Amy N. Balbierz

Infant Mortality

            Infant Mortality is a global public health issue.  Highly preventable deaths are occurring in the Third World, United States, and locally in Cleveland, Ohio.  The root of infant mortality is the uneven distribution of resources or lack of resources.  In essence, like the old African Proverb states, “It takes a Village to Raise a Child,” “children will thrive only if their families thrive and if the whole society cares enough to provide for them” [6].  Infants are the faces of the future.  The infant survival rate measures quality of life.  Society cannot change the poverty over the mother’s 9-month pregnancy however; public health policy can change the pregnancy outcomes.

Infant survival rate increases with the completion of each trimester (1st, 2nd, & 3rd trimesters).  Gestation is classified into three categories:  preterm (less than 37 weeks of gestation), term (37-41 weeks), and post-term (42 weeks or more) [12]. A live birth is defined as, “the complete expulsion/ extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, that, after separation, breathes or shows any evidence of life, such as beating of the heart, pulsation of the umbilical cord, movement of the voluntary muscles whether or not the umbilical cord is cut” [12].  Advances in medical technology increased the survival rate of those infants weighing less than 750 grams or 1pound 10.5 ounces [12]. The PMR, or the Perinatal Mortality Rate is defined by the National Center for Health Statistics as the number of late fetal deaths (fetal deaths of 28weeks or more gestation) plus early neonatal deaths  (deaths of infants 0 to 6days of age) per 1,000 live births plus fetal deaths [12]. 

The most current public release by the Centers for Disease Control, National Vital Statistics Reports, January 24, 2005 enumerates why the U.S. infant mortality rate increased slightly from 6.8 infant deaths per 1,000 live births in 2001 to 7.0 in 2002 [12].  Historically, the IMR has declined throughout the 21st century however the majority of the increase in babies weighing less than 750 grams were Non-Hispanic white, non-Hispanic black, and Hispanic descent, their mothers were ages 20-34 years of age, and were mostly single births [12].  American Indian mothers were the only exception to the increase in Infant Mortality from 2001 to 2002 [12].  The only statistically significant increase in death rate occurred among African American women [12].  There are many factors that contribute to the increase in infant mortality from 2001-2002.

The main predictor of an infant’s chances for survival is birth weight.  In 2002, the United States had the highest proportion of births weighing in the range of 500 to 750 grams.  Babies weighing 500-750g at birth have a lower survival rate.  In fact, from 2001 to 2002, babies weighing less than 750grams composed 81% of the observed total increase in infant mortality [12].

The root of disparity in World Health Care is an imbalance of resources.  The inequality of distribution harvests the world’s heath state.  The multi-faceted causes of mortality are as diverse as the kaleidoscope of people that it affects.  The infant mortality rate varies tremendously among less developed nations [8].  Frey and Field enumerate five macro-social change theories that can explain the variation of infant mortality across less developed countries: modernization theory, dependency/ world-systems theory, gender stratification theory, economic disarticulation theory, and developmental theory [8].  Rarely have these five theories been examined simultaneously (215).  The main goal of “The Determinants of Infant Mortality in the Less Developed Countries: A Cross-National Test of Five Theories” is to evaluate which of the five theories work or do not work in an additive fashion.

Infancy factors were measured by the nation’s ratings:  industrialization, female education, economic stability, and its comparison to a control variable (Sub-Saharan African countries) [8].  This paper indicated that certain theories are supported while others are rejected as predictors of poor health outcomes.  The paper’s results indicated that while certain theories support poor health outcomes while other certain theories do not. 

Industrialized nations, in particular the United States, have a warped sense of world poverty.  Yes, poverty exists in our nation, our town, and our street.  However, poverty also occurs in Third World countries.  A different type of poverty exists in these countries that is not as prevalent in the United States: complete and total lack of food and water.  In most instances, starvation can and is prevented by industrialized nations.  However, the major causes of infant mortality in less developed nations are easily prevented or cured: diarrhea, acute respiratory disease, measles, tetanus, and malaria.  In the last thirty years, infant deaths due to these causes has declined yet these rates are still considered high and tend to fluctuate between countries [8].

