Systematic exclusion at study commencement masks earlier menopause for Black women in the Study of Women's Health Across the Nation (SWAN).

BACKGROUND: Shorter average lifespans for minoritized populations are hypothesized to stem from 'weathering' or accelerated health declines among minoritized individuals due to systemic marginalization. However, evidence is mixed on whether racial/ethnic differences exist in reproductive ageing, potentially due to selection biases in cohort studies that may systematically exclude 'weathered' participants. This study examines racial/ethnic disparities in the age of menopause after accounting for differential selection 'into' (left truncation) and 'out of' (right censoring) a cohort of midlife women. METHODS: Using data from the Study of Women's Health Across the Nation (SWAN) cross-sectional screener (N = 15 695) and accompanying ∼20-year longitudinal cohort (N = 3302) (1995-2016), we adjusted for potential selection bias using inverse probability weighting (left truncation) to account for socio-demographic/health differences between the screening and cohort study, and multiple imputation (right censoring) to estimate racial/ethnic differences in age at menopause (natural and surgical). RESULTS: Unadjusted for selection, no Black/White differences in menopausal timing [hazard ratio (HR)=0.98 (0.86, 1.11)] were observed. After adjustment, Black women had an earlier natural [HR = 1.13 (1.00, 1.26)] and surgical [HR= 3.21 (2.80, 3.62)] menopause than White women with natural menopause-corresponding to a 1.2-year Black/White difference in menopause timing overall. CONCLUSIONS: Failure to account for multiple forms of selection bias masked racial/ethnic disparities in the timing of menopause in SWAN. Results suggest that there may be racial differences in age at menopause and that selection particularly affected the estimated menopausal age for women who experienced earlier menopause. Cohorts should consider incorporating methods to account for all selection biases, including left truncation, as they impact our understanding of health in 'weathered' populations.

Cost-related prescription non-adherence and patient-reported outcomes in systemic lupus erythematosus: The Michigan Lupus Epidemiology & Surveillance program.

OBJECTIVES: Medication access and adherence play key roles in determining patient outcomes. We investigated whether cost-related non-adherence (CRNA) to prescription medications was associated with worse patient-reported outcomes in a population-based systemic lupus erythematosus (SLE) cohort. METHODS: Sociodemographic and prescription data were collected by structured interviews in 2014-2015 from patients meeting SLE criteria in the established Michigan Lupus Epidemiology & Surveillance (MILES) Cohort. We examined the associations between CRNA and potential confounders such as sociodemographics and health insurance coverage, and outcome measures of SLE activity and damage using multivariable linear regression. RESULTS: 462 SLE participants completed the study visit: 430 (93.1%) female, 208 (45%) Black, and mean age 53.3 years. 100 (21.6%) participants with SLE reported CRNA in the preceding 12 months. After adjusting for covariates, CRNA was associated with both higher levels of current SLE disease activity [SLAQ: ß coeff 2.7 (95% CI 1.3, 4.1), p < 0.001] and damage [LDIQ ß coeff 1.4 (95% CI 0.5, 2.4), p = 0.003]. Race, health insurance status, and fulfilling Fibromyalgia (FM) Survey Criteria were independently associated with both higher (worse) SLAQ and LDIQ scores; female sex was further associated with higher SLAQ scores. CONCLUSION: Patients with SLE who reported CRNA in the previous 12 months had significantly worse self-reported current disease activity and damage scores compared to those not reporting CRNA. Raising awareness and addressing barriers or concerns related to financial implications and accessibility issues in care plans may help to improve these outcomes.

Disparities in Reproductive Aging and Midlife Health between Black and White women: The Study of Women's Health Across the Nation (SWAN).

This paper reviews differences in the experience of the menopause transition and midlife health outcomes between Black and White women who participated in the Study of Women's Health Across the Nation (SWAN), a 25-year, longitudinal, multi-racial/ethnic cohort study. We identify health disparities, i.e., instances in which Black women's outcomes are less favorable than those of White women, and consider whether structural racism may underlie these disparities. Although SWAN did not explicitly assess structural racism, Black women in SWAN grew up during the Jim Crow era in the United States, during which time racism was legally sanctioned. We consider how we might gain insight into structural racism by examining proxy exposures such as socioeconomic characteristics, reports of everyday discrimination, and a range of life stressors, which likely reflect the longstanding, pervasive and persistent inequities that have roots in systemic racism in the US. Thus, this paper reviews the presence, magnitude, and longitudinal patterns of racial disparities observed in SWAN in six areas of women's health - menopause symptoms, sleep, mental health, health related quality of life, cardio-metabolic health, and physical function -and elucidates the contextual factors that are likely influencing these disparities. We review the strengths and weaknesses of SWAN's design and approach to analysis of racial disparities and use this as a springboard to offer recommendations for future cohort studies.

