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Tier 1 - Health status and outcomes

1.20 Infant and child mortality

Key facts

Why is it important?

Infant mortality (less than 1 year of age) and child mortality (0–4 years of age) are long-established measures of child health as well as the overall health of the population and its physical and social environment. Australia’s infant and child mortality rates have declined over the last 100 years due to improved social and public health conditions. In the first half of the twentieth century, there were improvements in sanitation and health education. This was followed by the development of immunisation and, in more recent years, better treatment in neonatal intensive care and interventions for Sudden Infant Death Syndrome (SIDS). However, there is a large gap in infant and child mortality between Aboriginal and Torres Strait Islander people and non-Indigenous Australians. In 2008, the Council of Australian Governments committed to halving the gap in mortality rates for Indigenous children under 5 years by 2018. However, this target was not met.

The recently established National Agreement on Closing the Gap has identified the importance ensuring Indigenous Australian children are born healthy and strong. This includes a specific outcome, target and indicators to direct policy attention and monitor progress. Reporting arrangements for the new agreement are being established. The data presented in this report predates the establishment of the Agreement.

The key risk factors associated with infant and child mortality include low birthweight and pre-term births, maternal health and behaviours (for example, nutrition during pregnancy, smoking and alcohol use), socioeconomic status and access to health services (AIHW 2014a; PM&C 2020). Access to quality medical care, public health initiatives and safe living conditions serve as protective factors and can improve the chances of having a healthy baby (AIHW 2018). Studies have shown an association between inadequate antenatal care and higher rates of these risk factors, so improved access to, and take-up of, antenatal care services presents opportunities for improving child outcomes (Taylor et al. 2013).

Burden of disease

Infant deaths (deaths of children aged less than one year) contribute substantially to total years of life lost (YLL) due to premature mortality for Indigenous Australians, accounting for 11% of the total YLL in 2011. Infant and congenital conditions were responsible for 80% of YLL for Indigenous babies under 1 (AIHW 2016).

Findings

What does the data tell us?

Child deaths

In the period 2014–2018, there were 603 deaths of Indigenous children aged 0–4 (85% or 514, were infant deaths) and 3,672 deaths of non-Indigenous children of the same age group (84% or 3,068 were infant deaths). Among this age group, the Indigenous child death rate was twice the rate for non‑Indigenous children (146 and 72 per 100,000, respectively) (Table D1.20.1). Data in this measure are available for five jurisdictions that had Indigenous identification data of adequate quality (New South Wales, Queensland, Western Australia, South Australia and the Northern Territory).

Between 1998 and 2018, the death rate for Indigenous children aged 0–4 declined by 42%. The gap between Indigenous and non‑Indigenous Australians narrowed by 40%. Both changes were significant (Figure 1.20.1).

The greatest improvements in the death rate for Indigenous children aged 0–4 occurred earlier in the period, between 1998 and 2008. There was a significant decrease (of 30%) in the death rate for Indigenous children aged 0–4 and a significant decrease (of 50%) in the gap between Indigenous and non-Indigenous children over the period. Between 2008 and 2018, the death rate for Indigenous children continued to decline (by 7%), but this was not a statistically significant change. The gap with non-Indigenous children widened significantly (by 51%) over the period 2008 to 2018 (Table D1.20.3, Figure 1.20.1).

Figure 1.20.1: Death rates for children aged 0–4 and children aged 1–4, NSW, Qld, WA, SA and NT combined, by Indigenous status and age group, 1998–2018

In this figure, the first line chart shows that between 1998 and 2018, the death rate for Indigenous children aged 0 to 4 decreased from 217 to 141 per 100,000, and for non-Indigenous children it decreased from 115 to 67. The second line chart shows that over the same period, the death rate for Indigenous children aged 1 to 4 for Indigenous was highest in 2005 at 53 per 100,000 and then decreased to 27 per 100,000 in 2018. For non-Indigenous children aged 1 to 4 the death rate decreased from 33 to 13 per 100,000 between 1998 and 2018.

