Running Head: Education on the Prevention of Infant Mortality 1

Infant Mortality in the United States:

Nursing Education to Prevent and Decrease Sudden Infant Death

Cali Gialousis

Lucia Petrus

Angela McCue

Taylor Seitz

Nursing 3749 Nursing Research

Youngstown State University

Mrs. Molly Roche

Summer 2017
Education on the Prevention of Infant Mortality 2

Outline
● Introduction to the Research Study
o Education and Infant Mortality
● Theoretical Framework
o Sister Callista Roy’s Adaptation to Change Theory
● Abstract
● Introduction to Literature Review
o Causes & Prevention of Infant Mortality During 3 Stages of Pregnancy
▪ Prepartum
▪ During Delivery
▪ Postpartum
● Review of Literature Body
o Prepartum/In Utero Education & Prevention
▪ Causes of infant mortality during pregnancy
● Poor sexual hygiene
● Smoking
● Infections
▪ Poor prepartum healthcare & nutrition
● Healthcare visits
● Folic acid
o Education in hospital, during delivery
▪ Bed sharing/co-sleeping in the maternity ward
▪ Infant-safe sleep program
● Evaluating an effective sleep program to prevent SIDS
▪ Maternal characteristics associated with suffocation & strangulation
▪ Improving health outcomes with support groups
● Evaluating the effectiveness of community-based programs
o Postpartum Education & Prevention
▪ Home healthcare to decrease infant mortality
▪ Availability of pediatric care
▪ Follow-up care for high risk infants
● Summary
● Reference Page
Education on the Prevention of Infant Mortality 3

Abstract

Infant mortality continues to be a rising problem, affecting infants from birth to 1 year of age in

the United States. This literature review evaluates the effectiveness of nurse teachings for

prepartum care, education on infant sleep position and newborn assessment, and discharge

teaching for the further prevention of infant death. The studies in this research were conducted in

doctor’s offices, hospitals, and in the community. A convenience literature review of 12 articles

concludes that with proper education provided at the right stage of pregnancy in the correct way,

the causes of infant mortality are preventable.

Education on the Prevention of Infant Mortality 4

Nursing Education and Decreased Infant Mortality in the United States

This study explores the relationship between education and infant mortality. The purpose

of this research is to evaluate the effectiveness of patient teaching provided by nurses to

expecting and new mothers, as well as their family members, regarding the care of new infants.

Providing proper education to parents and family members of new infants before, during, and

after delivery will significantly reduce infant mortality rates in the U.S.

The theoretical framework for the research is guided by Sister Callista Roy’s theory of

adaptation to change. The emphasis Roy places on adaptive and coping abilities, including the

need for alterations in the person's environment provides a framework for examining the

importance of making changes to better fit the lifestyle of parenthood regarding infant care and

parental decisions that will prevent infant mortality. The need for making these changes is

examined before, during, and after pregnancy for new mothers as well as family members.

Literature Review

This research review looks at 12 articles on the relationship between increased nursing

education and decreased infant mortality. These articles identify the causes of infant mortality

throughout the stages of pregnancy and birth including prepartum, postpartum, and in-hospital

care. By examining the causes of infant mortality throughout these stages, research suggests

ways in which proper nursing interventions can decrease the occurrence of unexplained infant

death. Guided by Sister Callista Roy’s Adaptation to Change Theory, this review is organized by

stages in which education should be implemented to produce change, therefore, preventing infant

mortality prior to, during, and after birth.

Spina bifida and anencephaly are two major birth defects associated with high rates of
Education on the Prevention of Infant Mortality 5

infant mortality and disability (Botto et al., 1999). A 1991 randomized double-blind trial by the

Medical Research Council’s Vitamin Study Group provided evidence that folic acid prevents the

majority of spina bifida and anencephaly. This evidence led to a mandate, in 1998, by the United

States that wheat flour and maize be fortified with folic acid to help prevent these diseases. A

recent study shows that approximately 1300 new cases of spina bifida and anencephaly are

prevented each year in the United States mandated that wheat and maize be fortified with folic

acid. (Williams et al., 2015).

