Infant Mortality Rate by Sumayya Naseem 5th July, 2013

1. In the name of ALLAH, most gracious, most merciful

2. Infant Mortality Rate (IMR)
5 Major Diseases, Factors & Levels of Intervention of IMR
By: Sumayya Naseem, Optometrist, MMSPH S

3. Contents of the Presentation
1. Introduction to IMR
2. IMR of various Countries
3. Causes & main Diseases responsible for high IMR
4. Factors Responsible
5. Strengthening of Child Health Services (Levels)
6. Integration of Infant Health services with other Sectors and
Programs
7. Organizations Currently working for reduction of IMR

4. What is Infant Mortality Rate (IMR)
?
• Definition: Infant mortality is the death of a child less than
one year of age. Infant mortality is the death of a child before
the child's first birthday.
• Globally, ten million infants and children die each year before
their fifth birthday. Out of which 99% belong to developing
countries.
• This rate is often used as an indicator for the level of health in a
country.

5. Forms of infant mortality
1. Neonatal mortality is newborn death occurring within 28 days
postpartum. Neonatal death is often attributed to inadequate access
to basic medical care, during pregnancy and after delivery. This
accounts for 40-60% of infant mortality in developing countries.
2. Perinatal mortality is late fetal death (22 weeks gestation to birth),
or death of a newborn up to one week postpartum
3. Post neonatal mortality is the death of children aged 29 days to one
year. The major contributors to post neonatal death are
malnutrition, infectious disease, and problems with the home
environment.

6. IMR of Various Countries (latest)
Country & Infant mortality rate (deaths/1,000 live births)
• Afghanistan 121.6 (highest in the World)
• Ethiopia 75.2 (14th Rank)
• Pakistan 61.2 (26th Rank)
• Bangladesh 48.9 (47th Rank)
• India 46.07 (50th Rank)
• China 15.6 (111th Rank)
• Singapore 2.6 (218th Rank)
• Japan 2.2 (220th Rank)
• Monaco 1.8 (Lowest in the World)

7. Causes of Infant Mortality
• Some causes of infant mortality are malformations, sudden infant
death syndrome, maternal complications during pregnancy
accidents and unintentional injuries.
• Environmental and social barriers prevent access to basic medical resources and
thus contribute to an increasing infant mortality rate.
• Ninety-nine percent of infant deaths occur in developing countries, and eighty-
six percent of these deaths are due to infections, premature births, complications
during delivery and birth injuries.
• Common causes are preventable with low-cost measures.
• In the United States a primary determinant of infant mortality risk is infant
birth weight with lower birth weights increasing the risk of infant mortality.
• The determinants of low birth weight include socio-economic, psychological,
behavioral and environmental factors

8. Main 5 Diseases responsible for high
IMRs
1. Acute Respiratory Infection (Pneumonia)
2. Diarrheal Diseases
3. Malnutrition (under nutrition)
4. Malaria
5. Other diseases which are preventable through Immunization
Some other causes are HIV AIDS, Meningococcal Meningitis,
Dengue, Tuberculosis and Childhood Disabilities (physical and
psychological).

9. 1. Acute Respiratory Infections
(ARI)
• Pneumonia is one of the deadliest diseases in Pakistan. This
bacterial disease kills approximately 2 millions children in Pakistan
each year.
• Respiratory infections are infections in any area of respiratory tract,
including nose, middle ear, throat, wind pipe, air passages and
lungs.
• The common symptoms are fever, breathlessness, headaches, runny
nose, ear problems and coughs.
• Some interventions are marked according to their effectiveness, as
high effectiveness and medium effectiveness.

10. • High Effectiveness (Potential Impact
more than 10%):
• Pneumococcal Vaccines
• Reduction of Indoor Pollution
• Reduction of Low Birth Weights
• Reduction of Underweight
• Medium Effectiveness (Potential Impact
5-10%):
• Increase in Measles Immunization
• Pneumonia Vaccine
• Increase in Breast Feeding

11. 2. Diarrhea
• Diarrhea stand second in line among the factors that consume lives
of approximately 15 % of our children under 5 years.
• Diarrheal diseases and dehydration are responsible for 3 M children
deaths every year. Mostly in developing countries, e.g. Pakistan.
• Diarrhea causes dehydration of fluids in body as well as electrolyte
imbalance and this can prove fatal within hours.
• One of the most important reasons of Diarrhea is contaminated
water and poor living conditions. Others are lack of awareness, lack
of awareness/access to ORS, lack of health facilities or incorrect
case management (at home or health facility).
• 5 causing organisms are : Rota virus, Escherichia coli, Shigella,
Campylobacter jejuni and cryptosporidium.

