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Postneonatal mortality: a performance indicator of the child health care system.

This discussion presents the rationale for using postneonatal mortality as a proxy health status measure, briefly reviews some recent epidemiologic observations and international comparisons related to postneonatal mortality, focuses on implications of postneonatal mortality as a performance indicator of the child health care delivery system, especially for vulnerable infants, and concludes with some thoughts about policy issues concerning health care for children.
 A first birthday has been heralded as one of life's most celebrated and significant anniversaries. This is not only a personal moment marking a milestone along life's continuum, it is also a sentinel measure or indicator of the health status of the children living in a particular society and indeed of the society itself.
 We have characterized this qualitative marker as an infant mortality rate. We have also differentiated two age periods during the first year of life, the first 28 days and the 11 months remaining until 1 year of age, yielding neonatal and postneonatal mortality rates. Traditionally, these two rates have been considered to be reflective of nature and nurture, or endogenous and exogenous events; neonatal mortality is associated more closely with biologic processes in utero and at delivery, whereas postneonatal mortality is influenced more by parenting or caring for the infant directly, and consequently more amenable to the effects of proper interventions.
 Our accumulated knowledge clearly indicates, however, that both nature and nurture affect the well-being of the infant. Moreover, the distinction between neonatal mortality and postneonatal mortality based solely on "age-at-death" may be less useful today; advances in life-saving perinatal technology often extend survival beyond the first 28 days of life but not beyond the first birthday.