CHAPTER ONE
INTRODUCTION TO THE STUDY
Background of the Study
The joy of every parent is to see their children grow healthy and live to continue their lineage. Sadly, some newborns do not live to celebrate their first birthday. Finding solutions to this problem has moved from the individual or household level through the national level to the global stage. The biggest source of resources of every nation is their human capital. This is replenished through procreation and nurturing the newborns to fill up the spaces left behind by the aged. The total number of newborns that do not live to celebrate their first anniversary per 1000 live births is termed as infant mortality rate (IMR). Infants are all newborns that are less than one year or 12 months old.
Infant mortality rates vary across regions, sub-regions and countries. This is because there are different factors that contribute to infant mortality at each level. Globally, neonatal deaths (as a result of intrapartum-related complications, preterm birth complications, congenital abnormalities, pneumonia, sepsis or meningitis and other neonatal disorders) contribute highest to under-five mortality in all the regions of the world (Liu et al., 2010). Apart from Africa that has malaria and diarrhea as the next highest cause of under-five deaths after other disorders, the Americas, Europe, and Western Pacific have injury as the next highest cause of under-five death after other disorders (Liu et al., 2010). However, Eastern Mediterranean and Southeast Asia have diarrhea as the next highest cause of under-five death after other disorders (Liu et al., 2010).
Globally, the infant mortality rate was evaluated to be 30.5 deaths per 1000 live births in 2016, which was a 47.1% reduction in the 1990 estimated rate of 64.8 deaths per 1000 live births (WHO,
2016a). Prior to the Sustainable Development Goal three, the Millennium Development Goal four intended at reducing under-five mortality rates by two-thirds between 1990 and 2015. Most of the countries across the globe adopted this goal; drafted and implemented policies and interventions that would help them meet this goal.
Among the regions of the world, the European region is the only one that came very close, with a reduction in their infant mortality rate from 24.9 deaths per 1000 births in 1990 to 8.7 deaths per 1000 births in 2015 (WHO, 2016a). As at 2016, the European region is the region with the lowest infant mortality rate, which stood at 8.3 deaths per 1000 live births. Africa among other regions of the world still had the utmost infant mortality rate of 52.3 deaths per 1000 live births (WHO, 2016a). Currently, sub-Saharan Africa’s rate of infant mortality is 56 death per 1000 live births (Population Reference Bureau, 2017). Infant mortality rate in sub-Saharan Africa is greater than that of Africa as a whole, simply because the countries in sub-Saharan Africa on the average have a higher infant mortality rate. Countries like Egypt, Tunisia, and Algeria in the northern part of Africa have much lower infant mortality rates of 16, 15 and 21, respectively (Population Reference Bureau, 2017). In addition, sub-Saharan Africa, has a high doctor to patient ratio, this makes it difficult for doctors to give their very best to a particular case. Also there is a vast socioeconomic disparity across place of residence (Gyimah, 2002). The health systems lack both the human resource and the necessary technology to save lives, especially, from preventable deaths.
There has been a stable reduction in the infant mortality rate of Ghana for some time now. Ghana’s infant mortality rates according to the 1998, 2003, 2008 and 2014 Ghana Demographic and Health Survey (GDHS) reports are 57, 64, 50 and 41 deaths per 1000 live births, respectively (GSS & Macro International, 1999; GSS GHS & ICF International, 2015; GSS GHS & ICF Macro, 2009; GSS NMIMR & ORC Macro, 2004). Over the years, successive governments have initiated and
implemented policies and interventions to take Ghana’s infant mortality rate to its current state. Some of these policies include “Ghana’s Under-five Child Health Strategies: 2007-2015”, “WHO Expanded Program on Immunization”, “Maternal and Child Health Strategies and Action Plans in Ghana”, “Integrated Management of Neonatal and Childhood illness Strategy”, “The National Health Insurance Scheme (Free Maternal Health Care)”, “the Community-based Health and Planning Service (CHPS) initiative”, just to mention few. The free maternal health care service was built into the National Health Insurance Scheme in 2008 to allow pregnant women access to antenatal care and also postnatal care after delivery (HERA-HPG, 2013). Most of these interventions have been targeted at rural areas in the country because that is where mortality has been highest and under-five mortality is currently highest. However, Ghana’s infant mortality is still high compared to the developed countries after several policies and interventions have been put in place. This current study seeks to examine factors associated with infant deaths in rural Ghana.