In this study, researchers obtained the annual number of births within each country from

the latest United Nations database of births (2013). Estimates of the prevalence of neural tube

defects were collected from the latest March of Dimes Global Report on Birth Defects.

Researchers only included countries that had mandatory fortification and added at least 1.0 ppm

folic acid to their wheat and maize. This is the first time time that researchers have collected such

data. According to the March of Dimes Global Report on Birth Defects, the average global birth

prevalence of spina bifida and anencephaly was 2.4 per 1000 live births. Based on this statistic,

researchers conclude that mandatory folic acid fortification at 200 mg a day would prevent and

lower the rate of spina bifida and anencephaly to a total of 0.5 per 1000 births.

There is an important need to promote the prevention of folic acid preventable spina

bifida and anencephaly by a global folic acid fortification mandate. Successful interventions will

not only prevent FAPSBA, but will also contribute to reducing perinatal, neonatal, infant, and

under-five mortality associated with FAPSBA.

There are some limitations in this analysis. Estimates are based on older and modeled

data, and may not be an accurate description of current statistics. Researchers conclude from this
Education on the Prevention of Infant Mortality 6

study that there is an urgent need for all countries to require folic acid fortification. When

implemented and monitored successfully, folic acid fortification is proven to make significant a

contribution toward preventing FAPSBA and reducing rates of infant mortality as well as

disabilities associated with these preventable birth defects.

Neural tube defects (NTDs) are congenital malformations of the brain and spinal cord.

They are caused when the neural tube fails to close shortly after conception. These diseases are

associated with infant mortality. This article focuses on infants with open neural tubes. A

conservative estimate of incidence of states that there are 300,000 new cases of NTDs a year,

followed by 41,000 deaths. This article looks to discover what effect folic acid has on these

diseases.

Researchers reviewed the published literature to determine studies that looked at the

effects of folic acid take preconceptionally on NTDs. The population studied were infants and

the information looked at was the effect of folic acid supplementation using folic acid tablets

0.36 mg once daily to 5 mg once a week or food that was fortified with folic acid. This group

was compared to infants born from pregnancies without a supplement of folic acid.

The number of neonatal deaths due to congenital causes is estimated using a statistical

model. A major weakness of this approach is that only deaths in newborns with visible

congenital malformations will be attributed to congenital causes. NTDs remain an important yet

potentially preventable cause of neonatal mortality. There is quality evidence showing that

periconceptional folic acid fortification contributed to NTD reduction of 70%.

The US infant mortality rate has been steadily decreasing in recent years. It went from

6.75 per 1,000 live births in 2007 to 5.96 per 1,000 live births in 2013 (Matthews, 2015). A
Education on the Prevention of Infant Mortality 7

major contributor to infant mortality is preterm birth. Preterm birth is the cause of two thirds of

infant deaths.The aim of this study is to break down the change in the US infant mortality rate

into that proportion attributable to the change in the distribution of gestational age and the

proportion attributable to gestational age specific mortality for the total, non- Hispanic black,

non-Hispanic white, and Hispanic populations.

Centers for Disease Control and Prevention National Vital Statistics System’s provided

data for researchers from period-linked birth and infant death files for 2007 and 2013. Data was

included if the gestational age on the death certificate was greater than 22 weeks. There were

24,633 infant deaths and 4,304,549 live births in 2007 and 19,301 infant deaths and 3,924,071

live births for 2013. 31% of the overall infant mortality decrease is due to changes in the

gestational age distribution and 69% is due to improvements in gestational age-specific survival.

Infant mortality improved between 2007 and 2013 as a result of both improvements in

preterm birth and survival after birth. Decreases in mortality at each week of preterm gestation,

with the exception of a small increase at 33 weeks, contribute to the overall decrease. That being

said, each week a child is in utero their chances of survival increase. Obstetrical practices likely

have impacts in achieving reductions in infant mortality, particularly with regard to improving

the overall gestational age distribution. Reasons for declining preterm birth rates include

changes in risk factors for preterm birth, interventions for prevention, and promulgation of

evidence-based practices aimed at reducing morbidity and mortality of extremely preterm

neonates have demonstrated success.