Longitudinal trends in perfluoroalkyl and polyfluoroalkyl substances among multiethnic midlife women from 1999 to 2011: The Study of Women's Health Across the Nation.

BACKGROUND: Limited information exists regarding longitudinal trends in midlife women's exposure to perfluoroalkyl and polyfluoroalkyl substances (PFAS). Further, little is known about how patterns of exposure differ by race/ethnicity and reproductive characteristics including parity and menopause. OBJECTIVE: We aimed to examine temporal variations in serum PFAS concentrations among midlife women from the Study of Women's Health Across the Nation. METHODS: Serum concentrations of 11 PFAS homologues were measured in 75 White, Black and Chinese women with blood samples collected in 1999-2000, 2002-2003, 2005-2006, and 2009-2011. Rates of changes in PFAS concentrations were calculated assuming a first-order elimination model. Associations between PFAS concentrations and race/ethnicity, menstruation and parity were evaluated with linear mixed models, adjusting for age, body mass index and study site. RESULTS: Serum concentrations of linear-chain perfluorooctanoic acid (n-PFOA), linear- and branched-chain perfluorooctane sulfonic acid (n-PFOS and sm-PFOS) decreased significantly (-6.0%, 95% CI: -8.3%, -3.6% per year for n-PFOA; -14.8%, 95% CI: -17.3%, -12.3% per year for n-PFOS; -16.9%, 95% CI: -19.1%, -14.6% per year for sm-PFOS); whereas perfluorononanoic acid (PFNA) increased (16.0%, 95% CI: 10.6%, 21.6% per year). Detection rates of perfluorodecanoic acid (PFDeA) and perfluoroundecanoic acid (PFUA) doubled. Temporal trends varied significantly by race/ethnicity. Chinese women tended to have consistently higher PFNA concentrations at each follow-up visit, compared with White and Black women. Serum PFHxS concentrations significantly decreased in White and Black women, but not in Chinese. Menstruating women consistently had lower concentrations. Parity was associated with lower concentrations at baseline but the differences between nulliparous and parous women became smaller over time. CONCLUSIONS: Our results suggest longitudinal declines in serum concentrations of legacy PFAS and increases in serum concentrations of emerging compounds from 1999 to 2011 in midlife women. Temporal trends in PFAS concentrations are not uniform across race/ethnicity and parity groups.

Urinary metals and metal mixtures in midlife women: The Study of Women's Health Across the Nation (SWAN).

BACKGROUND: Little is known about the extent of exposure to metals and metal mixtures among midlife women. OBJECTIVES: We assessed exposure to multiple metals in the Study of Women's Health Across the Nation (SWAN), a multi-site, multi-racial/ethnic cohort of women at midlife. METHODS: We measured urinary concentrations of 21 metals (arsenic, barium, beryllium, cadmium, cobalt, chromium, cesium, copper, mercury, manganese, molybdenum, nickel, lead, platinum, antimony, tin, thallium, uranium, vanadium, tungsten and zinc) using high-resolution inductively coupled plasma-mass spectrometry among 1335 white, black, Chinese and Japanese women aged 45-56 years at the third SWAN annual visit (1999-2000). Least squared geometric mean concentrations were compared across race/ethnicity, education, financial hardship, smoking, secondhand smoking, seafood intake and rice intake groups. Overall exposure patterns of multiple metals were derived using k-means clustering method. RESULTS: The percentage of women with detectable concentrations of metals ranged from 100% for arsenic, cesium, molybdenum and zinc, to less than 5% for platinum; 15 metals had detection rates of 70% or more. Asian women, both Chinese and Japanese, had higher urinary concentrations of arsenic, cadmium, copper, mercury, molybdenum, lead and thallium, compared with other race/ethnic groups, independent of sociodemographic, lifestyle, dietary, and geographic characteristics. Seafood and rice intake were important determinants of urinary arsenic, cesium, mercury, molybdenum and lead levels. Two distinct overall exposure patterns- "high" vs. "low" -- were identified. Women in the "high" overall exposure pattern were more likely to be Asians, current smokers, and to report high consumption of seafood and rice. Black women were less likely to have the high exposure pattern. CONCLUSIONS: Metal exposure of midlife women differs by racial/ethnic, sociodemographic, lifestyle, dietary, and geographic characteristics. Asian women may be experiencing the highest exposures to multiple metals compared with other racial/ethnic groups in the United States.

