Effects of economic downturns on child mortality: a global economic analysis, 1981-2010

Association of socioeconomic disadvantage and ethnicity with perinatal neonatal, and infant mortality in Slovakia

BACKGROUND

Infant mortality rates are reliable indices of the child and general population health status and health care delivery. The most critical factors affecting infant mortality are socioeconomic status and ethnicity. The aim of this study was to assess the association between socioeconomic disadvantage, ethnicity, and perinatal, neonatal, and infant mortality in Slovakia before and during the COVID-19 pandemic.

METHODS

The associations between socioeconomic disadvantage (educational level, long-term unemployment rate), ethnicity (the proportion of the Roma population) and mortality (perinatal, neonatal, and infant) in the period 2017-2022 were explored, using linear regression models.

RESULTS

The higher proportion of people with only elementary education and long-term unemployed, as well as the higher proportion of the Roma population, increases mortality rates. The proportion of the Roma population had the most significant impact on mortality in the selected period between 2017 and 2022, especially during the COVID-19 pandemic (2020-2022).

CONCLUSIONS

Life in segregated Roma settlements is connected with the accumulation of socioeconomic disadvantage. Persistent inequities between Roma and the majority population in Slovakia exposed by mortality rates in children point to the vulnerabilities and exposures which should be adequately addressed by health and social policies.

Infant mortality in the municipality of São Paulo: trend and social inequality (2006-2019)

OBJECTIVE

Considering the published evidence on the impact of recent economic crises and the implementation of fiscal austerity policies in Brazil on various health indicators, this study aims to analyze how the trend and socio-spatial inequality of infant mortality behaved in the municipality of São Paulo from 2006 to 2019.

METHODS

This is an ecological study with a temporal trend analysis that was developed in municipality of São Paulo, using three residence area strata differentiated according to their social vulnerability following the 2010 São Paulo Social Vulnerability Index. Infant mortality rate, as well as neonatal, and post-neonatal mortality rates, were calculated for each social vulnerability stratum, each year in the period, and for the first and last three triennia. Temporal trends were analyzed by the Prais-Winsten regression model and inequality magnitude, by rate ratios.

RESULTS

We found a decline in infant mortality rate and its components from 2006 to 2015, greater in the stratum with low social vulnerability and in the post-neonatal period when compared to the neonatal one. This decline ended in 2015, stagnating in the next period (2016-2019). Our analysis of infant mortality inequality across social vulnerability stratum showed a significant increase from the initial to the final triennia in the analyzed period; rate ratios increased from 1.36 to 1.48 in the high stratum (compared to the low social vulnerability stratum), and from 1.19 to 1.32 between the medium and low social vulnerability strata.

CONCLUSIONS

The observed stagnation of infant mortality rate decline in 2015 and the increase in socio-spatial inequality point to the urgent need to reformulate current public policies to reverse this situation and reduce inequalities in the risk of infant death.

The influence of the Great Recession on perinatal health-an ecological study on the trend changes and regional differences in Portugal

Background

Few studies examine the relationship between socioeconomic factors and trends in mortality in high-income European countries. Due to the lack of regional-level data, most recent studies on social inequality in Portugal do not investigate regional differences. This study analyses time trends and regional disparities in the evolution of perinatal mortality (PMR) and infant mortality (IMR) associated with demographic and socioeconomic indicators following Portugal's 2008 economic and financial crisis.

Methods

Associations were assessed using generalised linear models. A Poisson joinpoint regression model was applied to identify relevant PMR and IMR changes between 2000 and 2018. Country regional disparities were analysed using Mixed Effect Multilevel models.

Findings

IMR and PMR significantly decreased in the pre-crisis period but not in the post-crisis period. The significant differences between regions in IMR and PMR in 2000 were followed by a different evolution of regional IMR after 2008. PMR and IMR were not significantly associated with socioeconomic indicators. A significant positive association with maternal age at first birth was identified.

Interpretation

Results confirm the influence of the crisis on PMR and IMR trends in Portugal, taking into account recurring associations between macroeconomic cycles, variations in mortality trends, macroeconomic volatility, and stagnation of IMR and PMR. Regional inequalities confirm the internal variability of the crisis influence and persistent spatial inequalities affecting IMR patterns.

Funding

FCT, under the Institute of Public Health of the University of Porto (ISPUP)-EPIUnit (UIDB/04750/2020) and ITR (LA/P/0064/2020), Maastricht University's external PhD programme under the Care and Public Health Research Institute (CAPHRI), and the RECAP preterm project (grant agreement no 733280).