The strength of this analysis is that 2 full years of national data are used, and it

represents the recent infant mortality experience in the United States. The analysis is based on
Education on the Prevention of Infant Mortality 8

vital records and has limitations imposed by missing and misclassified information.

According to the neonatal mortality rate by Millennium Development Goal region

reduction rate differentials show that the decline in neonatal mortality rate has been lagging

behind those of post-neonates. Each year, approximately 2.8 million children die within their

first 28 days of life. Many of these deaths are caused by preventable complications such as

preterm birth, delivery complications, and infection. Preterm birth causing low birth weight is the

biggest risk factor.

The Every Newborn Action Plan was put in to place based on this evidence to end

newborn deaths and still births by 2035. The main goal of this plan is to reduce the rate of

neonatal death to less than 10 per 1,000. In order to avoid preventable deaths, there must be a life

cycle approach to care including preconception and prenatal. Interventions during pre-partum

include delaying age at first pregnancy, meeting unmet family needs, birth spacing, and

enhancement of nutrition status. All of these factors have been related to improved maternal,

neonatal, and fetal outcomes. Bhutta et al. systematically reviewed interventions across the

continuum of care and various delivery platforms, and then modelled the effect and cost of scale-

up. Approximately 47% of infant death and 64% of still births can be prevented using family

planning services, according to estimates. Prenatal care is important for long term health and

nutrition. Limitations of this study include using estimates to make conclusions based on data as

opposed to actual data testing.

While in-utero education is important at the beginning of a pregnancy in preventing early

causes of spontaneous abortion and its contributing factors, there are different considerations

during delivery and directly after birth while still under physician care in the hospital setting.
Education on the Prevention of Infant Mortality 9

Once a birth occurs, it is a responsibility of the healthcare team involved to ensure the health and

safety of the infant and mother, as well as to provide education that will allow the mother and

other family members to continue this health and safety after departing the hospital. By closely

considering the causes of infant mortality that occur during delivery, within the hospital setting,

and after returning home, a plan for implementing proper education can be determined.

Bed sharing between infants and their parents is known to be risky and yet hospitals

continue to allow mothers and infants to sleep together, especially if the mother chooses to

breastfeed. BT Thach and his group of researchers quantify the risk involved by examining this

behavior related to infant death during the hospital stay. In 2011, email requests were sent to all

the members of the National Association of Medical Examiners for information on infant deaths

that occurred while sharing a bed in the hospital. Information on 15 infant deaths was returned.

The affected infants involved in this study prior to their death were healthy, had no physical

problems, and were delivered without complications. All 15 infant deaths include one or more

identified risk factors of bed sharing, the number of associated deaths shown in parentheses:

Breastfeeding while lying down (8), obesity (2), swaddling (2), infants less than 4 months of age

(15), sedating medication (4), excessive maternal exhaustion (15), and smoking (2).

In concluding the study, Thach and his team confirm that the causes leading to infant

death are preventable and there is a need for education on prevention techniques. With only a

few infant deaths to study, Thach recommends that all infant deaths or near deaths while in the

hospital be reported to state health agencies so that more information will be available for further

research. Thach’s research is limited by the suspected under-reporting of infant deaths during

their hospital stay.

Education on the Prevention of Infant Mortality 10

The educational approaches that are recommended suggest further education be provided

to new mothers including the importance of providing care in a well-lit room. Thach suggests

more education on skin-to-skin and bed-sharing risks, how to assess an infant's breathing, skin

color, and response to stimuli, and the importance of sitting upright when breast feeding should

be presented to new parents directly after delivery. Close supervision during the hospital stay by

a trained person should also be implemented in order to continuously assess both infant and new

mother. Training another family member who will have close contact both during and after the

hospital stay is important in ensuring the continued monitoring of safe practices. With any health

program, infant and new mothers should be continuously monitored for any changes in health

status or adverse effects that may occur, modifying the health plan as needed (Thach, 2014).

According to the Centers for Disease Control and Prevention, there are three commonly

reported infant deaths: SIDS, suffocation or strangulation from bed sharing and “unknown

causes”. As of 2014, SIDS represented 44% of infant deaths, bed sharing represented 25%, and

“unknown causes” represented 31% of all infant deaths. Based on these statistics, a 6 person

interdisciplinary team of nurses, a physician, an occupational therapist, and a respiratory

therapist from a Philadelphia hospital formed to tackle this growing problem.

