Mortalidad infantil en Europa central: efectos de la transición
Witold ZatoñskiI; Malgorzata MikuckaI; Carlo La VecchiaII,III; Peter BoyleIV
IThe Maria Sklodowska-Curie Memorial Cancer Center & Institute of Oncology, Warsaw, Poland
IIIstituto di Ricerche Farmacologiche Mario Negri, Milano, Italy
IIIIstituto di Statistica Medica e Biometria, Università di Milano, Milano, Italy
IVInternational Agency for Research on Cancer (IARC), Lyon, France
OBJECTIVE: To address the issue of infant mortality as an important health indicator, we systematically analyzed trends in infant mortality in five central and eastern European (CEE) countries (the Czech Republic, Hungary, Poland, Slovakia and Slovenia).
METHODS: Infant mortality rates (per 1,000 live births) and trends were computed using the World Health Organization database, as well as selected European databases.
RESULTS: In 1990, mortality rates in most CEE countries were appreciably higher than the mean European Union value of 9.2/1,000 (up to 14.8/1,000 in Hungary and 19.4/1,000 in Poland). However, between 1990 and 2001, infant mortality decreased substantially in all CEE countries, and in 2001 the rates in the Czech Republic (4.0/1,000) and Slovenia (4.3/1,000) were lower than the EU average of 4.6/1,000.
DISCUSSION: Infant mortality is an important indicator of the improvements in health observed in CEE countries over the last decade.
Keywords: Infant mortality. Democracy. Trends.
OBJETIVO: Para estudiar la aplicación específica de la mortalidad infantil como indicador relevante de la salud, hemos considerado sistemáticamente las tendencias en la mortalidad infantil en 5 países de Europa central y del este (República Checa, Hungría, Polonia, Eslovaquia y Eslovenia).
MÉTODOS: Hemos calculado las tasas de mortalidad infantil (por 1.000 nacidos vivos) y las tendencias a partir de la base de datos de mortalidad de la Organización Mundial de la Salud, así como otras bases de datos europeas y nacionales seleccionadas.
RESULTADOS: En 1990, la mayoría de los países de Europa central y del este tenían tasas apreciablemente mayores que el valor medio de la Unión Europea de 9,2/1.000, hasta 14,8/1.000 en Hungría y 19,4/1.000 en Polonia. Sin embargo, entre 1990 y 2001, la mortalidad infantil disminuyó sustancialmente en todos los países de Europa central y del este, y en 2001 las tasas en la República Checa (4,0/1.000) y Eslovenia (4,3/1.000) fueron menores que la media de la Unión Europea (4,6/1.000).
DISCUSÍON: La mortalidad infantil es un indicador relevante de los cambios favorables de la salud observados en países de Europa central y del este durante la década pasada.
Palabras clave: Mortalidad infantil. Democracia. Tendencias.
Infant mortality is an important indicator of health-related socioeconomic and cultural conditions, as well as of organizative and technical advancements in medical care. It is known, in fact, that infant mortality tends to be higher in countries with greater social and health-related inequalities, and to rise in countries which have suffered substantial socioeconomic, cultural and political disruption1.
Former non-market economy Central and Eastern European (CEE) countries underwent major political and social changes over the last two decades, and the collapse of socialized health systems led to the question of possible worsening of relevant health indicators2. Thus, to address the specific issue of infant mortality as a relevant health indicator, we systematically considered trends in infant mortality in five CEE countries.
The countries considered in this investigation are the Czech Republic, Hungary, Poland, Slovakia and Slovenia, i.e. the countries that first entered the period of political and economic transition during the late 1980's (in the rest of accession countries, the political and economical transition started later, in the mid 1990's). For the purpose of comparison, European Union (EU) average data were used. The source of the data was the WHO database (http://www3.who.int/whosis/menu.cfm). For the years 2000 and 2001, the EU average was derived (for year 2000) and estimated (for year 2001) from Eurostat data. For Slovakia 1970-85 and Slovenia 1970-83 data from national offices (Institute of Public Health of the Republic of Slovenia and Institute of Health Information and Statistics of Slovakia) were used. The infant mortality rate was computed on the basis of the World Health Organization definition. Numbers of births were used to compute rates per 1,000 live-born. The average infant mortality rate for the whole region analysed (i.e., the 5 countries of interest) was also computed. The average per cent change per year (annual percent change) was computed for each country and region, for each selected period. The computation was based on exponential function as a model of time trends.
In the year 1990, the lowest infant mortality rates were observed in Slovenia (8.3/1,000) and the Czech Republic (10.8/1,000). The highest ones were in Poland (19.4/1,000) and Hungary (14.8/1,000). The average rate for the EU, with a value of 9.2/1,000, was appreciably lower than in CEE countries considered (average value: 16.6/1,000) (table 1).
In the period 1990-2001 infant mortality rates decreased in all countries of interest (fig. 1). These declines were substantial and steady, and a few increases of infant mortality rates that occurred in Slovakia and Hungary in selected years were of minor value, possible due to vagaries of chance. Only the freezing of infant mortality decrease in Slovenia between 1989 and 1992 (with values 8.1/1,000 in 1989 and 8.9/1,000 in 1992) appears to be real.
