Desigualdades sociales en la mortalidad de niños menores de cinco años: revisión sistemática

Social inequalities in under-five mortality: a systematic review

Maylen L. Rojas-Botero Yadira E. Borrero-Ramírez Flor de María Cáceres-Manrique Acerca de los autores

RESUMEN

Objetivo

Identificar las características de los estudios sobre desigualdades sociales, en la mortalidad de niños menores de cinco años; sus perspectivas teóricas, ejes de desigualdad, métodos y resultados.

Método

Revisión sistemática de la literatura. Se consultaron cuatro bases de datos electrónicas y Google Scholar; se incluyeron estudios entre 2010 y 2018.

Resultados

Se analizaron 126 artículos. En el 62,7%, se estudió el territorio como eje de desigualdad, seguido por los determinantes socioeconómicos (27,8%). La mortalidad neonatal, infantil y en la niñez fue analizada en el 19,0%, 49,2% y 32,3%, respectivamente. Predominaron los estudios ecológicos (62,7%) y longitudinales (50,0%). Se encontró una disminución considerable en las tasas de mortalidad; sin embargo, el descenso no fue homogéneo entre subpoblaciones.

Conclusiones

La literatura reporta una marcada disminución de la mortalidad en niños menores de cinco años; no obstante, las brechas entre distintos ejes de desigualdad continúan y en algunos lugares se han incrementado. Las brechas entre los estratificadores variaron de acuerdo con el tiempo, lugar, eje de desigualdad y tipo de mortalidad analizada.

Palabras Clave:
Determinantes sociales de la salud; estratificadores de equidad; disparidades en el estado de salud; mortalidad del niño; revisión sistemática (fuente: DeCS, BIREME)

ABSTRACT

Objective

To identify the characteristics of the published studies on social inequalities in under-five mortality, their theoretical perspectives, axes of inequality, methods and results.

Method

We carried out a systematic literature review. We consulted four electronic databases and Google Scholar, for studies published between 2010 and 2018.

Results

We analyzed 126 articles. In 62.7%, territory was studied as the axis of inequality, followed by socioeconomic determinants (27.8%). Neonatal, infant and under-five mortality was analyzed as an output in health in 19.0%, 49.2% and 32.3%, respectively. It predominated ecological (62.7%) and longitudinal (50.0%) studies. Significant reductions in mortality rates were found, however, the decline was not homogeneous among subpopulations.

Conclusions

The literature reports a marked decrease in under-five mortality; however, the gaps between different axes of inequality continue and in some cases they have increased. Gaps varied according to time, place, axis of inequality and type of mortality analyzed.

Key Words:
Social determinants of health; equity stratifiers; health status disparities; child mortality; systematic review (source: MeSH, NLM)

Las desigualdades sociales en salud (DSS) son consideradas un problema global que supera el sector sanitario y afecta diferencialmente a los grupos sociales, con importantes brechas entre países y en su interior 11. Marmot M. Social determinants of health inequalities. Lancet. 2005 [Cited 2020 May 9]; 365(9464):1099-1104. Available from: Available from: https://bit.ly/2YQdRPI . DOI: 10.1016/S0140-6736(05)71146-6.
https://bit.ly/2YQdRPI...
. El estudio de las DSS se ha realizado desde distintos enfoques que explican las vías a través de las cuales los determinantes sociales configuran la salud de las poblaciones.

Para el análisis de las DSS, se utilizan categorías analíticas que se inscriben en cuerpos teóricos particulares; por ejemplo, clase, posición y estatus socioeconómico pertenecen a enfoques diferentes 22. Muntaner C, Rocha KB, Borrell C, Vallebuona C, Ibáñez C, Benach J, et al. Clase social y salud en América Latina. Rev Panam Salud Publica. 2012 [Cited 2020 May 9]; 31:166-175. Available from: Available from: https://bit.ly/3clxOl1 .
https://bit.ly/3clxOl1...
. Estas categorías no son agregados nominales, sino que comprenden jerarquías sociales que producen disparidades históricas en la distribución de la riqueza, el poder y el prestigio 33. Breilh J. Epidemiología crítica: ciencia emancipadora e interculturalidad . Buenos Aires: Lugar; 2003.,44. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health: Commission on Social Determinants of Health final report. Geneva: World Health Organization; 2008., e inciden directa e indirectamente en la salud de los individuos.

En el caso de los niños, las desigualdades sociales influyen en los resultados en salud a corto y largo plazo. De acuerdo con Unicef, entre 1989 y 2018 la mortalidad en niños menores de cinco años (MNMJ) en el mundo disminuyó en un 60% 55. Unicef. For every child, every right: The Convention on the Rights of the Child at a crossroads. New York: Unicef; 2019.; no obstante, y pese al avance, las DSS persisten entre diferentes poblaciones, con peores resultados para los grupos socialmente en desventaja, como minorías étnicas, en contextos de precariedad y con deficientes condiciones ambientales 66. Braveman P. What are Health Disparities and Health Equity? We need to be clear. Public Health Rep. 2014 [Cited 2020 May 9]; 129(Suppl 2):5-8. Available from: Available from: https://bit.ly/3dvXqvJ . DOI:10.1177/00333549141291S203.
https://bit.ly/3dvXqvJ...
.

Este estudio tuvo como propósito identificar las características de la producción académica publicada entre 2010 y 2018 sobre DSS en la MNM5: las perspectivas teóricas, métodos, ejes de desigualdad y magnitud de las brechas.