This team of researchers consulted other local hospitals, clinics, and examined the current

literature to determine a safer way for babies to sleep. Based on location, they found that

between 2009 and 2010 there were 487 infant deaths. Of these deaths, 89 infants died due to

sudden, unexplained sleep related issues and of these deaths only 10 (11%) of the infants were in

what is considered a fully safe sleep environment. It was also discovered that 34 (38%) of the 89

infant deaths were due to accidental suffocation. Upon further investigation, the team found that

there is inconsistency in how infants are put to sleep while in the NICU.
Education on the Prevention of Infant Mortality 11

Audits from 2014 data of this research show that the nursing staff was following the safe

sleep practices only 20% of the time. This data also showed that the sleep environment was not

safe due to loose blankets or infants were being placed on their sides or stomachs. They also

found that after discharge, unsafe sleep practices are continuing in the home. Based on this

information, the team realized that these behaviors were modifiable with education and modeling

of safe sleep practices while in the hospital. With this in mind, the team implemented the use of

“bundles” to be used by the NICU staff as well as other pediatric hospital floors. These bundles

are prepared care packages for use by clinicians and other medical professionals that include

sleepsacks, clinical guidelines for a safe sleep environment, standardized caregiver discharge

education, and providing outreach education sessions in the community during a woman’s

prenatal visits.

In November and December 2014, the NICU staff was educated on how to use these

bundles, and in January 2015, the program was fully implemented. Internal audits are still

ongoing and include the monitoring of infants while sleeping in NICU cribs, compliance of the

staff providing caregiver education, including showing the NIH safe sleep video and obtaining

signed documents, and follow up phones calls for two months after discharge to caregivers.

Results within 6 months of implementation show that 90% of NICU nurses and staff are now

modeling safe sleep practices compared to 20% before implementation. Random chart audits of

30 infants show 100% compliance with caregiver education as well as follow ups after discharge

find that most caregivers follow the safe sleep practices at home by not cosleeping with their

infant and using a hard flat sleeping surface. From the start of the intervention in January 2015 to

the end of the year, there were no sleep-related infant deaths among patients discharged from the

NICU.
Education on the Prevention of Infant Mortality 12

This study is limited because of the lack of resources to follow all patients discharged

from the NICU. It is also limited because available infant death statistics in the state of

Pennsylvania take three years to publish. It is further limited by the inability to track all infant

patients at all hospital or clinics local, state and nationwide. In conclusion, it has been found that

standardization of safe sleeping practices, clear guidelines, and increased education among staff

in the NICU and other pediatric floors as well as for caregivers have the potential to dramatically

improve infant care while in the hospital as well as at home (Zachritz, W., Fulmer, M., &

Chaney, N., 2016).

Following in the same pretense of the Philadelphia study, Boston Children’s Hospital

(BCH) also decided to see how they would be able to increase the number of infants being

placed in a safe sleep environment while admitted to the NICU. BCH studied two NICU units

that are affiliated with them. Each NICU unit had a research team that had a neonatologist,

nurses, clinical nurse educator, occupational therapists, and physical therapists. These two teams

were responsible for providing professional input on how this initiative would be implemented.

The teams decided the parameters for this study would be any infant who is older than 34 weeks,

weighs more than 1800 g, and has no acute medical condition. The infants who meet this criteria

were placed into one of two sleep practices: Safe Sleep Practice (SSP) or NICU therapeutic

positioning (NTP) which is what is normally used in the NICU setting. During the time period of

November 2013 through June 2014, nurse educators trained NICU nurses in safe sleeping

practices and provided web based learning modules that all NICU nurses had to complete as a

continuing education program. Once trained, the nurses were then tasked with educating the

families as well as following the safe sleeping practice guidelines. Daily audits were performed

by the nurse educators and other members of the intervention teams to ensure that all staff was
Education on the Prevention of Infant Mortality 13

adhering to the SSP initiative and to measure the benefits of the SSP. The results of this

initiative show that there was significant improvement with SSP compliance (25.9% to 79.7%)

and that SSP can easily be taught and used in the care of infants in NICU’s. Though this

initiative was limited because of the short time period, audits during the day and not at night

when infants are asleep, and the inability to follow up with home SSP compliance, BCH

concludes that SSP can be successfully implemented in the NICU environment and believes that

further implementation of SSP education at the bedside that starts at the time of admission and

continues til discharge will lead to a greater compliance of SSP at home and therefore decrease

infant mortality in the United States.

