Postneonatal Mortality Research Articles

Mortalidade infantil: tendência temporal e contribuição da vigilância do óbito

Resumo Objetivo Analisar a tendência temporal da mortalidade infantil na cidade de Recife, Pernambuco, Brasil e avaliar a contribuição da vigilância do óbito como instrumento para aprimoramento das estatísticas vitais e planejamento de ações. Métodos Foram calculados os coeficientes de mortalidade infantil, neonatal e pós-neonatal para o período de 1980 a 2012. Utilizou-se o modelo de regressão exponencial para análise da tendência. Para avaliar a contribuição da vigilância do óbito infantil foi realizado um estudo sobre as variáveis, causas básicas e associadas da Declaração de Óbito, e da evitabilidade. Resultados A tendência do coeficiente de mortalidade infantil e seus componentes etários foram decrescentes. Após a investigação da vigilância do óbito infantil nenhuma variável da Declaração de Óbito ficou incompleta e, em 52% dos óbitos, a causa básica foi melhor definida. Quase 80% dos óbitos foram classificados como evitáveis e 51,3% reduzíveis por adequada atenção à mulher na gestação. Conclusão A mortalidade infantil apresentou tendência decrescente e a vigilância do óbito infantil contribuiu para aprimorar as estatísticas vitais, fundamental para o planejamento das ações de saúde materno-infantil.

Trend in infant mortality rate in Argentina within the framework of the Millennium Development Goals.

Infant mortality rate (IMR) is an indicator of the health status of a population and of the quality of and access to health care services. In 2000, and within the framework of the Millennium Development Goals, Argentina committed to achieve by 2015 a reduction by two thirds of its 1990 infant mortality rate, and to identify and close inter-jurisdictional gaps. The objective of this article is to describe the trend in infant mortality rate in Argentina and interjurisdictional gaps, infant mortality magnitude and causes, in compliance with the Millennium Development Goals. A descriptive study on infant mortality was conducted in Argentina in 1990 and between 2000 and 2013, based on vital statistics data published by the Health Statistics and Information Department of the Ministry of Health of Argentina. The following reductions were confirmed: 57.8% in IMR, 52.6% in neonatal mortality rate and 63.8% in post-neonatal mortality rate. The inter-provincial Gini coefficient for IMR decreased by 27%. The population attributable risk decreased by 16.6% for IMR, 38.8% for neonatal mortality rate and 51.5% for post-neonatal mortality rate in 2013 versus 1990. A significant reduction in infant mortality and its components has been shown, but not enough to meet the Millennium Development Goals. The reduction in IMR gaps reached the set goal; however, inequalities still persist.

Feeling the Squeeze: The Effect of Birth Spacing on Infant and Child Mortality During the Demographic Transition

A negative association between birth spacing and infant and child mortality has been consistently identified within modern populations in developing countries. Generally speaking, children born following shorter birth intervals have been found to have higher mortality (Hobcraft, McDonald, & Rutstein, 1985; Kozuki et al., 2013; Rutstein, 2005). The reasons for this association are unclear, however. Leading hypotheses attempt to explain these differences as a result of sibling competition, maternal depletion, infection transmission, or unobserved maternal factors that simultaneously influence fertility and infant mortality (e.g. inadequate breastfeeding practices), but none has had overwhelming support. This study contributes to this body of research in a few important ways. First, it examines this association in a historical context, which has largely been ignored, and documents how the relationship evolved over the course of economic development. The data come from the Roteman Database, a longitudinal register kept for Stockholm, Sweden between 1878 and 1926. Second, it attempts to isolate some of the hypothesized causal mechanisms by studying variation within families by controlling for maternal fixed-effects thereby eliminating the potential for compositional differences among mothers to drive this relationship. Third, it exploits variation in the timing of death of older siblings to assess the plausibility of the different causal mechanisms. Results suggest that the relationship between preceding interval length and mortality holds even when accounting for unobservable maternal factors, particularly for post-neonatal and early childhood (age 1-4) mortality. The association disappeared over time as infectious disease mortality fell and deaths of previous siblings during the postnatal period disproportionately tended to increase the risk of dying among index children. These findings strongly suggest that the relationship is related to the transmission of disease between siblings.

Why Is Infant Mortality Higher in the United States Than in Europe?

