Under-five Child Mortality and Child-Abuse-Related-Deaths

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Under-five Child Mortality and Child-Abuse-Related-Deaths

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Under-five Child Mortality and Child-Abuse-Related-Deaths in the former USSR: Is there an under reporting of abuse related deaths?
**Professor Colin Author, Ph., MA., FRSA., AcSS., Research Professor in Psychiatric Social Work, School of Health & Social Care, Bournemouth University, and Visiting Professor Dept of Psychiatry, University of Southampton; and Dr. Saalim Mirza, MB.;BS., Wessex Deanery, Dept of Psychiatry, University of Southampton, UK Text 2,985 words. ** Corresponding Author,
Professor Colin Pritchard, Research Professor in Psychiatric Social Work, School of Health & Social Care, Bournemouth University, Royal London House, Christchurch Road, Bournemouth BH1 3 LT [email protected] 0044 238076648 or 07825248004

Under-five Child Mortality and Child-Abuse-Related-Deaths in the former USSR: Is there an under-reporting of abuse related deaths?
Abstract The study explores the former USSR countries `Under-fives’ Child Mortality Rates (CMR) and Child-Abuse-Related-Deaths (CARD), since the end of the Soviet Union and asks whether there has been an `under-reporting’ of CARD? W.H.O. under-five mortality rates per million (pm) were extracted for 1988-90 compared with 2008-10 for CMR and confirmed and possible CARD. Possible CARD are Undetermined Deaths(UnD) and Ill-Defined Signs & Symptoms (IDSS) and as these categories have been linked to under-reporting of CARD. CMR and CARD odds ratio calculated and correlated to determine possible underreporting of CARD. Seven countries met the UNICEF objective of reducing CMR; five halving their previous USSR rate. Russian CARD at 29pm is highest but six countries rates were less than 10pm. Undetermined Deaths (UnD) increased in Kazakhstan 13-fold, Belarus 8 times, Ukraine seven and in Russia more than four. Ill-defined deaths trebled in Belarus, and rose more than 25% in Kazakhstan, Georgia and Ukraine. CARD significantly correlated with UnD but not with CMR. Odds ratios of CMR to CARD categories were substantial, more than 4.1:1 in Belarus, Kazakhstan, Russia and Ukraine, indicating possible under-reporting of CARD. Despite CMR improvements, this first-ever study of former USSR countries should alert the authorities of Belarus, Kazakhstan, the Russian Federation and the Ukraine to the extent of possible child abuse.
Key Words: child mortality, under-reporting homicide, USSR.
Declaration: The study had no external funding nor do the authors have any vested
interest in the study.

Background. Following the end of the Soviet Union there were major rises in violent adult deaths in many of the former USSR countries (Maksimova et al, 2006; Varnik et al, 2010; Lysova et al, 2012; Stametel, 2012). This led to the question of what happened to child mortality since the end of the Soviet Union, especially the most vulnerable, the under-five year olds. This reflects the UNICEF statement that, “in the last analysis child mortality rates (CMR) are an indicator of how well a nation meets the needs of its children” (UNICEF, 2001) and is a Millennium goal for the developing countries to reduce CMR by 2% per annum by 2015 (UNMDG, 2009). Another measure of “how well a nation meets the needs of its children” is associated with child neglect and at its extremes, Child-Abuse-Related-Deaths (CARD) which, despite recent improvements in many Western countries (Pritchard, Williams, 2010; Finkelhor, 2012) is a continuing concern (NSPCC, 2002; Brandon et al, 2098). A literature search on child neglect in the former USSR counties found 52 studies but only five were relevant (Andreev et al, 1995; Berrien et al, 1995; Dalenberg et al, 2004; Kerfoot et al, 2007; Zabina et al, 2009), as the majority concerned older adolescents and HIV infections (Vermeiren et AL, 2003; Kissin et al 2007). There were only two studies that explored the prevalence of child abuse (Andreev et al, 1995; Berrien et al, 1995) and this poses the question of whether CARD, of the under-fives in particular, is either not a problem amongst the former USSR countries or, if the problem exists, is there possible under-reporting of abuse related deaths? To determine how well the former USSR countries are “meeting the needs of their children” total Child Mortality Rates (CMR) for the under-fives and confirmed and possible CARD in the ten former USSR countries are analysed from the break-up of the Soviet Union to the present, 2010. Confirmed CARD are categorised as homicides and the fatal sequel of an assault, coded X85 to Y09 and Y871 (WHO, 2012). Possible CARD are drawn from the categories `Undetermined Deaths’ (UnD) and `IllDefined Signs & Symptoms’ (IDSS) deaths as it has long been argued that these

