Child Mortality in India: Status, Challenges and Way Forward – Explained, pointwise

Introduction

The Report Levels and Trends in Child Mortality was released recently by the United Nations Inter-agency Group for Child Mortality Estimation (UNIGME). The Report estimates that globally, 5 million children died before their fifth birthday (under-five mortality) in 2021. Of these, 2.3 million deaths occurred in the first month (neonatal deaths). India’s share in under-five deaths is 709,366 (~0.7 million, 14% share) and the share in neonatal deaths is 441,801 (~0.4 million, 19% share). Many of these deaths are preventable. Moreover there are wide variations in the child mortality in India, between various States, and between rural and urban areas. The Government has taken several steps to reduce child mortality in India. While there have been visible benefits of these measures, efforts should be continued to bring the child mortality level to that of the developed countries.

What is Child Mortality and its status in India?

Child Mortality is the death (mortality) of children under 5 years of age. According to UNICEF, Child Mortality or Under-5 Mortality Rate refers to the probability a newborn would die before reaching exactly 5 years of age, expressed per 1,000 live births.

Infant Mortality Rate (IMR) refers to the probability of dying between birth and exactly 1 year of age, expressed per 1,000 live births.

Neonatal Mortality Rate (NMR) refers to the probability of dying during the first 28 days of life, expressed per 1,000 live births.

Trends in India: According to the Sample Registration System (SRS) Statistical Report, 2020 released in September 2022, India’s Under-5 Mortality Rate stood at 32 while Infant and Neonatal Mortality Rates were 28 and 20 respectively.

Source: Economic Times

The NMR ranges from 23 in rural areas to 12 in urban areas. The IMR ranges from 31 in rural areas to 19 in urban areas.

According to the SRS 2020 Report, 6 States/ UTs have already attained SDG target of NMR (<=12 by 2030). These are Kerala (4), Delhi (9), Tamil Nadu (9), Maharashtra (11), Jammu & Kashmir (12) and Punjab (12).

11 States/UTs have already attained SDGs target of U5MR (<=25 by 2030). These are Kerala (8), Tamil Nadu (13), Delhi (14), Maharashtra (18), J&K (17), Karnataka(21), Punjab (22), West Bengal (22), Telangana (23), Gujarat (24), and Himachal Pradesh (24).

What are the reasons for high Child Mortality in India?

Poor Infrastructure: There are structural issues like lack of appropriate facility at primary healthcare centres, delays in referring patients [to specialists] and lack of transportation (especially in rural and remote areas) which lead to high infant deaths.

Poor Nutrition: A significant proportion of population lives below the poverty line. Pregnant women in poor families lack access to adequate nourishment during pregnancy which results in complications in pregnancy and child-birth. Poor nutrition during pregnancy also leads to nutrition deficiency in the child.

Lack of Skilled Personnel: There is shortage of doctors, nurses, and other staff, especially in rural areas. This hinders regular supervision and timely referral of women to emergency obstetric care when complications are diagnosed.

Education and Awareness Deficit: Women in poor families lack awareness about nutrition requirement. They may also be unaware of other precautions required during and after childbirth. They rely more on traditional midwives in comparison to modern healthcare

Child Marriage: Child Marriage is still prevalent in many parts of India. It leads to early pregnancy (younger age) and more frequent pregnancies etc. Children born to early pregnancies are more vulnerable to death at early age.

Premature Births: Premature birth refers to child born before 37 weeks of pregnancy. Premature or ‘Preterm Babies’ are two to four times at higher risk of death after birth in comparison to those born after 37 weeks of gestation.

What steps have been taken to reduce Child Mortality?

National Rural Health Mission: The launch of facility-based newborn care under the National Rural Health Mission has created Newborn Baby Care Corners at every point of childbirth, Newborn Stabilisation Units at First Referral Units (Community Health Centres) and Special Newborn Care Units at District Hospitals across the country.

The Integrated Child Development Services (ICDS) Scheme: The beneficiaries under the Scheme are children in the age group of 0-6 years, pregnant women and lactating mothers. Among its various objectives are to improve the nutritional and health status of children in the age-group 0-6 years and to reduce the incidence of mortality, morbidity, malnutrition and school dropout.

Capacity Building of Health Care Providers: Various trainings are being conducted under National Rural Health Mission (NRHM) to train doctors, nurses and ANM for early diagnosis and case management of common ailments of children. These trainings are being undertaken under the Integrated Management of Neonatal and Child Illness, Navjat Shishu Suraksha Karyakram (NSSK) etc. Funds and technical support are provided by the Government of India under NHM to the States for conducting these trainings.

