Editing Infant mortality (section)

==Differences in measurement==

[[File:Infant Mortality Rate by Region 1950-2050.png|thumb|upright=1.65|Infant mortality rate by region]]
[[File:Life Expectancy at Birth by Region 1950-2050.png|thumb|upright=1.65|[[Life expectancy]] at birth by region]]
The infant mortality rate correlates very strongly with the likelihood of [[state failure]], and is among the best predictors thereof.<ref>{{Cite journal |name-list-style=vanc |vauthors=King G, Zeng L |year=2011 |title=Improving Forecasts of State Failure |journal=World Politics |volume=53 |issue=4 |pages=623–58 |doi=10.1353/wp.2001.0018 |jstor=25054167 |s2cid=18089096 |ssrn=1082922}}</ref> IMR is therefore also a useful indicator of a country's level of health ([[Human development (economics)|development]]), and is a component of the [[physical quality of life index]].

The method of calculating IMR often varies widely between countries, as it is based on how they define a live birth and how many premature infants are born in the country. Depending on a nation's live birth criterion, vital registration system, and reporting practices, reporting may be inconsistent or understated.<ref>{{Cite journal |vauthors=Anthopolos R, Becker CM |year=2010 |title=Global Infant Mortality: Correcting for Undercounting |journal=World Development |volume=38 |issue=4 |pages=467–81 |doi=10.1016/j.worlddev.2009.11.013}}</ref> The reported IMR provides one statistic which reflects the standard of living in each nation. Changes in the infant mortality rate "reflect enduring social and technical capacities that become attached to a population".<ref name="Bishai" /> The [[World Health Organization]] (WHO) defines a live birth as any infant born demonstrating independent signs of life, including breathing, heartbeat, umbilical cord pulsation or definite movement of voluntary muscles.<ref>{{Cite web |title=Neonatal mortality rate (per 1000 live births) |url=https://www.who.int/whosis/indicators/2007MortNeoBoth/en/ |url-status=dead |archive-url=https://web.archive.org/web/20111221191114/http://www.who.int/whosis/indicators/2007MortNeoBoth/en/ |archive-date=December 21, 2011 |access-date=2013-08-26}}. WHO. 2011</ref> This definition is used in Austria,<ref>{{Cite web |last=Allmer |first=Gertrude |title=Bundesgesetz über den Hebammenberuf (Federal law on the midwifery profession) |url=http://www.pflegerecht.at/Druck/Versionen-Berufsrecht/Druckversion-HebG.pdf |archive-url=https://web.archive.org/web/20131002191821/http://www.pflegerecht.at/Druck/Versionen-Berufsrecht/Druckversion-HebG.pdf |archive-date=2013-10-02}}</ref> and is also used in Germany, but with one slight modification: muscle movement is not considered to be a sign of life.<ref>{{Cite web |title=PStV – Einzelnorm |url=http://www.gesetze-im-internet.de/pstv/__31.html |access-date=2013-09-29 |website=Gesetze-im-internet.de}}</ref> Many countries, including certain European states (e.g. France) and Japan, only count cases where an infant breathes at birth as a live birth, which makes their reported IMR numbers somewhat lower and increases their rates of [[perinatal mortality]].<ref>{{Cite magazine |date=2006-09-24 |title=Behind the Baby Count |url=http://health.usnews.com/usnews/health/articles/060924/2healy.htm |url-status=dead |magazine=U.S. News & World Report |archive-url=https://web.archive.org/web/20070824012048/http://health.usnews.com/usnews/health/articles/060924/2healy.htm |archive-date=August 24, 2007 |access-date=2014-03-24 |vauthors=Healy B}}</ref> In other countries, the Czech Republic and Bulgaria, for instance, requirements for live birth are even higher.<ref>{{Cite web |title=Demographic Statistics: Definitions and Methods of Collection in 31 European Countries (by European Communities, 2003) |url=http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-CC-03-005/EN/KS-CC-03-005-EN.PDF |archive-url=https://web.archive.org/web/20131213060234/http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-CC-03-005/EN/KS-CC-03-005-EN.PDF |archive-date=2013-12-13 |access-date=2013-09-29}}</ref>

Although many countries have [[Vital registration|vital registration systems]] and specific reporting practices, there are often inaccuracies in the statistics, particularly in rural communities in developing countries. In those communities, some other alternative methods for calculating infant mortality rate are used, for example, popular death reporting and household survey. Studies have shown that when comparing three information sources{{emdash}}official registries, household surveys, and popular reporters{{emdash}}the popular death reporters are the most accurate; popular death reporters include midwives, gravediggers, coffin builders, priests, and others, essentially people who knew the most about the child's death. In developing nations, access to vital registries, and other government-run systems which record births and deaths, is difficult for poor families for several reasons. These struggles force families to take drastic measures, like having unofficial death ceremonies for their deceased infants. As a result, government statistics will inaccurately reflect a nation's infant mortality rate. Popular death reporters have first-hand information, and, provided this information can be collected and collated, can provide reliable, accurate death counts for a nation, as well as meaningful causes of deaths that can be measured and studied.<ref name="Nations" />

