A relação entre os determinantes sociais em saúde e os investimentos setoriais e a mortalidade infantil em municípios brasileiros com mais de 80 mil habitantes

Investments in health have controversial influence on results of the health of populations, besides being subject rarely explored in literature. Moreover, from the 1970s, the social determinants of health have been consolidated in the disease process as multifactorial factors (social, economic, cultural, etc.) that directly or indirectly influence the occurrence of health problems of populations, as well as mortality rates. This study aimed to evaluate the influence of these investments and the social determinants of health on infant mortality and its neonatal and post-neonatal mortality. This is an ecological study, in which the sample was composed of Brazilians cities with over 80,000 inhabitants, avoiding fluctuations in mortality rates for common small populations, and ensure greater coverage of information systems on mortality and births Brazilians and, therefore, increase data consistency. To isolate the effect of investments in health, we used multiple linear regression. The socioeconomic indicators (p <0.001, p = 0.004, p <0.001), the inequality index (p <0.001, p = 0.001, p = 0.006) and coverage of prenatal visits (p <0.001, p <0.001; p = 0.005) were associated with infant mortality rate total, neonatal and post-neonatal, and the Gross Domestic Product per capita only influenced the overall infant mortality rate and neonatal (p=0.022; 0.045). Investments in health, in this model, lost statistical significance, showing no correlation with mortality rates among children under one year. We conclude that the social determinants of health has an influence on the variation in mortality rates of Brazilian cities, however the same was not observed for indicators of health investment

Infant mortality rates according to socioeconomic status in a Brazilian city

OBJECTIVE: Data from municipal databases can be used to plan interventions aimed at reducing inequities in health care. The objective of the study was to determine the distribution of infant mortality according to an urban geoeconomic classification using routinely collected municipal data. METHODS: All live births (total of 42,381) and infant deaths (total of 731) that occurred between 1994 and 1998 in Ribeirão Preto, Brazil, were considered. Four different geoeconomic areas were defined according to the family head's income in each administrative urban zone. RESULTS: The trends for infant mortality rate and its different components, neonatal mortality rate and post-neonatal mortality rate, decreased in Ribeirão Preto from 1994 to 1998 (chi-square for trend, p<0.05). These rates were inversely correlated with the distribution of lower salaries in the geoeconomic areas (less than 5 minimum wages per family head), in particular the post-neonatal mortality rate (chi-square for trend, p<0.05). Finally, the poor area showed a steady increase in excess infant mortality. CONCLUSIONS: The results indicate that infant mortality rates are associated with social inequality and can be monitored using municipal databases. The findings also suggest an increase in the impact of social inequality on infant health in Ribeirão Preto, especially in the poor area. The monitoring of health inequalities using municipal databases may be an increasingly more useful tool given the continuous decentralization of health management at the municipal level in Brazil.

Infant mortality and low birth weight in cities of Northeastern and Southeastern Brazil

OBJECTIVE: To compare estimates of low birth weight (LBW), preterm birth, small for gestational age (SGA), and infant mortality in two birth cohorts in Brazil. METHODS: The two cohorts were performed during the 1990s, in São Luís, located in a less developed area in Northeastern Brazil, and Ribeirão Preto, situated in a more developed region in Southeastern Brazil. Data from one-third of all live births in Ribeirão Preto in 1994 were collected (2,839 single deliveries). In São Luís, systematic sampling of deliveries stratified by maternity hospital was performed from 1997 to 1998 (2,439 single deliveries). The chi-squared (for categories and trends) and Student t tests were used in the statistical analyses. RESULTS: The LBW rate was lower in São Luís, thus presenting an epidemiological paradox. The preterm birth rates were similar, although expected to be higher in Ribeirão Preto because of the direct relationship between preterm birth and LBW. Dissociation between LBW and infant mortality was observed, since São Luís showed a lower LBW rate and higher infant mortality, while the opposite occurred in Ribeirão Preto. CONCLUSIONS: Higher prevalence of maternal smoking and better access to and quality of perinatal care, thereby leading to earlier medical interventions (cesarean section and induced preterm births) that resulted in more low weight live births than stillbirths in Ribeirão Preto, may explain these paradoxes. The ecological dissociation observed between LBW and infant mortality indicates that the LBW rate should no longer be systematically considered as an indicator of social development.