The US has higher infant mortality than peer countries. In this paper, we combine micro-data from the US with similar data from four European countries to investigate this US infant mortality disadvantage. The US disadvantage persists after adjusting for potential di erential reporting of births near the threshold of viability. While the importance of birth weight varies across comparison countries, relative to all comparison countries the US has similar neonatal (<1 month) mortality but higher postneonatal (1-12 months) mortality. We document similar patterns across Census divisions within the US. The postneonatal mortality disadvantage is driven by poor birth outcomes among lower socioeconomic status individuals.

Thirteen-year mortality and morbidity in preterm infants in Switzerland

ObjectiveTo report the population-based, gestational age (GA)-stratified mortality and morbidity for very preterm infants over 13 years in Switzerland.DesignA prospective, observational study including 95% of Swiss preterm infants (GA <32...

Timing of initiation, patterns of breastfeeding, and infant survival: prospective analysis of pooled data from three randomised trials.

Although the benefits of exclusive breastfeeding for child health and survival, particularly in the post-neonatal period, are established, the independent beneficial effect of early breastfeeding initiation remains unclear. We studied the association between timing of breastfeeding initiation and post-enrolment neonatal and post-neonatal mortality up to 6 months of age, as well as the associations between breastfeeding pattern and mortality. We examined associations between timing of breastfeeding initiation, post-enrolment neonatal mortality (enrolment 28 days), and post-neonatal mortality up to 6 months of age (29-180 days) in a large cohort from three neonatal vitamin A trials in Ghana, India, and Tanzania. Newborn babies were eligible for these trials if their mother reported that they were likely to stay in the study area for the next 6 months, they could feed orally, were aged less than 3 days, and the primary caregiver gave informed consent. We excluded infants who initiated breastfeeding after 96 h, did not initiate, or had missing initiation status. We pooled the data from both randomised groups of the three trials and then categorised time of breastfeeding initiation as: at ≤1 h, 2-23 h, and 24-96 h. We defined breastfeeding patterns as exclusive, predominant, or partial breastfeeding at 4 days, 1 month, and 3 months of age. We estimated relative risks using log binomial regression and Poisson regression with robust variances. Multivariate models controlled for site and potential confounders. Of 99 938 enrolled infants, 99 632 babies initiated breastfeeding by 96 h of age and were included in our prospective cohort. 56 981 (57·2%) initiated breastfeeding at ≤1 h, 38 043 (38·2%) at 2-23 h, and 4608 (4·6%) at 24-96 h. Compared with infants initiating breastfeeding within the first hour of life, neonatal mortality between enrolment and 28 days was higher in infants initiating at 2-23 h (adjusted relative risk 1·41 [95% CI 1·24-1·62], p<0·0001), and in those initiating at 24-96 h (1·79 [1·39-2·30], p<0·0001). These associations were similar when deaths in the first 4 days of life were excluded (1·32 [1·10-1·58], p=0·003, for breastfeeding initiation at 2-23 h, and 1·90 [1·38-2·62], p=0·0001, for initiation at 24-96 h). When data were stratified by exclusive breastfeeding status at 4 days of age (p value for interaction=0·690), these associations were also similar in magnitude but with wider confidence intervals for initiation at 2-23 h (1·41 [1·12-1·77], p=0·003) and for initiation at 24-96 h (1·51 [0·63-3·65], p=0·357). Exclusive breastfeeding was also associated with the lower mortality during the first 6 months of life (1-3 months mortality: exclusive vs partial breastfeeding at 1 month 1·83 [1·45-2·32], p<0·0001, and exclusive breastfeeding vs no breastfeeding at 1 month 10·88 [8·27-14·31], p<0·0001). Our findings suggest that early initiation of breastfeeding reduces neonatal and early infant mortality both through increasing rates of exclusive breastfeeding and by additional mechanisms. Both practices should be promoted by public health programmes and should be used in models to estimate lives saved. Bill & Melinda Gates Foundation through a grant to the WHO.

Increased Duration of Paid Maternity Leave Lowers Infant Mortality in Low- and Middle-Income Countries: A Quasi-Experimental Study.