MÉTODO

Tipo de estudio

Revisión sistemática de la literatura. Los criterios para la revisión se establecieron a priori en términos de pregunta PICO: P, Niños menores de cinco años; I, Determinantes sociales de la salud; C, Subgrupos que constituyen ejes de desigualdad; O, Mortalidad.

Criterios de selección

Artículos indexados en SCÍELO, PubMed, LILACS, Ebsco y Google Scholar; publicados en español, inglés y portugués entre enero de 2010 y diciembre de 2018; que estudiaran DSS en la MNM5, incluyendo la mortalidad peri-natal -MP-, neonatal -MN-, infantil -MI- y en la niñez.

Se excluyeron los artículos no originales, teóricos, metodológicos, históricos, de evaluación de intervenciones o políticas públicas, o de factores de riesgo sin análisis de desigualdad.

Estrategia de búsqueda

La consulta se realizó en abril de 2019. Dos personas del equipo (MR y YB) desarrollaron e implementaron independientemente los algoritmos de búsqueda, adaptados de acuerdo con las especificaciones de cada base de datos electrónica. A continuación, se muestra la estrategia utilizada en PubMed: ("health inequalities"[Title/Abstract] OR "social inequalities"[Title/Abstract] OR "social in-equity"[Title/Abstract] OR "health disparities"[Title/Abs-tract]) AND ("infant mortality"[MesH Terms] OR "child mortality"[MesH Terms] OR "childhood mortality"[Title/ Abstract] OR "under five mortality"[Title/Abstract]) AND ("2010/01/01"[PDAT]: "2018/12/31"[PDAT]).

Proceso de selección

Inicialmente, se identificaron los artículos duplicados. Luego, MR aplicó los criterios de selección a títulos y después a resúmenes. YB corroboró los artículos excluidos. Las discordancias fueron solucionadas por un tercero.

Extracción de datos

Las tres autoras leyeron textos completos y extrajeron datos de forma independiente; cada manuscrito fue revisado y calificado por dos evaluadoras; en el caso de discrepancia, la tercera fungió como árbitro. Los datos extraídos se consignaron en una matriz en MS Excel®.

Evaluación de calidad

Se utilizaron 10 ítems adaptados del índice para evaluar el riesgo de sesgo 77. Font-Ribera L, García-Continente X, Davó-Blanes MC, Ariza C, Díez E, García M, et al. El estudio de las desigualdades sociales en la salud infantil y adolescente en España. Gac Sanit. 2014 [Cited 2020 May 9]; 28(4):316-325. Available from: Available from: https://bit.ly/2Wjkg44 DOI: 10.1016/j.gaceta.2013.12.009.
https://bit.ly/2Wjkg44...
. Cada ítem se calificó así: 0=ausencia total; 0,5=ausencia parcial; y 1=presencia suficiente. Se consideró un artículo de alta calidad si el puntaje total era mayor que 8,5, de calidad media cuando estuvo entre 7 y 8, y de baja calidad si fue menor que 7.

Análisis de los datos

Los resultados fueron resumidos narrativamente. Se calcularon algunos indicadores bibliométricos, se reportaron los cuerpos teóricos declarados y el método -diseño, unidad de análisis, fuentes y operacionalización de ejes de desigualdad-. Se describió la magnitud de la MNM5, sus principales causas y brechas, según el eje de desigualdad. La concordancia inter-evaluadoras para valorar la calidad se evaluó con el coeficiente de correlación intraclase, símil al kappa ponderado considerando el acuerdo parcial 88. Streiner D, Norman G, Cairney J. Health Measurement Scales: A practical guide to their development and use. 5a ed. London: Oxford; 2015.. Se construyeron mapas, tablas y gráficos en Stata14®, Tableau® y MS Word®.

Consideraciones éticas

Esta investigación hace parte de la tesis doctoral de MR, avalada por el Comité de ética de la investigación de la Facultad Nacional de Salud Pública (CI 341-2018).

RESULTADOS

Artículos identificados

Se identificaron y recuperaron 217 artículos, de los cuales 91 fueron descartados. Finalmente, se analizaron 126 manuscritos. La Figura 1 detalla el proceso de selección.

Figura 1
Descripción del proceso de selección

Año de publicación, población de estudio y país del investigador principal

Los artículos se publicaron, principalmente, en inglés y en el 2013 (18,3%). Los países más analizados fueron Brasil e India (18 y 11 artículos) (Figura 2). Las investigaciones analizaron poblaciones de Argentina 99. Marro MJ, Fattore GL. Análisis de tendencia de la desigualdad en la mortalidad materno-infantil, Argentina, 1990-2010. Rev argent salud pública. 2018 [Cited 2020 May 9]; 9(35):17-24. Available from: Available from: https://bit.ly/2WHkpgF .
https://bit.ly/2WHkpgF...

10. Augsburger AC, Gerlero SS, Galende S, Moyano CB. La expresión de las desigualdades sociales en la mortalidad infantil. Información epidemiológica en regiones seleccionadas de la provincia de Santa Fe (Argentina). Rev Fac Nac Salud Pública. 2013 [Cited 2020 May 9]; 31(supl1):139-148. Available from: Available from: https://bit.ly/2yIOaWu .
https://bit.ly/2yIOaWu...

