[Social inequalities and health. Socioeconomic level and infant mortality in Chile in 1985-1995]. / Desigualdades sociales y salud. Nivel socioeconómico y mortalidad infantil en Chile, 1985-1995.

BACKGROUND: The strong relationship between social inequalities and health have been extensively reported. AIM: To measure the effects of social inequalities, assessed through maternal educational level, on infant mortality in Chile. MATERIAL AND METHODS: Using death and birth electronic databases of the Instituto Nacional de Estadisticas, the annual rates of infant mortality per years of approved studies of both parents and per cause were calculated. RESULTS: In the 1990-1995 period, there is a clear gradient of infant mortality according to the level of education of the mother (38.2 per 1000 born alive among those without education versus 7.8 per 1000 born alive among those with university education). The same tendency is maintained for neonatal and post-neonatal mortality. All groups of causes had a similar effect, standing out diseases of the respiratory system with a relative risk (RR) of 14.3 and a population attributable risk (PAR) of 73%, trauma with a RR of 11.3 and a PAR of 69% and infectious diseases with a RR of 10.8 and a PAR of 62%. Between 1985 and 1995, absolute inequalities decreased but relative inequalities remained constant. CONCLUSIONS: The great social inequality in infant mortality has persisted in Chile during the last years. To adequately assess the national progresses in population health using infant mortality as an indicator, the gaps between social groups must be born in mind.

PIP: Birth and death statistics from Chile¿s National Institute of Statistics were used to determine the influence of socioeconomic status as measured through maternal educational level on infant mortality from 1990-95 and to assess trends since 1985. The rates of infant, neonatal, and postneonatal mortality were calculated for 6 educational groups for the mother and father: 0, 1-3, 4-6,7-9, 10-12, and 13 or more years. The deaths were classified by cause according to the International Classification of Diseases and to Taucher¿s classification into avoidable, difficult to avoid, poorly defined, and other causes. A clear association was observed in levels of infant mortality according to maternal education. Infant mortality rates ranged from 38.2/1000 live births for children of illiterate mothers to 7.8/1000 for children of mothers with higher education. A child of an illiterate mother had a risk of death in the first year 4.9 times higher than the child of a mother with higher education. The same trend was observed for neonatal mortality and for paternal education. The mortality gradient by maternal education was maintained for all causes of death and both classifications studied. Diseases of the respiratory system had a relative risk (RR) of 14.3 and a population attributable risk (PAR) of 73%, trauma had an RR of 11.3 and PAR of 69%, and infectious diseases had an RR of 10.8 and PAR of 62%. Infant mortality rates declined between 1985-95 in all maternal educational groups, but the inequalities remained.

Time-trends and causes of infant, neonatal and postneonatal mortality in Mexico, 1980-1990.

OBJECTIVE: This article analyzes the time-trends and causes of infant, neonatal, and postneonatal mortality in Mexico during the 1980's. MATERIAL AND METHODS: Data on infant deaths came from yearly tabulations (1980 to 1990) published by the Mexican government. Time-trends of mortality rates were determined by simple linear regression models. The parallelism test was performed for evaluating similarities in trends in neonatal and postneonatal mortality rates by causes. RESULTS: During the 1980's, infant mortality rates in Mexico declined from 40.4 to 31.1/1000 (beta = -0.791). Postneonatal mortality rates showed a strong decrease (beta = -0.892), while neonatal mortality rates were almost stationary (beta = 0.089). Significant rate decreases were observed for intestinal infections, Pneumonia and influenza and All other causes while Certain perinatal problems, Congenital defects and Nutritional deficiencies increased. No changes were observed in Acute respiratory infections. The neonatal proportional mortality showed an incremental trend accounting for 37.6% in 1980 and ascending to 48.8% in 1990 of the mortality in the first year of life. CONCLUSIONS: This analysis indicates that the reduction in infant mortality in Mexico during the 1980's was due to declining postneonatal mortality while neonatal mortality rates remain almost unchanged.

