Infant death in India

JAN 1

Mains   > Social justice   >   Health   >   Health

WHY IN NEWS?

During December 2019 and in the 1st week of January, 104 infants died in government run J.K Lon Maternal and Child Hospital in Kota, Rajasthan. State run civil hospitals in Rajkot and Ahmedabad witnessed 219 deaths of children in the month of December 2019.

INFANT MORTALITY IN INDIA

  • CURRENT STATUS
    • According to the Sample Registration System data released by the office of the Census and Registrar General of India, the overall IMR for India for 2017 is 33 per 1,000 live births, just a point lower than 34 recorded in 2016.
    • Among the bigger states, Kerala (10), Tamil Nadu (16) and Maharashtra (19) are at the top three positions while Madhya Pradesh (47), Assam (44) and Uttar Pradesh (41) are at the bottom three positions.
  • WHY THIS IS A CAUSE OF CONCERN:
    • Every day, India witnesses the death of an estimated 2350 babies aged less than one year.
    • The problem remains severe in the northern states of Madhya Pradesh, Uttar Pradesh, Rajasthan, Assam and Bihar.
    • As such India has the highest child deaths in the world and our IMR fares worse than Nepal (28), Bangladesh (27), Bhutan (26), Sri Lanka (8) and China (8).
  • PERFORMANCE OF STATES - “HEALTHY STATES PROGRESSIVE INDIA” REPORT
    • The report released by NITI Aayog aims to promote a co-operative and competitive spirit amongst the States and UTs to rapidly bring about transformative action in achieving the desired health outcomes
    • It is based on 23 indicators categorized into Health Outcomes (Neonatal Mortality rate, Total Fertility Rate, Under 5 Mortality Rate, etc.), Governance and Information and Key inputs and processes.
    • It is found that states which lag behind in this report also has a greater number of infant deaths. For eg: Madhya Pradesh, Uttar Pradesh, Assam etc.

CAUSES / CHALLENGES

  • Institutional
    • Inadequate public health expenditure - India’s public expenditure of health continues to remain one of the lowest globally, at 1.28% of GDP (2017-18) according to National Health Profile 2019.
    • Lack of proper infrastructure
      • A limited number of beds creating conditions of overcrowding, where newborns are placed closer together and at more risk for potential infection to spread.
      • The World Health Statistics, say that India ranks among the lowest globally in the number of hospital beds to population with 0.9 beds per 1000 population – far below the global average of 2.9 beds.
      •  In many government-run hospitals, neonatal intensive care units have a dearth of trained nursing staff.
    • Shortage of primary health centers with adequate staff
      • Most of the deaths are from infections such as pneumonia, which can be treated at the primary level, the preventive and primary healthcare system in the country is broken.
      • PHCs require 25,650 doctors across India to tend to a minimum of 40 patients per doctor per day for outpatient care, as per Indian Public Health Standards (IPHS)
      • Of the 156,231 sub-centres in India, 78,569 were without male health workers, 6,371 without auxiliary nurse midwives and 4,263 without either, according to Rural Health Statistics, 2017 
    • Shortage of skilled medical workforce
      • There is only one government doctor for every 10,189 people in India, whereas the WHO recommendation is 1:1000.
      • India has a shortage of an estimated 6 lakh doctors and 2 million nurses.
    • High out-of-pocket expenditure
      • In India, 65% of health expenditure is out-of-pocket, and such expenditures push some 57 million people into poverty each year.
    • According to WHO, babies who die within the first 28 days of birth often suffer from conditions and diseases associated with a lack of quality care at birth or in the days immediately after.
  • Nutritional
    • Malnutrition was the predominant risk factor for death among children under five years of age in every Indian state in 2017, accounting for 68.2% of total deaths.
    • Anemia – more than half of Indian women are anemic.
    • Pneumonia, which causes 12.9% of child deaths, and diarrhea, responsible for 8.9% of child deaths, are the main preventable causes of death among children
    • The biggest problem in rural and tribal areas is low birth weight of children and mother’s poor nutrition.
      • One in five children (21.4%) was born with low birth weight (under 2.5 kg), and only half of all children were exclusively breastfed (53.3%) for six months, which improves child health and cognition, according to a report by the Indian Council of Medical Research
    • Vaccination coverage
      • According to Health Ministry, the vaccination cover in India after several rounds of Intensified Mission Indradhanush now stands at 87%. This means over 33 lakh children continue to miss out on some or all vaccinations every year
  • Social/ Educational
    • Lack of education in the mother
      • According to UNICEF, children born to mothers with at least 8 years of schooling have 32% lesser chances of dying in neonatal period and 52% lesser chances in the post-neonatal period, as compared to illiterate mothers.
      • States with the highest IMR- Madhya Pradesh, Assam, Uttar Pradesh, Rajasthan- also have fewer women with more than 10 years of education and a higher proportion of child marriages.
    • Age of mother at the time of birth
      • Infant and Under 5 mortality are highest among mothers under age 20.
    • Inadequate spacing between births, whether the child is born at home or in a facility
      • According to NFHS – 4, only 78.9% births in India happen in a facility I.e. about 54 lakh births in a year still happen outside of a facility where hygiene levels can be low, sometimes without the help of trained worker
    • Poor sanitation / hygiene
      • Systems that ensure hygiene are lax. For instance, there are no limits on visiting hours nor is there a bar on the number of visitors allowed into the hospital wards.
      • Lack of hygiene all around public hospitals and poor hygiene practices increases the risk of infection
      • Visitors often don’t wear a mask when entering Newborn Care Units
      • Threats from outside like open defecation, wild pigs, often choked sewers, and indiscriminate tobacco spits.
    • Lack of awareness about best hygiene practices in remote and rural areas
  • Other challenges 
    • Mothers and children in the lowest economic bracket have about a two and a half times higher mortality rate.
    • Social norms and socio-cultural factors often affect accessibility to healthcare and nutrition as well as water and sanitation services and facilities in many regions.
    • Groups such as rural communities, Scheduled Castes and Scheduled Tribes and minorities have a higher IMR and U5MR.
    •  Families have little access to accurate and comprehensive information about healthy maternal, neonatal and child health practices, social services entitlements and how to use them. These keys to child survival include: the age of a mother at childbirth and her education level, spacing between children, gender-discriminatory child rearing practices, access to improved sanitation, drinking water quality and maternal and child nutrition.
    •  There aren’t enough skilled personnel and specialists in child healthcare, leading to a lack of demand for health services and the promotion of healthy practices and care-seeking behaviours among families.