Source: Tables D1.20.3, D1.20.18. AIHW and ABS analysis of the ABS Causes of Death Collection.

In 2014–2018, the death rate for Indigenous males aged 0–4 was slightly higher than for Indigenous females aged 0–4 (159 and 131 per 100,000, respectively) (Table D1.20.2).

Infant deaths

Infant deaths (deaths of children aged less than one year) accounted for 85% of all deaths among Indigenous children aged 0–4 in 2014–2018 (Table D1.20.1). The death rate for Indigenous infants was 2.1 times the rate of non-Indigenous infants (6.3 and 3.1 per 1,000 live births, respectively). Infant deaths in the neonatal period (fewer than 28 days) accounted for 65% (336) of all infant deaths (Table D1.20.4).

The death rate for Indigenous infants declined significantly (by 69%), from 13.5 to 5.1 per 1,000 live births, between 1998 and 2018. The gap between death rates for Indigenous infants and non-Indigenous infants narrowed significantly (by 86%) over the same period (Figure 1.20.2).

The greatest improvements in infant death rates were seen prior to 2008, with the gap between Indigenous and non-Indigenous infants narrowing by 61% between 1998 and 2008 (from 9.0 to 3.1 per 1,000 live births). From 2008 to 2018, there was no significant change in the gap between Indigenous and non-Indigenous infants. Over this period, there was a smaller decrease in the death rate for Indigenous infants (a 16% decrease that was not significant) than non-Indigenous infants (a significant decline of 29%) (Table D1.20.8, Figure 1.20.2).

Figure 1.20.2: Infant (less than 1 year old) death rates, by Indigenous status, NSW, Qld, SA, WA and NT combined, 1998–2018

This line chart shows that the death rate for Indigenous infants decreased from 13.5 per 1,000 live births in 1998 to 5.1 per 1,000 in 2018, and the death rate for non-Indigenous infants decreased from 4.4 to 2.9 per 1,000 live births over the same period.

Source: Table D1.20.8. AIHW and ABS analysis of the ABS Causes of Death Collection.

In 2016–2018, the death rate for Indigenous infants varied across Australia; the rate was lowest in South Australia (4.2 per 1,000 live births) and highest in the Northern Territory (13.7 per 1,000 live births) (Table D1.20.9, Figure 1.20.3).

Figure 1.20.3: Infant (less than 1 year old) death rates, NSW, Qld, WA, SA and the NT, by jurisdiction and Indigenous status, 2016–2018

This bar chart shows that the infant death rate was highest in the Northern Territory, both for Indigenous infants (13.7 per 1,000 live births) and non-Indigenous infants (5.1 per 1,000). The infant death rate was the lowest was in South Australia for Indigenous infants (4.2 per 1,000) and in Western Australia for non-Indigenous infants (2.3 per 1,000).

Source: Table D1.20.9. AIHW and ABS analysis of the ABS Causes of Death Collection.

Causes of death

In the five year period 2014–2018, the most common causes of death for Indigenous infants were conditions originating in the perinatal period (57%), such as the influence of maternal factors related or unrelated to pregnancy, complications of pregnancy, labour or delivery, disorders related to the length of gestation or fetal growth and respiratory and cardiovascular disorders specific to the perinatal period.

The second-leading cause of death for Indigenous infants was signs, symptoms and ill-defined conditions (15%), which includes sudden unexpected death in infancy and SIDS—two conditions that accounted for 9.9% and 4.7% of Indigenous infant deaths, respectively. The third most common cause of death for Indigenous infants was congenital malformations, which accounted for 14% of infant deaths (Table D1.20.13, Figure 1.20.4).

Figure 1.20.4: Causes of infant (less than 1 year old) death, by Indigenous status, NSW, Qld, WA, SA and NT combined, 2014–2018

This bar chart shows that among infants (those aged less than 1 year old) over half of deaths (57% for Indigenous infants and 55% for non-Indigenous infants) were caused by certain conditions originated in perinatal period, such as maternal factors, complications of pregnancy, labour or delivery, disorders related to the length of gestation or fetal growth and respiratory and cardiovascular disorders specific to the perinatal period.