12. 4 Types of Diarrhea are:
1. Acute Watery Diarrhea: Including cholera which lasts for
several hours or days. Main danger is dehydration. Also weight
loss.
2. Acute Bloody Diarrhea: Also called Dysentery. Main dangers are
intestinal damage, sepsis and malnutrition. Dehydration can
occur.
3. Persistent Diarrhea: which lasts for 14 days or longer. Dangers
are malnutrition and dehydration.
4. Diarrhea with severe malnutrition (Marasmus or Kwashiorkor):
Main dangers are severe infection, dehydration, heart failure and
minerals and vitamins deficiency.
 Usually more than 3 times in 24 hours. But number does
not matter, it is the consistency that matters.

13. Prevention of Diarrhea
Diarrhea can be prevented by pursuing multisectoral efforts:
• Improving access to clean water and safe sanitation, promoting hygiene
education, exclusive breast feeding.
• Improved complementary feeding practices, immunizing all children
especially against measles.
• Using latrines, keeping food and water clean, washing hands with soap
before touching food, and sanitary disposal of stools.
• The common thread that links these infectious diseases is the nutrition of
the mother and child. Malnutrition predisposes children to disease, and
diseases often result in worse nutritional status, and consequently a vicious
circle of cause and effect is established.
• Adequate health care services, also access to ORS/ ORT.

15. 3. Malnutrition (under nutrition)
• Malnutrition plays a very significant direct or indirect role in more
than half of the nearly 12 million deaths each year of children under
five in developing countries.
• In turn, malnutrition itself also intensify the symptoms of
preventable illnesses.
• It has multiple causes, including a lack of food, common and
preventable infections, inadequate care, and unsafe water.
• Strategies and interventions to improve the nutritional status of
women and children aim to overcome many of the major health
challenges posed by malnutrition.

16. • About 20 per cent of babies born in developing countries
weigh less than 2.5 kg (UNICEF 1997) which is an
important factor contributing to the burden of malnutrition
in developing countries.
• Few specific actions in developing countries have been supported to reduce the
prevalence of low birth weight. The most effective interventions are considered to be
smoking cessation, antimalarial chemoprophylaxis, and balanced protein-energy
supplementation for the mother.
• Zinc, folate, iron, and magnesium supplementation in gestation and probably the
reduction of teenage pregnancies.
• Protecting, promoting, and supporting exclusive breast feeding for 4 to 6 months
from birth and continued breast feeding with adequate complementary foods for 2
years or beyond is crucial in developing countries.
• In case of infant feeding formula, access to the knowledge that how to prepare,
feeding formula, clean boiled water and fuel.
• Fortified food for the mother and children, e.g. fortified milk, oils, salt etc with
Vitamin A, E, Iron, Iodine, etc.

17. • Vitamin A Deficiency causes Eye Damage, Blindness, skin
disorders, impaired immunity and Death.
• Prevention: Vitamin A capsules, Fortified foods and awareness about
Vitamin A rich foods. etc.
• Iodine Deficiency causes mental and physical
retardation, Goiter, Cretinism and speech and
hearing defects.
• Prevention: Iodized Salt, awareness about
iodine rich foods.
• Iron Deficiency Anemia in mother causes Low Birth Weight
in infant, poor growth and development, impaired cognitive abilities and
reduced resistance to disease, impairing their right to achieve their fullest
potential.
• Prevention: Fortified food for mother, Iron tablets, Supplementation and
use of Iron rich food.

18. 4. Malaria
• This formidable tropical parasitic disease kills at least a million people
annually, three-quarters of them are children.
• Million people who die of malaria-related causes each year, 90 per cent are
in Africa.
• Malaria is the third in ranking among the fatal diseases for the kids.
• Some of other symptoms are fever, shivering, flu and anemia, which may
range over severe types.
• Malaria is considered as the deadliest and the most life threatening disease
in human history. It was obliterated in 1960’s era but it has slowly and
gradually reappeared and haunting our society.
• Now, owing to floods in the country malaria become contagious and it’s
constantly on the rise. Anti-malarial medication can be used to effectively
cure this ailment.
• Malaria infection contributes to (severe) anemia during pregnancy, putting
the woman at risk of hemorrhage and death. Maternal anemia increase the
risk of low birth weight, the single greatest risk factor for neonatal
mortality.

19. • For children, wherever malaria is common and access to diagnostic
facilities scarce, it is important to treat any fever as if it were malaria. A full
course of a recommended anti malarial drug should be given to the child
immediately, even if the fever disappears rapidly.
• Malaria is a disease of poverty. It affects primarily the poor, who tend to live
in malaria-prone areas, in dwellings that offer no or few barriers against
mosquitoes. By sapping peoples' health, strength, and productivity, malaria
generates still more poverty.
• Prevention:
• Insecticide treated Bed Nets
• Drainage of stagnant water pools
• Governments should help by encouraging the
commercial sector to make quality nets insecticide
more affordable and more available.

