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close this bookThe Nutrition and Health Transition of Democratic Costa Rica (International Nutrition Foundation for Developing Countries - INFDC, 1995, 228 pages)
close this folder3. Development and characteristics of health and nutrition services for urban and rural communities of Costa Rica
View the document(introductory text...)
View the documentIntroduction
View the documentBackground information on community outreach programs
View the documentMethodological characteristics of the Costa Rican health programs
View the documentNutrition programs
View the documentImpact of the programs on the health of children living in rural areas
View the documentConclusions
View the documentReferences
View the documentBibliography

Impact of the programs on the health of children living in rural areas

Much research and many reports have analyzed the health and nutrition status of the Costa Rican population during the two decades covered by this study (González-Vega, 1985; Ministerio de Salud, 1976; Sáenz, 1985b; Sandiford et al., 1991; Villegas and Ozuna, 1979). Most of them analyze the trends of national health indicators either as a whole or broken down into urban and rural categories. There are two health and nutrition indicators, however, which have been followed through the years by locality (broken down into counties and even smaller geographic units, such as districts). These indicators are infant mortality and height of children entering school. Both indicators reflect the health and nutrition situation during childhood, including the impact on the mother and child of the environment and the health services.

Infant Mortality

Toward the end of the 1960s, infant mortality in Costa Rica was greater than 70/1,000 live births. In 1970, the national average was 68.2/1,000 live births; the Huetar Atlantic Region, however, attained 110/1,000 live births (Behm and Robles, 1988). At the time, Costa Rican infant mortality did not differ considerably from that of other Central American countries (Behm and Robles, 1988; Behm and Barquero, 1990).

All health regions showed a dramatic drop in infant mortality during the 1970s. The drop was proportionally greater in those regions which had higher infant mortality figures initially (see Table 4).

Infant Mortality by Degree of Urban Density

The higher the degree of "rurality," the more unfavorable living conditions are for the population. Therefore, infant mortality is expected to be higher in rural than in urban areas. As shown in Table 5, this difference was noticeable in 1970; however, it began to disappear by the end of the 1970s.

Infant mortality rates were stable from 1980 through 1985 and then dropped further. Thus all population groups studied, and particularly those from rural areas, showed a significant decrease in infant mortality rates. The absolute difference between urban and rural infant mortality rates, therefore, tends to decrease with time. All this implies that in both absolute and relative terms, the infant mortality rates of rural areas decreased more than those of urban areas.

Causes of Death in Children Under One Year of Age

By 1986,82% of all deaths of children under 1 year of age were certified by a physician, and nearly all deaths were duly registered (Behm and Barquero, 1990). In 1970, the main cause of death in this age group was infectious disease: approximately 25% of the children died of intestinal infections and 20% of respiratory infections. Ten years later, infant mortality rates had decreased as a result of the control of diarrheal diseases (36% of the total decrease in infant mortality rates), control of acute respiratory tract infections (22%), and vaccinations to prevent other infectious diseases (9%). Perinatal causes of death also decreased during the same time, but to a lesser degree. At present, perinatal events continue to be the most frequent cause of infant mortality (see Table 6). It should be noted, however, that they decreased significantly in both rural and urban populations between 1985 and 1989.

TABLE 4. Trends in Infant Mortality by Costa Rican Health Region, 1970-1990

Year

Region


Central

Northern Huetar

Chorotega

Atlantic Huetar

Brunca

1970

68.5

87.5

88.9

110.1

84.0

1975

38.7

53.8

52.9

81.9

58.2

1980

21.7

21.2

26.4

31.5

22.0

1985

21.0

19.5

19.8

25.7

24.6

1990a

13.3

19.3

18.4

19.4

18.2

a Office of the Director of Statistics and Surveys; tabulations of deaths, 1990

Source: Behm and Robles, 1988

TABLE 5. Infant Mortality in Costa Rica by Degree of Urban Density, 1970-1989

Degree of Urban Density

Infant Mortality per 1,000 Live Births


1970

1980-1981

1984-1985

1988-1989

Total urban

50.1

16.8

16.9

13.5

Metropolitan area

45.8

16.3

16.1

12.6

Intermediate citya

57.4

17.0

17.9

14.5

Remainder of urban population

54.5

17.9

18.0

14.8

Total rural

70

21.7

20.7

16.3

a Includes 10 cities with more than 12,000 inhabitants

Source: Behm and Robles, 1988; Behm and Barquero, 1990

Trends in Infant Mortality Rates by Counties

In 1970, 71 out of 75 counties in the country had infant mortality rates greater than 30/1,000 live births, and some of these even had rates greater than 100/1,000. In 1981, however, only 7 out of 81 counties had infant mortality rates of more than 30/1,000, and 51 had rates of less than 20/1,000.