11. Meritano J, Tsavoussian L, Címbaro R, Solana C. Evaluación de la mortalidad neonatal en la Ciudad Autónoma de Buenos Aires según la residencia de la población y la pertenencia al subsistema de salud. Arch Argent Pediatr. 2016 [Cited 2020 May 9]; 114(5):405-411. Available from: Available from: https://bit.ly/35OVVWM .
https://bit.ly/35OVVWM...
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, Bangladesh 1313. Huda TM, Tahsina T, El-Arifeen S, Dibley MJ. The importance of intersectoral factors in promoting equity-oriented universal health coverage: a multilevel analysis of social determinants affecting neonatal infant and under-five mortality in Bangladesh. Glob Health Action. 2016 [Cited 2020 May 9]; 9(29741). Available from: Available from: https://bit.ly/2YRIkN8 . DOI:10.3402/gha.v9.29741.
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14. Adams AM, Rabbani A, Ahmed S, Mahmood SS, Al-Sabir A, Rashid SF, et al. Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development. Lancet. 2013 Dec [Cited 2020 May 9]; 382(9909):2027-37. Available from: Available from: https://bit.ly/2AasDGp . DOI: 10.1016/S0140-6736(13)62060-7.
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15. Minnery M, Firth S, Hodge A, Jimenez-Soto E. Neonatal mortality and inequalities in Bangladesh: Differential progress and sub-national developments. Matern Child Health J. 2015 [Cited 2020 May 9]; 19(1):2038-47. Available from: Available from: https://bit.ly/35Y5gvT . DOI: 10.1007/s10995-015-1716-z.
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19. Alves R, Santana V, Moura C, Queiroz R, Costa C. Inequalities in health: living conditions and infant mortality in Northeastern Brazil. Rev Saude Publica . 2015 [Cited 2020 May 9]; 49(5):1-9. Available from: Available from: https://bit.ly/3cklX6N . DOI:10.1590/S0034-8910.2015049004794.
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20. Gonçalves A, Costa M, Paim J, Vieira L, Braga JU, Barreto M. Social inequalities in neonatal mortality and living condition. Rev Bras Epidemiol. 2013 Sept [Cited 2020 May 9]; 16(3):682-91. Available from: Available from: https://bit.ly/3bl4h9Y . DOI:10.1590/S1415-790X2013000300012.
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21. Martins EF, Rezende EM, De-Mattos, Felix FC. Perinatal mortality and socio-spatial inequalities. Rev Lat Am Enfermagem. 2013 Oct [Cited 2020 May 9]; 21(5):1062-1070. Available from: Available from: https://bit.ly/35Ng5Av . DOI:10.1590/S0104-11692013000500008.
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22. Barros FC, Matijasevich A, Harris J, Giugliani E, Maranhão AG, Monteiro CA, et al. Recent trends in maternal, newborn, and child health in Brazil: progress toward Millennium Development Goals 4 and 5. Am J Public Health. 2010 Oct [Cited 2020 May 9]; 100(10):1877-1889. Available from: Available from: https://bit.ly/2WjyIZH . DOI:10.2105/AJPH.2010.196816.
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23. Faria R, Santana P. Variações espaciais e desigualdades regionais no indicador de mortalidade infantil do estado de Minas Gerais, Brasil. Saúde Soc. 2016 [Cited 2020 May 9]; 25(3):736-749. Available from: Available from: https://bit.ly/3cnRapN . DOI:10.1590/S0104-12902016147609
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24. Gava C, Cardoso AM, Basta PC. Infant mortality by color or race from Rondónia, Brazilian Amazon. Rev Saúde Pública. 2017 Apr [Cited 2020 May 9]; 51(35). Available from: Available from: https://bit.ly/2WkIkUc . DOI: 10.1590/S1518-8787.2017051006411
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25. Almeida W da S de, Szwarcwald CL. Mortalidade infantil e acesso geográfico ao parto nos municípios brasileiros. Rev Saúde Pública . 2012 [Cited 2020 May 9]; 46(1):68-76. Available from: Available from: https://bit.ly/2Wj98UH .
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26. Murakami GF, Guimarães MJ, Sarinho SW. Sociodemographic inequalities and cause of death among children aged under 5 years in the Brazilian State of Pernambuco. Rev Bras Saúde Mater Infant. 2011 [Cited 2020 May 9]; 11(2):139-52. Available from: Available from: https://bit.ly/2YPU3f9 .
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27. Garcia LP, Santana LR. Evolution of socioeconomic inequalities in infant and child mortality in Brazil, 1993-2008. Ciénc Saúde Coletiva. 2011 Sept [Cited 2020 May 9]; 16(9):3717-3728. Available from: Available from: https://bit.ly/3duVPGH . DOI: 10.1590/S1413-81232011001000009.
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28. Caldas AD, Santos RV, Borges GM, Valente JG, Portela MC, Marinho GL. Mortalidade infantil segundo cor ou raça com base no Censo Demográfico de 2010 e nos sistemas nacionais de informação em saúde no Brasil. Cad Saúde Pública. 2017 Aug [Cited 2020 May 9]; 33(7). Available from: Available from: https://bit.ly/3bjIyiD . DOI: 10.1590/0102-311X00046516.
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29. Ramalho WM, Sardinha LM, Rodrigues IP, Duarte EC. Inequalities in infant mortality among municipalities in Brazil according to the Family Development Index, 2006-2008. Rev Panam Salud Publica . 2013 [Cited 2020 May 9]; 33(3):205-12. Available from: Available from: https://bit.ly/2LkM41u .
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31. Maia LT, De-Souza W, Mendes A. Diferenciais nos fatores de risco para a mortalidade infantil em cinco cidades brasileiras: um estudo de caso-controle com base no SIM e no SINASC. Cad Saúde Pública . 2012 Nov [Cited 2020 May 9]; 28(11):2163-2176. Available from: Available from: https://bit.ly/2xPJAVU .
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32. De-Oliveira G, Lima MC, Lyra C, Oliveira AG, Ferreira MA. Desigualdade espacial da mortalidade neonatal no Brasil: 2006 a 2010. Cien Saúde Coletiva. 2013 [Cited 2020 May 9]; 18(8):2431-2441. Available from: Available from: https://bit.ly/2WNoq36 .
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33. Drumond E, Abreu DM, Machado C, Gomes F, Franca E. Racial dis-parities and avoidable infant mortality in a city of Southeastern Brazil, 2001-2009. J Trop Pediatr. 2013 [Cited 2020 May 9]; 59(1):23-8. Available from: Available from: https://bit.ly/35P24Cy . DOI: 10.1093/tropej/fms039.
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34. Wood CH, de-Carvalho JA, Horta CJ. The color of child mortality in Brazil, 1950-2000: social progress and persistent racial inequality. Lat Am Res Rev. 2010 [Cited 2020 May 9]; 45(2):114-39. Available from: Available from: https://bit.ly/2YOE40U .
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, el Sur Global 125125. Sosnaud B, Beckfield J. Trading equality for health? Evaluating the trade-off and institutional hypotheses on health inequalities in the Global South. J Health Soc Behav. 2017 Jul [Cited 2020 May 11]; 58(3):340-56. Available from: Available from: https://bit.ly/3coEM8R . DOI:10.1177/0022146517721950.
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y el mundo 126126. Garces-Ozanne A, Kalu EI, Audas R. The effect of empowerment and self-determination on health outcomes. Health Educ Behav. 2016 Sep [Cited 2020 May 11]; 43(6):623-31. Available from: Available from: https://bit.ly/2Y-VAFgO . DOI:10.1177/1090198116667665.
https://bit.ly/2Y-VAFgO ...