PIP: This report describes the time-trends and causes of infant, neonatal, and postneonatal mortality in Mexico during 1980-90. Data were obtained from annual data collected by the General Direction of Statistics and Information of the Secretary of Health. The infant mortality rate (IMR) declined during the 1980s due to declines in the postneonatal mortality rate (PMR). The neonatal mortality rate (NMR) remained stable at around 15.2/1000. IMR declined from 40.4/1000 to 31.1/1000. PMR declined from 25.6/1000 to 16.2/1000. Both changes in PMR and IMR were statistically significant. Rates of mortality due to intestinal infections, pneumonia, and influenza declined. Perinatal problems and congenital defects increased. Significant increases occurred for nutritional deficiencies in IMR and PMR. Acute respiratory infections remained about the same. State variation in infant mortality shows that some states have double the IMR. Further analysis is needed to determine the trends in state-specific IMR and PMR. Decreases in pneumonia and influenza are accounted for by increased levels of sanitation, improved literacy of women, promotion of oral rehydration therapy, massive immunization campaigns against measles, and greater access to health care services. The trends are considered reliable based on the assumption that births are underregistered.

[Changes in infant mortality]. / Cambios en la mortalidad infantil.

PIP: Mexico's infant mortality rate is estimated to have declined from 189 in 1930 to 129 in 1950 and 30 in 1995. The infant mortality rate has continued its decline despite the economic crisis of recent years. The use of oral rehydration therapy has reduced mortality from diarrhea, and the spread of family planning has reduced the numbers of births at high risk due to maternal age, parity, or short birth intervals. The types of causes of infant death have changed as the numbers have decreased. They can be grouped in ascending order according to the difficulty of prevention: diseases preventable by immunization, acute diarrhea, acute respiratory infections, perinatal disorders, and congenital anomalies. Over two-thirds of infant deaths recorded since 1950 have been due to these causes. Infectious diseases, including diarrhea, acute respiratory infections, and conditions preventable by immunization predominated as causes of infant mortality before 1930. As the epidemiological transition progresses, diseases preventable by immunization lose importance, and diarrhea and respiratory infections occupy the first two places, with perinatal disorders being third. Between 1980 and 1990, in Mexico, diarrhea and acute respiratory infections dropped to second and third place after perinatal disorders, with congenital anomalies in fourth place. In most developed countries, perinatal disorders and congenital anomalies are the two most frequent causes of death, while diarrhea and respiratory infections no longer appear in the top five. In 1995, the four main causes in Mexico in descending order were perinatal disorders, congenital anomalies, acute respiratory infections, and diarrhea.^ieng

Epidemiological transition in Latin America: the case of Chile.

To describe Chile's stage of epidemiological transition, a descriptive study of the changes to the demographic and economic profile of this country during the last 20 years is presented. The decline in the total fertility rate from 3.4 in 1970 to 2.6 in 1992 and the important decrease in general and infant mortality rate has led to an increase of life expectancy of 8 years for men and 9 years for women. This has resulted in changes to the age structure and causes of mortality and morbidity of the population. A reduction of 82% in the proportion of deaths among children < 1 year and a 73% increase of mortality amongst those 65 years and older can be observed. In line with these changes non-communicable diseases have increased from 53.7% of all deaths in 1970 to 74.9% in 1991. In the same period mortality rates from cardiovascular causes have decreased from 189.6 to 161.1 per 100,000 population, whilst their relative proportion of all causes has increased from 22.3% to 29%. High prevalence of risk factors should lead to a significant increase of chronic diseases in future years. Regarding morbidity, a high incidence rate for tuberculosis persists together with an increase of infections of the digestive system and of sexually transmitted diseases. A decrease in the rates of diseases preventable by immunisation has been noted. It is concluded that, as defined by population mortality statistics, Chile is in a post-transition stage but with a persistence of some infectious diseases corresponding to a transitional stage of development.

The Cuban health care system and factors currently undermining it.

This paper explores the dynamics of health and health care in Cuba during a period of severe crisis by placing it within its economic, social, and political context using a comparative historical approach. It outlines Cuban achievements in health care as a consequence of the socialist transformations since 1959, noting the full commitment by the Cuban state, the planned economy, mass participation, and a self-critical, working class perspective as crucial factors. The roles of two external factors, the U.S. economic embargo and the Council of Mutual Economic Cooperation (CMEA), are explored in shaping the Cuban society and economy, including its health care system. It is argued that the former has hindered health efforts in Cuba. The role of the latter is more complex. While the CMEA was an important source for economic growth, Cuban relations with the Soviet bloc had a damaging effect on the development of socialism in Cuba. The adoption of the Soviet model of economic development fostered bureaucracy and demoralization of Cuban workers. As such, it contributed to two internal factors that have undermined further social progress including in health care: low productivity of labor and the growth of bureaucracy. While the health care system is still consistently supported by public policy and its structure is sound, economic crisis undermines its material and moral foundations and threatens its achievements. The future of the current Cuban health care system is intertwined with the potentials for its socialist development.

