International Journal of Epidemiology, Vol 28, 267-275, Copyright © 1999 by International Epidemiological Association
AC Terra de Souza, E Cufino, KE Peterson, J Gardner, MI Vasconcelos do Amaral and A Ascherio
BACKGROUND: Infant mortality rates vary substantially among municipalities
in the State of Ceara, from 14 to 193 per 1000 live births. Identification
of the determinants of these differences can be of particular importance to
infant health policy and programmes in Brazil where local governments play
a pivotal role in providing primary health care. METHODS: Ecological study
across 140 municipalities in the State of Ceara, Brazil. RESULTS: To
determine the interrelationships between potential predictors of infant
mortality, we classified 11 variables into proximate determinants (adequate
weight gain and exclusively breastfeeding), health services variables
(prenatal care up- to-date, participation in growth monitoring,
immunization up-to-date, and decentralization of health services), and
socioeconomic factors (female literacy rate, household income, adequate
water supply, adequate sanitation, and per capita gross municipality
product), and included the variables in each group simultaneously in linear
regression models. In these analyses, only one of the proximate
determinants (exclusively breastfeeding (inversely), R2 = 9.3) and one of
the health services variables (prenatal care up-to-date (inversely), R2 =
22.8) remained significantly associated with infant mortality. In contrast,
female literacy rate (inversely), household income (directly) and per
capita GMP (inversely) were independently associated with the infant
mortality rate (for the model including the three variables R2 = 25.2).
Finally, we considered simultaneously the variables from each group, and
selected a model that explained 41% of the variation in infant mortality
rates between municipalities. The paradoxical direct association between
household income and infant mortality was present only in models including
female illiteracy rate, and suggests that among these municipalities,
increases in income unaccompanied by improvements in female education may
not substantially reduce infant mortality. The lack of independent
associations between inadequate sanitation and infant mortality rates may
be due to the uniformly poor level of this indicator across municipalities
and provides no evidence against its critical role in child survival.
CONCLUSIONS: These results suggest that promotion of exclusive
breastfeeding and increased prenatal care utilization, as well as
investments in female education would have substantial positive effects in
further reducing infant mortality rates in the State of Ceara.
ARTICLES
Variations in infant mortality rates among municipalities in the state of Ceara, Northeast Brazil: an ecological analysis
Harvard School of Public Health, Department of Maternal and Child Health, Boston, MA 02115, USA.
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