The modernization theory supports the belief that industrialization reduces infant mortality through increased economic output [8].  “Economic growth fosters improvements in education, housing, nutrition, health care, sanitation, and various public services that reduce infant mortality” [8].  When the economy is on the rise, morale and energy are positive.  Positive energy translates into healthy mothers and healthy babies. A strong modernized economy creates jobs while boosting morale.

Counter to the modernization theory is the dependency/world systems theory.  The dependence/ world-systems theory argues that as the dependent country extracts goods from the alpha country the dependent country keeps losing while the alpha country keeps winning [8].  “Dependent relations between countries are thought to retard human well-being in the dependent countries because dependent relations promote resource and surplus extraction that could otherwise be invested in economic growth and public programs designed to increase human well-being” [8]. This give and take relationship is a tug of war between the “haves” and “have nots”.  The rich win while the poor countries lose.  The dependency/ world systems theory is grounded on exploiting the periphery poor countries by the core-industrialized nations [8].

One of the most convincing theories is the gender stratification theory.  As the female gender is appreciated, so is her role as a mother.  Female education is one of the most important ways of reducing infant and child mortality [8].  “Educated mothers are more likely to seek health care for their children; a literate mother is more likely to be able to communicate with health care providers, and female education has positive effects on the balance of family relationships regarding child care” [8].  Educated mothers tend to have a higher self-esteem than uneducated mothers that triggers healthy outcomes and healthy babies [8].

The economic disarticulation theory is the idea that a country’s disarray is based upon the disjointed economy and the uneven development [8].  Public funds are channeled away from humanitarian efforts [8].  “In effect, economic disarticulation reduces human well-being and increases infant mortality because of economic stagnation and the unequal nature of the economic development that accompanies economic disarticulation [8].  The influx in the state of the economy creates strain between the rich and the poor.  The rich get richer and the poor get poorer. 

The final theory in question is the developmental state theory.  Developed eveloped nations share the wealth of their development [8].  Developed states increase human well-being: “they engage in redistributive efforts (such as the provision of educational, public health, and other services) that meet the basic needs of the poor” [8].  A strong foundation increases human well-being and positive life outcomes [8].  Frey and Field studies the existence/non-existence of these five theories in fifty-nine low and middle-income countries. Industrial employment, economic dependence, gender equality, economic disarticulation, and state strength [8].  These variables were documented over a 15-year span to assess the long-term consequences on infant mortality [8].

The most supported finding was that the status of the Sub-Saharan African countries are directly linked to infant mortality rates [8].  There is no clear reasoning to this fact.   However, one thought is that the environment has a negative force on infant mortality [8].  “Resource degradation, pollution, climatic factors can adversely affect human health” [8].  The harsh climate tends to increase the odds of contracting malaria and other diseases [8].  In addition, Africa has a history of civil war and slavery [8].  Many civilian casualties are infants.  Warfare deaths are relatively modest over a long period of time, however warfare creates peaks in high mortality [10].  Malnutrition and communicable diseases are spread by war.  Infants are at a higher mortality risk due to a weakened immune system [10].  This strife and animosity will not dissolve over night.  Rather, Sub Saharan Africa rebuilding will take time.

The authors, Frey and Field concluded that Sub-Saharan African countries are in the most need of assistance [8].  “Policies promoting economic “rearticulation” and female education and reductions in foreign debt are the types of policies that are likely to result in the greatest reductions in infant mortality in the less developed countries” [8].  Today, the majority of infant deaths are centered in South Asia and Sub-Saharan Africa. The investment in basic health systems has put a dent in the high infant mortality rate centered in South Asia and Sub-Saharan Africa.  The 2000 statistics are staggering: 2.4 million children dying in India, half of 10.8 million estimated deaths of children under the age of 5 Nigeria, China, Pakistan, Democratic Republic of Congo, and Ethiopia [19].

However, the spread of disease has tapered off since the 1970’s.  In the 1970’s roughly only 15% of the world’s population was vaccinated [17].  Vaccinations are crucial in disease prevention.  Vaccinations help build the body’s immune response to ward off such communicable diseases as polio and rubella.  UNICEF has made tremendous strides to contain and prevent the spread of disease.  UNICEF developed a network of vaccine refrigerators and trained health care workers that were strategically placed in disease stricken areas of developing countries [17].  Although UNICEF and other non-profit organizations have made heroic efforts, another 500,000 lives yearly could be saved by the administration of the Hepatitis B vaccine and the measles vaccine [17]. 