PIP: The dynamics of health care in Cuba during a period of severe crisis was explored within an economic, social, and political context. Cuban achievements in health care since 1959 were a consequence of the full commitment to health care by the state, the planned economy, and mass participation. In 1959 the infant mortality rate was 60/1000 live births and life expectancy was 65.1 years. By the period of 1983-88 Cuba had attained an infant mortality rate of 15/1000 and female life expectancy of 76 years compared to the figures of 27/1000 and 73 years, respectively, in South Korea. In response to problems that arose in the 1960s an improved health care model stressing the involvement of health care workers in the community was proposed in 1974. In the early 1980s 20,000 family physicians were trained to provide primary care services in the communities. Two external factors, the US economic embargo and the Council of Mutual Economic Cooperation (CMEA), shaped the Cuban society and economy, including its health care system. The U.S. embargo forced Cuba to pay higher transportation costs to import medical supplies from Soviet-bloc countries. Once the Soviet bloc collapsed, Washington further tightened the embargo through the Torricelli Bill of 1992, which bars U.S. subsidiaries in other countries from trading with Cuba and forbids US portage for 6 months to any ship that has docked in Cuba. As a result, in 1993 Cuba's imports for public health cost an extra $45 million. The CMEA was an important source for economic growth; however, the adoption of the Soviet model of economic development contributed to two internal factors that have undermined health care: low productivity of labor and the growth of bureaucracy. Social expenditures declined from 70% of the GNP in 1970 to 36% in 1995. Meanwhile, administrative personnel grew from 90,000 persons in 1973 to 240,000 persons in 1984. In 1995 some 50,000 physicians were serving a population of 11 million. Since 1986 a total of 1042 individuals have been found to be HIV positive. The policy of forced isolation of HIV-positive persons and AIDS patients was relaxed recently. While the health care system and its structure is sound, the economic crisis undermines its material and moral foundations and threatens its achievements.

Demographic crisis and recovery: a case study of the Xavante of Pimentel Barbosa.

PIP: This case study of the Xavante of Pimentel Barbosa is an example of an Amazonian Indian group that, when exposed to White society, experienced the common history of diseases and social disruption, and then eventually, recovered from the demographic shock, increased fertility, and reduced mortality. Early contact for the Xavante was during the early 18th century in Goias state, Brazil; by the end of the 19th century the Xavante had migrated west into Mato Grosso in isolation. Brazilian government interests (1940s) and a research expeditionary group (1962) resulted in health posts and extensive genetic, epidemiologic, and demographic studies. The results showed good physical and nutritional status, but stress from epidemic disease and social disruption. Conditions had improved by 1976, and the battle was with encroaching ranchers. Strong indian political action led to the securing of boundaries within the Pimentel Barbosa reservation by 1977. The population doubled from 249 in 1977 to 411 in 1988, and increased to 3 villages. There was evidence of a return to more traditional practices. Data collection for this analysis occurred during 1976-77 and 1988 and 1990. Results were provided for recent demographic change, recent births and deaths, factors affecting fertility, fertility change, parity and infant mortality, life expectancy changes, infanticide, population growth, marriage patterns, and health changes. Fertility histories were collected from 71 women in 1971 and 109 women in 1990. Difficulties were encountered due to Xavante differences in enumeration of children. In the comparison of the surveys in 1977 and 1990, there was close correspondence of reported births, and discrepancies of 4-9 births and in age at death. The difficulties encountered were attributed to problems with interpreters. The demographic analysis showed evidence of introduced diseases, which increased infant mortality and threatened population replacement, followed by decreased infant mortality and a large cohort of reproductive age women increasing population growth. The history of this and similar populations is one of a rise and fall in population since colonial times. The seminomadic nature of this group may have saved them from extinction.^ieng

Decline and unevenness of infant mortality in Salvador, Brazil, 1980-1988.

