BIBLIOGRAPHIC INPUT SHEET TEMPORARY Patterns of mortality ...

74' Patternsof Mortality in Childhood
ties that could be encountered in making
the assignments, it was considered important
to establish the interrelationships
among the causes found in each death. In
this way, knowledge could be obtained of
the true associations and of their direct or
indirect causal roles. With such knowledge,
it is possible to recommend effective action
in the health field with emphasis on
prevention,
The assignment of causes was based on
all the information available for each death.
The starting point was selection of the
underlying cause of death in accordance
with the definition* and the rules for selection
and modification set forth in the International
Classification of Diseases (WHO,
1967).
After the underlying cause and the intermediary
and terminal diseases or morbid
conditions were established, the contributory
causest were determined.
In all the analyses in this Investigation
the multiple causes of death have been
classified in two main groups: underlying
and associated. From the definition of the
former, it is clear that there are as many
underlying causes as there are deaths. The
group of associated causes comprises both
the contributory and the consequential
causes, or consequences, the term consequential
signifying those morbid conditions
that are usually included in the chain
triggered by the underlying cause (i.e., the
intermediate and terminal conditions).
The rationale of this classification is
similar to that of the international form of
medical certificate of cause of death, in
*Underlying cause is "the disease or injury which
initiated the train of morbid events leading directly
to death."
t Contributory cause is "any other significant condition
which unfavorably influenced the course of the
morbid process and thus contributed to the fatal outcome,
but which was not related to the disease or condition
directly causing death."
which the underlying cause and its chain of
events are stated in Part I (items a, b, and
c) and the contributory conditions in Part
II. However, from the study of interrelations
of causes in the Investigation, it appears
that in reality the intermediate and
terminal causes (complications or consequences)
are not the result of the underlying
cause alone. Instead, it is the complex
of underlying cause-ccntributory cause
which together give origin to the fatal com­
plications (Serrano, 1969). The implications
of this concept are exceedingly important
from the preventive viewpoint because
measures aimed at preventing the underlying
cause are not sufficient if the contributory
conditions remain. One example is
the common association of nutritional
deficiency and infection, which necessitates
prevention of both components of the complex,
without which the phenomenon of
"substitution" may come into play-that is,
a death prevented by suppressing one
underlying cause (usually an infection)
may later occur as the result of another
underlying cause (another infection) if the
contributory condition (nutritional deficiency)
remains. In this and other chapters
that follow more evidence is brought forth
to elucidate the synergistic effects between
nutritional deficiency and infection (Scrimshaw
et al., 1968), and certain other important
associations are discussed.
The neonatal age group is one in which
associations and interrelationships of causes
of death are of great importance. Deaths
during this period may he the result of
prenatal factors (maternal or fetal), conditions
present during birth, postnatal conditions,
or combinations of any of these.
Among the prenatal maternal factors, some
are related to pregnancy itself and some to
other conditions. These other conditions in
the mother, however, may be intimately