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Child and Infant Mortality Among American Indians and Alaska Natives

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Child and Infant Mortality Among American Indians and Alaska Natives DISCUSSION PAPER What’s Killing Our Children? Child and Infant Mortality among American Indians and Alaska Natives Teshia G. Arambula Solomon, PhD, The University of Arizona, Native American Research and Traning Center; Felina M. Cordova, MPH, University of Arizona, Native American Research and Training Center; Francisco Garcia, MD, MPH, Pima County Health Department March 7, 2017 As an obstetric resident I once took care of a young Native American woman who had been transported by helicopter from a remote rural community because she had been assaulted by her intoxicated partner. She was early in her third trimester, and the damage to her face and extremi- ties was dramatic but not life threatening. However, the trauma to her abdomen resulted in a fracture of the femur of her unborn 28-week-old female fetus. Our team recognized that while we could successfully get her safely through her pregnancy, the real challenges she and her daughter faced would come upon her return home. For American Indian people, context matters and is a key determinant of health and mortality. We need to examine what’s really killing our children across a spectrum of health indicators, and public health needs to intervene at all levels. —Francisco Garcia, MD, MPH The very vulnerable demographic group of American Public health has long used such mortality statistics Indian and Alaska Native (AIAN) youth face unique and to create a picture of the health of the community. important challenges. We need to hear from native In a recent article, Wong et al. (2014) used a novel stakeholders and experts in American Indian health technique—data linkage—to create a unique dataset about the contextual factors (poverty, low educational matching Indian Health Service (IHS)-eligible partici- attainment, and substance abuse) that represent a pants with vital statistics for AIAN child and infant threat to native communities in this country. To begin mortality rates by region. By reducing racial misclas- to mitigate that threat, researchers, opinion leaders, sification through this method, the authors present human services providers, and the general popula- the patterns of AIAN infant and child mortality experi- tion need to begin to understand what is killing native enced by AIAN as compared to white infants and chil- children [1]. dren, creating a frightening picture of problems affect- In this paper we use the lens of infant and childhood ing AIAN children, families, and communities. mortality as a tool to recognize opportunities for action This paper discusses AIAN infant and child death in that could have an impact on this perhaps most critical an effort to understand the root causes of significant indicator of the health of this population. We attempt disparities and calls for serious efforts by public health to extract some lessons from the lived experiences and health care institutions for prevention and inter- of too many reservation and urban Indian communi- vention to address core problems. We begin by draw- ties and turn these tragic stories into useful tools for ing attention to the importance of understanding the broader policy and health system change. problems in data for AIAN populations and the need Perspectives | Expert Voices in Health & Health Care DISCUSSION PAPER to continuously improve data collection and analysis the United States but particularly in AIAN communi- for the population. We conclude with opportunities for ties (Hamilton et al., 2013). In 1915, the total U.S. in- action, particularly for policy makers. fant mortality rate was as high as 99.9/1,000 births. By 2010, the rate had dropped to 6.1/1,000. The dra- The Need to Reduce Misclassification on matic decline can be primarily attributed to preven- Death Certificates tion and control of infectious disease through public Identification of AIAN status is an influential factor in health measures. Trends for AIAN infant mortality U.S. vital statistics data and is influenced by histori- also appear to be declining, from 62.7/1,000 in 1955 cal, political, legal, and cultural definitions. There are to 8.3/1,000 in 2010; however, there is variation across 567 federally recognized tribes in the United States states and regions of the United States, with New Mexi- and 76 state-recognized tribes, as well as people who co reporting the lowest infant mortality rate for AIAN at self-identify as AIAN and belong to terminated tribes 5.0/1,000 and North Dakota reporting one of the high- or unrecognized tribes because they cannot document est at 16.6/1,000 (Hamilton et al., 2013). their family history. Racial identity is determined on birth certificates generally by the mother and is pre- Leading Causes of Death sumed to have a high rate of accuracy. In some tribes, Wong et al. (2014) report