1.20 Infant and child mortality

Key messages

• 622 deaths of Aboriginal and Torres Strait Islander children aged 0–4 were recorded in the 5-year period 2015–2019. Of these deaths, 85% (527) were infants (aged under 1). Among infants who died, the majority (65% or 342) were aged under 28 days.
• The leading cause of death for Indigenous infants in 2015–2019 was conditions originating in the perinatal period (57%); while for Indigenous children aged 1–4, it was injury and poisoning (47%).
• The rate of deaths among Indigenous children aged 0–4 was 2.1 times as high as the rate of non-Indigenous children in 2015–2019.
• Between 2010 and 2019 there was no significant change in the mortality rate for Indigenous children aged 0–4. However, the rate for non-Indigenous children declined by 28%, resulting in a widening of the gap (by 58%).
• The death rate for Indigenous infants was 1.9 times as high as for non-Indigenous infants. Between 2010 and 2019, there was no significant change in the Indigenous infant mortality rate.
• 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.

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.

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).

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.

In July 2020, the National Agreement on Closing the Gap (the National Agreement) identified the importance of making sure Aboriginal and Torres Strait Islander people enjoy long and healthy lives, and ensuring Aboriginal and Torres Strait Islander children are born healthy and strong. To support these outcomes the National Agreement specifically outlines the following targets to direct policy attention and monitor progress:

• Target 1—Close the Gap in life expectancy within a generation, by 2031, (with infant and child mortality as supporting indicators)
• Target 2—By 2031, increase the proportion of Aboriginal and Torres Strait Islander babies with a healthy birthweight to 91 per cent.
• Target 4—By 2031, increase the proportion of Aboriginal and Torres Strait Islander children assessed as developmentally on track in all five domains of the Australian Early Development Census (AEDC) to 55 per cent.

For the latest data on the Closing the Gap targets, see the Closing the Gap Information Repository.

The new National Aboriginal and Torres Strait Islander Health Plan 2021–2031 (the Health Plan), provides a strong overarching policy framework for Aboriginal and Torres Strait Islander health and wellbeing and is the first national health document to address the health targets and priority reforms of the National Agreement.

‘Healthy babies and children (Age range: 0–12)’ is one of the key life course phases focused on in the Health Plan, and two objectives specifically address this age range:

• Objective 4.2. Deliver targeted, needs-based and community-driven activities to support healthy babies
• Objective 4.3. Deliver targeted, needs-based and community-driven activities to support healthy children.

Both the National Agreement and the Health Plan are discussed further in the Implications section of this measure.

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 10% of the total YLL in 2018. Infant and congenital conditions were responsible for 82% of YLL for Indigenous babies under 1. Low birthweight and a short gestation period accounted for 44% of the total burden attributable to infant and congenital conditions (AIHW 2022).

Findings

What does the data tell us?

Mortality data in this measure are from 5 jurisdictions for which the quality of Indigenous identification in the deaths data is considered to be adequate; namely, New South Wales, Queensland, Western Australia, South Australia, and the Northern Territory (see Data sources: National Mortality Database).

Child deaths

In the period 2015–2019, there were 622 deaths of Indigenous children aged 0–4 (85% or 527, were infant deaths) and 3,649 deaths of non-Indigenous children of the same age group (84% or 3,048 were infant deaths). Among this age group, the Indigenous child death rate was 2.1 times as high as the rate for non‑Indigenous children (150 and 71 per 100,000, respectively) (Table D1.20.1).

In the 5-year period 2015–2019, the death rate for Indigenous children aged 0–4 was highest for those in the Northern Territory (308 per 100,000), followed by Western Australia (174 per 100,000), Queensland (159 per 100,000), South Australia (132 per 100,000), and was lowest for Indigenous children in New South Wales (101 per 100,000). The death rate for Indigenous children in the Northern Territory was 3.1 times as high as for Indigenous children in New South Wales, and 2.3 times as high as for Indigenous children in South Australia (Table D1.20.1).

