| ||||||
|
| ||||||
|
MORTALITY IN DEVELOPING COUNTRIES Mortality in developing countries was the theme of a meeting on 11 December 1989 at the Centre for Population Studies, London School of Hygiene and Tropical Medicine. In the first paper by Mrs Sian Curtis and John McDonald, the Hobcraft method was applied to estimate relative risks of infant mortality in Brazil using DHS data on numbers of births in specific periods of time before and after the index birth (as a measure of birth spacing), and the risk factors of sex, birth order, maternal age at birth, and maternal education. There was very strong association between birth spacing and neonatal mortality, with the highest relative risk occurring when there were two or more births in the two years preceding the index birth, and the next highest when there were two or more births in the period 2-4 years previously. Postneonatal mortality showed similar results, and the relative risks associated with the death of the previous child were similar in size. These results are generally similar to those in WFS studies for Latin-American countries. Dr Oona Campbell used data from the 1987 DHS in Mali to show the difficulties of estimating proximate determinants of mortality from retrospective surveys. While concluding that most difficulties arose because of the poor quality of data on dead children, she demonstrated age-changes in the relationship between breastfeeding and child mortality. There is a protective effect of breastfeeding for the first twelve months, but then this disappears between twelve and eighteen months, and breastfeeding prolonged after this age may adversely affect survival. The reason was suggested by data on diarrhoeal morbidity amongst living children. Under six months of age, the children most at risk were those who received solid supplements, for three to five times as many children in this group suffered from diarrhoea as in those who were exclusively breastfed. By contrast, children who continued to be breastfed over twelve months of age had poorer weights for age than weaned children. It seems that the timing of weaning is critical if it is too early the risk of diarrhoeal disease increases, at later ages inadequate supplementation increases the risk of malnourishment. Dr Tim Dyson discussed famines in South Asia. He picked out regions with the most reliable registration data, Madras, Central Provinces, and Bombay Presidency, for the three great 19th century famines (1876-8, 1896-7, and 1899-1900), and in the 20th century the Bengal famine of 1943-44 and the Bangladesh famine of 1974-75. The price of rice was used as an indicator of famine intensity and this showed clear trends. In all cases there was a diminution in the number of conceptions preceding the mortality peak, possibly a conscious reaction to the mounting adversity, so that peak death rates coincided with low birth rates. In the first three of these famines, which were caused by drought, peak mortality coincided with the return of the rains, the main cause of death being malaria at this stage, for the other fatal diseases (cholera, dysentery and diarrhoea) had their maximum mortality at an earlier stage. In all except Bangladesh, the famine mortality peak was a magnification of usual fluctuations in the death rate. The largest proportional increases in mortality occurred in older children and adults, age groups in which the death rates are normally low, so that the preponderance of infant and child deaths during the crisis represented a relatively small proportional increase over the high death rates usual for these age groups. In each famine, male mortality increased more than female, on account of possibly physiological differences, or possibly diminished exposure to risk of maternity in the women. This was a most important study, since data of comparable quality are rarely available in other areas susceptible to famine. Finally the policy implications of mortality research were discussed by Dr John Seeman, who pointed out that relief organisations, no matter whether government, international, or charitable, tended to act on an ad hoc basis, i.e. they reacted to crises as they occurred and were not always guided by explicit policies. Because of the nature of some mortality crises, especially in times of natural disasters, interventions were often futile. He indicated that long term intervention programmes, initiated with outside help but sustained through the efforts of the communities in which they operated, were required. A sound basis for formulating health intervention policies could only come from solid research, repeated in a sufficient number of populations for their findings to be truly general. He saw no need for research to be part of an intervention programme, even research aimed at evaluating the effects of the intervention. A spirited meeting | ||||||