127. Bendavid E. Changes in child mortality over time across the wealth gradient in less-developed countries. Pediatrics. 2014 Dec [Cited 2020 May 11]; 134(6):e1551-1559. Available from: Available from: https://bit.ly/2yMH3MK . DOI:10.1542/peds.2014-2320.
https://bit.ly/2yMH3MK...

128. Chuang KY, Sung PW, Chang CJ, Chuang YC. Political and economic characteristics as moderators of the relationship between health services and infant mortality in less-developed countries. J Epidemiol Community Health . 2013 [Cited 2020 May 11]; 67(12):1006-12. Available from: Available from: https://bit.ly/35NBgme .
https://bit.ly/35NBgme...

129. Amouzou A, Kozuki N, Gwatkin DR. Where is the gap?: the contribution of disparities within developing countries to global inequalities in under-five mortality. BMC Public Health . 2014 Mar [Cited 2020 May 11]; 14(216):1-5. Available from: Available from: https://bit.ly/3boymWj . DOI:10.1186/1471-2458-14-216.
https://bit.ly/3boymWj...

130. Gakidou E, Cowling K, Lozano R, Murray CJ. Increased educational attainment and its effect on child mortality in 175 countries between 1970 and 2009: a systematic analysis. Lancet. 2010 Sep [Cited 2020 May 11]; 376(9745):959-74. Available from: Available from: https://bit.ly/2zxhWxC . DOI:10.1016/S0140-6736(10)61257-3.
https://bit.ly/2zxhWxC...

131. Brinda EM, Rajkumar AP, Enemark U. Association between gender inequality index and child mortality rates: a cross-national study of 138 countries. BMC Public Health . 2015 Mar [Cited 2020 May 11]; 15(97):1-6. Available from: Available from: https://bit.ly/2Llga56 . DOI:10.1186/s12889-015-1449-3.
https://bit.ly/2Llga56...

132. Ruiz JI, Nuhu K, McDaniel JT, Popoff F, Izcovich A, Criniti JM. Inequality as a powerful predictor of infant and maternal mortality around the world. Plos one . 2015 Oct [Cited 2020 May 11]; 10(10):e0140796. Available from: Available from: https://bit.ly/3bqSPJQ . DOI:10.1371/journal.pone.0140796
https://bit.ly/3bqSPJQ...

133. Almasi-Hashiani A, Ayubi E, Fahimfar N, Khosravi A, Karamzad N, Safiri S. Economic inequality and infant, under-5-year-old, maternal, and crude mortality rates. J Arch Mil Med. 2015 [Cited 2020 May 11]; 3(3). Available from: Available from: https://bit.ly/2LlTFgk . DOI: 10.5812/jamm.28205.
https://bit.ly/2LlTFgk...
-134134. Marphatia AA, Cole TJ, Grijalva-Eternod C, Wells JCK. Associations of gender inequality with child malnutrition and mortality across 96 countries. Glob Health Epidemiol Genom. 2016 [Cited 2020 May 11]; 1:1-8. Available from: Available from: https://bit.ly/3boDWYo . DOI:10.1017/gheg.2016.1.
https://bit.ly/3boDWYo...
.

Figura 2
Distribución de los artículos seleccionados según país estudiado, país del investigador principal, año e idioma de publicación

Calidad de los artículos

La mayoría tuvo calidad alta (66,7%), el 27,0% y el 6,3% fue de media y baja, respectivamente. Los ítems más débiles fueron el enfoque teórico, el análisis estadístico y la discusión a la luz de la teoría subyacente.

El acuerdo global entre las evaluadoras fue del 96,0%. La correlación intraclase fue alta (ICC=0,88; IC95% 0,82 - 0,91); se encontraron cinco discrepancias solucionadas por la tercera autora.

