It is unknown whether rural isolation may affect birth outcomes and infant mortality differentially for Indigenous versus non-Indigenous populations. We assessed birth outcomes and infant mortality by the degree of rural isolation among First Nations (North American Indians) and non-First Nations populations in Manitoba, Canada, a setting with universal health insurance.
A geocoding-based birth cohort study of 25,143 First Nations and 125,729 non-First Nations live births to Manitoban residents, 1991-2000. Degree of rural isolation was defined by an indicator of urban influence (no, weak, moderate/strong) based on the percentage of the workforce commuting to urban areas.
Preterm birth and low birth weight rates were somewhat lower in all rural areas regardless of the degree of isolation as compared to urban areas for both First Nations and non-First Nations. Infant mortality rates were not significantly different across areas for First Nations (10.7, 9.9, 7.9, and 9.7 per 1,000 in rural areas with no, weak, moderate/strong urban influence, and urban areas, respectively), but rates were significantly lower in less isolated areas for non-First Nations (7.4, 6.0, 5.6, and 4.6 per 1,000, respectively). Adjusted odds ratios showed similar patterns.
Living in less isolated areas was associated with lower infant mortality only among non-First Nations. First Nations infants do not seem to have similarly benefited from the better health care facilities in urban centers, suggesting a need to improve urban First Nations' infant care in meeting the challenges of increasing urban migration.
Department of Obstetrics and Gynecology, Hôpital Sainte-Justine and Université de Montréal, Montréal, Quebec. zhong-cheng.luo@recherche-ste-justine.qc.ca
Information on health disparities between Aboriginal and non-Aboriginal populations is essential for developing public health programs aimed at reducing such disparities. The lack of data on disparities in birth outcomes between Inuit and non-Inuit populations in Canada prompted us to compare birth outcomes in Inuit-inhabited areas with those in the rest of the country and in other rural and northern areas of Canada.
We conducted a cohort study of all births in Canada during 1990-2000 using linked vital data. We identified 13,642 births to residents of Inuit-inhabited areas and 4,054,489 births to residents of all other areas. The primary outcome measures were preterm birth, stillbirth and infant death.
Compared with the rest of Canada, Inuit-inhabited areas had substantially higher rates of preterm birth (risk ratio [RR] 1.45, 95% confidence interval [CI] 1.38-1.52), stillbirth (RR 1.68, 95% CI 1.38-2.04) and infant death (RR 3.61, 95% CI 3.17-4.12). The risk ratios and absolute differences in risk for these outcomes changed little over time. Excess mortality was observed for all major causes of infant death, including congenital anomalies (RR 1.64), immaturity-related conditions (RR 2.96), asphyxia (RR 2.43), sudden infant death syndrome (RR 7.15), infection (RR 8.32) and external causes (RR 7.30). Maternal characteristics accounted for only a small part of the risk disparities. Substantial risk ratios for preterm birth, stillbirth and infant death remained when the comparisons were restricted to other rural or northern areas of Canada.
The Inuit-inhabited areas had much higher rates of preterm birth, stillbirth and infant death compared with the rest of Canada and with other rural and northern areas. There is an urgent need for more effective interventions to improve maternal and infant health in Inuit-inhabited areas.
Notes
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(1) To determine the infant mortality rate (IMR) in American Indians/Alaska Natives (AI/AN) and whites between 1995-1999 and 2000-2004. (2) To compare the leading causes of infant mortality in AI/AN and whites. (3) To examine differences in neonatal vs. postneonatal causes of death in whites and AI/AN.
Using the 1995-99 and 2000-04 Centers for Disease Control and Prevention's National Center for Health Statistics national linked birth/infant death data, we examined neonatal and post-neonatal IMR among AI/AN and whites.
AI/AN experienced significantly greater overall IMR in 1995-1999 and 2000-2004 than whites. While the reduction in the IMR between these time periods was statistically significant for whites, the reduction among AI/AN was not. We found that AI/AN had an IMR 1.5 times as high as that of whites.
While the overall IMR has decreased in AI/AN, disparities in postneonatal IMR persist between AI/AN and Whites.
OBJECTIVES: Because of a lack of Aboriginal identifiers on death registrations, standard data sources and methods cannot be used to estimate basic health indicators for Inuit in Canada. Instead, a geographic-based approach was used to estimate life expectancy for the entire population of Inuit-inhabited areas. DATA SOURCES: The data are from the Canadian Mortality Database and the Census of Canada. ANALYTICAL TECHNIQUES: Areas where at least 33% of residents were Inuit were identified, based on census results. Vital statistics death records for 1989 through 2003 and census population counts for 1991, 1996 and 2001 were used to compute abridged life tables for the Inuit-inhabited areas in each of the three 5-year periods centered around those census years. MAIN RESULTS: In 1991, life expectancy at birth in the Inuit-inhabited areas was about 68 years, which was 10 years lower than for Canada overall. From 1991 to 2001, life expectancy in the Inuit-inhabited areas did not increase, although it rose by about two years for Canada as a whole. As a result, the gap widened to more than 12 years. Life expectancy in the Inuit-inhabited areas was generally highest in the Inuvialuit region (Northwest Territories) and Nunavut (Territory), followed by Nunatsiavut (Labrador) and Nunavik (Quebec). While these results are not specific to the Inuit population, such geographic-based methods can be used with any administrative datasets that include postal codes or municipal-level locality codes.
