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Health behaviour and health awareness in infant mortality in the Gaza Strip

Mazen Abuqamar, Danny Coomans, Fred Louckx
DOI: http://dx.doi.org/10.1093/eurpub/ckr105 539-544 First published online: 25 August 2011

Abstract

Background: Infant death rate has declined over the past decades, yet remains high in Palestine. The topic of infant death is well researched and for the first time in Palestine. The objective of our study is to assess the level of awareness and health behaviour of mothers and how this behaviour has affected infant mortality. Methods: Person to person interviews were done with 550 mothers of infants (275 cases and 275 controls) in the Gaza Strip. Stillbirths were excluded. Binary logistic regression analyses were used to identify the relationship of health behavioural factors and infant mortality. Result: The study showed that infant mortality risks were higher in mothers exposed to passive smoking. Infant mortality was lower for infants receiving exclusive breastfeeding. There was also a significant association between the sleeping position of the baby and infant mortality. Conclusion: The findings underscore the importance of explicit attention to health education. A well-organized consultation and health promotion approach should focus on couples whose child has died, in order to combat infant mortality.

Introduction

The infant mortality rate (IMR) is defined as the risk for a live born child to die before its first birthday. It is known to be one of the most sensitive and commonly used indicators of the social and economic development of a population.1,2 At the individual level, significant disparity of health behaviour and awareness among mothers are repeatedly recorded, even when the overall IMR reaches very low levels.3 Protective maternal behaviours including co-sleeping behaviour, especially among mothers who breastfeed, exclusive breastfeeding and proper care of babies are vital components of infant survival.4,5

There are a great many literature reviews focusing on the determinants of infant and child mortality.6,7 Most of these studies have shown a significant association between the level of health behaviour and awareness of parent and infant–child mortality.8–10 Vigorous educational campaigns have positive effects on infant survival by informing mothers on the positive effects of breastfeeding, how to care for the baby, longer birth intervals and fewer children.11

In Palestine, many research studies were carried out on the medical causes of infant mortality. Our study offers important insights into health behaviour and awareness and how this can affect the health status of infants. We aim to assess the impact of parent's health behaviour and awareness on the survival of their infant.

Methods

Life-births who died before their first anniversary (cases) vs. life-births who survived the first year of life (controls) were enrolled into a case–control study conducted in the Gaza Strip. This design was selected because it is relatively simple, requires few subjects and is logistically easy and less expensive.12 Individual matching was applied by selection of one control for each case. We carried out matching for location of residence, gender and civilian status. The study was conducted in all governorates of Gaza (North, Gaza, Middle, Khanyounis and Rafah). The inclusion criteria were: considered as the case group—babies born alive who died within their first year of life in the Gaza Strip during 2008; considered as the control group—babies who did not die within their first year of life and were born during the period June 2007–end of May 2008. We excluded stillbirths and twin status.

First, we gathered the numbers of dead infants during 2008 (990 dead infants) and babies born during the period from first of June 2007 to end of May 2008 (50 000 live births) from civilian records (Ministry of Civilian Affair).

Cases were selected using a systematic random sampling technique. Initially we identified the required sample size, which were 330 dead infants (30 for the pilot study and 300 for the main study). Then, we divided the total number of the population (990 dead infants) with the sample size to obtain the sampling fraction. The sample fraction was 3 and so we started selection with number 1 then 4, 7, 10 and so on.

Approval was received from all participants, the ethical committee of the academic hospital of the Free University of Brussels and the Ministry of Health in the Gaza Strip prior to the start of the study.

Data collection started at the 1 September 2009 and finished at the end of January 2010.

Person-to-person interviews were carried out with the cases and control mothers. Five female qualified staff members, with a social and medical background, interviewed the mothers at home. Their work was supervised on location by Walid Sabah, Head of the Health Education department of the Ministry of Health in the Gaza Strip. The completed questionnaires were scanned and sent as soft copies to the researcher working at the Department of Medical Sociology of the Free University of Brussels. Hard copies of the questionnaires were printed in Brussels, where the data entry took place.

