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The Lost Decade: Infant Mortality in Ghana

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Title:
The Lost Decade: Infant Mortality in Ghana
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Journal of Undergraduate Research
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Harper, Genevieve
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Gainesville, Fla.
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University of Florida
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English

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serial ( sobekcm )

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Ghana is hailed as “an island of peace and stability” in the volatile landscape of sub-Saharan West Africa; a success story of the World Bank and International Monetary Fund (Atakpu, 2004). Four peaceful democratic transitions between 1996 and 2008 have placed Ghana firmly, in the eyes of the world, as the clear leader amongst sub-Saharan African countries in the race for human development. In spite of this, the infant mortality rate in Ghana is high relative to the rest of the world. It is a contributing factor in the ranking of Ghana as 135th for human development out of the 177 countries studied by the 2007-2008 United Nation's Human Development Report. The level of poverty reduction and economic stability achieved in Ghana since the year 2000 has not been matched by a proportional reduction in the infant mortality rate which, rather than trending downwards as expected, has stagnated (Department for International Development, 2008). Physical quality of life can be described by a number of indicators. One of the most important and reliable is the infant mortality rate (Shen and Williamson, 1997). As the main causes of infant mortality are highly preventable, in places where infants are regularly dying the physical quality of life is poor (Frey, Field, 2000). Ghana is an example of economic growth and human development not progressing at commensurate rates—evidenced by the stagnation in the reduction of infant mortality experienced over the past decade. This paper examines the factors associated with infant mortality rates, along with the possible reasons for the persistence of high levels of infant mortality in Ghana. Sub-Saharan Africa is subject to conditions which make its infant mortality rates higher than in the rest of the world. Though Ghana has achieved more economic success than most of its sub-Saharan African counterparts, most of the countries in the region are stricken by similar issues. While certain factors contributing to the stagnation in Ghanaian infant mortality like the Human Immunodeficiency Virus (HIV) seem obvious, others are more insidious and difficult to isolate. This paper provides substantial evidence that the failure to reduce measured infant mortality rates in Ghana between 2000 and 2007 is due mainly to extremely high levels of neonatal mortality. Also, the poor allocation of foreign aid has helped to perpetuate an infrastructure of healthcare and education that is inadequate for the needs of the country.

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The Lost Decade: Infant Mortality in Ghana


College of Liberal Arts and Sciences, University of Florida


Introduction

Ghana is hailed as "an island of peace and stability" in
the volatile landscape of sub-Saharan West Africa; a
success story of the World Bank and International
Monetary Fund (Atakpu, 2004). Four peaceful democratic
transitions between 1996 and 2008 have placed Ghana
firmly, in the eyes of the world, as the clear leader amongst
sub-Saharan African countries in the race for human
development. In spite of this, the infant mortality rate in
Ghana is high relative to the rest of the world. It is a
contributing factor in the ranking of Ghana as 135th for
human development out of the 177 countries studied by the
2007-2008 United Nation's Human Development Report.
The level of poverty reduction and economic stability
achieved in Ghana since the year 2000 has not been
matched by a proportional reduction in the infant mortality
rate which, rather than trending downwards as expected,
has stagnated (Department for International Development,
2008).
Physical quality of life can be described by a number of
indicators. One of the most important and reliable is the
infant mortality rate (Shen and Williamson, 1997). As the
main causes of infant mortality are highly preventable, in
places where infants are regularly dying the physical
quality of life is poor (Frey, Field, 2000). Ghana is an
example of economic growth and human development not
progressing at commensurate rates-evidenced by the
stagnation in the reduction of infant mortality experienced
over the past decade.
This paper examines the factors associated with infant
mortality rates, along with the possible reasons for the
persistence of high levels of infant mortality in Ghana.
Sub-Saharan Africa is subject to conditions which make its
infant mortality rates higher than in the rest of the world.
Though Ghana has achieved more economic success than
most of its sub-Saharan African counterparts, most of the
countries in the region are stricken by similar issues. While
certain factors contributing to the stagnation in Ghanaian
infant mortality like the Human Immunodeficiency Virus
(HIV) seem obvious, others are more insidious and
difficult to isolate. This paper provides substantial evidence
that the failure to reduce measured infant mortality rates in
Ghana between 2000 and 2007 is due mainly to extremely


high levels of neonatal mortality. Also, the poor allocation
of foreign aid has helped to perpetuate an infrastructure of
healthcare and education that is inadequate for the needs of
the country.

