ORIGINALES BREVES

Infant mortality in Central Europe: effects of transition

Witold Zatoñski^a  Malgorzata Mikucka^a  Carlo La Vecchia^b,c  Peter Boyle^d

^aThe Maria Sklodowska-Curie Memorial Cancer Center & Institute of Oncology, Warsaw, Poland
^bIstituto di Ricerche Farmacologiche Mario Negri, Milano, Italy
^cIstituto di Statistica Medica e Biometria, Università di Milano, Milano, Italy
^dInternational Agency for Research on Cancer (IARC), Lyon, France

Former non-market economy Central and Eastern European (CEE) countries underwent major political and social changes over the last two decades, and the collapse of socialized health systems led to the question of possible worsening of relevant health indicators². Thus, to address the specific issue of infant mortality as a relevant health indicator, we systematically considered trends in infant mortality in five CEE countries.

Methods

The countries considered in this investigation are the Czech Republic, Hungary, Poland, Slovakia and Slovenia, i.e. the countries that first entered the period of political and economic transition during the late 1980's (in the rest of accession countries, the political and economical transition started later, in the mid 1990's). For the purpose of comparison, European Union (EU) average data were used. The source of the data was the WHO database (http://www3.who.int/whosis/menu.cfm). For the years 2000 and 2001, the EU average was derived (for year 2000) and estimated (for year 2001) from Eurostat data. For Slovakia 1970-85 and Slovenia 1970-83 data from national offices (Institute of Public Health of the Republic of Slovenia and Institute of Health Information and Statistics of Slovakia) were used. The infant mortality rate was computed on the basis of the World Health Organization definition. Numbers of births were used to compute rates per 1,000 live-born. The average infant mortality rate for the whole region analysed (i.e., the 5 countries of interest) was also computed. The average per cent change per year (annual percent change) was computed for each country and region, for each selected period. The computation was based on exponential function as a model of time trends.

Results

In the year 1990, the lowest infant mortality rates were observed in Slovenia (8.3/1,000) and the Czech Republic (10.8/1,000). The highest ones were in Poland (19.4/1,000) and Hungary (14.8/1,000). The average rate for the EU, with a value of 9.2/1,000, was appreciably lower than in CEE countries considered (average value: 16.6/1,000) (table 1).

In the period 1990-2001 infant mortality rates decreased in all countries of interest (fig. 1). These declines were substantial and steady, and a few increases of infant mortality rates that occurred in Slovakia and Hungary in selected years were of minor value, possible due to vagaries of chance. Only the freezing of infant mortality decrease in Slovenia between 1989 and 1992 (with values 8.1/1,000 in 1989 and 8.9/1,000 in 1992) appears to be real.

In 2001, the lowest infant mortality rates were observed in the Czech Republic (4.0/1,000) and Slovenia (4.3/1,000). These values were indeed below the EU average (4.6/1,000) (table 1). The highest infant mortality rates in 2001 were observed in Poland (7.7/1,000) and Hungary (8.1/1,000). The annual percent change between 1990 and 2001 was highest in the Czech Republic (-9.9%) and Poland (-9.1%).

In all CEE countries, the percent decline was greater in the 1990's, compared to the 1980's. The change in fall was greatest in Poland (9.1% per year, compared to 3.1%) and in the Czech Republic (9.9 compared to 4.9%). In Hungary, the change in fall was smaller (5.8 compared to 3.9%), and in Slovenia and Slovakia changes were minor. Over the last decade, all CEE countries considered had greater annual percent change than the average EU one, leading to a levelling of infant mortality rates between accession countries and EU member states before 2004.

Over more recent years, some of the CEE countries considered reached infant mortality rates lower than the EU as a whole, reflecting the stronger falls registered throughout the last decade. Interestingly, the annual percent change in East Germany (former German Democratic Republic, -7.4% in the 1990s, compared to -5.4% in the 1980s) during the 1990s was smaller than in the Czech Republic or Poland⁴. There are also differences in the components of infant mortality in various countries and regions. Thus, although there were declines in infant mortality in both parts of Germany in the 1990's, these were driven by a fall in neonatal mortality in the East, but of post-neonatal mortality in the West⁴.

In the Check Republic, the decline in neonatal mortality registered between 1989-91 and 1994-95 was due to an improvement in the survival of infants of all birth weights, but especially for these of low birth weight, pointing to a relevant effect of better access to health case⁵.

Some changes of pregnant women behaviour (like decrease in smoking prevalence) and a wider availability of modern medical technology are also likely to have contributed to the substantial declines in infant mortality observed across various CEE countries⁷. It is also possible, however, that socioeconomic improvements had a relevant impact, following the establishment of democracy in these countries^2,8-11. An ecological exercise including data from 170 countries and using three different types of information -i.e., life expectancy, maternal mortality and infant mortality trends- showed, in fact, that after a country's wealth, level of inequality and size of its public spending were adjusted for, democracy had an independent favourable effect on health¹⁰.

Infant mortality is therefore a major indicator of the positive health changes that have been recorded in CEE countries during the last decade⁶.

W. Zatoñski participated in preparing concept of analysis, supervising the data analysis, writing and editing of the paper; M. Mikucka participated in data analysis, writing and editing of the report; C. La Vecchia participated in preparing concept, writing and editing of the paper; P. Boyle participated in preparing concept, and editing of the paper

None declared.

Partial funding: EU Council: HEM. Closing the Gap. Reducing Premature Mortality, Baseline for Health Evaluation Monitoring Following Enlargement (Grant Agreement N.⁰ 2003121).

The authors would like to thank Ms Anna Barkova from Institute of Health Information and Statistics in Slovakia, and Ms Jozica Selb from Institute of Public Health in Slovenia for supplying data for the study.

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