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Improving Infant Mortality Rate (IMR) in India is a challenge!

The infant mortality rate (IMR) is defined as the risk for a live-born child to die before its first birthday. It is known to be one of the most sensitive and commonly used indicators of social and economic development. These included proximate factors (like nonmedical factors and medical care during the antenatal period, care at birth, and preventive and curative care in the postnatal period); maternal factors (like age, parity, and birth intervals); and household- and community-level factors (like water, sanitation, and housing). These studies concluded that a substantial decline in infant mortality rate is possible without significant improvement in economic development.

They propose increased access to a minimum package of essential services that would significantly reduce high infant mortality rates: reproductive health services; prenatal care; improved breastfeeding practices; immunization; home-based treatment of diarrhoea; and timely introduction of supplementary foods.

Mortality is very responsive to social, economic, and psychological factors. Historically, mortality has often been used as a barometer of welfare. Statistical studies in the 19th and 20th century showed concern for socio-economic differences in infant and crude mortality. Level of death rate; more importantly, infant mortality rate reflects a society’s status of wellbeing.  Such aspects can be taken as indicators of quality of life. It is because, more than any other age group of a population, an infant’s survival depends on the socio-economic conditions of their environment.

About IMR

Several indicators of infant mortality are used to measure levels and trends; it includes the neonatal and post neonatal mortality rates, the infant mortality rate, and the U-5 mortality rate. Infant Mortality Rate is the number of deaths of children less than one year of age in a given year per 1000 live births in that year. The present Infant mortality rate in India stands at 40 per 1000.

The concerted global and national efforts have been made to improve infant mortality, especially in the post neonatal phase, less attention has been given to determinants of prenatal and neonatal mortality. Neonatal mortality has been gradually increased as a percentage of total child mortality because of the faster decline in the post neonatal mortality rate.

Maternal Determinants of Infant Mortality Rate (IMR)

The demographic characteristics of both mother and child have been found to play an important role in children’s survival probability. The maternal determinants like age at effective marriage, mother’s age at childbirth, birth order of the child, birth interval, and child’s weight/size at birth and sex of the child based on three rounds of NFHS levels and trends of infant and child mortality and its components.

Age at Effective Marriage

Age at effective marriage impacts childbearing because women who marry early have an average a longer period of exposure to pregnancy and a greater number of lifetime births. As per legal provisions, a girl in India can’t marry before the age of 18 and a boy before 21, but still, a large number of girls, particularly in rural areas, married before the age of 18 years.

Mother’s Age at Childbirth

The age of the mother at a time of childbirth has an important bearing on the child’s survival. Women who give birth or become pregnant before they attain full physical growth tend to be at greater risk of complications during pregnancy or childbirth. Children born to adolescent mothers are at higher risk. Infant and under-5 mortality rates are highest among mothers under 20 years of age. In contrast, children born to mothers aged 35 and above are likely to have an increased risk of mortality because of a higher risk of pregnancy complications. Thus, a U-shaped relationship is observed between the mother’s age at childbirth and U-5 mortality.

Birth Order

The effect of birth order affects one’s risk of survival mostly during infancy. Analyzing mortality by birth order reveals that the neonatal and under-five mortality was higher among the first-order births. Reasons behind it may be firstborn children are born to a young mother who is biologically unprepared to bear and bring up a child. First-order births are born to mothers with limited knowledge and experiences. Children of high birth orders have the highest risk of dying in the first five years of age. It may be attributed to mothers who are physically more worn out and older, affected by competition from older siblings in terms of food and other family resources, cared for by someone other than the mother, considered superfluous, families of lower education and income.

Birth Interval

The interval between two births shows a strong effect on infant and child mortality rates. It has two-way effects on infant and child mortality. The shortest birth interval,  less than two years, carries the greatest risk of mortality, and the risk of mortality is generally observed to decline with each increase in the birth interval. Mothers whose births are spaced too closely may not recover their health before becoming pregnant, which can hinder the fetus’s growth and development. On the other hand, a child born too soon after the first may divert time, attention, and resources of the caretakers from the first child, affecting the care that the child receives. This, in turn, may diminish the prospects of this child surviving childhood.

High-Risk Births

The mother’s age at birth of the child, birth order of the child, and the interval between births have a strong influence on infant and child mortality. The parents can avoid high-risk births by controlling these proximate determinants. Based on the National Family Health Survey, all births during the five years preceding the survey have been categorized according to the proportionate risk associated with the child’s survival. A birth is classified as high risk if it has one or more of the following characters: (i) mother’s age is less than 18 years, (ii) mother’s age is more than 34 years, (iii) previous birth interval is less than 2 years, and (iv) birth order is more than three.

Child Determinants of Infant Mortality Rate (IMR)

Changes in levels and differentials in neonatal, post neonatal, infant, child, and under-five mortality are other factors to know infant mortality rate. It is observed that neonatal mortality rates for males are higher than the female, which can be attributed to girls’ biological advantage. The parental care of the child affects the mortality beyond the neonatal period. A variety of cultural and traditional factors may be responsible for the higher mortality among girls beyond the neonatal period. Traditionally preference is given to sons over daughters in terms of food, prevention of diseases, and treatment of illness, resulting in higher post neonatal and child mortality among girls.