The questionnaire included questions about family characteristics (maternal history, paternal history), pregnancy history, latest pregnancy (course of pregnancy, perinatal care use and delivery), health behaviour and lifestyle habits (during pregnancy, after delivery) and living conditions.

Pilot testing was done prior to the start of the main study. The aim of the pilot study was to check the reliability and validity of the questionnaire as well as to evaluate the possible outcome. We also wanted to identify obstacles we were likely to face during the data collection, such as the accessibility of the participants, in order to minimize the non-response rate in the main study. The pilot study was performed on 60 participants (30 cases and 30 controls), representing 10% of the main study. The pilot study was conducted in the Gaza governorate, because it is the biggest governorate and the most representative for the sample (including refugees, non-refugees, low and high socio-economic levels). Four staff members carried out the pilot study during a 10-day period. Every interviewer did one to two interviews daily at the mother's home. As a result of our pilot study our questionnaire was updated. As access to the participants proved to be rather difficult, we recruited one more interviewer for the main study.

For the main study, 285 dead infants were selected as case. We selected equal numbers for control. The response rate was 96% (275 cases, 275 controls).

Variables

We considered the following variables as health behaviour and health awareness factors according to the definition of the Palestinian Annual Health Report (MoH, 2007) and Strategic Health Plan of the Palestinian Authority (2003).

Practicing sport during pregnancy was categorized as never, once a week, twice a week or more than two times a week. Passive smoking was categorized as mothers either exposed to passive smoking or not. Our study included only passive smoking, because only 1% of the mothers were smokers. Exclusive breastfeeding was defined as the mother breastfeeding her baby for 6 months. Sleep location was categorized as the baby sleeping alone or with the parents. Sleeping position of baby was categorized as supine position, prone position or side position. The prone position was defined as being in horizontal position when lying face down. The source of drinking water was categorized as tap water, boiled tap water and mineral water. The final variable was categorized as babies receiving iron and vitamin supplement or not.

Duration of pregnancy was categorized as term (≥37 weeks of gestation) and pre-term birth (<37 weeks of gestation).

Neonatal mortality refers to a death of a live-born baby during the first 28 completed days of life, while post-neonatal mortality covers the remaining 11 months of the first year of life. Early neonate refers to a death of a live-born baby during the first week of life, while late neonate refers to death of a live-born baby from the second week up to end of the fourth week.

Proximate factors were defined as main medical causes of infant mortality in the Gaza Strip. They were categorized as prematurity and low birth weight, congenital anomaly, respiratory disease, infectious disease and septicaemia, sudden infant death and malnutrition.

Statistical analysis

All analyses were performed with the Statistical Package for the Social Sciences (SPSS) (IBM–SPSS Statistics v19.0). Descriptive statistics were used to describe the main features of the data and to study the first-hand relationship between the variables. Bivariate chi-square test was used to identify significant associations (α = 0.05) between each of the covariates of interests and dependent variable.

Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated as estimates of relative risk.

Two logistic models were developed. The first model represents the association of health behaviour and health awareness factors with infant mortality, while adjusting for the effect of pregnancy duration (term and pre-term birth). In the second model, the effects of health behaviour and health awareness variables were measured, still excluding pre-term babies from each group.

We used also binary logistic regression to assess the association between health behavioural and awareness factors and dichotomous dependant variable (neonate or post-nate) after adjusting for proximate factors.

A significant result means that the P-value for the ordinal level measure is <0.05 and the CI is 95%.

Ethical approval

We obtained the necessary approvals to conduct this study. We obtained four consent forms: from the Ministry of Health; from the Helsinki committee in the Gaza strip; from the UZ-VUB ethical committee; and from the parents.