Sewerage as a protective factor for prevalence of hookworm infection in schoolchildren in Brazil: A multilevel ecological analysis of national prevalence surveys (1950-2018)

INTRODUCTION

The prevalence of hookworm infection in Brazil has decreased considerably in recent decades. However, there is no definitive consensus as to which changes have contributed to this reduction. A hypothesis is that improvements in environmental factors have contributed to lowering the parasite load and the level of host-parasite contact.

METHODS

This is an ecological study using unbalanced panel data from two Brazilian surveys (1947-1953 and 2010-2015), with municipalities as the analysis unit. The sample comprised 1428 municipalities, in which a total of 745,983 schoolchildren aged 7 to 14 were examined. Zero-inflated Poisson regression models, with fixed and random effects were estimated to evaluate the association of potential explanatory variables with the prevalence of hookworm infection at a significance level of 5 %.

RESULTS

We identified a significant decrease in the prevalence between the first and last analyzed periods (RR 0.096; CI 0.086-0.107); The following variables were found to have a protective effect: access to sanitary sewage systems (RR 0.984, CI 0.982-0.986), urbanization (RR 0.995, CI 0.993-0.997), and gross domestic product (RR 0.929, CI 0.912-0.945).

CONCLUSION

The findings of this study show a decrease in the prevalence of hookworm infections over six decades in schoolchildren in the Brazilian municipalities. Environmental, demographic, and economic factors were associated with this trend. A historical analysis indicates that interventions aimed at improving sanitation contributed to reducing the disease prevalence.

2008 economic crisis impact on perinatal and infant mortality in Southern European countries

INTRODUCTION

The study of crisis events provides important lessons to prepare for upcoming events. The Great Recession's impact on perinatal health in Europe can provide relevant insights into the healthcare and social protection systems' response to the protection of the health of the most vulnerable groups.

OBJECTIVE

To assess time trends and international disparities in perinatal mortality rates (PMR) and infant mortality rates (IMR), following the Great Recession, and their association with socioeconomic indicators in Portugal, Greece, Italy and Spain.

METHODS

Associations were assessed through generalised linear models for all four countries. A Poisson joinpoint regression model was applied to explore PMR and IMR trend changes between 2000 and 2018. Country disparities were analysed using mixed-effects multilevel models.

RESULTS

IMR and PMR have decreased overall in the four selected countries between 2000 and 2018. Still, whereas in Spain, Italy and Portugal the decreasing pace was attenuated after 2009, in Greece a positive trend was found after the 2008 crisis. IMR and PMR were significantly associated with socioeconomic indicators in all four countries. National disparities in the evolution of IMR and PMR were significantly associated with most socioeconomic indicators between 2000 and 2018.

CONCLUSION

Our results confirm the impact of the Great Recession on PMR and IMR trends in all four countries, taking recurring associations between macroeconomic cycles, variations in mortality trends, macroeconomic volatility and stagnation of IMR and PMR into account. The association with socioeconomic indicators stresses the need to strengthen social protection and healthcare systems to better protect the population's health from the earliest days.

Is Economic Growth Good for Population Health? A Critical Review

A large multidisciplinary literature discusses the relationship between economic growth and population health. The idea that economic growth is good for societies has inspired extensive academic debate, but conclusions have been mixed. To help shed light on the subject, this paper focuses on opportunities for consensus in this large literature. Much scholarship finds that the health-growth relationship varies according to (1) which aspect of "health" is under consideration, (2) shape (e.g., positive linear or logarithmic), (3) issues of timing (e.g., growth over the short or long term), (4) a focus on health inequalities as opposed to population averages, and (5) multivariable relationships with additional factors. After reflecting upon these findings, I propose that economic growth promotes health in some respects, for some countries, and in conjunction with other life-supporting priorities, but does not by itself improve population health generally speaking. I then argue there is already wide, interdisciplinary consensus to support this stance. Moreover, policies focusing exclusively on economic growth threaten harm to both population health and growth, which is to say that political dynamics are also implicated. Yet multivariable approaches can help clarify the bigger picture of how growth relates to health. For moving this literature forward, the best opportunities may involve the simultaneous analysis of multiple factors. The recognition of consensus around these issues would be welcome, and timely.

Supplementary Information

The online version contains supplementary material available at 10.1007/s42650-023-00072-y.

