Abstract
India suffers from high mortality of children under the age of five years. Enormous social and economic costs are linked to the high-mortality risk of children. It is critical to examine causal factors underlying high proportion of child deaths (both under-5 and neonatal mortality) on a regular basis and strategize effective interventions to reduce the mortality risk. Given the country’s limited resource-settings and relatively low expenditure on public health care, a more targeted approach to tackling the burden of child mortality may be considered. This article analyses secondary data on social indicators with regard to four key interventions associated with newborn and child health, namely: delivery care, feeding practices, preventive and curative disease control (immunisation, supplementation and inpatient care), and nutritional status. In the light of these data, it examines, more specifically, the situation in five Indian states which carry the highest child mortality risk. It calls for evidence-based state-specific interventions as the strategy to reduce the overall burden of under-5 child deaths.
Keywords
Introduction
India is touted to become one of the youngest nations in the world by 2022. Sustained inclusive development holds the key to tapping the potential of human capital. A healthy and disease-free population can productively contribute to a country’s growth and incomes. On the contrary, there are high economic and social costs associated with poor health and survival outcomes. With over 163 million in the age group of 0–6 years as per the Census 2011 in India, survival risk associated with children is a significant indicator of the adequacy and quality of health systems in the country. More specifically, the first five years of life are the most crucial for a child, owing to the high morbidity and mortality risk. The risk is highest during the first month of life termed as neonatal mortality rate (NMR). UNICEF defines the probability of dying between birth and exactly five years of age, expressed as per 1,000 live births as the under-5 mortality rate (U5MR). Between 2005 and 2017, the average U5MR in India declined from 47.1 to 39.4 and is now almost at par with the global average of 39 (UN Inter-agency Group for Child Mortality Estimation, 2018). However, in terms of absolute numbers, the country has the highest number of under-5 deaths, with significant regional differences (Liu et al., 2019). Five of India’s highest mortality risk states, namely Assam, Madhya Pradesh, Odisha, Uttar Pradesh (UP) and Meghalaya, carry the bulk of the country’s under-5 mortality burden with variations in cause-of-death (Liu et al., 2019). If U5MR for these five states is improved, India would be able to make more substantial strides in reducing child mortality. Therefore, given the country’s limited resource-settings and relatively low public health care expenditure, a more targeted approach with a focus on bottom performers may be considered.
Objective and Methodology
The aim of this article is to undertake a comprehensive analysis of the key indicators that impact U5MR and NMR in India and recommend an evidence-based approach. The interventions recommended are state-specific for each of the five high-mortality risk states based on the analysis of state-specific causes of child mortality. A two-pronged approach has been adopted, wherein the relative performance of each state between 2006 and 2016 has been studied and the state’s comparative performance vis-à-vis the other high-mortality risk states and the national average has been examined. High-mortality risk states have been selected based on the statistics published by Liu et al. (2019) for U5MR and NMR in India. The associated social indicators have been taken from the National Family Health Survey (NFHS) 2005–2006 and 2015–2016 which provides a rich and systematic source of information and an empirical foundation for this analysis. Due to unavailability of certain social indicators in the NFHS, data points on preterm births, intrapartum-related events, sepsis and meningitis, and so on have been extracted from the study undertaken by Liu et al. (2019) for 2015.
Key Interventions to Tackle Child Mortality
Saving the lives of children is a function of four key interventions. Any analysis of U5MR needs to predominantly focus on neonatal mortality, which constitutes nearly 47 per cent of the total U5MR (Hug, Alexander, You, & Alkema, 2019). In fact, the world over, 2.5 million children die in the first 28 days of life, making the neonatal period the highest risk period for a child’s survival (WHO, 2018). To add, the majority of the deaths occur in the first week of life, with around 25 per cent–45 per cent children dying in the first 24 hours of birth. Meanwhile, South Asian and sub-Saharan African countries account for nearly 79 per cent of the total neonatal deaths (Hug et al., 2019). In the context of India, preterm births, intrapartum complications and sepsis/meningitis are leading causes of neonatal mortality. A sustained effort to increase institutional deliveries and ensuring greater access to medical interventions holds the key to tackling such birth-related complications. Accordingly, the first factor is delivery care, assessed in terms of the percentage of institutional births and institutional births in a public facility which is indicative of access to public health infrastructure in our analysis. These indicators highlight the quantitative and accessibility aspect of delivery care. Altman, Sidney, Costa, Vora, and Salazar (2017) highlight the role of access to institutional delivery and obstetric care in reducing NMR, particularly in low-income settings. With respect to health infrastructure, Rammohan, Iqbal, and Awofeso’s (2013) findings for India establish a relationship between neonatal survival and geographical access to health care. Other indicators in our analysis include the percentage of preterm births, intrapartum-related events and prevalence of sepsis. These parameters indicate the qualitative aspect of delivery care.