Results

Table 1 summarizes the influence of health behaviour and health awareness on infant mortality in the Gaza Strip. Passive smoking was higher among the mothers of dead infant (59%) than among the mothers of surviving infants (38%). Over 95% of surviving infants received exclusive breastfeeding, whereas only 68% of dead infants had exclusive breastfeeding. The Sleeping position and sleep location of the baby are predisposing factors for sudden infant death. The prone position was more present among dead infants (43%) than among surviving infants (24%). Over 95% of surviving infants had a single bed, whereas only 68% of dead infants had a single bed. The mothers who practiced sports during pregnancy were higher among live-births’ mothers (16%) compared with dead infants’ mothers (5%). Over 68% of surviving infants received iron and vitamins drops, while only 23% of dead infants received these drops.

View this table:
Table 1

Cross tabulation and chi-square tests—health behaviour and health awareness

DeterminantsCase, n (%)Control, n (%)χ2 valueP-value
Passive smoking during pregnancy275 (100)275 (100)23.60.000
    Yes163 (59.2)106 (38.5)
    No112 (40.8)169 (61.5)
Exclusive breastfeeding275 (100)275 (100)70.60.000
    Yes187 (68.0)263 (95.6)
    No88 (32.0)12 (4.4)
Sleeping position of baby275 (100)275 (100)21.20.000
    Supine85 (31.0)114 (41.5)
    Prone118 (43.0)67 (24.3)
    Side position72 (26.0)94 (34.2)
Sleep location of baby275 (100)275 (100)25.40.000
    Alone118 (68.0)263 (95.6)
    Shared with parents157 (32.0)12 (4.4)
Sport during pregnancy275 (100)275 (100)19.20.000
    Never261 (95.0)231 (84.0)
    Once a week8 (3.0)23 (8.5)
    Twice a week2 (1.0)12 (4.3)
    More than two times a week3 (1.0)9 (3.2)
Babies received iron and vitamins275 (100)275 (100)113.50.000
    Yes65 (23.6)189 (68.7)
    No210 (76.4)85 (31.3)
Source of drinking water (baby)275 (100)275 (100)34.80.000
    Tap water11 (4.0)2 (1.0)
    Boiled tap water232 (84.3)188 (68.3)
    Mineral water32 (11.7)85 (29.7)
  • P < 0.05 indicates a significant association.

The source of drinking water was also a determinant factor of infant mortality. Thirty per cent of surviving infants received mineral water and 68% received boiled tap water, whereas 11% of dead infants received mineral water, 84% received boiled tap water and 4% tap water.

All health behaviour and health awareness variables had significant association with infant mortality when they were tested separately by chi-square test (P-value = 0.000).

In table 2, the first model showed that passive smoking, breastfeeding, sleeping position and sleep location were found to be statistically significant for infant mortality.

View this table:
Table 2

Logistic regression—health behaviour and health awareness in infant mortality

DeterminantsP-valueAdjusted OR (95% CI)P-value*Adjusted OR* (95% CI)
Passive smoking during pregnancy0.0390.029
    Yes0.0391.82 (1.14–3.19)0.0292.23 (1.39–4.28)
    No11
Breastfeeding0.0480.037
    Non-exclusive breastfeeding0.0482.01 (1.48–4.08)0.0372.83 (1.24–6.71)
    Exclusive breastfeeding11
Sleeping position of baby0.0290.009
    Supine0.0791.2 (0.42–2.84)0.0951.3 (0.29–3.19)
    Prone0.0132.95 (1.37–4.92)0.0043.47 (1.44–6.21)
    Side position11
Sleep location of baby0.0410.011
    Shared with parents0.0411.85 (1.08–3.91)0.0112.04 (1.39–5.28)
    Alone11
Sport during pregnancy0.1230.042
    Non-exerciser0.1230.83 (0.29–2.15)0.0421.92 (1.05–3.85)
    Exerciser11
Babies received iron and vitamins0.2010.010
    Yes11
    No0.2011.43 (0.29–5.31)0.0102.39 (1.28–6.01)
Source of drinking water (baby)0.0780.014
    Tap water0.0322.89 (1.85–4.71)0.0043.29 (1.96–8.49)
    Boiled tap water0.1341.01 (0.21–2.81)0.0921.73 (0.85–3.26)
    Mineral water11
  • P < 0.05 indicates a significant association.