categories contain `hidden’ CARD because the mode of lethality are similar to abuse related deaths and of course the perpetrators will seek to obscure their behaviour (Creighton, 1993, Emery, 1993; Schmidt & Madea, 1995; NSPCC, 2002; Newton & Vandeven, 2006). In regard to USSR adult violent deaths it was found that there was an underreporting because it embarrassed the former regime, seen in the in disproportionately high levels undetermined adult deaths (UnD) (Wasserman & Varnik, 2006; Lysova et al, 2012), hence the rationale to explore under-five UnD and IDSS deaths as a possible source of under-reporting of CARD. To determine how well the ex-USSR countries have “met the needs of their children” changes in Child Mortality Rates (CMR) and actual and possible CARD, are analysed from 1988 up to the latest data available, 2010. This hypothesis-stimulating study has three research questions:- since the end of the Soviet Union have the former USSR countries:1] met the UN objectives of reducing CMR of under-fives; 2] reduced actual and possible CARD, and, 3] are there any statistical indications of possible under-reporting of child (0-4years) homicides?
Methodology Child Mortality Categories: WHO data for under-fives (0-4years) are extrapolated to calculate a 3-year-average baseline1988-90 for each country to be compared with that country’s latest 3-year-average index up to 2008-10 (WHO, 2012). There are a few countries with earlier index years that are indicated in the tables. However, data for Turkmenistan was only available up to1998 so they are excluded from any intercountry comparison. Child-Mortality-Rates (CMR): The total combined boy and girl child mortality rates per million (pm) are extrapolated for Infant (<1 yr) and Young Child (1-4 years) from which an Under-five (0-4years) CMR is calculated, that is Total Deaths All Causescoded 0050-0080 (WHO, 2012).

Child-Abuse-Related-Deaths (CARD): Confirmed CARD are based upon 0-4 year old Homicide statistics (Coded 7210) (WHO, 2012). Possible-CARD categories are:-: (i) Undetermined Deaths (UnD), defined as “ deaths of undetermined intent are All Other External Causes (coded 7240), and when it is “not possible for the medical or legal authorities to determine whether it was accident, self-harm or assault”. It includes “poisoning…(ranging from drugs to vapours and gases)…hanging…..suffocation…. drowning and submersion ”; but in each case “intent could not be determined”, coded Y10-89. All these methods of lethality contain a degree of violence and are thought likely to be the source of any under-reported CARD (Creighton, 1993; Emery, 1993; Schmidt & Medea, 1995; Newton & Vandeven, 2006). However, whilst an UnD will always remain `undetermined’, considering the methods of lethality, an UnD in an under-five year old might be thought suspicious (NSPCC, 2002; Pritchard & Williams, 2010). Indeed, Australia and the USA recently created `infant mortality review panels’ to address this problem, which led to lower reporting of UnD but rises in confirmed CARD (Bennett et al, 2006;Jenny & Isaacs, 2006; Pritchard & Williams, 2010). (ii) III-Defined Signs and Symptoms (IDSS) This category, coded R00-99, is where there are “other sudden deaths of unknown causes, excluding sudden cardiac death” (R96), and “unattended deaths”, where “the body was found but no cause could be discovered”(R96-7), and “other ill-defined and unspecified causes of mortality (R99). The IDSS category also includes Sudden-Infant-Death-Syndrome’ (SIDS)” (R95) (WHO, 2012) and earlier child protection researchers thought that SIDS probably contained `hidden’ or under-reported CARD (Emery, 1993; Schmidt & Madea, 1995; Newton & Vandeven, 2006). However caution is required as more recent research indicates that SIDS have a complex multi-causal inter-active etiology (Bennett et al, 2006; Matturi et al 2008; Woodruff et al, 2008).