Statement of the Problem
The situation regarding infant and under-five mortality in sub-Saharan Africa is quite dire and necessitates up-to-date studies that examine factors associated with these deaths. There have been a lot of studies across the globe in the area of neonatal, post neonatal, infant and under-five mortality. Most of this literature was documented after the millennium development goals of 2000, since goal four of the millennium development goals was to reduce under-five mortality by two- thirds by 2015. Several studies have employed the Demographic and Health Survey data and logistic regression analysis to examine the determinants of infant mortality in various countries. Most of these studies found immunization, place of residence, parity and ethnicity as factors influencing infant mortality (Ntenda, Chuang, Tiruneh, & Chuang, 2014; Suwal, 2001). Becher et
al. (2004) also used data from a demographic surveillance system with cox regression models to estimate risk factors of infant and child mortality in rural Burkina Faso. They found that children born as twins and mothers’ death to be the greatest risk factor of death, especially among infants (Becher et al., 2004). These articles reveal that the vulnerability of the rural areas in terms of infant mortality has been with us for a long time. Thus, infants growing up in rural areas in less developed countries are more likely to experience poor health, mostly as a result of socioeconomic weakness and poor health infrastructure.
Some studies have considered only socioeconomic factors of infant mortality. In Damghanian et al.’s (2014) article that looked into “socioeconomic inequality and its determinants regarding infant mortality in Iran”, they discovered that the infant mortality rate among the high socioeconomic group was 15.1 deaths per 1000 live births whilst those in the low socioeconomic group had 42.3 deaths per 1000 live births (Damghanian, Shariati, Mirzaiinajmabadi, Yunesian, & Emamian, 2014). Also, in Gyabaah’s (2015) thesis that studied “the factors explaining the observed patterns in under five mortality” using the 2008 Ghana Demographic and Health Survey, he found age of respondent, number of people in the household and ethnicity to be significant risk factors of under-five mortality in Ghana (GYABAAH, 2014).
To the best of my knowledge, only a few studies employ logistic regression modelling to examine factors associated with infant mortality in a rural residence of a country, in a period when the rural infant mortality rate is lower than that of the urban (Mugo, Agho, Zwi, Damundu, & Dibley, 2017; Omedi & Gichuhi, 2014). Ghana’s 2014 DHS, for the first time shows an advantage on the part of rural residence with respect to infant mortality rate (GSS GHS & ICF International, 2015). Looking back at the level of infant mortality rate from the 1993 Ghana Demographic Health Survey (GDHS) report through to the 2014 GDHS report, there has been a steady reduction in the
infant mortality rate. A critical look at the trend of the infant mortality rate in Ghana, considering urban and rural settlements from 1993 to 2014, shows that the urban areas IMR is stalled at 49 deaths per 1000 live births (GSS & Macro International, 1994, 1999; GSS GHS & ICF International, 2015; GSS GHS & ICF Macro, 2009; GSS NMIMR & ORC Macro, 2004). However comparing the 1993 and the 2003 reports, there has been a marginal increase from 54.9 deaths per 1000 live births in 1993 to 55 deaths per 1000 live births in 2003 respectively (GSS & Macro International, 1994; GSS NMIMR & ORC Macro, 2004). The rural areas, on the other hand, had a steady reduction in the infant mortality rate from 82.2 deaths per 1000 live births in 1993 (GSS & Macro International, 1994) through to 46 deaths per 1000 live birth in 2014 (GSS GHS & ICF International, 2015).
Rural areas are considered to be socioeconomically lower and also lack adequate medical facilities compared to the urban areas, and the literature generally reports infant mortality as higher in rural residence and similarly among low socioeconomic groups (Damghanian et al., 2014; Suwal, 2001). Figure 1.1 below is a trend graph of infant mortality rates in Ghana by place of residence from 1993 to 2014. This graph reveals that infant mortality rates in the past 20 years in the rural areas have been higher than urban except for 2014. From 2003 to 2014, there has been a steady and steep reduction in the infant mortality rate in the rural areas of Ghana. Even though the rate of urban residence was lower in comparison to rural residence over the years, it has been stalling for the periods 2008 and 2014. It is against this background that it interests me to investigate factors associated with infant deaths1 in the rural areas of Ghana in Period One (1998 and 2003 GDHS pooled dataset) and Period Two (2008 and 2014 GDHS pooled dataset).
