“Infant Mortality in Armenia 1992–2003”: A comment

The purpose of this comment is to counsel caution in some of the conclusions drawn in an otherwise fine article recently published in Economics and Human Biology on infant mortality in Armenia by Hakobyan, Mkrtchyan and Yepiskoposyan. These relate first, to the reliability of estimates and trends in infant mortality estimated from DHS data; second, to the interpretation of what the authors consider to be a ‘low’ infant mortality rate in former communist countries given their level of economic development; and third, to the role of the health care infrastructure in countries of the former Soviet Union in producing these ‘low’ infant mortality levels. This comment argues that trends in infant mortality in Armenia and other CIS countries, although probably declining, are perhaps less certain than the authors allow, that existing evidence does not suggest that they are uniformly low by global standards, or that the health care systems in CIS countries are uniformly effective in reducing infant deaths.     

Infant mortality in Armenia, 1992–2003

Health system reforms have been taken in Armenia during a time of dramatic economic and fiscal distress. It is important to assess trends in health indicators and ascertain if the changes in socio-economic systems affected the health status of infants as the most vulnerable part of the population. We find that infant mortality has fallen during the period c. 1992-2003 in spite of the difficult economic circumstances because of health-care procedures that were introduced. Particular attention is paid to the underreporting of infants' death cases in the state registration system as well as to estimating the role of different factors influencing infant mortality in Armenia.     

Socioeconomic development,medical care,and nutrition as determinants of infant mortality in less‐developed countries

Abstract

Using data for sixty less‐developed countries, we constructed a causal model in which medical care, nutrition, status of women, and socioeconomic development are examined as determinants of infant mortality. Social and economic development are treated as exogenous variables; medical care, nutrition, and status of women are viewed as variables endogenous to the model. The model is tested by maximum likelihood methods. Results indicate that good nutrition and the presence of informally trained health care personnel, i.e., midwives, are more significantly related to low rates of infant mortality than are the employment status of women and the presence of formally trained health care personnel such as physicians and nurses. The general level of social and economic development conditions these relationships.     

Health care in Armenia today.

Although one of the smallest of the new independent states of the former Soviet Union, the Republic of Armenia has an ancient tradition and a strong ethnic identification, greatly enhanced by the diaspora. In addition to the problems following the dissolution of the Soviet Union, Armenia has had to contend with a draining war in Nagorno-Karabakh and the after-effects of a devastating earthquake in 1988. Humanitarian efforts have ranged from emergency supply deliveries to longer-term sustainable health care partnerships. The United States government, through the Agency for International Development, has organized such partnerships, partially as a result of a multinational mission in 1992 and a subsequent hospital-to-hospital program developed by the American International Health Alliance. We describe the current state of health care in Armenia and some of the problems that need to be addressed to improve health care services to its citizens.     

The Matthew effect in health development.

A study was conducted examining the paradox that populations with a poor standard of health seem to achieve only meagre improvements over time, whereas those with a good standard of health seem to show continual, substantial improvement. The health states of 122 nations were measured by reference to their infant mortality in 1965 and the changes that occurred over the next 20 years. Countries with low infant mortality in 1965 (for example, Japan and East Germany) achieved substantial, further declines over the 20 years, whereas in countries such as Rwanda and Ethiopia infant mortality hardly declined at all or even increased (Ethiopia 165/1000 to 168/1000). In 48 countries for which data were available there was a close link between the change in health state of a people and the ratio of government expenditure on health and defence. As the ratio increased in favour of defence, so the improvement in health state of a people declined; the reverse was also true. At the primary care level disparity in uptake of care both among and within communities was associated with literacy and socioeconomic state, services inadvertently being aimed at those sections most likely to benefit. The forces that act to produce this setting of unequal care must be checked at both national and primary levels if we are to have "Health for All by the Year 2000."     

Health transition: examples from the western Pacific.

