Different health systems - Different mortality outcomes? Regional disparities in avoidable mortality across German-speaking Europe, 1992-2019.

BACKGROUND: Evaluating the impact of health systems on premature mortality across different countries is a very challenging task, as it is hardly possible to disentangle it from the influence of contextual factors such as cultural differences. In this respect, the German-speaking area in Central Europe (Austria, Germany, South Tyrol and large parts of Switzerland) represents a unique 'natural experiment' setting: While being exposed to different health policies, they share a similar culture and language. METHODS: To assess the impact of different health systems on mortality differentials across the German-speaking area, we relied on the concept of avoidable mortality. Based on official mortality statistics, we aggregated causes of death below age 75 that are either 1) amenable to health care or 2) avoidable through primary prevention. We calculated standardised death rates and constructed cause-deleted life tables for 9 Austrian, 96 German, 1 Italian and 5 Swiss regions from 1992 to 2019, harmonised according to the current territorial borders. RESULTS: There are strong north-south and east-west gradients in amenable and preventable mortality across the studied regions to the advantage of the southwest. However, the Swiss regions still show significantly lower mortality levels than the neighbouring regions in southern Germany. Eliminating avoidable deaths from the life tables reduces spatial inequality in life expectancy in 2017/2019 by 30% for men and 28% for women. CONCLUSIONS: The efficiency of health policies in assuring timely and adequate health care and in preventing risk-relevant behaviour has room for improvement in all German regions, especially in the north, west and east, and in eastern Austria as well.

The end of urban sprawl? Internal migration across the rural-urban continuum in Switzerland, 1966-2018.

In high-income countries, migration redistributed populations from congested city centres into the sparsely populated outskirts, raising challenges to environmental and population health and the conservation of biodiversity. We evaluate whether this periurbanisation process came to a halt in Switzerland by expecting a decline in internal migration and a renewed residential attractiveness of urban agglomeration centres (i.e., re-urbanisation)-two recent trend changes observed in Europe. Relying on data from censuses, registers and surveys, we describe trends in the intensity, geography and sociodemographic differentials of migration across consistently defined urban agglomeration density zones between 1966 and 2018. Although the overall intensity of migration declined, the rate increased among the working age population in part because of the societal diffusion of tertiary education. The dominant urban-bound migration flows are increasingly confined within agglomerations over time. After the diffusion of periurbanisation down the city hierarchy between 1966 and 1990, we observe the emergence of re-urbanisation in some agglomerations and sociodemographic groups around 2000. However, this phenomenon has been temporarily inflated by period-specific transformations in Swiss society. More recently, the process of periurbanisation intensified again and expanded more and more beyond official agglomeration borders.

Sedimentary faecal lipids as indicators of Baltic Sea sewage pollution and population growth since 1860 AD.

The stress on the environment is increasing as the human population living on it increases. Water eutrophication, a leading cause of impairment of many freshwater and coastal marine ecosystems in the world, is a typical consequence of anthropogenic pressure on the environment. The Baltic Sea represents an excellent example of eutrophication-related massive bottom water deoxygenation since 1950s, when the nutrient inputs derived from agricultural fertilisers and wastewater discharges increased significantly. Faecal lipids (ß-stanols) represent a tool to estimate qualitatively anthropogenic sewage pollution in the environment. The present study shows that a ratio to evaluate sewage pollution based on faecal ß-stanols preserved in modern sediments reflects the eutrophication status of the Baltic Sea and rivers from its catchment area, as well as the nutrient inputs in the central Baltic Sea since 1860. A second ratio, which allows differentiating between livestock breed and human faecal matter, reflects human population growth in the Baltic Sea Eastern European countries since 1860, and more specifically in St. Petersburg. Sedimentary faecal biomarkers are thus reliable indicators for both population growth and anthropogenic sewage pollution in the Baltic Sea, and may thus be useful to evaluate the past and present status of this environment.

