1. Sugrue, Noreen M.
  2. Kenner, Carole DNS, RNC, FAAN
  3. Finkelman, Anita MSN, RN

Article Content

The Lancet series on neonatal survival1 illuminated the continued massive problem of neonatal mortality. The numbers quoted were about 4 million neonates who die annually on a global basis, with this number accounting for almost half of all childhood deaths under the age of 5 years. Yet there are many programs aimed at improving these outcomes.


With all of the lip service given globally to the importance of protecting infants and children, why are the neonatal, infant, and childhood mortality rates so high? Why are preventable illnesses and deaths so prevalent? Why are we unlikely to meet the Millennium Development Goal (MDG) 4, which is aimed at reducing the under-5-years-of-age mortality? Arguably, MDG 4 is one of all the MDGs that is most indicative of improved/improving quality of life, globally. It is the most succinct measure of a society's commitment to eradicate poverty and premature morbidity and mortality. One of the most fundamental facts known to nurses is that there is a link between poverty and health that must be broken if we are to "fix" the problem of premature and preventable morbidity and mortality. Why is this not the foundation for global health policies?


It is not news that a child born to a poor woman is less well off than a child born to a nonpoor woman. Children born to poor women are more likely than children born to nonpoor women to witness or experience the following:


* a mother ill or dead from a pregnancy complication


* premature morbidity and mortality


* less access to quality healthcare, education, housing, or nutrition



In other words, neither the long- nor the short-term health and social conditions of children born to poor women are promising. Now place these poor women and children in countries whose relative and absolute wealth is low; the scale of the health, economic, and social problems these children will confront increases exponentially.


Too often healthcare providers, health policy analysts, and political leaders want to address the plight of ill, dying, or dead children because there is something morally troubling and unsettling about children born into and living in conditions that place them at high risk for premature morbidity and mortality. The presence of these conditions and wanting to rectify them drives political leaders and healthcare providers to form an alliance dedicated to improving the health of children and their mothers. This approach, driven by a desire to do good things and "fix" what is wrong in order that the healthcare system can provide better care, is to be applauded. We ought to be grateful for and to such initiatives. But we also note that what is being done is not enough. The current approach provides only part of the solution to addressing the health of neonates, infants, and child globally.


Well documented in the scientific and popular literatures is the link between poverty and poor maternal and child health outcomes. What this literature underscores are the links between health, healthcare, and poverty, and that they feed off of each other. If you are poor, you have less access to care than the nonpoor have, and with less access to care, you are likely to be sicker and less able to work, earn a living wage, and provide for yourself and your family. Yet, the actions of policy makers and healthcare providers focus only on "fixing" the healthcare systems. More training, more personnel, greater availability of medicines, more equipment, better hospitals, and clinics-if these are provided, then it is believed that the health of people, especially women and children, will improve.


There is some truth in this perspective as vaccines, prenatal care, and clean hospitals and clinics do save lives and head off some mortality. However, is it enough? Is it enough to talk about and structure policies aimed at improving healthcare delivery independent of changing the social and economic conditions in which people live? The answer appears to be a resounding no.


Nurses treat their patients in a holistic manner. They care about and attend to the medical conditions, but they also attend to and care about the familial, economic, social, and community contexts/conditions that patients face. Trained and educated to understand the holistic nature of health, nurses understand that they must learn about and perhaps even assist in changing the nonhealth conditions of patients, if patients truly are to have an opportunity for better health outcomes.


In short, because of their education, training, and worldview, nurses know that to actually affect health outcomes, the familial, social, and economic conditions in which people live must be addressed. Because nurses know this, they try to work with patients, other providers, community members, and family members to ensure the best possible outcomes. However, nurses are doing this without the political or economic infrastructure and policies needed to alter the abject poverty of their patients. It is beyond what nurses are educated or capable of doing. What is missing from global health and welfare policy debates is an acknowledgment of the link between poverty and health-what is missing is what nurses know to be true, sustainable good health outcomes cannot be achieved if patients are living in poverty.


Public policies, globally, too often are segmented, myopic, and not connected to the realities of how people live. Providing more healthcare personnel and better facilities is important but it is not enough. To fundamentally improve the lives of women and children, especially neonates, public policy must take on the holistic approach so central to nursing.


Disorders related to premature births and low birth weight, leading causes of neonatal mortality and contributing to most of the infant mortality (under one year of age), could be obliterated with appropriate education, nutrition, healthcare, and housing. Protection during the perinatal period increases improved neonatal, infant, and childhood health outcomes. Our public policies fall far short of providing what is necessary to address adequately and with certainty the morbidity and mortality rates of neonates, infants, and children.


The challenge for nurses is to translate what they know into data, policy recommendations, and programs that rectify the problem of premature morbidity and mortality in neonates, infants, and children. It is not enough to know that the link between poverty and healthcare exists and must be broken. Nurses must highlight the existence of the link and provide policy and programmatic options for altering the connection between poverty and health. That is a tall order, but it is a directive to be taken seriously if the youngest of patients are to be helped. The challenge for policy makers is to start listening to nurses-the people who care for the patients and spend the most time with them, to listen to what neonates, infants, and children need to avoid tragic and preventable premature morbidity and mortality.


The challenge for nurses is to infuse the policy arena with the scientific and clinical knowledge that leads to only one conclusion, namely, we structure healthcare policies to sever the link between poverty and health. When we do that, meeting MDG 4 as well as the other MDGs will be a foregone outcome, and premature morbidity and mortality among neonates, infants, and children will be part of our history.


Noreen M. Sugrue


University of Illinois at Urbana-Champaign College of Nursing, University of Oklahoma


Carole Kenner, DNS, RNC, FAAN


Dean, College of Nursing, University of Oklahoma President, Council of International Neonatal Nurses


Anita Finkelman, MSN, RN


Assistant Professor, College of Nursing University of Oklahoma, Oklahoma City




1. Lawn JE, Cousans S, Zupan J, for the Lancet Neonatal Survival Steering Team. Neonatal survival 1: 4 million neonatal deaths: When? Where? Why? Lancet. 2005;364;399-401. [Context Link]