Psychosocial and health-related risk factors for depressive symptom trajectories among midlife women over 15 years: Study of Women's Health Across the Nation (SWAN).

BACKGROUND: Psychosocial and health-related risk factors for depressive symptoms are known. It is unclear if these are associated with depressive symptom patterns over time. We identified trajectories of depressive symptoms and their risk factors among midlife women followed over 15 years. METHODS: Participants were 3300 multiracial/ethnic women enrolled in a multisite longitudinal menopause and aging study, Study of Women's Health Across the Nation. Biological, psychosocial, and depressive symptom data were collected approximately annually. Group-based trajectory modeling identified women with similar longitudinal patterns of depressive symptoms. Trajectory groups were compared on time-invariant and varying characteristics using multivariable multinomial analyses and pairwise comparisons. RESULTS: Five symptom trajectories were compared (50% very low; 29% low; 5% increasing; 11% decreasing; 5% high). Relative to whites, blacks were less likely to be in the increasing trajectory and more likely to be in the decreasing symptom trajectory and Hispanics were more likely to have a high symptom trajectory than an increasing trajectory. Psychosocial/health factors varied between groups. A rise in sleep problems was associated with higher odds of having an increasing trajectory and a rise in social support was associated with lower odds. Women with low role functioning for 50% or more visits had three times the odds of being in the increasing symptom group. CONCLUSIONS: Changes in psychosocial and health characteristics were related to changing depressive symptom trajectories. Health care providers need to evaluate women's sleep quality, social support, life events, and role functioning repeatedly during midlife to monitor changes in these and depressive symptoms.

Perceived stress across the midlife: longitudinal changes among a diverse sample of women, the Study of Women's health Across the Nation (SWAN).

Background: In women, midlife is a period of social and physiological change. Ostensibly stressful, cross-sectional studies suggest women experience decreasing stress perceptions and increasing positive outlook during this life stage. The aim of this paper was to describe the longitudinal changes in perceived stress as women transitioned through the midlife. Methods: Premenopausal women (n = 3044) ages 42-52 years at baseline, were recruited from seven sites in the Study of Women's Health Across the Nation, and followed approximately annually over 13 visits with assessment of perceived stress and change in menopausal status. Longitudinal regression models were used to assess the effects of age, menopausal status and baseline sociodemographic variables on the trajectory of perceived stress over time. Results: At baseline, mean age was 46.4 ± 2.7 years; participants were white (47%), black (29%), Hispanic (7%), Japanese (9%), or Chinese (8%). Hispanic women, women with lesser educational attainment, and women reporting financial hardship were each more likely to report high perceived stress levels at baseline (all p < 0.0001). After adjustment for baseline sociodemographic factors, perceived stress decreased over time for most women (p < 0.0001), but increased for both Hispanic and white participants at the New Jersey site (p < 0.0001). Changing menopausal status was not a significant predictor of perceived stress. Conclusions: Self-reported stress decreased for most women as they transitioned across the midlife; changing menopausal status did not play a significant role after adjustment for age and sociodemographic factors. Future studies should explore the stress experience for women by racial/ethnic identity and demographics.

Childhood socioeconomic circumstances and depressive symptom burden across 15 years of follow-up during midlife: Study of Women's Health Across the Nation (SWAN).