BackgroundMaternity leave reduces neonatal and infant mortality rates in high-income countries. However, the impact of maternity leave on infant health has not been rigorously evaluated in low- and middle-income countries (LMICs). In this study, we utilized a difference-in-differences approach to evaluate whether paid maternity leave policies affect infant mortality in LMICs.Methods and FindingsWe used birth history data collected via the Demographic and Health Surveys to assemble a panel of approximately 300,000 live births in 20 countries from 2000 to 2008; these observational data were merged with longitudinal information on the duration of paid maternity leave provided by each country. We estimated the effect of an increase in maternity leave in the prior year on the probability of infant (<1 y), neonatal (<28 d), and post-neonatal (between 28 d and 1 y after birth) mortality. Fixed effects for country and year were included to control for, respectively, unobserved time-invariant confounders that varied across countries and temporal trends in mortality that were shared across countries. Average rates of infant, neonatal, and post-neonatal mortality over the study period were 55.2, 30.7, and 23.0 per 1,000 live births, respectively. Each additional month of paid maternity was associated with 7.9 fewer infant deaths per 1,000 live births (95% CI 3.7, 12.0), reflecting a 13% relative reduction. Reductions in infant mortality associated with increases in the duration of paid maternity leave were concentrated in the post-neonatal period. Estimates were robust to adjustment for individual, household, and country-level characteristics, although there may be residual confounding by unmeasured time-varying confounders, such as coincident policy changes.ConclusionsMore generous paid maternity leave policies represent a potential instrument for facilitating early-life interventions and reducing infant mortality in LMICs and warrant further discussion in the post-2015 sustainable development agenda. From a policy planning perspective, further work is needed to elucidate the mechanisms that explain the benefits of paid maternity leave for infant mortality.

The large contribution of twins to neonatal and post-neonatal mortality in The Gambia, a 5-year prospective study

BackgroundA high twinning rate and an increased risk of mortality among twins contribute to the high burden of infant mortality in Africa. This study examined the contribution of twins to neonatal and post-neonatal mortality in The Gambia, and evaluated factors that contribute to the excess mortality among twins.MethodsWe analysed data from the Basse Health and Demographic Surveillance System (BHDSS) collected from January 2009 to December 2013. Demographic and epidemiological variables were assessed for their association with mortality in different age groups.ResultsWe included 32,436 singletons and 1083 twins in the analysis (twining rate 16.7/1000 deliveries). Twins represented 11.8 % of all neonatal deaths and 7.8 % of post-neonatal deaths. Mortality among twins was higher than in singletons [adjusted odds ratio (AOR) 4.33 (95 % CI: 3.09, 6.06) in the neonatal period and 2.61 (95 % CI: 1.85, 3.68) in the post-neonatal period]. Post-neonatal mortality among twins increased in girls (P for interaction = 0.064), being born during the dry season (P for interaction = 0.030) and lacking access to clean water (P for interaction = 0.042).ConclusionMortality among twins makes a significant contribution to the high burden of neonatal and post-neonatal mortality in The Gambia and preventive interventions targeting twins should be prioritized.

Acute exposure to fine and coarse particulate matter and infant mortality in Tokyo, Japan (2002–2013)

Few studies have evaluated the effect of short-term exposure to particulate matter (PM) less than 2.5μm in diameter (PM2.5) or to coarse particles on infant mortality. We evaluated the association between short-term exposure to PM and infant mortality in Japan and assessed whether adverse health effects were observable at PM concentrations below Japanese air quality guidelines. We used a time-stratified, case-crossover design. The participants included 2086 infants who died in the 23 urbanized wards of the Tokyo Metropolitan Government between January 2002 and December 2013. We obtained measures of PM2.5 and suspended particulate matter (SPM; PM<7μm in diameter) from one general monitoring station. As a measure of coarse particles, we calculated PM7–2.5 by subtracting PM2.5 from SPM. We then used conditional logistic regression to analyze the data. Same-day PM2.5 was associated with increased risks of infant and postneonatal mortality, especially for mortality related to respiratory causes. For a 10μg/m3 increase in PM2.5, the odds ratios were 1.06 (95% confidence interval: 1.01–1.12) for infant mortality and 1.10 (1.02–1.19) for postneonatal mortality. PM7–2.5 was also associated with an increased risk of postneonatal mortality, independent of PM2.5. Even when PM2.5 and SPM concentrations were below Japanese air quality guidelines, we observed adverse health effects. This study provides further evidence that acute exposure to PM2.5 and coarse particles (PM7–2.5) is associated with an increased risk of infant mortality. Further, rigorous evaluation of air quality guidelines for daily average PM2.5 and larger particles is needed.