Infant mortality: comparison between two birth cohorts from Southeast and Northeast, Brazil

OBJECTIVE: To obtain population estimates and profile risk factors for infant mortality in two birth cohorts and compare them among cities of different regions in Brazil. METHODS: In Ribeirão Preto, southeast Brazil, infant mortality was determined in a third of hospital live births (2,846 singleton deliveries) in 1994. In São Luís, northeast Brazil, data were obtained using systematic sampling of births stratified by maternity unit (2,443 singleton deliveries) in 1997-1998. Mothers answered standardized questionnaires shortly after delivery and information on infant deaths was retrieved from hospitals, registries and the States Health Secretarys' Office. The relative risk (RR) was estimated by Poisson regression. RESULTS: In São Luís, the infant mortality rate was 26.6/1,000 live births, the neonatal mortality rate was 18.4/1,000 and the post-neonatal mortality rate was 8.2/1,000, all higher than those observed in Ribeirão Preto (16.9, 10.9 and 6.0 per 1,000, respectively). Adjusted analysis revealed that previous stillbirths (RR=3.67 vs 4.13) and maternal age <18 years (RR=2.62 vs 2.59) were risk factors for infant mortality in the two cities. Inadequate prenatal care (RR=2.00) and male sex (RR=1.79) were risk factors in São Luís only, and a dwelling with 5 or more residents was a protective factor (RR=0.53). In Ribeirão Preto, maternal smoking was associated with infant mortality (RR=2.64). CONCLUSIONS: In addition to socioeconomic inequalities, differences in access to and quality of medical care between cities had an impact on infant mortality rates.

Surveillance of mother-to-child HIV transmission: socioeconomic and health care coverage indicators

OBJECTIVE: To identify clustering areas of infants exposed to HIV during pregnancy and their association with indicators of primary care coverage and socioeconomic condition. METHODS: Ecological study where the unit of analysis was primary care coverage areas in the city of Porto Alegre, Southern Brazil, in 2003. Geographical Information System and spatial analysis tools were used to describe indicators of primary care coverage areas and socioeconomic condition, and estimate the prevalence of liveborn infants exposed to HIV during pregnancy and delivery. Data was obtained from Brazilian national databases. The association between different indicators was assessed using Spearman's nonparametric test. RESULTS: There was found an association between HIV infection and high birth rates (r=0.22, p<0.01) and lack of prenatal care (r=0.15, p<0.05). The highest HIV infection rates were seen in areas with poor socioeconomic conditions and difficult access to health services (r=0.28, p<0.01). The association found between higher rate of prenatal care among HIV-infected women and adequate immunization coverage (r=0.35, p<0.01) indicates that early detection of HIV infection is effective in those areas with better primary care services. CONCLUSIONS: Urban poverty is a strong determinant of mother-to-child HIV transmission but this trend can be fought with health surveillance at the primary care level.

Infant Mortality in Iowa Interim Study Committee, January 1992

The Infant Mortality in Iowa Interim Study Committee was established by the Legislative Council to review historical trends in Iowa's infant mortality rates to identify the extent of the problem on a statewide basis. Identify areas in the state with the greatest incidence of infant mortality, and research health complications. Identify factors which lead to impoverished families, and research access to health care services. Survey and review the current structure of service provided to pregnant women in Iowa health care facilities, and solicit information on the level of existing prenatal services. Recommend changes in Iowa's health care system which would lower Iowa's infant mortality rate.

The expression of vulnerability through infant mortality in the municipality of Embu