Data relating to infant mortality in Salvador, Brazil, were analyzed in order to determine how infant mortality evolved in various parts of the city during the period 1980-1988. This analysis showed sharp drops in the numbers of infant deaths, proportional infant mortality (infant deaths as a percentage of total deaths), and the infant mortality coefficient (infant deaths per thousand live births) during the study period despite deteriorating economic conditions. It also suggested that while these declines occurred throughout the city, the overall distribution of infant mortality in different reporting zones remained uneven. Among other things, these findings call attention to a need for further investigation of the roles played by various health measures (including immunization, control of respiratory and diarrheal diseases, encouragement of breast-feeding, and monitoring of growth and development) and of reduced fertility (resulting from birth spacing, use of contraceptives, and female sterilization) in bringing about declines in infant mortality during hard economic times.

PIP: Infant mortality has declined since the 1940s in the Americas and specifically in Brazil. Infant mortality in Brazil was 65 deaths/1000 live births regardless of the recession. The aim of this study was to determine the patterns of change in infant mortality in 76 reporting zones in Salvador, Brazil, between 1980 and 1988, based on death records and decedent's place of residence. Data were analyzed in terms of changes in proportional infant mortality and the infant mortality coefficient. Quartiles were set at low (3.9 to 17.1 deaths/100 total deaths), intermediate (17.9 to 25.8), and high (37.5 to 52.5). Averages of each quartile were computed for 1980 and 1988 and compared. Live birth rates were used in computing the infant mortality coefficients; deaths/1000 live births were grouped by low, intermediate, and high, and average values calculated for 1980 and 1988. The problems of distortion in using these data are discussed. The results show declines in proportional infant mortality from 17.4% to 30.8% of total mortality and in infant mortality coefficients from 71.9 to 31.6 deaths/1000 live births. Proportional infant mortality declined by 43.5% between 1980 and 1988; the coefficient of infant mortality decreased by 56.1% for the same period. The absolute number of deaths also declined. In the quartile analysis, the rates of decline were greatest for intermediate, high, and very high proportional infant mortality and for the coefficient of infant mortality. There was also uneven distribution of deaths in different quartiles. The geographic location of reporting zones is visually displayed; it is apparent that there were few very high zones in 1988 and a sharp reduction in high zones for proportional infant mortality. The map of average infant mortality coefficients shows marked declines in very high zones; there were increases in areas with low and intermediate coefficients. Suggestions for additional research were to evaluate a longer time series and to analyze the influence of socioeconomic change on the declines.

Estimating infant mortality rates prospectively in Honduras.

In order to determine the validity of infant mortality estimates based on retrospective reporting, the Honduran Ministry of Health carried out a follow-up survey of women interviewed in a 1987 national survey. Women were interviewed approximately 14 months after the baseline survey and were asked about the outcomes of their pregnancies and the survival status of their young children. The overall infant mortality rate calculated from the follow-up survey was lower than that obtained from the baseline survey, due to the particularly low rate among the group of women who were pregnant at the time of the baseline survey. Possible explanations for this low rate are discussed.

PIP: Indirect and direct methods may be used to estimate infant mortality rate (IMR). Respondents surveyed retrospectively about births, deaths, and corresponding dates often, however, omit or misreport vital events. Prospective studies virtually eliminate the potential for these types of errors. To test the validity of IMR estimates based upon retrospective reporting, this paper compares the former with estimates drawn from baseline survey data obtained 14 months prior. Baseline data came form 10,159 women ages 15-44, interviewed in 1987, by the Ministry of Health of Honduras. 1048 women were pregnant at baseline, and IMR was estimated to be 48/1000. The follow-up survey questioning pregnancy outcome and survival status of respondents' young children achieved a 74% response rate, and yielded an estimated IMR of 26/1000 for newborns. IMR estimated from follow-up data is probably unrealistically low given mortality trends and socioeconomic conditions in HOnduras. 3 sources of error potentially contributing to low IMR for the cohort of newborns are considered: pregnancy denial, unreported, and underreporting of pregnancies. Future studies should be conducted with more than 1048 pregnant women, baseline survey should be improved to better detect pregnancies, and regional and community studies should be considered in an effort to reduce study cost and boost response rates at follow-up.

Infant mortality and crisis in Mexico.

Data derived from the Encuesta Nacional de Fecundidad y Salud (ENFES) confirm that overall levels of infant mortality in Mexico have been steadily declining. However, a more specific analysis furnishes evidence that this decline has occurred at varying rates within different social groups, reflecting an increase in social inequalities. The analytical strategy used in this article leads to three basic conclusions: (1) the impact of the economic crisis on infant mortality is reflected not in a reversal of the declining trend but an increase in social inequalities; (2) certain variables universally accepted as determinants of infant mortality, such as mother's education, seem nonsignificant for some social sectors; and (3) certain biodemographic characteristics assumed to have a uniform mortality-related behavior vary among sectors, suggesting that even these constants are determined by social factors.

