Toward an Explanation of Rapidly Declining Trends in Infant Mortality in Taiwan

By Wu, Jennifer Chun-Li; Chiang, Tung-liang | International Journal of Child and Adolescent Health, January 1, 2011 | Go to article overview

Toward an Explanation of Rapidly Declining Trends in Infant Mortality in Taiwan


Wu, Jennifer Chun-Li, Chiang, Tung-liang, International Journal of Child and Adolescent Health


Introduction

While most countries experienced a steady improvement in infant mortality in the last century, recent trends in parts of the world showed a stagnation of decline, and in some cases, the trend went in the wrong direction, with high mortality rates still far from acceptable [1]. Global commitment and call to action have led to the reduction of infant mortality being listed as a central Millennium Development Goal [2]. Taiwan's experiences represent a case in which a relatively low-income country had achieved a large reduction in infant mortality within a rather short period, and can offer valuable lessons for countries seeking to attain this goal. The infant mortality rate in Taiwan dropped from 44.7 per 1000 live births in 1952 to 5.4 in 2005, an eight-fold decline (see figure 1). When we examined the composition of infant mortality, deaths in the post-neonatal period had consistently accounted for over 60 percent prior to the mid 1990s. In the past decade, the proportion of infant deaths occurring in the first 28 days of life has exceeded that in the postneonatal period. On the cause of death for infants, infectious diseases had been the major killer in Taiwan, with pneumonia and gastroenteritis together accounting for half of all infant deaths in the 1950s and remaining important causes (one-third) until the 1980s. With the fall of infant mortality, infectious diseases also gave way to congenital anomalies, accidents, and perinatal conditions such as birth injury, asphyxia and problems relating to prematurity and low birthweight as the leading causes of deaths. In 2005, close to one half of infant deaths were due to perinatal conditions mentioned above, and congenital anomalies accounted for one in four infant deaths (Table 1).

Taiwan has enjoyed a high infant survival rate comparable to those in developed countries [3]. Could this have been an artifact of misreporting? By Taiwanese law, all births and deaths must be registered by families to their local household registration system. Because some families failed to report infant deaths to the household registration system, particularly those occurring in the neonatal period [4], there were worried of under-registration. A compulsory birth report system was later introduced in 1995, where healthcare providers are also obligated to report all births to the government. Even though the potential bias from under-registration was possible prior to 1995, it was unlikely that the long-term decline in infant mortality in Taiwan was affected by under-registration alone, as the new reporting system would have resulted in an increase in death reporting. What then, were the factors behind Taiwan's achievements in reducing infant mortality? In this chapter, we adopt Mosley and Chen's conceptual framework for child survival to guide our discussion on the determinants of infant mortality trends in Taiwan.

The Mosley-Chen framework integrates the concerns and analytical approaches which have traditionally divided social and medical science research [5]. Central to their framework is the idea that all socioeconomic and cultural variables must operate through a set of proximate determinants that directly affect the risk of child morbidity and mortality.

These socioeconomic variables are namely the focus of social science research on child mortality, and can be defined as individual, household or community-level characteristics such as individual attitude, household income, political economy, etc. Proximate determinants, on the other hand, correspond to biological mechanisms in medical science for the explanations of disease and the outcome of disease processes. Five groups of proximal determinants were identified in the MosleyChen framework: maternal factors, environmental contamination, nutrition deficiency, injury and personal illness control.

Built on this analytical approach, this chapter is organized into three main sections. The first two sections give a historical overview of Taiwan's social context, and depict the evolution of its child and maternal health policies. …

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