There are several elemental methods at decreasing the world infant mortality rate.  First, the promotion of exclusive breastfeeding for the first six months of life [17].  Lactating mothers give anti-bodies to their infants via breast milk.  When a baby is supplemented with tap water, the water oftentimes is contaminated due to a lack of a sanitation system.  Unclean water increases the infant’s risk of infection and diarrhea [17] Diarrhea leads to dehydration, which can lead to possible death [17]. 

Second, the sleeping under the protection of insecticide sprayed nets will keep the malaria carrying mosquitoes and other contagious insects at bay.  These nets are not expensive; the cost is roughly $5.00.  Yet, in developing countries, $5.00 is a large % of their gross income [17].  Another regulation is to make sure that the infants and children are indeed screened in and that it is just not the adult population that is benefiting from the protective netting [17].  The goal of these nets is the protection of sleeping infants from contractile diseases.  Thirdly, building immunity via well care, vitamin and zinc supplements, sanitation of public and private locations, and administering anti-biotics [17].  Prenatal care and postnatal care are crucial in an infant’s development and maturation.

In order to instill breastfeeding, vaccinations, nutrition, and anti-viral drugs the health promotion movement has to be supported by the community it serves.  Underdeveloped nations must be embraced by effective educational and medical training.  Health care workers must teach the healing side of medicine and the promotion of healthy outcomes while not posing a threat to the audience.  The underprivileged must gain trust in order to take heed of the medical institution’s instructions.  But, in Tanzania we found that if we found that if we could treat just a single child, that child’s ‘miraculous’ recovery set an example for the whole community and soon mothers were willingly bringing their children to the health care workers.” [17]. As seen in Tanzania, it takes small steps to bridge the gap between the served and underserved.

As in all things that are valuable and worth waiting for, medical relief will take large sums of money and volunteer efforts.  The ceasing of infant mortality will not be attained overnight.  However when one ponders the thought that the United States and Europe combined spend 17 billion annually on pet food funding infant and child health does not seem as an enormous feet.  These “simple” interventions are estimated at 1 billion for vaccines, $2.5 billion for malaria prevention and 4 billion for basic treatment of childhood illness [17].

The Academy for Educational Development, AED, is an organization making strides in combating infant and maternal mortality.  The vitals indicate that 80 newborns die in Mali everyday and that a Mali woman dies every three hours due to pregnancy or labor [1].   The AED has created a 20-person team comprised of a mid-wife, pediatrician, statistician, economist, sociologist, and educator [1].  This advocacy model reviews and evaluates local and international surveys, studies, and reports and then gives feedback on the resulting lives lost and the loss of economic stability (Academy for Educational Development).  The AED’s “Reduce” advocacy model and the “Alive” model are trying to stop the estimated deaths of 34,000 mothers and 340,000 newborns in the next 12 years [1]. 

The key factors of the “Reduce” advocacy model are that mothers wait too long to seek help.  The major delays that lead to dying during labor and delivery are: 1. The delay on the part of the mother, family, and community in recognizing threatening conditions, 2. The delay in reaching a health care facility due to lack of transportation, 3. The delay on receiving appropriate and adequate medical treatment on arrival to the hospital/clinic [1].

 The key factors of the “Alive” model are a sterile birth environment and correct neonatal measures to instill healthy outcomes.  The key points to increasing newborn vitality are: 1. Ensure a clean delivery and appropriate cutting of the umbilical cord, 2.  Pat dry the fluids from the infant’s body and wrap the infant in blankets immediately upon delivery, and 3.  Initiate breastfeeding lessons as soon after birth as possible [1].  The mother’s mammary glands first secrete colostrums.  Colostrum is rich in anti-bodies that will help build the infant’s immune system.  In addition, breast milk keeps the infant’s internal body temperature stable [1].

