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Year : 2021  |  Volume : 10  |  Issue : 1  |  Page : 21-26

Infant mortality in Empowered Action Group states in India: An analysis of sociodemographic factors

Public Health Specialist, Department of Pediatrics, Safdarjung Hospital, New Delhi, India

Date of Submission14-Jan-2020
Date of Decision30-May-2020
Date of Acceptance24-Aug-2020
Date of Web Publication19-May-2021

Correspondence Address:
Dr. Manas Pratim Roy
Public Health Specialist, Department of Pediatrics, Safdarjung Hospital, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None


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Introduction: Infant mortality rate (IMR) is considered one of the key indicators of the social and economical development of a country. Therefore, some sociodemographic indicators were evaluated from eight poorly performing states of India.
Materials and Methods: Data from National Family Health Survey 4 (2015-16) were analyzed, using Pearson Correlation Coefficient. Female literacy, provision for improved drinking water and sanitation, use of clean fuel for cooking, measles vaccination, the occurrence of diarrhea, and exclusive breastfeeding were taken into account. Rural and urban parts were considered separately.
Results: Lower IMR was noted in urban areas in Empowered Action Group (EAG) states. Urban Odisha recorded better IMR than other units (21/1000 live births). Female literacy (r = −0.558) and improved sanitation (r = −0.555) were significantly related to IMR. In comparison to National Family Health Survey 3 (2005-06), appreciable reduction was noted in IMR in urban Rajasthan (53%) and urban Odisha (48%).
Conclusion: Literacy and improved sanitation are important factors associated with infant mortality in EAG states. Strategies targeting social development could spell wonder in the future, in terms of reducing IMR in these states.

Keywords: EAG states, female literacy, household environment, infant mortality, National Family Health Survey

How to cite this article:
Roy MP. Infant mortality in Empowered Action Group states in India: An analysis of sociodemographic factors. J NTR Univ Health Sci 2021;10:21-6

How to cite this URL:
Roy MP. Infant mortality in Empowered Action Group states in India: An analysis of sociodemographic factors. J NTR Univ Health Sci [serial online] 2021 [cited 2022 Dec 10];10:21-6. Available from: https://www.jdrntruhs.org/text.asp?2021/10/1/21/316325

  Introduction Top

Riding on the global effort to reduce childhood mortality, India so far recorded certain progress in reducing infant mortality. National Family Health Survey (NFHS) 4 reported an Infant mortality rate (IMR) of 41/1000 live births in 2015-16.[1] IMR varies widely across the world, ranging from 51/1000 live births in Africa to 8/1000 in Europe.[2] In India, it was 68/1000 live births in 2000.[3] The momentum achieved during Millennium Development Goal has been shifted to Sustainable Development Goal, to bring down mortality further. Still, there were 802,000 infant deaths in 2017.[4]

However, the progress has been uneven, with a steep difference existing between Kerala and Uttar Pradesh, two states of the same country, the former having IMR one-tenth than the other. Several factors could be identified, based on other studies from different parts of the world, for explaining prevailing inequity in IMR. Education, breastfeeding practices, and household environment are some of them, apart from access to health services.[5],[6] However, most of the studies were localized, giving rise to problem in extrapolating their findings.[7],[8] The problem is the same for India which contributes to 18% of global pool of infant deaths. Such efforts were rare when researchers analyzed data representing multiple states for defining factors that could reduce IMR substantially. This is important since getting rid of disparity among states, in terms of child death, would be the first step in successfully implementing any nation-wide strategy. A wide range of factors starting from literacy to drinking water have been implicated earlier in determining infant mortality.[9],[10] In this background, the present article analyzed data from eight poor-performing states from India.

