a Department of Public Health, Faculty of Medicine and Health Sciences, Erasmus University Rotterdam, Rotterdam, The Netherlands.
b Netherlands Interdisciplinary Demographic Institute, The Hague, The Netherlands.
Reprints requests: Judith H Wolleswinkel-van den Bosch, Department of Public Health, Faculty of Medicine and Health Sciences, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands. E-mail: j.h.vandenbosch{at}mgz.fgg.eur.nl
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Abstract |
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Data and Methods Mortality and population data were derived from Statistics Netherlands for 16 towns and 11 rural areas. Mortality levels and their decline were estimated with a Poisson regression model. The associations of the estimated levels and declines, and determinants of infant and early childhood mortality were analysed using multivariate linear regression analysis. The causes of death studied were major contributors to infant mortality (convulsions, acute digestive disease, acute respiratory disease) and early childhood mortality (encephalitis/meningitis, acute respiratory disease, measles).
Results Infant mortality rates were high in the south-western part of The Netherlands in 18751879. Due to a rapid decline in the western regions, this pattern changed to a north-south gradient in 18951899. Early childhood mortality showed an urban-rural gradient in 18751879 with mortality high in towns. This gradient had largely disappeared by18951899, due to a rapid decline in mortality in towns. Roman Catholicism was significantly associated with infant mortality (particularly from diarrhoeal disease) in 18751879 and 18951899. The association with Roman Catholicism was stronger in 18951899 because mortality declines were less rapid in Roman Catholic areas in 18751879 to 18951899. Urbanization was significantly associated with early childhood mortality (particularly from respiratory disease) in 18751879 and 18951899. This association weakened over time, due to the rapid decline in mortality in towns.
Conclusions Different determinants of mortality (decline) were important in infant and early childhood mortality and they acted on different causes of death. Therefore, infant and childhood mortality should be studied separately. International comparison of the results showed that findings with respect to determinants of mortality (decline) for one country do not necessarily apply to other countries. The results for The Netherlands with respect to infant mortality differed from England and Wales.
Keywords History, infant mortality, early childhood mortality
Accepted 23 May 2000
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Introduction |
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The rise in living standards and particularly improvements in nutrition have long been considered as the most important determinants of the decline in mortality (including infant and child mortality).2 Others have questioned the importance of the role of nutrition in mortality decline and concluded that the public health movement working through local governments should be seen as the leading force behind the decline of mortality in the late 19th and 20th centuries.3 There are also some important studies that specifically address historical infant and childhood mortality decline, and they have shaped the existing ideas on determinants of 19th and early 20th century infant and child mortality.
Woods et al.4,5 have published two papers on the causes of the rapid infant mortality decline in England and Wales in the period 18611921. Infant mortality rates were high in urban areas in England and Wales. This was called the urban-sanitary-diarrhoeal-effect. It implies higher infant mortality in towns in hot summers, in which due to bad sanitary conditions, high mortality from diarrhoeal disease occurred. The effect of bad sanitary conditions on infant mortality in towns has also been highlighted by others.69 Woods et al.45 also concluded that social class and income had a significant effect on the level of infant mortality but it was not so influential on the timing and pace of infant mortality decline. This conclusion has been confirmed in a multivariate explanatory analysis (including urbanization and fertility) for the period 18951911.10
In the US, child mortality was amongst the highest of the world around 1900, while income levels were among the highest. The inequality in child mortality by social class was much lower in the US compared to England and Wales. The most advantaged social classes enjoyed no advantage with regard to mortality. These findings led Preston and Haines to argue that lack of knowledge rather than lack of resources was principally responsible for foreshortening life.11 They also found that ethnicity was a more important factor in mortality than social class, urbanization and income. The idea that cultural factors, such as the effect of new ideas on disease processes and health behaviours, have been important determinants of infant and childhood mortality (decline) has been put forward by many authors, and has been suggested as a new direction for research on infant and childhood mortality decline.1114
The aim of this study is to determine the relative importance of several determinants of all-cause and cause-specific infant and early childhood mortality rates and their decline in The Netherlands in the period 18751879 to 18951899. Mortality started to decline rapidly in The Netherlands around 18751879. The decline in early childhood mortality was greater compared to infant mortality decline.15 So far, few studies have analysed cause-specific infant and early childhood mortality or included mortality decline beside mortality levels. In this paper results will be presented for three important causes of infant and early childhood mortality. The relative importance of determinants of infant and early childhood mortality (decline) are analysed with a multivariate regression model, in which the regional variation in the prevalence of determinants, mortality levels and their decline in The Netherlands is used.