Modelos teóricos o conceptuales

En 23 manuscritos (18,3%), se manifestó el modelo teórico que sustentó la investigación; el más utilizado fue el modelo de la Comisión de la OMS 135135. Commission on Social Determinants of Health. A conceptual framework for action on the social determinants of health. Discussion paper for the Commission on Social Determinants of Health. World Health Organization; 2007., seguido por el marco analítico de Mosley y Chen 136136. Mosley WH, Chen LC. An analytical framework for the study of child survival in developing countries. Population and Development Review. 1984 [Cited 2020 May 11]; 10(1):25-45. Available from: Available from: https://bit.ly/2xS0Cmf .
https://bit.ly/2xS0Cmf...
(Cuadro 1). En algunos artículos se distinguen elementos implícitos del modelo de la Comisión; sin embargo, en la mayoría no se identificó un enfoque teórico claro.

Cuadro 1
Modelos teóricos o conceptuales explícitos en los manuscritos Modelo teórico o conceptual Manuscritos

Aspectos metodológicos de los estudios

Diseño

Fueron mayoritariamente estudios ecológicos -transversales, longitudinales y múltiples valoraciones transversales ecológicas- (62,7%). En menor proporción fueron estudios transversales con unidad de análisis individual (17,5%), entre otros. En el 38,1% de las investigaciones, la unidad de análisis fue individual; los demás (61,9%) analizaron conglomerados constituidos por regiones mundiales, países, unidades subnacionales, subestatales, municipales y submunicipales.

Fuentes de información

En todos los casos, utilizaron fuentes secundarias y casi la mitad recurrió a más de una fuente (45,2%). Tres estudios complementaron con fuentes primarias cualitativas 8282. Damghanian M, Shariati M, Mirzaiinajmabadi K, Yunesian M, Emamian MH. Socioeconomic inequality and its determinants regarding infant mortality in Iran. Iran Red Crescent Med J. 2014 Jun [Cited 2020 May 11]; 16(6):e17602. Available from: Available from: https://bit.ly/3dAZ6El . DOI: 10.5812/ircmj.17602.
https://bit.ly/3dAZ6El...
,100100. Olufunke F, Obafemi O. Ethnicity and child survival in Nigeria. Afr Pop Stud. 2011 [Cited 2020 May 11]; 25(1):92-112. Available from: Available from: https://bit.ly/2WMSpIE . DOI:10.11564/25-1-258.
https://bit.ly/2WMSpIE...
,110110. Málqvist M, Sohel N, Do TT, Eriksson L, Persson LA. Distance decay in delivery care utilisation associated with neonatal mortality. A case referent study in northern Vietnam. BMC Public Health . 2010 Dec [Cited 2020 May 11]; 10(762):1-9. Available from: Available from: https://bit.ly/2SPYSkT . DOI:10.1186/1471-2458-10-762.
https://bit.ly/2SPYSkT...
. Principalmente, se usaron estadísticas vitales, sistemas de vigilancia, programas y sistemas de información, del orden nacional y municipal.

Análisis de datos

La mitad de las investigaciones incluyeron análisis de tendencias en el tiempo; con periodos entre uno y 115 años, (Mediana: 17,5 años; Rq: 11-20 años). En muchos casos, se agruparon periodos según la disponibilidad de información o para obtener un mayor número de eventos por unidad de análisis.

Casi la mitad (42,9%) calculó índices para la estratificación socioeconómica y del sistema de salud; el más utilizado fue el índice de riqueza del hogar, derivado del programa DHS.

Medidas de frecuencia, magnitud y causas básicas de MNM5

Las tasas de mortalidad se estimaron utilizando métodos directos e indirectos. Se analizó la MI (49,2%), la MNM5 (32,3%), MN (19,0%) y MP (4,0%) utilizando, en todos los casos, los nacidos vivos -nv- como denominador. La brecha más amplia se observó en la MNM5, mientras en Saga (Japón, 2014) se registró una MNM5 de 1,7 muertes por cada mil nv; en Sierra Leona (2009), la tasa fue de 262,0 por cada mil nv.

Excepto un análisis en ciudades africanas 113113. Quentin W, Abosede O, Aka J, Akweongo P, Dinard K, Ezeh A, et al. Inequalities in child mortality in ten major African cities. BMC Med. 2014 Jun [Cited 2020 May 11]; 12(95):2-11. Available from: Available from: https://bit.ly/2zqaaFJ . DOI:10.1186/1741-7015-12-95.
https://bit.ly/2zqaaFJ...
, los estudios longitudinales reportaron tendencias decrecientes de mortalidad. Dicha disminución varió entre el 9,8% en cuatro años 2424. Gava C, Cardoso AM, Basta PC. Infant mortality by color or race from Rondónia, Brazilian Amazon. Rev Saúde Pública. 2017 Apr [Cited 2020 May 9]; 51(35). Available from: Available from: https://bit.ly/2WkIkUc . DOI: 10.1590/S1518-8787.2017051006411
https://bit.ly/2WkIkUc...
y 99,2% en 115 años 8585. Nagata C, Moriichi A, Morisaki N, Gai-Tobe R, Ishiguro A, Mori R. Inter-prefecture disparity in under-5 mortality: 115 year trend in Japan. Pediatr Int. 2017; 59(7):816-20. Available from: https://bit.ly/2Z4AobF.
https://bit.ly/2Z4AobF...
(mediana de variación porcentual anual promedio: 2,3%; Rq: 1,83,2% anual). Como puede verse en la Figura 3, existe una reducción importante en la MNM5; además, sobresale la dinámica de Bangladesh, con una de las tasas más altas al inicio del periodo y una reducción superior a la media.

