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Revista chilena de pediatría

Print version ISSN 0370-4106

Rev. chil. pediatr. vol.91 no.1 Santiago Feb. 2020  Epub Mar 11, 2020

http://dx.doi.org/10.32641/rchped.v91i1.1205 

ORIGINAL ARTICLE

Infant Mortality in the Metropolitan Region, Chile 2005-2014

Fernando González1  2 

Tania Alfaro3 

Olivia Horna-Campos3 

1 Department of Public Health, School of Medicine, Universidad de los Andes, Chile.

2 Department of Pediatrics and child Surgery, South campus, School of Medicine, Universidad de Chile, Chile.

3 School of Public Health, School of Medicine, Universidad de Chile, Chile.

Abstract:

Introduction:

Infant mortality depends on the economic, social, and cultural level of development of the place of residence.

Objective:

To describe the infant mortality rates (IMR) and the late infant mortality rates (LIMR) of the Metropolitan Region (MR) communes and to evaluate their trend between 2005 and 2014.

Material and Method:

Ecological study that describes the rates of the 52 communes of the MR. For the analysis, the IMR and LIMR were elaborated for each year and com mune and were compared using population attributable risk (PAR), attributable risk percent (AR%), and rate ratio (RR). Trends were analyzed through the Prais-Winsten model. A value p < 0.05 was considered a statistically significant trend.

Results:

The commune ‘Independencia’ presented the hig hest IMR and LIMR with 12.7 and 4.05 per 1000 live births respectively, 1.75 and 2.05 times more compared with the IMR and LIMR of the MR. The commune ‘Las Condes’ and ‘Vitacura’ presented the lowest IMR and LIMR respectively. The IMR trend regarding 2005 increased in Lo Barnechea, Lo Espejo, and Recoleta, and decreased in Las Condes, Macul, Pudahuel and San Bernardo. The LIMR decreased in Peñalolén, Puente Alto, Las Condes, Providencia, San Bernardo, Macul, Pudahuel, Tala- gante, Pedro Aguirre Cerda, and Quilicura, and increased in Peñaflor.

Conclusion:

The regional IMR and LIMR hide the slight increase in rates and the persistence of heterogeneity among communes. This forces us to explore the causes of these inequities through future analytical studies.

Keywords: Infant Mortality; Late Infant Mortality; residence; inequity; Chile

Introduction

What do we know about the subject matter of this study?

In Chile, infant mortality has not experienced a significant decrease in the last decade, however, it is one of the lowest in Latin America. Furthermore, it has not been possible to reduce the gaps within the country, as is the case between local communities.

What does this study contribute to what is already known?

This study allows us to recognize the inequality gaps between mu nicipalities with higher and lower infant mortality rates and their sub-components, deepening the importance of characterizing differences in the territory in order to develop public policies in line with local needs.

The infant mortality rate (IMR) is an indicator that strongly represents the health level of a population1,2,3. A high rate reflects a significant percentage of avoidable and premature deaths that we can prevent through in dividual and collective actions aimed at influencing the social and economic determinants of health4,5,6,7,8,9.

One of the first studies of social segregation, car ried out in New York in 1948, describes the differences between the African-American and Caucasian popula tions10. Infant and fetal mortality rates were directly re lated to the proportion of the African-American popu lation living in the neighborhood, which represents the first report of residential segregation.

Another study showed that social deprivation in a specific geographical area, measured through the Townsend deprivation index (unemployment, non home ownership, and household overcrowding), is strongly associated with IMR. This factor shows a so cioeconomic gradient where 20% of the population with the lowest socioeconomic level has an IMR rang ing from 21% to 55% greater than the highest socio economic one11.

Studies conducted in Latin American and Carib bean countries have shown that increased access to education for women and increased vaccination cover age, among other factors, have lowered the IMR of the region by reducing the social gradient12,13,14.

In 2015, the IMR in Chile was 6.9:1,000 live births (LB), which reflexes a 0.1 decrease compared with 2014. Although it is one of the lowest rates in Latin America, it presents a heterogeneous distribution among the country’s regions and communes and depends on so cio-economic variables15.

