Submitted by crinadmin on
Summary: While the crisis of avoidable child
mortality in non-industrialized
countries is well recognized, the
magnitude of the problem in the United
States can not be overlooked. While the crisis of avoidable child mortality in non-industrialized
countries is well recognized, the magnitude of the problem in the
United States can not be overlooked. The United States has seen
dramatic improvements in child survival in the past century.
Important strides in living conditions, public health, and medicine
have largely eliminated many health threats posed by a vast array of
deadly but preventable childhood diseases. Nonetheless, today the
United States lags far behind many other countries in infant
survival. As one of the wealthiest nations in the world, and one that
allocates extraordinary resources to health care, the United States
carries the disrepute of an infant mortality rate that is worse than
all other industrialized countries. The crux of the U.S. infant
survival situation now lies in the racial and socioeconomic
differentials in health and well-being. The comparatively high level
of U.S. infant mortality is due, in large part, to gross disparities
in death rates between different
groups within the country. Despite continuing improvements in the
health of children overall, racial minority and socioeconomically
disadvantaged children still fare considerably worse than others.
High child mortality is not only a tragedy in its own right, it is
also a negative reflection of the state of health and well-being of
the country. The implications of high and disparate infant mortality
rates in the United States are even more alarming when demographic
trends are considered. The percentage of children in population
groups with disproportionately high mortality is increasing. First,
the percentage of children who are black continues to rise, although
not as quickly as Hispanic and Asian populations. Second, the
proportion of children in poverty is growing. The U.S. child poverty
rate has risen to nearly 22 percent of all U.S. children, and is now
the highest in the industrialized world. The increase in the
percentage of children in poverty has occurred among white, black,
Hispanic, Asian, and Native American children. As the United States
faces an increasing proportion of its child population born into
vulnerable circumstances, the hope for a healthy society is
threatened.
The United States must address the racial and socioeconomic
disparities in infant and child death rates. Black and poor infants
should have the same opportunity for survival as does the population
at large. Effective strategies need to integrate the socioeconomic
with the biological and behavioral approaches. The United States has
seen dramatic changes in public benefits in health care and social
welfare since the 1980s. While the U.S. strategies for reducing
infant mortality have had mixed success in the last two decades,
"reforms" in the social and health delivery systems, if not carefully
scrutinized, may undermine the significant gains so far, and increase
the risk of further deterioration in infant and child health
differentials between people in different socioeconomic classes.
Reduction in socioeconomic supports for vulnerable infants and
children would likely worsen the disparities in child health and
survival.
Healthy People 2000 is a national initiative that sets specific
objectives for achieving health for all U.S. residents. While major
improvements in health among U.S. residents were achieved during the
1980s, Healthy People 2000 places emphasis on reducing the persistent
health disparities between those who bear the disproportionate
burdens of illness and death and the population at large. The
country's gross disparities in infant mortality are associated with
racial and ethnic background, as well as the gender and socioeconomic
status of various population groups. Progress to date has been mixed,
with some improvement for all groups and a deterioration in the
health condition of some disadvantaged groups. The status of black
infants as compared to whites is an apt illustration. Use of prenatal
care has improved for both blacks and whites, but remains
significantly higher for whites. The incidence of low birth weight
remains stable for whites and has worsened for blacks. The disparity
in black and white infan
t deaths rates is growing. It now appears unlikely that the main
objectives in reducing racial disparities in U.S. infant health can
be achieved by the target year.
The widening disparity gap in infant mortality, and in socioeconomic
status, of various population groups in the United States points to a
general failure on the part of the U.S. government to live up to
international standards to protect and provide for all of its
infants. The United States has not ratified the U.N. Convention on
the Rights of the Child. The U.S. Senate Foreign Relations Committee
has continued to take an obstructionist stance with the treaty
ratification process. Nonetheless, the United States has ratified the
Convention on the Elimination of Racial Discrimination and the
International Covenant on Civil and Political Rights, which require
the government to take steps to protect its children against racial
disparities in child survival and development.
Findings of the U.S. case study
The United States has seen dramatic improvements in child survival in
the past century. Nonetheless, the country has an infant mortality
rate that is worse than 20 other industrialized countries, while the
death rate among U.S. black infants is even higher than those of
developing countries such as Costa Rica, Cuba, and Sri Lanka.
Eight in ten deaths to children under age five in the United States
occur in the first year of life. There is more information available
about infant deaths than deaths to children aged 1 through 4 years
because U.S. data collection, reporting, and research focuses on the
infancy period. Significant discrepancies exist in the collection of
data useful for understanding and preventing the underlying causes of
disparities in infant mortality. Vital records of births and deaths
are the primary data sources for understanding patterns of U.S.
infant mortality, but information about the household income status
of infants at the time of their birth or death has never been
collected on vital records in the United States.
