Theoretical Issues General Conceptual Approaches

In general, two theoretical frameworks have been used by demographers to provide guidance and structure in research on pregnancy outcomes. The first has been termed the social model, and the second is often referred to as the medical model (e.g., Cramer

1 Lack of maturity refers to infants who are small for gestational age (SGA) or intrauterine growth retarded (IUGR). These are terms that no doubt will (and should) continue to be employed. For the sake of clarity,

1 prefer the term immature to make clear that the focus is on the mortality risk of live-born infants, not the fetal growth curve (Frisbie et al. 1998b). As is conventional, I use preterm or prematurity synonymously with short gestation.

2 Throughout, the term pregnancy outcomes will be employed to refer to both infant mortality and birth outcomes.

1995). "Social models stress the power of social variables to determine infant survival and the importance of structural change in overcoming disparate outcomes. Medical models stress pathways of frank pathophysiology and their potential interruption through clinical interventions'' (Wise 1993: 9). Not surprisingly, most demographers and other social scientists have relied on the social model, while public health and medical researchers have primarily used the medical model. Until fairly recently, many researchers have proceeded as if the two approaches were competing. For example, Wise notes that, although "vast sociologic, anthropologic, and demographic literature exists on the causes of infant mortality,'' [this body of knowledge] "is rarely tapped in the exploration of clinical pathways to adverse birth outcomes.'' The reverse is also true, as "the social sciences continue to make little use of the clinical literature in refining the search for relevant social and behavioral factors'' (1993: 9).

Today, the situation is changing. As evidenced in Wise's work, there is a growing interest in cross-disciplinary collaboration with social scientists on the part of public health and medical researchers. Further, I believe a consensus is emerging in support of the view expressed by Frank, who points out (citing Carey 1997) that, in demography, there is a growing recognition that "studies of biology of death, mortality, longevity, and life are all informed by biological processes that demographers cannot afford to ignore'' (2001: 563).

The involvement of demographers in multidisciplinary research is facilitated by the fact that the social demography of infant mortality has drawn heavily on the proximate determinants approach advanced by Mosley and Chen (1984). Despite a keen interest in those factors, especially socioeconomic variables, that are more causally distant from the outcomes of interest, the heart of this approach ''is the identification of proximate determinants that directly influence the risk of child morbidity and mortality'' (Mosley and Chen 1984: 27). Although the Mosley-Chen typology includes maternal characteristics, it is heavily weighted in the direction of biomedical factors, including environmental influences, nutrition, injury, and personal illness control (preventive and remedial) as intervening factors, thereby helping to set the stage for integrating the social and medical approaches.

This conceptual scheme is most applicable in studies of child mortality and morbidity. However, in infant mortality research, this framework has been adapted and expanded so that race/ethnicity, nativity, and other factors have joined SES as the most distal variables. Birth weight, gestational age, and maturity of infant are viewed as the most vital proximate determinants.3

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