The Industrial Revolution ushered in a rapid transition from agriculture to industrialization. Some biological effects of this transition included increasing life expectancy, reduced infant mortality, and some decline in fertility. Reduced infant mortality first brought about an increase in life expectancy, but as humans were able to control infectious diseases, child and adult mortality also decreased. Now, accidents and chronic diseases are responsible for most mortality in many age groups. This shift from infectious diseases to accidents and chronic diseases is called the health transition. Japan and US are Pacific Basin countries which have relatively high life expectancy and low infant mortality (1988, 75.54 years vs. 71.38 years, and 4.4 vs. 9.9, respectively). These figures suggest that these countries rather advanced in the health transition. Japan may have better life expectancy than the US because of the effect of environmental factors, ethnic diversity, and health care differentials by social class on cardiovascular disease and cancer mortality. China and Thailand hold intermediate positions (67.98 years (1985-1990) vs. 63.82 years (1985-1986), and 32.4 vs. 39, respectively). Some research indicates that urban conditions and factory work increase the cardiovascular disease risk among the Chinese. Recent research suggests that access to immunization and modern medical care for acute disease are the only critical variables of the health transition rather than other variables. Papua New Guinea is not progressing very well (53.18 years and 58). Papua New Guinea has not yet been able to control infectious diseases, especially malaria. This comparison illustrates that populations progress through the health transition at different rates.     

Neonatal mortality in the empowered action group states of India: trends and determinants

In India, the eight socioeconomically backward states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal and Uttar Pradesh, referred to as the Empowered Action Group (EAG) states, lag behind in the demographic transition and have the highest infant mortality rates in the country. Neonatal mortality constitutes about 60% of the total infant mortality in India and is highest in the EAG states. This study assesses the levels and trends in neonatal mortality in the EAG states and examines the impact of bio-demographic compared with health care determinants on neonatal mortality. Data from India's Sample Registration System (SRS) and National Family and Health Survey (NFHS-2, 1998-99) are used. Cox proportional hazard models are applied to estimate adjusted neonatal mortality rates by health care, bio-demographic and socioeconomic determinants. Variations in neonatal mortality by these determinants suggest that universal coverage of all pregnant women with full antenatal care, providing assistance at delivery and postnatal care including emergency care are critical inputs for achieving a reduction in neonatal mortality. Health interventions are also required that focus on curtailing the high risk of neonatal deaths arising from the mothers' younger age at childbirth, low birth weight of children and higher order births with short birth intervals.     

Increased Duration of Paid Maternity Leave Lowers Infant Mortality in Low- and Middle-Income Countries: A Quasi-Experimental Study

Background

Maternity leave reduces neonatal and infant mortality rates in high-income countries. However, the impact of maternity leave on infant health has not been rigorously evaluated in low- and middle-income countries (LMICs). In this study, we utilized a difference-in-differences approach to evaluate whether paid maternity leave policies affect infant mortality in LMICs.

Methods and Findings

We used birth history data collected via the Demographic and Health Surveys to assemble a panel of approximately 300,000 live births in 20 countries from 2000 to 2008; these observational data were merged with longitudinal information on the duration of paid maternity leave provided by each country. We estimated the effect of an increase in maternity leave in the prior year on the probability of infant (<1 y), neonatal (<28 d), and post-neonatal (between 28 d and 1 y after birth) mortality. Fixed effects for country and year were included to control for, respectively, unobserved time-invariant confounders that varied across countries and temporal trends in mortality that were shared across countries. Average rates of infant, neonatal, and post-neonatal mortality over the study period were 55.2, 30.7, and 23.0 per 1,000 live births, respectively. Each additional month of paid maternity was associated with 7.9 fewer infant deaths per 1,000 live births (95% CI 3.7, 12.0), reflecting a 13% relative reduction. Reductions in infant mortality associated with increases in the duration of paid maternity leave were concentrated in the post-neonatal period. Estimates were robust to adjustment for individual, household, and country-level characteristics, although there may be residual confounding by unmeasured time-varying confounders, such as coincident policy changes.

Conclusions

More generous paid maternity leave policies represent a potential instrument for facilitating early-life interventions and reducing infant mortality in LMICs and warrant further discussion in the post-2015 sustainable development agenda. From a policy planning perspective, further work is needed to elucidate the mechanisms that explain the benefits of paid maternity leave for infant mortality.     

Stagnant Neonatal Mortality and Persistent Health Inequality in Middle-Income Countries: A Case Study of the Philippines

Background

The probability of survival through childhood continues to be unequal in middle-income countries. This study uses data from the Philippines to assess trends in the prevalence and distribution of child mortality and to evaluate the country’s socioeconomic-related child health inequality.

Methodology

Using data from four Demographic and Health Surveys we estimated levels and trends of neonatal, infant, and under-five mortality from 1990 to 2007. Mortality estimates at national and subnational levels were produced using both direct and indirect methods. Concentration indices were computed to measure child health inequality by wealth status. Multivariate regression analyses were used to assess the contribution of interventions and socioeconomic factors to wealth-related inequality.