Prepregnancy Body Mass Index and Infant Mortality in 38 U.S. States, 2012-2013.

To estimate whether prepregnancy body mass index (BMI) is related to infant mortality and whether adherence to weight gain recommendations mitigates the relationship between BMI and infant mortality. This was a cohort study using 2012-2013 U.S. national linked birth certificate and infant death files for 38 states and the District of Columbia with the BMI measure, including 6,419,836 singleton births and 36,691 infant deaths (infant mortality rate 5.72/1,000). Prenatal weight gain in three categories was based on adherence to Institute of Medicine recommendations. The outcome measure was infant deaths in the first year of life subdivided into two time periods: neonatal (less than 28 days) and postneonatal (28 days to 1 year). With normal prepregnancy weight as a reference, after adjustment, the odds ratio (OR) for an infant death rose from 1.32 (95% confidence interval [CI] 1.27-1.37) for mothers in the obese I category to 1.73 (95% CI 1.64-1.83) for obese III. Higher BMI was related to higher rates of both neonatal and postneonatal mortality. The adjusted OR for the risk of an infant death among singleton, term, vertex births for those gaining less than the recommended weight was 1.07 (95% CI 1.01-1.12) and 1.04 (95% CI 0.99-1.09) for those gaining more than recommended. Even after controlling for multiple risks, prepregnancy BMI was strongly related to infant mortality. Efforts to lower the infant mortality rate may benefit from a focus on reducing obesity among women of reproductive age.

On the Question of the Diagnosis of Sudden Infant Death Syndrome

Sudden Infant Death Syndrome (SIDS) is one of the leading causes of postneonatal mortality of infants in most developed countries. This paper presents data on terminology and on the study of SIDS in developed countries, and also examines problems of SIDS diagnostic in Russia in comparison with the results of own researches, analyzes risk factors, which are universal as for SIDS, and also for perinatal and infant death in general. The large variability of SIDS diagnosis in Russia suggests that this diagnosis often does not comply with international standard: post-mortem examination of community-acquired sudden death cases is often carried out by a forensic expert, but not by a children's pathologist, and they do not use virological and microbiological methods of investigation. In some cases, there is no infant's record or case record from children's polyclinic.

Investigating the Decline of Fetal and Infant Mortality Rates in Alaska During 2010 and 2011.

The U.S. infant mortality rate has been steadily declining since 2007. Although the downward trend has been notable in Alaska since 2006 when the rate was 6.9 infant deaths per 1000 live births, a dramatic drop in infant mortality occurred in 2010 and 2011 when the infant mortality rate fell to 3.8 infant deaths per 1000 live births during both years. The purpose of this study was to investigate the sudden decrease in fetal and infant mortality rates (FIMR) using the perinatal periods of risk (PPOR) method, an approach that has not been used previously in Alaska. The study was conducted for 251 fetal and infant deaths in 2004-2006, 265 deaths in 2007-2009, and 129 deaths in 2010-2011. Data were stratified by Alaska Native (AN) and White maternal race and urban/rural residence. Among both urban and rural White women, the rate ratios (RR) for FIMRs between the earlier and later time periods were not significantly different. The postneonatal mortality rate (PNMR) among AN infants living in rural areas decreased significantly (RR 0.40; 95 % confidence interval 0.21-0.76) between 2007-2009 and 2010-2011. An unexplained increase in sudden unexplained infant death was noted in 2009, followed by a precipitous decrease in 2010-2011. No other unusual distribution of the cause specific mortality rates was observed. The decrease in the Alaska Native FIMR might have been due to focused efforts for preventing postneonatal sleep associated deaths. Education for prevention of sleep related deaths, particularly in rural communities, is necessary to maintain Alaska's low PNMR.

Overall Postneonatal Mortality and Rates of SIDS.