20. 5. Other diseases which are preventable
through Immunization
• Although vaccines are one of the most cost-effective ways in which to reduce child
mortality, many children in the poor areas of the world do not have access to
childhood vaccines. In some countries, only 30 per cent of children may be
vaccinated.
• Even fewer children have access to the recently licensed and expensive vaccines that
are likely to have a major additional impact on decreasing child mortality such as
vaccine for Haemophilus influenzae type B (for pneumonia).
• Immunization has been one of the greatest public health success stories. Between
1980 and 1990, a massive effort raised coverage rates worldwide from 5 to 80 per
cent. Organizations funding in vacciantion are USAID, GAVI, WHO, World Bank,
UNICEF and Rockefeller foundation.
• Deaths from six major childhood diseases (measles, tetanus, whooping cough,
tuberculosis, polio, and diphtheria) have been slashed by 3 million a year. At least
750000 fewer children are left blind, paralyzed, or mentally disabled.

21. • Newer vaccines, such as those for hepatitis B, Haemophilus influenzae type B,
and yellow fever are now widely used in developed countries. While children in
developing countries may have access to six or seven vaccines, children in
industrialized countries can now expect to receive 11 or 12. Thus the gap between
rich and poor children is widening.
• In 1999, GAVI (Global Alliance for Vaccines and Immunization )has established
five strategic objectives:
• improve access to sustainable immunization services;
• expand the use of all existing, safe, and cost-effective vaccines where they
address a public health problem;
• accelerate the development and introduction of new vaccines and technologies;
• accelerate research and development efforts for vaccines needed primarily in
developing countries;
• make immunization coverage a centerpiece in development efforts.
• Tuberculosis and HIV AIDS are discussed in detail.

22. a. HIV/ AIDS
• HIV/AIDS is today the world's most rapidly spreading
infectious disease for which science still has no cure. HIV/AIDS has
reversed the survival, health, and wider human development gains of many
countries and will continue to negatively affect all aspects of community life
and children's well being in the regions most heavily affected for decades to
come
• Nearly 12 million children have already been orphaned
• 11 men, women, and children around the world get infected per minute. 1
child per minute.
• Nearly 4.5 million children below the age of 15 years have been infected
with HIV since the AIDS epidemic began, and more than 3 million of them
have already died of AIDS.
• Though Africa accounts for only 10 per cent of the world's population, it is
home to 90 per cent of the world's HIV-infected children, largely as a
consequence of high fertility rates combined with very high levels of HIV
infection among women.

23. • Mother-to-child transmission is by far the largest source of HIV infection in
children below the age of 15 years.
• In countries where blood for transfusion and blood products are regularly
screened, and where clean syringes and needles are widely available in health
centres and hospitals, mother-to-child transmission is virtually the only source
of infection in young children.
• The virus may be transmitted during pregnancy, childbirth, or breast feeding.
Where no preventive measures are taken, the risk of a baby acquiring the virus
from an infected mother ranges from 25 to 45 per cent in developing countries.
• Evidence suggests that the risk of transmission increases when the mother has a
higher viral load (this is the case when a person is newly infected with HIV or is
in an advanced stage of disease), or if the baby is highly exposed to the mother's
infected body fluids during birth.
• It is estimated that a child born uninfected to an HIV-positive mother has a 20
per cent chance of acquiring the virus from her milk if he or she is breast fed. In
places where breast feeding is the norm, this route may account for more than
one-third of mother-to-child transmissions of the virus.

24. • Since there is a possibility of transmitting HIV through breast feeding,
replacement feeding is an option for mothers. If an HIV-infected mother
has access to an adequate supply of breast-milk substitutes, knows how to
use them, has access to fuel and clean water, and the time to prepare breast-
milk substitutes safely, refraining from breast feeding will reduce the risk of
transmitting HIV through breast feeding.
• In countries where families live in poverty, have limited education, and poor
access to the resources required to provide safe feeding alternatives to
breast feeding and counseling, the risk of death from diarrhea, respiratory,
and other infections associated with replacement feeding can be as great or
greater than the risk of transmitting HIV through breast feeding.
• In cultures where breast feeding is the norm, the very fact that she chooses
not to breast feed may draw attention to her HIV status and invite
discrimination or even violence and abandonment by her family and
community.