It is stressed that the greatest caution is required in considering UnD and IDSS as abuse-linked, lest we inadvertently add further distress to bereaved parents. Statistics: The Spearman rank order (Rho) correlation is used to test any statistical association between the categories CMR, Homicides, Undetermined and Ill-DefinedSign-&-Symptom deaths. The ratio of change is the difference between a country’s baseline and the index year mortality rates for each of the categories. Ratios of greater than 1.10 or lesser than 0.90, would be considered to be clinically and statistically significant (Guildford, 1978). However in previous international comparative studies only ratios of greater than 1.20 or, lesser than 0.80 were considered as indicating substantial change (Pritchard & Williams, 2010; Pritchard & Hickish, 2011; Pritchard & Wallace, 2011). To examine whether there is any indication of possible under-reporting over the period, CMR to CARD and Possible CARD Odds ratios are calculated. An example best illustrates the point. If country X CMR ratio of change was 0.75, in effect a 25% fall over the period, whilst the UnD ratio was 1.2; in effect a 20% rise. To calculate the Odds ratio we divide the UnD ratio of 1.20 by the CMR: ratio 0.75 yielding CMR: UnD Odds ratio of 1.6 highlighting the disproportionate rise in UnD over the same period that CMR fell. A positive substantial Odds ratio of 1.20 is thought to be indicative of possible underreporting, though only country-specific research could confirm this. Contexts - There are two important global contexts in which to considered child mortality namely the economic and the religio-cultural, which might well influence differences between the countries. The Economic: It is recognised that poverty is a major factor related to child mortality (UNICEF, 2001; UNMDG, 2009; Pritchard & Williams, 2011) and there are wide economic variations between the different republics, with the Russian Federation continuing to be the richest country amongst the former USSR (Brown, 2010; US Bureau of Statistics, 2012). Unfortunately standardised economic data was only available for five of the ten countries (US Bureau of Statistics, 2012) so it is not

possible to make any meaningful economic contextual analysis but the issue needs to be borne in mind when considering the results. The Relgio-Cultural: Four of the former USSR countries, despite 90 years of secular government, still reflect the `Orthodox’ national religious tradition, whilst six can be ascribed as `Islamic’, which continued strongly under the Soviet period (Roi, 2000; Brown, 2010). However, as with all former USSR countries they contain a mixture of different nationalities and faiths, and variation of within faiths, especially in the `Islamic ‘ countries, and not just between the major Sunni and Shia divide, which are important cultural influences (Roi 2000; Brown, 2010; Lings, 2006; Fadiman & Frager, 1997).
Results Child-Mortality-Rates (CMR) 1988-90 v 2008-10 In all countries, male mortalities were higher than female and the CMR are the combined male and female rates for the under-fives. Table [1] shows the highest current CMR (0-4years) per million (pm), excluding Turkmenistan whose latest index year was as early as 1998 (21,432pm), the highest ranged from 14,904pm in Kyrgyzstan, 9,734pm in Kazakhstan down to 2,561pm in Belarus 2,561pm and 4,399pm in Russia. The improvements in the former USSR countries are seen in the averages of the two periods: initially 14,741pm but by 2008-10 down to 7213pm an equivalent fall of 56% since the end of the Soviet Union. All former USSR countries had substantial CMR falls, with ratios of more than <0.80 over the period; notably in Tajikistan 0.25, Russia 0.35, Azerbaijan 0.37, Belarus and Uzbekistan 0.4, these are equivalent to falls of more than 50%, meeting the UN Millennium Goal targets of 2% p.a.
Insert Table [1]
Confirmed Child-Abuse-Related-Deaths (CARD): Table [2].

The highest current (2008-10) confirmed CARD were in Russia at 29pm, followed by the Ukraine 19pm, and, Belarus and Kazakhstan at 17pm, no other country’s CARD rate exceeded 7pm. Russian rates were equivalent to a 40% rise but with the exception of Kazakhstan, all the other countries had ostensibly had more than halved their confirmed CARD. Under-five CMR: CARD Odds ratios: Relative to the changes in CMR, there were disproportionate and substantial changes in the Odds ratios of CMR to CARD. Russia had the greatest proportionate rise at 1: 4.1 followed by Kazakhstan 1:1.52, and Azerbaijan falling just short at 1: 1.19. Conversely, there were Odds ratios of less than 1: 0.80 in Georgia, Kyrgyzstan, Tajikistan and Ukraine, indicating that CARD fell proportionately more than total CMR.
Insert Table [2]
Possible-CARD: Undetermined Deaths (UnD): Table [3]. The highest UnD were in Kazakhstan at 338pm then Belarus 297pm, Ukraine 270pm and Russia 254pm. Except for Azerbaijan at 59pm the four other countries had UnD rates of less than 20pm. There were however major differences between the countries, with remarkable increases in Kazakhstan, up13-fold, Belarus up more than 8-fold, the Ukraine rose seven times, and, Russia UnD rate quadrupled, with a doubling in Azerbaijan since the break- up of the USSR. Conversely, there were notable falls in the five remaining countries. CMR: UnD Odds ratios: There were substantial CMR: UnD Odds ratios indicative of possible under-reporting of CARD. The largest were in Belarus 1: 21.5, followed by Kazakhstan 1: 20.5, Russia 1:13.1, the Ukraine 1:11 and in Azerbaijan 1: 5.9.

