More Than Milk: The Social Determinants of Infant Mortality
Opinion Article by Dr. Khutso N. Sebetseba
“She did everything right — attended antenatal visits, breastfed exclusively — but her baby didn’t make it.”
That’s how a nurse in a rural clinic described a recent loss. The child’s mother was 17, underweight, and lived more than 20km from the nearest health facility. Her baby had severe diarrhoea. They got there too late.
It’s easy, in public health discourse, to speak in neat policy terms – early initiation of breastfeeding, exclusive feeding for six months, growth monitoring. But survival is seldom shaped by feeding alone. Infant mortality is a complex tapestry, woven with threads of poverty, education, housing, health access, race, and gender. Milk matters. But so do the conditions in which it is given.
The Hard Numbers
Globally, 2.3 million infants died in the first month of life in 2023, and another 1.5 million before their first birthday. In sub-Saharan Africa, the infant mortality rate is 48 deaths per 1,000 live births – more than 12 times higher than in high-income countries¹. South Africa has made important strides, yet significant disparities remain between urban and rural areas, private and public sectors, and across provinces².
Poverty, Food Insecurity & Maternal Nutrition
Undernourished mothers often give birth to underweight infants – a key risk factor for neonatal death³. In communities where food insecurity is chronic, feeding choices are constrained. Breastfeeding may be interrupted by the need to return to work, or by myths around “thin milk” and hunger. Worse still, access to safe water and sanitation is often lacking, increasing the risk of infection even with proper feeding practices.
Education and Health-Seeking Behaviour
Maternal education consistently ranks among the strongest predictors of child survival. A 2025 study published in BMC Public Health analyzing DHS data across 14 sub-Saharan countries found that children of mothers with lower socioeconomic status and less education were significantly more likely to die before their first birthday 4. The study highlights how disparities in infant mortality remain concentrated among poorer and less educated populations – especially those with limited access to health services, information, and early danger sign recognition. Inadequate responses to these inequities continue to perpetuate preventable losses.
In a recent Gauteng-based study, mothers cited stigma, misinformation, and fear of judgment by health workers as reasons for early introduction of solids or formula – often by 2–3 months 5. These decisions, while seemingly minor, increase the risk of infections, diarrhoea, and growth faltering.
Healthcare Access & Systemic Barriers
Physical access to clinics, inconsistent staffing, long waiting times, and poor treatment from health workers contribute to delayed care-seeking and missed opportunities. In under-resourced settings, this is compounded by a lack of neonatal beds, skilled birth attendants, or emergency transport.
Infants die not just from disease, but from distance, delay, and dysfunction.
Equity Matters: Not All Babies Start Life on Equal Footing
A baby born to a teenage mother in an informal settlement has a vastly different survival outlook than one born in a middle-income suburb – even if they’re both breastfed. Social determinants are not side issues. They are central.
The 2024 Global Breastfeeding Scorecard calls on countries to move beyond individual behaviour change campaigns and address the enabling environments -maternity protection, cash transfers, housing security, and primary healthcare 6.
We Must Layer Our Interventions
Improving infant survival isn’t about choosing between clinical and social solutions. It’s about doing both. Promoting exclusive breastfeeding and ensuring mothers have clean water. Encouraging clinic visits and making those visits free from shame. Distributing growth charts and strengthening food systems.
Because milk saves lives. But so does dignity. So does information. So does trust.
Dr. Khutso N. Sebetseba is an HMI Senior Fellow for Infant Health, Nutrition and Equity with extensive experience and special interests in newborn care, allergies and respiratory conditions, infectious diseases (particularly paediatricHIV), Neonatology and paediatric ICU care.
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References
1. UNICEF. Levels and Trends in Child Mortality Report 2023.
2. National Department of Health. Saving Lives: South Africa’s Perinatal Problem Identification Programme Annual Report, 2022.
3. World Health Organization. Born Too Soon: The Global Action Report on Preterm Birth. 2023.
4. Anteneh RM et al. Decomposing socioeconomic and educational inequalities in infant mortality in Sub-Saharan Africa. BMC Public Health, 2025.
5. Tuthill et al. Why women stop exclusive breastfeeding early in South Africa, 2023.
6. WHO & UNICEF. 2024 Global Breastfeeding Scorecard.
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