  • P-value and Adjusted OR: all variables were entered in one model with adjustment for pregnancy duration (pre-term, term)

  • P-value* and Adjusted OR*: all variables were entered in one model-related infant mortality for only term baby.

The risk of infant death was almost twice as high among mothers who were exposed to passive smoking than among mothers not exposed to passive smoking (OR 1.82, CI = 1.14–3.19).

The risk of dead infants was also twice as high among infants who did not receive exclusive breastfeeding and infants sharing their bed with parents (OR 2.01, 1.85, CIs = 1.48–4.08, 1.08–3.91). The risk of infant death was three times higher among infants sleeping in prone position than among infants sleeping in side position (OR 2.95, CI = 1.37–4.92).

The risk of infant death was three times higher among infants who received tap water compared with infants receiving mineral water as a source of drinking (OR 2.89, CI = 1.85–4.71).

We found, according to the ORs, that the prone sleeping position and tap water were the strongest health behaviour factors, followed by non-exclusive breastfeeding, bed-shared sleep location and passive smoking.

In the second model, all health behaviour and health awareness factors had a significant association with infant mortality.

Not all results of first model confirm the significant association tested by model two, because of the effect of pre-term birth on the infant mortality. So, sport during pregnancy, iron and vitamin supplements and source of drinking water were not significant determinants for infant mortality (P-value = 0.123, 0.201, 0.078).

Table 3 shows the influence of health behaviour and health awareness factors on the infancy period among cases after adjusting for the proximate factors.

View this table:
Table 3

General characteristics and adjusted ORs of neonatal and post-natal mortality

DeterminantsEarly (0–7)Late (8-28)Neonate (0–28)Post-neonate (29-365)P-value (Adj. OR, 95% CI)
N (%)N (%)N (%)N (%)
Passive smoking during pregnancy110 (100)48 (100)158 (100)117 (100)0.038
    Yes60 (54.5)20 (41.7)80 (50.6)64 (54.7)2.23 (1.05–4.73)
    No50 (45.5)28 (58.3)78 (49.4)53 (45.3)1
Exclusive breastfeeding110 (100)48 (100)158 (100)117 (100)0.052
    Yes54 (49.1)25 (52.1)79 (50.0)94 (80.3)1
    No56 (50.9)23 (47.9)79 (50.0)23 (19.7)1.08 (0.45–3.97)
Sleeping position of baby110 (100)48 (100)158 (100)108 (100)0.071
    Prone70 (63.6)33 (68.7)103 (65.1)63 (58.3)1.19 (0.28–4.67)
    Side position40 (36.4)15 (31.3)55 (34.9)45 (41.7)1
Sleep location of baby110 (100)48 (100)158 (100)111 (100)0.110
    Alone52 (47.3)27 (56.3)79 (50.0)73 (65.8)1
    Shared with parents58 (52.7)21 (43.7)79 (50.0)38 (34.2)0.52 (0.23–1.16)
Sport during pregnancy110 (100)48 (100)158 (100)117 (100)0.217
    No97 (88.2)34 (70.8)131 (82.9)107 (91.5)2.18 (0.63–7.69)
    Yes13 (11.8)14 (29.2)27 (17.1)10 (8.5)1
Babies received iron or vitamins110 (100)48 (100)158 (100)117 (100)0.022
    Yes23 (20.9)0 (0.0)23 (14.6)42 (35.9)1
    No87 (79.1)48 (100.0)135 (85.4)75 (64.1)2.98 (1.78–3.75)
Source of drinking water (baby)110 (100)48 (100)158 (100)110 (100)0. 199
    Tap water33 (30.0)11 (22.9)44 (27.8)28 (25.5)2.1 (0.94–4.11)
    Boiled tap water66 (45.5)28 (58.3)94 (59.5)63 (57.2)0.98 (0.34–1.78)
    Mineral water11 (24.5)9 (18.9)20 (12.7)19 (17.3)1
  • P < 0.05 indicates a significant association.