Figura 3
Tasas de mortalidad en la niñez iniciales y finales reportadas en estudios longitudinales, según variación y tiempo evaluado. Revisión de la literatura, 2010-2018

Se declararon las causas básicas de defunción en el 12,7% de los artículos, correspondientes a malformaciones congénitas, deformidades y anomalías cromosómicas, enfermedades infecciosas y parasitarias, entre otras; la mayoría de las cuales son consideradas evitables.

Estratificadores para el análisis de desigualdad

El 78,6% de los estudios utilizó un eje de desigualdad. Los determinantes territoriales fueron los más utilizados (62,7%), seguidos de los socioeconómicos (27,8%), demográficos (16,7%) y del sistema de salud (8,7%); en menor medida, se encontraron los ambientales (4,0%), del contexto político (3,2%), género (2,4%) y factores conductuales y biológicos (2,4%). A continuación, se detalla la operacionalización de los ejes de desigualdad.

Estratificadores territoriales

Se identificaron dos formas de entender el territorio como eje de desigualdad. La primera -enfoque tradicional- utiliza las divisiones político-administrativas del Estado-nación, operacionalizado a través de países, provincias, prefecturas, regiones, estados/departamentos, agrupaciones insulares, distritos, municipios, comunas, barrios, cantones y bloques/áreas censales.

La segunda aproximación concibe el territorio como el espacio donde se articulan características de la estructura social que reproducen y refuerzan la estratificación, configuran las diferencias en los procesos de exposición y condicionan las oportunidades individuales y colectivas de alcanzar el mayor potencial de salud 137137. Borrell C, Malmusi D. La investigación sobre los determinantes sociales y las desigualdades en salud: evidencias para la salud en todas las políticas. Informe SESPAS 2010. Gac Sanit . 2010 Dec [Cited 2020 May 11]; 24(1):101-108. Available from: Available from: https://bit.ly/2ztNUdU . DOI:10.1016/j.gaceta.2010.05.005.
https://bit.ly/2ztNUdU...
. Así, se analizaron divisiones político-administrativas en función de su situación socioeconómica, ámbito urbano/rural, grupos étnicos, condiciones ambientales, infraestructura pública y condiciones del sistema de salud.

Estratificadores socioeconómicos

Se emplearon las categorías posición social (78,1%) y clase social (15,6%). La posición social se operacionalizó a nivel individual o familiar a través de riqueza, ingresos, estatus socioeconómico, fuente de pago de la atención médica, privación socio-material, facilidades y tenencia de bienes en el domicilio, material de la vivienda, estado conyugal de la madre, estatus migratorio, casta y educación (principalmente de la madre, pero también del padre). Entre tanto, la clase social, además de las anteriores características, incluyó la ocupación de la madre, de los padres, del jefe del hogar y el lugar de empleo.

Estratificadores demográficos

Usaron principalmente las categorías raza, etnia y color de piel. En menor medida se analizó sexo del niño y edad materna.

Estratificadores del sistema de salud

Se analizó el aseguramiento en salud (público/privado), acceso a la atención prenatal, lugar de ocurrencia del parto y distancia a los servicios de salud, de emergencia obstétrica y neonatal.

Estratificadores ambientales

Pocas investigaciones utilizaron características ambientales como estratificadores de desigualdad. Se destaca la vulnerabilidad del ambiente construido, exposición ambiental negativa, ruido, índice de verdor y contaminación del aire con dióxido de nitrógeno.

Estratificadores del contexto político

Un estudio utilizó el grado de democracia, medido a través del índice del proyecto Polity IV 128128. Chuang KY, Sung PW, Chang CJ, Chuang YC. Political and economic characteristics as moderators of the relationship between health services and infant mortality in less-developed countries. J Epidemiol Community Health . 2013 [Cited 2020 May 11]; 67(12):1006-12. Available from: Available from: https://bit.ly/35NBgme .
https://bit.ly/35NBgme...
. Adicionalmente, se emplearon indicadores de gobernanza mundial del Banco Mundial 127127. Bendavid E. Changes in child mortality over time across the wealth gradient in less-developed countries. Pediatrics. 2014 Dec [Cited 2020 May 11]; 134(6):e1551-1559. Available from: Available from: https://bit.ly/2yMH3MK . DOI:10.1542/peds.2014-2320.
https://bit.ly/2yMH3MK...
. Por otra parte, la categoría gobernanza y liderazgo fue medida a través del índice de percepción de corrupción en el sector público, de Transparency International 118118. Muldoon KA, Galway LP, Nakajima M, Kanters S, Hogg RS, Ben-david E, et al. Health system determinants of infant, child and maternal mortality: A cross-sectional study of UN member countries. Glob Health. 2011 Oct [Cited 2020 May 11]; 7(42). Available from: Available from: https://bit.ly/2Z0pUJY . DOI:10.1186/1744-8603-7-42.
https://bit.ly/2Z0pUJY...
; y finalmente, el empoderamiento y autodeterminación fue medido a través del índice de derechos políticos y libertades civiles de Freedom House 126126. Garces-Ozanne A, Kalu EI, Audas R. The effect of empowerment and self-determination on health outcomes. Health Educ Behav. 2016 Sep [Cited 2020 May 11]; 43(6):623-31. Available from: Available from: https://bit.ly/2Y-VAFgO . DOI:10.1177/1090198116667665.
https://bit.ly/2Y-VAFgO ...
.

Género como estratificador

Tres estudios analizaron estas desigualdades a través del índice de desigualdad de género del PNUD y el nivel de autonomía de la madre; no obstante, este último se limita a la participación en la toma de decisiones en salud del hijo.