Findings

Despite substantial reductions in national under-five and infant mortality rates in the early 1990s, the rates of declines have slowed in recent years and neonatal mortality rates remain stubbornly high. Substantial variations across urban-rural, regional, and wealth equity-markers are evident, and suggest that the gaps between the best and worst performing sub-populations will either be maintained or widen in the future. Of the variables tested, recent wealth-related inequalities are found to be strongly associated with social factors (e.g. maternal education), regional location, and access to health services, such as facility-based delivery.

Conclusion

The Philippines has achieved substantial progress towards Millennium Development Goal 4, but this success masks substantial inequalities and stagnating neonatal mortality trends. This analysis supports a focus on health interventions of high quality – that is, not just facility-based delivery, but delivery by trained staff at well-functioning facilities and supported by a strong referral system – to re-start the long term decline in neonatal mortality and to reduce persistent within-country inequalities in child health.     

Infant and child mortality in Pakistan--some trends and differentials

Data from reproductive histories collected in the Population, Labor Force and Migration Survey (PLM) of 1979 are used to analyze trends and differentials in infant and child mortality in Pakistan. Comparisons with the Pakistan Fertility Survey (PFS) findings are also presented. The main concern is to provide from the latest national data, the PLM, direct measures of infant and child mortality and to demonstrate the relatively static and low chances of survival for children in Pakistan. The apparent trends from the PLM and the PFS are similar and seem to confirm that infant and childhood mortality has ceased to decline, at least rapidly, since 1965-69. Neonatal mortality is higher at levels of 70-85 deaths/1000 compared to postneonatal mortality of 40-60 deaths/1000. Improvements in neonatal rates from 1950 until 1975 are only approximately 1/2 of those for postneonatal rates for that period. The relationship between maternal age and mortality in the PLM data confirms that children of youngest mothers experienced the highest rates of infant mortality; mortality is again higher for children of oldest mothers aged 35 and above. The pattern of mortality in the 2 surveys is similar except that in the PFS there was little variation among births higher than 5th order. Sex differentials in mortality are very clear in both surveys. Boys have higher chances of dying in the 1st month of life but then the probability of their surviving from age 1 to 5 years is higher, reflecting the behavioral preference for the male sex in this society. The data also demonstrate an almost monotonic decline in infant and child mortality associated with longer birth intervals. Childhood mortality shows a less clear association with preceding birth interval than does infant mortality. While neonatal mortality is much higher in rural than in urban areas, there are negligible differences in the postneonatal rate. The urban-rural differential continues into childhood, reflecting lower health care and nutrition of children in rural areas. The data confirm the importance of parental education, particularly that of mothers, as a contributor to the health and mortality of infants. Mortality between age 1 and 5 years for children of the rural educated group is lower than that for the urban uneducated indicating the strong influence that education of mothers can have in preventing child loss. The combined evidence from the PFS and PLM data stresses the importance of improving health facilities in the rural areas, in aneffort to reduce the differences in mortality by area of residence. The data from both surveys also suggest the need to restrict motherhood to between the ages of 20 and 34, when obstetrical and health risks are minimal, and indicate the definite advantages of increasing the spacing between children.     

Does the level of infant mortality affect the rate of decline?: Time series data from 21 countries

Some scholars have suggested that an inverse care law holds for infant mortality--that infant mortality reductions are more rapid in regions with lower infant mortality. This theory has not been subjected to proper quantitative analysis. This paper examines time series data on infant mortality from 21 countries to test whether percentage reductions in infant mortality are larger when infant mortality is lower. We apply the Dickey-Fuller generalized least squares (DFGLS) unit root test to infant mortality rate (IMR) time series data from 21 mostly European nations for 1870-1988 to test the statistical significance of beta in a regression analysis of Deltaln IMR(t)=alpha+beta ln IMR(t-1)+epsilon(t). Evidence that beta is significant and negative would support the claim that infant mortality declines more rapidly when substantial mortality reductions have already been achieved. With the preferred specification, the DFGLS unit root test rejected the inverse benefit hypothesis in all countries except the Netherlands at the 5% and 10% cutoffs and Australia at the 10% cutoff. The rejection of the inverse benefit hypothesis was robust to alternative specifications of the lag structure of IMR and to transformations of IMR other than logarithmic. Based on late 19th and 20th century data from countries in Europe and Latin America, there is scarce evidence that percentage reductions in infant mortality are generally smaller in higher mortality countries. These findings suggest that large percentage reductions in infant mortality are possible for countries at any stage in economic development and are reflective of durable advances in human knowledge, social institutions and physical capital.     