Socioeconomic development predicts a weaker contraceptive effect of breastfeeding.

The contraceptive effect of breastfeeding remains essential to controlling fertility in many developing regions of the world. The extent to which this negative effect of breastfeeding on ovarian activity is sensitive to ecological conditions, notably maternal energetic status, has remained controversial. We assess the relationship between breastfeeding duration and postpartum amenorrhea (the absence of menstruation following a birth) in 17 World Fertility Surveys and 284 Demographic Health Surveys conducted between 1975 and 2019 in 84 low- and middle-income countries. We then analyze the resumption of menses in women during unsupplemented lactation. We find that a sharp weakening of the breastfeeding-postpartum amenorrhea relationship has globally occurred over the time period analyzed. The slope of the breastfeeding-postpartum amenorrhea relationship is negatively associated with development: higher values of the Human Development Index, urbanization, access to electricity, easier access to water, and education are predictive of a weaker association between breastfeeding and postpartum amenorrhea. Low parity also predicts shorter postpartum amenorrhea. The association between exclusive breastfeeding and maintenance of amenorrhea in the early postpartum period is also found in rapid decline in Asia and in moderate decline in sub-Saharan Africa. These findings indicate that the effect of breastfeeding on ovarian function is partly mediated by external factors that likely include negative maternal energy balance and support the notion that prolonged breastfeeding significantly helps control fertility only under harsh environmental conditions.

Regional variations in the rural-urban fertility gradient in the global South.

The study of regional trends in the rural-urban fertility gradient helps us to understand the pace of completion of the fertility transition and the geography of urban growth in the global South. We question whether the hypothesized inverted U-shaped evolution in rural excess fertility is confirmed in four developing regions, and investigate the underlying fertility dynamics by place of residence. Using multiple surveys for 60 developing countries, we analyze long-term rural and urban trends in cohort fertility. The regional comparison is controlled for the international heterogeneity in the stages attained in the fertility transition and the context of urbanization. We found a clearly inverted U-shaped trend in the rural-urban fertility gradient in Latin America, the Middle East and Northern Africa. In Asia, rural excess fertility remained limited. In sub-Saharan Africa it increased monotonically until the most recent cohorts. These differences stem from variations in the urban-to-rural diffusion of the onset of fertility transition and, in sub-Saharan Africa, from a slower pace of decline in rural areas.

Fertility and union formation during crisis and societal consolidation in the Western Balkans.

Fertility decline in central and eastern Europe (CEE) since the fall of the communist regimes has been driven by both stopping and postponement of childbearing: two processes that have been related to crisis and economic development, respectively. In the Western Balkans these economic and political contexts followed each other in the form of a biphasic transition. I examine whether this sequence triggered fertility responses like those observed elsewhere. Relying on three independent data sources, I cross-validate the levels of, and describe the trends in, union formation and fertility (by birth order) between 1980 and 2010. Results do not reveal widespread declines in fertility to lowest-low levels during the most acute period of crisis. The subsequent postponement of marriage and first birth was also limited, and the two-child family remains the norm. This relative resilience of childbearing patterns compared with other CEE countries is discussed with reference to the institutional context.

On the plausibility of socioeconomic mortality estimates derived from linked data: a demographic approach.

