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Infant mortality: no room for complacency
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A complex set of biological, socio-economic, demographic and cultural factors underlie infant mortality. There are no quick fixes to solve the problem. The National Population Policy 2000 has outlined the specific interventions that are necessaryto tackle the situation.
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INFANT MORTALITY rate is a sensitive index of socio-economic conditions of a population. It is an excellent indicator of the level and quality of health care and other social infrastructure available to a population. The National Population Policy 2000 has identified reduction of IMR to 30 per 1000 live births as one of the more important national socio-demographic goals to be achieved by 2010.
Tamil Nadu has shown impressive strides in bringing down IMR — Tamil Nadu and West Bengal (IMR-51) share the third rank in 2000 among the bigger States of India. The only two States above it are Kerala (14) and Maharashtra (48). In rural areas the State has an IMR of 57 and is placed fourth jointly with Maharashtra, while in urban areas it has an IMR of 38 and is placed seventh jointly with Punjab. Though the achievements so far have been commendable, the fact that the IMR in Tamil Nadu is almost 3 times that in Kerala and that the gap between urban and rural areas of the State is wide, suggests that there is no room for complacency.
Stagnation
Trends indicate a considerable slowing down, in fact, almost stagnation of IMR in both rural and urban areas. In 1971 the IMR was 113. It declined to 91 in 1981 and further to 57 in 1998 and 51 in 2000. Between 1971 and 1981, the decline was 22 points. In the next decade 1981-91, it declined by 34 points but from 1991 to 2000 it declined by 6 points only. While it is welcome that the IMR has been declining over the years, it is disturbing that the rate of decline has been slowing down and is almost stagnating in the recent years.
Infant mortality has two components — neo-natal mortality (infant deaths occurring in the first month or less than 29 days) and its sub-classification of early neo-natal mortality (infant deaths occurring in the first week or less than 7 days) and late neo-natal mortality (infant deaths occurring between 7-29 days of birth) are very sensitive to biological or endogamous causes. Postnatal mortality (infant deaths occurring from 29 days to less than 1 year) is more dependent on exogenous factors like nature and quality of environment.
Neo-natal mortality accounts for 75 per cent of infant mortality in Tamil Nadu. The proportion is high in rural (76 per cent) as well as urban areas (69 per cent). Of this early neo-natal mortality accounted for 56 per cent in 1999 — 55 per cent in rural areas and 56 per cent in urban areas. Endogenous factors are generally more difficult to control and therefore this is a cause for great alarm. Late neo-natal mortality and postnatal mortality contribute 44 per cent of the IMR — 45 per cent in rural areas and 44 per cent in urban areas. This is an indication that exogenous factors like deteriorating environment and lack of infrastructure are responsible for high infant mortality.
Causes: A look at the causes of death of infants in rural areas reveals that respiratory infection of the newborn, causes peculiar to infancy, pre-maturity, congenital malfunction, diarrhoea of the newborn and birth injury are broad categories that account for more than 80 per cent of the infant deaths in rural areas of Tamil Nadu. Accidents and injuries, fevers, digestive disorders, disorders of respiratory system, disorders of central nervous system, disorders of circulatory system, other clear symptoms and cord infection are the other causes.
In urban areas causes like slow foetal growth, malnutrition, immaturity, birth trauma, hypoxia, birth asphyxia, other respiratory conditions and other conditions in perinatal period account for nearly 75 per cent of the infant deaths. Infectious and parasitic diseases like intestinal infectious diseases, TB, other bacterial diseases, viral diseases contribute around 7 per cent. Congenital anomalies and other causes bring up the rest. If a dent has to be made in reduction of IMR, there is an urgent need to tighten up the health care delivery system all over the State. Policy intervention to improve the reach and quality of health care has to be given the utmost priority.
Socio-economic, cultural and demographic causes of infant mortality in Tamil Nadu are:
Infanticide: Studies conducted by the Tamil Nadu Government point out that one of the causes of high female IMR in some pockets of the State could be due to the pernicious practice of infanticide. Genderwise ENMR figures of some districts (source DPH Tamil Nadu) and the records of Primary Health Centres seem to indicate the prevalence of female infanticide in some districts of Tamil Nadu like Dharmapuri, Madurai and Salem. Studies by certain demographers state that female infanticide deaths account for around one sixth of all female infant deaths in the State and these are largely confined to 100 blocks located in 6-7 districts. (Venkatesh Athreya and Sheela Rani Chunkath).
Literacy: Infant mortality declines sharply with increasing education of the mother, ranging from a high of 89 per 1,000 live births for illiterate mothers to a low of 34 per 1,000 live births for mothers with at least a high school education (NFHS 1992).
Medical attention: Receiving medical maternity care (antenatal or delivery care by a trained health professional) for mothers is associated with substantially lower mortality risks. Infant mortality is much higher for births with no care (111 per 1,000 live births) than for births with either antenatal or delivery care (65 per 1,000 live births) and births with both antenatal and delivery care (51 per 1,000 live births) (NFHS 1992).
Age of mother, birth order and spacing: There is a close correlation between age of mother and birth order, with higher order births occurring at older ages. There is a steady increase in child mortality with birth order. Child-spacing patterns also have a powerful effect on the survival chances of children. Infant mortality risks increase sharply as the length of the preceding birth interval decreases. Infant mortality is well over two times higher for children with a preceding interval of less than 24 months than for children with a preceding interval of 48 months or more (95 compared with 42 per 1,000 live births). Mortality risks are sharply higher for children of very young and older mothers, for higher order births, and for births occurring within 24 months of a previous birth. The proportion of births occurring within 24 months of the previous birth (13 per cent) is only slightly higher than the proportion of births that occur to mothers with more than three children (10 per cent). The risk ratio for births occurring within 24 months of the previous birth is lower (1.38) than the risk for births to mothers with more than three children (1.73). Because a large proportion (23 per cent) of all births fall in these two categories, and because births in these categories have high risk ratios, the results suggest that a substantial reduction in mortality could be attained by discouraging childbearing after the third child and childbearing within 24 months after the previous birth (NFHS 1992).
Birth weight: Another important determinant of the survival chances of children is the baby's weight at the time of birth. Many studies have found that low birth weight babies (under 2,500 grams) have a substantially increased risk of mortality.
A complex set of biological, socio-economic, demographic and cultural factors underlie infant mortality. There are no quick fixes to solve the problem. The National Population Policy 2000 has outlined the specific interventions that are necessary to tackle the situation. The Government of Tamil Nadu as well as the non-governmental organisations are already seized of the entire gamut of issues and are working on a multi-pronged strategy to consolidate the gains made so far. Policy intervention to address the entire complex of issues is already on the anvil. What is required is the coordinated implementation of the strategy in a mission mode if the goal of reducing IMR to 30 per 1,000 live births is to be achieved.
C. CHANDRAMOULI
(The author is Director of Census Operations, Tamil Nadu. The views expressed are personal).
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