India accounts for the largest number of deaths of infants primarily because it has failed to provide them and their mothers access to critical health care

India loses 4,200 children under the age of five every day. This figure is certainly unacceptable for any emerging country. The collective ache of losing so many newborns is worsened by the realisation that many of these deaths are preventable.

The country accounts for nearly a fifth of the world’s child deaths. In terms of numbers, it is the highest in the world — nearly 16 lakh every year. Of these, more than half die in the first month of life. Officials believe that the reason for this is the absence of steps to propagate basic healthy practices relating to breast feeding and immunisation. Also the large reproductive population of 2.6 crore remains bereft of care during the critical phases of pregnancy and post-delivery.

Added to this is the prevalence of child marriages, anaemia among young women and a lack of focus on adolescent sanitation, all of which impact child death rates.

Millennium goals

While India in recent years has made appreciable achievements in bringing down deaths per 1,000 live births (infant mortality), deaths within 28 days of birth (neonatal) and under-five mortality are the areas which can certainly do with some more attention.

In recent years, the Under Five Mortality Rate (U5MR) has declined sharply. In fact in the last two decades, it has fallen faster than the global average. While the global decline in child mortality was 35 per cent, India registered a healthier fall of 48.7 per cent between 1990 and 2010. In terms of numbers, 2010 saw U5MR decline by nearly half to 59 per 1,000 live births.

Worryingly, more than half, 33, were neonatal deaths or infants who died within 28 days of birth. In other words, the neonatal mortality rate has remained stagnant and has begun constituting an even larger proportion of the total number of child deaths. Part of the reason is that in the last two decades, efforts to tackle the problem were not as well funded as HIV and AIDS prevention. Now with the health-care sector’s and diminishing donor enthusiasm for HIV and AIDS prevention, mother and child care is coming back into prominence. The urgency to show results is also necessitated because India needs to meet the Millennium Development Goals (MDGs) by 2015 which still appear a long distance away.

This should be welcome news for those battling infant deaths in the country. But given the vastness of the country, achievements in reducing child mortality are not uniform. While some States have done extremely well, there are others that have fallen behind.

State variations

While Kerala is the leader in reducing infant mortality by a wide margin, Tamil Nadu, Maharashtra, Karnataka and Andhra Pradesh have bucked the national average decline of 7.25 per cent between 2008 and 2010. Haryana and Bihar, with a decline rate of just over seven per cent, manage to just about touch the national average.

Among the larger States that fare badly are Jharkhand and Madhya Pradesh (M.P.), with Assam for company. West Bengal, Punjab, Jammu & Kashmir, Uttar Pradesh (U.P.), Rajasthan and Chhattisgarh are just below the national average.

Just as there are variations among States in reducing child deaths, there are wide disparities within States as well. For example in Assam, the U5MR in Kokrajhar is double that of Dhemaji district. In Chhattisgarh, U5MR in Durg is half that of the tribal dominated Surguja. It’s the same story in Patna and Sitamarhi in Bihar. While 53 children per 1,000 live births die in Patna, the figure is 106 for Sitamarhi. These disparities are even starker in Rajasthan and Jharkhand. Then there are stand-alone districts in many States where child deaths are rampant such as Kandhamal (145) in Odisha, Shrawasti (142) in U.P. and Panna (140) in M.P.

These figures are important in the discourse on approaches to reducing child deaths. Both the Centre and the States will have to address these disparities — regional, State and inter-State — if they are committed to achieving the 12th Plan goal of U5MR of 33. This target in itself requires a tremendous effort because India has aimed higher than the MDGs of 38 deaths per 1,000 live births. If the current rate of decline continues, Odisha is probably the only State that will not achieve the 12th Plan target (2017).

Targeting adolescents

To sustain this high rate of annual decline, it cannot be business as usual, as an officer of the Ministry of Health and Family Welfare put it. Each State will have to identify a specific goal to meet the target. These could be enhanced coverage of health and nutrition, water, sanitation and hygiene which can prevent pneumonia and diarrhoea.

It is also equally important to forge interlinkages and package different interventions at various levels like linking child survival to reproductive health, family planning, and maternal health.

According to national surveys, adolescents (15-19 years) contribute about a sixth of total fertility in the country. With the substantial unmet need of contraception — nearly a quarter of married adolescents (15–19 years) — and low condom use by them in general, girls in this age band are at a high risk of contracting sexually transmitted infections, HIV and unintended and unplanned pregnancies. All these impact the child mortality rate.

In addition to focusing attention to addressing disparities within States and among regions, there is an urgent need to bring health and child services under universal health coverage with a focus on special requirements of vulnerable and marginalised groups.

Inexpensive lifesaving treatments remain inaccessible to a vast majority of Indian children, and especially those in the poorest groups within the country. All these challenges can only be met by State intervention.

Therefore, universalisation of maternal health and child services, which includes special newborn care, skilled delivery, immunisation and management of diarrhoea, seems to be the only answer if India is to achieve the high goals of reducing child deaths it has set for itself.

aarti.dhar@thehindu.co.in

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