PIP: The characteristics and extent of and trends and differentials in infant mortality in Mexico are examined. Bivariate and multivariate analyses were based on data from the Encuesta Nacional de Fecundidad y Salud (ENFES) in 1987. The birth period was 1976-85, and the infant mortality reference period is June 1980. Analysis included breakdowns by social sector (agricultural and nonagricultural: middle-class nonmanual workers (25.5%), working-class manual workers (46.3%), salaried workers (33.5%), and nonsalaried workers (12.8%). Infant mortality is measured as the probability of death between birth and 2 years (2q0). The results show a decline in infant mortality, but the rate of decline is unequal among social strata. There was a 11.4% decline between 1976-85 in 2q0. The patterns were as follows: infant mortality is higher at 34 and 20 years; higher order pregnancies had higher infant mortality; longer average time between pregnancies yielded lower infant mortality; 2q0 is greater in towns of 20,000 population and lower in metropolitan areas; 2q0 is higher among women with little or no education; 2q0 among women with a negative score on the Index of Housing Services (INSEVI) is twice that of women in the middle and higher categories; and 2q0 is higher among women in the agricultural sector. There was a 17% rise in 2q0 (from 73.8 to 86.2 deaths/1000) between 1972-80 in the agricultural sector, and the nonagricultural sector showed uneven declines. Among women in the middle-class nonmanual sector there was a decline of 18% (27.9 deaths/1000; among working-class nonsalaried workers, 12%; and among working-class salaried workers, 5% (48.6 deaths/1000). In the analysis of differentials, 1) age of mother at time of birth, 2) mother's education, and 3) the INSEVI index of services available in the dwelling confirmed the presence of differentials in infant mortality. For total population, age of the mother at time of birth shows a typical U-shaped pattern, but the social sector analysis shows that the age mortality relationship is inverse when good services are available in the dwelling, with the exception of working-class nonsalaried workers. In the agricultural sector, 2q0 of mothers aged 15-19 is 10 times higher than women aged 35-39 with similar services in the homes. The multivariate model reveals that mother's education is not significant in all models. The relationship between size of place of residence is inversely related to mortality only among women in the middle-class nonmanual workers. In all nonagricultural sectors, availability of adequate services has a strong effect on reducing 2q0. Age of mother at time of birth and birth order are the only variables significant in all 4 models.

Why Nicaraguan children survive. Moving beyond scenario thinking.

PIP: The authors respond to Tony Dajer's critique of their study concerning the trend in Nicaraguan infant mortality and its possible explanations. It is pointed out that the sharp decline in Nicaragua's infant mortality in the mid-1970s is an intriguing phenomenon, since it began to occur at a time of economic slump, civil disturbance, and under a government that gave low priority to the social sector. It is contended that a number of factors (among them the Managua earthquake) prompted the government to shift its allocation of resources from hospital-based health care in the capital city to ambulatory health care throughout the country. After the revolution, the Sandinista government continued this process. Dajer's characterization of USAID-funded clinics as "notoriously ineffective" is rejected; arguing that although operating under overt political guidelines, these projects are well-advised by experts. Dajer's question as to the importance of health care within the Sandinista government is considered. It is maintained that the revolution was not fought in order to reduce infant mortality, and that health was not the primary concern of the Government of National Reconstruction. It was the international solidarity movement, not the Sandinista government, which focused so intently on infant mortality, hoping to find good news to report. The issue of health care had the added advantage of being politically noncontroversial. It is also maintained that since the mid-70s, the country's health policy has remained stable, despite the radical changes in government because the international arena helps determine national health policy.^ieng

[Mortality by cause among children younger than age one in Mexico]. / La mortalidad por causas de menores de 1 ano en Mexico.

"This article presents the levels and trends of deaths among children [in Mexico] under the age of one, by groups of causes, for some states, for the years 1979-1985. Identifying the causes of death according to the international classification of diseases, both for deaths among children under the age of one and for total deaths, the goal is to establish a comparison of the levels of general and infant mortality by groups of causes. The data are taken from the statistical yearbooks of the Head Office for Statistics, for the years 1979 to 1985." (SUMMARY IN ENG)

Mexico.