  • P-value and adjusted OR: all variables were entered in one model with adjustment for proximate factors (low birth weight and prematurity, congenital anomaly, respiratory diseases, infectious diseases, sudden infant death and malnutrition)

When health behavioural and health awareness factors were entered into a logistic regression model and adjusted for proximate factors, the significant associations were absent in most factors except passive smoking and iron and vitamin supplements.

Figure 1 showed that pre-term birth and low birth weight were higher among case group (19.85%, 19.65 of total sample) than among control group (6.38%, 4.73% of total sample). There is a high correlation between pregnancy duration and birth weight (73.6%, not shown).

Figure 1

Pregnancy duration and birth weight among cases and controls

Discussion

Our study highlights the influence of health behaviour and health awareness on infant mortality. Unhealthy behaviour by and low health awareness of the parents are risk factors for having dead infants. The scientific literature has linked declining infant mortality primarily to awareness of the mothers to affordable health services, breastfeeding and nutrition standards, universal immunization and vitamins, non-smoking and prenatal and obstetric services.13–15

The results of our study are consistent with previous research studies that showed the impact of passive smoking on infant mortality. The study of Karcaaltincaba et al.16 in Turkey shows the harmful effects of passive smoking on infant and foetus (miscarriage, intrauterine growth retardation, pre-term birth, foetal mortality–morbidity, post-partum infant death, premature rupture of membranes, lung disease and attention deficit). The study of Wirth et al.17 in France also supports our findings, when it shows that smoke exposure can have serious health consequences leading to infant mortality (sudden infant death, respiratory infections). In addition, smoking by the father appears to increase the risk for infant mortality, but this is not found in all studies.18,19

In our study, the sleeping position and sleep location of the baby are highly correlated with infant death. Many research studies confirm the relationship between the Sleeping position and sudden infant death and which is considered one of the main causes of infant mortality.20–22 The study of Hauck et al.,23 found that approximately one-third of the sudden infant deaths could be attributed to a prone position. The sleep location of the baby is also a crucial cause of infant mortality. Bed-sharing is also a cause of sudden infant death. The women most likely to bed-share are low-income and single mothers.24 Three major epidemiological studies have shown that when a committed caregiver, usually the mother, sleeps in the same room but not in the same bed with their infant, the chance of the infant dying from sudden infant death syndrome (SIDS) is reduced by 50%.25–27

Exclusive breastfeeding also has a substantial independent influence on infant mortality in our results. Many research studies proved this influence on infant survival.8,11,15 Breastfed infants in the USA have lower rates of morbidity, especially from infectious disease, but there are no contemporary US studies of the effect of breastfeeding on all-cause mortality in the first year of life.28 The study of Vennemann et al.29 in Germany shows that both partial breastfeeding and exclusive breastfeeding are associated with a reduced risk of infant death. The study of Ford et al.30 in New Zealand has also shown a substantial association of exclusive breastfeeding with a reduced risk of infant mortality.

Few research studies examined the relationship between exercise (sport) during pregnancy and infant mortality. Until now exercise during pregnancy has not been conclusively demonstrated to be beneficial in improving perinatal outcome.31 Our results show a positive association between exercise during pregnancy and infant survival. The study of Hall and Kaufmann32 in USA on 845 pregnant women supports our findings, when it found that the pregnancy outcomes were more favourable in the exercise groups, particularly the high-exercise group. In a prospective study on 800 pregnant women, Hatch et al.33 found the value of exercise during pregnancy is controversial. Both benefits and risks have been hypothesized. He reports that a moderate exercise level is positively associated with foetal growth and that it gives a good prognosis of a healthy neonatal period. In contrast with our findings, the study of Cavalli and Tanaka34 found no relationship between exercise during pregnancy and infant mortality. They found that maternal leisure-time physical activities before and/or during pregnancy had no bearing on the delivery of a low birth weight baby that is the main cause of infant mortality.

