Study shows deep inequalities in childhood death in Brazil

Between January and August 2019, sixteen indigenous children died in Alto do Rio Purus, in the state of Acre. The youngest was only a one-month-old baby. All died of diarrhea. These cases are worthy of notice and science show that it is not a temporary crisis. We are talking about a chronic condition caused by the living and health conditions of indigenous children in Brazil. According to an article published in the October issue of The Lancet Global Health, based on a study led by the Centre for Data and Knowledge Integration for Health (Cidacs), indigenous children are 14 times more likely to die of diarrhea. This same risk is 72% higher among black children, when compared with the odds involving children born to white mothers.

Science already knows that, just like elderly people, children under five years of age are more susceptible to the risks related to the place where they live, including quality of water, access to basic sanitation or lack thereof, the lack of access to health services, education levels, etc. The issue for this study was: within these conditions, does being a child and an “ethnic” one to boot make a difference whether they live or die? “Racism operates as a factor that determines the living conditions of this child, the mother's years of schooling, the place the child is born. For all these reasons, it is a factor that must be taken into account”, explains Poliana Rebouças, a researcher associated to Cidacs/Fiocruz Bahia, who led the study.

The analysis observed 19,515,843 children born between January 1st, 2012 and December 31st, 2018. Based on this expressive sample collected from the Live Birth System (Sinasc), the study verified how many and which of these children also appeared in another system, the Mortality System (SIM, in the Portuguese acronym). The data extracted in 2020 showed that 224,213 children under 5 were later found in the SIM. “What we bring with this study is the fact that these deaths very often have preventable causes, such as diarrhea, malnutrition, pneumonia or the flu”, says Rebouças.

Like all epidemiological surveys, this one also refers to compared risk. In this case, the group used as base for comparison is that of children born to white mothers, in that same period, always compared with other groups, which is the case of children of black or brown mothers. In the case of black mothers, there is a 39% higher risk of their babies dying before they turn 5 years old. In this same group, their children are twice as likely to die from malnutrition.

The research also observed the causes of these deaths: diarrhea, malnutrition and pneumonia are the outcomes most often associated with the death of children below 5 years of age. While diarrhea affects the lives of indigenous children 14 times more, malnutrition affects them 16 times more, and pneumonia 7 times more. Among brown women, there is also the risk of losing their children to these outcomes. These risks were quantified: 72% for diarrhea, 78% for pneumonia, and twice as high for malnutrition. All this when compared with children born to white mothers. As for accidental deaths, children of black mothers have 37% more risk of dying than children of white mothers. Among indigenous, this risk jumps up to 74%.

Who are these mothers?

Among the variables observed was the status of these mothers, in terms of relationship: 52% of black women were not married. Among indigenous women, this percentage is 43%. 45% of brown women are unmarried, as are 36% of white women. Not only are black women more often single mothers, but they also make up a significant part of the female population with four children (three children alive at the time of birth of the fourth child, plus the child who is being born). This group is led by the indigenous women with the highest number of children: they are 34%, black women are 14%, brown women are 12%, and white women are 6% of this population.

An important factor for the survival of children and their mothers is that they go through at least six pre-natal medical appointments. For this reason, the research observed those who went through less than three appointments; the group that was least benefitted by prenatal care was indigenous mothers: almost a third (29%) of them only went through half the appointments recommended by health organizations. This ratio was the same among black and brown women (11%), and only 5% among white women. Underscoring what has been observed in other surveys, racial inequalities express themselves also as barriers to access to maternal health services and this has severe consequences for maternal and infant health.

The study indicates that there are insufficient resources to reduce ethnic-racial inequalities for indigenous, black, and brown populations, and this results in a reality that is unfavorable for these groups. “National policies for Integrated Health for Indigenous Peoples have been around since 2002; national policies for Integrated Health for Black People were established in 2006, but they need more funds so they can be actually implemented, and the study shows this need”, adds Rebouças.

The survey explains that in Brazil, black, brown and indigenous mothers live in unfavorable conditions, with fewer school years, fewer pre-natal appointments or a late beginning of pre-natal follow-up, and they live further away from health services, which may be an issue when labor comes. These life circumstances result in a higher risk of negative outcomes, such as low weight at birth, small size for gestational age, premature birth, and higher incidence of preventable diseases, all of which increase the risk of infant mortality.

Premature birth is also a factor with higher prevalence among indigenous children, and is present in 15% of births. This means that out of ten babies, more than one was born ahead of time, which directly affects their development. These indigenous babies were born with less than 2.5 kg in 90% of the cases.

The study used information on the babies and the mothers, made available by Sinasc, such as race/color, place of residence, mother’s school degree, whether she is in a stable relationship when the baby is born, how many pre-natal appointments she attended, etc. In order to create comparison groups, it is necessary to evaluate the variables, that is, these sets of information that are included in health records. In this case, all this information is included in the Live Birth Declaration signed by a physician, the same document necessary to register the baby’s birth and give it the status of Brazilian citizen.

Data integration

Data integration is used at Cidacs/Fiocruz Bahia. What does it mean? It means looking for information on a given person in two or more databases (information systems). In this study, based on a plan outlined by the scientists, the 19 million children born between 1 January 2012 and 31 December 2018, and who were in the National System of Live Births, were also searched for in the Mortality System (SIM); 224,213 were in both systems.

This search is known as linkage. This part of the study does not involve the health scientist; it is provided by the Cidacs/Fiocruz Bahia Data Platform, which carries out the selection of what users are searching for in each information system to the extraction from the base. That is, it delivers the aligned data. As these data were not thought of in scientific research, the challenge begins with the differences in how each piece of data is requested by the user. For instance: one system requests parentage, while the other asks for the mother’s name. These are the same variable, under different names. These differences are studied by the Data Curatorship of Cidacs/Fiocruz Bahia, and are processed by the Data Production team, including engineers, scientists and statisticians.

Even before carrying out anything, Cidacs/Fiocruz Bahia needs to plan and very often create a way to solve scientific problems. In order to integrate these bases, the algorithm used was Cidacs-RL, developed by former scholarship students of the Center. Based on epidemiology knowledge, the groups are separated. In this case, time of birth, such as being less than 27 days old, being less than one year old, and being between one year and four years, 11 months and 29 days. Each group is then compared with its similar groups, so the comparison is adequate to what science already knows about each stage of life. This is because newborns cannot be compared with 4-year-olds, for instance. Each of these phases is defined according to consolidated knowledge that health sciences have gathered about these age groups.