Hertel observed that the socioeconomically disad vantaged ones are at significantly higher risk of IMR due to infectious diseases and trauma during the first month of life16. The Late Infant Mortality Rate (LIMR) or post-neonatal is an interesting indicator since it rep resents with greater sensitivity the impact of the social determinants of health on population groups16.

Another important determinant is the area of resi dence which defines the conditions in which people live, leading to a higher or lesser ‘risk’ of illness or death17,18. The objective of this study is to describe the IMR of the Metropolitan Region’s (MR) municipalities and to evaluate its trend between 2005 and 2014.

Material and Method

Descriptive ecological study that explores the IMR and LIMR’s geographical distribution in the 52 com munes of the Metropolitan Region’s (RM) provinces: Santiago, Cordillera, Chacabuco, Maipo, Melipilla, and Talagante. We analyzed the period between 2005 and 2014, using the commune as analysis unit.

On the one hand, the IMR is defined by the sum of total deaths of infants under 1 year of age in each commune per 1,000 LB within the 9-year study period. On the other hand, the LIMR is defined by the sum of total deaths of newborns over 28 days and under 1 year of age in each commune per 1,000 LB in the same pe riod. These data were collected from the Department of Statistics and Health Information (DEIS) and the National Institute of Statistics (INE).

We compared the IMRs between communes with the regional standard and with the commune that has the lowest rate of the analyzed ones. We used three indicators for this end: Population Attributable Risk (PAR), Attributable Risk Percentage (AR%), and Rate Ratio (RR). The PAR was calculated through the for mula PAR = (Communal IMR - Reference IMR); the AR% = (Communal PAR/IMR)*100; and the RR was calculated using the formula RR = (Communal IMR / Reference IMR). When the commune with the lowest rate was used as a reference, the PAR and AR% were expressed as RPAR and RAR%, respectively.

The trend of IMFs by commune and year were as sessed using the Prais-Winsten regression represented as graphics generated using the STATA 14.0 software. An upward or downward trend was considered statisti cally significant with a p < 0.05 value. A map developed with the R software shows the IMR’s geographical dis tribution in the MR.

Results

Comparing Commune with Regional Standards

Between January 1, 2005, and December 31, 2014, 989,173 children were born in the MR and 7,164 chil dren under one year of age died, resulting in an IMR of 7.24:1,000 LB during the decade. When analyzing the MR’s provinces, Maipo presented the highest IMR (9.01:1,000 LB) and Melipilla and Chacabuco present ed the lowest one. In the Santiago province, 729,745 children were born and 3,674 died, resulting in an IMR of 7.10:1,000 LB during the studied decade.

The communes with the highest IMR were San Bernardo and Independencia. The last one presents a 12.7:1,000 LB rate. Its PAR compared with the MR is 5.46:1,000 LB, with 43% of AR%, and 1.75 of RR (Table 1).

Table 1 Comparison of impact indicators of the Infant Mortality Rate in relation to regional IMR and referential commune, 2005 - 2014. 

*reference value: Infant Mortality in the Metropolitan Region (7.24 x 1000 LB); Reference value: Infant Mortality in the Vitacura Commune (4.88 x 1000 LB); **commune with lower rate of infant mortality (excluding Alhue and San Pedro due to its low birth rate); ***commune with a higher rate of infant mortality; IMR: infant mortality rate; LB: live (new)borns; Prov: province; Par: Population attributable risk; Par0/!: Popu lation attributable percentage; RR: Rate ratio; CPAR: Communal population attributable risk; CAR%: Communal percentage attributable risk.

Without considering the communes Alhué and San Pedro, which have extremely low birth rates and ex ceptional deaths, Lo Barnechea, Vitacura, Las Condes, Ñuñoa, and Pudahuel showed rates lower than 6:1,000 LB. The commune Las Condes presented the lowest IMR, with a 4.88:1,000 LB rate over the decade, -48.4% of AR%, and 0.67 of RR (Table 1).

Inter-community comparison

The commune Las Condes, which has the lowest IMR, was selected as the commune of reference. When comparing such commune with the other ones, the RAR% vary widely, reaching a maximum of 61.6% in Independencia, with a 2.6 RR between both communes (Table 1).