Source: Table D1.20.13. AIHW and ABS analysis of the ABS Causes of Death Collection.

For Indigenous children aged 1–4, injury accounted for around half of the deaths (49%), compared with 32% for non-Indigenous children. The injury mortality rate for Indigenous children aged 1–4 was 2.8 times the non-Indigenous rate (13 and 4.8 per 100,000, respectively). For Indigenous children aged 1–4, the next highest causes of death were infectious and parasitic diseases (7.9%) and diseases of the nervous system and respiratory system (both 6.7%) (Table D1.20.14, Figure 1.20.5).

Figure 1.20.5: Causes of death among children aged 1–4, by Indigenous status, NSW, Qld, WA, SA and NT combined, 2014–2018

This bar chart shows that injury caused about half (49.4%) of all deaths of Indigenous children aged 1 to 4, and 32.5% of deaths of non-Indigenous children. The next most common cause of death for Indigenous children aged 1 to 4 was certain infectious and parasitic diseases which accounted for 7.9% of deaths of Indigenous children and 6.5% of deaths of non-Indigenous children.

Source: Table D1.20.14. AIHW and ABS analysis of the ABS Causes of Death Collection.

International comparisons

International statistics show that Indigenous infants in the United States and New Zealand have higher death rates than infants in the general population, and these gaps are similar to but smaller than the gap in death rates between Indigenous Australian and non-Indigenous Australian infants (ratios 1.4 and 1.8 compared with 2.1). In the United States, the death rate for American Indians/Alaskan Natives was 8.3 per 1,000 live births, compared with 5.8 per 1,000 live births for the total population in 2017. In New Zealand the infant death rate for Maoris was 5.9 per 1,000 live births compared with 3.2 per 1,000 live births for other infants in 2016 (Table D1.20.11).

Caution must be used when comparing data with other countries due to variations in data quality, the methods applied for addressing data quality issues and the definitions for identifying the Indigenous status of individuals.

What do research and evaluations tell us?

Child mortality is associated with a variety of factors such as maternal health, quality and access to medical care, socio-economic conditions and public health practices.

Maternal smoking continues to pose a challenge for reducing Indigenous infant and child mortality. Although the number of Indigenous mothers who were smoking during pregnancy is declining, over 43% smoked in the first 20 weeks of pregnancy in 2017, which was nearly 4 times the rate of non-Indigenous mothers (11%) (AIHW 2019).

Apart from adverse postnatal outcomes caused by maternal smoking during pregnancy, researchers found that smoking during lactation and second-hand smoke exposure were associated with increased risk of SIDS, neurodevelopmental and behavioural disorders, short-term sleep disruption, increased risk of obesity, impaired glucose homeostasis and increased risk of long-term respiratory allergy (asthma and rhinitis) (Banderali et al. 2015).

Health services play a critical role in the reduction of major risk factors for child mortality. In a systematic review of maternal and child health and wellbeing (MCH) programs, Jongen and others (2014) highlighted the importance of community health services for the health of Indigenous mothers and babies (Jongen et al. 2014). It was found that being community based or community controlled is an important factor in the success of Indigenous MCH programs around Australia.

Although the most common component of MCH interventions was identified as health promotion/education and advice/support, smoking cessation interventions to help Indigenous women who smoked during pregnancy have been underutilised. There was a lack of evaluation of the effectiveness of approaches to smoking cessation among Indigenous pregnant women (Jongen et al. 2014).

Another study identified that involving Indigenous women in decisions about their health care were a feature of quality care. It was noted that Aboriginal Community Controlled Health Services were better placed than mainstream services to be able to address these barriers through delivering care that meets Indigenous women’s social, practical and health care needs, and by having strong links with the community (Hunt 2006).

However, several factors impeded providers’ interaction with Indigenous women, including cultural gaps, communication difficulties, a lack of time in appointments, lack of continuity of care, prescriptive protocols and provider concerns about Indigenous women making decisions not in line with health recommendations (Hunt 2006).