[[UNICEF]] uses a statistical methodology to account for reporting differences among countries:
{{Blockquote|UNICEF compiles infant mortality country estimates derived from all sources and methods of estimation obtained either from standard reports, direct estimation from micro data sets, or from UNICEF's yearly exercise. In order to sort out differences between estimates produced from different sources, with different methods, UNICEF developed, in coordination with WHO, the WB and UNSD, an estimation methodology that minimizes the errors embodied in each estimate and harmonize trends along time. Since the estimates are not necessarily the exact values used as input for the model, they are often not recognized as the official IMR estimates used at the country level. However, as mentioned before, these estimates minimize errors and maximize the consistency of trends along time.<ref>{{Cite web |title=Millennium Indicators |url=http://mdgs.un.org/unsd/mdg/Metadata.aspx?IndicatorId=0&SeriesId=562 |access-date=2013-09-29 |website=United Nations |archive-date=2011-05-03 |archive-url=https://web.archive.org/web/20110503203831/http://mdgs.un.org/unsd/mdg/Metadata.aspx?IndicatorId=0&SeriesId=562 |url-status=dead }}</ref>}}

Another challenge in comparing infant mortality rates is the practice of counting frail or premature infants who die before the normal due date as [[miscarriage]]s, or counting those who die during or immediately after childbirth as [[stillbirth]]s. Therefore, the quality of a country's documentation of [[perinatal mortality]] can greatly affect the accuracy of its infant mortality statistics. This point is reinforced by the demographer [[Ansley J. Coale|Ansley Coale]], who finds the high ratios of reported stillbirths to infant deaths in Hong Kong and Japan in the first 24 hours after birth dubious. As this pattern is consistent with the high male to female sex ratios recorded at birth in those countries it suggests two things: that many female infants who die in the first 24 hours are misreported as stillbirths rather than infant deaths; and that those countries do not follow WHO recommendations for the reporting of live births versus infant deaths.<ref>{{Cite journal |vauthors=Coale AJ, Banister J |date=August 1994 |title=Five decades of missing females in China |url=https://zenodo.org/record/1235093 |journal=Demography |volume=31 |issue=3 |pages=459–79 |doi=10.2307/2061752 |jstor=2061752 |pmid=7828766 |s2cid=24724998 |doi-access=free}}</ref>

Another seemingly paradoxical finding is that when countries with poor medical services introduce new medical centers and services, instead of declining, the reported IMRs often increase for a time. This is mainly because improvement in access to medical care is often accompanied by improvement in the registration of births and deaths. Deaths that might have occurred in a remote or rural area, and not been reported to the government, might now be reported by the new medical personnel or facilities. Thus, even if the new health services reduce the actual IMR, the reported IMR may increase.{{citation needed|date=July 2023}}

The country-to-country variation in child mortality rates is huge, and growing wider despite progress in decreasing the overall IMR. Among the world's roughly 200 nations, only Somalia showed no decrease in the under-5 mortality rate over the past two decades. In 2011 the global rate of under-5 deaths was 51 deaths per 1,000 births. Singapore had the lowest rate at 2.6, while Sierra Leone had the highest at 185 child deaths per 1,000 births. In the U.S., the rate was 8 under-5 deaths per 1,000 births.<ref>{{Cite news |date=2011-02-28 |title=Child mortality falls more than 40 percent in the past two decades |newspaper=The Washington Post |url=https://www.washingtonpost.com/national/health-science/child-mortality-falls-more-than-40-percent-in-the-past-two-decades/2012/09/12/8a5bbc68-fd14-11e1-8adc-499661afe377_story.html |vauthors=Brown D}}</ref>

Infant mortality rate (IMR) is not only a statistic but also a reflection of socioeconomic development, as such it effectively represents the presence of medical services in a country. IMR is an effective resource for health departments making decisions on medical resource allocation, and also formulates global health strategies and helps evaluate their success. The use of IMR helps solve the inadequacies of other [[Vital statistics (government records)|vital statistic]] systems for global health as most neglect infant mortality rates among the poor. There remains a certain amount of unrecorded infant death in rural area as they either do not have the concept of reporting early infant death, or they do not know about the importance of the IMR.<ref name="Nations" />