The second intervention covers breastfeeding practices—a critical and cost-effective measure to improve the likelihood of newborn survival. Early initiation of breastfeeding and exclusive breastfeeding can significantly contribute to reducing child mortality. Edmond et al. (2006) conducted a surveillance system based analysis to evaluate the correlation between early initiation of breastfeeding from the first hour through day seven along with the type of breastfeeding (i.e., exclusive, pre-dominant or partial) and the risk of NMR. They found the risk of neonatal death was 4-fold and 2.4-fold higher for newborns who were partially breastfed and experienced delayed initiation of breastfeeding (i.e., later than the day of birth) respectively. Breast milk is known to provide immunological benefits to the infant and is associated with lower morbidity levels. In the context of India, breastfeeding is universal. However, the statistics for exclusive breastfeeding up to six months are not as promising (Patel et al., 2010). For our analysis, we use two indicators, that is, children breastfed during the first hour of birth and children under six months who are exclusively breastfed to assess this degree of success achieved in this intervention.
The third major intervention is disease control which primarily comprises of child immunisation and administration of supplements (preventive) and treatment of childhood diseases (curative). Muldoon et al. (2011) argue that disease-focused initiatives have a positive impact on reducing all-cause mortality rates. UNICEF advocates immunisation as the most cost-effective measure to avert childhood mortality. In developing countries like India, under-5 children are most susceptible to three major diseases-diarrhoea, pneumonia and acute respiratory infection (ARI). Diarrhoea and pneumonia are the two-leading infectious disease-related mortality causes in India. To start with, diarrhoea is the third leading cause of childhood mortality in India (Lakshminarayanan & Jayalakshmy, 2015). The duration and symptoms can be eased through the administration of oral rehydration salt (ORS) solution and zinc, and in severe cases, inpatient care is required. Prevalence of pneumonia is linked to risk factors such as exposure to infection, undernutrition, poor breastfeeding practices and has an adverse impact on both child health and survival. In cases of ARI, specialised medical intervention through inpatient care can play a critical role in saving lives. Meanwhile, vitamin A deficiencies among children carry high morbidity risk (with illnesses like anaemia) and the immunity of the affected children stands compromised. In moderate cases, it leads to an eye disorder called xerophthalmia, whereas severe cases can potentially result in blindness. Vitamin A supplementation is a well-established intervention to prevent vitamin A associated mortality among children.
To assess a state’s relative performance in preventive care, we use the percentage of children fully immunised and percentage of children administered with vitamin A. Meanwhile for assessing the degree of curative care, we employ two types of indicators in our study. First, the prevalence of a specific disease among children—namely diarrhoea, pneumonia and ARI. Second, the curative aspect is examined in terms of zinc and ORS administration (specifically for diarrhoea) and cases of diarrhoea and ARI taken to a health facility. Accordingly, these factors taken together, provide us with a reasonable understanding of the effectiveness of clinic-based health care and community-based health care.
Fourth, the level of nutritional intake is a significant indicator of mortality and morbidity risk among children. Undernutrition is associated with higher susceptibility to diseases such as anaemia, slow cognitive development, poor immunity and high risk for birth defects (Food Safety and Standards Authority of India, 2018). That being said, child malnutrition creates a self-perpetuating cycle wherein malnourished girls mature to become malnourished mothers giving birth to preterm/low birth weight children who face a higher risk of mortality. In the context of India, the incidence of undernutrition which takes the form of stunting, wasting and underweight is substantially high. NFHS 2015–2016 illustrates some worrying trends with stunting, wasting and underweight children at 38.4 per cent, 21 per cent and 35.8 per cent, respectively. Meanwhile, India is among the top three countries with the highest burden of wasting in children—leading to high morbidity and mortality rates (Global Nutrition Report, 2018).
Accordingly, instead of a blanket approach, each high-mortality risk state must be analysed in the light of its performance across these four interventions. In our analysis, we have used proxy indicators to reasonably assess performance. After investigating the performance, a specific and targeted intervention plan has been charted out for each of the five states.
Evidence-based State-specific Analysis
Table 1 shows the social indicators associated with the four major interventions that impact child and neonatal survival outcomes. Table 2 lists the five states with the highest child mortality rates in India. Using data from both tables, evidence-based state-specific analysis has been undertaken.