Quality of maternal and neonatal care in Albania, Turkmenistan and Kazakhstan: a systematic, standard-based, participatory assessment

Background

Progress in maternal and neonatal mortality has been slow in many countries despite increasing access to institutional births, suggesting deficiencies in the quality of care. We carried out a systematic assessment of the quality of maternal and newborn care in three CEE/CIS countries, using an innovative approach to identify priority issues and promote action.

Methods

A standard-based tool, covering over 400 items grouped in 13 main areas ranging from support services to case management, was used to assess a sample of ten maternity hospitals in Albania, Kazakhstan and Turkmenistan. Sources of information were visit to services, medical records, observation of cases, and interviews with staff and mothers. A score (range 0 to 3) was attributed to each item and area of care. The assessment was carried out by a multidisciplinary team of international and national professionals. Local managers and staff provided the necessary information and were involved in discussing the findings and the priority actions.

Results

Quality of care was found to be substandard in all 13 areas. The lowest scores (between one and two) were obtained by: management of normal labour, delivery, obstetric complications and sick babies; infection prevention; use of guidelines and audits; monitoring and follow-up. Neonatal care as a whole scored better than obstetric care. Interviewed mothers identified lack of information, insufficient support during labour and lack of companionship as main issues. Actions to improve quality of care were identified at facility as well as at central level and framed according to main health system functions.

Conclusions

Quality of care is a key issue to improve maternal and neonatal outcomes, particularly in countries such as CEE/CIS where access to institutional births is nearly universal. Approaches that involve health professionals and managers in comprehensive, action-oriented assessments of quality of care are promising and should be further supported.     

Infant and child mortality in Bangladesh

Socioeconomic differences and trends in infant and child mortality in Bangladesh are examined using data from the 1975 World Fertility Survey and 1979 Contraceptive Prevalence Survery. There is evidence of some recent decline in infant mortality and child mortality. Logit analysis of infant and child mortality indicates that sociodemographic variables such as mother's education, recent period, or higher birth orders, has significant independent effects upon the reduction of infant and child mortality. Other variables such as fetal loss, father's education, or land ownership had no consistent significant effect. On the other hand the effect of urban residence on infant and child mortality was positive after the control of sociodemographic variables. Mere concentration on the supply of modern medical services may bring limited returns unless they are reinforced by appropriate social changes, in particular those affecting the socioeconomic status of women. Educated mothers are likely to belong to higher income households, have better knowledge of how to care for children, and can bring more resources to the care of a sick child.     

Implementation of malaria control

Global trends of infant and child mortality have decreased over the last 30 years, while the proportion of malaria deaths has progressively increased due to the deteriorating situation in sub-Saharan Africa. The Global Malaria Control Strategy promoted by WHO has encountered several obstacles to its implementation. Early diagnosis and prompt treatment can reduce malaria mortality, but there is still low investment on safe and effective modalities of care delivery at the periphery, where most of the malaria burden exists. Selective vector control (indoor residual spraying and insecticide-treated nets) plays a significant role outside Africa, but its wider use is limited by cost/affordability problems and operational issues (supply, delivery and logistics). Alternative methods such as environmental management and biological control are cost-effective only under very specific epidemiological situations. In most countries forecasting, early detection and containment of malaria epidemics is deficient, and there is separation between the research and control communities, particularly in Africa. Involvement of the internal agencies, strategic investments in capacity building and institutional networking are needed to strengthen capacity for malaria and research in the countries. The major responsibility is to guide the expenditure made by the communities (which far out-weigh the limited share of national health budgets) towards the most cost-effective approaches to reduce malaria mortality and morbidity.     

Loneliness: Its Correlates and Association with Health Behaviours and Outcomes in Nine Countries of the Former Soviet Union

Background

Research suggests that the prevalence of loneliness varies between countries and that feeling lonely may be associated with poorer health behaviours and outcomes. The aim of the current study was to examine the factors associated with loneliness, and the relationship between feeling lonely and health behaviours and outcomes in the countries of the former Soviet Union (FSU) – a region where loneliness has been little studied to date.

Methods

Using data from 18,000 respondents collected during a cross-sectional survey undertaken in nine FSU countries – Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine – in 2010/11, country-wise logistic regression analysis was conducted to determine: the factors associated with feeling lonely; the association between feeling lonely and alcohol consumption, hazardous drinking and smoking; and whether feeling lonely was linked to poorer health (i.e. poor self-rated health and psychological distress).