  Methods Top

It was an ecological study. Data were retrieved from the public domain of NFHS 4, conducted in 2015-16. NFHS is a periodical comprehensive approach to find out perspective of the beneficiaries of health care across the country. Interviews were completed for 699,686 women, with 97% response rate. They were asked about their children, whether alive or not. The results are presented in percentages and the identity of any individual is not exposed. Infant mortality considered the probability of dying between birth and first birthday and expressed as number of deaths per 1000 live births. The quality of mortality estimates depends on birth histories recorded from the mother.[1]

Along with IMR, the following continuous variables were considered: female literacy, provision for improved drinking water and improved source of sanitation, use of clean fuel for cooking, children vaccinated with measles, prevalence of diarrhea in past 2 weeks preceding survey, and children exclusively breastfed. Piped water into dwelling/yard/plot, public tap/standpipe, tube well or borehole, protected dug well, protected spring, rainwater, and community RO plant were considered as improved drinking water source. Improved sanitation included flush to piped sewer system, flush to septic tank, flush to pit latrine, ventilated improved pit (VIP)/biogas latrine, pit latrine with slab, twin pit/composting toilet, which is not shared with any other household. Clean fuel considered electricity, LPG/natural gas, and biogas. For measles vaccination, children between the age of 12 and 23 months were assessed. Children under 6 months of age were assessed for exclusive breastfeeding (EBF).

Empowered Action Group (EAG) states, as defined by the Government, include eight states, viz., Bihar, Chhattisgarh, Rajasthan, Uttar Pradesh, Uttarakhand, Odisha, Jharkhand, and Madhya Pradesh.

The study was conducted in accordance with the Declaration of Helsinki. Informed written consent was not taken because the study was a retrospective analysis of anonymous data. Data both from rural and urban areas were considered separately. Best and worst performer was assessed after comparison between states. Pearson Correlation Coefficient was calculated between IMR and other variables. Using a bar diagram, differences were displayed on relationship of female literacy, sanitation, and clean fuel with IMR. Data from 2015-16 were compared with National Family Health Survey 3 (2005-06) on IMR and other indicators. P value <0.05 was considered significant. PASW for Windows software (version 19.0; SPSS Inc, Chicago) was used.

Ethical clearance

The study complied with the Declaration of Helsinki (1964) and approval from the Ethical Committee was not sought as the study deals with anonymous database.

  Results Top

Average IMR in the states under study was 43.9/1000 live births, whereas national average was 41/1000 live births. There was a 3.2 times variation in IMR between the units, with highest in rural Uttar Pradesh (67/1000 live births) and lowest in urban Odisha (21/1000 live births). High coverage was noted in improved drinking water (91.1%) and measles vaccination (82.1%) but female literacy was only 67.3%.

Baseline data for IMR and related factors for EAG states are given in [Table 1] and [Table 2]. Best and worst performer for each indicator was compared in [Table 3]. Urban Uttarakhand scored higher than others in female literacy. In a household environment, comprising sanitation, drinking water, and clean fuel, rural Chhattisgarh performed worst in all three of while urban Uttarakhand put up best performance across the parameters. In most of the cases, an improvement in female literacy was associated with reduction in IMR. For example, urban Bihar recorded IMR 15/1000 live births less than its rural counterpart, while female literacy was 24.3 percent point better in urban than rural part [Figure 1]. Similarly, in [Figure 2], urban Bihar recorded IMR 15/1000 live births less than its rural counterpart, while improved sanitation was 34.2 percent point better in urban than rural part. The relation between IMR clean fuel was depicted in [Figure 3] in similar way.
Table 1: Baseline Data for IMR and IMR Related Factors in EAG States: Rural

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Table 2: Baseline Data for IMR and IMR Related Factors in EAG States: Urban

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Table 3: Best and Worst Performer in IMR Related Factors in EAG States

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Figure 1: Comparison between EAG states on urban-rural difference in IMR and female literacy

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Figure 2: Comparison between EAG states on urban-rural difference in IMR and improved sanitation

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Figure 3: Comparison between EAG states on urban-rural difference in IMR and use of clean fuel

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IMR was negatively and significantly correlated with female literacy (r = −0.558, P = 0.025) and improved sanitation (r = −0.555, P = 0.026). Positive correlation was there between IMR and prevalence of diarrhea [Table 4].
Table 4: Correlation Between IMR and Related Factors in EAG States