Infant deaths

In 2015–2019, 527 infant deaths (deaths of children aged less than one year) accounted for 85% of all deaths among Indigenous children aged 0–4 (Table D1.20.1). Of these infants, 342 deaths were in the neonatal period (aged under 28 days) which accounted for almost two-thirds (65%) of all infant deaths and just over half (55%) of all child deaths (aged 0–4). The death rate for Indigenous infants was 1.9 times the rate of non-Indigenous infants (5.9 and 3.0 per 1,000 live births, respectively) (Table D1.20.4).

In the 3-year period 2017–2019, the infant death rate was highest in the Northern Territory (12.1 per 1,000 live births) followed by Queensland (6.0 per 1,000), Western Australia (5.9 per 1,000), South Australia (4.7 per 1,000) and was lowest in New South Wales (4.3 per 1,000) (Table D1.20.9, Figure 1.20.1).

Figure 1.20.1: Infant (less than 1 year old) death rates, NSW, Qld, WA, SA and the NT, by jurisdiction and Indigenous status, 2017–2019

Source: Table D1.20.9. AIHW National Mortality Database.

The death rate for Indigenous infants in the 3-year period 2017–2019 was not significantly different from the rate in 2008–2010 in any of the 5 jurisdictions except for Queensland, where the rates declined from 8 to 6 per 1,000 live births (Table D1.20.9).

Causes of death

For Indigenous infants, in the 5-year period 2015–2019, the most common causes of death were conditions originating in the perinatal period (57%) (Figure 1.20.2) – for example, the influence of 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. The death rate for conditions originating in the perinatal period was twice as high for Indigenous Australians as non-Indigenous Australians and accounted for 57% of the gap in infant mortality rates.

The second leading cause of death for Indigenous infants was congenital malformations, which accounted for 15% of infant deaths. The third most common cause of death for Indigenous infants were signs, symptoms, and ill-defined conditions (14%), which includes sudden unexpected death in infancy (SUDI) and sudden infant death syndrome (SIDS), accounting for 9.7% and 4.7% of Indigenous infant deaths, respectively (Table D1.20.13).

Deaths due to SIDS among Indigenous infants was lower in 2015–2019 than in 2010–2014 (reduction from 49 to 25 deaths, or from 0.6 to 0.3 deaths per 1,000 live births) (Table D1.20.13).

Figure 1.20.2: Causes of infant (less than 1 year old) death, by Indigenous status, NSW, Qld, WA, SA and NT combined, 2015–2019

Note: Diseases and conditions presented in the underlying table with small counts have been included into the other conditions category for this figure. Therefore, this category does not reflect the other conditions grouping presented in table D1.20.13.

Source: Table D1.20.13. AIHW National Mortality Database.

For Indigenous children aged 1–4, injury and poisoning accounted for almost half of the deaths (47%). The most common causes of injury deaths were transport accidents (16% of injury deaths among Indigenous children) and accidental drowning (10%). The death rate due to injury and poisoning for Indigenous children aged 1–4 was 2.7 times the rate for non-Indigenous children (14 and 5.0 per 100,000, respectively). Deaths due to injury and poisoning accounted for 61% of the gap in death rates between Indigenous and non-Indigenous children aged 1⁠–⁠4.

For Indigenous children aged 1–4, the next highest causes of death were infectious and parasitic diseases (10%), diseases of the nervous system, and signs, symptoms and abnormal clinical and laboratory findings (both 6.3%) (Table D1.20.14, Figure 1.20.3).

Figure 1.20.3: Causes of death among children aged 1–4, by Indigenous status, NSW, Qld, WA, SA and NT combined, 2015–2019

Note: Diseases and conditions presented in the underlying table with small counts have been included into the other conditions category for this figure. Therefore, this category does not reflect the other conditions grouping presented in the table.

Source: Table D1.20.14. AIHW National Mortality Database.

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, although they also suggest these gaps are smaller than the gap in death rates between Indigenous Australian and non-Indigenous Australian infants.

In the United States, the death rate for American Indians/Alaskan Natives infants was 7.7 per 1,000 live births, compared with 5.7 per 1,000 live births for the total population in 2018.

