Mortality inequality in 159 months children across Iranian provinces : National Hospital Medical Records System

Objective: To determine inequality in mortality in 159 months children across Iranian provinces using hospital medical records system. Methodology: After designing and examining a national questionnaire in hospitals for mortality data collection of children 1-59 months, 40 Medical Universities were asked to fill in the questionnaires and return to the main researcher in the health ministry in 2009. Results: Mortality in 1-59 months children was unequally distributed across Iranian hospitals. Cough, drowsiness, and eating and drinking problem were the most important reasons of hospitalization in both genders. There were significant differences between boys and girls in vomiting (p=0.005), drowsiness (p=0.024), and bleeding (p=0.004). Most of the patients had very bad and not suitable situation at entrance (p=0.211). There was a significant difference between two sexes in vaccination (p=0.019). There was no significant difference between boys and girls on first weight in hospital, last weight, breaths per minute, and pulse rate per minute (p > 0.05). The first five most important diagnosis were congenital, accident (girls) pulmonary (boys), cardiovascular, CNS and metabolic diseases. Conclusions: Our results suggest that inequality in 1-59 months mortality based on hospital medical records system needs more attention in Iran as a whole and in most of its provinces by policy-makers. Investigating why inequality is higher in some provinces deserves special attention. In addition, it is advisable to conduct provincial representative surveys to provide recent estimates of heath inequalities and to allow monitoring


INTRODUCTION
More than 8 million children die annually worldwide 1 and child mortality has received substantial attention as an important section of the United Millennium Development Goals (UNMDG). 2 In fact, over the recent decades, and particularly since the World Summit for Children in 1990 3 , there has been increasing interest in measuring child mortality, both as a health indicator and as a basic measure of human development. 46][7] Some researchers have recommended that decreases in children mortality could be at least partly attributed to the improved measurement of children mortality. 8Thus, increased policy discussion of investment in children health is resulting in more local measurements of children mortality. 9However, despite considerable efforts, our knowledge on the impact of intervention strategies for many countries is not strong. 4A vital registration system which could record all births and deaths is the optimal way to monitor children mortality; however, very few developing countries have complete vital registration systems. 10hild mortality is often used as an indicator of population health. 11Moreover, in developing countries, data on child mortality are relatively reliable compared to other measures of population health. 11In fact, children mortality is a key health outcome in developing countries. 12In countries with complete vital registration systems which records all births and deaths, children mortality could directly be calculated.In the absence of a complete vital registration system; however, child mortality must be estimated using live births.
Furthermore, health policy makers always need appropriate and up-to-date information about mortality, in order to evaluate the efficacy of current system and to design of suitable intervention studies.With increasing concern about equity in children survival, it is as important to be able to measure and monitor child mortality at the subnational level (i.e. at province level), as current birth histories are often inappropriate for this purpose.There is a special emphasis on the health of Iranian children and therefore many preventive measures are being carried out to improve their health.Therefore, in 1997, the study on the registration of death and its cause was carried out in Bushehr Province as a pilot study.In 1999, Semnan, Eastern Azarbayejan and Chahar Mahal and Bakhtiary provinces were added to this project.Another six provinces in 2000 and rest of the provinces have been added in 2002.The primary results of the mentioned studies have revealed that despite favorable results of current activities of improvement of national health and declining mortality in children, the current information system needs revision. 13he main aim of this study was to explore the current process of health services on mortality among 1-59 months children based on hospital medical records.There was also an assumption that there was an inequality among different universities, which are covering health of residents of different Iranian provinces.As it is unknown to what extent 1-59 months mortality has been equally distributed within the country, this study was designed to describe the inequality in 1-59 months mortality in Iranian hospitals.

METHODOLOGY
Data: Birth history data and data on determinants of 1-59 months mortality were obtained from Iranian Demographic and Health Surveys (DHS), which are nationally representative surveys among ever-married women aged 15-49 years. 13,14t should be noted that since 1985, the responsibility of health management of Iranian population has been shifted to Universities of Medical Sciences.In 2009, there were 40 medical universities (in 30 Iranian provinces).In the primary step, a national qualitative health survey (including new questionnaire for gathering better information) has been carried out among health experts of three selected medical universities: Shahid Beheshti, Semnan and Arak.Based on their comments, the primary designed quantitative questionnaires have been revised.Then, the revised questionnaires were filled in Arak.After resolving the observed practical problems, the final questionnaire was prepared and sent to 40 medical universities in order to be filled in all parts of Iran in 2009.The requested data on mortality of children 1-59 months in different parts of Iran have been collected and sent to the main researcher in the health ministry.
Using the designed questionnaire, in addition to age and sex of deceased children, some other information has also been collected across the country, based on hospital medical records.It included the reason of hospitalization, situation at entrance to the hospital (suitable, not suitable, very bad and unknown), (first) diagnosis, difficulty in referral, vaccination, having history, availability of growth card, growth trend (declining, increasing, no change, and unknown), weighting gain, complete registration, situation in the ward, need to blood transfusion, need to electroshock, revival, having emergency signs, the reason for no offer, discharge reason, and diagnosis (based on ICD-10 categories).For quantitative variables mean, standard deviation, median, mode, first quartile and third quartile have been calculated such as: entrance (month, day, and hour), exit (month, day, and hour), Physician's order (month, day, and hour), hospitalization (month, day, and hour), first weight in the hospital, last weight, breaths per minute, and pulse rate per minute.Statistical analysis: All questionnaires were entered inside the pre-designed program (Microsoft Access 2007).After determining the distribution of 1-59 months mortality among the medical universities, these distributions were considered to interfere the correlations with other variables.Chi-square test has been applied for nominal and ordinal variables.ANOVA and t-student test have been used for measuring the difference among quantitative variables among groups.SPSS for Windows (version 19.0) has been used for the analysis.