disparities in the infant death however, citizenship follows one parent over the other. rates between AIAN and whites. Infant mortality was In matriarchal tribes, for example, if the father is AIAN significantly higher among AIAN across the age span and the mother is not, the child may not receive tribal as compared to non-Hispanic white mothers. The AIAN membership. infant death rate for the period of 1999–2009 was al- Racial identity for the purpose of the death certifi- most double (914.3/100,000 AIAN, 567.3/100,00 white), cate may be determined by a parent or other family and the postneonatal (age 28–364 days) rate (53 per- member, but more likely it will be reported by a physi- cent) was significantly higher than the white rate (34 cian, coroner, or mortician, creating an increased risk percent); the neonatal (< 28 days) rate was significantly for misclassification by race. Such misclassification higher as well (434/100,000). would underestimate the deaths of the population. In general the leading causes of death for AIAN chil- Espey and colleagues (Espey et al., 2014; Espey et al., dren less than 1 year of age can be grouped into three 2005) have used a data linkage [2] process to reduce different diagnostic categories: congenital malforma- racial misclassification of AIAN in mortality data and tions, sudden infant death syndrome (SIDS), and un- cancer incidence data. Such efforts have enhanced our intentional injuries (Wong et. al, 2014). AIAN infants understanding of native health disparities and high- and neonates also died of medical conditions result- lighted differences among the population by region. ing from short gestation and low birth weight; ma- Table 1 illustrates the variability in AIAN demographics. ternal complications of pregnancy; complications of placenta, cord, and membranes; and bacterial sepsis. Differences in Data Infants also suffered from diseases of the circulatory According to the 2010 U.S. vital statistics, infant mortal- system, influenza and pneumonia, and homicide. Neo- ity appears to be decreasing at dramatic rates across nates also died of necrotizing enterocolitis (inflamma- Table 1 | U.S. American Indian and Alaska Native Demographic Data Count % of US Total Population Population 2014—1 or more race (A) 4,519,000 1.4 Population 2014—AIAN only (B) 3,957,000 1.2 Projected population in 2016—1 or more race (B) 10,169,000 2.0 Projected population in 2016 —AIAN only (B) 5,607,000 1.3 Population 0-15 years in 2014 (A) 1,154,000 1.87 Live Births 2013 (C) 45,997 1.17 Source: CDC, 2015 (A); Colby & Ortman, 2015 (B); and CDC, 2013 (C). Page 2 Published March 7, 2017 What’s Killing Our Children? Child and Infant Mortality among American Indians and Alaska Natives tion of the intestines), respiratory distress and intra- relative to the mother’s behavior, including alcohol and uterine hypoxia (deprivation of an adequate amount tobacco consumption, stress, and reduced exposure of oxygen), neonatal hemorrhage, and birth asphyxia to environmental toxins. Prenatal care provides ac- (failure to initiate and sustain breathing at birth). After cess to imaging and is typically the pathway for detect- the first year of life, mortality in AIAN children shifts ing potential birth defects. Despite this, prenatal care largely to accidental and nonaccidental trauma, includ- utilization is typically low in AIAN populations, as with ing homicide and suicide, accounting for 41 percent of other low-income populations (IHS, 2005; APA, 2014). all deaths among AIAN children (Wong et al., 2014). All The prenatal care participation rate for on-reservation of the top 10 causes of death for this population were women served by IHS is low (67 percent) compared to significantly higher than the white rates. The causes the U.S. all-races rate of 81 percent (IHS, 2005; APA, with the largest disparities between AIAN children and 2014). This finding is crucial because prenatal care and their white counterparts were flu/pneumonia, menin- childbirth classes represent critical opportunities to gitis, and homicide (Wong et al., 2014). deliver health education messages to decrease the risk Beyond the significant disparities in overall rates, the of SIDS and unintentional injuries. study team also found significant disparities in specif- ic causes by age. SIDS was one of the top 10 causes Causes Relevant to Mode of Delivery across the three age categories, with AIAN infant rates Maternal complications at the time of delivery and dur- double the rates for white infants. SIDS rates in Alaska ing the puerperium [3] are exacerbated in the absence and the Northern Plains were four times higher among of appropriate birthing environments, access to the AIAN infants than among white infants. Such high rates appropriate level of perinatal care of complications, have been documented for more than 25 years (Wong and emergency maternal transport when that care is et al., 2014). Of all the deaths among AIAN children, not readily available.
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