===Europe and US===
{|class="wikitable floatright" style="width: 40%; text-align:left"
|+Requirements for reporting a live birth, United States and selected European countries, 2004<ref>{{Cite report |url=https://www.europeristat.com/images/doc/EPHR/european-perinatal-health-report.pdf |title=European Perinatal Health Report |last=Euro-Peristat Network |date=2004 |pages=40 |access-date=March 8, 2019}}</ref><ref>{{Cite report |url=https://www.cdc.gov/nchs/data/hus/hus08.pdf |title=Health United States, 2008 with special feature on the health of young adults. |last=US Department of Health and Human Services |date=2009 |pages=193 |access-date=March 8, 2019}}</ref>
! Reporting requirement
!Country
|-
| style="width: 50%;" | All live births || style="text-align:left;"| Austria, Denmark, England and Wales, Finland, Germany, Hungary, Italy, Northern Ireland, Portugal, Scotland, Slovak Republic, Spain, Sweden, United States
|-
| style="width: 50%;" | Live births at 12 weeks of gestation or more|| style="text-align:left;"| Norway
|-
| style="width: 50%;" | Live births at 500 grams birthweight or more, and less than 500 grams if the infant survives for 24 hours|| style="text-align:left;"| Czech Republic
|-
| style="width: 50%;" | Live births at 22 weeks of gestation or more, or 500 grams birthweight or more|| style="text-align:left;"| France
|-
| style="width: 50%;" | All live births for civil registration, births at 500 grams birthweight or more for the national perinatal register|| style="text-align:left;"| Ireland
|-
| style="width: 50%;" | Live births at 22 weeks of gestation or more, 500 grams birthweight or more if gestational age is unknown|| style="text-align:left;"| Netherlands
|-
| style="width: 50%;" | Live births at 500 or more grams birthweight|| style="text-align:left;"| Poland
|-
|}
The inclusion or exclusion of high-risk neonates from the  reported IMRs can cause problems in making comparisons. Many countries, including the United States, Sweden and Germany, count any birth exhibiting any sign of life as alive, no matter the [[gestational age|month of gestation]] or neonatal size. All of the countries named in the table adopted the WHO definitions in the late 1980s or early 1990s,<ref>{{Cite journal |vauthors=Duc G |year=1995 |title=The crucial role of definition in perinatal epidemiology |journal=Sozial- und Präventivmedizin |volume=40 |issue=6 |pages=357–60 |doi=10.1007/BF01325417 |pmid=8578873 |s2cid=35350473}}</ref> and they are used throughout the European Union.<ref>{{Cite web |title=Definition of data collected in the European Union, see item 8 |url=http://ec.europa.eu/health/ph_projects/2001/monitoring/fp_monitoring_2001_a1_frep_01_en.pdf |website=Europa (web portal)}}</ref> However, in 2009, the US CDC issued a report that stated that the American rates of infant mortality were affected by the high rates of premature babies in the United States compared to European countries. It also outlined the differences in reporting requirements between the United States and Europe, noting that France, the Czech Republic, Ireland, the Netherlands, and Poland do not report all live births under 500&nbsp;g and/or 22 weeks of gestation.<ref>{{Cite web |date=2009-11-04 |title=Preemies Raise U.S. Infant Mortality Rate |url=http://www.webmd.com/baby/news/20091103/preemies-raise-us-infant-mortality-rate |access-date=2009-11-04 |website=WebMD |vauthors=Hendrick B}}</ref><ref>{{Cite news |date=2009-11-03 |title=Premature births worsen US infant death rate |agency=Associated Press |url=http://www.denverpost.com/food/ci_13707079 |vauthors=Stobbe M}}</ref><ref name="pmid21058532">{{Cite journal |vauthors=MacDorman MF, Mathews TJ |year=2010 |title=Behind international rankings of infant mortality: how the United States compares with Europe |journal=International Journal of Health Services |volume=40 |issue=4 |pages=577–88 |doi=10.2190/HS.40.4.a |pmid=21058532 |s2cid=3190009 |hdl-access=free |hdl=2027/uc1.31210022969875}}</ref> However, differences in reporting are unlikely to be the primary explanation for the high rate of infant mortality in the United States compared to countries at a similar level of economic development. Rather, the report concluded that the primary reason for the higher infant mortality rate in the US compared to Europe was the much higher number of preterm births.<ref name="pmid21058532" />

