United Arab Emirates











Highest IMR


Lowest IMR















Czech Republic






South-East Asia





Highest IMR


Lowest IMR



Sri Lanka




Democratic People’s Republic of Korea














Western Pacific





Highest IMR


Lowest IMR





Lao People’s Democratic Republic




Papua New Guinea


New Zealand


Solomon Islands






Republic of Korea



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.




The National Fetal and Infant Mortality Review Program (NFIMR)


World Health Organization


Kids Count 2004


Healthy People 2010


Cuyahoga County 2003 Annual Report


Association of SIDs and Infant Mortality Programs




Office of Disease Prevention and Health Promotion


New! Nelson Textbook of Pediatrics, 17th Edition


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



(Alphabetical order)

[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

            Report, by Child Fatality Review Committee.  Cuyahoga County Family & Children First

            Council 2003.


[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.”

            EHW Environmental Health Watch.  20 April 2005.  Healtheon/WebMD. 26 July 2000.


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

            Last Updated 09/04.


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

            Infant Mortality among twins and singletons.”  Paediatric and Perinatal Epidemiology 2001,

            15; 12-18.  US Government.

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


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


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

            WHO Reproductive Health, 2000.