What is the current state of Infant Mortality Rate in India?

Infant Mortality Rate (IMR) has been a serious issue of discussion in the past years. Although India’s IMR has fallen as compared to the previous years, the rate still remains high in some states. Here is what PV Rao, Director, Pennar Industries opines on the same, stressing how it needs to be reduced further.

Between 2019 and 2021, 35 children below the age of one died for every 1,000 children born, 15 per cent fewer than the 41 infant deaths per 1,000 live births in 2015-16, shows the latest health data from India’s national survey. The average neonatal mortality rate (NMR), which is deaths in the first 28 days of life for every 1,000 births, in India has fallen from nearly 30 deaths in 2015-16 to 25 in 2019-21. If we talk about the states, the greatest improvement, based on the percentage change, was seen in Sikkim, while the highest increase was in Tripura.

Infant mortality rate (IMR) can not be solely attributed to medical factors which include, healthcare services, health infrastructure, antenatal/pregnancy care, maternal health, postnatal care, immunizations, and the overall preventive health system, but also to deeper social problems, such as malnutrition and sanitation.

Although the average IMR in India, i.e. infant deaths before one year for every 1,000 live births, has fallen overall but unfortunately has increased in some states. The states with the lowest neonatal, infant, and child mortality rates include Sikkim, Puducherry, Kerala, and Goa.

In India, an estimated 26 million children are born every year. As per Census 2011, the share of children (0-6 years) accounts for 13% of the total population in the Country. The child health programme under the National Health Mission (NHM) comprehensively integrates interventions that improve child survival and addresses factors contributing to infant and under-five mortality. It is now well recognized that child survival cannot be addressed in isolation as it is intricately linked to the health of the mother, which is further determined by her health and development as an adolescent.

Therefore, the concept of Continuum of Care, which emphasizes care during critical life stages in order to improve child survival, is being followed under the national programme. Another dimension of this approach is to ensure that critical services are made available at home, through community outreach and through health facilities at various levels (primary, first referral units, tertiary health care facilities).

The government of India besides the NHM has introduced various new and ongoing schemes with an aim to lower the maternal and infant mortality rates in the country. These cover the entire gamut of essential services to ensure a healthier new generation of Indians. However, it is important that there is a continuum of care maintained, and the focus especially in low-performing regions is never lost, so that the results of these programmes are repaid.

With the birth of 25 million children each year, India accounts for nearly one-fifth of the world’s annual childbirths. Every minute one of those babies dies. Nearly 46 per cent of all maternal deaths and 40 per cent of neonatal deaths happen during labour or the first 24 hours after birth. Pre-maturity (35 per cent), neonatal infections (33 per cent), birth asphyxia (20 per cent) and congenital malformations (9 per cent) are among the major causes of newborn deaths.

Death during and after delivery are largely preventable by enabling access to skilled birth attendants and emergency obstetric care. In the post-new-born period, survival rates also rise sharply with early and exclusive breastfeeding and immunization against measles and other vaccine-preventable diseases. Nearly 3.5 million babies in India are born too early, 1.7 million babies are born with birth defects, and one million newborns are discharged each year from Special New-born Care Units (SNCUs). These newborns remain at high risk of death, stunting, and developmental delay.

India has made progress in the reduction of newborn mortality with it’s share of the global newborn mortality burden coming down from one-third of newborn deaths in 1990 to below a quarter of total newborn deaths today. There are nearly one million fewer newborn deaths and ten thousand fewer maternal deaths each month in India in 2017 as compared to in 2000. This is a result of more and more women delivering in health facilities. Just over a decade ago, six out of ten women delivered in their homes, without the support of a skilled birth attendant, putting both themselves and their new-born at risk. Today, this number has reduced threefold with eight out of ten women delivering in a health facility.

The quality of service delivery, though, has not kept pace with the increase in coverage. Early initiation of breastfeeding among just 42 per cent, high rates of stillbirths (5 per 1000 births) and many deaths due to asphyxia in SNCUs are consequences of low quality of healthcare delivery across the Country. The increase in coverage has also been inequitable with 21 per cent (NFHS 4) of women – the majority of who are tribal and from the poorest households, often in hard-to-access areas, still delivering in their homes.

The first 28 days of a newborn’s life is a critical window of opportunity for the prevention and management of maternal and newborn complications, which can otherwise prove fatal. Although India has shown significant progress in the reduction of child mortality, now the focus needs to be on reaching the most marginalized, with a special focus on the girl child. While the rapid scale-up of SNCUs in the country has accelerated the reduction of neonatal mortality, it has also brought to light socio-cultural barriers in care seeking even for newborn girls.

In many cases, newborn girls are denied their right to proper care, especially in the states of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. Despite the availability of free service, less than half (41 per cent) of admissions to the SNCUs are of girls. In 2019, 190,000 fewer newborn girls were admitted to over 849 SNCUs across India. Though evidence reveals newborn girls as biologically stronger, they remain socially vulnerable due to widespread male child preference, reflected in the higher infant and less than five mortality of girl children. India is the only large country in the world where more girl babies die than boy babies. The gender differential in under 5 mortality is 3 percent.