Measurement Issues

Economic growth is often measured by the gross
domestic product (GDP) per capital. This measure is
problematic when determining levels of development as
per capital income may vary widely amongst a population.
A few very rich people may raise the GDP to a level that is
not representative of the majority. Gross National Product
(GNP) and its variant GDP tend to undervalue and exclude
the contribution of women as much of their work is
undertaken within the household and the service sector
(Harris, 1997). In addition, the quality of data in de-
veloping countries is often poor, leading to incorrect
assessments of GDP (Nassar and Payne, 2007). The sole
use of GNP or GDP as a measure of development risks
excluding vital components of the economy and painting
an inaccurate portrait of the level of economic
development.
Despite the best efforts of agencies (The World Health
Organization, The United Nations, etc.) the accuracy of
demographic data obtained in developing countries is
questionable (Sibai, 2004). The most common mistakes
made in data collection tend to cause an underestimation of
the infant (death > one month), and more specifically
neonatal (death < 28 days), mortality rate. Heaping, the
phenomenon where parents report the death of an infant
but round the age up to one year, is problematic as it leads
to a misclassification of the death as a child mortality
rather than an infant mortality (Johnson et al., 2005).
Parents are also likely to underreport deaths that occur
early in infancy which then causes an underestimation of
the neonatal morality rate (Ghana Statistical Services and
MacroInternational Inc.,1999). With these statistical
discrepancies in mind, the question must be asked: is the
stagnation of infant mortality in Ghana real? Or, have data
collection and reporting methods merely improved, causing
more deaths to be accurately reported?
A qualitative analysis of the literature finds that levels
of neonatal mortality in earlier decades were under-


University of Florida I Journal of Undergraduate Research I Volume 10, Issue 4 I Summer 2009


Genevieve Harper







GENEVIEVE HARPER


estimated to a greater extent than today while rates of
infant mortality have actually been falling. When the two
are combined to find the overall infant mortality rate, there
is indeed a stagnation caused by the greater reported
number of neonatal deaths. This paper finds support for the
hypothesis that the greater involvement of international
bodies in data collection within Ghana since its democratic
transition may have improved the accuracy of demographic
statistics obtained since.

Why Are Infants Dying?

While the factors that affect infant mortality are wide-
ranging and difficult to isolate, sub-Saharan Africa is
subject to certain diseases and environmental issues that
substantially contribute to high levels of infant mortality.
Many infants in Ghana are dying from inherently fixable
problems. The examination of individual contributing
factors provides insight into what might be done to fix
these problems. This paper hypothesizes that improved
female education is necessary to end the stagnation in the
reduction of infant mortality in Ghana (Gill, Pande and
Malhotra, 2007). In addition, continued economic
development will lead to an improved physical quality of
life for the population and eventually reduce the infant
mortality rate.

Neonatal Mortality
In order to meet the millennium development goals of
reducing child mortality for those under age 5, Ghana must
conquer its high incidence of neonatal mortality. Neonatal
mortality (death < 28 days) has increased, whereas there
has been slight improvement in mortality for infants aged 1
to 11 months (Pond, Addai and Kwashie, 2005 p. 1846).
The neonatal mortality rate increased from approximately
30 per 1,000 in the 1998 Ghana Demographic and Health
Survey (GDHS) to 43 per 1,000 in the 2003 GDHS
(Ghana's Development Agenda and Population Growth,
2006, p 21). It is possible that recent demographic surveys
have underestimated the number of neonatal deaths
occurring by either contributing them to infant deaths or
simply by the parents not reporting them (Johnson,
Rutstein and Govindasamy, 2005). A reduction in neonatal
deaths is highly achievable, yet in order to do so certain
Ghanaian cultural taboos regarding child-rearing must be
overcome.
Regional differences are most apparent when dealing
with cultural taboos surrounding child rearing. Newborn
babies in certain cultural settings within Ghana are denied
colostrum, the mother's nutrient rich first milk, during the


first few days of life. This denial is due to the belief the
colostrum is dirty and will cause the baby to be ugly
(Gyimah, 2005). A study that took place in rural Ghana
concluded that, "16% of neonatal deaths could be saved if
the infants were fed from day 1 and 22% if breastfeeding
started within the first hour" (Edmond et al., 2006 p. 384).
Not only do cultural beliefs include breastfeeding, but
they also often dictate the type and amount of food women
are allowed to consume while pregnant. The women of the
Mole-Dagbani group of northern Ghana are denied protein
during pregnancy, which in turn significantly affects the
women's nutritional status as well as the infant's birth
weight (Gyimah, 2005). Low birth weight babies comprise
from 60 to 80% of neonatal deaths (Lawn, Cousens and
Zupan, 2005 p. 896). Low birth weight can contribute
indirectly to neonatal deaths by making the infant more
vulnerable to diarrhea, sepsis and pneumonia (Black et al.,
2008). Maternal mortality is also strongly correlated with
neonatal mortality (Lawn, Cousens, and Zupan, 2005).
Between 1990 and 2005 there has been very little reduction
to the maternal mortality rate in Ghana, which quite
probably has contributed to the stagnation in the reduction
of infant mortality (Gill and Pande, 2007). Decreasing
maternal deaths and increasing health care coverage to
under-served areas is vital to reducing neonatal mortality.