GOVERNMENT INITIATIVES

  • Promotion of Institutional deliveries through cash incentive under Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakaram (JSSK) entitles all pregnant women (PW) delivering in public health institutions to free ante-natal check-ups, delivery including Caesarean section, post-natal care and treatment of sick infants till one year of age.
  • Strengthening of delivery points for providing comprehensive and quality Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) Services, ensuring essential newborn care at all delivery points, establishment of Special Newborn Care Units (SNCU), Newborn Stabilization Units (NBSU) and Kangaroo Mother Care (KMC) units for care of sick and small babies.
  • Facility-based newborn care under the National Rural Health Mission has created Newborn Care Corners at every point of childbirth, newborn stabilization units at First Referral Units and special newborn care units at district hospitals across the country
  • Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) is implemented to provide fixed-day assured, comprehensive and quality antenatal care universally to all pregnant women on the 9th of every month.
  • Name based tracking of mothers and children till two years of age (Mother and Child Tracking System) is done to ensure complete antenatal, intranatal, postnatal care and complete immunization as per schedule.
  • LaQshya a Labour Room quality improvement programme is implemented in over 2100 health facilities across the country including medical colleges
  • Universal Immunization Programme (UIP) is supported to provide vaccination to children against life threatening diseases such as Tuberculosis, Diphtheria, Pertussis, Polio, Tetanus, Hepatitis B, Measles, Rubella, Pneumonia and Meningitis caused by Hemophilus Influenzae B.
    • Mission Indradhanush and Intensified Mission Indradhanush” was launched to immunize children who are either unvaccinated or partially vaccinated, i.e., those that have not been covered during the rounds of routine immunization for various reasons.
  • Mothers’ Absolute Affection (MAA) programme for improving breastfeeding practices (Early Initiation Breastfeeding within one-hour, Exclusive Breastfeeding up to six months and initiation of complementary feeding at six months of age with continued breastfeeding up to two years or beyond) through mass media campaigns and capacity building of health care providers in health facilities as well as in communities.
  • India Newborn Action Plan (INAP) was launched in 2014 to make concerted efforts towards attainment of the goals of “Single Digit Neonatal Mortality Rate” and “Single Digit Still Birth Rate,” by 2030.
    •  Comprehensive Lactation Management Centers (CLMCs) at facilities with SNCU and Lactation Management Units (LMUs) at the Sub-district level are made functional to ensure availability of Human Milk for feeding small newborns.
    •  Home Based Newborn Care (HBNC) and Home-Based Care of Young Children (HBYC) are provided by ASHAs to improve child rearing practices.