Late Infant Mortality Analysis

In the specific commune-by-commune analysis of the LIMR, Vitacura presents the lowest rate (1.08:1,000 LB), while Independencia presents the highest one (4.38:1,000 LB). When compared with the regional standard, the PAR of Vitacura is -1.05, AR% -97.6, and RR 0.51, while the indicators of Independencia are PAR 2.25, AR% 51.31, and RR 2.05 (Table 2).

Table 2 Comparison of impact indicators of the Late Infant Mortality Rate in relation to regional LIMR and referential commune, 2005 - 2014. 

*reference value: Late Infant Mortality in the Metropolitan Region (2.13 x 1000 LB); Reference value: Late Infant Mortality in the Vitacura commune (1.08 x 1000 LB); **commune with lower rate of late infant mortality (excluding Alhué due to its low birth rate); ***commune with a higher rate of late infant mortality; LIMR: late infant mortality rate; LB: live (new)borns; PAR: Population attributable risk; PAR%: Popu lation attributable percentage; RR: Rate ratio; cPAR: communal population attributable risk; cAR%: communal percentage attributable risk.

In the analysis with the commune Vitacura as refer ence, there was a higher variation than that observed in the IMR, reaching maximum values in the com mune Independencia. This commune has a 3.3:1,000 LB RPAR, 75.3% RAR%, and 4.05 RR (Table 2).

Trend Evaluation

It was observed that the IMR of the MR follows a decreasing trend regarding 2005 (coefficient -0.075; 95%CI:-0.11 to -0.03), indicating that the IMR de creases 0.075:1,000 LB on average per year (Table 3). The communes that showed a significant increase in the period were Lo Barnechea (coefficient 0.33; 95%CI: 0.07 to 0.58), Lo Espejo (coefficient 0.27; 95%CI: 0.05 to 0.49), and Recoleta (coefficient 0.45; 95%CI: 0.18 to 0.73). The communes that showed a decrease with respect to 2005 were Las Condes (coefficient -0.24; 95%CI:-0.41 to -0.07), Macul (coefficient -0.31; 95%CI:-0.57 to -0.05), Pudahuel (coefficient -0.39 (95%CI:-0.76 to -0.01), and San Bernardo (coefficient -0.23; 95%CI:-0.38 to -0.08) (Figure 1).

Table 3 Trend for communes of the Metropolitan Region, 2005-2014. 

* 95% confidence interval; & Statistically significant; > Increase; < Decrease.

Figure 1 communes with significative variations in the trends of the infant mortal ity rate, Metropolitan Region, 2005-2014. 

Regarding LIMR, the MR shows a significant nega tive trend of 0.08:1,000 LB over the studied decade (Ta ble 3). Peñalolén, Puente Alto, Las Condes, Providen cia, San Bernardo, Macul, Pudahuel, Talagante, Pedro Aguirre Cerda, and Quilicura all showed significant de creases over the decade under study, while only Peña- flor showed a significant increase in its LIMR (Figure 2).

Figure 2 Communes with significative variations in the trends of the late infant mortality rate, Metropolitan Region, 2005-2014. 

The heat map shows the geographical distribution of the IMR among the MR’s communes, the color of the commune represents the indicator magnitude. The darker the color, the highest the figure. (Figure 3).

Figure 3 Heatmap of infant mortality rate in communes of the Metropolitan Region, periodz 2005-2014. 

Discussion

The study results show the heterogeneity persis tence of the IMR among the provinces and communes of the MR, however, the inequalities remain despite the significant decrease due to the implementation of social policies, such as the Comprehensive Protection System for Early Childhood Chile Crece Contigo (Chile Grows with You), among others.

Our study shows differences that are unthinkable in an OECD country. For instance, 43% of deaths of children under one year of age in the commune Inde pendencia could be avoided if it had the same IMR as the MR. Also, the risk of a child death is 75% higher in this commune than in the MR and, just by having born in Independencia, the risk of an infant dying in her/his first year of life during the decade studied was 2.6 times higher than the one of a child born in Las Condes. Specifically, when analyzing the LIMR, which mainly groups the preventable causes of death in early childhood, the difference is even greater. In the com mune Independencia, one in two child deaths after the month of life could be avoided if it had the same indi cators of the MR, while the risk of child death between the month and year of life in Independencia during the decade studied is four times higher than the risk of the commune Vitacura.