Conversely there were Odds ratios of under 1: 08 in Georgia, Kyrgyzstan, Tajikistan and Turkmenistan, indicating that UnD fell more substantially than did CMR in these countries.
Insert Table [3]
Ill-Defined Signs & Symptoms (IDSS): The current highest IDSS rates were in Belarus at 423pm, followed by Kazakhstan 391pmand Russia at 263pm, with lows of under 150pm in Kyrgyzstan, Tajikistan, Georgia and Uzbekistan. Belarus trebled its IDSS rate and Kazakhstan increased by the equivalent of 72%, Georgia 54% and the Ukraine 27%. CMR: IDDS Odds ratios: There were notable rises in CMR to IDSS ratios in Belarus 1: 8.9, Russia 1: 2.9, Kazakhstan 1: 2.15 and the Ukraine 1:1.47 and Azerbaijan 1:1:59, with below 1: 0.80 Odds ratios in Tajikistan, Kyrgyzstan and Uzbekistan.
Insert Table [4]
Correlating the CMR and CARD Mortalities: Table 5 shows the inter-correlations of all four separate mortality categories with each other for the pre and post break-up of the Soviet Union. For the 1988-90 baseline year, the only significant and positive correlation was between CMR and Ill-Defined deaths (Rho=+0.7333 p<0.01). By 2008-10 there were however major changes as CMR correlated negatively but not significantly with all the other categories (Homicides (Rho = -0.5208 p<1.0 a trend), IDDS (Rho= -0.400 n.sig) and UnD (Rho= -0.3701 n.sig). Conversely, there were significant positive correlations between Homicides, Undetermined deaths (Rho = +0.9042 p<0.001), positive but not significantly with IllDefined Signs and Symptoms (Rho= +0.4625). CHECK rhO

There was a significant trend, probability falling just short of statistical significance between UnD and IDDS (Rho= +0.5167 p<0.1).
Discussion. Limitations: The key limitation to this study depends upon how accurate and reliable was the reported statistics for the baseline years of 1988-90 in relation CARD, in view of the problems found earlier about adult violent death that were said to have a `political dimension’ and had been treated as `top secret’ (Wasserman & Varnik, 1998). Therefore, if the current levels of CARD had occurred prior to the end of the USSR, they might have been `politically’ unacceptable and therefore not reported. However, this does not seem to be the case as Undetermined and Ill-Defined reported deaths rose markedly from the earlier period, indicating that CARD and UnD and IDSS rates are reasonably reliable and that there are real increases, which in terms of UnD and IDSS are likely to contain under-reported abuse deaths. A minor limitation was that there was no exact temporal matching of the latest data, especially Turkmenistan whose index years were 1996-98 but the Odds ratio was essentially testing a country against itself, to indicate changes in that nation’s ability “to meet the needs of its children” over the period. Despite the above limitations, this first comparative analysis of child mortality and abuse related deaths in the former Soviet Union countries shows that there have been major changes to which the relevant authorities should respond. Salient Findings: The first research question of this hypothesis stimulating study is answered in the affirmative, as seven of the ten former USSR countries substantially reduced their total CMR, meeting or coming close to achieving the UN Millennium goals to reduce under-five CMR by 2% p.a. In regard to reducing actual and possible Child-Abuse-Related-Deaths the picture is more mixed. Reported confirmed CARD increased only in Russia but the major rises in Undetermined deaths, in Belarus, Kazakhstan, Russia and the Ukraine, at a time
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