Gross disparities in infant and child mortality rates persist among
different groups in the country. Poor children and black children are
the most vulnerable. Black children under five years of age die at
twice the rate of whites. Of the 32,000 infant deaths in 1994, almost
one third were black, even though black infants represented only 16
percent of all babies born alive that year. The risk of death is
higher for black infants than whites for all leading causes of infant
death except congenital anomalies. The mortality rate among infants
from poor families is 60 percent higher than for infants above the
poverty level. The poverty rate among black children is more than
three times that among white children. These disparities are growing
in terms of both race and poverty.
Child mortality rates in the United States are linked to biological,
behavioral, social, and economic factors including maternal health,
socioeconomic conditions, public health practices, and access to
quality health care and social services. The disparities in these
factors among population groups generally parallel the disparities in
the death rates.
In its failure to address socioeconomic and racial disparities in
mortality rates and underlying causes of death, the United States has
failed to live up to international standards to protect equally all
of its infants-no matter their race or economic status-and to provide
conditions adequate for survival and healthy development.
Recommendations
Ratify the Convention on the Rights of the Child; the International
Covenant of Economic, Social, and Cultural Rights; and the Convention
on the Elimination of All Forms of Discrimination Against Women.
Ensure implementation and compliance with all human rights
obligations under treaties and instruments to which the U.S. is a
party.
Promote and protect children's rights, in particular rights related
to child health and survival, through adequate programs and funding.
Achieve further reductions in the disparity in infant mortality (and
morbidity from poor birth outcomes). Such reductions require changes
in social and economic barriers to healthy pregnancy and birth
outcome. Both the public and private sectors should increase their
investment in health care coverage, child care, education and
training.
Ensure that the changes in public benefits and health care delivery
do not further threaten child health and survival. Several examples
include:
changes in eligibility for Medicaid on pregnant women;
food stamp allocations and the effects on pregnant women and
children;
change in prenatal care services for immigrants;
changes in supplemental security income eligibility on infants and
children with disabilities;
federal funding for Maternal and Child Health State Block Grants
Program; and,
transition from welfare to work.
Implement strategies that minimize the risks of unintentional
injuries and violence toward children. Child-welfare and law-
enforcement agencies should collaborate to help protect children who
are not adequately protected by their own families. When child abuse
and neglect occurs, existing services to deal with this maltreatment
need to respond more quickly. Prevention of child abuse and neglect
should focus on the millions of high-risk families who are living
below poverty or are plagued by domestic violence and substance
abuse, the major risk factors for child maltreatment.
Develop an organized public education and advocacy program to
heighten awareness of the need to improve maternal and infant health,
directed toward the general public, women of childbearing age,
families, teachers, and employers.
Adopt an integrated policy on children's health and well-being in
both the federal and state governments, addressing not only the
medical needs of all expectant mothers and newborns, but also
investing in broad-based preventive (or promotive) approaches. An
integrated policy on infant and child health should include:
redistribution of health care and social services toward children;
paid parental leave;
subsidized child care;
expansion of earned income tax credit;
guaranteed access to social and health care for all pregnant women
and infants; and,
health insurance for all uninsured children.
Strengthen coordination between state and federal programs and social
and health services for women and their children. A comprehensive
service delivery system is needed, offering perinatal clinical
services and linkages between community-based health care and social
services.
Centralize and coordinate maternal and child care services to make
available "one-stop" visits.
Refer and coordinate services to assure a healthy pregnancy and a
safe, supportive environment for the infant. Referrals from
medical/health to social or community-based services should be made,
especially in times of crisis when families may have the most
difficulty following through.
Link mechanisms for referral, tracking, and follow-up of clients
among health and social service organizations that provide:
> health services specific to preconception, prenatal, perinatal,
postpartum, and pediatric care;
> social services specific to housing, employment, mental health,
substance abuse, poverty, and child care.
Increase funding at the state and federal level for monitoring, data
collection, and research on the status of children's health and well-
being:
demonstration projects aimed at reducing the racial and socioeconomic
disparities in mortality (and morbidity) among infants and children;
Infant Mortality Reviews;
monitoring of health status of racial, ethnic, and socioeconomic
subgroups of the population; and,
interdisciplinary research in the following areas:
> etiology of major causes of infant death (and morbidity) including
preterm birth, low birth weight, congenital anomalies, etc., with an
emphasis on what factors are responsible for the racial/ethnic
disparities in cause-specific infant mortality;
> availability and potential development of prenatal care systems,
with emphasis on how specific prenatal care services that are or
could be provided during the course of a pregnancy may reduce infant
mortality; and,
> the role of socioeconomic, environmental and lifestyle factors,
along with genetic and physiological factors.
Cultural competency in health and social service provisions should be
strengthened, particularly in such areas as provider-client
communications and medical practices.