The World Health Organization deciphers the World Infant Mortality Rate into the following regions:  Africa, The America’s, Eastern Mediterranean, Europe, South East Asia, and the Western Pacific [9].  A closer look at the highest and lowest 5 infant mortalities from each of these regions is extracted below.

Infant and Under 5 Mortality Rates by WHO. Year 2000. [9]

IMR=Infant Mortality Rate (number of deaths among infants*1000/live births)

Africa

 

 

 

Country

Highest IMR

Country

Lowest IMR

Angola

261.5

Seychelles

11.1

Sierra Leone

257.7

Mauritius

13.4

Niger

239.0

Cape Verde

35.3

Liberia

231.1

Algeria

35.7

Mali

204.8

Botswana

58.6

The Americas

 

 

 

Country

Highest IMR

Country

Lowest IMR

Haiti

88.9

Canada

4.6

Bolivia

66.4

Cuba

7.5

Guyana

45.2

***U.S.A

7.5

Dominican Republic

41.1

Bahamas

8.3

Guatemala

38.5

Chile

8.5

Eastern Mediterranean

 

 

 

Country

Highest IMR

Country

Lowest IMR

Afghanistan

176.2

Bahrain

5.6

Somalia

157.1

Cyprus

6.4

Djibouti

138.2

Kuwait

7.7

Sudan

107.2

United Arab Emirates

9.3

Iraq

102.6

Qatar

13.2

Europe

 

 

 

Country

Highest IMR

Country

Lowest IMR

Azerbaijan

78.3

Sweden

2.4

Tajikistan

74.8

Luxembourg

3.2

Kyrgyzstan

54.4

Finland

3.2

Turkmenistan

52.3

Czech Republic

3.4

Kazakhstan

40.5

Norway

3.5

South-East Asia

 

 

 

Country

Highest IMR

Country

Lowest IMR

Myanmar

111.5

Sri Lanka

15.3

Nepal

85.9

Democratic People’s Republic of Korea

33.1

Bangladesh

76.6

Thailand

35.8

India

76.2

Maldives

38.3

Bhutan

68.3

Indonesia

39.5

Western Pacific

 

 

 

Country

Highest IMR

Country

Lowest IMR

Cambodia

137.2

Singapore

2.6

Lao People’s Democratic Republic

105.8

Japan

3.4

Papua New Guinea

73.7

New Zealand

4.9

Solomon Islands

65.9

Australia

5.0

Kiribati

60.5

Republic of Korea

5.6

 

There is quite a gradation in country infant mortality rates.  The lowest infant mortality is not dependent on a country’s wealth.  Rather, the lowest percentage of deaths per every 1,000 live births is clustered in the Northern Europe and the Western Pacific.  The lowest infant mortality rates in the world are held by Sweden (2.4%) and Singapore (2.6%).

            How does the U.S.A. compare?  Although reliable data for 2003 and 2004 are not available yet, in 2002, roughly 7 babies died for every 1,000 live births [11].  Then why does the United States, known as the richest and most powerful country in the world, have twice the IMR seen in Sweden and Japan?  Furthermore, according to the CIA World Factbook, Cuba is one of 41 countries that have a better infant mortality rate than the United States [11].  The higher prevalence of death in the United States than in some 3rd world countries is an indicator that wealth does not predict survival rate.

            The spike in the 2002 IMR might be a single blip on the radar screen or on the other hand a predictor of rates to come.  Either scenario indicates that there are more areas for improvement on the horizon.  According to Sandy Smith, from the Centers for Disease Control, statisticians are confident that there was not further decline in the IMR but rather a decrease in rate or a leveling off at a higher IMR [11].  Again, the accurate decision is too soon to call.

            Beyond the numbers or the potential cyclic infant mortality pattern, the moral of the story is how to improve the United State’s humanitarian effort.  The truth is, everyday an average of 77 babies die in the United States and one woman dies in childbirth [11].  These statistics are grim.  The worst part is, “America’s children are at greater risk than they’ve been in for at least a decade,” said Dr. Irwin Redlener, associate dean of the Mailman School of Public Health at Columbia University and President of the Children’s Health Fund [11].  Today’s children are tomorrow’s leaders, researchers, doctors, and teachers.  It is essential that today’s teachers confront the ailing situation.

