such as sub-Saharan Africa, most births occur at home due to the inaccessibility or absence of care.
Countries with the lowest infant mortality rates include developed countries such as Iceland, Sweden, Finland, Japan, Greece, Norway, and the Czech Republic (2.5-2.8 per 1,000 live births). In 2011, the United States had a higher infant mortality rate (6.6 per 1,000 live births) than 27 other countries. Despite the frequent provision of risk-appropriate care (i.e., level III facilities) in the United States, preterm births are a major contributor to the country’s poor international ranking among developed countries. Substantial variation in infant mortality rates also occur within countries. In the United States, for example, the highest rates occur in Mississippi and Alabama.5 More than 50% of infant deaths occur among infants with gestation of 32 weeks or less.
The most prevalent causes of infant mortality include birth defects, preterm birth (i.e., birth before 37 weeks gestation), low birth weight, maternal complications of pregnancy, infection, sudden infant death syndrome (SIDS), and unintentional injuries such as suffocation. Lack of access to appropriate healthcare is also a risk factor for infant mortality, especially during the neonatal period (< 28 days). Other risk factors for infant mortality identified in epidemiologic studies include lower socioeconomic status, lower educational attainment, and decreased access to prenatal care or underutilization of prenatal care services. Preventable causes of preterm birth and low birth weight include maternal smoking and illicit drug use. Maternal stress and racism may also contribute to poor birth outcomes.6-7 In the United States, the infant mortality rate among African Americans is over twice the rate for Whites. The infant mortality rate is also higher among American Indians and Alaska Natives than for Whites.8 Research conducted in developing countries has shown that intense indoor air pollution from cooking in poorly ventilated homes is associated with neonatal death.9