Childhood socioeconomic disadvantage may contribute to adult depression. Understanding pathways by which early socioeconomic adversity may shape adult depression is important for identifying areas for intervention. Studies to date have focused on one potential pathway, adult socioeconomic status (SES), and assessed depression at only one or a few time points. Our aims were to examine (a) the association between childhood SES (low vs. high) and depressive symptom burden in midlife and (b) whether adult socioeconomic, psychosocial, and physical health characteristics are important pathways. Using annual data from a cohort of 1109 black and white US women recruited in 1996-1997, we evaluated the association between childhood SES and depressive symptom burden across 15 years in midlife and whether adult characteristics-financial difficulty, lower education, stressful events, low social support, low role functioning, medical conditions, and bodily pain-mediated the association. Depressive symptom burden was estimated by calculating area under the curve of annual scores across 15 years of the Center for Epidemiological Studies Depression (CES-D). In unadjusted models, low childhood SES was associated with greater depressive burden (P = 0.0002). Each hypothesized mediator, individually, did not reduce the association. However, when five of the hypothesized mediators were included together in the same analysis, they explained more than two thirds of the association between childhood SES and depressive symptom burden reducing the P value for childhood SES to non-significance (P = 0.20). These results suggest that childhood SES influences midlife depressive symptom burden through a cluster of economic stress, limited social resources, and physical symptoms in adulthood.

Life-Course Socioeconomic Status and Metabolic Syndrome Among Midlife Women.

OBJECTIVES: We examine whether women's risks of having metabolic syndrome (MetS) at pre/early-menopausal baseline, and of developing MetS after baseline, are associated with childhood and adult socioeconomic statuses (SESs); and whether the associations are mediated by adult reproductive, economic, behavioral, and psychosocial factors. METHOD: Using data on white and black women collected prospectively for 12 years in the Study of Women's Health Across the Nation, we estimated odds of MetS at pre/early-menopausal baseline with logistic regression, and incidence of MetS after baseline with Cox proportional hazards models. RESULTS: Women raised in "adverse" childhood SES had marginally greater odds of MetS at baseline than did women raised in "good" SES, and women with a high school credential or less had significantly greater odds than college-educated women, in mutually adjusted models. The elevated odds partly reflected SES-related differences in exercise and alcohol consumption. Incidence after baseline was associated with education, not childhood SES, and partly mediated by health behaviors. Differences in the probability of surviving without MetS between the most and least socioeconomically advantaged women nearly doubled between ages 50 and 60. DISCUSSION: Childhood and adult SES predict women's risks of MetS as they approach the menopause transition; adult SES is primarily important afterwards.

Risk Factors for Low Birthweight in Zimbabwean Women: A Secondary Data Analysis.

BACKGROUND: Low birth weight (LBW) remains the main cause of mortality and morbidity in infants, and a problem in the care of pregnant women world-wide particularly in developing countries. The purpose of this study was to describe the socio-demographic, nutritional, reproductive, medical and obstetrical risk factors for delivering a live LBW infant at Harare Maternity Hospital, Zimbabwe. METHODS: A secondary data analysis from data obtained through a questionnaire and delivery records was conducted. Linear regression models with a complimentary log-log link function were used to estimate the relative risks for all LBW, term LBW and preterm LBW. RESULTS: The frequency of LBW was 16.7%. Lack of prenatal care (adjusted relative risk [ARR] 1.69, 95% CI 1.44, 1.98), mother's mid-arm circumference below 28.5 cm, (ARR 1.35, 95% CI 1.19, 1.54) and rural residence (ARR 1.22, 95% CI 1.04, 1.40) increased the risk of LBW. Eclampsia, anemia, and ante-partum hemorrhage, were associated with LBW (ARR 2.64, 95% CI 1.30, 5.35; ARR = 2.63, 95% CI 1.16, 5.97; and ARR = 2.39, 95% CI 1.55, 3.68), respectively. Malaria increased the risk of LBW (ARR = 1.89, 95% CI 1.21, 2.96). Prenatal care, infant sex, anemia, antepartum hemorrhage, premature rapture of membranes and preterm labor were associated with the three LBW categories. History of abortion or stillbirth, history of LBW, malaria, eclampsia, and placenta Previa, were associated with all LBW and preterm LBW, while pregnancy induced hypertension, and number of children alive were associated with all LBW and term LBW. CONCLUSIONS: LBW frequency remains high and is associated with nutritive, reproductive, medical and obstetrical factors. Preterm LBW and term LBW have similar and also different risk factors. Understanding the role of different risk factors in these different LBW categories is important if the goal is to reduce LBW frequency, and its complications, in Zimbabwe.