BACKGROUND: Reliable estimates of mortality according to socioeconomic status play a crucial role in informing the policy debate about social inequality, social cohesion, and exclusion as well as about the reform of pension systems. Linked mortality data have become a gold standard for monitoring socioeconomic differentials in survival. Several approaches have been proposed to assess the quality of the linkage, in order to avoid the misclassification of deaths according to socioeconomic status. However, the plausibility of mortality estimates has never been scrutinized from a demographic perspective, and the potential problems with the quality of the data on the at-risk populations have been overlooked. METHODS: Using indirect demographic estimation (i.e., the synthetic extinct generation method), we analyze the plausibility of old-age mortality estimates according to educational attainment in four European data contexts with different quality issues: deterministic and probabilistic linkage of deaths, as well as differences in the methodology of the collection of educational data. We evaluate whether the at-risk population according to educational attainment is misclassified and/or misestimated, correct these biases, and estimate the education-specific linkage rates of deaths. RESULTS: The results confirm a good linkage of death records within different educational strata, even when probabilistic matching is used. The main biases in mortality estimates concern the classification and estimation of the person-years of exposure according to educational attainment. Changes in the census questions about educational attainment led to inconsistent information over time, which misclassified the at-risk population. Sample censuses also misestimated the at-risk populations according to educational attainment. CONCLUSION: The synthetic extinct generation method can be recommended for quality assessments of linked data because it is capable not only of quantifying linkage precision, but also of tracking problems in the population data. Rather than focusing only on the quality of the linkage, more attention should be directed towards the quality of the self-reported socioeconomic status at censuses, as well as towards the accurate estimation of the at-risk populations.

Internal and International Migration Across the Urban Hierarchy in Albania.

The interactions between the processes of urbanization and international migration in less developed and transition countries have important repercussions for socioeconomic development, but are not well understood. Based on the retrospective data from the Albanian Living Standards Measurement Survey 2008, we first assess the geography of migration in terms of the rural-urban continuum, the urban hierarchy and the outside world since 1990. We then investigate the spatio-temporal diffusion of rural-to-urban and international movements using survival models. Results reveal an immediate onset of large-scale rural exodus, despite the post-communist crisis. Internal migrants mainly moved to the capital, bypassing secondary cities, and were predominantly female. Initially, international migrants were primarily men who tended to originate from the main urban agglomerations. The diffusion of opportunities to emigrate down the urban hierarchy and across the sexes then redirected the rural exodus abroad, despite domestic economic development. This evolution in population mobility is related to the gendered patterns and interlinkages of the two flows, as well as to rising inequalities within the urban hierarchy.

The role of migration in the urban transition: a demonstration from Albania.

Although natural increase has been recognized as the main driver of postwar urban growth in developing countries, urban transition theory predicts a dominant role for population mobility in the early and late phases of the process. To account for this discrepancy between theory and empirical evidence, I demonstrate the complex role played by internal and international migration in the pattern of urban growth. Using a combination of indirect demographic estimations for postwar Albania, I show that the dominant contribution of natural increase from the 1960s to the 1990s was induced by a limited urban in-migration; this was due to the restrictions on leaving the countryside imposed under communist rule and, thereafter, to the redirection abroad of rural out-migrants. Although young adults in cities also engaged in international movements and significantly reduced their fertility, the indirect effects of rural-to-urban migration attenuated the fall in urban birth rates and postponed demographic aging. In-migrants swelled urban cohorts of reproductive age and delayed the urban fertility transition. Despite a high level of urban natural increase in Albania, I thus conclude that the role of population mobility dominated in the early and most recent phases of urban growth. The results also have implications for our understanding of demographic processes during the second urban transition in developing countries.

The start of the sexual transition in Mali: risks and opportunities.

Analysis of data from a questionnaire survey of 2,000 young Malians undertaken by the authors in 2002 demonstrates that, even in underprivileged urban and rural populations, changes in sexual behavior are emerging. Among women, first sex and motherhood are taking place slightly later, and a minority is now dissociating sexuality and procreation. Our data confirm the considerable impact of female education on this transition. Girls'sexual activity before procreation is also influenced by lower religiosity. Among men, in contrast, in a traditional context of late sexual debut and fatherhood, the trend is toward earlier sexual activity and procreation. Fatherhood is delayed, however, among better-educated, wealthier, and less religious urban men, who therefore experience a longer period of sexual activity before they begin to build their own families. The study concludes with an analysis of the possible association of the sexual transition with young people's increased vulnerability resulting from their adoption of risky sexual behaviors and from unfavorable conditions surrounding the arrival of their first child.