A prospective cohort study in Brisbane found that a significant reduction in preterm births can be achieved with targeted innovation through a multi-agency partnership. The partnership has increased Indigenous community accessibility to maternity services for Indigenous families and improved the management of these services. These have led to culturally responsive early intervention that would not otherwise be available through a hospital-based tertiary maternity service (Kildea et al. 2019).

A review of the New Directions program found that New Direction’s organisations saw improvements in seven out of eight maternal and child health measures, compared with four out of eight measures for non-New Direction organisations. Areas of improvements include the proportion of first antenatal visits before 13 weeks of pregnancy, birthweight recorded, child health assessment, adult health assessment, child immunisations at age 1 recorded, immunisations at age 2 recorded and immunisations at age 3 recorded. The only measures that did not improve were for the proportion of babies recording normal birthweights (AIHW 2014b).

A study in New South Wales found that Indigenous children are almost twice as likely to die as non-Indigenous children in tertiary children’s hospital networks. The higher number of deaths in Indigenous children are most commonly from outer regional and remote areas, and for children aged under 2 years with perinatal or circulatory conditions (Singer et al. 2019).

There is a high burden of child injury and child mortality in remote communities. It has been well documented that injuries resulting from external causes are major causes of death for Indigenous children in Australia. Research has found that Indigenous children across different communities around the world experience a significantly higher burden of morbidity and mortality from unintentional injuries. Most of these injuries, such as burns, poisoning and transport injuries, are highly preventable. The risks of these injuries are increased by high exposure to hazards in the living environment, lack of means of protection and living in remote areas (Möller et al. 2015).

Implications

The Indigenous infant mortality rate decreased during the period 1998 and 2018. However, progress since 2008 has slowed and substantial gaps still exist between the Indigenous and non-Indigenous populations for infant and child mortality. This is a significant concern for policy and efforts to halve the gap that had sought greater improvement over the past decade.

A continued focus on maternal and child health services to deliver quality continuity of care for mothers and babies during and after pregnancy is needed. A key component of improving pregnancy outcomes is early and ongoing engagement in antenatal care, which is facilitated by the provision of culturally appropriate and evidence-based care relevant to the local community (Clarke & Boyle 2014). These services also need to be geographically accessible and offer outreach services and home visits and provide continuity of care and integration with other services (AHMAC 2012). Strategies addressing potentially modifiable risk factors (such as smoking, alcohol and substance use) as well as fostering positive health behaviours (such as healthy diet and exercise) should be an important focus of antenatal care delivery.

There has been an increase in Indigenous Australian mothers attending antenatal care in the first trimester, a slight increase in attendance at five or more antenatal sessions, and a decrease in smoking during pregnancy (AIHW 2019). However, progress in these indicators has not translated into a stronger improvement in the Indigenous child mortality rate. Further research (including data linkage) is needed to better understand the reasons why.

Preconception care, typically through primary health care, can be an important avenue to address risk factors for women of reproductive age, including improving reproductive health literacy. However, time constraints and competing priorities for preventive health in the primary health care setting may mean preconception care is underutilised, particularly among Indigenous Australian women at the younger and older ends of reproductive age. Integrating preconception care into existing clinical practice with existing Medicare items such as health assessments and chronic disease management will provide more opportunities for brief interventions (Griffiths et al. 2020).

The new National Agreement on Closing the Gap was developed in partnership between all Australian governments and the Coalition of Aboriginal and Torres Strait Islander Peak Organisations. This new agreement outlines a better way of working, with governments working in genuine partnership with Aboriginal and Torres Strait Islander people to achieve better outcomes. The National Agreement sets out ambitious targets and new priority reforms that will change the way governments work to improve outcomes experienced by Indigenous Australians. The National Agreement specifically outlines the following outcome and target to direct policy attention and monitor progress:

  • Outcome 2—Aboriginal and Torres Strait Islander children are born healthy and strong.
    • Target—By 2031, increase the proportion of Aboriginal and Torres Strait Islander babies with a healthy birthweight to 91 per cent.