            Infant Mortality does not have a quick fix.  Public Health issues, including infant mortality, are compounded by poverty.  The right and left politicians agree that there is not an easy solution to poverty [1].  Its simple to point the finger to those on welfare, government assistance, and even the homeless as those “subgroups” where death dominates.  Yes, the poverty level does aggravate the IMR but the mortality rate does not discriminate to one class of people in particular. Rather, infant death can be documented in all income levels and rural and urban areas.  In 2004, the Institute of Medicine, a branch of the National Academy of Sciences, “estimated that a lack of health insurance coverage causes 18,000 unnecessary deaths a year” [11].  These numbers are preventable.

            Community influences the prevalence of infant mortality.  An infant’s death is a measure of a community’s overall social and economic well being [2].  If the neighborhood structure is not sound then the infant vitality crumbles.  In order to strike out infant mortality, the infant needs a supportive team composed of family, community, and governmental agencies.  An example of a Public Health Strategy that evaluates the community involvement or lack thereof is the Fetal and Infant Mortality Review [2].  The FIMR case review team is composed of health, social service, and other infant mortality experts.  The review team examines case summaries, charts and conducts interviews.  Depending on the team’s evaluation of the data and either does or does not recommend proper community action. 

The goal of FIMR interventions is to improve future family’s outcomes.  The FIMR process is coined  “The Cycle of Improvement”.  There are four turns in the circle: 1. Data Gathering, 2. Case Review, 3. Community Action, and 4. Changes in Community Systems.  On the national level, the National Fetal and Infant Mortality Review (NFIMR) Program, addresses FIMR issues and provides a resource center that lends advice on implementation of infant review methods [2].  NFIMR is collaboration between the Federal and Maternal and Child Health Bureau and the American College of Obstetricians and Gynecologists.  The NFIMR issues addressed include:  confidentiality, liability, data collection, home interview techniques, coalition building, taking recommendations to action, coordination with other local mortality reviews, and local FIMR assessment [2].

            Another public health organization is the office of Disease Prevention and Human Promotion is a key benefactor in the Healthy People 2010 initiative.  The year 2010 is the proposed year to achieve 28 specific focus areas.  A comprehensive set of disease prevention and health promotions objectives, Healthy People 2010, hopes to instill in all Americans.  A diverse group of diverse scientists established Healthy People 2010, in order to increase quality and quantity of healthy years of life and to eliminate health disparities [15].  One of the focus areas is Maternal, Infant, and Child Health.  By the year 2010, the goal is to eliminate the disparities among racial and ethnic groups with infant mortality levels above the national level [15].

            The leading causes of infant death in the United States include the following: birth defects, prematurity/low birth weight, sudden infant death syndrome, maternal complications of pregnancy and respiratory distress syndrome [13].

            In the state of Ohio, uninsured mothers are eligible for free prenatal care.  Compared to the average national rates, Ohio’s uninsured rates for mother and child were a little lower (Ohio Children 9% vs. U.S.Children 12.5% and Ohio Women 14.3% vs. U.S. Women 18.3%) [13].  State and federal grant money subsidizes prenatal care. 

            Ohioans receive aid from Medicaid as well as the State Children’s Health Insurance Program (S-CHIP).  The State Children’s Health Insurance Program maybe used by the state’s choice.  Secondly, Title V Block Grants underwrite women of childbearing age, infants, and children with special needs [13].  Title V consists of block grants allocated to city, state, and local agencies.  For instance, the federal government funded the research of 15 cities including Cleveland, Ohio, to study how to decrease the IMR by 50% in 5 years [3].  Locally, Healthy Family/ Healthy Start is a federally funded program.

            Cindie Carroll-Pankhurst, PhD, MPA, a maternal and child health specialist in Cuyahoga County, along with the Child Death Review Committee have led the continuing examination of the causes and circumstances leading to deaths of Cleveland children [3].  The Child Death Review Committee is a multidisciplinary interagency composed of physicians, the county coroner’s office, social workers, child protective services, prosecutors, and hospitals [5].  With compliance of The Cuyahoga county coroner, as well as the Cleveland Police Department the data has been evaluated [3].   The committee’s objectives include:  to quantify and categorize child deaths, identify significant socioeconomic cultural safety, health and systems factors that contribute to child mortality, improved death investigations, provide better understandings of death, recommending strategies to prevent deaths, promoting interagency communication, and facilitating planning and provisional services [5].

