Infant Mortality - As outrage continues over the deaths of babies in Rajasthan and Gujarat, the fact remains that India has the most child deaths in the world. In 2017, UNICEF estimated 8,02,000 babies had died in India.
- The death toll of children dying from Acute Encephalitis Syndrome (AES) in Bihar’s Muzaffarpur crossed 100.
- Over 70 children had died in a matter of days at Uttar Pradesh’s Gorakhpur.
- The infant mortality rate (IMR) – is the number of deaths per 1,000 live births of children under one year of age.
- The rate for a given region is the number of children dying under one year of age, divided by the number of live births during the year, multiplied by 1,000.
- The infant mortality rate (IMR) in the country currently stands at 33 per 1,000 live births.
- Neonatal mortality rate (NNMR) – is the number of deaths per 1,000 live births of children between 0 and 28 days of age. The neonatal mortality rate of India has dipped from 25 per 1,000 live births in 2016 to 24 in 2017.
- The under-five mortality rate (U5MR) – is the number of deaths per 1,000 live births of children under five years of age. It was 39 per 1,000 live births in 2017.
- While infant mortality is not a target the SDGs will monitor, it will monitor neonatal mortality–death during the first 28 days of life–a key component of infant mortality.
- Under the World Health Organization’s Sustainable Development Goal 3 (SDG3), all countries should aim to reduce neonatal mortality to 12 deaths per 1,000 live births per year, and under-five mortality to a maximum of 25.
Significance of IMR:
The factors that impact the IMR reflect the well-being of a nation. Environmental and living conditions, rates of illness, the health of mothers and their access to quality pre- and post-natal care contribute to infant survival rates.
India continues to show impressive decline in infant deaths: IMR substantially declined over the period from 79 per 1,000 live births in NFHS-1 (1992-93) to 41 per 1,000 live births in NFHS-4
- India has reduced its infant mortality rate (IMR) by 42% over 11 years--from 57 per 1,000 live births in 2006 to 33 in 2017, as per the latest government data released on May 30, 2019.
- Between 2014 and 2017, India’s IMR has declined by 15.4%.
- As per Sample Registration System (SRS) Report published by the Registrar General of India(RGI) in 2013, 15 States/UTs have already achieved Millenium Development Goal 4 (IMR ≤ 29) namely Kerala, Tamil Nadu, Goa, Andaman & Nicobar Islands, Chandigarh, Daman & Diu, Delhi, Lakshadweep, Puducherry, Manipur, Maharashtra, Nagaland, Tripura, Sikkim, Punjab.
- According to the latest Sample Registration System, SRS bulletin, India has also recorded a major drop in birth cohort, (babies born during the year) which has for the first time come down to below 25 million.
- A major reason for this achievement is the increase in the number of institutional deliveries. In 2005, only 38? liveries were taking place in hospitals; but now, more than 79.8% are institutional deliveries.
State Wise performance: According to the latest report from the Sample Registration System (SRS) bulletin, with smaller, more literate states reporting IMRs close to or better than richer countries and larger, poorer states reporting more deaths than poorer countries, indicating the uneven nature of healthcare.
- According to the latest India’s Sample Registration System, Goa, Puducherry, Kerala and Manipur saw the lowest infant-mortality rates in 2016, while Madhya Pradesh, Assam, Odisha and Uttar Pradesh saw the highest, in that order. All four leading States have traditionally been high spenders on healthcare.
- The gender gap in India for child survival: A female infant is more likely to survive in only five out of 29 states, according to the 2017 Sample Registration Survey (SRS).
- Male babies have an IMR of 35 deaths per 1,000 live births, while female babies have an IMR of 39 per 1,000 live births.
- The rural-urban difference: In comparison to 2015, the rural-urban difference narrowed by one point (16 to 15). The rural IMR declined by 3 points (41 to 38).
- Average total medical expenditure per childbirth in a public hospital: Rs 1,587 in a rural area and Rs 2,117 in an urban area
- Among the Empowered Action Group (EAG) States and Assam, all States except Uttarakhand have reported a decline in IMR in comparison to 2015.
Reasons behind IMR: The main reasons for Infant Mortality in India as per the Registrar General of India (2001-03) are perinatal conditions (46%), respiratory infections (22%), diarrhoeal diseases (10%), other infectious and parasitic diseases (8%) and congenital anomalies (3.1%).
Lack of education in the mother, malnutrition (more than half of the Indian women are anaemic), age of the mother at the time of birth, spacing, and whether the child is born at home or in a facility also determine IMR.
- Pradhan Mantri Matru Vandana Yojana (PMMVY): The PMMVY is targeted only at women delivering their first child. A cash amount of ₹6,000 is transferred to the bank account of the beneficiary in three instalments upon meeting certain conditions including early registration of pregnancy, having at least one ante-natal check-up and registration of childbirth.
- Pradhan Mantri Surakshit Matritva Abhiyan: Health ministry launched an innovative scheme to provide free health check-ups to pregnant women at government health centres and hospitals by private doctors.