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When compared with NFHS 3 (2005-06), it was noted that except urban Uttarakhand, all other units across EAG states recorded reduction in IMR. Maximum reduction was noted in urban Rajasthan (53%) and urban Odisha (48%) [Figure 4].
Figure 4: Comparison between EAG states on percent changes in IMR between 2005-06 and 2015-16

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  Discussion Top

The article focuses on IMR and some of its related factors. In general, the rate was higher in rural areas, with the exception of Uttarakhand. Studies from other developing countries also reported the same trend.[11],[12],[13] While demographic factors could be the underlying reason, the absence of improved health facilities in rural areas could not be overlooked. Lack of transport facility could be another reason. However, a decreasing trend in IMR was noted overall, suggesting the result of several interventions for improving maternal and child health including Janani Suraksha Yojana and Navajata Shishsu Suraksha Karyakram.

Variations have been noted among studied states in all the parameters. We are yet to achieve 100% availability of drinking water in any of the states. The use of clean fuel is still in a dilapidated condition in rural areas. EBF is not in practice in a larger chunk of the community. There may be issues like access, availability, and utilization of health services. There may be other dimensions like social culture. Few of these parameters were considered to determine IMR in EAG states.

Literacy has been long recognized as the cornerstone of development. It is obvious that with literacy, individual gains confidence. Female literacy, thus, propels female autonomy and participation in decision making.[14],[15] Therefore, factors like immunization and breastfeeding may get influenced by literacy level of mothers, thus impacting child survival. As suggested by Palloni, educated mothers are more likely to reside in an area with better medical services, sanitation, and drinking water.[12] Reducing IMR in isolation would be impossible without any preceding change in female literacy, as highlighted in the present study. With rural parts of Bihar and Chhattisgarh still recording female literacy less than 50%, it remains a matter of concern. Kumar et al. mentioned how gender gap in literacy could affect utilization of health care.[16]

Sanitation is another factor determining mortality. Globally, 280,000 deaths are caused by inadequate sanitation.[17] Diarrhea being one of the major killers of children, provision of safe sanitation could go a long way in reducing child deaths. As a cost-effective intervention, the popularity of sanitation among policymakers could be better demonstrated by the implementation of Total Sanitation Campaign and Swachh Bharat. Use of improved sanitation has increased from a mere 29.1% to 48.4% between 2005-06 and 2015-16. In this context, it may be mentioned that poor sanitation for few families may leave the entire community exposed.[18] SDG 6 calls for sustainable management of sanitation.

From the present study, it is evident that rural areas continue to struggle to put up a decent figure in ensuring safe sanitation. Uttarakhand is the only state where rural part recorded more than 50% households having improved sanitation. Thus, the disparity between urban and rural parts probably stands between our efforts and ensuring better access to sanitation. As a matter of fact, hygienic toilets are concentrated in urban areas.[5] With urban areas becoming the epicenter of economic growth, the disparity in terms of availability and access would exacerbate in future. How to close the gap between two ends will remain a matter of further research.

Use of clean fuel in the country has increased from a mere 25.5% to 43.8% between National Family Health Survey 3 (2005-06) and National Family Health Survey 4 (2015-16). Though the present study could not find any significant correlation with IMR, previous studies indicated the influence of the same on infant mortality.[6],[19] Similarly, measles vaccination or EBF were not significantly related to IMR but they are seen to reduce IMR, as evident from the analysis.

Between two national surveys, India reduced IMR by 28%. Among EAG states, urban parts of Rajasthan and Odisha put up a massive reduction during that period. It is somewhat surprising that urban Uttarakhand recorded more than double IMR in the same time period. This is more so because rural Uttarakhand reduced 22% reduction in IMR. It is unlikely that the same state policy on child health may result in such contrast. The factors considered in the present paper could not explain higher mortality in urban Uttarakhand. It calls for further state specific analysis of the data.