These differences could be explained by social de terminants of health that show an impact on infant mortality, such as smoking in pregnancy19, mother with lower education level20, and the lack of adherence to medical follow-up visits and indications, which are more prevalent in socially deprived groups.

Differences among communes could reflect resi dential segregation that may be related to the inequity in health, economic, social, and environmental indica tors between them21. The northern area, where Inde pendencia is located, has a higher percentage of poor households, presenting greater overcrowding, a higher unemployment rate, and a lower average of years of schooling than the national and MR ones22, and it is also one of the areas that have a significant percentage of immigrants (4.7%) from Peru, Haiti, Argentina, and Colombia29.

This situation has influenced the birth rate increase, especially in recent years, due to the characteristics of the mainly female and young population, similar to what has been described in other regions of the globe, which has been called the ‘feminization of migration’23.

The rise in the IMR could be explained by the in crease in the birth rate of immigrant mothers from countries with low rates of birth control or due to the barriers that hinder the access of this population to health services in our country, such as the lack of time ly delivery of information, cultural aspects, language, geographic, and administrative barriers that worsen in undocumented migrants24,25.

In Chile, there are studies that show that immigrant women, especially those of African descent, have little birth control and, therefore, late detection of maternal and fetal diseases26.

In recent years, the Chilean Ministry of Health has modified the regulatory framework in order to im prove access to health care for immigrants, especially for certain priority groups, such as protection of preg nant women, childcare, emergency care and care for undocumented immigrants. Thus, Circular A 15 No. 6 states that all facilities in the public health system must provide both health care and services regardless of their legal status in the country24. However, the ben eficiary population is not always aware of these regula tions. Even in this scenario of increasing immigration, the gaps in IMR between communes in our country are still longstanding27, therefore, migration is only one factor that would accentuate these differences.

In Chile, the decrease in IMR occurred due to pub lic health interventions20, however, quality education without differences in socioeconomic status is still a challenge28. Thus, in Chile, municipalities with high IMRs such as Independencia and San Bernardo have poverty percentages of 9.8% and 9.2%, respectively, while in Las Condes and Vitacura these percentages are 0.6% and 0%29.

The differences recorded in overall IMR are also confirmed in the assessment of IMR trends by commune, where Lo Barnechea, Lo Espejo and Recoleta have increased their rates. In the case of Lo Barnechea and Lo Espejo, it could be explained by the growth in the number of inhabitants in recent years, generally be cause of the young population.

Recoleta, on the one hand, has a significant number of immigrants which, as already mentioned, influences the birth and mortality rate. On the other hand, the communes that decreased the IMR in the period were Las Condes, Macul, Pudahuel, and San Bernardo. The decrease in the IMR in Las Condes is in line with the high socio-economic and quality of life indicators and the high number of people aged over 60 in the com mune (20.34%). In contrast, Macul, Pudahuel, and San Bernardo maintain higher levels of poverty (5.3%, 7.8%, and 9.2%, respectively)29.

The strategy of focusing on individual interven tions to improve health and reduce inequities has not proven to be effective by itself, unlike community interventions30. Therefore, strategies must have a univer sal and cross-sectoral approach, beyond the healthcare sector.

One example of a successful universal policy that has narrowed the gap of unequal conditions for child development, has been increased paid parental leave to attend prenatal follow-up visits and care the child in the first months of life, for both mother and father31. In Chile, this policy has been implemented with the ex tension of postnatal parental leave.

The largest reductions in the IMR in our country were related to improvements in living conditions of housing and education, to the increase in the health budget, and the implementation and improvement of maternal and child health programs, such as comple mentary feeding programs, prenatal and well-child care32,33.