In New Zealand, the infant death rate for Maoris was 4.5 per 1,000 live births compared with 4.3 per 1,000 live births for other infants in 2018 (Table D1.20.11).

In comparison, the rate for Indigenous infants was 1.9 times that of non-Indigenous Australians in 2019 (5.8 compared with 3.1 deaths per 100,000, respectively).

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.

Changes over time

To describe trends in mortality data, linear regression has been used to calculate the per cent change over time. This means that information from all years of the specified time period are used, rather than only the first and last points in the series (see Statistical terms and methods).

Between 2006 and 2019, in the 5 jurisdictions combined (New South Wales, Queensland, Western Australia, South Australia, and the Northern Territory), there was no significant change in the death rate for Indigenous children aged 0–4. However, there were improvements in the Northern Territory with the rate declining by 19% over this period. For non-Indigenous children, the rate declined by 41% in all 5 jurisdictions combined, with reductions seen in all jurisdictions except the Northern Territory (Table D1.20.3, Figure 1.20.4).

Over the most recent decade, 2010 to 2019, there was no significant change in the death rate for Indigenous children aged 0–4 in the 5 jurisdictions combined, or in any individual jurisdictions. For non-Indigenous children over the same period the rate declined by 28%. As a result, the absolute gap between Indigenous and non-Indigenous children (based on rate difference) widened (by 58%) (Table D1.20.3, Figure 1.20.4).

Though there is some year-to-year variability, the relative gap between Indigenous and non-Indigenous children generally increased over the decade, with rate ratios in the range 1.6–1.7 between 2010 and 2012, 1.9–2.0 between 2013 and 2016, and 2.1–2.3 between 2017 and 2019 (Table D1.20.3, Figure 1.20.4).

For Indigenous children aged 1–4, there was no significant change in the death rate in the decade from 2010 to 2019, nor over the longer period from 2006.

There was also no significant change in the absolute gap between Indigenous and non-Indigenous children aged 1–4 in either period (Table D1.20.18, Figure 1.20.4).

Figure 1.20.4: Death rates and changes in the gap for children aged 0–4 and 1–4, by Indigenous status, NSW, Qld, WA, SA and NT combined, 2006 to 2019

 

Sources: Tables D1.20.3 and D1.20.18. AIHW National Mortality Database.

The death rate for Indigenous infants declined by 34% between 2006 and 2019 (from 9.4 to 5.8 per 1,000 live births) but did not change significantly over the decade from 2010 to 2019. For non‑Indigenous infants, the rate declined by 33% between 2006 and 2019, and 23% over the decade from 2010 to 2019.

There were no significant changes in the absolute gap (rate difference) between Indigenous and non-Indigenous infants over either period. Over the decade to 2019, the relative gap (based on rate ratio) between Indigenous and non-Indigenous infants ranged from 1.5 (in 2012) to 2.1 (in 2017) (Table D1.20.8, Figure 1.20.5).

Figure 1.20.5: Infant (less than 1 year old) death rates and changes in the gap, by Indigenous status, NSW, Qld, WA, SA and NT combined, 2006 to 2019

Source: Table D1.20.8. AIHW National Mortality Database.

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, socioeconomic 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, 42% smoked in the first 20 weeks of pregnancy in 2019. After adjusting for differences in the age‑structure between the 2 populations, the rate of smoking in the first 20 weeks of pregnancy among Indigenous mothers was nearly 4 times the rate of non-Indigenous mothers (AIHW 2021).

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 et al. (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, across a range of health care settings, several factors impeded providers’ interaction with Indigenous women. This includes 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 S et al. 2019).

A prospective interventional trial in a Brisbane hospital assessed the effectiveness of a new Birthing in Our Community (BiOC) service on key maternal and infant health outcomes. The study found that women receiving services from the locally co-designed program were more likely to attend 5 or more antenatal visits, less likely to have a preterm birth and more likely to exclusively breastfeed on discharge from hospital compared with women receiving standard care services (Kildea et al. 2021).  