Social Indicators Associated with Child Mortality in Five High-mortality Risk States of India
U5MR and NMR Statistics for the Five High-mortality Risk States of India
Assam
Assam, the state with the highest U5MR of 73.12, has an NMR of 27.70. NMR is explicable in terms of the relatively low percentage of institutional births at 70.6 per cent vis-à-vis other high-mortality risk states and the national average of 79 per cent (Madhya Pradesh: 80.8% and Odisha: 85.3%). Meanwhile, the increase in institutional births at a public facility from 13 per cent to 60 per cent is commendable. With respect to feeding practices, Assam’s performance has been comparatively promising. The percentage of children breastfed during the first hour and exclusively breastfed for six months are at 64.4 per cent and 63.5 per cent, respectively.
Seemingly, a larger proportion of children in Assam die in the first 1–59 months than during the first week of life. A significant explanatory factor is the state’s poor performance when it comes to child immunisation. Assam has the lowest coverage of fully vaccinated children among the five states at 47.1 per cent (Madhya Pradesh: 53.6%, Odisha: 78.6%, UP: 51.1% and Meghalaya: 61.4%). The corresponding figures for the national average and best performer Puducherry are 62 per cent and 91 per cent, respectively. Furthermore, statistics for vitamin A supplementation are dismal—a whopping 10 per cent lower than the national average of 60 per cent. Add to that, the state’s relatively poor performance in the treatment of childhood diseases. Despite progress in reducing the burden of acute respiratory tract infections (ARTI) and diarrhoea, the role of public health care in ensuring treatment and supplement administration has been suboptimal. The statistics for ORS and zinc administration for children suffering from diarrhoea stand very low. On average, over 50 per cent of the children displaying symptoms of fever of ARI are not taken to a health facility. With regard to nutritional status, Assam shows some worrying trends as well. The proportion of wasted and severely wasted children has in fact increased since 2006, whereas the burden of stunting and underweight children is also very high. These factors together explain why Assam has the highest U5MR in India.
This calls for a greater focus on vaccination programmes and treatment of childhood infections through a more accessible and robust system of health infrastructure. The nutritional outcomes also need to be given due attention. A generic approach would have directed higher investments on reducing NMR based on overall national trends of high NMR. On the contrary, a state-specific approach, in this case, would focus a greater attention on children who are 1–59 months.
Madhya Pradesh
Madhya Pradesh has a very high incidence of NMR (35.99) accounting for over half of the state’s U5MR (67.07). To start with, institutional births have substantially increased from 26.2 per cent to 80.8 per cent since 2006 and become equivalent to the national average. Evidently, this means that NMR is likely to be linked to poor child-feeding practices and birth-related complications. For instance, only around a third of the total newborn are breastfed in the first one hour. Crucially, early initiation of breastfeeding in the first hour of birth is a significant determinant of NMR. Furthermore, the large proportion of preterm births (28.5%), intrapartum-related events (8.3%) and cases of sepsis (6.2%) certainly contribute significantly to the NMR. Child immunisation rates are also relatively low with nearly half of the children left unvaccinated with respect to basic vaccines. Only 55.2 per cent and 26.6 per cent of children suffering from diarrhoea are administered life-saving supplements of ORS and zinc, respectively. The fact that around 70 per cent of cases of diarrhoea and ARI are taken to a health facility is promising. Another area of serious concern is malnutrition. Madhya Pradesh ranks fifth in terms of state-wise burden of stunting at 42 per cent. Despite the burden of undernutrition, wasting indicators have visibly declined over the previous decade.A way forward, therefore, requires a three-pronged strategy. First, to encourage early initiation of breastfeeding and exclusive breastfeeding for newborns. Second, investments in quality of delivery care to reduce birth-related mortality risk due to factors such as sepsis, preterm births and intrapartum-related events. Third, focused interventions to improve the nutritional status, immunisation coverage and supplementation for children which are essential pre-requisites to reducing morbidity and mortality rates.
Odisha
For Odisha, a major proportion of under-5 mortality occurs in the first 28 days of life as indicated by its high NMR of 38.2 and U5MR of 64.13. On further analysis, we find that the percentage of institutional births is the highest in Odisha at 85.3 per cent exceeding the national average of 79 per cent with over three quarters taking place in the public health facility. Moreover, 78.6 per cent fully immunised and approximately 70 per cent children are breastfed in the first hour and 65.6 per cent exclusively until 6 months—much higher than national averages equivalent to 62 per cent and 42 per cent, respectively. The high percentage of preterm births (26.5%), intrapartum-related events (11.2%) and sepsis (8.8%) in newborns have significant explanatory power for the high NMR. The state’s performance, however, is quite modest with respect to the treatment of childhood diseases. The underlying factor can, therefore, be pinned to the high burden of undernutrition. Alarmingly, the statistics for wasting and severe wasting have shown an increase from 19.6 per cent to 20.4 per cent and 5.2 per cent to 6.4 per cent, respectively.