PIP: Results of Mexico's 1987 National Survey of Fertility and Health (ENFES) shows significant changes in total fertility rates (TFR) and contraceptive prevalence rates. These changes are due i large part to the institutionalization of a population policy enacted in 1972 that has continued to receive strong support from the government. The TFR declined from 6.3 to 3.8 with urban rates falling 50% and rural rates 3/4. Between 1976-86 use of modern contraception doubled, going from 23-45%. Use of the pill declined while female sterilization increased for 9-36%; IUD's remained the 2nd most popular method at 18%. Contraceptive prevalence rates mirror changes in desired family sizes; women between 15-19 now desire 2.6 children while women at the end of their reproductive cycle expect to have 4. Infant mortality rates dropped from 85 to 47/1000 between 1970 and 1987. 62% of illiterate women wish to stop childbearing as compared with 49% of women with secondary schooling. This difference is related to differences in the ages of the 2 groups; as education has spread, women without any schooling tend to be older and have higher parity; and in spite of wanting to stop childbearing, they are 10 times less likely to use contraception than their more educated counterparts. 67% of the women interviewed received prenatal care from a doctor, with higher rates among the urban population. Between 80-90% of women breastfed their children, with higher rates among the rural poor.^ieng

Women's status and infant mortality in rural Colombia.

This paper investigates the effects of maternal demographic characteristics and social and economic statuses on infant mortality in rural Colombia. Demographic characteristics include the age of the mother, parity and length of preceding interbirth interval, and sex of infant. Measures of women's status at the time of birth include education, wage labor and occupation, economic stratum, place of residence, and whether the mother is living with a husband. The life history data for the study (involving 4,928 births) were collected in 1986 from a representative sample of two cohorts of women resident in rural central Colombia. Overall differentials in infant mortality by measures of women's status are small and are in good part associated with the differing reproductive behaviors of the women and variations in breastfeeding practices. The sharp declines in infant mortality recorded in rural Colombia in recent years appear less related to improved status of women than to reductions in fertility that enhance infant survivorship and to public health interventions shared by all segments of the population.

PIP: As part of the demographic transition that has been unfolding in Colombia over the last 5 decades, both urban and rural areas have experienced substantial declines in infant mortality. This decline is generally attributed to extensive countrywide health campaigns during the 1950s and 60s aimed at the prevention of disease, government-supported child immunization campaigns during the 1970s and 80s, and improvements in the population's educational level. To investigate the dynamics behind the sharp decline in infant mortality, life history data were collected in 1986 from a representative sample of 2 cohorts of women living in rural central Colombia. 4928 births were available for analysis. The cohorts included women born in 1937-46, who were of reproductive age in the early 1960s when fertility began its decline, or 1955-61, who entered their reproductive period in the 1980s after the sharp decline in fertility. Measures of women's status and demographic characteristics at the time of each birth were reconstructed for the analysis. A total of 207 children born to the study subjects died before their 1st birthday, yielding a 0.042 probability of infant death. Substantial declines in this probability were observed over time, with 0.072 of infants born before 1960 dying compared to 0.050 of those born in 1960-72 and 0.033 of infants born after 1972. Logit model analysis of the life history data indicated that changes in the status of women, including educational attainment, have had only a slight impact on the sharp declines in infant mortality in rural Colombia. More important have been reductions in fertility that have cut the number of high parity and closely spaced births and the prevalence of breastfeeding among rural mothers.

[Introduction: the demographic transition in the 1980s]. / Introduccion: la transicion demografica en la decada de los ochenta.

PIP: The authors review aspects of Mexico's demographic transition, with a focus on the 1980s. Population politics, contraceptive use patterns, changes in overall and infant mortality, and increased female labor force participation are considered as contributory factors to this transition.^ieng

Survey report: Dominican Republic.