Factors related to age at natural menopause: longitudinal analyses from SWAN.

Early age at the natural final menstrual period (FMP) or menopause has been associated with numerous health outcomes and might be a marker of future ill health. However, potentially modifiable factors affecting age at menopause have not been examined longitudinally in large, diverse populations. The Study of Women's Health Across the Nation (SWAN) followed 3,302 initially premenopausal and early perimenopausal women from 7 US sites and 5 racial/ethnic groups, using annual data (1996-2007) and Cox proportional hazards models to assess the relation of time-invariant and time-varying sociodemographic, lifestyle, and health factors to age at natural FMP. Median age at the FMP was 52.54 years (n = 1,483 observed natural FMPs). Controlling for sociodemographic, lifestyle, and health factors, we found that racial/ethnic groups did not differ in age at the FMP. Higher educational level, prior oral contraceptive use, and higher weight at baseline, as well as being employed, not smoking, consuming alcohol, having less physical activity, and having better self-rated health over follow-up, were significantly associated with later age at the FMP. These results suggest that age at the natural FMP reflects a complex interrelation of health and socioeconomic factors, which could partially explain the relation of late age at FMP to reduced morbidity and mortality.

Relationship of race-ethnicity, body mass index, and economic strain with longitudinal self-report of physical functioning: the Study of Women's Health Across the Nation.

PURPOSE: This study examined progression and improvement of physical functioning limitations during the mid-life and whether race-ethnicity, economic strain, or body mass index were associated with these changes. METHODS: Women from the Study of Women's Health Across the Nation with one or more measure of self-reported physical functioning, categorized as no, some, or substantial limitations, between study visits 4 and 12 were included (n = 2497). RESULTS: When women were aged 56-66 years, almost 50% reported limitations in functioning. African American women were more likely to report substantial (odds ratio, 1.63; 95% confidence interval, 1.06-2.52) and Chinese women were more likely to report some limitations (odds ratio, 2.03; 95% CI, 1.22-3.36) compared with Caucasian women. Economic strain and obesity predicted limitations. The probability of worsening ranged from 6% to 22% and of improving ranged from 11% to 30%. Caucasian and Japanese women had the highest probability of remaining fully functional (80% and 84%, respectively) compared with 71% of African American women. CONCLUSIONS: Race-ethnicity, obesity, and economic strain were associated with prevalence and onset of physical functioning limitations. Functional improvement is common, even among vulnerable subgroups of women. Future studies should characterize predictors of decline and improvement so that interventions can sustain functioning even in the context of many known immutable risk factors.

Gender attitudes and fertility aspirations among young men in five high fertility East African countries.

The relationship between women's attitudes toward gender equality and their fertility aspirations has been researched extensively, but few studies have explored the same associations among men. Using recent Demographic and Health Survey data from five high fertility East African countries, we examine the association between young men's gender attitudes and their ideal family size. Whereas several DHS gender attitude responses were associated with fertility aspirations in select countries, men's greater tolerance of wife beating was consistently associated with higher fertility aspirations across all countries, independent of education, income, or religion. Our findings highlight the overlapping values of male authority within marriage and aspirations for large families among young adult males in East Africa. Total lifetime fertility in East Africa remains among the highest worldwide: thus, governments in the region seeking to reduce fertility may need to explicitly scrutinize and address the reproduction of prevailing masculine values.

Women's sexual empowerment and contraceptive use in Ghana.

Pervasive gendered inequities and norms regarding the subordination of women give Ghanaian men disproportionately more power than women, particularly in relation to sex. We hypothesize that lack of sexual empowerment may pose an important barrier to reproductive health and adoption of family planning methods. Using the 2008 Ghana Demographic Health Survey, we examine the association between women's sexual empowerment and contraceptive use in Ghana among nonpregnant married and partnered women not desiring to conceive in the next three months. Increasing levels of sexual empowerment are found to be associated with use of contraceptives, even after adjusting for demographic predictors of contraceptive use. This association is moderated by wealth. Formal education, increasing wealth, and being in an unmarried partnership are associated with contraceptive use, whereas women who identify as being Muslim are less likely to use contraceptives than those who identify as being Christian. These findings suggest that to achieve universal access to reproductive health services, gendered disparities in sexual empowerment, particularly among economically disadvantaged women, need to be better addressed.

