Cuban Medical Research

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	Child And Adolescent Gynecological Services In Primary Care Sexual Function And Sex Hormones In Women With Premature Menopause Living Conditions And Maternal And Child Health Hormonal Contraception Cohort Study Cost Estimate For Pregnant Women Regarding Attendance At Prenatal Care Services In Three Havana Municipalities, Year 2000

LIVING CONDITIONS AND MATERNAL
AND CHILD HEALTH

Ricardo Batista Moliner, MD [1] [1];
Gisele Coutin Marie MD [2] [2]
Dr. Pablo Feal Cañizares MD [3] [3]

ABSTRACT:  The identification of health inequalities and their correlation with socioeconomic factors is a frequently raised issue. In Cuba, social development and achievements in public health have favored the reduction of the great disparities among people with unequal living conditions before 1959. However, differences in the behavior of some health indicators still exist. Using a correlation analysis between a living condition index and maternal and child health indicators, we have conducted a study to explore maternal and child health inequalities among Cuba’s municipalities and their correlation with living conditions there. We calculated and compared infant mortality, low birth weight, and fetal and maternal mortality for each municipality for the period 1997-1999. We found that the municipalities with least favorable living conditions had the worst results among the health indicators studied. These differences were especially significant regarding infant mortality, low birth weight, and fetal mortality.

Introduction

In recent years, the international scientific community, particularly those devoted to studying and tackling public health problems or working with health authorities in various countries, have emphasized the need to identify and deal with health inequalities in the world population.

In the 1990s, public health research and publications, including ones with a purely biomedical or clinical approach, carried multiple studies of the inequalities existing among various groups and communities in many countries and regions of the world, as well as the link between certain characteristics of those populations and their health status or specific health problems.

Demographic, ethnic, physical, and social factors have largely been documented as determinants in the health status of a population.1,2  In this sense, great importance is given to the role of social factors, especially living conditions, which are defined as "the objective conditions in which people lead their social and individual lives; which have been classified into three main groups: working conditions,  family conditions, and community conditions.” 3 Thus living conditions are the sum of the processes that characterize and reproduce the particular form of each population group’s participation in the functioning of the whole society; i.e. , the production, distribution, and consumption of goods and services created by the society, as well as its particular power relations.

References to the correlation between health and living conditions date from ancient times. In the 2nd century N.E. , Galen stated: "…the life of many individuals is affected by  the particularities of their occupation…some live this way because of poverty.”  4  This situation was evident during slavery and the Middle Ages.

The works of important philosophers and medical thinkers of the 18th and 19th centuries, reflected the fact that the situation of the poorer classes was dramatically worse than that of the bourgeoisie or people with a more favorable economic position. This is also reflected by Engels, who exposed the poor living conditions of the English proletariat in industrial cities, and the impact of these on their health.5  From this period, there is another important work by the renowned English physician William Farr who, in 1885, published a valuable vital statistics report that corroborated Engels’ statements, establishing that people with different living conditions (sanitation, water supply, economical situation, etc. ) had different mortality patterns.6

In spite of the fact that numerous scientific and technological advances have been introduced into medical sciences during the 20th century, they do not reach all those who need them, and the conditions in which people live continue to determine differences in their health status; not even civilized and developed Europe escapes this situation.7

In Latin America, the deterioration of living conditions as a result of neoliberal policies, keeps most of the impoverished population immersed in a permanent health crisis. Numerous studies carried out in this region clearly demonstrate this situation.8-10

Before 1959, the situation in Cuba was similar to that of other countries in the region. However, the  revolution brought about major changes aimed at eliminating unequal living conditions in the Cuban population, the majority of which suffered terrible health problems. The socioeconomic transformations carried out by the Cuban government, including the equitable distribution of the national income; as well as the implementation of fair and comprehensive development policies throughout the country, providing equal basic services and integral development opportunities to all (education, health, culture, recreation, work, etc. ) are aimed at diminishing inequalities among the country’s regions and communities, especially the least developed ones.

Cuba’s social policy strategy has been essentially directed at the elimination of inequalities and, chiefly of one of its worse expressions:  inequities in human reproduction and well-being. The first actions taken by the Cuban government included those focused on maternal and child health; as well as massive literacy and education campaigns, along with an integral plan for the construction of schools and primary healthcare centers. Top priority was given to rural areas, where overall sanitation and housing policies were also implemented.