Nowadays, the existence of specific programs that educate and achieve a change in risk behavior in less- favored social groups34 such as the Acute Respiratory Infections (IRA) program, a universal policy that has specific strategies for patients with chronic obstructive pulmonary disease or asthma35, will allow maintaining the reductions in IMR achieved today. However, the difficulty in further reducing the already low levels of IMR remains, since prematurity and congenital mal formations are the main contributors to IMR, which are not easy to prevent due to their multi-causal na ture.

Increased chronic comorbidities during pregnancy, increased gestational age, and fertility treatments that present a higher probability of multiple pregnancy are, among others, proven risk factors in the Chilean popu lation, which contribute to increasing the premature births rate. However, there are real strategies identified to reduce the mortality associated with prematurity where access to fair and quality healthcare is essential36.

In Chile, this context contributes to ‘the tyranny of averages’ that hides the phenomena still present, rep resented in the unresolved inequalities between com munes as those presented in this work and adding fu ture challenges, such as those arising from migration, cross-culturalism, and the country’s development that could help to increase the premature birth rate. This means that those strategies that were effective in reduc ing IMR in groups of people with higher levels of pov erty and lower schooling levels must be added to those of the epidemiological transition in our country.

In the 1960s, the problem of IMR was addressed from a much broader perspective than the healthcare sector, considering the mother-child dyad and the so cial determinants where it developed. Today, when we have better records and more precise and affordable methodological tools, we must resume the IMR analy sis and, with a preventive view, propose concrete mea sures for sustaining the achievements made, reduce inequities within our country, and avoid increases in IMR in groups at risk due to access barriers that people who enter the healthcare system may face.

Strategies to reduce risk factors for non-commu nicable diseases will also improve the health of future pregnant women and their children. In this light, it is essential to concentrate cross-sectoral efforts on educa tion by improving its quality, as well as on health care. These measures could be implemented by strengthen ing the training of the health team in subjects related to the populations at greatest risk, such as migration, transculturality, and adolescent pregnancy from the first years of professional training and/or training con tinuously the health teams in these matters, as well as in the health problems that prevail today in our popu lation.

Likewise, it is essential greater participation of vulnerable populations in health decision-making. This will allow us to understand why policies aimed at reducing inequities in Chile have not been effective enough, which leads us to rethink what changes in our society are currently not being adequately addressed to contribute to the reduction of such inequities, repre sented by the inequality in the IMR.

Limitations

Although in Chile the scope of vital event statistics since 1990 is considered solid, a possible limitation of our study is related to the potential inter-communal variability in the quality of the statistics, as occur inter regionally, where ill-defined deaths vary between 1.5% and 13.7%37. However, in Chile, the current legislation safeguards the quality of vital statistics through child mortality audits according to the regulation in force revised in 201238. Since 1885, our country has also the legal obligation to register births and deaths, in couple with the estimation and correction of late birth registrations carried out by the INE39.

Finally, this study shows that observing the re gional average indicator hides the differences between the current IMR and LIMR in the territory. Therefore, public policies must be addressed from different levels and under the slogan ‘health in all policies’, consider ing social determinants expressed as marginalization, poverty, rurality, and lack of access, and crucial factors such as education and health. These determinants have shown in several studies a close relationship with IMR and LIMR, and even more in the current demographic and epidemiological context, where identifying char acteristics of the social and physical environment is a challenge that can explain inequities such as migration, pregnancy at extreme ages, and high-risk pregnancies, which could change the infant mortality profile of the country.

Ethical Responsibilities

Human Beings and animals protection: Disclosure the authors state that the procedures were followed ac cording to the Declaration of Helsinki and the World Medical Association regarding human experimenta tion developed for the medical community.

Data confidentiality: The authors state that they have followed the protocols of their Center and Local regu lations on the publication of patient data.

Rights to privacy and informed consent: The authors state that the information has been obtained anony mously from previous data, therefore, Research Ethics Committee, in its discretion, has exempted from ob taining an informed consent, which is recorded in the.

Conflicts of Interest: Authors declare no conflict of interest regarding the present study.

Financial Disclosure: Authors state that no economic support has been as sociated with the present study.

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Received: May 17, 2019; Accepted: September 28, 2019

* Correspondence: Olivia Horna-campos. E-mail: oliviahorna@med.uchile.cl.

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