Based on these indicators, it is possible to see that the Odisha government needs to direct efforts towards improving nutritional outcomes for young children. Furthermore, it needs to focus on the quality of health infrastructure and delivery care so that complications associated with preterm births, intrapartum events and sepsis can be handled effectively.
Meghalaya
In Meghalaya, a considerable proportion of under-5 mortality (61.68) occurs in the post-neonatal period. NMR equivalent to 23 may potentially be attributed to the lowest percentage of institutional births among the five states at 51.4 per cent with only 39.5 per cent taking place in a public facility. While the proportion of breastfed children in the first one hour is promising at 60.6 per cent, only 35.8 per cent are exclusively breastfed thereafter. The statistics with respect to preterm birth (14.6%) and sepsis (4%) are relatively dismal. Meanwhile, child mortality may be linked to three major factors. First, inadequacies in the treatment of childhood diseases with a three-fold and two-fold increase in the prevalence of ARI and diarrhoea, respectively. However, the state’s performance in terms of curative care through supplementation and inpatient care has been more encouraging. Second, the relatively low immunisation coverage with nearly 40 per cent children going unvaccinated. These two indicators highlight a potential deficit in the public health care infrastructure. Third, Meghalaya suffers from an extremely high incidence of stunting at 43.8 per cent and overall undernutrition. This is what justifies the overall high burden of child mortality.
Understandably, micro-interventions to tackle malnutrition along with sustained efforts to encourage institutional births would allow the state to traverse a long way in tackling U5MR and NMR.
Uttar Pradesh (UP)
High burden of neonatal deaths (35.25) in UP may primarily be associated with the relatively low percentage of institutional births at 67.8 per cent vis-à-vis national average of 79 per cent and other high-mortality risk states (Madhya Pradesh: 80.8%, Odisha: 85.3% and Assam: 70.6%). Child-feeding practices are bleak at best with just a quarter of children breastfed in the first hour compared to 42 per cent national average. Breastfeeding practices and low immunisation are a function of maternal education. Not just that, statistics for preterm births (25.9%), intrapartum-related events (11.3%) and sepsis (8%) are worrying. These factors are leading contributors to NMR in north India and imply potential deficiencies in the quality of health care in UP. The percentage of mothers exclusively breastfeeding their children has in fact declined from 51.3 per cent to 41.6 per cent, whereas the national average has increased from 46 per cent to 55 per cent. At the same time, child immunisation is extremely low despite noticeable progress in the past decade. The state’s performance as regards the administration of supplements such as ORS (37.9%) and zinc (12.6%) has been below par.
Less than 40 per cent of children are provided vitamin A supplementation and as high as 4.4 per cent children suffer from pneumonia (Madhya Pradesh: 2.6%, Odisha: 3.1%, Assam: 2% and Meghalaya: 3.4%) explaining the state’s high child mortality risk. Meanwhile, nutritional outcomes for children are disquieting with an increase in the burden of wasting and severe wasting. After Bihar, UP has the second highest incidence of stunting in India at 46.3 per cent.
Based on our analysis, the focus should be on strengthening all four interventions in addition to investing in maternal education to promote breastfeeding.
Conclusion
In conclusion, a one-size-fits-all the Indian states approach may be successful in modestly bringing down the national average of U5MR. But crucially, much depends on understanding the state-specific child mortality causes and focused interventions to bring about a more substantial and noticeable reduction in U5MR in India. Based on our analysis, we have charted out focused key interventions based on state-specific evidence indicated with “X” for each state (Table 3). However, it must be emphasised that the probable causes of child mortality cannot be fully examined using the existing data and therefore merit further research.
State-specific Focused Interventions to Reduce U5MR
Declaration of Conflicting Interests
The author confirms that she is submitting her original work and has all the rights to the work. She is submitting the work for first publication to the Indian Journal of Human Development and it is not being considered for publication elsewhere and has not already been published elsewhere. She has obtained and can supply all necessary permissions for the reproduction of any copyright works not owned by SAGE. The author is extremely grateful for the paper authored by Liu et al. (2019) published in the Lancet using findings from which she was able to undertake this analysis.
Funding
The author received no financial support for the research, authorship and/or publication of this article.