Results

The prevalence of loneliness varied widely among the countries. Being divorced/widowed and low social support were associated with loneliness in all of the countries, while other factors (e.g. living alone, low locus of control) were linked to loneliness in some of the countries. Feeling lonely was connected with hazardous drinking in Armenia, Kyrgyzstan and Russia but with smoking only in Kyrgyzstan. Loneliness was associated with psychological distress in all of the countries and poor self-rated health in every country except Kazakhstan and Moldova.

Conclusions

Loneliness is associated with worse health behaviours and poorer health in the countries of the FSU. More individual country-level research is now needed to formulate effective interventions to mitigate the negative effects of loneliness on population well-being in the FSU.     

Underlying and proximate determinants of diarrhoea-specific infant mortality rates among municipalities in the state of Céara, north-east Brazil: an ecological study

This ecological study examines the variations in diarrhoea-specific infant mortality rates among municipalities in the State of Ceará, north-east Brazil, using data from a community health workers' programme. Diarrhoea is the main cause of postneonatal deaths in Ceará, and diarrhoea mortality rates vary substantially among municipalities, from 7 to 50 per thousand live births. To determine the inter-relationships between potential predictors of diarrhoea-specific infant mortality, eleven variables were classified into proximate determinants (i.e. adequate weight gain and exclusive breast-feeding in first 4 months) and underlying determinants (i.e. health services and socioeconomic variables). The health services variables included percentage with prenatal care up-to-date, participation in growth monitoring and immunization up-to-date, while the socioeconomic factors included female illiteracy rate, per capita gross municipality product and percentage of households with low income, percentage of households with inadequate water supply and inadequate sanitation, and urbanization. Using linear regression analysis variables were included from each group to build regression models. The significant determinants of variability in diarrhoea-specific infant mortality between municipalities were prevalence of infants exclusively breast-feeding, percentage of infants with adequate weight gain, percentage of pregnant women with prenatal care up-to-date, female illiteracy rate and inadequate water supply. These findings suggest that community-based promotion of exclusive breast-feeding in the first 4 months and care-giving behaviours that prevent weight faltering, including weaning practices and feeding during and following diarrhoea episodes, may further reduce municipality-level diarrhoea-specific mortality. Primary heath care strategies addressing these two proximate determinants provide only a partial solution to reducing diarrhoeal disease mortality. Improvements in municipal health services (prenatal care) and socioeconomic status variables, including water supply and maternal education, can also contribute to reduction of infant mortality due to diarrhoea. These results may be used by government health officials to set priorities by considering not only the strength of the association between selected risk factors and diarrhoea mortality rates, but also the prevalence of the risk factors being considered at the municipality level. Finally, the methods used are applicable to other settings with community-based primary health care decentralized to the state or municipal level.     

Measuring the health of nations: analysis of mortality amenable to health care

Objective To assess whether and how the rankings of the world''s health systems based on disability adjusted life expectancy as done in the 2000 World Health Report change when using the narrower concept of mortality amenable to health care, an outcome more closely linked to health system performance.Design Analysis of mortality amenable to health care (including and excluding ischaemic heart disease).Main outcome measure Age standardised mortality from causes amenable to health careSetting 19 countries belonging to the Organisation for Economic Cooperation and Development.Results Rankings based on mortality amenable to health care (excluding ischaemic heart disease) differed substantially from rankings of health attainment given in the 2000 World Health Report. No country retained the same position. Rankings for southern European countries and Japan, which had performed well in the report, fell sharply, whereas those of the Nordic countries improved. Some middle ranking countries (United Kingdom, Netherlands) also fell considerably; New Zealand improved its position. Rankings changed when ischaemic heart disease was included as amenable to health care.Conclusion The 2000 World Health Report has been cited widely to support claims for the merits of otherwise different health systems. High levels of health attainment in well performing countries may be a consequence of good fortune in geography, and thus dietary habits, and success in the health effects of policies in other sectors. When assessed in terms of achievements that are more explicitly linked to health care, their performance may not be as good.     