            The subcommittees convene to discuss medical records, police evidence, and any social service involvement.  The Child Death Review Committee formulates the date in to an annual report.  The Cuyahoga County’s 2003 Annual Report may be accessed via www.cuyahoga.oh.us/protectingourfuture .  In 2003, 136 infant deaths were recorded in Cuyahoga county [4].  Although Cuyahoga’s Infant Mortality and Child Mortality rates continue to decline, infant mortality accounts for 72% of all deaths from birth to age 17 [4].  The estimated 2003 IMR, 7.9 deaths per 1,000 live births, is slightly higher than the U.S. 2002 infant mortality rate, 7.0.  Infant deaths in 2003 are accounted primarily to prematurity (76), sleep related deaths/ Sudden Infant Death Syndrome (27), and birth defects (15) [4].  There have been public health campaigns to stress placing children on their backs while sleeping.  For example, the Back to Sleep Campaign in 1994, saw a reduction in SIDs in all races [16].  There has been some discussion in Cleveland that some SIDs autopsies could actually be pulmonary hemorrhage caused by a fungus, Stachbotrys, found in the newborns’ homes.  Dr. Dearborn et al have studied the link of this fungus to 7 SIDs cases [14].

            In addition to a large percentage of Cleveland infants dying, predominantly the minority children are 2.5 greater risk of death than white children [4].  The disparity in African American infants versus Caucasian infants has relatively remained unchanged in the last 10 years [3].  Although, there are stark racial disparities in Cleveland, in Cincinnati, at the southern end of Ohio, exhibits much worse statistics.  [3].  Relative to Cincinnati, located in Hamilton County, the Cleveland racial gap between Caucasians and African Americans does not seem so wide.

            Cleveland, Ohio is known for its developmental extremes.  On the positive side, Cleveland is known for its world-class medical facilities: The Cleveland Clinic Foundation (CCF), University Hospitals of Cleveland (UHC), and Metro Health Medical Center.  On the negative side, the U.S. Census Bureau recently rated Cleveland, the nation’s poorest city [19].  With the exodus of steel, manufacturing companies, and the spiraling decline in the Cleveland Public Schools’ high school graduation rates there is no wonder that in some east neighborhoods the IMR is three times the national average [7].  Almost half of Cuyahoga’s infant deaths occurred in Cleveland’s east side [7].  Areas with the highest term history of poverty do not have the highest IMR.  Rather, the IMR has skyrocketed in emerging poverty areas such as: Lee-Miles, Euclid-Green, Buckeye-Shaker, Woodland Hills, and lastly Ohio City to the west [7].  The emerging poverty is affected by the increase in unemployment and the loss of health insurance in the 1980’s [7].  Oftentimes, the uninsured mothers think they are ineligible or are unaware of the Medicare programs [7].

            The predictors of IMR are poverty, not married, age, predominantly African American population, substandard housing, crime rates, and additional undiscovered factors [7].  The neighborhoods near the eastern city limits now have the highest infant death rates but are not correctly targeted for outreach or other preventable programs.  In addition, the near west side neighborhoods including Ohio City and Tremont have public housing and section 8 housing that some low-income single mothers are moving into.  In essence, these new poverty sections are isolated from the metropolitan city center.  Additional confounders include: smoking, inadequate prenatal care, teen pregnancies, drug use, infections, domestic violence, and lack of family planning [4]

            The moral of the infant mortality state either here in Cleveland, Ohio, the United States, and in Third World countries is that public health organizations have made heroic strides in disease prevention, prenatal care, and health education.  However, there is always room for improvement.  An impoverished mother cannot change her economical status in 9-month pregnancy however; public health organizations are important variables to healthy pregnancy.  Examples of how to reach expectant mothers include public service announcements and billboards.    Education and prevention are cheaper in the long run than the physical and emotional cost of a premature baby.