A review of the New Directions program found that New Direction’s organisations saw improvements in 7 out of 8 maternal and child health measures, compared with 4 out of 8 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

There was no significant change in the Indigenous child mortality rate between 2006 and 2019 and the gap between Indigenous and non-Indigenous child mortality rates widened. Over the same period, the Indigenous infant mortality rate declined by 34%, although there was a similar decline for the non-Indigenous infant mortality rate of 33%. Substantial gaps still exist between the Indigenous and non-Indigenous populations for infant and child mortality. This is a significant concern for policy that had sought greater improvement over this period.

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 5 or more antenatal sessions, and a decrease in smoking during pregnancy (AIHW 2021). However, progress in these indicators has not yet been sufficient enough to be translated into a stronger improvement in the Indigenous child mortality rate. Further research (including data linkage) is needed to better understand the reasons why. With regards to birthweight, the HPF feature article ‘Key factors contributing to low birthweight among Aboriginal and Torres Strait Islander babies’ presents more detailed statistical analysis on low birthweight including trend analysis of gestational age (pre-term, early term, full term births), birthweight and key contributing factors such as maternal health, smoking during pregnancy and antenatal care attendance. It also provides analysis of the level of improvement required in smoking rates to meet the birthweight target in the National Agreement.

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, along with service gaps, indicate 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 National Agreement was developed in partnership between all Australian governments and the Coalition of Aboriginal and Torres Strait Islander Peak Organisations. Each party to the National Agreement has developed their own Implementation Plan and will report annually on their actions to achieve the outcomes of the Agreement. Plans have been developed and will be delivered in partnership with Aboriginal and Torres Strait Islander partners.

The Health Plan, released in December 2021, is the overarching policy framework to drive progress against the Closing the Gap health targets and priority reforms. States, territories and other implementation partners can take flexible approaches to implementing Health Plan priorities. Their approaches will depend on local needs and priorities, led by Aboriginal and Torres Strait Islander people and communities (Department of Health 2021).

Implementation of the Health Plan aims to drive structural reform towards models of care that are prevention and early intervention focused, with greater integration of care systems and pathways across primary, secondary and tertiary care. It also emphasises the need for mainstream services to address racism and provide culturally safe and responsive care, and be accountable to Aboriginal and Torres Strait Islander people and communities.

The Health Plan suggests that efforts should be targeted at providing strengths based, culturally safe and holistic, affordable services to ensure a strong start to life. Birthing on Country services have the potential to support healthy pregnancies and should be explored as a way to offer an integrated, holistic and culturally safe model of care. For example, Birthing on Country services can support reduction and cessation of smoking in pregnancy through health-literacy approaches.

As part of the National Agreement, the health sector was identified as one of 4 initial sectors for joint national strengthening effort and the development of a 3-year Sector Strengthening Plan. The Health Sector Strengthening Plan (Health-SSP) was developed in 2021, to acknowledge and respond to the scope of key challenges for the sector, providing 17 transformative sector strengthening actions. Developed through strong consultation across the Aboriginal and Torres Strait Islander community-controlled health sector and other Aboriginal and Torres Strait Islander health organisations, the Health SSP will be used to prioritise, partner and negotiate beneficial sector-strengthening strategies.

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: Australian Health Ministers' Advisory Council.
• 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 2018. Closing the Gap targets: 2017 analysis of progress and key drivers of change. Canberra: AIHW.
• AIHW 2021. Australia's mothers and babies. Canberra: AIHW.
• AIHW 2022. Australian Burden of Disease Study: Impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2018. Canberra: Australian Institute of Health and Welfare.
• 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.
• Department of Health 2021. National Aboriginal and Torres Strait Islander health plan 2021–2031. Government of Australia.
• 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, Gao Y, Hickey S, Nelson C, Kruske S, Carson A et al. 2021. Effect of a Birthing on Country service redesign on maternal and neonatal health outcomes for First Nations Australians: a prospective, non-randomised, interventional trial. The Lancet Global Health 9:e651-e9.
• 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 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.