Child’s Size at Birth

Birth weight is another important indicator of the chances of a child’s survival and the risk of childhood diseases. In India, the weight of babies was not being measured at birth in most cases. However, with an increase in institutional deliveries, the situation has improved substantially. In the absence of birth weight, the size of the child at birth reported by the mother is a useful proxy for birth weight.

Nutritional Status of Children

Like in other developing countries, children in India are vulnerable to malnutrition because of low dietary intakes, infectious diseases, lack of appropriate care. During National Family Health Surveys, all children under five years of age were weighed and measured to assess nutritional status. Evaluation of nutritional status is based on the rationale that there is a statistically predictable distribution of children of a given age with respect to height and weight in a well-nourished population. The use of the standard reference population as a point of comparison facilitates the examination of differences in the anthropometric status of subgroups in a population and changes in nutritional status over time.

Prevention of Anaemia in Children

Prevalence of anemia is another indicator to assess the nutritional status of children. Haemoglobin is necessary for transportation of oxygen from the lungs to other tissues and organs of the body. Anemia in children is a serious concern because it can result in impaired cognitive performance, behavioral and motor development, coordination, language development, scholastic achievement, and increased morbidity from infectious diseases. Anemia increases with the birth order of the child, but the relationship is not strong. In rural areas, anemia was considerably higher than in urban areas. It was higher for children of women with no education, for scheduled tribes, and children in the households of lower wealth quintiles.

Prevention of Diarrhoea in Children

Diarrhoea is another single most common cause of death among children under age five following acute respiratory infection. Deaths from acute diarrhoea are most often caused by dehydration due to loss of water and electrolytes. Dehydration related deaths can be prevented by prompt administration of rehydration solutions. India’s government has launched the Oral Rehydration Therapy Programme as one of its priority activities for child survival. The important goal of the program is to increase awareness among mothers and communities about diarrhoea’s causes and treatment.

Iron Supplementation

Iodine is an important micronutrient. A lack of iodine in a diet can lead to Iodine Deficiency Disorders (IDD), which can cause speech and hearing impairments and depleted levels of energy in children. Iodine deficiency is a single most important and preventable cause of mental retardation.

How can the Infant Mortality Rate be monitored?

The following factors can help in improving the infant mortality rate, as mentioned below:

improving the infant mortality rate

Mother’s Education

A mother’s education is important because it facilitates her integration into a society impacted by traditional customs, exposes her to better nutrition, contraceptives to space births, and knowledge about childhood illnesses and treatment. Education heightens a mother’s ability to use government and private health care resources, and it may increase the autonomy necessary to advocate for her child in the household and the outside world. Mother’s education is often just a good indicator of other socio-economic factors that affect under-five mortality directly. Hindrise has taken an initiative to provide awareness among the new mothers or the women who are in their last stage of pregnancy.

Post Natal Care

Postnatal Care is important, as suggested by the Reproductive and Child Health Programme. It recommends three postnatal visits to provide health care to the mother and the infant during the first few weeks after delivery. A large proportion of maternal & neonatal deaths occur during the 48 hours after delivery. Therefore, it is important to receive health checkups soon after delivery, particularly for non-institutional births. Our volunteers at Hindrise Foundation have tied up with the care centre to provide good care to newly born.

Prevention and Need for Vaccination

The potential for vaccination to reduce infant mortality has already been demonstrated time and time again. Polio is the clearest example of this, its elimination in India sparing countless children from disability, or, in its worst case, fatality. Vaccination in India is run on a state by state approach; some states are taking it into their hands to ensure children are vaccinated. It was observed that a higher percentage of children in urban areas received vaccination and vitamin A supplementation than in rural areas. Though the immunization coverage increased in subsequent surveys still, more efforts are required to cover all children. Hindrise has also started a campaign on a monthly basis to provide care to mother and children with proper vaccination. This camp is generally organised with the tie of rural government hospitals with time to time. 

Conclusion

Child health policies should be reviewed to sustain the achievements that have already been made, enhance quality and efficiency, and address specific neonatal care gaps. Existing child health programs and several strategies, including initiatives for the eradication of vaccine-preventable childhood diseases and specific health and nutrition interventions, need to be examined in the context of socio-economic and State-specific approaches. It is revealed that the economic status of the household is an important factor in the infant and child mortality rates. To reduce infant and child mortality, not only the health services, water, and sanitation facilities be improved by proper implementation of the programs, but also the poverty elimination programs be implemented effectively.

Factors contributing to the slow decline include the lower social, cultural, and health status of women in India. Hence improving female education and nutrition, and increasing the use of health services during pregnancy and delivery, would lower infant mortality. The level of infant morbidity and mortality is higher for girls aged one month to 5 years than for boys. Eliminating gender differences in mortality rates will significantly reduce infant mortality overall. An initiative by the Government of India ‘Beti Bachao Beti Padhao‘ aims to create awareness among the masses to eliminate discrimination against girl child at all stages.