Projecting a positive trend in pediatric health care

Infant mortality, though on the decline, is still a serious health concern in the United States and Philadelphia presents the worst-case scenario. Though government sponsored programs have helped mitigate the crisis there is still a lot to be done in terms of enabling easy access of quality maternity care to people from diverse economic, ethnic and cultural backgrounds.

Infant mortality is a serious concern worldwide and infant mortality rate is considered an indicator of the health standard of a nation. In the United States, over the last few decades there has been a steady drop in the infant mortality rates indicating a positive change in maternal health care facilities. The infant mortality rate, which was as high as 96.5 per 1000 live births in the early part of 20th century has now dropped considerably to 6.8 per 1,000 live births as projected by the 2001 statistics. However in some regions like Philadelphia the problem is acute. West Philadelphia for example, suffers the distinction of being the city with the highest infant mortality rate, one that is almost double the national average. There are many reasons, which contribute to this negative health picture in the region. Let us analyze the issue of infant mortality in a little detail so that we may gain better insight into the problem and try to find out remedial measures for the same.

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Infant Mortality (An Overview)

Infant mortality by definition refers to the ‘death of infants that occur within the first year of their life.” The infant mortality rate is the “number of infant deaths within the first year of life per 1,000 live births per year.” [UDOH]. Infant deaths fall under the following two categories namely perinatal deaths and neonatal deaths. Perinatal deaths include fetal deaths, those that occur after 20 or more weeks of gestation, and deaths that occur within the first 28 days after delivery of the baby. Neonatal deaths refer to infant deaths that occur after 28 days of birth and within one year. This classification serves to provide us with a better picture of the actual conditions that result in infant deaths. It has to be noted however, that, in general many conditions that originate in the perinatal period are responsible for the large proportion of deaths in the neonatal period.

Philadelphia (A Special Case)

Nationwide, the infant mortality rate has been steadily decreasing projecting a positive trend in pediatric health care. In Philadelphia, though infant mortality is showing a gradual decline over the last decade, the mortality rate is still very high compared to the national average. One reason for this poor scenario in Philadelphia is the clear contrast that exists in health care access between the rich and poor communities. For example the University City and Mantua, two neighborhood regions in Philadelphia present a good contrast of wealth and poverty side by side. Speaking of this disparity Ms. Whelan, a Senior nurse in Mantua says, “Here we are blocks away from major medical centers, and we had one of the worst infant mortality rates. We had high teen-age pregnancy, all of these health indicators like third-world countries,.” [Jerry Janda]. A survey conducted in 1999 showed that more than 17% of families living in Philadelphia were well below the federal poverty level.

The problem is that, while the rich people can avail of the excellent services offered by the numerous private health clinics in the city the vast majority of the poor are literally dependent on the public hospitals. Economic disparity and the consequent hurdles in access to quality health care is identified to be the key factor contributing to the high infant death rate in the city.

General Causes for Infant Mortality (Literature review)

The 1999 study by Lorraine Halinka Malcoe, Gary M. Shaw, et.al, was pivotal in understanding the various causes of infant mortality. This was a comprehensive study, which analyzed the effect of congenital anomalies on the infant mortality on a whole. For the study the researchers took the available data on the California birth defects program and performed a comparative study with the available birth death records of 278646 children between 1983 and 1986. The children chosen for the study were all from black and white communities. From this huge pool of data the researchers compared malformed infants with nonmalformed infants so as to ascertain the effect of congenital abnormalities on infant death rates.

The study clearly revealed a positive link between the presence of congenital anomalies and infant deaths. The researchers identified that congenital anomalies increased the risk of infant mortality nine fold in the case of black children while the risk factor was even higher for white children at 17.8 times. On an overall count it was found that congenital anomalies were responsible for the death of 33% of white and 19% black infants. The study also showed that congenital anomalies presented a great risk to infants irrespective of the body weight at the time of the birth. (low or high)[Lorraine Halinka Malcoe] However in Philadelphia perinatal conditions were responsible for almost 45% of natural infant deaths projecting a dismal picture of access to perinatal care. [Mary Harkins]