One of the cornerstones of Cuba’s social policy, aimed at eliminating inequalities, was the improvement of women’s living conditions, which unquestionably has had an impact on subsequent changes in the reproductive health of the Cuban population.

This policy has significantly improved the living conditions of the population. However, in spite of the Cuban government’s efforts, inequalities in living conditions still persist in some areas that, in turn, have an effect on their population’s health status.

Recent studies conducted by Cuban authors like Amaro Guerra and Villorio Sánchez, at the Cuban Institute for Domestic Demand, have focused on the identification of health status inequalities in regions with different levels of socioeconomic development.11-13

Maternal and child health care are among the areas in which the reduction of inequalities in regional living conditions, and the resulting reduction of health status differences, have had an unquestionable impact. The implementation and consolidation of the Cuban Maternal-Child Program in the early 1970s gave top priority to actions dealing with the delivery of healthcare to these two population groups, which has become one of the major achievements of Cuban society.

Infant mortality has declined in an almost lineal progression from approximately 60 per 1,000 live births, in the late 1950s, to 6.4, at the end of 1999. A look at this indicator by provinces and regions between 1980 and 1999, reveals a progressive decrease in the differences between the maximum and the minimum rates for each province as compared with the national rate, thus approaching the national global figure (Figure 1).

Figure 1. Maximum and Minimum Provincial Infant Mortality Rates Compared with National Rates.

Other indicators of infant and maternal health also follow this pattern. For example, changes in the national fertility rate before and after 1959 reveal a reduction of differences between urban and rural areas.14

An indicator that intuitively reveals the correlation between the level of socioeconomic development and living conditions is low birth weight (LBW), which in turn has an impact on mortality rates. Low birth weight has also shown a clear tendency to descend, with a brief oscillating interference during the most critical years of the special period (the period of Cuba’s harshest economic crisis). This reaffirms the correlation between this indicator and socioeconomic changes.

Although the efforts of the Cuban government to further reduce inequalities are patent, as well as the unquestionable advances and positive results in the main maternal and child health indicators, it is still unknown whether still-existing differences in the levels of maternal and child health among the country’s municipalities are related to the living conditions of their populations. We presume that there are still differences in some of these indexes that are the expression of variations in the living conditions of the inhabitants in each region.

In order to corroborate our hypothesis we have tried to determine the existence of differences in the levels of maternal and child health among the country’s municipalities, which have been divided into strata, based on the characteristics of their living conditions.

Objectives

Identify differences in the levels of maternal and child health among municipalities belonging to the same stratum of living conditions.

Determine the maternal and child health indicators that are most affected in territories with least favorable living conditions.

Detect associations among the health indicators evaluated in each stratum studied.      

Method

Ecological comparative study of multiple groups of population (municipalities)

For our study, we gathered data on a group of maternal and child health indicators from available sources at the municipal level and compared their distribution, taking into consideration the living condition stratum in each case. Moreover, we evaluated the correlation among some of these indicators in each stratum.

The indicators used were:

• Infant mortality (deaths per 1,000 live births)
• Low birth weight: LBW (percentage of total live births)
• Maternal mortality (deaths per 10,000 live births)
• Fetal mortality (deaths per 1,000 live births)     
• Percentage of abortions (abortions for every 100 births)

• Apartments
• Huts
• Percentage of population with running water 
• Percentage of population with flush toilets
• Housing in good condition
• Type 4 housing (wooden with cardboard or thatched roof)
• Physician per inhabitants
• Immigration-emigration ratio
• Women of working age who are employed      

In order to carry out comparisons between the strata we used the chi-square test, and calculated the Pearson correlation coefficient to detect associations among the parameters used in the study. Statistical calculations were carried out using the EPIDAT 2.0 software package.

Results

The classification of the country’s municipalities into strata according to their living conditions is shown in Table 1. As shown in this table, almost 40% of the country’s municipalities belong to stratum III (with least favorable living conditions, in contrast with the ones in the other two strata).

Table 1. Classification of municipalities according to living conditions. Cuba 1998

The fertility rate was higher in stratum II municipalities, followed by stratum III ones. (Table 2), stratum I has the lowest rate in spite of the fact that 47.3% of women of fertile age live in these municipalities.