Reductions in sudden infant death syndrome (SIDS) are commonly attributed to modifications in infant sleep environments. Approaches to diagnosis in sudden infant death, death scene investigations, the prevalence of intrinsic risk factors for SIDS, and the potential influence of treatment-related factors on infant vulnerability have also changed. Understanding all contributory factors may help reduce residual SIDS rates. We analyzed US Mortality Multiple Causes Records for 1983 to 2012 to compare SIDS postneonatal mortality rates with a projection applying non-SIDS mortality changes, using those changes as a proxy measure for alterations in intrinsic risk. Composites of neglect-related, unknown, and circumstantial respiratory diagnoses were measured, as was a cumulative composite of unexplained infant death diagnoses. Cluster analysis with leading causes of postneonatal mortality and SIDS mortality rates for low birth weight infants were also examined. SIDS and non-SIDS postneonatal mortality rates were concordant over time. Important variance was seen 1994 to 1996, coinciding with Back-to-Sleep initiation. Other variance, eliminated in the cumulative composite, appeared related to differences in diagnostic practices. Changes in SIDS rates resembled changes in mortality from congenital malformations, respiratory distress of the newborn, and diseases of the circulatory system. SIDS rates for low birth weight infants followed broader postneonatal trends. SIDS mortality followed trends in overall postneonatal mortality, including effects of changes in the infant sleep environment and diagnostic classification. Preventing asphyxia risk in the sleep environment must be coupled with efforts to understand intrinsic biological pathways, some potentially associated with other categories of infant and perinatal mortality.

Cardiorespiratory control and cytokine profile in response to heat stress, hypoxia, and lipopolysaccharide (LPS) exposure during early neonatal period.

Sudden infant death syndrome (SIDS) is one of the most common causes of postneonatal infant mortality in the developed world. An insufficient cardiorespiratory response to multiple environmental stressors (such as prone sleeping positioning, overwrapping, and infection), during a critical period of development in a vulnerable infant, may result in SIDS. However, the effect of multiple risk factors on cardiorespiratory responses has rarely been tested experimentally. Therefore, this study aimed to quantify the independent and possible interactive effects of infection, hyperthermia, and hypoxia on cardiorespiratory control in rats during the neonatal period. We hypothesized that lipopolysaccharide (LPS) administration will negatively impact cardiorespiratory responses to increased ambient temperature and hypoxia in neonatal rats. Sprague-Dawley neonatal rat pups were studied at postnatal day 6-8. Rats were examined at an ambient temperature of 33°C or 38°C. Within each group, rats were allocated to control, saline, or LPS (200μg/kg) treatments. Cardiorespiratory and thermal responses were recorded and analyzed before, during, and after a hypoxic exposure (10% O2). Serum samples were taken at the end of each experiment to measure cytokine concentrations. LPS significantly increased cytokine concentrations (such as TNFα, IL-1β, MCP-1, and IL-10) compared to control. Our results do not support a three-way interaction between experimental factors on cardiorespiratory control. However, independently, heat stress decreased minute ventilation during normoxia and increased the hypoxic ventilatory response. Furthermore, LPS decreased hypoxia-induced tachycardia. Herein, we provide an extensive serum cytokine profile under various experimental conditions and new evidence that neonatal cardiorespiratory responses are adversely affected by dual interactions of environmental stress factors.

On the Quantity and Quality of Girls: New Evidence on Abortion, Fertility, and Parental Investments

The introduction of prenatal sex-detection technologies in India has led to a phenomenal increase in abortion of female fetuses. We investigate their impact on son-biased fertility stopping behavior, parental investments in girls relative to boys, and the relative chances of girls surviving after birth. We find a moderation of son-biased fertility, erosion of gender gaps in breastfeeding and immunization, and complete convergence in the post-neonatal mortality rates of boys and girls. For every five aborted girls, we estimate that roughly one additional girl survives to age five. The results are not driven by endogenous compositional shifts, being robust to the inclusion of mother fixed effects. Our findings have implications not only for counts of missing girls but also for the later life outcomes of girls, conditioned by greater early life investments in them.

