Geographical disparity, child and maternal mortality

Original Article Trend of geographical disparities in child and maternal mortality indicators in Northwest

Mahasti Alizadeh1, Delara Laghousi2

1 MD, MPH, Professor of Community Medicine. Social Determinants of Health Research Center and Department of Community Medicine, School of Medicine, University of Medical Sciences, Tabriz, Iran 2 Department of Community Medicine, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran Corresponding author and reprints: Mahasti Alizadeh. Social Determinants of Health Research Center, Department of Community Medicine, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran. Email: [email protected] Accepted for publication: 11 November 2015

Abstract Background: The present study was conducted to assess the trend of geographical disparities in child and maternal mortality rates in 20 districts of East Azerbaijan, in the Northwest of Iran, between 1999 and 2013. Methods: Data on to health indicators between 1999 and 2013, extracted from population registry panels (ZIJ), was made available for the study by the East Azerbaijan Health Center. Disparities were measured by calculating the Index of Disparities (IDisp) and the trend was assessed using the general linear model test. Results: All the four indicators revealed decreasing trends between 1999 and 2013 (P<0.001), while there were no significant differences among the districts studied (P>0.05). The ranges of the IDisp between 1999 and 2013 were 19-32% for Neonatal Mortality Rate (NMR), 16-22% for Infantile Morality Rate (IMR), 14-20% for Under 5 Mortality Rate (U5MR), and 120-143% for Maternal Mortality Rate (MMR), which revealed an increasing trend for all the indices. The trend of health indicators before and after implementation of the family physician program showed no significant difference for MMR (P= 0.228), while significant declining trends were observed for NMR, IMR, and U5MR (P<0.001). Conclusion: The results showed that despite the downtrend in NMR, IMR, U5MR, and MMR indicators, there are still geographical disparities in these indicators among districts of the , in the Northwest of Iran.

Keywords: Geography; Infant Mortality; Maternal Mortality; Registries

Cite this article as: Alizadeh M, Laghousi D. Trend of geographical disparities in child and maternal mortality indicators in Northwest Iran. SDH. 2015;1(4):132-140.

Introduction The aim of health policy makers was that he unnecessary, avoidable, and unfair the mortality rate of children under 5 years differences in health are defined as reach two-thirds of the rate between the inequity in health, which is years 1990 and 2015 (2). Tsynonymous with disparity, and it is a According to the Millennium difference in which disadvantaged social Development Goals (MDG) 2015 report, groups –such as the poor, racial/ethnic the death rate of children under 5 years in minorities, women, or other groups who every region of the world has declined by have persistently experienced social more than half, with the exception of disadvantage or discrimination– Oceania; however, the process is not systematically experience worse health sufficient to reach the MDG target and than more advantaged social groups (1).