Neighborhood socio-environmental vulnerability and infant mortality in Hermosillo, Sonora / Vulnerabilidad socioambiental y mortalidad infantil en barrios de Hermosillo, Sonora

OBJECTIVE: This paper explores the impact of contextual variables at the neighborhood level on a health marker in the city of Hermosillo, Mexico and discusses the importance of collaboration between planners and health professional to minimize the negative effect of contextual factors on urban health. MATERIALS AND METHODS: Few studies in Mexico have assessed health outcomes at the intra-urban scale and their interaction with neighborhood-level contextual variables. Using spatial analysis and geographical information systems, the paper explores the association between infant mortality and an index of socio-environmental vulnerability used to measure urban contextual factors. RESULTS: Two high infant mortality clusters were detected within neighborhoods characterized by relatively good environmental conditions and one in a neighborhood with a poor environment. CONCLUSIONS: Our results show the clustering of high infant mortality areas and some association with built environment factors in Hermosillo. The results support the need to reconnect public health and urban planning as a way to create healthier environments in Mexican cities.

OBJETIVO: Este artículo explora el papel de factores contextuales a nivel de colonia sobre un marcador de salud en la ciudad de Hermosillo, México y discute la importancia de la colaboración entre planificadores urbanos y profesionales de la salud para minimizar el impacto negativo de factores contextuales sobre la salud de la población urbana. MATERIAL Y MÉTODOS: Pocos estudios en México han evaluado las condiciones de salud a escala intra-urbana y su interacción con variables contextuales a nivel de colonia. Utilizando análisis espacial y sistemas de información geográfica, el artículo explora la relación entre mortalidad infantil y un índice de vulnerabilidad socio-ambiental construido para medir factores contextuales urbanos. RESULTADOS: Dos conglomerados de alta mortalidad infantil fueron detectados dentro de colonias caracterizadas por condiciones ambientales relativamente buenas y uno en una colonia con un ambiente pobre. CONCLUSIONES: Los resultados indican la formación de conglomerados de alta mortalidad infantil y una conexión moderada con factores del medio ambiente construido en Hermosillo. Estos resultados apoyan la necesidad de reconectar la salud pública y la planeación urbana como un método para crear ambientes más sanos en las ciudades de México.

Neighborhood socio-environmental vulnerability and infant mortality in Hermosillo, Sonora.

OBJECTIVE: This paper explores the impact of contextual variables at the neighborhood level on a health marker in the city of Hermosillo, Mexico and discusses the importance of collaboration between planners and health professional to minimize the negative effect of contextual factors on urban health. MATERIALS AND METHODS: Few studies in Mexico have assessed health outcomes at the intra-urban scale and their interaction with neighborhood-level contextual variables. Using spatial analysis and geographical information systems, the paper explores the association between infant mortality and an index of socio-environmental vulnerability used to measure urban contextual factors. RESULTS: Two high infant mortality clusters were detected within neighborhoods characterized by relatively good environmental conditions and one in a neighborhood with a poor environment. CONCLUSIONS: Our results show the clustering of high infant mortality areas and some association with built environment factors in Hermosillo. The results support the need to reconnect public health and urban planning as a way to create healthier environments in Mexican cities.

Intimate partner violence affects skilled attendance at most recent delivery among women in Kenya.

Delivery assistance by skilled health personnel is a key progress indicator for Millennium Development Goal 5, which aims to reduce the worldwide maternal mortality ratio by 75% between 1990 and 2015. The role of socio-demographic factors in determining skilled attendance at delivery has been widely explored, but relatively little attention has been paid to the effect of gender power relations on delivery care. This analysis investigated whether women's status in the household, as measured by their experience of intimate partner violence (IPV), affected skilled attendance at most recent delivery among women in Kenya. Cross-sectional data were obtained from the 2003 Kenya Demographic and Health Surveys (KDHS). 975 ever-married women who had given birth in the past year and completed the KDHS domestic violence module were included in the analysis. Logistic regression was used to assess the association between skilled attendance and IPV. In this sample, 46% reported having experienced any type of IPV, with 39% reporting physical violence, 21% emotional violence, and 13% sexual violence. After adjusting for demographic characteristics and number of antenatal visits, lifetime experience of emotional violence was found to decrease the odds of skilled attendance at most recent delivery by 40%, while lifetime experience of physical violence reduced the odds by 29%. Women's experience of IPV may influence receipt of skilled attendance during parturition, and should be addressed as national programs and their international partners align efforts to contribute to the achievement of Millennium Development Goal 5.