Accidental suffocation and strangulation in bed (ASSB) is the most frequently reported

cause of death accounting for nearly 400 deaths annually. ASSB is preventable and it is

important to identify the underlying risk factors however difficult that may be. This study’s

primary focus is to identify the maternal and infant characteristics seen with the increase in

ASSB in the US using secondary objectives that didn’t involve race/ethnicity. Birth and

death certificate data from January 2000 through December 2003 were obtained because these

years contained the most frequent national data however; this data is limited because not all

states use the new birth certificates which allow for more variables to be collected.

Using this data, a population-based study was performed with the primary outcome being

ASSB related deaths. Maternal risk factors available through birth certificate data included:

education, age, race/ethnicity, place of birth, prenatal care, smoking during pregnancy, and the

number of pregnancies. Infant risk factors included: sex, gestational age, birthweight, and

presence of congenital anomalies at birth. Frequency distribution of the risk factors for the

mother and child among ASSB deaths were then compared to survivors and the differences were
Education on the Prevention of Infant Mortality 14

analyzed using the Mantel-Haenszel chi-square tests. Odd ratios were used and any maternal or

infant ratios greater than 2.0 were considered strong predictors of ASSB. Once the parameters

were set, the final population used for this study is 11, 573, 678 infants, of which 1, 064 infants

died of ASSB. The ASSB mortality rate is 9.19 infant deaths per 100,000 live births during this

study period.

It is found that infants with ASSB mortality are more likely to have mothers who had

more than one child, are less educated, are either African-American or Native

American/Alaskan Native, and are US born; who had no prenatal care, and who smoked during

pregnancy. This study also shows that infants with the highest ASSB mortality rates are male and

are born between 20 and 33 weeks gestation. It also shows that most ASSB mortalities (71%)

occur before 4 months of age. Based on this study it is important to understand sleep practices

and caregiver behaviors. With this knowledge of risk factors, health care providers and health

educators need to develop specific educational strategies that target the populations containing

the highest maternal and infant risk characteristics.

This study recommends the education of caregivers with children under the age of 4

months be educated on safe sleeping practices. The sample size of this study lends validity

however this study is still limited by the data collected. Death certificates do not always report

specific cause of suffocation. It is also limited because of the modifiable factors associated with

ASSB mortality. It also does not take into effect the infant's sleeping position or sleeping

environment at the time of death. In conclusion, this study finds it is best to perform a risk

assessment on each individual mother at the time of admission and then perform an infant risk

assessment upon birth in order to tailor the education of safe sleeping practices unique to that

specific family (Carlberg, M. M., Shapiro-Mendoza, C. K., & Goodman, M., 2011).
Education on the Prevention of Infant Mortality 15

In the article of “Infant Mortality in the United States (1998),” a study is conducted on

how participation in the Special Supplemental Nutrition Program for Women, Infants, and

Children (WIC) and Medicaid impacts infant mortality in the United States. It is believed that

participating in either program helps less privileged mothers and their babies by providing

money for nutrition, care products, and health care. Even before this study, it is proven that better

nutrition for both the mother and infant can reduce the risk of infant mortality within the first

year of life ( Stanford Children's Health. 2017).

Poverty continues to be a growing problem in the US, and programs like WIC allow

women to properly nourish their newborns despite a low socioeconomic status. This study

suggests that with proper nourishment of both mother and infant, occurrences of infant mortality

within the US can be reduced. While poverty causes a lack of access to proper nourishment,

many low-income families also lack health insurance, making it difficult to access proper

postpartum education after leaving the hospital. Programs like Medicaid help low-income

mothers afford health care for themselves and their infants when private insurance is not

accessible. By being in the Medicaid program, women can continue to seek proper care and

education after leaving the hospital. Infant survival among low-income families can be affected

differently based on participation in WIC or Medicaid as well as what stage of pregnancy the

infant and mother enter into either program (Moss, Carver. 1998). This study looks at both

endogenous deaths, which occur during pregnancy and delivery, and exogenous deaths, which

occur during infancy. It is concluded that WIC and Medicaid participation reduce both

exogenous and endogenous deaths.