PIP: The results of the Dominican Republic's 1986 Demographic and Health Survey suggest increased reliance on effective means of contraception but a continued preference for large family size. The survey covered 7649 women 15-49 years of age. Although only half of the women surveyed were currently using a contraceptive method, over 93% of these women were relying on an effective method, largely female sterilization. A desire to become pregnant was the main reason given for nonuse of contraception. However, 29% of women who were not using a method of contraception at the time of the survey indicated they did not want to become pregnant within the next 2 years. Many of these women expressed unfounded fears about the side-effects of contraceptive methods such as the pill. The 1986 survey recorded a total fertility rate of 3.7 lifetime births/woman for the 1983-85 period--the 1st time this rate has dropped below 4. However, survey respondents indicated a desired fertility rate of only 2.8 births, suggesting an unmet need for family planning services in the Dominican Republic. Another survey finding--that 68 infants/1000 die before their 1st birthday--suggests a need for greater access to maternal-child health services, especially in the country's rural areas.^ieng

[How long will we endure the sorrow of thirty deaths per thousand ?]. / Hasta cuando se llegara a las treinta defunciones por mil/

PIP: Infant mortality in Mexico has been declining since 1950. Between 1950- 60 it declined by more than 30% going from 132 to 90.3/1000 live births; from 1960-70 it declined by 15%; by 1970-1980 by 31% and from 1980-87 by 14% going from 53.1 to 46.6/1000. During 1950-1988 mortality among boys was 12% higher than among girls. The states with the highest infant mortality rates (IMR) in 1988 were: 1) Oaxaca with 73.6/1000; 2) Puebla with 60.1/1000 and 3) Hidalgo with 59.1/1000. Those states with the lowest IMR were Mexico City with 35.7 and Nuevo Leon with 32.3. It was found that IMR were 4 times higher in places with less than 2500 inhabitants as well as in places without water, light or electricity. However, the mother's education is the most important factor determining IMR.^ieng

[Family planning in Chile and its effect on health indicators]. / La planificacion familiar en Chile y su efecto sobre los indices de salud

PIP: In 1938 when the infant mortality rates (IMR) in Chile were over 200/1000 the Minister of Health, Dr. Eduardo Cruz Coke, decided that the principal cause for such a high IMR was malnutrition; he introduced a law that provided all living infants with powdered milk. The introduction of antibodies during the 50's also helped lower the IMR. By 1960 the IMR had dropped to 120.3/1000, a 37.6% drop in 20 years and by 1987 the IMR was 18.7/1000, a 90.3% drop in 47 years. The heavy drop in IMR between 1940-60 led to an increase in the population, with a parallel increase in the incidence of illegal abortions. Chilean hospital statistics indicate that in 1940 16,560 (13.9% of those 15-44) women were diagnosed with abortions and by 1960 it was 40,186 (29.8%). This increase of 114% in 20 years burdened the hospital care system until it reached "epidemic" proportions. By 1958 Dr. Jaime Zipper introduced the IUD to provide women with an alternative to abortion. By the mid-60's a group of OB-GYN's organized the Asociacion Chilena de Proteccion de la Familia (APROFA). In 1965 APROFA became an IPPF affiliate with access to modern methods of contraceptives. The article also includes 2 tables and 6 graphs with a demographic analysis of Chile's population by age groups and by health care status in the last 45 years.^ieng

[Peruvian demographic transition]. / Transicion demografica Peruana.

PIP: The demographic transition is conceptualized as the historic change from high to low fertility and mortality rates in a population. Peru's population was reduced by an estimated 80% as a result of new diseases, destruction of the economy, and the brutal regime of colonial exploitation after the Spanish conquest. From colonial times to the least the 1940s, Peru's principal population problem was the scarcity of manpower. The population grew at an annual rate of about .03% between 1650 and 1800, increasing to about 1.3% between 1876 and 1940. High fertility throughout the 19th century and a stabilization of mortality due to reduced incidence and deadliness of epidemics contributed to the increased growth rate. In the 1940s the process of demographic transition was initiated by abrupt declines in mortality. The crude death rate declined from 27/1000 in 1940 to 16/1000 in 1961 and 9/1000 in 1988, with the rate still declining. Fertility remained high and possibly increased slightly. The crude birth rate was estimated at 45/1000 in 1940 and 45.4/1000 in 1961. Improvements in infant and general mortality rates in developing countries like Peru result from diffusion of technological advances in prevention and control of diseases and improvement in health services rather than from changes in the economic and social structure. The 3rd phase of the demographic transition began with declines in fertility from 45.4/1000 in 1961 to 42.0/1000 in 1972 and 36.0/1000 in 1981. Despite declines, mortality and fertility continue to be elevated in Peru. The theory of demographic transition views the reduction of infant mortality, improvements in health and educational conditions and the condition of women, and more equitable income distribution as essential for a true decline in birth rates. In Peru, however, fertility has declined in a context of deteriorating living conditions and in the absence of effective family planning programs. The process of demographic transition must be accelerated, which will require improvements in education, income, and availability of sanitary services among other changes.^ieng

[Child survival: magnitude of the problem in Latin America]. / La sobrevivencia en la infancia: las dimensiones del problema en América Latina.

