Comparing progress toward the millennium development goal for under-five mortality in León and Cuatro Santos, Nicaragua, 1990–2008

Abstract

BackgroundSocial inequality in child survival hampers the achievement of Millennium Development Goal 4 (MDG4). Monitoring under-five mortality in different social strata may contribute to public health policies that strive to reduce social inequalities. This population-based study examines the trends, causes, and social inequality of mortality before the age of five years in rural and urban areas in Nicaragua.MethodsThe study was conducted in one rural (Cuatro Santos) and one urban/rural area (León) based on data from Health and Demographic Surveillance Systems. We analyzed live births from 1990 to 2005 in the urban/rural area and from 1990 to 2008 in the rural area. The annual average rate reduction (AARR) and social under-five mortality inequality were calculated using the education level of the mother as a proxy for socio-economic position. Causes of child death were based on systematic interviews (verbal autopsy).ResultsUnder-five mortality in all areas is declining at a rate sufficient to achieve MDG4 by 2015. Urban León showed greater reduction (AARR = 8.5%) in mortality and inequality than rural León (AARR = 4.5%) or Cuatro Santos (AARR = 5.4%). Social inequality in mortality had increased in rural León and no improvement in survival was observed among mothers who had not completed primary school. However, the poor and remote rural area Cuatro Santos was on track to reach MDG4 with equitable child survival. Most of the deaths in both areas were due to neonatal conditions and infectious diseases.ConclusionsAll rural and urban areas in Nicaragua included in this study were on track to reach MDG4, but social stratification in child survival showed different patterns; unfavorable patterns with increasing inequity in the peri-urban rural zone and a more equitable development in the urban as well as the poor and remote rural area. An equitable progress in child survival may also be accelerated in very poor settings.

Child survival revolutions revisited – lessons learned from Bangladesh, Nicaragua, Rwanda and Vietnam

“…There were, in spite of an overall downward trend, some increases in mortality at the time of the liberation from the Somoza dictatorship in 1979 and during a period of the US‐backed Contras war in the following decade. At the end of the study period in 2005, the under‐five mortality rate was approaching 20 per 1000 4, 5.…”

“…Essential health services were made available free of charge to previously underserved parts of the population, resulting in a dramatic improvement in child survival during a period of war and unrest 4. The improved education levels of girls and women also contributed substantially to the improvement in child health and survival 5, 20.…”

“…The Nicaraguan data were derived from the Health and Demographic Surveillance System in the city and surrounding countryside of León, a university town north of the capital, Managua 4, 5, 54. The study period covered 1970–2005.…”

Breaking the cycles of poverty: Strategies, achievements, and lessons learned in Los Cuatro Santos, Nicaragua, 1990–2014

“…These achievements should also be viewed against the background of the hardship of the Nicaraguan revolution and the Contras war of the 1980s [ 18 ]. In spite of those difficulties, that early period also implied considerable progress in literacy and education [ 19 , 20 ], improved child survival, reduced total fertility rates [ 21 – 24 ], and advances in poverty alleviation [ 25 , 26 ]. The Nicaraguan communities have been involved in a broad range of development activities, for example, the national literacy campaign, inspired by the pedagogy of Paulo Freire [ 20 , 27 ].…”

“…Los Cuatro Santos is a frontier area in north-western Nicaragua that was profoundly affected by the war in the 1980s and by Hurricane Mitch in the 1990s. The population in this area has been successful in poverty alleviation [ 26 ] and reduction of under-five mortality [ 24 ]. The area has also been studied with a focus on the nutrition transition, infant and child feeding and nutritional status [ 28 – 30 ], migration and remittances [ 31 ], and environmental improvements [ 32 ].…”