In 2001, the lowest infant mortality rates were observed in the Czech Republic (4.0/1,000) and Slovenia (4.3/1,000). These values were indeed below the EU average (4.6/1,000) (table 1). The highest infant mortality rates in 2001 were observed in Poland (7.7/1,000) and Hungary (8.1/1,000). The annual percent change between 1990 and 2001 was highest in the Czech Republic (-9.9%) and Poland (-9.1%).
In all CEE countries, the percent decline was greater in the 1990's, compared to the 1980's. The change in fall was greatest in Poland (9.1% per year, compared to 3.1%) and in the Czech Republic (9.9 compared to 4.9%). In Hungary, the change in fall was smaller (5.8 compared to 3.9%), and in Slovenia and Slovakia changes were minor. Over the last decade, all CEE countries considered had greater annual percent change than the average EU one, leading to a levelling of infant mortality rates between accession countries and EU member states before 2004.
Contrary to what had been forecasted by several scientific and political groups, (e.g., Paniccia3), in the period of political transformation considered no increase in infant mortality in CEE countries was observed. On the contrary, the key message from this systematic analysis of infant mortality over the last two decades is the substantial decline observed in countries of the area, despite the societal changes and related social disruptions occurred in several of these countries in the late 1980's and early 1990's, and despite some freezing of decline of infant mortality rates in Slovenia during the Balkan conflict, although Slovenia was only marginally affected by that conflict.
Over more recent years, some of the CEE countries considered reached infant mortality rates lower than the EU as a whole, reflecting the stronger falls registered throughout the last decade. Interestingly, the annual percent change in East Germany (former German Democratic Republic, -7.4% in the 1990s, compared to -5.4% in the 1980s) during the 1990s was smaller than in the Czech Republic or Poland4. There are also differences in the components of infant mortality in various countries and regions. Thus, although there were declines in infant mortality in both parts of Germany in the 1990's, these were driven by a fall in neonatal mortality in the East, but of post-neonatal mortality in the West4.
In the Check Republic, the decline in neonatal mortality registered between 1989-91 and 1994-95 was due to an improvement in the survival of infants of all birth weights, but especially for these of low birth weight, pointing to a relevant effect of better access to health case5.
Some changes of pregnant women behaviour (like decrease in smoking prevalence) and a wider availability of modern medical technology are also likely to have contributed to the substantial declines in infant mortality observed across various CEE countries7. It is also possible, however, that socioeconomic improvements had a relevant impact, following the establishment of democracy in these countries2,8-11. An ecological exercise including data from 170 countries and using three different types of information -i.e., life expectancy, maternal mortality and infant mortality trends- showed, in fact, that after a country's wealth, level of inequality and size of its public spending were adjusted for, democracy had an independent favourable effect on health10.
Infant mortality is therefore a major indicator of the positive health changes that have been recorded in CEE countries during the last decade6.
W. Zatoñski participated in preparing concept of analysis, supervising the data analysis, writing and editing of the paper; M. Mikucka participated in data analysis, writing and editing of the report; C. La Vecchia participated in preparing concept, writing and editing of the paper; P. Boyle participated in preparing concept, and editing of the paper
Conflict of interest statement
Partial funding: EU Council: HEM. Closing the Gap. Reducing Premature Mortality, Baseline for Health Evaluation Monitoring Following Enlargement (Grant Agreement N.0 2003121).
The authors would like to thank Ms Anna Barkova from Institute of Health Information and Statistics in Slovakia, and Ms Jozica Selb from Institute of Public Health in Slovenia for supplying data for the study.
1. Bryce J, El Arifeen S, Pariyo G, Lanata CF, Gwatkin D, Habicht JP, et al. Reducing child mortality: can public health deliver? Lancet. 2003;362:159-64.
2. Zatonski W, Boyle P. Health transformations in Poland after 1988. J Epidemiol Biostat. 1996;1:183-97.
3. Paniccia R. Economic shocks, impoverishment and poverty-related mortality during the Eastern European transition. Research Paper from World Institute for Development Economics Research; 1997.
4. Nolte E, Brand A, Koupilova I, McKee M. Neonatal and postneonatal mortality in Germany since unification. J Epidemiol Community Health. 2000;54:84-90.
5. Koupilova I, McKee M, Holcik J. Neonatal mortality in the Czech Republic during the transition. Health Policy. 1998;46:43-52.
6. Zatonski WA, McMichael AJ, Powles JW. Ecological study of reasons for sharp decline in mortality from ischaemic heart disease in Poland since 1991. BMJ. 1998;316:1047-51.
7. La Vecchia C, Parazzini F, Levi F. Perinatal and infant mortality: a worldwide issue. Eur J Public Health. 1996;6:157-8.
8. Sen A. Poverty and famines: An essay on entitlement and deprivation. Oxford: Clarendon Press; 1982.
9. Sen AK. Development as freedom. Freedom in the World Country Ratings 1972-73 to 2001-2002. Nueva York: Knopf; 1999 [consultado 15/11/2003]. Disponible en: http://www.freedomhouse.org
10. Franco A, Álvarez-Dardet C, Ruiz MT. Effect of democracy on health: ecological study. BMJ. 2004;329:1421-3.
11. Ruger JP. Democracy and health. QJM. 2005;98:299-304.
Prof. Witold Zatoñski.
The Maria Sklodowska-Curie Memorial Cancer Center
& Institute of Oncology, 5 W.K.
Roentgena Street, 02-781. Warsaw. Poland.
Correo electrónico: email@example.com
Recibido: 2 de septiembre.
Aceptado: 12 de octubre de 2005.