PIP: This document summarizes the most relevant epidemiologic characteristics of infant and child mortality in Latin America. The gap in infant mortality rates between Latin America and the developed countries is wide and appears to be increasing. In the developed countries, 980 of each 1000 infants survive to the age of 5, but only 900 did so in Latin America in 1975-80. Infant mortality declined in Latin America between 1950-55 and 1980-85 from 128 to 63/1000 live births, with a slight increase in the rate of decline over the past decade. The great differences in social and economic development within Latin America are reflected in mortality rates before the age of 5 that also vary widely, from 34/1000 in Cuba to 221/1000 in Bolivia in 1975-80. Latin American countries with moderate risk of early childhood mortality are led by Cuba and Costa Rica, with rates of 34-35/1000. The 2 countries are very different politically but both have implemented vigorous social policies that benefitted their entire populations. Both had sustained mortality declines between 1955-80. Argentina, Chile, Uruguay, Venezuela, and Panama had mortality rates of 46-56/1000. Within the region, 16.4% of births and 8% of deaths in children under 5 are estimated to occur in these 7 countries. The countries of very high mortality include the least developed Caribbean, Central American, and Andean countries: Haiti, guatemala, Honduras, Nicaragua, Bolivia, and Peru. 3 of these countries contain large indigenous populations that have largely remained outside the development process. Their average rate of infant mortality is 162/1000. 14.7% of births and 27.0% of deaths in children under 5 in Latin America occur in these 6 countries. The intermediate group contains the 2 most populated countries of the region, Brazil and Mexico. The risk of death under age 5 ranges from 74 to 114/1000 and averages 99/1000. The 7 countries account for 68.9% of births and 68% of deaths in children under 5. The rate of decline in infant mortality in Latin America is on the whole moderate, with no sign of acceleration. Progress is slowest in the countries with the highest rates. Available data clearly demonstrate excess mortality in rural areas, especially when compared to capital cities, but the degree of disparity varies among countries. In countries with high mortality and a large rural population, sustained decline in national mortality rates will require rural populations to be incorporated in the decline. In 1985, about 40% of Latin American children under 5 were believed to be in rural areas, but the proportion rural was 57% in the countries with highest mortality. Statistical information on causes of death in children under 5 is most deficient in exactly the areas where it is most needed. Most deaths are clearly due to infectious diseases and conditions preventable by vaccination. Social inequalities in survival of young children have been extensively described as a function of paternal occupational status, maternal education, and geographic factors. More effective policies are needed to ensure a more equitable distribution of wealth that will make possible a major improvement in child survival.^ieng

[Mortality. The behavior of mortality through 1987]. / Mortalidad. Comportamiento de la mortalidad hasta 1987.

PIP: Mexico's crude death rate has declined from 33/1000 in the early 20th century to about 6/1000 in 1985-87. Mortality declined sharply from 1640-60. more slowly from 1960-77, and rapidly again beginning around 1980. The explanation for the mortality decline lies both in advances in medical and health care and in economic growth of the country. The mortality declines in the late 1970s and early 1980s probably resulted primarily from extension of primary health care programs in rural areas. The infant mortality rate has declined from 288.6/1000 live births in 1900 to 73.8 in 1960 and 42 in 1986-87. At present 30% of deaths in Mexico are to children under 5, but little is known of the impact of the country's economic crisis on mortality in this age group. The strong mortality decline between 1950-70 was in the economically active age group of 15-64 years. Excess male mortality in this group reached a maximum in 1980: for each death of woman there were 150 male deaths. Between 1960-80 the rate of deaths due to infection, parasfitism, and respiratory disease declined by 5%, the rate of death from cancer remained almost unchanged, and the rate of death from cardiovascular diseases increased by 9%. Deaths from accidents, homicide, suicide, and other violence increased by 38%. Male general mortality rates were 25% higher than female in 1980. Mexican life expectancy increased from 49.6 years in 195 to 67 in 1987. Life expectancy was 65.6 for males and 71.7 for females. Average life expectancy was 69 for the more privileged social sectors and 56.7 for agricultural workers in 1965-79. The life expectancy of urban women was 3 years longer than that of rural women and 10.4 years longer than that of rural men.^ieng