Until the 1990s, Russia and the Soviet Union did not count, either as a live birth or as an infant death, extremely premature infants that were born alive but failed to survive for at least seven days (infants born weighing less than 1,000&nbsp;g, of less than 28 weeks gestational age, or less than 35&nbsp;cm in length, who that breathed, had a heartbeat, or exhibited voluntary muscle movement).<ref>{{Cite journal |vauthors=Anderson BA, Silver BD |year=1986 |title=Infant Mortality in the Soviet Union: Regional Differences and Measurement Issues |journal=Population and Development Review |volume=12 |issue=4 |pages=705–38 |doi=10.2307/1973432 |jstor=1973432}}</ref> Although such extremely premature infants typically accounted for only about 0.5% of all live-born children, their exclusion led to an estimated 22%–25% lower reported IMR.{{efn|In 1990, the Baltic states moved to the WHO standard definition; in 1993 Russia also moved to this definition.}} In some cases, too, {{Speculation inline|date=July 2023|text=perhaps because}} hospitals or regional health departments were held accountable for lowering the IMR in their [[Catchment area (human geography)|catchment area]], infant deaths that occurred in the 12th month were "transferred" statistically to the 13th month (i.e., the second year of life), and thus no longer classified as an infant death.<ref>{{Cite journal |vauthors=Blum, Alain |year=1987 |title=Une nouvelle table de mortalité pour l'URSS (1984-1985) |journal=Population (French Edition) |volume=42 |issue=6 |pages=843–862 |doi=10.2307/1532733 |jstor=1532733}}</ref><ref>{{Cite book |title=Demographic Trends and Patterns in the Soviet Union before 1991 |vauthors=Ksenofontova NY |publisher=Routledge |year=1994 |isbn=978-0-415-10194-3 |veditors=Lutz W, Scherbov S, Volkov A |location=London |pages=359–378 |chapter=Trends in infant mortality in the USSR}}</ref>

===Brazil===
{{One source|section|talk=|date=July 2023}}
In certain rural developing areas, such as northeastern Brazil, infant births are often not recorded, resulting in the discrepancies between the infant mortality rate (IMR) and the actual number of infant deaths. Access to vital registry systems for infant births and deaths is an extremely difficult and expensive task for poor parents living in rural areas. Government and bureaucracies tend to show an insensitivity to these parents and produce broad disclaimers in the IMR reports that the information has not been properly reported, resulting in discrepancies. Little has been done to address the underlying structural problems with the vital registry systems regarding the lack of reporting in rural areas, which has created a gap between the official and popular meanings of child death.<ref name="Nations" />

It is also argued that the bureaucratic separation of vital death recording from cultural death rituals is to blame for the inaccuracy of the infant mortality rate (IMR). Vital death registries often fail to recognize the cultural implications and importance of infant deaths. These systems can be an accurate representation of a region's socio-economic situation, if the statistics are valid, which is unfortunately not always the case. An alternate method of collecting and processing statistics on infant and child mortality is via "popular death reporters" who are culturally linked to infants and may be able to provide more accurate statistics.<ref name="Nations" /> According to [[Ethnography|ethnographic]] data, "popular death reporters" refers to people who had inside knowledge of ''anjinhos'', including the grave-digger, gatekeeper, midwife, popular healers etc.—all key participants in mortuary rituals.<ref name="Nations" /> Combining the methods of household surveys, vital registries, and asking "popular death reporters" can increase the validity of child mortality rates. However there remain barriers that affect the validity of statistics of infant mortality, including political economic decisions: numbers are exaggerated when international funds are being doled out; and underestimated during reelection.<ref name="Nations" />{{Failed verification|date=July 2023}}

The bureaucratic separation of vital death reporting and cultural death rituals stems, in part, from [[structural violence]].<ref>{{Cite journal |vauthors=Farmer PE, Nizeye B, Stulac S, Keshavjee S |date=October 2006 |title=Structural violence and clinical medicine |journal=PLOS Medicine |volume=3 |issue=10 |pages=e449 |doi=10.1371/journal.pmed.0030449 |pmc=1621099 |pmid=17076568 |doi-access=free }}</ref> Individuals living in rural areas of Brazil need funds for lodging and travel in order to report births to a Brazilian Assistance League office, this deters registration as often these individuals are of lower income and cannot afford such expenses,<ref name="Nations" /> similar barriers exist when choosing to report infant mortality. Financial constraints such as reliance on [[food supplement]]ations may also lead to skewed infant mortality data.<ref name="Nations" />

In developing countries such as Brazil the deaths of impoverished infants are regularly not recorded into the countries vital registration system, which skews statistics. Culturally validity and contextual soundness can be used to ground the meaning of mortality from a statistical standpoint.{{clarify|date=July 2023}} In northeast Brazil they have accomplished this standpoint while conducting an ethnographic study combined with an alternative method to survey infant mortality. These types of techniques can develop quality data that will lead to a better portrayal of the IMR of a region.<ref name="Nations" />

Political economic reasons have been seen to skew the infant mortality data in the past when governor Ceara devised his presidency campaign on reducing the infant mortality rate during his term in office. By using this new way of surveying, these instances can be minimized and removed, overall creating accurate and sound data.<ref name="Nations" />{{relevance inline|date=July 2023}}