International Ranking of Infant Mortality Rates: Taiwan Compared with European Countries

Rankings of infant mortality rates are commonly cited international comparisons to assess the health status of individual countries. We compared the infant mortality rate of Taiwan with those of European countries for 2004 according to two definitions. First, the countries were ranked on the basis of crude infant, neonatal, and postneonatal mortality rates. The countries were then ranked according to the mortality rates calculated after exclusion of live births with a known birth weight of <1000g, which is the definition set by the World Health Organization. Taiwan was ranked 11(th), 12(th), and 15(th) among 26 high-income countries for crude infant, neonatal, and postneonatal mortality rates, respectively. The ranks were 12(th), 16(th), and 15(th), respectively, for mortality rates, excluding live births with a birth weight of <1000g. However, in only seven, four, and 10 countries were the mortality rate ratios statistically significantly lower than Taiwan in infant, neonatal, and postneonatal mortality, respectively, according to the second definition. The ranking of Taiwan was similar (11(th) vs. 12(th)) according the two definitions. However, after consideration of the confidence interval, only six countries (Sweden, Finland, Czech Republic, Belgium, Austria, and Germany) had infant mortality rates statistically significantly lower than those of Taiwan in 2004.

Behavior Change After 20 Months of a Radio Campaign Addressing Key Lifesaving Family Behaviors for Child Survival: Midline Results From a Cluster Randomized Trial in Rural Burkina Faso.

In Burkina Faso, a comprehensive 35-month radio campaign addressed key, multiple family behaviors for improving under-5 child survival and was evaluated using a repeated cross-sectional, cluster randomized design. The primary outcome of the trial was postneonatal under-5 child mortality. This paper reports on behavior change achieved at midline. Fourteen community radio stations in 14 geographic areas were selected based on their high listenership. Seven areas were randomly allocated to receive the intervention while the other 7 areas served as controls. The campaign was launched in March 2012. Cross-sectional surveys of about 5,000 mothers of under-5 children, living in villages close to the radio stations, were conducted at baseline (from December 2011 to February 2012) and at midline (in November 2013), after 20 months of campaigning. Statistical analyses were based on cluster-level summaries using a difference-in-difference (DiD) approach and adjusted for imbalances between arms at baseline. In addition, routine health facility data were analyzed for evidence of changes in health facility utilization. At midline, 75% of women in the intervention arm reported recognizing radio spots from the campaign. There was some evidence of the campaign having positive effects on care seeking for diarrhea (adjusted DiD, 17.5 percentage points; 95% confidence interval [CI], 2.5 to 32.5; P= .03), antibiotic treatment for fast/difficult breathing (adjusted DiD, 29.6 percentage points; 95% CI, 3.5 to 55.7; P= .03), and saving money during pregnancy (adjusted DiD, 12.8 percentage points; 95% CI, 1.4 to 24.2; P= .03). For other target behaviors, there was little or no evidence of an impact of the campaign after adjustment for baseline imbalances and confounding factors. There was weak evidence of a positive correlation between the intensity of broadcasting of messages and reported changes in target behaviors. Routine health facility data were consistent with a greater increase in the intervention arm than in the control arm in all-cause under-5 consultations (33% versus 17%, respectively), but the difference was not statistically significant (P= .40). The radio campaign reached a high proportion of the primary target population, but the evidence for an impact on key child survival-related behaviors at midline was mixed.

Changes in government spending on healthcare and population mortality in the European union, 1995-2010: a cross-sectional ecological study.

Economic measures such as unemployment and gross domestic product are correlated with changes in health outcomes. We aimed to examine the effects of changes in government healthcare spending, an increasingly important measure given constrained government budgets in several European Union countries. Multivariate regression analysis was used to assess the effect of changes in healthcare spending as a proportion of total government expenditure, government healthcare spending as a proportion of gross domestic product and government healthcare spending measured in purchasing power parity per capita, on five mortality indicators. Additional variables were controlled for to ensure robustness of data. One to five year lag analyses were conducted. European Union countries 1995-2010. Neonatal mortality, postneonatal mortality, one to five years of age mortality, under five years of age mortality, adult male mortality, adult female mortality. A 1% decrease in government healthcare spending was associated with significant increase in all mortality metrics: neonatal mortality (coefficient -0.1217, p = 0.0001), postneonatal mortality (coefficient -0.0499, p = 0.0018), one to five years of age mortality (coefficient -0.0185, p = 0.0002), under five years of age mortality (coefficient -0.1897, p = 0.0003), adult male mortality (coefficient -2.5398, p = 0.0000) and adult female mortality (coefficient -1.4492, p = 0.0000). One per cent decrease in healthcare spending, measured as a proportion of gross domestic product and in purchasing power parity, was both associated with significant increases (p < 0.05) in all metrics. Five years after the 1% decrease in healthcare spending, significant increases (p < 0.05) continued to be observed in all mortality metrics. Decreased government healthcare spending is associated with increased population mortality in the short and long term. Policy interventions implemented in response to the financial crisis may be associated with worsening population health.