Resources:

UNICEF

            www.unicef.org

The National Fetal and Infant Mortality Review Program (NFIMR)

            www.acog.org/goto/nfimr

World Health Organization

            www.who.int/en/

Kids Count 2004

            www.kidscount.org

Healthy People 2010

            www.healthypeople.gov

Cuyahoga County 2003 Annual Report

            www.cuyahoga.oh.us/protectingourfuture

Association of SIDs and Infant Mortality Programs

            www.asip1.org

Healthfinder

            www.healthfinder.gov

Office of Disease Prevention and Health Promotion

            http://odphp.osophs.dhhs.gov

New! Nelson Textbook of Pediatrics, 17th Edition

            http://www.nelsonpediatrics.com

Gabbe et al.  Obstetrics:  Normal and Problem Pregnancies.  Churchill Livingstone; 4th Edition (August

            2001).

Bibliography

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[1] AED (Academy for Educational Development).  “AED Advocacy Models Help

            Combat Infant and Maternal Mortality.”  Academy for Educational Development, 2004.

            AED>Health>International>Combating Maternal Mortality

[2] Buckley, K.A., Koontz, A.M., & Casey, S (1998).  Fetal and Infant Mortality Review (FIMR) Man            Manual:  A Guide for Communities.  Washington, DC:  National Fetal and Infant Mortality

            Review Program.

[3] Carroll-Pankhurst.  “Infant Mortality.”  Public Health Management and Policy MPHP 439.  CASE,

            Bolton School of Nursing Room NOA 260, Cleveland. 3 Mar. 2005.

[4] Child Fatality Review Committee.  “Protecting Our Future”  Rev. of Cuyahoga 2003 Annual

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            Council 2003.

            <www.cuyahoga.oh.us/protectingourfuture>

[5] Cindie Carroll-Pankhurst, PhD, MPA, speaker.  A Review of Cuyahoga County’s Infant and Child.              Media 687 MSASS.  Videocassette.

[6] Clinton, Hillary Rodham.  It takes a Village and Other Lessons Children Teach Us.  New York:

            Simon& Schuster, 1996.

[7] Coulton, Claudia J. and Julian Chow.  An Analysis of Infant Mortality in the Cleveland Area. 

            Neighborhood Profile Series No. 5.  Cleveland:  Center for Urban Poverty and Social Change

            Mandel School of Applied Social Sciences, Case Western Reserve University, 1991.

[8] Frey, Scott R. and Carolyn Field.  “The Determinants of Infant Mortality in the Less Developed

            Countries:  A Cross-National Test of Five Theories”  Social Indicators Research 52: 215-234. 

            Kluwer Academic Publishers: Netherlands, 2000.

[9] Infant and UnderFive Mortality Rates by WHO Region.  Chart.  World Health Organization, 2000.

[10] Kent, George.  The Politics of Children’s Survival.  New York: Praeger Publishers, 1991.

[11] Kristof, Nicholas. [New York Times Columnist]  “Infant Mortality is a Grim Omen for the Poor.” 

            The Plain Dealer.  17 Jan. 2005, B7.

[12] MacDorman MF, Martin JA, Matthews TJ, et al.  Explaining the 2001-02 Infant Mortality

            Increase:  Data from the linked birth/infant data set.  National Vital Statistics Reports;

            Vol 53 no 12.  Hyattsville, Maryland:  National Center for Health Statistics, 2005.

[13] March of Dimes Birth Defects Foundation.  Summary Rankings, 1998-2000 Averages.

            Perinatal Profiles, 2003: Ohio.

[14] Moran, Mark, MPH.  “Healthy House Answers Prove Elusive in Mold-Linked Deaths.”

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[15] Office of Disease Prevention and Health Promotion.  “Healthy People 2010”

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[16] Parker, Jennifer D., Kenneth C. Schoendorf and John L. Kiely.  “A Comparison of recent trends in

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[17] Peck, Peggy.  “11 Million Forgotten Children.”  UPI Science News.  (2003).  26 Feb. 2005.

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[18] The Associated Press.  Cleveland Rated Poorest Big City in the U.S. 20 April, 2005

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 [19] WHO.  “Reproductive and Family Health in the Western Pacific Region.”  Part One & Part Two

            WHO Reproductive Health, 2000.

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