In the cross-sectional survey, the study compares participating and nonparticipating

women whose household incomes are 185% below the poverty line. Samples from 9,953 live
Education on the Prevention of Infant Mortality 16

births and 5,332 infant deaths from NYC and the District of Columbia are utilized. A limitation

of this study is that certain ethnicities are not used. The response rate is 74% among mothers who

experienced a live birth and 68% from those who went through an infant death. Another aspect

of the study includes the mother's age and educational level. Most mothers participating in the

study are more than 30 years old, white, married, and had at least a high school education. The

final sample consists of 5,019 survivors, 860 exogenous deaths, and 1,917 endogenous deaths.

For the purpose of this study, a woman is considered a program participant based on the

following: Receipt of WIC food for herself during the pregnancy, receipt of WIC food for herself

and the infant after birth, utilization of WIC or Medicaid as the source of prenatal care, or

utilization of WIC or Medicaid for payment toward any infant illness, and for general care of the

infant after birth. Multiple factors affecting the birth of an infant are examined, including

prenatal care, attendance of childbirth classes, weight gain, and smoking.

The following results were concluded: Mothers in the WIC program are more likely to

have health problems than nonparticipants, infants involved in WIC participation are less likely

to die of endogenous causes, and mothers without any health insurance are at a higher risk for

death. In conclusion, being a part of WIC during pregnancy reduces both endogenous and

exogenous infant deaths; however, being a part of Medicaid has no varying effect of infant

deaths compared to belonging to a private insurance. Having access to both supplemental

programs and health insurance better enables mothers to care for their infants, thus leading to a

reduction in infant mortality.

In an article by Texas A&M, infant mortality is defined as the death of babies under the

age of one. Unlike some countries, the United States includes the deaths of prematurely born
Education on the Prevention of Infant Mortality 17

infants in this analysis, causing a spike in the number of deaths per year of babies born at full

term. This article defines controllable risk factors as the use of tobacco, alcohol, cocaine, and

other drugs, as well as the lack of access to quality prenatal care. The research conducted

suggests that infants born to wealthier and better educated families have better survival rates for

their newborns compared to new mothers without proper education or financial means to get

prenatal and postnatal care.

According to research, more than 20 percent of babies in the United States are not being

put on their backs, which is the safest way for them to sleep. A key finding in this article is about

the benefits of home nurse visits. Home visits after a mother gives birth to an infant allow a

nurse to provide and teach proper care in the home. This includes checkups, prevention of SIDS,

and inspection of the home for possible hazards. "We have considerable research evidence of the

beneficial effects of home nurse visits for new moms, with special emphasis on the health

benefits to their children," said Lisako McKyer, PhD, associate dean for climate and diversity

and associate professor at the Texas A&M School of Public Health. For example, research

reveals that regular visits from nurses and similar paraprofessionals lead to better psychological

outcomes for both mother and infant, which means lower health care costs over the course of

their lives (Infant Mortality, 2016).

Home nurse visits also help teen mothers or mothers who are addicts by providing

teaching that these mothers might not otherwise receive. In the end, these home visits allow

mothers to learn what they didn’t learn in the hospital to care for their infant and prevent infant

mortality. These visits are essential in giving proper health care to newborn families who need it.

The safer home translates to less money spent on treating sick and injured infants, which is

especially important considering the cost of care for the rest of the baby's life.
Education on the Prevention of Infant Mortality 18

This article encourages mothers to allow for home health visits as a necessary step in

providing the best possible care for their infant. While home health visits are an investment, it is

argued that they are an important investment toward a healthy life of the baby, reducing future

medical expenses. It is also suggested that home health visits reduce emergency room visits

within the first week of a newborn's life. The literature proves that proper access to health care

can help reduce infant mortality and enhance an infant’s overall health.