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Data and Methods |
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Determinants of mortality
The determinants of infant and early childhood mortality used in this study are wealth tax, female labour participation, percentage Roman Catholic, urbanization and soil type. These are indirect determinants of infant and early childhood mortality that affect mortality through other, more direct, determinants, for example breastfeeding and housing conditions. Data for these determinants were most readily available in The Netherlands.
Wealth tax is used as an indicator of wealth. Wealth can influence health through improvement at the household level, such as better food or housing, access to medical care, but wealth can also have a beneficial indirect effect on health through increased governmental expenditure on e.g. water supply and sewage systems. The wealth tax variable used in this study consisted of six components: rental value of houses and other buildings, tax on the number of doors and windows connected to the open air, tax on the number of fireplaces, tax on furniture, tax on servants and maids, and tax on horses. The tax on rental value (part of the wealth tax variable used in the analyses) differed according to the size of the town. Other components such as tax on horses or servants were independent of town size.17 Adding urbanization to the regression model partly corrects for the effect of differential tax values by town size.
The effect of female labour participation on mortality can either be positive or negative. Labour participation by the mother can increase the level of wealth of the household through a second wage. However, a working mother could also mean reduced care levels for the children, e.g. no breastfeeding (or for a shorter period) for the infants.8,18
Cultural factors can influence mortality (decline) through determinants related to health behaviours. In this study percentage Roman Catholics is used as a cultural factor. It has been reported that breastfeeding was less common among Roman Catholics compared to other religious denominations.19 High marital fertility levels were also related to Roman Catholicism, there was a strong adherence to folk medicine among Roman Catholics, and they were less inclined to accept new ideas (e.g. on hygiene).20,21
Urbanization can be related in various ways (positive and negative) to infant and early childhood mortality (decline). High urban infant mortality rates have been related to the negative health affects of industrialization.4,5,22,23 However, there were no major urban-industrial conurbations in The Netherlands like those found in England and Wales.24 On the other hand, urban society was more open to new ideas (including those on hygiene and child care) compared to rural areas. People with different socio-cultural backgrounds lived together in the cities which facilitated the acceptance of other opinions on a number of things.25 City life could also affect health through good infrastructure in the form of schooling and medical care.
The type of soil was also related to mortality. In The Netherlands, regions can be roughly divided into sandy areas and those with predominantly clay soil. The type of soil affected economic development of the region. The farming in the unfavourable sandy soil areas was largely mixed subsistence farming when compared to the clay areas. In the latter regions, the economy was more market-oriented.26 The market-oriented regions were also the regions that were culturally the most diverse. Besides this economic and cultural relationship with mortality (decline), the type of soil could also have a direct association with mortality. Clay soil was more brackish as compared to sandy soil, which made the groundwater less suitable as drinking water. As a result more polluted surface water was used in those areas for drinking and washing.27 Table 1 gives the variables used in the analyses in this study using the parameters of years in the study and data source.
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Method |
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E(Yirt) = expected number of deaths per sex category (i), region (r) and 5-year interval (t)
Nirt = population numbers per sex category, region and 5-year interval
= intercept (i.e. log regional mortality rate 18751879 men, region Amsterdam)
ßi = log relative risk sex-category i (men reference category)
r = log relative risk regional mortality rate (Amsterdam reference category)
= log annual mortality decline (region Amsterdam)
r = difference in annual mortality decline between region(r) and Amsterdam
T = year since 18751879 (0 for 18751879, 10 for 1885 1889, 20 for 18951899)
In the case of infant mortality the population numbers were live births, and no distinction between the sexes could be made. In the case of early childhood mortality the population was the number of children aged 14 years by sex. The estimates for the logarithm of infant and early childhood mortality levels in the 27 regions for the 5-year intervals 18751879 (+
r ) and 18951899 ((
+
r)+(
+
r).20) and the estimates for the logarithm of mortality decline in the period 18751879 to 18951899 (
+
r) were used in a multivariate linear regression analysis in order to relate those estimates to the determinants of mortality (decline) used in this study. In order to determine whether the regional mortality rates and declines differed significantly, we performed a likelihood ratio test; all tests were significant. To present significant differences in rates and decline from Amsterdam for individual regions (i.e.
r and
r differs significantly from zero), results of T-tests will be presented.