Nonviable Infants and Mortality rate study by Gibson and Culhane revealed another important maternal health trend in Philadelphia. The study, which analyzed about 26,863 birth records of children born in Philadelphia in 1992 found that around 1,5% of the (395) infant deliveries occurred before or during the 22 weeks gestation period. 68.1% or 269 of this group were stillborn and 126 live born infants. Another vital fact was that of the 126 premature infants, 88.1% (111) were black and 11.9% (15) were white indicating a clear disparity between the two communities. When these nonviable infants were excluded, the infant mortality rate for Philadelphia declined from 15.5 per 1000 to 9.3 per 1000. This 40% difference in infant mortality rate due to nonviable infants reflects the need for improved prenatal care. Loss of pregnancy before 23 weeks (nonviable) presents a big problem and in particular the disparity in the nonviable birth ratio between the two communities suggest the need for improving access to prenatal health care for the black community. [Eric Gibson]

Neonatal Deaths

Statistical analysis indicates that in Philadelphia the major cause of neonatal deaths is the complications resulting from medical conditions originating in the perinatal period. Medical records for year 2000 show that a total of 127 deaths directly attributable to perinatal complications. The figures also show that black Infants are more prone to perinatal complications (with as much as 90 infants of the 127). [John F. Street] Low birth weight is also a leading cause for infant mortality. The 1998 annual statistics show that LBW is responsible for 20% of neonatal deaths. Tobacco smoking and alcohol have been identified as the leading causes for LBW condition. [Centers for Disease Control and Prevention]

Teenage Pregnancy

Teenage Pregnancy is again an important factor that directly increases the infant mortality rate. In Philadelphia the Bridesberg/Kensington/Richmond and Upper north neighborhoods have a very high rate of teenage pregnancies. Teenage pregnancies cause concern because majority of the teenage mothers give birth to babies with very low body weight and consequently these babies face high mortality risk. Alcoholism is another factor, which increases the infant mortality rate. Fetal mortality rates are found to be 35% higher for women who use tobacco and 77% for those who drink alcohol during the gestation period. On an average at least 3% of the pregnant women were consuming alcohol in most of the regions within Philadelphia. The direct link between alcohol consumption and birth deformities creates more problems and seriously affects the health of the infant.

Community Wise Risk Assessment

Various studies pertaining to different aspects of infant mortality have shown the black community to be the most affected and having the highest infant mortality rate. In 1999 a total of 253 infants died and the infant mortality rate for Philadelphia was 11.7 deaths per 1,000. With 16.7 deaths per 1000 births, black infants constitute four out of every five infant deaths in the city. [Mary Harkins-Schwarz]. The African-American community again figured up high in the list of fetal morality rate with as much as 12.7 per 1000 pregnancies as indicated by the 1995 statistics. Prenatal screening and proper medical care during the gestation period would be the key in reducing fetal mortality for this high risk group. Furthermore, African-American women constitute more than 75% of the total HIV infected women in Philadelphia. This already proposes a serious risk of infant mortality due to vertical transmission of AIDS from mother to infant. The Maternity Care Coalition along with the Women’s Christian Alliance group together manage the ‘Healthy Living Project’ funded by the center for disease control to manage the acute AIDS affected regions like Strawberry mansion and other areas of west Philadelphia. [MCC]

Economic Implications

Smoking, drinking and substance abuse during pregnancy incur a huge treatment cost. LBW, Fetal alcohol syndrome (FAS) and other complications that result from these habits is a huge economic drain on the government health care system. Each year up to $9.7 billion is expended for treating infants suffering from fetal alcohol syndrome. Similarly every year the health care department spends more than 500$ million for treating infants suffering from intra-uterine cocaine exposure. Asides these, birth complications that arise due to smoking incurs an additional $2 billion in expenditure. [Centers For Disease Control and Prevention]. If enough awareness is created by means of active counseling programs to stop alcohol and substance abuse during pregnancy we would not only be saving the precious lives of infants and preventing many serious problems like cerebral palsy, autism etc. But also be saving a huge chunk of money that could be allotted to improve other areas of maternal care.

