Authored by Dr Saheb Sahu, FAAP, MPH.
Definition of Terms
Neonatal Mortality Rate – Number of deaths of children under 28 days of life per 1,000 live births.
Infant Mortality Rate – Number of deaths of children under one year of age per 1,000 live births.
Under-Five Mortality Rate – Refers to death of children under the age of five per 1,000 live births.
According to the World Health Organization (WHO), 5.6 million children under the age of five years died worldwide, in 2016. This translates into 15,000 children deaths per day. More than half of these deaths are due to conditions that could be prevented or treated with access to simple affordable interventions. The leading causes of death of children under five include:
- Pneumonia
- Preterm (premature) birth
- Diarrhea
- Malaria
- Malnutrition
Pneumonia, diarrhea and malaria together are the cause of 3 out of every 10 child deaths before the age of five.
A child’s risk of dying is highest in the first 28 days of life (the neonatal period). Globally 2.6 million children died in the first month of life in 2016, accounting for 46% of under-five deaths. Improving the quality of care before birth (antenatal care), care at the time of birth and care after birth (post natal care) are essential to prevent these deaths.
Malnourished children have a much higher risk of death from common childhood illness such as diarrhea, pneumonia and malaria. Nutrition related factors contribute to about 45% of under-five deaths in children (who.in/media Centre/factsheet).
India and Odisha Child Mortality
1-Neonatal mortality (per 1000 live births)
2011 2013
India 31 28
Kerala 7 6
Jharkhand 29 26
Odisha 40 37
2- Infant Mortality (IMR) (per 1000 live births)
India 53 40
Kerala 12 12
Jharkhand 46 37
Odisha 69 51
3- Under 5 Mortality (U-5MR) (per 1000 live births) for 2013
India 52 Male – 49, Female – 56, Rural – 58
Kerala 13 Male – 12, Female – 14, Rural – 13
Jharkhand 50 Male – 47, Female – 54, Rural – 53
Odisha 68 Male – 67, Female – 70, Rural – 72s
*niti.gov.in
According to UNICEF, there has been a consistent decline in Infant Mortality Rate (IMR) and Under –Five Mortality Rate (U-5MR) in India. The rate of decline in current decade is higher than the previous decade. The IMR and the U5MR rates have also declined in Odisha in recent years, but the rates are still very high. If we take the example of IMR, the 2008 rate for Odisha was 69 per 1000 live births (India was 53) and 2013 rate was 51. It is a decrease of 20% in five years, not bad but not good either. Jharkhand is a poor state like Odisha. It has high tribal population, but its IMR in 2013, was 37 compare to 51 for Odisha. The IMR for the state of Kerala with similar population as Odisha was 12. Odisha still has a long way to go.
What Determines Child Survival in India?
Maternal and Demographic Factors:
- Education: Children born to mothers with at least 8 years of schooling have more chances to survive.
- Age of the mother: children born to adolescent mothers are at higher risk of dying. This is true even in developed countries.
- Spacing between childbirths: Children born less than two years after the first delivery are less likely to survive.
- Maternal Nutrition Status: Mortality among children born to malnourished, anemic, as well as obese mothers is higher.
- Attendance at childbirth: Deliveries attended by health professional have a lower risk of death for both the mother and her baby.
Social Economic Factors:
- Social Group: Children born to SC and ST families have higher risk of dying than other groups.
- Economic Status: Mortality among poor people as measured by standard of living index (SLI) is higher.
- Environmental Factors: Child mortality rates are higher among children living in households without safe-drinking water or access to toilets.
What Government of Odisha should do to reduce the high child mortality rate?
“Infant Mortality Rate continues to be high in Orissa. It is recognized that about 60% of infant deaths occur during neonatal period (first four weeks of life). Most of these deaths are due to pre-maturity, low birth weight, respiratory infections, diarrhea and malnutrition. It is also acknowledged that infant mortality is higher in lower socioeconomic groups residing in backward tribal districts of Orissa. Notwithstanding the fact that several strategic interventions are being implemented to reduce MMR (Maternal Mortality Rate) and IMR, the decline has been marginal.”
Department of Health & Family Welfare, Government of Odisha (health.odisha.gov.in/IMR-Mission) Nov. 6th 2017
It is at least hopeful that Odisha government is acknowledging that all its programs to reduce Infant and maternal mortality rates are not working that well. The government has diagnosed the problems but the treatment it is providing is not working. What the government of Odisha can and should do to correct the situation?
- Educate all girls up to 10th Educated girls marry later, have fewer children and space them better. Multiple studies from around the world have shown that, overall mortality of their children is lower.
- Provide Water (safe drinking water), Sanitation (toilets) and Hygiene (Wash) at schools, colleges and household level.
- Provide adequate nutrition (calories, protein, vitamins (folic acid), minerals (iron) to all school going boys and girls and pregnant mothers.
- Child mortality rate in rural areas and among the tribal people is unacceptably high. More healthcare resources should be directed towards the rural and tribal areas.
- Direct cash grant to the poor- Poverty, illiteracy, lack of awareness of various welfare programs and high child mortality rates are interconnected. The very poor do not have the knowledge or the means to take advantage of many government programs with wonderful names like Janani Surakhya Yojana (JSY), NRHM (National Rural Health Mission), to reduce the death rate among their children. The government of Odisha should provide a direct cash grant of fifteen to twenty thousand rupees per poor household per year. The money should be directly deposited in their bank account or distributed via debit card. It is important to eliminate the middle men. It will cost the government 8%to 10% of the state’s budget (2017 budget) and will reduce the high poverty rate of Odisha below the national average in 4-5 years. With money in hand the poor will be able to buy more food, send their children to school (reduce child labor) and keep them at school.
This direct money grant program is not as radical as it seems. There are multiple studies to show that the poor use their money more wisely than most people think. They know their priorities better than the government officials. Conditional cash grant programs have been quite successful in Brazil, Mexico, Turkey and many more countries around the world (bolsafamilia.org).The government of Odisha, should be the first state in India to try this direct cash grant program. The downside risk is very low but the upside potential is quite high. Odisha will be no longer one of poorest state in India in 3-4 years.
Conclusion
Illiteracy, poverty, malnutrition and high child mortality rate are interrelated. The child mortality rate of Odisha is unacceptably high. It is even higher than that of Jharkhand which has a high tribal population like Odisha. There is also a large discrepancy in child mortality rate among the 30 districts. The department of Health & Family Welfare admits on its own web site that the rate of decline in recent years has been marginal. There are resources available from UNICEF, USAID, Bill &Melinda Gates Foundation, World Bank, Government of U.K. and Norway and the central government at Delhi to reduce the child death rate in Odisha. But no amount of external aid will help unless the government of Odisha executes its own programs to reduce its high poverty rate and high child mortality rate.The government of Odisha should significantly increase its health budget and spend most of the money in preventive care (water, sanitation, hygiene, nutrition,and health education). Acute care should be covered by health insurance for all Oriyas as has been done in Andhra Pradesh and Chhattisgarh.
Sources:
- Niti Aayog. Niti.gov.in/content/under-5-mortality-rate
- Niti.gov.in/content/infant-mortality-rate
- Unicef-India.www. Unicef.in/fact sheet
- Dept of Health & Family Welfare, Government of Odisha, health.odisha.gov.in/imr-mission
Dr. Saheb Sahu is a pediatrician and neonatal specialist. He was the managing director of Kalinga Hospital, Bhubaneswar, for 4 years.