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Results |
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The variance explained by the variables in the model for early childhood mortality was higher in 18751879 as compared to 18951899. The variables in the model explained most of the variance in early childhood mortality from encephalitis/ meningitis. As far as early childhood mortality declines are concerned, the variables explained best the variance in acute respiratory disease mortality.
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Discussion |
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Data and Methods
Cause-specific mortality data
In this study, specific causes of death were studied beside all-cause infant and early childhood mortality. The reliability of historical cause-specific mortality data has been the subject of much debate. As far as the causes of death studied in this paper are concerned, convulsions is not a clearly defined cause of death. Convulsions might be a symptom of a variety of diseases with fever.28 Others have argued that the category convulsions mainly covered diarrhoeal disease with cramps.29
In the case of acute respiratory disease, confusion with tuberculosis and chronic respiratory disease has been suggested by several authors.30 We do not consider this a big problem here because we only studied the age groups 0 and 14 years. This makes confusion with chronic respiratory disease and tuberculosis, causes of death occurring mostly at adult ages, less likely.
With respect to acute digestive disease, confusion with the vague cause-of-death category debility has been reported in a 19th century Dutch article on health in several cities.31 This suggests that in the case of acute digestive disease regional differences in coding or diagnosis existed in the late 19th century. Therefore, it should be kept in mind that part of the regional variation in the estimates of mortality from acute digestive disease in this study could be caused by differences in registration. The association between infant mortality from acute digestive disease and percentage Roman Catholics is so strong that it is unlikely that incorrect coding can completely explain the association.
Regression models
The analysis of determinants of infant and early childhood mortality levels and their decline was conducted in two steps. First, regional mortality levels and declines were estimated using Poisson regression models. Second, those estimates were related to a set of independent variables in a multivariate linear regression analysis. By using the estimates of mortality decline in the multivariate regression analysis, the estimated declines are used as point-estimates. Information on the accuracy of the estimates of regional mortality levels and declines is lost in the second step of the analysis. In order to determine whether residual variation in the estimates was large, the average variation around the point estimates was expressed as a percentage of the variation between the point estimates. Residual variation was not very large in most cases. Considerable residual variation was present in case of infant mortality from acute respiratory disease in 18751879 and 18951899, for early childhood mortality from diphtheria in 18751879 and 18951899, and in case of early childhood mortality from acute respiratory disease and measles in 18951899.
If variables in a multivariate model are strongly correlated we cannot distinguish their associations with the dependent variable, i.e. mortality rate or decline. This is known as the multicollinearity problem. The variance-covariance matrices of the parameters of the models used in this study were calculated.32 A relatively high correlation was found for urbanization and wealth tax (0.70) in 18751879 and 189591899.
Determinants of infant and early childhood mortality levels and decline
Percentage Roman Catholics
The percentage Roman Catholics was an important determinant of infant mortality (decline) in The Netherlands in 18751879 and 18951899 (Table 4). The association of percentage Roman Catholics and infant mortality became stronger over time, because infant mortality declined less rapidly in Roman Catholic regions in the period 18751879 to 18951899. Characteristics of Dutch Roman Catholic regions were the high level of marital fertility, the fact that Roman Catholics were less inclined to accept new ideas on disease processes and hygiene compared to Protestants (the Roman Catholic population has been described as strongly obedient to authorities, i.e. the Roman Catholic clergy), and, related to these characteristics, there was a strong adherence to folk medicine,20,21 and a tendency not to breastfeed infants.19 Two important changes occurred in the late 19th century among Dutch Catholics which are important in this respect. There was a change in attitude and habits regarding sexuality, also called a shame complex. There was a lot of emphasis on repressing physical and sexual urges, and as a result of that women had to cover their bodies completely, and breastfeeding (particularly intensive and long-term breastfeeding) was discouraged. This development started after 1850. A second change was the development of a social contamination complex, which made contact between Dutch Catholics and other groups increasingly problematic. This development occurred after 1865. The intellectual growth of Dutch Catholics was limited by the teachings of the church. In 1864 the Pope, in his encyclical Syllabus Errorum, renounced liberal and socialist ideology. This resulted in a very suspicious attitude towards new ideas including those in the area of medical care and public health.19
Convulsions and acute digestive disease were the causes of death most strongly related to the percentage Roman Catholics in a region. Acute digestive disease mortality was strongly related to marital fertility as well (results not shown). The association of infant mortality from acute digestive disease and Roman Catholic regions with high levels of marital fertility might be related to a common determinant viz. breastfeeding. Breastfeeding is related to longer birth intervals, and is beneficial for the infant: it is sterile and contains maternal antibodies.33,34 There are, however, no data on breastfeeding available for the regions in this study.