Iron deficiency and iron deficiency anaemia are major public health problems that affect millions of individuals throughout the life cycle, particularly infants and pregnant women.35 Our findings show that the administration of iron and vitamins to the babies had a positive impact on infant survival. The study of Money36 in New Zealand is consistent with our finding when it reports the existence of a dietary link between infant mortality (sudden infant death) and vitamin E/selenium deficiency.

Local and international reports support our findings that tap water is unhealthy source for drinking and lead for morbidity and mortality. In 2000, the World Health Organization (WHO) and UNICEF37 found that more than one-fifth of the drinking water samples from existing urban water systems in developing countries were contaminated with bacteria and pollutants. A total of 90% of the Gaza Strip water samples were found to contain nitrate concentrations that were between two and eight times higher than the limit recommended by the WHO.38 In babies <6 months, nitrate can lead to methaemoglobinaemia, diarrhoea and acidosis. Mahmoud Daher, WHO officer in Gaza, declared that the risk of outbreak of waterborne and food-borne diseases was high during the conflict since 2007, because drinking water had not been properly chlorinated due to movement restrictions. Cutler and Grant39 found that clean water was responsible for cutting three-quarters of infant mortality and nearly two-thirds of child mortality in the USA in the first 40 years of the 20th century.

To our knowledge, our study is the first of this kind in the Gaza Strip. This is the first study in Palestine in which health behaviour and health awareness factors were considered when assessing the IMR.

Our study is also original in its design because it first assesses the effect of each variable separately on infant mortality; afterwards it enters all variables together in logistic regression model.

Although our findings offer insights into health behavioural and health awareness factors and their effect on infant mortality, they must be interpreted in the light of a certain study limitation. The majority of outcomes were based on self reporting, which is liable to social desirability and recall bias.

Conclusions

This is the first study in Palestine in which health behaviour and health awareness factors were considered when assessing the IMR. We hope this study will be the first step of a more evidence-based approach of infant mortality in the Gaza Strip.

Improved knowledge of the risks of passive smoking has favourably influenced legislation banning smoking in enclosed public places. While there is a strong need for education on quitting smoking during pregnancy; prevention of passive smoking should have the highest priority.

There is an identified need for campaigns to avoid bed-sharing and prone sleeping position. We would also recommend including advising breastfeeding up to 6 months of age in all infant mortality risk-reduction messages. This supports the need for more positive promotion and active community support to further enhance the level and length of exclusive breastfeeding.

We also share the point of view of Palestinian and German scientists, when they recommend that the authorities in the Gaza Strip take immediate measures to combat excessive nitrate levels in drinking water.

Funding

Department of Research and Development of the Free University of Brussels [PKC OZR1887/MEZOWER1, 2009/0172].

Conflicts of interest: None declared.

Key points

  • This is the first study in Palestine in which health behaviour and health awareness factors were considered when assessing the IMR in the Gaza Strip.

  • Prone sleeping position and bed-sharing with parents are predisposing factors for infant mortality.

  • Breastfeeding is a protective factor against infant mortality.

  • The risk of infant death was higher among infants who received tap water compared with infants receiving mineral water as a source of drinking water.

  • Pre-term birth has a moderate confounding effect on the association of health behavioural and health awareness factors and infant mortality.

Acknowledgments

The authors gratefully thank those who made this study possible. The authors are heartily thankful to Mr Walid Sabah who was the Regional Supervisor of the staff members in Gaza Strip. The authors the five staff members (Fulla Sharaf, Affaf Al Najjar, Amera EL-Nawajha, Sama Al-Sahar and Sohear Keshttah) who carried out the interviews with the mothers in Gaza Strip. Without their collaboration obtaining such relevant data would have been impossible. M.A. (corresponding author) contributed to the conception and design of the study. He gathered the data, contributed to the analysis and interpretation of the data and wrote the article. He gives his final approval to the published version. D.C. contributed to the statistical side of the study and the interpretation of data. He revised the article critically for the statistical content and gives his final approval to the published version. F.L. contributed to the conception and design of the study and the interpretation of the data. He revised the article critically for intellectual content and gives his final approval to the published version.

References

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