- “LaQshya” (Labour room Quality improvement Initiative): The Union Health Ministry recently announced the launch of LaQshya, a programme aimed at improving quality of care in labour room and maternity operation theatre.
- The National Health Mission is conceived as the primary tool to reach health targets: maternal mortality ratio (MMR) of less than 70 deaths per 100,000 live births, the neonatal mortality rate (NMR) of 12 deaths per 1,000 live births and under-five mortality rate (U5MR) of 25 deaths per 1,000 live births.
- Interventions under the National Health Mission (NHM):
- Promotion of Institutional deliveries through cash incentive under Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakaram (JSSK) which entitles all pregnant women delivering in public health institutions to absolutely free ante-natal check-ups, delivery including Caesarean section, post-natal care and treatment of sick infants till one year of age.
- Strengthening of delivery points for providing comprehensive and quality Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) Services,
- Establishment of Special Newborn Care Units (SNCU), Newborn Stabilization Units (NBSU) and Kangaroo Mother Care (KMC) units for the care of sick and small babies.
- Home Based Newborn Care (HBNC) is being provided by ASHAs to improve child-rearing practices.
- India Newborn Action Plan (IANP) to make concerted efforts towards the attainment of the goals of “Single Digit Neonatal Mortality Rate” and “Single Digit Stillbirth Rate”, by 2030.
- Early initiation and exclusive breastfeeding for the first six months and appropriate Infant and Young Child Feeding (IYCF) practices are promoted in convergence with the Ministry of Women and Child Development.
- Universal Immunization Programme (UIP) is being supported to provide vaccination to children against many life-threatening diseases such as Tuberculosis, Diphtheria, Pertussis, Polio, Tetanus, Hepatitis B and Measles.
- “Mission Indradhanush” has been launched to fully immunize more than 89 lakh children who are either unvaccinated or partially vaccinated; those that have not been covered during the rounds of routine immunization for various reasons.
- Rashtriya Bal Swasthya Karyakram (RBSK) for health screening, early detection of birth defects, diseases, deficiencies, development delays to provide comprehensive care to all the children in the age group of 0-18 years in the community.
- Iron and folic acid (IFA) supplementation for the prevention of anaemia among the vulnerable age groups, home visits by ASHAs to promote exclusive breastfeeding and promote the use of ORS and Zinc for management of diarrhoea in children.
- Government of India has adopted the Reproductive, Maternal, Newborn, Child and Adolescent Health Strategy (RMNCH+A) to improve maternally and child health outcomes.
- ICDS services are offered through a network of more than 1.3 million Anganwadi centres spread out across virtually every region in India.
- The investment on ensuring holistic nutrition under the POSHAN campaign and national commitment to make India open defecation-free by 2019 are steps that will help in accelerating progress further.
A new study has warned that over two-thirds of the districts in the country are unlikely to achieve the UN Sustainable Development Goal (SDG) target of reducing deaths to 25 or less per 1000 live births in under 5-year-old children and 12 or less per 1,000 live births for newborns by 2030. The study is based on analysis of data from the 2015–2016 National Family Health Survey (NFHS). The reasons are as follows:
- Malnutrition of Mothers: 58% of women who are breastfeeding are anaemic, compared with 50% of women who are pregnant and 52% who are neither pregnant nor breastfeeding.
- Prevalence of anaemia among women has seen little improvement in 10 years, witnessing a rather small decline from 55% in 2005-06 to 53% in 2015-16, acc. to the National Family Health Survey (NFHS-4).
- Poor vaccine compliance: According to the Health Ministry, the vaccination cover in India after several rounds of Intensified Mission Indradhanush (MI) and the original MI, now stands at 87%. 33 lakh children continue to miss out on some or all vaccinations every year.
- Lack of education in mothers: According to a UNICEF factsheet on child mortality in India, “… Children born to mothers with at least 8 years of schooling have 32% lesser chances of dying in the neonatal period and 52% lesser chances in the post-neonatal period, as compared to the illiterate mothers.”
- Underage mothers: It also notes that infant and under-five mortality rates are highest among mothers under age 20.
- Male domination: Women have negligible reproductive rights due to prevalent patriarchy in Indian society.
- Infection risks in a non-institutional birth: According to the National Family Health Survey-4, only 78.9% of births in India happen in a facility. This means 21.1% or about 54 lakh births in a year still happen outside of a facility where hygiene levels can be low, sometimes without the help of a trained health worker.
- Poor health expenditure: As per the National Health Profile 2019, between 2009-10 and 2018-19, India’s public health spending as a percentage of GDP went up by just 0.16 percentage points from 1.12% to 1.28% of GDP and remains a far cry from the 2.5% GDP health spend that has been India’s target for some years now.
- Per capita, public expenditure on health in nominal terms has gone up from Rs 621 in 2009-10 to Rs 1,657 in 2017-18.
- The abysmal state of Public Hospitals in India: There are several factors which can be attributed to poor healthcare in India— shortage of doctors, shortage of primary health centres and community health centres, their extremely poor conditions and lack of political will to improve the system.