The end of the COVID-19 pandemic

There are no widely accepted, quantitative definitions for the end of a pandemic such as COVID-19. The end of the pandemic due to a new virus and the transition to endemicity may be defined based on a high proportion of the global population having some immunity from natural infection or vaccination. Other considerations include diminished death toll, diminished pressure on health systems, reduced actual and perceived personal risk, removal of restrictive measures and diminished public attention. A threshold of 70% of the global population having being vaccinated or infected was probably already reached in the second half of 2021. Endemicity may still show major spikes of infections and seasonality, but typically less clinical burden, although some locations are still hit more than others. Death toll and ICU occupancy figures are also consistent with a transition to endemicity by end 2021/early 2022. Personal risk of the vast majority of the global population was already very small by end 2021, but perceived risk may still be grossly overestimated. Restrictive measures of high stringency have persisted in many countries by early 2022. The gargantuan attention in news media, social media and even scientific circles should be tempered. Public health officials need to declare the end of the pandemic. Mid- and long-term consequences of epidemic waves and of adopted measures on health, society, economy, civilization and democracy may perpetuate a pandemic legacy long after the pandemic itself has ended.

Estimated impact of the 2020 economic downturn on under-5 mortality for 129 countries

In low- and middle-income countries (LMICs), economic downturns can lead to increased child mortality by affecting dietary, environmental, and care-seeking factors. This study estimates the potential loss of life in children under five years old attributable to economic downturns in 2020. We used a multi-level, mixed effects model to estimate the relationship between gross domestic product (GDP) per capita and under-5 mortality rates (U5MRs) specific to each of 129 LMICs. Public data were retrieved from the World Bank World Development Indicators database and the United Nations World Populations Prospects estimates for the years 1990-2020. Country-specific regression coefficients on the relationship between child mortality and GDP were used to estimate the impact on U5MR of reductions in GDP per capita of 5%, 10%, and 15%. A 5% reduction in GDP per capita in 2020 was estimated to cause an additional 282,996 deaths in children under 5 in 2020. At 10% and 15%, recessions led to higher losses of under-5 lives, increasing to 585,802 and 911,026 additional deaths, respectively. Nearly half of all the potential under-5 lives lost in LMICs were estimated to occur in Sub-Saharan Africa. Because most of these deaths will likely be due to nutrition and environmental factors amenable to intervention, countries should ensure continued investments in food supplementation, growth monitoring, and comprehensive primary health care to mitigate potential burdens.

How many infants may have died in low-income and middle-income countries in 2020 due to the economic contraction accompanying the COVID-19 pandemic? Mortality projections based on forecasted declines in economic growth

OBJECTIVES

While COVID-19 has a relatively small direct impact on infant mortality, the pandemic is expected to indirectly increase mortality of this vulnerable group in low-income and middle-income countries through its effects on the economy and health system performance. Previous studies projected indirect mortality by modelling how hypothesised disruptions in health services will affect health outcomes. We provide alternative projections, relying on modelling the relationship between aggregate income shocks and mortality.

DESIGN

We construct a sample of 5.2 million births by pooling retrospective birth histories reported by women in Demographic and Health Surveys conducted in 83 low-income and middle-income countries between 1985 and 2018. We employ regression models with country-specific fixed-effects and flexible time trends to estimate the impact of gross domestic product per capita on infant mortality rate. We then use growth projections by the International Monetary Fund to predict the effect of the economic downturn in 2020 on infant mortality.

RESULTS

We estimate 267 208 (95% CI 112 000 to 422 415) excess infant deaths in 128 countries, corresponding to a 6.8% (95% CI 2.8% to 10.7%) increase in the total number of infant deaths expected in 2020.

CONCLUSIONS

The findings underscore the vulnerability of infants to the negative income shocks such as those imposed by the COVID-19 pandemic. While efforts towards prevention and treatment of COVID-19 remain paramount, the global community should also strengthen social safety nets and assure continuity of essential health services.

Clusters of cause specific neonatal mortality and its association with per capita gross domestic product: A structured spatial analytical approach

BACKGROUND

Infant mortality rate is a measure of population health and neonatal mortality account for great proportion of these deaths. Underdevelopment might be associated to higher neonatal mortality risk due to assistant related factors. Spatial and temporal distribution of mortality help identifying and developing strategies for interventions.

OBJECTIVE

To investigate the cluster areas of asphyxia-associated neonatal mortality and to explore its association with per capita gross domestic product (GDP) in São Paulo State (SP), Brazil.

METHODS

Ecological study including live births residents in SP from 2004-2013. Neonatal deaths (0-27 days) with perinatal asphyxia were defined as intrauterine hypoxia, birth asphyxia or meconium aspiration syndrome written in any line of the Death Certificate. Geoprocessing analytical approach included detection of first order effects through quintiles and spatial moving average maps, followed by second order effects by global and local spatial autocorrelation (Moran and LISA, respectively) before and after smoothing with local Bayesian estimates. Finally, Spearman correlation was applied between asphyxia-associated neonatal mortality and mean per capita GDP rates for the municipalities with significant LISA.

