United Nations crc/C/ind/3-4

Figure 6.1
Early childhood mortality rates in the National Family Health Surveys (NFHS)

Source: National Family Health Survey-3, Ministry of Health and Family Welfare, GoI, page 180.

2. 
   Children in the 0-4 age group account for about 19% of total deaths in the country. Major causes of death in this age group include perinatal conditions, respiratory infections, diarrhoeal diseases and other infections and parasitic diseases. All of these together account for nearly 80% of deaths in this age group.¹
   
3. 
   The infant mortality rate (IMR), according to 2008 Sample Registration System (SRS) in the country, is 53 per thousand live births. Again in this age group, perinatal conditions, respiratory infections, diarrhoeal diseases and other infectious and parasitic diseases are the main killer causes.² IMR is marginally higher for females (58) than males (56). However, in the neonatal period, like elsewhere, mortality in India is lower for females (37) than for males (41). As children get older, females are exposed to higher mortality than males. Females have 36% higher mortality than males in the postneonatal period, but 61% higher mortality than males at age 1-4 years.³ (See Annexure 6A.1 for details on early childhood mortality rates for demographic characteristics.)
   
4. 
   The perinatal mortality rate, which includes still births and very early infant deaths (in the first week of life), was estimated at 49 deaths per 1,000 pregnancies for the period 2001-05. In terms of socio-economic characteristics, perinatal mortality was highest among children of rural mothers, mothers with no education or less than five years of education, and mothers in the lowest wealth quintile.⁴ Disaggregation of perinatal deaths by its sub-causes shows that out of the total perinatal deaths, 56% are males and 44% females. Among the sub-causes, deaths due to premature birth or slow foetal growth are the maximum, followed by other causes, including haemolytic disease, asphyxia, and other perinatal jaundice.⁵
   
5. 
   Out of about 26.1 million children born every year in India, 0.892 million newborns die before one month of life.⁶ Neonatal Mortality Rate (NMR) in India is 34 per thousand live births, contributing to about 50% of all deaths in childhood.⁷ The prominent causes of death among neonates are: perinatal conditions, respiratory infections, other infectious and parasitic diseases, diarrhoeal diseases and congenital anomalies. The proportion of female deaths is higher on all these counts, except perinatal conditions and congenital anomalies.⁸ (See Annexure 6A.2 for details on top ten causes of death in the 0-4 age group).
   
6. 
   The major childhood illnesses prevalent in the country are acute respiratory infections (ARI), diarrhoea, measles and malaria. Malnutrition is responsible for 56% of under-five deaths. The risk of death rises among children who are mildly, moderately and severely malnourished. On an average, a child who is severely underweight is 8.4 times more likely to die from infectious diseases than a well-nourished child.⁹ The National Family Health Survey-3 (NFHS-3) shows 6% prevalence of ARI among children under five years, which is highest among infants aged 6-11 months (8%).¹⁰
   
7. 
   Vaccine-preventable diseases are also major childhood killers. The proportion of fully-immunised children in India in the age group of 12-23 months has increased from 45.9% (District Level Household Survey (DLHS-2) (2002-03)) to 54% (DLHS-3 (2007-08)). According to NFHS-3, the proportion of fully-vaccinated children in the age group of 12-23 months has increased from 42% (NFHS-2) to 43.5% (NFHS-3). Pulse Polio campaigns are being organised frequently to reduce the incidence of polio in the country. Pulse polio immunisation has been a massive programme, covering 166 million children in every National Immunisation Day (NID) round.¹¹ Out of the 35 States and Union Territories (UTs), 33 have become free from indigenous transmission of polio virus since 2004-05. Uttar Pradesh and Bihar are taking more time to achieve zero transmission due to several factors, including high population density and poor sanitation.¹²
   

6A.1.1 Urban-Rural Variations

8. 
   Infant mortality rates are considerably higher in rural areas than in urban areas. However, there has been improvement since 2000. In 2000 the IMR for rural areas was 74, compared to 44 in urban areas; it declined to 58 in rural areas and 36 in urban areas in 2008.¹³
   