- In India, there is one government doctor for every 10,189 people (the World Health Organization (WHO) recommends a ratio of 1:1,000) or a deficit of 600,000 doctors, and the nurse: patient ratio is 1:483, implying a shortage of two million nurses.
- Poverty: The vast majority of the worst-performing states on infant mortality rates are in the poorer states of north-central and eastern India, although there are some high-risk districts in richer, more developed states such as Andhra Pradesh and Gujarat.
- State-wise disparities: A study using data from 1983-84 to 2011-12 showed that per-capita spending on health in the Indian States was the biggest predictor of infant mortality, followed by female literacy and urbanization.
- Lack of health awareness and illiteracy: While it does help in setting up healthcare infrastructure, the willingness of people to access this infrastructure is crucial. On this count, southern States like Kerala and Tamil Nadu outperform, because of widespread literacy.
- The transport infrastructure of a State: the longer people take to reach hospitals when their infant is sick, the higher the risk of death.
- Demographics: For example, tribal communities in Odisha have high rates of malnutrition, a big cause of infant mortality.
- High fertility rate: High infant mortality rates are the result of high fertility rates. Fertility doesn’t need to be higher to offset those losses, it needs to be lower to avoid those losses. Better access to health care, for example, will lower infant mortality.
- Poor sanitation: Consumption of contaminated drinking water, improper disposal of human excreta, lack of personal and food hygiene, and improper disposal of solid and liquid waste have been the major causes of high infant mortality rate and high levels of malnutrition.
- Policy related Intervention Failures
- The National Rural Health Mission, launched in 2005, set India’s IMR target as 30 deaths per 1,000 live births by 2012. However, we have still not been able to achieve in 2017 the target set for 2012.
- The uptake of the Janani Suraksha Yojana has been lesser across States having lower literacy rates.
- Stretching the ICDS system thin: The infrastructure of ICDS centres is often terrible, which prevents them from delivering essential services.
- Anganwadi and ASHA workers are underpaid, overworked, and undertrained.
- Absenteeism and vacancy rates are incredibly high in certain states.
- Primary health centres which ASHAs are linked are ill-equipped. At times, these health centres do not even have a gynaecologist.
- Underachievement by the Poshan Abhiyaan: The focus of the scheme was to reduce stunting in children aged between 0 and 6 years from 38.4 per cent to 25 per cent by 2022. The aim of Poshan Abhiyaan is yet to be met, and there are only two more years to achieve the same.
- District wise approach: It is important to note that India experienced the highest reduction in mortality rate in the period 2005-2016 by focussing on targeted districts. Therefore, to achieve the SDG-related mortality goals at the district level, it needs to intervene more rigorously than ever.
- Ensuring that women go to hospitals to deliver their children: Focus should be increased on the Janani Suraksha Yojana, which has had a great impact on infant mortality since it began in 2005.
- Strengthening the National Rural Health Mission, pregnant women received better care and newborn immunisations improved.
- Improving mothers’ health: India has less than 15 years to halve its MMR from 130 per 100,000 live births to under 70, in order to meet a global Sustainable Development Goal (SDG) target--MMR lower than 70 by 2030.
- Making Poshan Abhiyan success by Improving ICDS:
- Using Integrated Child Development Services-Common Application Software extensively for furthering of the objectives of the ICDS Scheme. It is the DNA of POSHAN Abhiyaan.
- The government needs to invest in training and retaining quality early childhood care workers, fix the crumbling infrastructure of many Anganwadi centres, and deal with the accusations of wasted resources and widespread corruption
- Empowering Ashas: building a low-cost technology-enabled solution for empowering ASHA workers by educating her though innovative mobile learning platforms. Incentive packages for Ashas in order to motivate them.
- Strengthening Primary health centres (PHCs) through the National Rural Health Mission (NRHM): The Mission envisages strengthening PHCs by allotting a second doctor to address the shortage of manpower, and by providing for adequate drug supply and equipment through the Rogi Kalyan Samitis (RKSs) or other resources.
- Ensuring sexual and Reproductive Health and Rights for women (SRHR), which are fundamental for family planning and the overall well-being of individuals.
- Increasing public fundings: To reach the 2025 target of spending 2.5% of GDP on health, the National Health Policy mandated states to increase their health spending on primary care by at least 10% every year.
- Education of girls, avoiding early marriage and ensuring gender equality.
- Shifting expenditure and efforts away from a narrow focus on family planning--a euphemism for population control--to core health priorities such as communicable diseases, drug availability, and human resource deployment.
India has reduced its IMR by 53% over 25 years, instead of the 67% it had set in its MDG target. Most of the infant deaths are preventable in nature with varying reasons which need to be tackled. The MDG achievements of 2015 set the base for the 2030 sustainable development goals (SDGs). If India is to achieve its SDG targets across gender, wealth and caste, it needs more attention directed towards infant and maternal health policies, or 2030 will–once again–see India falling short of its health targets.