CONTEXTO E OBJETIVO: A mortalidade infantil expressa uma conjunção de fatores relacionados às condições de vida, trabalho e acesso aos serviços de saúde, e a identificação desses fatores pode contribuir para definição de intervenções em saúde. O objetivo deste trabalho foi analisar a expressão da vulnerabilidade e conseqüentes diferenças de acesso aos serviços de saúde e na ocorrência de óbitos em menores de um ano no município do Embu. TIPO DE ESTUDO E LOCAL: Estudo descritivo, no município de Embu. MÉTODOS: Foram coletados dados secundários (declarações de óbitos) e primários (entrevistas a famílias de crianças residentes do município do Embu, falecidas nos anos de 1996 e 1997, antes de completarem um ano). Variáveis estudadas foram relacionadas às condições de vida, renda e trabalho, à assistência pré-natal, ao parto e à atenção à saúde da criança, as quais foram comparadas com resultados obtidos em estudo realizado no ano de 1996. RESULTADOS: Verificaram-se diferenças estatisticamente significantes quanto a renda, trabalho sem carteira assinada e acesso a plano privado de saúde entre famílias de crianças que foram ao óbito. Verificaram-se, também, diferenças quanto ao acesso e à qualidade da assistência pré-natal, à freqüência de baixo peso ao nascer e a intercorrências neonatais. CONCLUSÕES: A situação de emprego/desemprego foi decisiva na determinação da estabilidade familiar, conferindo maior vulnerabilidade para ocorrência de óbitos infantis, somada às condições de acesso e à qualidade dos serviços de saúde

Variáveis de impacto na queda da mortalidade infantil no Estado de São Paulo, Brasil, no período de 1998 a 2008

This is an ecological, analytical and retrospective study comprising the 645 municipalities in the State of Sao Paulo, the scope of which was to determine the relationship between socioeconomic, demographic variables and the model of care in relation to infant mortality rates in the period from 1998 to 2008. The ratio of average annual change for each indicator per stratum coverage was calculated. Infant mortality was analyzed according to the model for repeated measures over time, adjusted for the following correction variables: the city's population, proportion of Family Health Programs (PSFs) deployed, proportion of Growth Acceleration Programs (PACs) deployed, per capita GDP and SPSRI (Sao Paulo social responsibility index). The analysis was performed by generalized linear models, considering the gamma distribution. Multiple comparisons were performed with the likelihood ratio with chi-square approximate distribution, considering a significance level of 5%. There was a decrease in infant mortality over the years (p < 0.05), with no significant difference from 2004 to 2008 (p > 0.05). The proportion of PSFs deployed (p < 0.0001) and per capita GDP (p < 0.0001) were significant in the model. The decline of infant mortality in this period was influenced by the growth of per capita GDP and PSFs.

Infant Mortality in Novo Hamburgo: Associated Factors and Cardiovascular Causes

Background: Infant mortality has decreased in Brazil, but remains high as compared to that of other developing countries. In 2010, the Rio Grande do Sul state had the lowest infant mortality rate in Brazil. However, the municipality of Novo Hamburgo had the highest infant mortality rate in the Porto Alegre metropolitan region. Objective: To describe the causes of infant mortality in the municipality of Novo Hamburgo from 2007 to 2010, identifying which causes were related to heart diseases and if they were diagnosed in the prenatal period, and to assess the access to healthcare services. Methods: This study assessed infants of the municipality of Novo Hamburgo, who died, and whose data were collected from the infant death investigation records. Results: Of the 157 deaths in that period, 35.3% were reducible through diagnosis and early treatment, 25% were reducible through partnership with other sectors, 19.2% were non-preventable, 11.5% were reducible by means of appropriate pregnancy monitoring, 5.1% were reducible through appropriate delivery care, and 3.8% were ill defined. The major cause of death related to heart disease (13.4%), which was significantly associated with the variables ‘age at death’, ‘gestational age’ and ‘birth weight’. Regarding access to healthcare services, 60.9% of the pregnant women had a maximum of six prenatal visits. Conclusion: It is mandatory to enhance prenatal care and newborn care at hospitals and basic healthcare units to prevent infant mortality.

Choosing health. Born equal? A report on inequalities in infant mortality in London. A technical report

This report explores the factors that contribute to infant mortality in the capital and ways in which commissioners might monitor the contribution of their local NHS to the national infant mortality target as well as contributing to maternity policy.

Factors associated with infant mortality.

Errata tipped in.

[impact Variables On The Decline In Infant Mortality In The State Of São Paulo, Brazil: 1998-2008].