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Alizadeh M et al. about 10 years or more are needed to reach negative impacts on maternal and child the global goal (3). health (9). After the Global Strategy of Health for All A significant reduction was seen in the meeting in Alma-Ata in 1978, the child mortality rate in Tanzania due to implementation of the primary care system access to effective and new healthcare in the form of health networks began for services, health education, and vaccination the first time in Iran rural areas in 1980. and malaria programs in the recent years. Currently, information on the health care A recent analysis has shown a 24% system is updated and recorded regularly reduction in child mortality between the in the population registry panel or Vital years 2000 and 2004. If this trend Horoscope (ZIJ) (4). continues, Tanzania will be among the Infant Mortality Rate (IMR) is related to a African countries that will achieve the number of health indeces including fourth MDG goal (10). maternal health, access to health care, The Ministry of Health in Iran initiated a socioeconomic conditions, and public series of health sector reforms, including health policies (5). the pilot of the family physician program International evidence shows that the in urban areas since 2001. The child highest rate of child mortality is seen in mortality rate has rapidly declined in Iran populations with low socioeconomic in the recent years. The statistics show a situations, so IMR is used as a standard decline from 28.6 deaths per thousand live index to measure socioeconomic births in 2006 to 21 in 2011 (4). Despite development and public health (4). progressive reduction of child mortality in Maternal mortality and the mortality of the country in the recent years, geographic children under 5 are considered to be disparities in child mortality continue to important indicators of public health and exist among different provinces; the socioeconomic development (6, 7) and geographical disparities are observed to be require policy-makers to make appropriate different even in cities of a province (5). decisions to decline the trend (7). Therefore, the present study was The maternal mortality rate in Iran reduced conducted to examine the 15 year trend of from 31 deaths per 100,000 live births in maternal and child mortality indicators and 2005 to 23 in 2013 (6) and the deaths of geographical inequalities in maternal and children under 5 years dropped from 26 child health in Northwest Iran and the deaths in 2005 to 17 in 2013 (8). impact of the family physician program on India, as the most populous country in the process. South Asia, has the highest death rate of children under 5 years in this region and Methods 20% of deaths under age 5 in the world. A East Azerbaijan province, located in study conducted in India to examine the Northwest Iran, has a population of over death of children during the last two 3,700,000, 20 districts, 59 cites, 142 decades showed that, despite the decrease villages and 69.2% urbanization. In the in mortality of children under 5 years in current observational study, secular trends India, compared to countries with similar of four health indicators, including the economic and social conditions, the rate IMR, (Neonatal Mortality Rate) NMR, was still at a high level. Epidemiologic and Under 5 Mortality Rate (U5MR) and demographic studies show that low Maternal Mortality Rate (MMR), were economic status, women's low level of used to observe health inequality in 20 education, poor maternal nutrition, low districts of East Azerbaijan. Data related to maternal marriage age, large family, health indicators between 1999 and 2013 women's lack of independence, and extracted from Vital Horoscope (ZIJ) was inadequate access to health services have

Social Determinants of Health, Vol.1, No.4, 2015 133 Geographical disparity, child and maternal mortality made available for the study by the East period. But the differences among the Azerbaijan Health Center. districts related to the indicator were A paired t-test was used to determine generally not significant during the same whether or not there was a difference in period (F=1.02 and P=0.40). secular trends of health indicators in the Also, comparison of the districts in pairs in districts studied before and after terms of health indicators using the general implementation of the family physician linear model revealed that the obtained program. Also, the general linear model IMR in , Kalaybar, and Hashtrood test was run in Statistical Package for the districts was higher than those of Social Sciences (SPSS) software version Ajabsheer and , and the 21 to assess the trend of health indicators difference was statistically significant (P= among these districts. 0.01). The Index of Disparity (IDisp), which is a The main effect of the IMR process with quantitative index to evaluate inequities F=103.2 and P=0.001 was significant, among population groups over time, was meaning that it had a significant decline used to measure the 15-year trend of health over 15 years. However, the difference inequalities. IDisp summarizes the was not statistically significant in this difference among specific group rates and indicator among the towns studied the reference rate, expresses the summed (F=1.029 and P=0.40). differences as a proportion of the reference In paired comparison of the towns’ IMR rate, and the obtained value is multiplied indicator, it was found that the indicator by 100. The total population rate of the was higher in Kalaybar compared with East Azerbaijan province is considered the those in Ajabsheer, Meyaneh, Varzeghan, reference rate. The following formula was , Bostanabad, Sarab, Shabestar, and used to calculate IDisp: Tabriz, and this difference was statically significant (P=0.02). IMR index in the town of Charoymaq was also higher than that in Shabestar where r indicates the index rate in the (P=0.01). target group, R refers to the index rate in The main effect of the U5MR process with the total population or reference F=96.44 and P<0.001 was found to be population, J is the number of groups significant, meaning that the U5MR compared, and n shows the number of the process had a significant decline over the groups. 15-year period studied. However, the A decreasing trend in IDisp would indicate difference was not statistically significant decline in health inequalities and also (F=1.028 and P=0.41). reflect an improvement in equality among However, in paired comparison of the the groups observed (11). Excel 2010 was towns’ U5MR index, it was found that the used to calculate the index. index was higher in Kalaybar than those in Julfa, Meyaneh, , Bostanabad, Results Sarab, Shabestar, and Tabriz, and it was The main effect of the secular trend of higher in Charoymaq than those in NMR with F=81.5 and P<0.001 was found Bostanabad, Julfa, and Shabestar (P=0.01). to be significant. That is, the NMR trend had a significant decline over the 15-year