Management of Malnutrition: Malnutrition reduces resistance of children to infections thus increasing mortality and morbidity among children. National Health Management is emphasising management of malnutrition to reduce child mortality. (a) Nutritional Rehabilitation Centres (NRCs) have been established for management of severe acute malnutrition; (b) Exclusive breastfeeding for first six months and appropriate infant and young child feeding practices are being promoted in convergence with Ministry of Woman & Child Development; (c) Ministry of Health & Family Welfare launched ‘MAA-Mothers’ Absolute Affection‘ programme in August, 2016 for improving breast feeding practices (Initial Breastfeeding within 1 hour, Exclusive Breastfeeding up to 6 months and Complementary Breastfeeding up to 2 years) through mass media and capacity building of health care providers in healh facilities as well as in communities; (d) National Nutrition Mission: It is the government’s flagship programme to improve nutritional outcomes for children, pregnant women and lactating mothers. It aims to reduce stunting and wasting by 2% per year (total 6% until 2022) among children and anaemia by 3% per year (total 9% until 2022) among children, adolescent girls and pregnant women and lactating mothers; (e) Management of Anaemia in Children: National Iron Plus Initiative (NIPI) was launched which was based on the life-cycle approach and covers all age-groups.

Home Based Newborn Care (HBNC): As 57 % of child deaths take place in the first 28 days of birth, home based newborn care through ASHA is being provided. The purpose of Home Based Newborn Care is to improve newborn practices at the community level and early detection and referral of sick newborn babies. The schedule of ASHA for Home Based Newborn Care consists of 6 visits in case of institutional deliveries.

Universal Immunisation Program (UIP): It was first introduced in 1985. Immunization is one of the key area under the National Health Mission (NHM). Under UIP, immunization is provided free of cost against 12 vaccine-preventable diseases; Nationally against 9 diseases: Diphtheria, Pertussis, Tetanus, Polio, Measles, Rubella, Hepatitis B, and Meningitis and Pneumonia; Sub-nationally against 3 diseases: Rotavirus diarrhoea, Pneumococcal Pneumonia, and Japanese Encephalitis. Mission Indradhanush (2014) and Intensified Mission Indradhanush (IMI)-2017 (recent version 4.0) have been launched to strengthen and re-energize the programme and achieve full immunization coverage for all children and pregnant women at a rapid pace.

Protecting Mothers: Paalan 1000: Journey of the First 1000 Days’, focuses on the cognitive developments of children in the first 2 years. PAALAN 1000 parenting app provides caregivers with practical advice on what they can do in their everyday routine and helps resolve the various doubts of parents and directs efforts in the development of a child.

Matritva Sahyog Yojana: It is a conditional Maternity Benefit (CMB) Scheme. The scheme is being implemented by the Ministry of Women and Child Development as the centrally sponsored scheme.It was launched for pregnant and lactating women to improve their health and nutrition status by providing cash incentives to pregnant and nursing mothers.

Policy Targets: In the National Health Policy (NHP) of 2017, the Government had committed to investing 2.5% of the GDP on health by 2025. Child Health Goals under SDG include Goal 3.2: By 2030, end preventable deaths of newborn and children under 5 years of age, with aim to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-5 mortality to at least as low as 25 per 1000 live births. India’s own NHP targets NMR of 16 and U5MR of 23 by 2025.

What more steps can be taken to further reduce Child Mortality?

First, Since ~50% of all under-5 deaths are among newborns, many can be prevented by reaching higher coverage of good quality antenatal care, skilled care at birth, postnatal care for the mother and the baby, and care of small and sick newborns. Focus should be on both antenatal and postnatal care.

Second, many child deaths are preventable through cost-effective interventions such as kangaroo care (where babies are kept in skin-to-skin contact with the mother), thermal control, breastfeeding support and basic care against infections and breathing difficulties. Enhancing awareness about these techniques in new mothers can help avoid these preventable deaths.

Third, The Government should address the neglected challenges like Stillbirths and preterm births. Both are highly sensitive ‘tracer indicators’ of the quality of maternal and child health services in particular, and overall health services in general.

Fourth, India’s health system needs more Government funding. At present, it is ~ 1.5% of the GDP. Children continue to die from preventable causes; pregnant women do not receive good quality care; aggregate mortality hides the inequities in health outcomes and the primary healthcare system is underfunded. The poorest and marginalised families bear the brunt of these inequities. Enhancing spending on healthcare can rectify these shortcomings..

Fifth,  The States should cooperate with each other and share the best practices amongst themselves in the spirit of cooperative federalism, e.g., the practices of Kerala can be replicated in other states like West Bengal, Bihar, Assam etc.

Sixth, The Government should provide greater incentives to ASHA workers who can raise awareness among the masses about the modern healthcare systems. Further, the government can enter into agreements with private medical colleges and induce greater numbers of doctors to serve in rural areas.

Conclusion

Child Mortality has improved a lot in last 2 decades. However, there is still a scope for lot of improvement. Learnings from successful interventions must be used in designing future interventions. Healthcare spending must be enhanced. ASHA workers are a crucial lever in the rural healthcare set-up. Their concerns should be adequately addressed, including enhancing their remuneration. Their role will be crucial in ensuring the achievement of the healthcare targets under the SDGs.

Syllabus: GS II, Welfare schemes for vulnerable sections of the population by the Centre and States and the performance of these schemes; GS II, Issues relating to development and management of Social Sector/Services relating to Health.

Source: The Hindu, Economic Times, NewsOnAir, National Health Mission