25. Prevention
• The strategy is sometimes referred to as 'primary prevention'. It involves promoting
safe and responsible sexual behaviour in couples, providing them with knowledge
about HIV/AIDS and how to prevent infection.
• It also means providing good-quality user-friendly prevention and treatment
programmes for other sexually transmitted diseases, the presence of which increases
the risk of HIV transmission up to 10-fold.
• Crucially, it means taking steps to deal with the cultural, legal, and economic factors
that make girls and women especially vulnerable to HIV infection by limiting their
autonomy and power to protect themselves.
• The provision of efficient and accessible family planning services to enable women to
avoid unwanted pregnancies and births. The aim is to ensure informed reproductive
choice.
• The provision of antiretroviral drugs for HIV-positive pregnant women (and
sometimes their babies), counselling on infant feeding, and support for the feeding
method(s) chosen by the mother. This package is often referred to as the
antiretroviral drug strategy.
• Provision of family planning services
• Youth Participation
• Confidential counseling and testing

26. b. Tuberculosis
• Someone in the world is newly infected with tuberculosis
every second
• Tuberculosis is the single largest killer of children in the world,
250 000 children. (UNICEF 2000).
• Tuberculosis is a contagious disease. Like the common cold, it spreads through
the air.
• Only people who are ill with pulmonary tuberculosis (tuberculosis of the lungs)
are infectious. When infectious people cough, sneeze, talk, or spit, they propel
tuberculosis germs known as bacilli into the air. A person needs only to inhale
these to be infected.
• DOTS Short-course chemotherapy refers to a process treatment regimen lasting
6 to 8 months and uses a combination of powerful anti tuberculosis drugs.
• Standardized regimens are based on whether the patient is classified as a new
case or a previously treated case. The most common antituberculosis drugs used
are isoniazid, rifampicin, pyrazinamide, streptomycin, and ethambutol.
• Drug treatment of each patient needs to be observed for at least the first 2
months.

27. Factors responsible
Many factors contribute to infant mortality such as:
• Maternal Factors: The mother’s level of education, no empowerment and
decision making power, mother’s sickness, mothers nourishmment status,
awareness, age of the mother and birth spacing.
• Medical Factors: Child born with low weight, born with diseases, premature
birth.
• Socioeconomic Factors : Low incomes and high cost of health facilities,
Poverty.
• Catastrophies: whether man made or natural say floods , earth quakes,
wars etc.
• Malnutrition: Protein energy malnutrition and micronutrient deficiency.
Vitamin A deficicency, lack of breast feeding and complementary feeding
• Infectious Diseases: Acute respiratory infection, diarrhea, measles

28. • Inaccessibility : To iodized salt, breast milk substitutes and health services.
• Unacceptability: e.g. polio vaccination in Pakistan
• Unawareness: Low Literacy rate
• Lack of care/interest: By mother, father and family.
• Socio Cultural norms: Decision maker in the family, Not availing health
facilities even free ones, consulting traditional healers, taking home
remedies.
• Environmental conditions: Unhygienic home environment and exposure
to cigarette smoke in the womb or after birth.
• Poor Sanitation and access to clean drinking water
• Immunization: Not availing free service of Immunization
• Political will and Health policies

29. Levels for strengthening child health
services/ Reducing IMR
Strengthening of child health services should be considered
at the following levels:
• Policy level:
Advocacy with governments and major donors for child-friendly movements,
including national health systems management and financing strategies that
ensure equitable access and quality of essential health care for marginal groups
(including health insurance systems for the poor), especially in the context of
privatization and decentralization, as well as review of policies on
decentralization, cost-sharing, and co-management of health systems.
• District level:
Improving access, quality, sustainability, and equity of health systems through
child- and women-friendly movements can be instrumental to efforts being
made in the regional context of privatization, decentralization, and economic
crisis.

30. • Community level:
Strengthening community links, which are essential
to facilitate family care, referrals of obstetric
complications and sick children, and increase health staff accountability for
quality care and equity of access. This includes improving the capacity and
motivation of primary health care staff (especially midwives), community health
and social volunteers, teachers, and mass organizations to support family care.
Improve capacities and motivation to identify limiting factors in family care
practices and resources and develop appropriate communication and
intersectoral support strategies to improve care and empower families.
• Family level and Mother Level:
Improving family care practices, especially breast feeding, household-level
integrated management of childhood illness, promotion of hygiene practices, use
of bed nets, and women's empowerment and psychosocial stimulation (which
are not only essential for prevention of protein-energy malnutrition and
sanitation but also for maternal mortality reduction and child mortality goals).
This implies identifying limiting factors in family care practices and resources as
well as developing appropriate communication and intersectional
support strategies to improve care and to empower families.

31. Integration of Infant Health programs with
other Sectors & Programs
• The integration of child health activities with activities in other sectors –
such as water and sanitation, education, food security, agriculture,
economic growth, microfinance, and democracy and governance – can
potentially achieve high-yield gains for health.
• Also integration with other related programs: HIV, Family
Planning/Reproductive Health, Maternal Newborn and Child Health .
• Doing awareness sessions and Advocacy for making the programs effective.

32. • Organizations working for infant health are: UNICEF, USAID,
WHO, FDA, Save the children, Hope for children, Children in the
new millennium, etc.

33. References
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