Urbanization
There have been many publications on the deleterious effects of the urban environment on infant mortality. Infant mortality levels increase as a result of insanitory conditions in towns, in particular in summer where high mortality from diarrhoeal disease has been described (the urban-sanitary-diarrhoeal-effect) not only for England and Wales, but also for other European countries such as France and Sweden.35,36
In The Netherlands, however, urbanization was not a significant factor in infant mortality in the late 19th century, and acute digestive disease mortality was even lower in towns compared to rural areas (Table 4). Percentage Roman Catholics was an important determinant of infant mortality instead. Comparable findings have been reported for nearby Germany.37,38 Others have reported that, in case of Germany, there was no clear urban-rural difference in infant mortality levels, but rather a regional difference.13
Early childhood mortality, on the other hand, was significantly higher in towns. In 18751879, mortality from encephalitis/ meningitis, and measles and acute respiratory disease mortality were all significantly higher in towns compared to rural areas. Early childhood mortality from acute digestive disease (results not shown) was also higher in towns, but this association was not significant. The deleterious effect of urban life on early childhood health in The Netherlands seemed to act predominantly through airborne infectious disease instead of acute digestive disease. The urban-rural difference for early childhood mortality had diminished by 18951899. Mortality declined more rapidly in towns in the period 18751879 to 18951899, so rural and urban mortality levels converged, except for early childhood mortality from encephalitis/meningitis (Table 5). This convergence of urban and rural mortality is in concordance with findings for England and Wales, and the US during comparable periods of time.9,11 In the US, mortality decline was most rapid in the, by then, ten largest cities, and has been related to the earlier introduction of all kinds of public health measures in those cities.11 Simple correlations in another Dutch study have shown that towns which spent relatively more money on water supply and sewerage systems had relatively strong mortality declines (Swartsenburg, unpublished manuscript 1981).
Other determinants of infant and early childhood mortality
Research for England and Wales has shown that income was an important determinant of levels of infant mortality, but that it was less important in cases of infant mortality decline.4,10 In our analyses, wealth tax was significantly associated with infant mortality from acute digestive disease in 18751879, but the association was not as expected (high tax levels were associated with high mortality rates). In the case of early childhood mortality, however, high tax levels (i.e. wealthy areas) were associated with significant lower mortality rates from measles in 18951899. Measles is a cause of death strongly related to living standards, especially nutrition, and probably also overcrowding.39,40 As in England and Wales, we did not find a significant association of infant or early childhood mortality decline and wealth. Another study for The Netherlands has shown that wealth tax did not play a role in all-cause mortality decline in the late 19th century, but it did play a role in the early 20th century (Wolleswinkel-van den Bosch, submitted).
Female employment has been implicated as a possible determinant of infant mortality.8,18 Simple correlations showed associations of high female employment levels with high infant mortality levels (results not shown). However, if other variables related to infant and childhood mortality were added to the model, female employment was, in most cases, associated with low infant (convulsions) and early childhood (measles) mortality (Table 4a,b). This suggests that the positive effect of female employment (increased household income) was more important than the negative effects (less breastfeeding or reduced child care) in The Netherlands in that period. The finding that, in particular, measles mortality was reduced in regions with high percentages of female labour participation fits in with the explanation of increased household income.
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Conclusion |
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References |
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