The annual Indigenous infant and child mortality rates are affected by variations in the numbers of deaths, lags in the registration of births and deaths and changes in Indigenous status identification. This affects comparability over time.

The Indigenous child mortality rate is also influenced by changes in data sources used in calculating the population estimates used in the statistics. As stated in the Summary report, over the period 1998 to 2006, rates may be less reliable than rates since 2006 since the reliability of the population estimates used in the statistics lessens the further away the time series moves from the 2016 Census upon which they are based (PM&C 2020). This may have the effect of overstating the early improvements in the Indigenous child mortality rate, while the more recent trends, based on more reliable data, indicate less progress has been made.

The time series analysis spanning 1998 to 2018 reflects the extent of the data that is available for both numerators and denominators. The time series from 2008 is chosen to reflect the baseline year for the expired target to halve the gap in child mortality by 2018, for which infant mortality was a supporting indicator.

The policy context is at Policies and strategies.

References

  • AHMAC (Australian Health Ministers’ Advisory Council) 2012. Clinical Practice Guidelines: Antenatal Care – Module 1. (ed., Department of Health and Ageing). Canberra: AHMAC.
  • AIHW (Australian Institute of Health and Welfare) 2014a. Timing impact assessment of COAG Closing the Gap targets: Child mortality. Canberra: AIHW.
  • AIHW 2014b. New Directions: Mothers and Babies Services—assessment of the program using nKPI data—December 2012 to December 2013. Canberra: AIHW.
  • AIHW 2016. Australian Burden of Disease Study: impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011. Australian Burden of Disease Study series 6. Cat. no. BOD 7. Canberra: AIHW.
  • AIHW 2018. Closing the Gap targets: 2017 analysis of progress and key drivers of change. Canberra: AIHW.
  • AIHW 2019. Australia's mothers and babies 2017—in brief. Canberra: AIHW.
  • Banderali G, Martelli A, Landi M, Moretti F, Betti F, Radaelli G et al. 2015. Short and long term health effects of parental tobacco smoking during pregnancy and lactation: a descriptive review. Journal of translational medicine 13:327.
  • Clarke M & Boyle J 2014. Antenatal care for Aboriginal and Torres Strait Islander women. Australian Family Physician 43:20-4.
  • Griffiths E, Marley JV & Atkinson D 2020. Preconception Care in a Remote Aboriginal Community Context: What, When and by Whom? International journal of environmental research and public health 17:3702.
  • Hunt J 2006. Trying to make a difference: a critical analysis of health care during pregnancy for Aboriginal and Torres Strait Islander women. Australian Aboriginal Studies:47.
  • Jongen C, McCalman J, Bainbridge R & Tsey K 2014. Aboriginal and Torres Strait Islander maternal and child health and wellbeing: a systematic search of programs and services in Australian primary health care settings. BMC pregnancy and childbirth 14:251.
  • Kildea S, Gao Y, Hickey S, Kruske S, Nelson C, Blackman R et al. 2019. Reducing preterm birth amongst Aboriginal and Torres Strait Islander babies: a prospective cohort study, Brisbane, Australia. EClinicalMedicine 12:43-51.
  • Möller H, Falster K, Ivers R & Jorm L 2015. Inequalities in unintentional injuries between indigenous and non-indigenous children: a systematic review. Injury prevention 21:e144-e52.
  • PM&C (Department of the Prime Minister and Cabinet) 2020. Closing the Gap Report 2020.
  • Singer R, Zwi K & Menzies R 2019. Predictors of in-hospital mortality in aboriginal children admitted to a tertiary paediatric hospital. International journal of environmental research and public health 16:1893.
  • Taylor LK, Lee YY, Lim K, Simpson JM, Roberts CL & Morris J 2013. Potential prevention of small for gestational age in Australia: a population-based linkage study. BMC Pregnancy and Childbirth 13:210.

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