Core-periphery differences in infant mortality

Regional trend variations in infant mortality due to perinatal conditions in the Netherlands

CONDENSATION

In the Netherlands, regional variations in trends in infant mortality due to perinatal conditions (1984-1994) exist, which could not be explained by health care characteristics (i.e., place or supervision of delivery and the presence of specialised neonatal care). The only sociodemographic factor that showed a consistent correlation with mortality was the percentage of Roman Catholic inhabitants of a region.

OBJECTIVE

To describe and explain regional variations in trends in infant mortality due to perinatal conditions.

STUDY DESIGN

A mixed (geographical and temporal) ecological design has been used. Infant mortality due to perinatal conditions was defined as mortality in the first year of life caused by diseases of the newborn period (chapter XV of the ICD-9). Trends in sex-adjusted mortality for the period 1984-1994 as well as mortality levels at the start of this period were calculated using log linear regression. Linear regression was used to examine the association between mortality trends and starting levels on the one hand and both health care and sociodemographic factors on the other.

RESULTS

Statistically significant variations in mortality trends were found between regions. The trends in the two Southern regions were found to deviate significantly from the national trend. No strong association was found between mortality and each of the health care factors (i.e. place and/or supervision of delivery and the presence of specialised neonatal care). The only sociodemographic factor that showed consistent results was the percentage of Roman Catholic inhabitants of a region: A higher percentage in 1985 was associated with a higher mortality in 1985 and a stronger mortality decline during the period 1984-1994. This association could not be explained by parity or the age of the mother.

CONCLUSIONS

Regional differences in trends in infant mortality due to perinatal conditions in the Netherlands could not be explained by variations in health care factors. This is an important finding as the Dutch system of obstetric care, that includes a considerable number of home deliveries, has been subject to much debate. Further research that includes other causes of death and determinants is needed to unravel the causes of the trend variations.

Social variation in infant mortality in a core city of Finland during the 19th and early 20th centuries. Positive effect of industrialization?

The aim of this study was to examine social variation (social class, legitimacy) in infant mortality in a core municipality (Viipuri) in Finland from 1819 to 1918. Data were obtained from the Population Change Tables of Finnish, Swedish and German parishes of the town of Viipuri. During the 19th and early 20th centuries the German parish socially had the highest rank and the Finnish one the lowest while the Swedish parish held an in-between position. The study period was divided into the preindustrial period (until 1868) and the period of industrialization (from 1868 onwards). Results of the study indicated a clear association between social class and infant mortality in the preindustrial period; in the period of industrialization the association was also clear but smaller. Legitimacy as a determinant of infant mortality became more marked towards the early 20th century. Industrialization brought with it some factors, such as numerous public health measures, which benefited the legitimate infants and narrowed their social group differences.

Core-periphery differences in children's health and use of general practitioner services in Finland from 1964 to 1987

Finland is a modern welfare state in Northern Europe especially proud of its development of programs for children's health. The aim of this study was to investigate the development of core-periphery differences in children's health and use of health services. The study material was obtained from the national health and social security interview survey carried out in 1964, 1968, 1976 and 1987. Age standardized prevalence of chronic diseases, number of restricted-activity days and physician contacts were presented for two age groups: 0-6-year-olds and 7-14-year-olds. The prevalence of chronic diseases was quite similar in the core and periphery in 1976 and 1987, but the number of restricted-activity days throughout the study period (1964-1987) was significantly higher in the core than in the periphery. The consistently higher frequency of physician contacts in the core in comparison with the periphery was spectacular; the welfare policy of the last decades seems to have had very little or no effect on this difference. The core-periphery division thus continues to have relevance with respect to the health of Finnish children.

Family resources and children's use of primary health care services in Finland in 1979

The purpose of the study was to determine how children's use of primary health care services was related to family resources (socio-economic status, marital and residential stability of the family, and core/periphery dichotomy). The population consisted of a random sample of 3201 children from 15 municipalities in the province of Uudenmaan lääni in Southern Finland in 1979. Among two-parent families in the core regions total utilization of primary health care services was significantly higher among the children of workers and upper white-collar employees. Children of farmers and lower white-collar employees in the periphery exhibited low primary health care utilization. Children in upper white-collar employees' families (both two- and one-parent) in core regions frequently used private services. Among children of one-parent families, exceptionally high users of private services were children of upper white-collar mothers in core regions, and of municipal health services the children of working-class mothers in the periphery. Non-migrated children had a slight tendency to use health services more than migrated children. Differences in family resources thus cannot be ignored when children's utilization of primary health care services is studied.

Children and core-periphery differences

This study examines the differences between children's (0-15 yr of age) use of primary care services in core and peripheral municipalities in Uusimaa province in southern Finland following the implementation of the Primary Health Care Act (1972). In the ecological study (municipality-based), children's total use of primary health care services during 1973-1979 was continuously lower in peripheral municipalities than in core areas in spite of the Primary Health Care Act, the express purpose of which was to reduce regional differences. Some equalization of utilization of private practitioners occurred during this period. The individual-based study material collected in 1979 enabled us to control for the influences of (1) distance to the core of the municipality, (2) age of the child, (3) socio-economic status of the family, (4) type of visit and (5) diagnosis. These factors somewhat modified the influence of the core/periphery dichotomy, but the overall picture that children in the core use more primary health care services remained the same. This suggest that health care policy should be quite specific and based on detailed regional analysis, if equalization between core and peripheral municipalities is to be achieved.