HIV/AIDS
Nowhere has HIV/AIDS had a more devastating impact
than in sub-Saharan Africa. It seems logical to conclude
that the failure to reduce infant mortality in Ghana is a
result of the increasingly deadly epidemic. However, infant
mortality in Ghana requires closer examination. According
to the United Kingdom's Department for International
Development (DFID), Ghana is an anomaly for sub-
Saharan Africa in that it has a relatively low rate of
HIV/AIDS with only 3.2% of the population infected
(DFID, 2008). As of 2005 the United Nations reported that
Ghana's HIV/AIDS rate was in decline for the first time in
five years (UN office for the coordination of humanitarian
affairs, 2005).
While still an official measure of the prevalence of
HIV/ AIDS in Ghana, the data used to obtain the afore-
mentioned results is quite probably incomplete. It is
difficult to ascertain the true presence of HIV/AIDS in the
population due to social stigmas surrounding the disease
and lack of health care facilities. This leads researchers to
believe that only approximately 30% of cases are reported.
In addition, variations in gender, region and occupation are
often overlooked in the collection of HIV/AIDS statistics
in Ghana (UNICEF, 2008). The divide between North and


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INFANT MORTALITY IN GHANA


South Ghana is particularly stark; prevalence rates of 3 to
6.5 percent exist in southern areas and approximately 1.8
percent in the less affected northern areas (United Nations
Office for the Coordination of Humanitarian Affairs, 2008).
A possible reason for the discrepancy in HIV/AIDS rates
between the North and South could be that there are very
few health care facilities in the rural Northern areas, thus
making it almost impossible for people to be tested even if
they are aware of the issue.
Under these circumstances, HIV/AIDS could be having
a much larger impact on infant mortality than otherwise
estimated. "The epidemic is concentrated in countries that
are low performers in life expectancy and infant and child
survival rates. It thus prevents them from catching up with
the high performers or at least from catching up as fast as
they would otherwise do" (Neumayer, 2004). An
improvement in HIV/AIDS treatment would undoubtedly
improve the Ghanaian infant mortality rate, yet likely not
to the same extent as treatment and prevention of other
problems such as diarrhea and malnutrition

Birth Order and Birth Spacing
A restructuring of birth spacing in Ghana is vital to
achieving a reduction in infant mortality. Birth order, birth
spacing, age and education of the mother are intrinsically
linked to infant mortality rates. Infants that are born first,
or are in high birth order amongst their siblings have higher
rates of mortality due in large part to the youth of the
mother (Ghana Statistical Services and MacroIntemational
Inc., 1999).
Infants born less than 24 months after the preceding
birth are more likely to die in infancy than those infants
born after a greater birth interval (Ghana Statistical
Services and MacroIntemational Inc., 1999). The mother's
body does not have sufficient time to recover after several
short birth intervals so the likelihood of her having an
infant with health issues goes up (Ghana Development
Agenda and Population Growth, 2006). Infants are also
prone to higher mortality rates when born closely to a
sibling as the amount of time a mother will then spend
breastfeeding is likely to be reduced (Ghana Development
Agenda and Population Growth, 2006).
The impact of birth order on infants could be reduced
by increasing the average age at which women give birth to
their first child. Increasing the age and education of the
mother would give first-born children a greater chance of
survival.
Problems created by poor birth spacing are fixable with
increased social education, particularly of females, and
improved usage of contraceptives.