This is an ecological, analytical and retrospective study comprising the 645 municipalities in the State of São Paulo, the scope of which was to determine the relationship between socioeconomic, demographic variables and the model of care in relation to infant mortality rates in the period from 1998 to 2008. The ratio of average annual change for each indicator per stratum coverage was calculated. Infant mortality was analyzed according to the model for repeated measures over time, adjusted for the following correction variables: the city's population, proportion of Family Health Programs (PSFs) deployed, proportion of Growth Acceleration Programs (PACs) deployed, per capita GDP and SPSRI (São Paulo social responsibility index). The analysis was performed by generalized linear models, considering the gamma distribution. Multiple comparisons were performed with the likelihood ratio with chi-square approximate distribution, considering a significance level of 5%. There was a decrease in infant mortality over the years (p < 0.05), with no significant difference from 2004 to 2008 (p > 0.05). The proportion of PSFs deployed (p < 0.0001) and per capita GDP (p < 0.0001) were significant in the model. The decline of infant mortality in this period was influenced by the growth of per capita GDP and PSFs.

Homicide mortality, socioeconomic development, and police violence in the city of Sao Paulo, Brazil

Objective. To analyze the association between police violence and homicide mortality rates taking into consideration the effect of contextual variables. Methods. This was an environmental, cross-sectional study that included the 96 census districts in the City of Sao Paulo. The association between the variables was analyzed using Spearman`s rank correlation and simple and multiple regression analysis. Results. Univariate analysis revealed a strong and significant association between homicide mortality coefficients and all the indicators of socioeconomic development and police violence. After controlling for potential confounding factors, the association between police violence and homicide mortality coefficients remained strong and significant. This significance was lost only after control for the size of the resident population. Conclusion. The results indicate that police action that violates basic human rights is not the right answer to urban violence. The combination of homicides from interpersonal violence and deaths from police violence results in negative socialization and promotes further violence.

The impact of perinatal and socioeconomic factors on mental health problems of children from a poor Brazilian city: a longitudinal study

Low birth weight and preterm birth, and social disadvantage may negatively affect mental health of children, but findings have been inconsistent. To assess the influence of perinatal and social factors on mental health problems in children aged 7-9 years. A random sample of 805 births in So Luis, Brazil was studied in 1997/1998 and again in 2005/2006. Perinatal, socioeconomic and demographic variables were assessed within 24 h after delivery. The Strengths and Difficulties Questionnaire (SDQ) was used to assess mental health problems in the children. Simple and multiple Poisson regressions were used for statistical analysis. The overall prevalence of mental health problems in the total sample was 47.7%. The prevalences of emotional and conduct problems were 58.2 and 48.8%, respectively. Only paternal age (< 20 years) was associated with mental health problems as measured by the full SDQ scale (prevalence ratio PR = 1.27). Children born to single mothers (PR = 1.31) and those with birth weight from 1,500 to 2,499 g (PR = 1.18) and from 2,500 to 2,999 g (PR = 1.17) had a higher risk of emotional problems, but those from low income families had a lower risk (PR = 0.80). Children with a father of less than 20 years had a higher risk of having problems with their peers (PR = 1.75). A maternal education of 9 years or over was inversely associated with peer (PR = 0.70) and conduct problems (PR = 0.73). Girls had a lower risk of conduct (PR = 0.77) and hyperactivity problems (PR = 0.68). A maternal education of 4 years or less increased the risk of hyperactivity (PR = 1.48). Socioeconomic and demographic conditions were better predictors of mental health problems in children than birth weight or preterm birth. However, since most effect sizes were small most mental health problems were, unexplained by the variables in the study.

Case-control study on infant mortality in Southern Brazil

OBJECTIVE: To identify risk factors associated with infant mortality and, more specifically, with neonatal mortality. METHODS: A case-control study was carried out in the municipality of Caxias do Sul, Southern Brazil. Characteristics of prenatal care and causes of mortality were assessed for all live births in the 2001-2002 period with a completed live-birth certificate and whose mothers lived in the municipality. Cases were defined as all deaths within the first year of life. As controls, there were selected the two children born immediately after each case in the same hospital, who were of the same sex, and did not die within their first year of life. Multivariate analysis was performed using conditional logistic regression. RESULTS: There was a reduction in infant mortality, the greatest reduction was observed in the post-neonatal period. The variables gestational age (<36 weeks), birth weight (<2,500 g), and 5-minute Apgar (<6) remained in the final model of the multivariate analysis, after adjustment. CONCLUSIONS: Perinatal conditions comprise almost the totality of neonatal deaths, and the majority of deaths occur at delivery. The challenge for reducing infant mortality rate in the city is to reduce the mortality by perinatal conditions in the neonatal period.