In the article, “First steps for Mommy and Me: A pilot intervention to improve nutrition

and physical activity behaviors of postpartum mothers and their infants”, a study is conducted to

assess the feasibility of pediatric care based intervention to promote healthful behaviors among

0-6 month old babies and their mothers. This article advocates for proper nutrition and healthy

lifestyles of both the mother and the infant to help reduce infant mortality.

Having proper nutrition helps nourish the infant, ensuring that he or she is healthy,

lowering the risk of low-weight infant deaths. In the study, a group of 60 mother-infant pairs are

studied, with 24 of those pairs being controlled. Visits and interviews of 95% of the pairs are

conducted by pediatricians, including motivational counseling with a health educator and

multiple parenting workshops. These encounters occur at birth and then again 6 months later,

focusing on the effects any intervention has on infant feeding, sleep duration, watching TV, and

mother’s responses to safety ques.

Throughout the study, researchers focus on the mother’s postpartum diet, exercise, TV,

and sleep. Health educators hired by the researchers interviewed mothers at 3 weeks, 6 weeks, 3

and 5 months postpartum. In each subject interview, healthy eating behaviors, exercise, sleep,

and TV are discussed to evaluate how mothers care for their infants after leaving the hospital.

These subject interviews also look at the infant's breastfeeding duration, introduction of solid
Education on the Prevention of Infant Mortality 19

foods, sleep, TV, and safety measures. The interviewers encourage the mothers to care for their

infants in a way that promotes better health. If the researcher feels the mother needs to change

her method of caring, education is provided on how to make necessary changes, including the

use of informative posters and handouts. After 6 months, the researchers returned to assess how

the education during the initial interview has affected health status and caring behaviors

including infant sleep, and breastfeeding durations, infant weight, and introduction to solid

foods.

The study concludes that there is no drastic difference in the outcomes of the mothers

who participated in the study versus nonparticipants; however, mothers do benefit from receiving

education. Having access to health educators and parenting workshops ensures that parents care

for their infants the proper way. Mothers are “somewhat or very” satisfied with this study and

feel benefited by it. The researchers feel that this study helps progress the care of infants, but

does not impact the mother’s own health behaviors. One limitation to this study is that it did not

focus on differences amongst lower income families and access to health care.

In the article, Improving Maternal and infant child health outcomes with community-

based support groups: Outcomes from Moms2B Ohio, a study being conducted examining the

outcomes of impoverished urban mothers attending a community-based pregnancy support

program, Moms2B. It started in 2011 and went to 2014. The results are based on 195 pregnant

women in attendance for one or more sessions. Out of the 195 women, 75% are African

American with incomes less than $800 per month and limited medical resources. Moms who

participated in the Moms2B programs saw a reduction in the rate of infant death within the first 4

years of the program. This shows that by attending and participating in the program it allowed

these misfortunate and impoverished mothers to learn the necessities to better care for their
Education on the Prevention of Infant Mortality 20

infants, which lead to a reduction in infant death.

From 2007 to 2010, there were 442 births and 6 infant deaths within the program of

study. From 2011 through 2014, there were 339 births with only 1 infant death (Gabe et al.,

2017). A strength of this article was that it was easily measurable in that the outcomes of the

study allowed the researchers to conclude that improvements were reached in infant health and

maternal outcomes.. Before doing this study, infant mortality rates among African Americans in

Ohio were ranked 50th in the nation in 2011 (Ohio Department of Health. 2015). Infant mortality

among African Americans in Ohio is twice that of white infants.

The Moms2B program was initiated to reduce disparities in infant mortality by focusing

on low income, predominantly African American pregnant women to improve their nutrition,

social and medical support while pregnant and continue through their child’s first year of life.

This study was conducted from 2011 to 2014 in Weinland Park, focusing on 24 pregnant African

American women living in the area. The mothers were recruited by sending out flyers to endorse

their participation. Participants were offered sessions every week that provided them with WIC

involvement, breastfeeding information and how to properly nurture and care for their infants.

The researchers used questionnaires to assess the mothers each week based on their needs.

Throughout the duration of the study, 194 Moms2B sessions were held and 206 pregnant women

were visited, with 61.7% of participants attending more than 3 sessions. This was the baseline

that the researchers felt they could get a positive impact from the sessions.