Factores conductuales y biológicos como estratificadores

En este eje se consideraron aspectos biológicos del niño, como apgar, peso al nacer, prematuridad, embarazo múltiple y malformaciones congénitas; y conductas maternas riesgosas, como consumo de alcohol y cigarrillo.

En la tabla 1, se presentan las brechas medidas según el eje de desigualdad y resultado en salud; se detectaron desigualdades en la MNM5 en todos los determinantes analizados; además, algunas diferencias entre territorios (por riqueza y área de residencia) se han ampliado en el tiempo, tanto de manera absoluta como relativa.

Tabla 1
Magnitud de las desigualdades sociales en la mortalidad en la niñez, según eje y medida de desigualdad

DISCUSIÓN

Se discuten tres aspectos: i) la tendencia global de la MNM5 y sus desigualdades; ii) un análisis de la producción académica sobre DSS en la MNM5 y iii) asuntos metodológicos concernientes a los estudios analizados y a esta revisión.

Unicef reportó que la MNM5 disminuyó globalmente en un 60% en tres décadas, pasando de 95,0 a 39,0 muertes por cada mil nv entre 1989 y 2018 55. Unicef. For every child, every right: The Convention on the Rights of the Child at a crossroads. New York: Unicef; 2019.; lo cual se relaciona con la mejoría en condiciones de vida, avance socioeconómico poblacional e implementación de medidas de salud pública 138138. Navarro V, Benach J. Las desigualdades sociales de la salud en España. Informe de la Comisión Científica de estudios de las desigualdades sociales de Salud en España. Rev Esp Salud Pública. 1996; 70(5-6):505-636. Available from: https://bit.ly/2LlHm3O.
https://bit.ly/2LlHm3O...
. No obstante, diversos organismos indican que aún existen importantes obstáculos en la garantía plena de los derechos y un riesgo latente de incremento en la mortalidad 55. Unicef. For every child, every right: The Convention on the Rights of the Child at a crossroads. New York: Unicef; 2019.,138138. Navarro V, Benach J. Las desigualdades sociales de la salud en España. Informe de la Comisión Científica de estudios de las desigualdades sociales de Salud en España. Rev Esp Salud Pública. 1996; 70(5-6):505-636. Available from: https://bit.ly/2LlHm3O.
https://bit.ly/2LlHm3O...
.

Si bien la MNM5 ha disminuido en el mundo, el descenso no es uniforme entre subgrupos poblacionales; en algunos casos la brecha ha aumentado. Esta investigación evidenció que la literatura científica documenta sistemáticamente disparidades en la MNM5 condicionadas por el lugar de residencia y sus condiciones contextuales, políticas, socioeconómicas, demográficas, ambientales, del sistema de salud y del rol de la mujer en la sociedad, con peores resultados para los grupos más desventajados. La mortalidad más alta se observó en países de bajos ingresos; y si bien es preciso un llamado a la cautela, dadas las diferencias temporales y metodológicas, deben señalarse las amplias desigualdades en la magnitud de la mortalidad.

Entre los estratificadores de desigualdad, el territorio tuvo un papel preponderante. Al respecto, se ha descrito que divisiones espaciales generan divisiones sociales, mismas que están asociadas a las DSS, revistiendo de importancia el lugar de residencia sobre los resultados sanitarios 139139. Curtis S. Health and inequality: geographical perspectives. London; Thousand Oaks, Calif: SAGE; 2004.. Por ejemplo, en Camboya la diferencia relativa en la MNM5 entre áreas urbanas y rurales pasó de 1,6 a 2,4 entre 1989-90 y 2009-10; es decir, para el último año la mortalidad en el ámbito rural duplicó la del área urbana 3636. Jimenez-Soto E, Durham J, Hodge A. Entrenched geographical and socioeconomic disparities in child mortality: Trends in absolute and relative inequalities in Cambodia. Plos one. 2014 [Cited 2020 May 9]; 9(10). Available from: Available from: https://bit.ly/2YPHrog . DOI:10.1371/journal.pone.0109044.
https://bit.ly/2YPHrog...
; o en Holanda, donde las diferencias en la MP a nivel de barrio llegaron hasta 5,6 veces 101101. Vos AA, Denkta§ S, Borsboom GJ, Bonsel GJ, Steegers E. Differences in perinatal morbidity and mortality on the neighbourhood level in Dutch municipalities: a population based cohort study. BMC Pregnancy Childbirth . 2015 Sep [Cited 2020 May 11]; 15(201):1-9. Available from: Available from: https://bit.ly/35TVD1c. DOI: 10.1186/s12884-015-0628-7 .
https://bit.ly/35TVD1c. DOI: 10.1186/s12...
. En estos casos, se reconoce el avance al entender esta categoría más allá de la división político-administrativa del Estado-nación.

El segundo eje más utilizado fue el socioeconómico. En Bangladesh, la brecha relativa de desigualdad por quintiles de riqueza en la MNM5 pasó de 1,9 en 1993-94 a 2,1 en 2011 1414. Adams AM, Rabbani A, Ahmed S, Mahmood SS, Al-Sabir A, Rashid SF, et al. Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development. Lancet. 2013 Dec [Cited 2020 May 9]; 382(9909):2027-37. Available from: Available from: https://bit.ly/2AasDGp . DOI: 10.1016/S0140-6736(13)62060-7.
https://bit.ly/2AasDGp...
. En Chile, los hijos de madres ubicadas en el decil educativo más alto tenían 74% menos riesgo de morir en comparación con aquellos del decil más bajo 4040. Castro R. Indicios de igualdad demográfica en Chile: el caso de la mortalidad infantil. Pap poblac. 2015 [Cited 2020 May 9]; 21(83):189-201. Available from: Available from: https://bit.ly/2WiFq2m .
https://bit.ly/2WiFq2m...
.