Because Vital Statistics data do not include information on Inuit identity in all jurisdictions, mortality rates cannot be calculated specifically for Inuit. However, Inuit in Canada are geographically concentrated--78% live in Inuit Nunangat, and 82% of the area's total population identify as Inuit. While there are limitations, geographic approaches can be employed to calculate mortality for the population of that area.
The Vital Statistics Database (1994 to 2008) and population estimates were used to calculate age-standardized mortality rates (ASMRs) in five-year intervals around the 1996 and 2006 Census years. Mortality rates were calculated for 1- to 19-year-olds living in Inuit Nunangat and those living elsewhere in Canada.
The ASMR in 2004-2008 for 1- to 19-year-olds in Inuit Nunangat was 188.0 deaths per 100,000 person-years at risk, five times the rate (35.3) elsewhere in Canada. The disparity had not narrowed over the previous decade. In Inuit Nunangat, injuries were responsible for 64% of deaths of children and teenagers, compared with 36% in the rest of Canada.
The persistently high mortality rates for children and teenagers living in Inuit Nunangat, compared with the rest of Canada, are important in understanding the health and socio-economic situation of residents of this region.
Perinatal Disparities Between American Indians and Alaska Natives and Other US Populations: Comparative Changes in Fetal and First Day Mortality, 1995-2008.
To compare fetal and first day outcomes of American Indian and Alaskan Natives (AIAN) with non-AIAN populations. Singleton deliveries to AIAN and non-AIAN populations were selected from live birth-infant death cohort and fetal deaths files from 1995-1998 and 2005-2008. We examined changes over time in maternal characteristics of deliveries and disparities and changes in risks of fetal, first day (
Alaska's postneonatal mortality rate of 3.4 deaths per 1,000 live births during 2006-2008 was 48% higher than the 2007 U.S. rate of 2.3 per 1,000. Among American Indian/Alaska Native (AI/AN) infants, the Alaska rate of 8.0 per 1,000 was 70% higher than the U.S. rate of 4.7. The Alaska Division of Public Health analyzed a linked birth-infant death file for 1989-2009 to examine temporal trends in postneonatal mortality in Alaska, specifically in the Alaska Native (AN) population. Overall and non-Alaska Native (non-AN) rates declined during the entire period, but no significant trends in AN-specific mortality were apparent. Infant mortality review committee findings indicated a decline during 1992-2007 among all postneonatal deaths attributed to sudden infant death syndrome (SIDS) or sudden unexplained infant death (SUID), but not for other causes. Lack of progress in reducing postneonatal mortality, particularly among AN infants, indicates a need for renewed emphasis within the Alaska health-care community. Current initiatives to reduce preventable causes of postneonatal mortality should be evaluated and successful models more widely implemented.
Immediately after the 1994 Back-to-Sleep campaign, sudden unexpected infant death (SUID) rates decreased dramatically, but they have remained relatively stable (93.4 per 100?000 live births) since 2000. In this study, we examined trends in SUID rates and disparities by race/ethnicity since the Back-to-Sleep campaign.
We used 1995-2013 US period-linked birth-infant death data to evaluate SUID rates per 100?000 live births by non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, American Indian/Alaska Native, and Asian/Pacific Islander racial/ethnic groupings. To examine racial/ethnic disparities, we calculated rate ratios with NHWs as the referent group. Unadjusted linear regression was used to evaluate trends (P
Notes
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Cites: MMWR Morb Mortal Wkly Rep. 2012 Jan 13;61(1):1-522237028
KEY FINDINGS: Data from the Linked Birth/Infant Death Data Set and Preliminary Mortality Data File, National Vital Statistics System. The U.S. infant mortality rate did not decline from 2000 to 2005. Data from the preliminary mortality file suggest a 2% decline in the infant mortality rate from 2005 to 2006. The U.S. infant mortality rate is higher than those in most other developed countries, and the gap between the U.S. infant mortality rate and the rates for the countries with the lowest infant mortality appears to be widening. The infant mortality rate for non-Hispanic black women was 2.4 times the rate for non-Hispanic white women. Rates were also elevated for Puerto Rican and American Indian or Alaska Native women. Increases in preterm birth and preterm-related infant mortality account for much of the lack of decline in the United States' infant mortality rate from 2000 to 2005. Infant mortality is one of the most important indicators of the health of a nation, as it is associated with a variety of factors such as maternal health, quality and access to medical care, socioeconomic conditions, and public health practices. The U.S. infant mortality rate generally declined throughout the 20th century. In 1900, the U.S. infant mortality rate was approximately 100 infant deaths per 1,000 live births, while in 2000, the rate was 6.89 infant deaths per 1,000 live births. However, the U.S. infant mortality rate did not decline significantly from 2000 to 2005, which has generated concern among researchers and policy makers.
Seasonal patterns of neonatal mortality and stillbirths have been found around the world. However, little is known about the association between season of birth and infant mortality of pre-industrial societies in a subarctic environment. In this study, we compared how season of birth affected the neonatal and stillbirth risk among the Sami and non-Sami in Swedish Sápmi during the nineteenth century. Using digitised parish records from the Demographic Data Base at Umeå University, we applied logistic regression models for estimating the association of season of birth with stillbirths and neonatal mortality, respectively. Higher neonatal mortality was found among the winter- and autumn-born Sami, compared to summer-born infants. Stillbirth risk was higher during autumn compared to summer among the Sami, whereas we found no seasonal differences in mortality among the non-Sami population. We relate the higher neonatal mortality risk among winter-born Sami to differences in seasonality of living conditions associated with reindeer herding.