To reduce infant mortality rates across the world, health practitioners, governments, and non-governmental organizations have worked to create institutions, programs and policies to generate better health outcomes. Current efforts focus on the development of human resources, strengthening health information systems, health services delivery, etc. Improvements in such areas aim to increase regional health systems and aid in efforts to reduce mortality rates.

Reductions in infant mortality are possible at any stage of a country's development. Rate reductions are evidence that a country is advancing in human knowledge, social institutions and physical capital. Governments can reduce the mortality rates by addressing the combined need for education (such as universal primary education), nutrition, and access to basic maternal and infant health services. A policy focus has the potential to aid those most at risk for infant and childhood mortality and allows rural, poor, and migrant populations.

Reducing the chances of babies being born at low birth weights and contracting pneumonia can be accomplished by improving air quality. Improving hygiene can prevent infant mortality. Home-based technology to chlorinate, filter, and solar disinfection for organic water pollution could reduce cases of diarrhea in children by up to 48%. Improvements in food supplies and sanitation have been shown to work in the United States' most vulnerable populations, one being African Americans. Overall, women's health status needs to remain high.

Promoting behavioural changes, such as hand washing with soap, can significantly reduce the rate of infant mortality from respiratory and diarrheal diseases. According to UNICEF, hand washing with soap before eating and after using the toilet can save more lives of children by cutting deaths from diarrhea and acute respiratory infections.

Focusing on preventing preterm and low birth weight deliveries throughout all populations can help to eliminate cases of infant mortality and decrease health care disparities within communities. Increasing human resources such as physicians, nurses, and other health professionals will increase the number of skilled attendants and the number of people able to give out immunized against diseases such as measles. Increasing the number of skilled professionals is negatively correlated with maternal, infant, and childhood mortality. With the addition of one physician per 10,000 people, there is a potential for 7.08 fewer infant deaths per 10,000.

When a woman becomes pregnant, certain steps can help to reduce the chance of complications during the pregnancy. Attending regular prenatal care check-ups will help improve the baby's chances of being delivered in safer conditions and surviving. Additionally, taking supplementation, including folic acid, can help reduce the chances of birth defects, a leading cause of infant mortality.

Abstinence from alcohol can also decrease the chances of harm to the foetus during pregnancy. Drinking any amount of alcohol during pregnancy may lead to Fetal alcohol spectrum disorders (FASDs) or alcohol-related birth defects. Tobacco use during pregnancy has also been shown to significantly increase the risk of a preterm or low birth weight birth, both of which are leading causes of infant mortality. Pregnant women should consult with their doctors to best manage any existing health conditions that they have to avoid complications of both their health as well as the fetus. Obese women are at an increased risk of developing complications during pregnancy, including gestational diabetes or pre-eclampsia. Additionally, they are more likely to experience a pre-term birth or have a child with birth defects.

Appropriate nutrition for newborns and infants can help keep them healthy and avoid health complications during early childhood. The American Academy of Paediatrics recommends exclusively breastfeeding infants for the first 6 months of life, followed by a combination of breastfeeding and other sources of food through the next 6 months of life, up to 1 year of age. Infants under 6 months of age who are exclusively breastfed have a lower risk of mortality compared to infants who receive a combination of breast milk and other food, as well as no breast milk at all. For this reason, breastfeeding is favored over formula feeding by healthcare professionals. It should be ensured that vaccinations are given at particular age ranges depending on the vaccination and are required to be done in a series of 1 to 3 doses over time depending on the vaccination.

It has been well documented that increased education among mothers, communities and local health workers results in better family planning, improvement in children's health, and lower rates of child deaths. High-risk areas, such as Sub-Saharan Africa, have demonstrated that an increase in women's education attainment leads to a reduction in infant mortality by about 35%. Similarly, coordinated efforts to train community health workers in diagnosis, treatment, malnutrition prevention, reporting and referral services have reduced infant mortality in children under 5 by as much as 38%. Public health campaigns centered around the "First 1,000 Days" of conception have been successful in providing cost-effective supplemental nutrition programs, as well as assisting young mothers in sanitation, hygiene and breastfeeding promotion. Increased intake of nutrients and better sanitation habits have a positive impact on health, especially in developing children. Educational attainment and public health campaigns provide the knowledge and means to practice better habits and lead to better outcomes against infant mortality rates.

Moreover, awareness about health services, education and economic opportunities is a must. For say, a reduction in GDP may result in a higher infant mortality rate, because if the household income is affected, the amount being spent on food and healthcare services will be reduced, hence, affecting the quality of life. On the contrary, a higher household income lets people have better access to nutritious food and better healthcare services, hence, reducing the incidence of malnourishment and infant mortality.

There is a need to enhance public health spending to a minimum of 5 per cent of the GDP in India. According to the National Health Accounts (NHA) estimate, the Government Health Expenditure (GHE) per person per year is only Rs 1,108 which comes to Rs 3 per day. This is in contrast to the Out-of-Pocket Expenditure (OPE) of Rs 2,394, which comes out to be 63 per cent of the total health expenditure. WHO's health financing profile for 2017 shows 67.78% of total expenditure on health in India was paid out of pocket, while the world average is just 18.2%. Given the magnitude of the challenge in reducing the infant mortality rate, huge investments will be needed in healthcare infrastructure and planning.

(Disclaimer: The opinions expressed in this article are that of the writer. The facts and opinions expressed here do not reflect the views of ETV Bharat.)