Adicionalmente, con excepción de los tres trabajos que analizaron estratificadores políticos, no se encontraron investigaciones que articularan determinantes estructurales, constituyendo un reto para la investigación futura; avances en este sentido permitirían una mejor comprensión de la constancia y ampliación de las brechas sociosanitarias, pese a la disminución de la MNM5.

El segundo aspecto para discutir corresponde a quiénes producen investigación en el campo y desde dónde lo hacen. Se encontró mayor producción en Brasil e India; además, se identificó que investigadores de países aventajados estudiaron países en vías de desarrollo y no sus propios territorios; no obstante, esto puede deberse al periodo seleccionado, más si se considera que el estudio de las DSS ha sido de interés en países como Inglaterra desde la década de los 80.

Además, la mayoría de los estudios provenían de instituciones académicas e investigativas y hospitales. La escasa participación de actores privados puede, por un lado, impactar la financiación; y por otro, sugerir poco interés de actores del mercado en la producción de evidencia que denuncie agravios, provea información para la acción política, visibilice injusticias y propenda por una distribución más justa en salud.

La investigación empírica sobre DSS requiere referentes teóricos claros que orienten la definición del método, el análisis y la interpretación de los resultados. Entre las limitaciones identificadas está la constante omisión del enfoque teórico, lo que genera inquietudes sobre la racionalidad de los estudios, la manera como los investigadores entienden el fenómeno y operacionalizan ejes de desigualdad. Esta debilidad teórica lleva a la utilización de variables de distintos niveles sin una estructura relacional ni jerárquica, que puede producir conclusiones imprecisas y limitar los alcances de la acción sanitaria. Una situación similar detectó Font-Ribera en su revisión sobre desigualdades sociales y salud infantil en España; algunos de los artículos omitieron la manera como definieron y midieron los determinantes sociales, lo que dificultó la valoración de los manuscritos 77. Font-Ribera L, García-Continente X, Davó-Blanes MC, Ariza C, Díez E, García M, et al. El estudio de las desigualdades sociales en la salud infantil y adolescente en España. Gac Sanit. 2014 [Cited 2020 May 9]; 28(4):316-325. Available from: Available from: https://bit.ly/2Wjkg44 DOI: 10.1016/j.gaceta.2013.12.009.
https://bit.ly/2Wjkg44...
.

En cuanto a las limitaciones propias de este estudio, se consultaron solo cuatro bases de datos electrónicas y nueve años de búsqueda; en este sentido, se desconoce la cantidad de investigaciones publicadas por fuera de este espacio y si sus características difieren de las observadas.

Como en toda revisión, los artículos incluidos dependen de la estrategia de búsqueda y de los criterios de selección; asimismo, el resultado de la calidad está sujeto a quién efectúe la valoración. No obstante, se resalta la utilización de amplias bases de datos bibliográficas, la búsqueda adicional en Google Scholar y la revisión inversa para adicionar estudios relevantes, así como el proceso duplicado para disminuir la carga subjetiva.

Finalmente, las publicaciones evidencian que las exposiciones diferenciales en los determinantes sociales de la salud condicionan las probabilidades de supervivencia en niños. El lugar importa, no es lo mismo nacer y vivir en cualquier territorio en relación a la garantía del derecho fundamental a la vida y a la distribución de las oportunidades de bienestar 140140. Cepal, Naciones Unidas. La matriz de la desigualdad social en América Latina. Santiago de Chile: Cepal; 2016.. También es crucial la realidad de la mujer en la sociedad, entretanto sus condiciones desempeñan un papel decisivo en el bienestar de los niños 141141. Jaramillo-Mejía M, Chernichovsky D, Jiménez-Moleón J. Determinantes de la mortalidad infantil en Colombia. Path Análisis. Rev. Salud Pública (Bogotá) 2018 [Cited 2020 May 11]; 20(1):3-9. Available from: Available from: https://bit.ly/2WkFePY . DOI:10.15446/rsap.V20n1.39247.
https://bit.ly/2WkFePY...
. Aún persisten disparidades en el riesgo de morir prematuramente dadas por la raza, la etnia y el color de piel; así como también las condiciones del contexto político, social, económico, ambiental y del sistema de salud •

Agradecimientos:

A Marcela Ruiz Pineda, por su apoyo en la lectura de artículos. Las tres autoras participaron en la concepción del proyecto de investigación, en el análisis de datos, interpretación de resultados, escritura del artículo y revisión crítica del manuscrito sometido.

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  • Conflictos de interés:
    Ninguno.
  • Financiación:
    Esta investigación fue financiada por el Grupo de Investigación Demografía y Salud de la Facultad Nacional de Salud Pública, Universidad de Antioquia, y por el Departamento Administrativo de Ciencia, Tecnología e Innovación -Colciencias- (beca doctorado nacional 647 de 2014). Número de registro en PROSPERO: CRD42019127187.

Fechas de Publicación

  • Publicación en esta colección
    06 Feb 2023
  • Fecha del número
    Mar-Apr 2020

Histórico

  • Recibido
    28 Abr 2020
  • Revisado
    08 Mayo 2020
  • Acepto
    10 Mayo 2020
Instituto de Salud Publica, Facultad de Medicina - Universidad Nacional de Colombia Bogotá - DF - Colombia
E-mail: revistasp_fmbog@unal.edu.co