Circumstances of post-neonatal deaths in Ceara, Northeast Brazil: mothers’ health care-seeking behaviors during their infants’ fatal illness
Introduction
Although the promotion of oral rehydration therapy (ORT) for the treatment of diarrheal diseases and the WHO case management strategy for acute respiratory infections (ARI) have contributed to significant reductions in infant mortality, these two conditions remain the leading causes of infant deaths in most developing countries (World Health Organization, 1990a, World Health Organization, 1990b, UNICEF, 1994a). Little is known, however, about the circumstances in which these deaths occur and the maternal and health services factors that may contribute to them. Conceivably, some of these deaths occur at home among children who were never seen by a doctor during the illness episode that resulted in death, whereas others may have occurred despite prompt medical intervention. Although many cases will fall in between these two extremes, a classification of deaths according to the circumstances of death may provide a useful basis for public health intervention. For example, whether more emphasis should be given to maternal education on the recognition and early treatment of illnesses, increasing the accessibility of health care, or improving the quality of the care already provided in hospital and health centers.
Previous studies have reported excess mortality among children discharged from hospital after treatment for diarrhea, with increased risk for those aged less than six months, who were non-immunized, non-breast fed and whose mothers were illiterate (Roy et al., 1983, Snaton et al., 1986, Fauveau et al., 1992, Victora et al., 1992; Islam, Rahman, Mhalanabis & Mahmudur Rahman, 1996). Other studies have demonstrated that maternal health care-seeking behaviors were associated with several factors including socioeconomic conditions, mothers’ knowledge and beliefs of disease causation and severity, mother’s popular beliefs and characteristics of health services (Prajitno et al., 1979, Ulin and Ulin, 1981, De Zoysa et al., 1984, Green, 1985, Selwyn, 1987, Bentley et al., 1988, Mull and Mull, 1988, Nations et al., 1988, Nations and Rebhun, 1988a, Nations and Rebhun, 1988b, Kumar et al., 1989; Nougtara, Saverborn, Oepan & Diesfeld, 1989; Olango and Aboud, 1990, Fernandez et al., 1991, DeClerque et al., 1992, Aguila and Brown, 1993; Hounsa, Godin, Alihonov, Valois & Girard, 1993, 1994; Hudelson, 1993, Singh, 1993, Ricci et al., 1996). For example, choice of “traditional/lay providers” (e.g. traditional healers, drug vendors) and poor home treatment have been attributed to mothers’ low educational status, lack of knowledge about disease causation and lack of perception of disease severity (Selwyn, 1987, Kumar et al., 1989, Nougtara et al., 1989, Olango and Aboud, 1990, DeClerque et al., 1992, Hounsa et al., 1993, Hudelson, 1993, Hudelson, 1994; Stewart, Parker, Chakraboty & Begum, 1994; Ricci et al., 1996). Further studies have provided evidence that factors such as lack of child care, inaccessibility to health facilities and perceived poor quality of medical care hinder mothers’ prompt care seeking and utilization of biomedical services during their infants’ illnesses (Stewart et al., 1994, Hudelson, 1994).
In Ceara State, Brazil, a few studies have described the role of popular beliefs in influencing mothers’ choice of health care and treatment for their ill infants (Nations and Rebhun, 1988a, Nations and Rebhun, 1988b, Nations et al., 1988), but no study has examined the influence of health care system factors in influencing infant survival. To identify the factors associated with preventable post-neonatal deaths and to estimate their relative importance we conducted a survey among a sample of 127 women who had recently lost a child.
Section snippets
Study setting
Ceara, is one of the poorest States in the Northeast of Brazil. According to a recent census 34.6% of the population lives in rural areas, 83% of families living in the rural area earn less than two minimum monthly salaries (US$ 200.00), 50% of women of reproductive age (15–44 yr) are illiterate, 45% of the houses are made of mud-stick, more than half of the population does not have access to potable water and 70% of the households do not have any type of sanitary facilities (IBGE, 1989,
Results
We completed interviews for 127 post-neonatal infant deaths that occurred in the 11 municipalities in Ceara, Northeast Brazil during the period of June 1995 to May 1996 (Table 1). The 127 interviews represented 78.5% of all mothers whose infants had died during the study period. Males accounted for 56.5% of the deceased infants in the study sample. Seventy-three (57.5%) of the infant deaths included in this study occurred in the high-IMR municipality group (mean IMR=147/1000 live births), and
Discussion
In interpreting our results, some limitations may be considered. First, there is the potential for recall bias given that the data were collected retrospectively and were based on mother’s recall, that can be inaccurate. Previous studies have suggested that mothers are able to retrospectively report signs and symptoms of their children’s fatal illnesses which can be used to diagnose the conditions present proximate to the time of death (Hoekelman et al., 1976, Kroeger, 1983, Alonso et al., 1987
Acknowledgements
The authors thank the P.A.C.S. headquarters program personnel for assistance in the recruitment of municipalities into the study, and the P.A.C.S. program personnel in the municipalities of Acarau, Amontada, Barroquinha, Baturite, Caninde, Cascavel, Chaval, Correau, Ocara, Maracanau and Varzea Alegre. We are also grateful to Dr. Jose Wellington O. Lima for his personal support throughout the field work and to Dr. Kristian Heggenhougen for his expertise in the review and critique of the
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