Infant mortality rates continued to improve in 1988. More than one-third of all counties (31 out of 81) had rates below 10/1,000, and only two had rates greater than 30/1,000 (see Table 7).

Nutritional Status of Children: Height Censuses of Children Attending First Grade

The height of seven-year-old children is an indicator that reflects the nutritional and health history of children in a population. In the early 1970s, Bengoa proposed height for age in seven-year-old children as a nutritional indicator to measure how social problems affect early childhood. Stunting at this age reveals, both the impact of nutrition, infections, and the effectiveness of health services. The first height census with national coverage was implemented in Costa Rica in 1979, as part of a national information system on nutrition. At the time, studies were being initiated in other Central American countries on stunting in seven-year-old children and its relation to other social indicators (Valverde et al., 1981). It was concluded that height at age 7 was a highly significant indicator of the social, nutritional, health, and environmental factors that have an adverse impact during the first years of life and, prevent children from developing their full growth potential.

TABLE 6. Infant Mortality Rates by Cause of Death, 1970-1989

Cause of Death

Infant Mortality Rate per 10,000


1970

1980

1985

1989

Contagious and parasitic diseases

250

22

13

10

Intestinal infections

170

15

10

8

Immunopreventable diseases

42

1

0

0

Malnutrition

21

2

2

2

Acute respiratory infections

23

26

16

12

Perinatal causes

143

83

92

63

Congenital abnormalities

30

40

40

44

Trauma and accidents

4

4

2

2

Other causes

48

13

11

6

Source: Behm and Robles, 1988; Behm and Barquero, 1990

The national height censuses included all children registered in first grade throughout the country. Altogether, five censuses of this kind have been done in Costa Rica, in 1979, 1981, 1983, 1985, and 1989.

The growth standard recommended by the World Health Organization (WHO) has been used to compare height data among countries and within a single country in different time frames. Variations between average growth and the reference standard are expressed in terms of standard deviations (Z scores) and are classified according to the following break points or risk levels:

· Severe stunting:

-3.00 SD or less

· Moderate stunting:

-2.99 to -2.00 SD

· Normal height:

-1.99 to +2.00 SD

· Above normal height:

over +2.00 SD

In this analysis, all children under -2.00 SD are considered stunted.

Table 8 summarizes the height trends of Costa Rican children as perceived in the five height censuses done in the country's 81 counties (M.E.P./OCAD/SIN, 1979, 1981, 1983, 1985, 1989).

Counties with less than 5% are considered to have no public health stunting problems. Those with 21% or more stunted children entering first grade (about age 7) are considered to have high prevalences of stunting. Counties in the three intermediate categories, i.e., 6-10%, 11-15%, and 16-20%, are considered to have low, medium, and high stunting prevalence rates, respectively. In 1979, there were no counties without height deterioration, and 60 of the 81 counties had either a low or high prevalence of stunting.

TABLE 7. Infant Mortality Rates by Counties in Costa Rica, 1970-1988

Infant Mortality Rate per 1000 Live Births

Number of Counties


1970

1981

1988

£10

1

10

31

10.1-20

0

41

36

20.1-30

3

23

12

>30

71

7

2

Source: Sistema Nacional de Salud, 1990, p. 28

Table 8 shows that the height status improved progressively in time up to the last height census taken in 1989. As a matter of fact, in 1989 only three counties fell into the high stunting prevalence category and none had a very high prevalence of this condition; 45 had a low stunting prevalence. Without exception, all counties show a trend toward a decrease in the percentage of stunted children. Whereas in 1979 most counties had very high stunting prevalences, as time went by they moved into the no deterioration or low stunting categories. The three counties that still had a high prevalence of stunting in 1989 were highly rural counties with very dispersed populations that were predominantly Indian (Talamanca and Buenos Aires) or indigent Nicaraguan emigrants (Upala).