RESULTS
Mortality in 1-59 months children was unequally distributed across Iranian hospitals.The hospitalization characteristics of Iranian deceased children 1-59 months in different universities for both sexes have been shown in Table-II.The most common month, day and hour of admission to hospital were June, 14 th of month and noon, respectively.These items for discharge were June, 14, and 10 in morning, respectively.None of them were significant between boys and girls.
Table-III demonstrates hospital medical records characteristics of 1-59 months deaths of Iranian children.Cough, drowsiness, and eating and drinking problem were the most important reasons of hospitalization in both genders.There were significant differences between boys and girls in vomiting (p=0.005),drowsiness (p=0.024), and bleeding (p=0.004).Most of the patients had very bad and not suitable situation at entrance (p=0.211).There was a significant difference between two sexes in vaccination (p=0.019).Growth trend of most children was unchanged or unknown.There was no significant difference between boys and girls on first weight in hospital, last weight, breaths per minute, and pulse rate per minute (p>0.05).There was an available history for most of deceased children and many of them were advised to refer to more extensive care.The most important emergency signs were pulmonary, shock and coma respectively.The main reason of discharge was death.Based on ICD-10 categorization, the first 5 most important diagnosis were congenital, accident (girls) pulmonary (boys), cardiovascular, CNS and metabolic diseases.

DISCUSSION
This study is one of the first to show the spatial distribution of the inequality of 1-59 months mortality within a developing country.Furthermore, it fills a gap concerning the lack of information on children mortality across Iran.It also shows that there is a lack of health services related to children mortality in hospitals.Mortality Various important health programs focus on children mortality; and most UN member states have agreed to the UN Millennium Goal (MDG) of reducing the under-five mortality by two-thirds between 1990 and 2015. 6Therefore, reducing disparities in mortality within countries is an important objective of national governments and international organizations. 15,16Although in the recent years, many studies have been performed on inequality and spatial distribution of children mortality in developing countries [17][18][19][20][21][22][23][24][25] ; however, not much is known about how inequalities change across Iranian hospitals, and what the determinants of these changes are.
It should be noted that the objective of our study was not to rank provinces according to their inequality, but to show the distribution of children 1-59 months mortality across Iranian hospitals which can help health planning and policy-making for promotion of health in Iran, especially in the hospitals.
There are some explanations for the observed inequality.For instance, the large number of death in children of Razavi Khorasan might largely be explained by differences in access to first care facilities, especially for Afghan immigrants, and the number of hospitals and population coverage in this medical university.Furthermore, in some provinces (and in turn hospitals), nutritional standards are less improved, women's literacy is less, and the number of health care facilities have not expanded yet.These changes were paralleled by different patterns of children mortality in different provinces.Moreover, during recent years, the Iranian population in some provinces has better access to better well equipped and well staffed hospitals with more medical experts and more skilled physicians.
Our study implies that widening socioeconomic inequalities in Iranian universities are not inevitable; declining inequalities may occur as well, certainly in absolute terms.An equitable distribution of primary health care development might be an important factor for preventing widening inequalities in child mortality.We can deduce the reasons for the existing conditions from experts as well as from local information in some provinces, but there is little research-based evidence to provide clear explanations, especially in urban areas.For instance, utilization of health care facilities in Sistan and Baluchestan is known to be far less than the rest of the country not only because of low availability of health care, but also as a result of people's attitude. 14This study indicates the necessity of better defining the determinants of both inequality and levels of child mortality as well as the contribution of each factor to different provinces focusing on hospital records.Furthermore, based on the published report of Iranian ministry of health, more than 80% of mortality in age group of 1-59 months take place in hospitals. 13,26Therefore, the further focus must be on the determination of inequality in hospitals.To do this, we should have standardized questionnaires to compare different hospital records.This study was the first step to examine the prepared national questionnaire.

CONCLUSION
Our results suggest that inequality in 1-59 months mortality based on hospital medical records needs more attention by policy-makers.Investigating why inequality is higher in some hospitals deserves special attention.In addition, it is advisable to conduct provincial representative surveys to provide recent estimates of hospital access inequalities and to allow monitoring over time.

Table - I
: Distribution of 1-59 months mortality across Iranian universities by sex in 2009.

Table -
II: Hospitalization characteristics of Iranian deceased children 1-59 months in 2009.Table-III: Hospital records characteristics of Iranian deceased children 1-59 months in 2009.