Differential mortality in Turkana agriculturalists and pastoralists

Nomadic pastoral populations appear to have much lower rates of growth than the otherwise very high growth rates now characteristic of populations in developing nations. Because dramatic declines in infant mortality have been a primary contributor to increased population growth rates in these countries, it has been assumed that nomadic pastoral populations are still characterized by high levels of mortality in the first few years of life. Few studies, however, have been undertaken to estimate demographic parameters for nomadic pastoral populations, and even fewer of a comparative nature have been undertaken to document the impact of subsistence strategy on demographic processes. This study compares indirect childhood mortality estimates for Turkana nomadic pastoralists with childhood mortality in a settled agricultural group within the same population and finds that pastoralists have substantially higher levels of mortality. Based on the childhood mortality estimates, model life tables are selected for pastoral and agricultural groups from which values for mean life expectancy and infant mortality are estimated and compared. Recent improvements in primary health care for the settled agricultural group are ruled out as being an important cause of their lower mortality levels, and some aspects of life-style associated with subsistence strategy are discussed as likely determinants of the mortality differences.     

Inequality in income and mortality in the United States: analysis of mortality and potential pathways.

OBJECTIVE--To examine the relation between health outcomes and the equality with which income is distributed in the United States. DESIGN--The degree of income inequality, defined as the percentage of total household income received by the less well off 50% of households, and changes in income inequality were calculated for the 50 states in 1980 and 1990. These measures were then examined in relation to all cause mortality adjusted for age for each state, age specific deaths, changes in mortalities, and other health outcomes and potential pathways for 1980, 1990, and 1989-91. MAIN OUTCOME MEASURE--Age adjusted mortality from all causes. RESULTS--There was a significant correlation (r = -0.62 [corrected], P < 0.001) between the percentage of total household income received by the less well off 50% in each state and all cause mortality, unaffected by adjustment for state median incomes. Income inequality was also significantly associated with age specific mortalities and rates of low birth weight, homicide, violent crime, work disability, expenditures on medical care and police protection, smoking, and sedentary activity. Rates of unemployment, imprisonment, recipients of income assistance and food stamps, lack of medical insurance, and educational outcomes were also worse as income inequality increased. Income inequality was also associated with mortality trends, and there was a suggestion of an impact of inequality trends on mortality trends. CONCLUSION--Variations between states in the inequality of the distribution of income are significantly associated with variations between states in a large number of health outcomes and social indicators and with mortality trends. These differences parallel relative investments in human and social capital. Economic policies that influence income and wealth inequality may have an important impact on the health of countries.     

Disparities and Trends in Birth Outcomes,Perinatal and Infant Mortality in Aboriginal vs. Non-Aboriginal Populations: A Population-Based Study in Quebec,Canada 1996–2010

Background

Aboriginal populations are at substantially higher risks of adverse birth outcomes, perinatal and infant mortality than their non-Aboriginal counterparts even in developed countries including Australia, U.S. and Canada. There is a lack of data on recent trends in Canada.

Methods

We conducted a population-based retrospective cohort study (n = 254,410) using the linked vital events registry databases for singleton births in Quebec 1996–2010. Aboriginal (First Nations, Inuit) births were identified by mother tongue, place of residence and Indian Registration System membership. Outcomes included preterm birth, small-for-gestational-age, large-for-gestational-age, low birth weight, high birth weight, stillbirth, neonatal death, postneonatal death, perinatal death and infant death.

Results

Perinatal and infant mortality rates were 1.47 and 1.80 times higher in First Nations (10.1 and 7.3 per 1000, respectively), and 2.37 and 4.46 times higher in Inuit (16.3 and 18.1 per 1000, respectively) relative to non-Aboriginal (6.9 and 4.1 per 1000, respectively) births (all p<0.001). Compared to non-Aboriginal births, preterm birth rates were persistently (1.7–1.8 times) higher in Inuit, large-for-gestational-age birth rates were persistently (2.7–3.0 times) higher in First Nations births over the study period. Between 1996–2000 and 2006–2010, as compared to non-Aboriginal infants, the relative risk disparities increased for infant mortality (from 4.10 to 5.19 times) in Inuit, and for postneonatal mortality in Inuit (from 6.97 to 12.33 times) or First Nations (from 3.76 to 4.25 times) infants. Adjusting for maternal characteristics (age, marital status, parity, education and rural vs. urban residence) attenuated the risk differences, but significantly elevated risks remained in both Inuit and First Nations births for the risks of perinatal mortality (1.70 and 1.28 times, respectively), infant mortality (3.66 and 1.47 times, respectively) and postneonatal mortality (6.01 and 2.28 times, respectively) in Inuit and First Nations infants (all p<0.001).

Conclusions

Aboriginal vs. non-Aboriginal disparities in adverse birth outcomes, perinatal and infant mortality are persistent or worsening over the recent decade in Quebec, strongly suggesting the needs for interventions to improve perinatal and infant health in Aboriginal populations, and for monitoring the trends in other regions in Canada.