Patralekha Chatterjee | India's infant mortality rate isn't a fringe issue

In a week when the word “fringe” is a headline-grabber, let me start by saying that updates about the country’s infant mortality rate (IMR) is not a fringe issue. It is central to a country’s future and its present.

Here’s why: The infant mortality rate, or the number of infant deaths out of every 1,000 live births, is a telling marker of the overall health and well-being of a population. Iniquitous access to medicine, skilled healthcare providers, clean water and nutritious food affect everyone’s health, but together they can dramatically impact infant mortality rates.

The latest data from the Registrar-General of India shows that India’s infant mortality rate is 28 (28 infant deaths per 1,000 live births). The reference year is 2020. The good news: we are saving more babies. Overall, the IMR at the all-India level has come down from 44 to 28 in the past decade. The corresponding dip in rural areas is 48 to 31; for urban areas, the figure is down from 29 to 19.
The grim news: the national average masks stark disparities between different states, and between the city and the village. Progress is slow in those states where infants have been dying in large numbers.

“Despite the decline in IMR over the last decades, one in every 36 infants die within the first year of their life at the national level (irrespective of rural or urban),” says the May 2022 SRS Bulletin from the Registrar- General’s Office.
India has made progress on the IMR front, but many of our neighbours and peers have done even better. Bangladesh’s IMR is down to 24. The corresponding figures for Nepal and Bhutan are 24 and 23 respectively. Sri Lanka is leagues ahead, with an IMR pegged at six. Pakistan is worse off, with an IMR of 56.

Should special allowances be made for India because it is a large and diverse country? Here’s the catch — Brazil and China — both large countries, and fellow members of BRICS — have much lower IMRs than India.

Among India’s big states/Union territories, only Kerala has a single digit IMR — six infant deaths per 1,000 live births).  Mizoram, which leads the IMR charts with three infant deaths per 1,000 live births, is in the list of smaller states. Interestingly, many states in India’s Northeast — Nagaland, Sikkim, Tripura, Manipur — do well on saving babies. Ditto with Goa.

Who are the laggards? Unsurprisingly, those states which have habitually trailed in human development, are also showing slow progress in arresting infant deaths.

Uttar Pradesh’s IMR is 38. Arguably, many more babies in the state now live to see their first birthday due to the rise in institutional deliveries and availability of sick new-born care units, but UP has to invest a lot more political energy into improving its IMR. Madhya Pradesh’s IMR score (43) is also worse than the national average.  Once again, there is a big gap between cities and
villages.

Whether a baby survives still depends on where it is born.

What is the big picture behind the numbers? Why do so many Indian children continue to die before their first birthday?

Having followed the IMR story for years, and talking to public health experts, some key issues leap out.

Infant mortality is the end-result of a whole chain of interlinked ground-level challenges. A high IMR exposes structural fault lines. It can’t be addressed by thinking in silos.

One key issue is nutrition, points out Dr Pavitra Mohan, a community health physician, paediatrician, and co-founder of Basic HealthCare Services, a Rajasthan-based NGO.

India continues to have a large pool of malnourished children. The World Health Organisation says that malnourished children, particularly those with severe acute malnutrition, have a higher risk of death from common childhood illnesses like diarrhoea, pneumonia, and malaria.

Malnourishment reduces immunity. In India, children suffering from Severe Acute Malnutrition (SAM) justifiably get attention. But then there is a larger pool of children suffering from moderate malnutrition (MAM). The latter are also at risk. Add to that another piece of stark reality — India has a large number of low-birthweight children. These children are at risk if they continue to be undernourished.

The second issue, says Dr Mohan, is the overall low quality of childcare during childbirth and after. In India, while the number of institutional deliveries has gone up, all health centres or hospitals are not the same. Every hospital does not have a labour room that is clean or well-staffed or well-resourced. The quality of care after a child comes home also varies.

Another key factor is maternal nutrition. The latest National Family Health Survey tells us that 52 per cent of pregnant women between the ages of 15 and 49 in the country are anaemic. This is higher than what it was during the previous NFHS (2015-2016).

When you look at the state-level data, the disparities leap out once again. What is really worrying is that in many states, anaemia is rising for both women and children. Maternal anaemia affects child survival and health.

There are other challenges: Infants in remote areas remain at risk. Highways and arterial roads help but roads alone can’t save babies if health centres are inaccessible or understaffed or under-resourced.

Finally, as Dr Mohan stresses, there is the core issue of underspending on public health. India still spends far too little on public health as a percentage of its gross domestic product (GDP). The annual health budget has hovered just above one per cent of GDP for the past decade. Some states allocate more resources on healthcare — Delhi and Tripura, for example, allocate nearly 10 per cent of their budget on healthcare. Unsurprisingly, when the overall spending on healthcare is low in most states, problems persist. All these issues are inter-connected and they cumulatively affect infant deaths.

One promising sign: Smaller states (carved out of bigger ones) are doing a better job of saving infants. For example, Uttarakhand has an IMR of 24 while the figure for Uttar Pradesh is 38. Chhattisgarh’s IMR is 38 while the figure for Madhya Pradesh is 43. Jharkhand’s IMR is 25; the corresponding figure for Bihar is 27. Telangana’s IMR is 21 while the figure for Andhra Pradesh is 24.

The bottom line — infants are our future. They must survive and thrive if India is to thrive. This can happen only if infant mortality is catapulted from the periphery to the centre of the political and societal priorities in the country.