9. 
   According to NFHS-3, the IMR and child mortality rates are considerably higher in rural areas than in urban areas. The rural-urban difference in mortality is especially large for children in the 1-4 age group, for whom the rate in rural areas is twice as high as the rate in urban areas. In both the neonatal and postneonatal periods, mortality in rural areas is about 50% higher than mortality in urban areas. A comparison of NFHS-2 and 3 shows that infant and child mortality rates have declined slightly faster in rural areas than in urban areas. Between 1991-95 and 2001-05, infant mortality declined by 27% in rural areas, compared to 21% in urban areas. During the same period, the child mortality rate declined by 45% in rural areas, compared to 40% in urban areas. Even in the neonatal period, the decline in mortality was slightly faster in rural areas (26%) than in urban areas (18%)¹⁴. The top 10 causes of death are common in rural as well as urban areas, with striking overall similarity in patterns, as observed in case of ages 0 to 4. Perinatal conditions, respiratory infections, diarrhoeal diseases and other infectious and parasitic diseases clubbed together account for more than 80% infant deaths in rural areas as well as in urban areas. The proportion of infant deaths due to malaria is more than twice in rural areas (1.2%) than urban areas (0.5%).¹⁵
   

6A.1.2 State Variations

10. 
    The IMR is highest in Uttar Pradesh (73), and lowest in Kerala and Goa (15). With respect to under-five mortality, Uttar Pradesh again has the highest rate (96) and Kerala has the lowest (16). Apart from Uttar Pradesh, high levels of infant and child mortality are found in Chhattisgarh and Madhya Pradesh in the central region, Assam and Arunachal Pradesh in the north-eastern region, Jharkhand, Orissa and Bihar in the eastern region, and Rajasthan in the northern region. In contrast, all States in the southern and western regions have lower levels of infant and child mortality. Three States in the north-eastern region have lower-than-average reported levels of neonatal mortality but higher-than-average rates of postneonatal and child mortality (Arunachal Pradesh, Meghalaya and Nagaland). (See Annexure 6A.3 for details on early childhood mortality rates by State.) The Office of the Registrar General India (ORGI) provides variation in the causes of IMR as a proportion of all infant deaths for two categories of States; the first category comprises the ‘Empowered Action Group (EAG) States’.¹⁶ The State of Assam has also been added to this list. The second category covers the remaining States and is labelled as ‘Other States’. Infant deaths account for about 19% of the total deaths in the EAG States and Assam and 9% in the Other States. Perinatal conditions, the top cause in both the category of States, accounts for 10% more deaths in the Other States, as compared to the EAG States and Assam. However, respiratory infections, diarrhoeal diseases and other infectious and parasitic diseases together account for about 45% deaths in EAG States and Assam, vis-à-vis 30% in Other States. Deaths due to nutritional deficiencies and malaria are also more prevalent in EAG States and Assam. In contrast, perinatal conditions and congenital anomalies dominate in the Other States. The proportion of males dying from perinatal conditions, congenital anomalies and unintentional injuries is higher than females in both the categories.¹⁷
    
11. 
    A preliminary analysis of States was carried out by the Third Joint Review Mission (JRM) of Reproductive and Child Health Phase-II (RCH-II) in 2007, in terms of current status of maternal mortality ratio (MMR), IMR, Total Fertility Rate (TFR), and past trends in terms of selected maternal health, child health, and family planning indicators. Eleven outcome indicators were studied, i.e. neonates who were breastfed during the first hour of life; neonates who were breastfed exclusively till six months of age; infants receiving complementary feeds apart from breastfeeding at nine months; 12-23-month-old children fully immunised; 6-35-month-old children, who are anaemic; pregnant women getting full antenatal care (ANC); pregnant women who are anaemic; deliveries by Skilled Birth Attendants (SBAs); contraceptive-prevalence rate for any modern method; and unmet need for spacing methods and terminal methods among eligible couples. The analysis suggests that in terms of RCH outcomes, the States can be grouped into four categories, category one being the best and category four being the worst.¹⁸ (See Figure 6.2.)
    

6A.2 Programmes

12. 
    The Ministry of Health and Family Welfare (MoH&FW) is implementing several programmes and schemes to address the issue of infant and child mortality. Notable among these are Universal Immunisation Programme, where immunisation of children is carried out against six vaccine-preventable diseases; control of deaths due to ARIs; Integrated Child Development Services (ICDS) Scheme, with focus on improving nutritional and health status of children below six years of age; and essential new-born care to address the issue of the neonates. (See Section 6C.3 for details.)