Statement of the Problem and Study Aim. Infant mortality is internationally recognized as one of the most important indicators of health and development, yet high rates continue to plague many under-resourced settings. In South Africa, overall infant mortality is estimated to be 54 per thousand with rates up to 15 times higher among blacks than whites.

The aim of this study was to understand better the factors associated with infant deaths in resource-poor settings of South Africa. The research objectives were to document: (1) caregivers' understandings of the events leading up to the infant's death, the accessibility and desirability of local health care, and their recommendations for improving local care, and (2) the assessment of community leaders and health providers regarding the accessibility and desirability of local health care, the factors they identified as associated with infant death, and their recommendations for improving local care.

Methods. This study was exploratory and qualitative, using in-depth interviews with 50 caregivers who experienced an infant death and 19 key informants in two South African communities, one rural and one urban. A biomedical assessment also was conducted to provide an additional viewpoint on the factors associated with each death.

Results. Caregivers reported using a variety of settings and providers during their infants' final illness including public and private allopathic providers, traditional healers, home remedies, and no care. The major factors found to influence care-seeking were caregivers' living conditions and resources, health care access and quality, and caregivers' explanatory models of infants' illnesses. There were important differences between caregiver and biomedical models of infant illnesses and of 'what went wrong.' However, assessments by both caregivers and clinicians indicated that, in many cases, the infant's death resulted because of an interaction of several modifiable factors.

Conclusions. This study provides new information regarding the context in which infant deaths occurred in two South African settings, motivations for caregivers' actions, and factors that contributed to a breakdown in the health 'system' for these children. The study also provides insights into how the health system can more effectively respond to the needs of these families.