Mortalidad infantil y marginación urbana: análisis espacial de su relación en una ciudad de tamaño medio del noroeste mexicano / Infant mortality and urban marginalization: a spatial analysis of their relationship in a medium-sized city in northwest Mexico

OBJETIVO: Identificar las áreas de alto riesgo de mortalidad infantil y su posible correlación con el nivel socioeconómico de una población, mediante la combinación de un sistema de información geográfica y técnicas de análisis espacial. MÉTODOS: Estudio exploratorio ecológico realizado en Hermosillo, capital de Sonora, México, en 2000-2003. Para cada área geoestadística básica (AGEB) de la ciudad se calcularon el índice de marginación urbana (IMU) y la tasa de mortalidad infantil (TMI). Los IMU y las TMI se procesaron estadísticamente para identificar los puntos de concentración geográfica y determinar el grado de correlación espacial entre ambos indicadores. Para evaluar la autocorrelación espacial general y los agrupamientos espaciales de las TMI y los IMU en la ciudad y sus AGEB se emplearon el índice de Moran I, el estadístico Ipop y el método de Besag y Newell. RESULTADOS: La TMI promedio fue de 14,3 por 1000 nacidos vivos, mayor en las AGEB con alto nivel de marginación social (16,2 por 1000) y menor en las de bajo nivel (11,7 por 1000). El IMU en los AGEB varió entre -3,1 y 6,6. Se encontró autocorrelación en los IMU (Moran I = 0,62), con agrupamientos significativos en el noroeste, noreste y suroeste de la ciudad. Se observaron agrupamientos locales de elevada TMI en las zonas central y occidental de Hermosillo, aunque sin autocorrelación (Moran I = -0,007). Se identificaron áreas de alto riesgo (altas TMI y altos IMU) en el noroeste de la ciudad. CONCLUSIÓN: Se encontraron agrupamientos espaciales con altas TMI en áreas socialmente marginadas del noroeste de Hermosillo, una ciudad de tamaño medio ubicada en el noroeste de México. Estos resultados, obtenidos mediante la combinación de técnicas de análisis espacial y herramientas de los SIG pueden ayudar a dirigir intervenciones específicas hacia esas áreas residenciales de alto riesgo.

OBJECTIVE: To identify areas with high risk of infant mortality and any possible correlation with the population’s socioeconomic status through the use of a geographicinformation system and spacial analysis techniques. METHODS: An exploratory ecologic study was conducted in Hermosillo, the capital of Sonora, Mexico, in 2000-2003. The urban marginalization index (UMI) and the infantmortality rate (IMR) were determined for each of the city’s basic geostatistical areas(BGA). The UMI and IMR were statistically calculated to identify geographic areas inwhich they were concentrated and to determine the degree of spatial correlation between these indicators. To determine the general spatial autocorrelation and spatialclustering of UMIs and IMRs within the city and the BGAs, Morans I index, Ipop statistics, and Besag and Newell’s method were employed. RESULTS: The mean IMR was 14.3 per 1000 live births, higher in the BGAs withgreater social marginalization (16.2 per 1000) and lower in those with less (11.7 per 1000). The UMI range was -3.1-6.6 (maximum: 4.3; minimum: -2.7). Autocorrelation was found among the UMI (Moran I = 0.62), with significant clustering in the city’s northwest, northeast, and southeast parts. Local clustering of high IMRs was found in Hermosillo’s central and western areas, albeit without autocorrelation (Moran I = -0.007). High risk areas (high IMR and high UMI) were found in the city’s north-western section. CONCLUSIONS: Spatial clusters with high IMR were found in socially marginalizedareas in the northwestern part of Hermosillo, a city of medium size located in north-western Mexico. These results, reached through a combination of spatial analysistechniques and geographic information tools can help guide interventions specifically designed for these high risk residential areas.