Inequality as a Powerful Predictor of Infant and Maternal Mortality around the World.

BackgroundMaternal and infant mortality are highly devastating, yet, in many cases, preventable events for a community. The human development of a country is a strong predictor of maternal and infant mortality, reflecting the importance of socioeconomic factors in determinants of health. Previous research has shown that the Human Development Index (HDI) predicts infant mortality rate (IMR) and the maternal mortality ratio (MMR). Inequality has also been shown to be associated with worse health in certain populations. The main purpose of the present study was to determine the correlation and predictive power of the Inequality Adjusted Human Development Index (IHDI) as a measure of inequality with the Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR), Early Neonatal Mortality Rate (ENMR), Late Neonatal Mortality Rate (LNMR), and the Post Neonatal Mortality Rate (PNMR).Methods and FindingsData for the present study were downloaded from two sources: infant and maternal mortality data were downloaded from the Global Burden of Disease 2013 Cause of Death Database and the Human Development Index (HDI) and Inequality-Adjusted Human Development Index (IHDI) data were downloaded from the United Nations Development Program (UNDP). Pearson correlation coefficients were estimated, following logarithmic transformations to the data, to examine the relationship between HDI and IHDI with MMR, IMR, ENMR, LNMR, and PNMR. Steiger’s Z test for the equality of two dependent correlations was utilized in order to determine whether the HDI or IHDI was more strongly associated with the outcome variables. Lastly, we constructed OLS regression models in order to determine the predictive power of the HDI and IHDI in terms of the MMR, IMR, ENMR, LNMR, and PNMR.Maternal and infant mortality were both strongly and negatively correlated with both HDI and IHDI; however, Steiger’s Z test for the equality of two dependent correlations revealed that IHDI was more strongly correlated than HDI with MMR (Z = 4.897, p < 0.001), IMR (Z = 2.524, p = 0.012), ENMR (Z = 2.936, p = 0.003), LNMR (Z = 2.272, p = 0.023), and PNMR (Z = 2.277, p = 0.023). Furthermore, side-by-side OLS regression models revealed that, when IHDI was used as the predictor variable instead of HDI, the R 2 value was 0.053 higher for MMR, 0.025 higher for IMR, 0.038 higher for ENMR, 0.029 higher for LNMR, and 0.026 higher for PNMR.ConclusionsEven when both the HDI and the IHDI correlate with the infant and maternal mortality rates, the IHDI is a better predictor for these two health indicators. Therefore, these results add more evidence that inequality is playing an important role in determining the health status of various populations in the world and more efforts should be put into programs to fight inequality.

The combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998-2010.

I examined the combined effects of access to primary care through the Family Health Program (FHP) and conditional cash transfers from the Bolsa Familia Program (BFP) on postneonatal infant mortality (PNIM) in Brazil. I employed longitudinal ecological analysis using panel data from 4583 Brazilian municipalities from 1998 to 2010, totaling 54 253 observations. I estimated fixed-effects ordinary least squares regressions models with PNIM rate as the dependent variable and FHP, BFP, and their interactions as the main independent variables of interest. The association of higher FHP coverage with lower PNIM became stronger as BFP coverage increased. At the means of all other variables, when BFP coverage was 25%, predicted PNIM was 5.24 (95% confidence interval [CI] = 4.95, 5.53) for FHP coverage = 0% and 3.54 (95% CI = 2.77, 4.31) for FHP coverage = 100%. When BFP coverage was 60%, predicted PNIM was 4.65 (95% CI = 4.36, 4.94) when FHP coverage = 0% and 1.38 (95% CI = 0.88, 1.89) when FHP coverage = 100%. The effect of the FHP depends on the expansion of the BFP. For impoverished, underserved populations, combining supply- and demand-side interventions may be necessary to improve health outcomes.