Women and Infant Mortality
Sub-Saharan Africa has a high preponderance of child
marriages (marriage before the age of 18). Ghana is no
exception with between 25.1% and 50% of women married
before the age of 18. In addition to the negative effects
upon the women themselves, infants born to mothers under
age 20 have a 73% higher mortality rate than infants born
to older mothers (Levine et al., 2008).
As discussed above, birth order and spacing have an
enormous impact on an infant's likelihood of survival. The
mother's age is an important factor in making decisions
concerning the number of children or the frequency at
which she desires to have them. Women under the age of
18 feel less able to speak to their husbands about concerns,
including contraception and birth spacing (Levine et al.,
2008). Women who first give birth at a young age are more
apt to have shorter birth intervals between their children
than would an older woman who had given birth for the
first time (Gyimah, 2005).
A number of studies find a pronounced negative
correlation between education attained by the mother and
levels of infant mortality (Ghana Statistical Services and
MacroInternational Inc., 1999; Field and Frey, 2000).
Annually, Ghana's population growth rate is 2.7%; one of
the highest population growth rates in the world (Ghana
Development Agenda and Population Growth, 2006). This
growth can be attributed to high fertility rates combined
with lack of contraceptive usage. Contraceptive usage goes
up by approximately 10% in urban areas and also improves
significantly with the educational level attained by the
mother (Studies in Family Planning, 2005; Gyimah, 2005).
34.2% of women between the ages of 15-29 do not use,
and do not intend to use, any form of contraceptive because
they fear the side effects (Studies in Family Planning,
2005). Contraceptive use and breastfeeding are correlates
of birth intervals; the more an infant is breastfed or a
couple uses contraceptives, the greater the birth interval
will be (Gyimah 2005).

Infrastructure and Foreign Aid
Ghana has been the favored child of the international
community amongst its sub-Saharan African con-
temporaries due to its relative success in economic
development. As of 2007, Ghana has been the recipient of
$1.136 billion (US$) in loans and grants but its external
debt remains high at $3.387 billion. Of these funds, the
World Bank has been the major multilateral contributor
(Goldsmith, 2001). Ghana has received nearly $37 million
($US) per year from 2004 to 2007 from the U.S. Agency
for International Development alone (USAID, 2008). Even


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GENEVIEVE HARPER


though these are large sums, Ghana's external debt requires
that money which could otherwise have been spent on
social services is used for debt service. In this manner,
Ghana is "aid dependent"; it could not carry on functioning
in its present manner without external funding and advice
(Goldsmith, 2001). In recognition of the problem that large
amounts of debt create for developing countries, The
International Monetary Fund and World Bank have made
debt relief available for heavily indebted countries, of
which Ghana is one, provided that they meet certain
conditions (International Monetary Fund, 2008).
The Heavily Indebted Poor Countries Initiative should
have freed up resources to spend on health, education and
social services yet this effect is not seen reflected in any
reduction of the rate of infant mortality. Clearly, Ghana
receives substantial amounts of aid, but why is it not
reaching the people who need it the most? Vast disparities
exist between regions and social classes with poor; the
richest 20% have a 46.6% share of the overall consumption
and income in the country (Human Development Report
2007/2008). While Ghana's level of political corruption is
better than much of sub-Saharan Africa, an elite class is
still in place controlling the disbursement of funds. Even
amongst the poor, women residing in rural areas remain the
most disadvantaged group of all with little to no access to
health care, credit or education.
The emergence of cost-effective public health care is
necessary within Ghana. The inadequate health care
infrastructure currently in place means that in 2003 only
6.6% of women were attended during childbirth by a
doctor with the vast majority of these residing in urban
areas (Studies in Family Planning, 2006). There are
approximately 15 physicians for each 100,000 people in
Ghana (Human Development Report 2007/2008).

Conclusion

The lack of a significant reduction of infant mortality
rates in Ghana between 2000 and 2008 is attributable to the
same factors affecting infant mortality in the rest of the
world, yet not enough has been done to combat these issues
in Ghana. Development aid has been disbursed in a manner
that has benefited mostly the urban population centers.
Rural areas are without adequate health care and
educational facilities thereby perpetuating the cycle of
poverty.
This paper finds support for the hypothesis that
increasing education, particularly with women, will lead to
a significant reduction in the rate of infant mortality in
Ghana. Birth spacing, education and age of the mother, can


be positively influenced through the educational and
financial empowerment of women. Social acceptance of
contraceptives must become more widespread.
A qualitative examination of the literature finds that
continued economic development could eventually bring
about a reduction in the infant mortality rate but must be
combined with social modernization in order to be most
effective. The effects of economic development on infant
mortality likely will not be felt for many years; Ghana has
already lost a decade to high rates of infant mortality-it
must not lose a generation.

Works Cited

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health consequences." The Lancet (2008): 243-60.
"Country Profiles: Ghana." Department for International Development. 11 Apr.
2008. .
"Debt Relief Under the Heavily Indebted Poor Countries Initiative." International
Monetary Fund. Mar. 2008. /exr/facts/hipc.htm>.
Edmond, Karen M., Charles Zandoh, Maria A. Quigley, Seeba Amenga-Etego,
Seth Owusu-Agyei, and Betty R. Kirkwood. "Delayed Breastfeeding
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