6. HEALTH AND MORTALITY INDICATORS
6.5 HEALTH INDICATORS
The Department of National Health and Population Development conducted a survey of health status and factors determining child survival for Region C in 1991. The framework of this report is based on the following concept:
The causes of and remedies for unsatisfactory child health outcomes should be sought in both the underlying socio-economic and the intermediate (behavioural) determinants of child health.
A further study was done by the HSRC to ascertain factors determining child survival among black households in the OFS (white) part of region C during the first quarter of 1991. In what follows, data from both these reports are presented to give a broad overview of the status of child health and health care in the region.
(a) UNDERLYING SOCIO-ECONOMIC DETERMINANTS OF CHILD HEALTH
Mother's educational level
In South Africa, if a mother has some secondary education, the risk of her infant dying is 25% lower than for a mother with only some primary education, and 33% lower than for a mother with no schooling, irrespective of other variables (DHS I, 1988). In Region C, the educational level of black mothers was lower in 1991 than the average for black mothers in the RSA in 1988. In 1991, a third of urban mothers and three-quarters of rural mothers in Region C had no schooling or only some primary education.
Mother's occupational status
The effect of the mother's participation in remunerative work on child survival depends upon the socio-economic conditions at home. In South Africa (DHS I, 1988), the finding was that the infant mortality risk was higher among working mothers, particularly in the lower blue collar category (farm workers and unskilled labourers) than among those who had never worked. The current survey showed that in Region C, 44% of rural mothers were in this high-risk category. This is probably related to the situation that, in general, mothers are compelled to work in order to supplement the basic needs of the family at the cost of the general care of the small children.
Husband's social status
The husband's educational and occupational status, independent of the status of the mother, are determinants of infant mortality. Slightly more than two-thirds of the rural husbands in Region C had no schooling or some primary education and almost half were employed in
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the lower blue collar sectors, compared with 38% and 10% respectively in urban areas.
Both these variables are associated with a higher infant mortality risk.
Housing and toilet facilities
The quality of the immediate physical environment of the child, inside and outside the home, was shown to be a determinant of child survival. The lower the quality of housing, the greater the need for hygienic practices in the home in order to minimize the risk of infection. In South Africa (DRS I, 1988), irrespective of other/actors, Western-type
housing was associated with lower child mortality risks. According to the current survey in Region C, 17% of the urban mothers lived in shacks, and in rural areas 53% lived in traditional housing while only 37% had Western-type housing.
Health education
Only 38% of the mothers knew how to mix their own oral rehydration solution (DRS).
The DRS education programme needs to be improved in urban and, in particular, rural areas, where the proportion of informed mothers was the lowest (33%), and the prevalence of diarrhoeal disease the highest.
Health care groups
Only a small proportion (12%) of mothers in this region knew of such a group in their vicinity, and very few (1-2%) were members of a health care group.
Accessibility of health facilities
Two-thirds of urban mothers, and half of those in rural areas, lived less than three kilometres from a mother and child health (MCR) clinic/mobile service; 12% of urban mothers, and 45% of rural mothers were more than five kilometres (one hour's walk) from the nearest health service.
On average, the nearest private doctor (and pharmacist) was physically more accessible than the nearest hospital.
Place of residence
Place of residence per se was not a significant determinant of child survival. The urban- rural differences in child survival should be addressed in terms of the urban-rural
differentials in socio-economic and behavioural determinants of infant and child mortality, and not only in terms of the urban-rural differences in the accessibility of health facilities.
(b) INTERMEDIATE (BEHAVIOURAL) DETERMINANTS Maternal reproductive practices
About half of the mothers over 25 years of age had a first birth during their teens, and about a quarter of previous birth intervals were less than 24 months. Both these categories are associated with an increased infant mortality risk independent of other factors.
Feeding practices
The mean duration of breast-feeding in Region C was 16 months. Even in urban areas breast-feeding was considered important: more than a third of the children who were 18 months old were still being breast-fed. A quarter of the infants 4-6 months of age received no supplementary feeding with solid foods (gruel, porridge or other mashed food).
Antenatal and birth care
In rural areas only half of the mothers gave birth in a health facility, compared with 85%
of urban mothers who did so. The infant mortality rate has been shown to be 2-3 times higher among children born at home than among those born in hospital.
Immunization coverage
Fifty-seven per cent of the children 12-23 months had both DPTIPolio3 and measles vaccinations; 68% of the children had DPTIPolio3 and 74% had a measles vaccination.
Care of ill children
Three in four ill children (ill with a diarrhoeal or respiratory disease) were taken to a health facility.
Use oj DRS in diarrhoea
Almost two-thirds of the children with diarrhoea received ORS.
(c) HEALTH OUTCOMES
The impact of inadequate socio-economic conditions and health-related behaviour of families, which undermine the chances of survival of children, was measured in terms of the following three outcomes.
Morbidity
Morbidity was measured in terms of the two commonest infectious diseases in children.
The two recent surveys indicate that Region C had a higher prevalence of diarrhoea than the average for South Africa in 1988. Almost half of the children under three years of age
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had a diarrhoeal or respiratory illness prior to this survey. The prevalence of diarrhoea was higher after the first six months of life (when the infant has greater hand and mouth contact with the environment) in rural areas, while respiratory illness was more prevalent in urban areas as a result of poorer environmental health factors.
Growth faltering
Among black young children (3-5 months) the level of growth faltering in Region C (13,9%) was six times higher than the level found in a developed country (2,3% : USA).
About a quarter of children with growth faltering had the condition to a serious degree.
The level increased during the first year of life, which is the stage of increased nutritional risk imposed by weaning and the higher prevalence of diarrhoea.
Mortality
In Region C the infant mortality rate for blacks during the five years preceding the current survey was calculated at 83.3 per 1 000 live births which is higher than the national
average of slightly higher than 60, found in 1988. The average could be deceiving as the ratio is much higher in the rural areas (100.7 per 1000 live births) than in the urban areas (45.3 per 1 000 live births). Nevertheless, in the long term, the index of child mortality by age of the mother indicated a declining trend in child mortality for this region. The
proportion of the children who had died was considerably lower among the younger generation than the older generation of mothers.