RESULTS

There were 6,713 asphyxia-associated neonatal deaths among 5,949,267 live births (rate: 1.13/1000) in SP. Spatial moving average maps showed a non-random distribution among municipalities, with presence of clusters (I = 0.048; p = 0.023). LISA map identified clusters of asphyxia-associated neonatal mortality in the south, southeast and northwest. After applying local Bayes estimates, clusters were more pronounced (I = 0.589; p = 0.001). There was a partial overlap of the areas of higher asphyxia-associated neonatal mortality and lower mean per capita GDP.

CONCLUSIONS

Spatial analysis identified cluster areas of high asphyxia-associated neonatal mortality and low per capita GDP rates, with a significant negative correlation. This optimized, structured, and hierarchical approach to identify high-risk areas of cause-specific neonatal mortality may be helpful for guiding public health efforts to decrease neonatal mortality.

Crises econômicas, mortalidade de crianças e o papel protetor do gasto público em saúde

Resumo O objetivo do estudo foi analisar como as crises econômicas afetam a saúde infantil a nível global e entre subgrupos de países com diferentes níveis de renda. Foram utilizados dados do Banco Mundial e da OMS para 127 países entre os anos de 1995 e 2014. Foi utilizado um modelo de efeitos fixos, avaliando o efeito da mudança em indicadores macroeconômicos (PIB per capita, taxa de desemprego e de inflação, e taxa de desconforto) na taxa de mortalidade neonatal, infantil, e de menores de cinco anos. Adicionalmente, avaliou-se a modificação do efeito da associação de acordo com a renda dos países e também a influência do gasto público em saúde nessa relação. As evidências mostraram que piores indicadores econômicos (menor PIB per capita e maiores inflação, taxa de desemprego e taxa de desconforto) estão associados com maiores taxas de mortalidade infantil. Nas subamostras por estrato de renda, observa-se a mesma relação, porém com efeitos de maior magnitude entre os países de renda baixa e média. Verificou-se ainda que um maior percentual nos gastos públicos em saúde ameniza os efeitos dos indicadores econômicos nas taxas de mortalidade infantil. Desta forma, é necessário aumentar a atenção aos efeitos nocivos das crises macroeconômicas para garantir melhorias na saúde infantil.

Economic Recession and Attendances in the Pediatric Emergency Department

The economic recession has been shown to have a negative impact on health services worldwide. The purpose of this study was to examine whether the recent financial crisis in Greece that started in 2009 has affected the attendances in the pediatric emergency department of a University Hospital covering for a large geographical area in Greece. The study was based on a retrospective analysis of the cases presented to the paediatric emergency department and compared the attendances in 2008 (i.e., before the beginning of the economic crisis) with those in 2013 and 2017. Data on demographics and characteristics of emergency department visits, such as timing, reason, and outcome were recorded for each child. There were a total of 35.572 children seeking examination in those three years and data were collected for 5662 (17.36%) of them. Overall, the attendance rate has increased up to 20% without an increase to the hospital admission rates which remained stable throughout the study periods. Between 2008 and 2017, the percentage of febrile children attending the ED increased by 33.8% and of those with respiratory disorders by 63.1%. Our results indicate that the need for pediatric hospital services has changed following the economic crisis which could reflect gaps in the primary care setting and could well also result from financial constraints.

The Brazilian health system at crossroads: progress, crisis and resilience

The Unified Health System (Sistema Único de Saúde (SUS)) has enabled substantial progress towards Universal Health Coverage (UHC) in Brazil. However, structural weakness, economic and political crises and austerity policies that have capped public expenditure growth are threatening its sustainability and outcomes. This paper analyses the Brazilian health system progress since 2000 and the current and potential effects of the coalescing economic and political crises and the subsequent austerity policies. We use literature review, policy analysis and secondary data from governmental sources in 2000-2017 to examine changes in political and economic context, health financing, health resources and healthcare service coverage in SUS. We find that, despite a favourable context, which enabled expansion of UHC from 2003 to 2014, structural problems persist in SUS, including gaps in organisation and governance, low public funding and suboptimal resource allocation. Consequently, large regional disparities exist in access to healthcare services and health outcomes, with poorer regions and lower socioeconomic population groups disadvantaged the most. These structural problems and disparities will likely worsen with the austerity measures introduced by the current government, and risk reversing the achievements of SUS in improving population health outcomes. The speed at which adverse effects of the current and political crises are manifested in the Brazilian health system underscores the importance of enhancing health system resilience to counteract external shocks (such as economic and political crises) and internal shocks (such as sector-specific austerity policies and rapid ageing leading to rise in disease burden) to protect hard-achieved progress towards UHC.