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Figure 1. A 15-year trend of neonatal mortality rate among districts of the East Azerbaijan province

Figure 2. A 15-year trend of IMR among districts of the East Azerbaijan province

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Figure 3. A 15-year trend of U5MR among districts of the East Azerbaijan province

The secular trend of MMR with F=3.44 displays the IDisp trends of mortality rate and P<0.001 was found to be significant, indicators between 1999 and 2013, and as well. That is, the MMR index over the Figure 6 displays this trend without the 15 years studied had a significant MMR. declining trend. However, the difference The ranges of the IDisp between 1999 and among the towns in terms of MMR over 2013 were 19-32% for NMR, 16-22% for this period was not generally significant IMR, 14-20% for U5MR, and 120-143% (F=1.021 and P=0.43). for MMR. Before the family physician In paired comparison of this index among program (1999-2005), the IDisp for NMR, districts, the index rates in Charoymag and IMR, and U5MR showed an increasing Harris counties were higher than those in steep, then the slope decreased while the Azarshar, Uskoo, Bonab, Tabriz, IDisp for MMR showed considerable Shabestar, and Kalaybar (P<0.05). fluctuations. A paired t-test was used to see if there were differences for health indicators Discussion before and after implementation of the Health disparity refers to the index of family physician program, that was started population groups who can benefit from in 2006. The results showed no significant health care based on race/ethnicity, gender, difference for MMR (P=0.22), while there age, socioeconomic status, and were significant differences for NMR, geographical location. IMR, and U5MR (P=0.001). Figure 5

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Figure 4. A 15-year trend of MMR among districts of the East Azerbaijan province

Many attempts have been made at the mortality rates trend, which is consistent national and international level to decline with the reduction of maternal and child inequalities in health that are unfair, mortality in the country and indicate unnecessary, and avoidable (12). In so adequate coverage of health care in East doing, the health system in Iran has made Azerbaijan. The results also showed a great efforts to reduce inequities in the significant difference among the NMR, health sector, and these efforts have placed IMR, and U5MR indicators before and Iran among the countries that are active in after the implementation of the family the fourth (reducing child mortality) and physician program in 2001, indicating the fifth (reducing maternal mortality) positive impact of this program. However, millennium development goals (13). They no difference was observed in the MMR observed that the decline in U5MR indicator. The reason for the lack of between 2000 and 2013 has been even difference could be due to the fact that Iran sharper than expected (14). However, has achieved the fifth millennium compared to some countries with similar development target to reduce maternal socioeconomic statuses, including Cuba, mortality by as much as 75% between Costa Rica, Sri Lanka, and Thailand, lots 1990 and 2015 (13). Also, following of work must be done in Iran regarding family planning coverage in Iran during IMR and U5MR (15). the past three decades, fertility has The results of the present study have significantly decreased, so has maternal shown a decline in the maternal and child mortality (16).