 MISSION AARDRAM (KERALA)

  • Mission AARDRAM aims at creating "People Friendly" Health Delivery System in the state. The approach will be need based and aims at treating every patient with ‘dignity'.
  • Through the state-of-the-art investigation and intervention protocols it envisages transforming all Primary Health Centers into Family Health Centers as a first level Health delivery point.
  • The mission envisages ensuring quality care at Primary Health Centers. All high footfall hospitals will be transformed to patient friendly Out Patient service providers.
  • The services include web-based appointment system, virtual queues, patient reception at registration centers, waiting rooms with wi-fi facilities and so on

KARNATAKA MODEL

  • Karnataka covers more than 90% of its population (APL and BPL) in tertiary care. The National Health Mission, Karnataka, augments primary healthcare, while secondary healthcare is provided through a mix of schemes - both state as well as central.
  • Tertiary care schemes are implemented by Karnataka in assurance mode as opposed to insurance mode. The scheme implemented for BPL families was commended by the World Bank which found a reduction of up to 64% in out of pocket expenses.
  • The Government of Karnataka has announced the convergence of all health insurance schemes; inclusion of all the families under UHC; and continuation of Yeshaswini scheme. All schemes to be brought under the control of Department of Health and Family Welfare.

WAY FORWARD:

  • Implementation of goals under the National Health Policy 2017:
    • Increase health expenditure by Government as a percentage of GDP from the existing 1.15% to 2.5% by 2025
    • Increase State sector health spending to >8% of their budget by 2020
    • Ensure the availability of paramedics and doctors as per Indian Public Health Standard norm in high priority districts by 2020.
      • The health sub-center is to be staffed by two auxiliary nurse midwives (ANM) with 18 months training and a male health worker.
      •  The primary health center is to be staffed by 3 doctors plus a fourth trained in indigenous medical systems as well as by 5 staff nurses and one ANM.
      • The community health centre which is conceived as a rural hospital with 30 beds, a functional operation theatre and blood storage facilities is to be staffed by 6 General duty doctors and six specialists and 19 nurses.
      •  The district hospital is to be staffed with at least 30 doctors and thrice as many nurses for a 101 to 200 bedded hospital.
    • Increase community health volunteers to population ratio as per IPHS norm in high priority districts by 2025
    • Establish public health care facilities as per IPHS norms across India by 2025.
      • a health sub-center for every 5000 population, a primary health center for every 30,000 population, a community health center for every 120,000 population and 100 to 200 bedded district hospital for every 1 million population.
    • Ensure district level electronic database of information on health system components by 2020
    • Establish federated integrated health information architecture, Health Information Exchanges and National Health Network by 2025
    • Increase utilization of public health facilities by 50% from current levels by 2025
    • Antenatal care coverage to be sustained above 90% and skilled attendance at birth above 90% by 2025.
    • Ensure that more than 90% of the newborn are fully immunized by one year of age by 2025.
  •  Other measures
    • Advocate kangaroo care (a method of holding premature infants so that there is skin-skin contact which keeps them warm) and to monitor neonates constantly
    • Educating women – as household wealth and maternal education play an important role in infant mortality. Further States with more educated women show better health outcomes for children.
    • Inter-sectoral convergence for better service delivery
    • Intensified health and nutrition services for the first 1000 days
    • Revamping the medical education system in order improve the quality of medical care as well as to address the shortage of trained medical force
    • Better supervisory systems to fix accountability
    • Public health must be pushed to the top of the political agenda and political parties must be held accountable for the state of healthcare in the country
    • Jan Andolan – building a people’s movement around infant deaths to stop. This approach will encourage a person not to look at the issue of infant deaths only as a condition, but also as a condition that is unjust, unfair and an issue that needs to be addressed. This issue not only needs the government and its policies, but also the involvement of the general public.
    • Infant mortality is a complex and multifactorial problem that has shown little improvement in the past several years, despite programmatic efforts. Further efforts to lower the IMR in India should focus on preventing preterm and low birth weight deliveries, upgrading health infrastructure, empowerment of women and on reducing the large and persistent differences in IMR between various states.

Prelims Question

Q. Even though India has made significant strides in reducing Infant Mortality Rate, we still have the highest infant deaths in the world. Analyse the causes and possible solutions.