Government Initiatives

The Healthy Start Program

Several federal and state government initiative programs are operational in Philadelphia and there have been considerable positive results. The Healthy Start Initiative program started way back in the 1990’s has reaped good results but still there is much to be desired. The West and Southwest regions of Philadelphia, one of the project areas covered under the “Healthy Start Initiative” is still falling way behind the healthy care 2010 objectives. Between 1998 and 2000, the three years under study, the west and southwest regions had 181 infant deaths giving a total infant mortality rate of 14.3 deaths per 1000 which is more than double the 2010 objective of 7. 2 deaths per 1000. [Deborah D. Roebuck]

Healthy Beginnings Plus This is another program managed by the “Division of Early Childhood, Youth and Women’s Health” which contracts hospitals in Philadelphia to provide maternal health care for all irrespective of their economic situation. The Maternity Services program (MSP) in particular is specially suited for uninsured and poor people and provides quality prenatal care. By having contracts with good health care clinics the healthy beginnings plus program strives to make sure that quality health care is easily available.. [Division of Early Childhood, Youth and Women’s Health]

Conclusion

Though the nationwide infant mortality rates are declining every year, we are still a long way away from the health 2000 objective of containing infant mortality rate to 4.5 per 1000 live births. With a large population of women who are economically backward West Philadelphia continues to have the highest rate of infant mortality in the whole of the nation. Inspite of the several healthcare initiatives undertaken by the government, quality health care still remains out of reach of a segment of the community and consequently there still remains a clear difference in the infant mortality rates between the different communities in Philadelphia. It is important to address this disparity by targeting intervention programs for the high-risk group. (African-American).

The problem of the lack of quality primary care providers for the economically downtrodden people needs to be addressed immediately in order to contain the high infant mortality rate. In conclusion we can say that the problem is not just about increasing the funds to the state but more importantly, is concerned with the proper allocation of the resources to the needy areas within the city. Effective management of resources, increasing the awareness among the less privileged people and providing easy access to Preconceptional, perinatal and neonatal care holds the key for successful containment of the prevailing high infant mortality rate in the city of Philadelphia.

Bibliography

Eric Gibson et.al, “Effect of Nonviable infant on the Infant Mortality rate of Philadelphia,” American Journal of Public Health, August 2000, Vol 90, pg 1303

Center for Disease Control, “Infants Death / Mortality: Data for U.S. In 2001,” Retrieved on March 13th 2004 from, http://www.cdc.gov/nchs/fastats/infmort.htm

Lorraine Halinka Malcoe, “The Effect of Congenital Anomalies on Mortality Risk

In White and Black Infants,” American Journal of Public Health, June 1999, Pg

Mary Harkins-Schwarz, “Philadelphia Interdisciplinary Youth Fatality Review team,” Retrieved on 17th March 2004, from, http://www.phmc.org/pdf/99ReportPIYFRT.pdf.

This Utah Department of Health (UDOH), “Infant Mortality,

Retrieved on March 17th 2004, at http://hlunix.hl.state.ut.us/matchiim/main/infntdth/define.htm

Centers for Disease Control and Prevention, “Maternal, infant and Child Health”

Retrieved on March 17th 2004, from, http://www.healthypeople.gov/document/html/volume2/16mich.htm

Deborah D. Roebuck, “West and Southwest Philadelphia; Healthy Start Initiative,”

Retrieved on March 16th 2004, from, https://performance.hrsa.gov/mchb/MCHProjects/AbstractIndexes/..%5CCollection%5CHealthy%20Start%5C2003%5COther%5CHTML%5CWestPhila.html

Division of Early Childhood, Youth and Women’s Health’, “Healthy Beginnings Plus: Prenatal Services,” Retrieved on March 17th 2004, at http://www.phila.gov/health/duplicate1/RG_2002-web.PDF

Maternity Care Coalition (MCC), “The Healthy Living Project Sponsors HIV / AIDS Workshop On World AIDS Day,” Retrieved on March 18th 2004, from, http://www.aegis.com/news/pr/2000/PR001148.html.

John F. Street, “Vital Statistics Report 2000: City of Philadelphia,”

Retrieved on March 16th 2004, from, http://www.phila.gov/health/units/ahs/vitalstats/2000_Vital_Statistics__Report.pdf.

Jerry Janda, “West Philadelphia Youths Hang Out on the Health Corner,”

Retrieved on March 17th 2004, from, http://www.upenn.edu/pennnews/current/features/1995/101095/Whelan.html.


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