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250

200

150 IDisp NMR 100 IDisp IMR

Disparity Index Disparity (%) IDisp U5MR 50

0

years

Figure 5. The IDisp trend of NMR, IMR, U2MR, and MMR in the districts of East Azerbaijan, 1999 to 2013

40

35 30 25 20 15 IDsNMR 10 IDsIMR 5 Index ofIndexdisparity (%) IDsU5MR 0

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Figure 6. The IDisp of NMR, IMR, and U5MR in the districts of East Azerbaijan, 1999 to 2013

As for child mortality, since Iran is on the seems to be effective in reducing NMR, as track for the fourth millennium well. development goal, it seems that the family In our study, the general trend of the physician program has increased the indicators was not significant in separate provision of health services to children. towns within the 15-year period studied. Moreover, since midwives, who play a key Also, in paired comparison, IMR, U5MR, role in increasing mothers’ awareness and MMR indicators were not in during pregnancy, were involved in the satisfactory condition in Charavimaq, family physician program, too, their role Harris, and Kalaybar, which could be due

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Alizadeh M et al. to their deprivation of and low access to was recommended to reduce this disparity health facilities. (15). In the present study, this indicator Ajabshir and Bostanabad districts differed showed a decreasing trend in East from Kalaybar, Bonab, and Hashtrood in Azerbaijan. Yet, the health sector cannot terms of the NMR indicator. Of course, the be the only entity responsible for this status of this indicator was better in disparity. Studies have shown that other Ajabshir and Bostanabad than in the three factors, including family income, maternal other districts. The probable reason for this education, adequate housing, water and in Bostanabad could be due its proximity sanitation systems, etc., are involved in to Tabriz, which makes the immediate leading to the disparity in maternal and referral of newborns possible in case there child mortality indicators (18, 19). is an urgent need for special care. Another Limitations of the study study carried out in the country showed In the present study, there was no lack of access to Neonatal Intensive Care possibility to evaluate other factors Unit (NICU) in addition to primary care in affecting the trend of disparities. Other most parts of Iran as a reason why decline advanced statistical methods to observe the in NMR indicator was slower than that for trend of inequality could be implemented, other indicators (15). as well. Based on the 2015 Millennium The results showed that, despite the Development Goals Report, the NMR in downtrend in NMR, IMR, U5MR, and the world in years 1990-2015 declined MMR indicators, there are still from 33 deaths to 19 per 1,000 live births. geographical disparities in these indicators However, since the decline in NMR is among districts of the East Azerbaijan slower than the mortality rate decline in 1- province. This shows that health facilities 5 year-old children, the highest U5MR has have not been distributed evenly among been allocated to the neonatal mortality for East Azerbaijan districts. the time being (3). Conflict of Interest One study conducted on disparities in Authors declare no conflict of interest. health indicators among Iranian villages Acknowledgment showed that, despite improvement and We would like to give our thanks to the promotion of health indicators in the staff of East Azerbaijan Health Center for country, it seems that this promotion has providing the researchers with data and Dr. not been homogeneous and balanced. In Maziar Moradi Lakeh for his erudite fact, not only has the improvement been comments. observed to be unequal in all indicators of the country, but there was heterogeneous References inequality in indicators’ improvement 1. Braveman P. Health disparities and health among the provinces of the country, too equity: concepts and measurement. Annu Rev (17). The results of disparity indicators in Public Health. 2006;27:167-94. the present study showed that disparity in 2. Minnery M, Jimenez-Soto E, Firth S, Nguyen K- health indicators over the past 15 years had H, Hodge A. Disparities in child mortality trends in two new states of India. BMC public health. an increasing trend. Of course, this upward 2013;13(1):1. trend is slow, which implies that health 3. Ki-Moon B. The Millennium Development facilities are not equally distributed among Goals Report 2013. United Nations Pubns. 2013. districts of the province and the facilities 4. Ghaemmaghami P, Zare N, Heydari S, Hemati are more concentrated in the centers of A, Alinejad V. Geographical Variation of Infant Mortality Rates in South of Iran: A Comparison of districts, especially in Tabriz. A study by Two Spatial Models. NATIONALPARK- Lakeh et al. showed that the disparity FORSCHUNG IN DER SCHWEIZ (Switzerland indicator was rising for NMR. In addition Research Park Journal). 2013;102(10). to primary health care, access to NICU

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