Table 2. Fertility rates by stratum Cuba 1997-1999

Infant Mortality

Infant mortality is a highly sensitive indicator of a nation’s health development level and of the health status of the population.15  In the three years studied, a total of 454,546 births occurred in the country, of which 3,134 died. This accounted for a mortality rate of 6.8 per 1,000 live births in that period, the municipality with the highest infant mortality being Cauto Cristo (15.8 per 1,000 live births). Candelaria had the lowest (1.12 per 1,000 live births).

A global analysis of living conditions by stratum showed significant differences among them. The most unfavorable behavior of infant mortality rate was found in stratum III, with a global rate of 7.64 per 1,000 live births. In the other strata, this indicator remained below 7 per 1,000 live births (Table 3).

Table 3. — Infant mortality by stratum. Cuba 1997-1999.

x2 = 20.3                    p= 0.000043

Low Birth Weight

This indicator has been consistently associated with infant mortality.16-18  In Cuba, numerous studies have also confirmed this finding.19-22  In our study, although significant differences among the strata were observed, the highest low birth weight rate was found in stratum III municipalities (6.88%), and the lowest, in stratum II ones (Table 4).

Table 4. — Low birth weight rate by stratum. Cuba 1997-1999.

x2 = 17.79       2 gl      p= 0.000125

Fetal Mortality

As with the above indicators, the highest fetal mortality rate was found in stratum III municipalities (12.58 per 1,000 live births), while the lowest was observed in stratum I ones (11.25). In this case, significant differences among the three strata were found (Table 5).

Table 5. — Fetal mortality by stratum. Cuba 1997-1999.

x2 = 13.34                  p= 0.00127

Maternal Mortality

No significant differences among strata were found regarding maternal mortality, in spite of being the variable that showed the largest gaps among the three strata. Stratum III municipalities also showed the worst results in this indicator, with a rate of 38.55 per 100,000 live births—higher than that of the country in the same period (31.73 per 100,000 live births).

Table 6. — Maternal mortality by stratum. Cuba 1997-1999.

x2 = 2.93                    p= 0.2307

A correlation analysis among some of the indicators studied and infant mortality indicates, overall , that there is a strong correlation between low birth weight and under one year mortality (r= 0.9459), between fetal death and postnatal death (r=0.8811). Maternal mortality did not show an important link with infant mortality.

It was in stratum III that the highest coefficient between the first two of these variables (low birth weight and under one year mortality) and infant mortality was found, which was, higher that 0.9, for both variables.

Discussion

As we have already said, infant and maternal health is a priority for the Cuban government and healthcare system. Moreover, there is a high level of awareness in the community regarding the importance of care to these population groups. However, as shown by the health indicators used in our study, relevant differences are still found.

Just as we expected, the highest rates of these indicators were found in stratum III municipalities (the ones with least favorable living conditions). Studies conducted some years ago also showed that stratum III municipalities had the highest mortality rate,23 and our study has corroborated these findings. Of the ten municipalities with higher infant mortality rates, seven belong to stratum III, while those with lower rates (for the period studied) belong chiefly to strata I and II (90%).

An interesting aspect in this analysis is the fact that the best results for almost all the indicators studied, were found in stratum II municipalities—the ones with the lowest rates of infant mortality, low birth weight and maternal mortality. This can be explained by the fact that these municipalities are in the provincial capitals or near them where the population has quick access to specialized health centers and, consequently, lower risk of perinatal complications. Furthermore, these are municipalities with sustained work in the prevention of low birth weight and under one year mortality.

In the case of maternal mortality, an irregular distribution of rates was found, with notable differences in living conditions among the groups studied, although those differences were not statistically significant, due to the reduced quantity of items observed in the strata. This great variability in maternal mortality is also present at the national level.

In the case of low birth weight, a solid correlation is also found which demonstrates the impact of low birth weight on the evolution of children under one year of age and their greater predisposition to life-threatening complications. Studies carried out in Cuba and other countries support this finding.

Conclusions

The existence of differences in living conditions has been found to have an impact on the health indicators of the population. In the case of maternal and child health, this becomes more evident, since these populations are highly sensitive to social development changes.

In Cuba, in spite of the fact that a clear reduction of socioeconomic differences among the main regions has been attained, unequal results are still found   In virtue of these findings, it is necessary to further analyze and identify differences among territories, as well as the  factors that make it possible to continue reducing such differences.

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