This study focused on women predominantly in poverty, enrolled in WIC and had some

stressors in their life. A weakness of this study is that it overrepresented African American

women. Infant mortality rates went from 14.2 to 2.9 per 1000 births. Most women in the study

agree that the Moms2B sessions truly helped them in their pregnancy. Breastfeeding also
Education on the Prevention of Infant Mortality 21

increased from 37.9 to 71.4%. It is believed that by providing these mothers with emotional and

physical health guidance they have better outcomes with their births. Finally, a major limitation

to this study is that it is confined to a small urban community in Ohio. It may have been different

had the population of the study been larger. Overall, this study proved that Moms2B is a

successful intervention in limiting infant mortality and providing mothers with the proper tools

to provide care to their infants.

Limitations

The literature presented in this review has limitations on the individual level that control

the results of the studies involved. Overall, many limitations have similar themes pertaining to

the race, age, socioeconomic status, and location of the sample. This includes, as mentioned in

each individual review, use of only certain ethnicities; small population and sample sizes; the

focus on only urban neighborhoods and impoverished mothers; the age and education level of the

mother; the lack of local, state, and national databases; estimates based on older and modeled

data lacking accuracy; limited reporting on infant deaths and causes; missing and misclassified

information; lack of resources; slow return times on published statistics; and variances in data

collection across state lines.

A major limitation in one of the studies was that deaths of newborns with visible

congenital malformations were the only deaths attributed to congenital causes. One study was

also specifically limited by the data and how it was collected regarding infant sleeping position.

Data collection through another research study was also limited by the difficulty to distinguish

between SIDS and death from suffocation and strangulation when discriminate investigation was

not done.
Education on the Prevention of Infant Mortality 22

Conclusion and Nursing Implications

While there are various causes occurring at different stages of pregnancy and birth, the

combined literature presented in this review seems to agree that infant mortality can be

significantly reduced and prevented by providing proper education to families. Guided by Sister

Callista Roy’s theory of adaptation to change, this research proves that by making important

lifestyle changes in how a mother cares for herself and her infant prepartum, during delivery, and

postpartum, the risk for infant mortality significantly decreases.

Taking steps to prevent infant mortality prepartum proves to be an essential part of

healthy living for infants. Expecting mothers as well as women who intend to become pregnant

need to increase their intake of folic acid in order to avoid preventable birth defects that can lead

to mortality. In addition to this increase, expecting mothers also need to take special care of their

child during pregnancy by first taking care of themselves by attending doctor’s appointment,

eating properly, and avoiding things that can cause potential birth defects.

Based on the literature, there is a need for a local, state, and national database on infant

mortality to understand infant mortality. Highly focused education for the staff as well as the

infant caregivers is needed from the moment of admission until discharge. Modeling of safe

sleep practices by hospital staff and caregivers during the hospital stay greatly increased

adherence to this practice once discharged to home. Focused and tailored education is needed for

mothers and infants who possess greater risk factors for sudden unexplained infant death.

Implementation of SSP can easily be integrated in to the care of infants in NICU’s as well as

other pediatric units.

In postpartum care, the studies concluded that mothers need education from nurses on
Education on the Prevention of Infant Mortality 23

how to provide the proper care for their infants. It is also suggested that through programs such

as Moms2B and informational support groups, new mothers can gather the knowledge they need

in order to prevent infant mortality. Another source for support are programs like WIC and

Medicaid that provide nutritional guidance and health insurance access.

The implications for nursing to reduce and prevent infant mortality in postpartum care are

clear to understand. It is important for nurses to encourage participation in support groups, such

as the Moms2B program. Attending and actively participating in 3 or more sessions is proven to

have a positive impact on mothers. Mothers who received nutritional support and educational

information by nurses while in the support programs were able to properly care for their infants,

which lead to a reduction in infant mortality. Home health visits by nurses ensures safe care of

infants within the home once being discharged from the hospital. It is proven that these visits

reduce future medical costs, as well, therefore reducing further medical problems that could lead

to infant mortality.
Education on the Prevention of Infant Mortality 24

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