In fact, the introduction of Accredited Social Health Activists (ASHA) at the grass-root level under National Rural Health Mission since 2005 has changed the pattern of service delivery. The giant leap in health-related indicators could be attributed to that. Addressing remaining disparity would be a major challenge in future for the strategy, perceived widely as a game changer.

The study shows that chance of infant mortality is high in areas not having basic household amenities. There have been constant efforts from the Government to improve such provisions. Ujjwala Yojana, a scheme to reach every household with clean fuel, has documented groundbreaking success in recent years, by providing more than 80 million connections.[20] The initiative, if persistently taken care of by ensuring regular supply of gas cylinders, could result in a substantial reduction in infant mortality in upcoming years.

To summarize, for addressing IMR, we need to underscore literacy and improved sanitation in EAG states. Adopting a holistic view, incorporating sociodemographic aspects, could be a key strategy for bringing down IMR in these states. States with poor literacy rate like Jharkhand, Bihar, Madhya Pradesh, and Rajasthan may find out districts in need of better attention and plan tailored interventions accordingly. Similarly, improved sanitation may also be ensured in rural areas, as the present study finds out scope of much development there. Focus on social conditions would definitely help in minimizing risk factors for infant mortality, particularly in EAG states. The role of front line health workers is very crucial for such interventions, as they will put more emphasis on illiterate women to develop their health-seeking behavior and child care practices. At the crossroad of health and social practices, we need to explore the possibilities of involving other community leaders for planning an effective intervention like provision of community latrine, where required. We also need to get down to district level for micro-management of basic amenities like drinking water, sanitation, and clean fuel. In addition, ensuring literacy and employment for women may boost female empowerment.

One of the limitations of the present study was the lack of district-level analysis to identify variations within a state. Being an ecological study, the study suffers from ecological fallacy. There might be some confounding factors which were not taken care of. Use of regression could have addressed such factors. The barriers for adopting healthy practices and accessing health services could not be determined. However, very few studies ever put focus on EAG states and bring up the concerns to achieve their health statistics at par with rest of the country. As a next step, there is a need for analyzing states like Kerala and Tamil Nadu to identify replicable practices in EAG states. Collective impact of all the efforts put across health and society could spell wonder, as conveyed by the study. For ensuring continuum of care throughout infancy, there is a need to put thrust in related areas like sanitation and drinking water. How multi-sectoral approach could be leveraged to reduce child mortality will be a matter of future research.

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Conflicts of interest

There are no conflicts of interest.

  References Top

International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-4), 2015-16: India. Mumbai: IIPS; 2017. Available from: http://rchiips.org/NFHS/NFHS-4Reports/India.pdf. [Last accessed on 2018 Jun 2].  Back to cited text no. 1
WHO Global Health Observatory Data. Infant Mortality 2018. Available from: https://www.who.int/gho/child_health/mortality/neonatal_infant_text/en. [Last accessed on 2018 Aug 08].  Back to cited text no. 2
Niti Aayog. Infant Mortality Rate. 2018. Available from: https://www.niti.gov.in/content/infant-mortality-rate-imr-1000-live-births. [Last accessed on 2018 Aug 8].  Back to cited text no. 3
United Nations Inter-agency Group for Child Mortality Estimation (2017). UNICEF; New York: 2017. Levels and trends in child mortality: Report.  Back to cited text no. 4
Hosseinpoor AR, Van Doorslaer E, Speybroeck N, Naghavi M, Mohammad K, Majdzadeh R, et al. Decomposing socioeconomic inequality in infant mortality in Iran. Int J Epidemiol 2006;35:1211-9.  Back to cited text no. 5
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Kumar K, Srivastava R, Mishra SK. Socio-demographic determinants of under-five mortality in rural Agra. Int J Community Med Public Health 2017;4:3108-12.  Back to cited text no. 7
Patel A, Kumar P, Godara N, Desai VK. A socio-demographic profile of infant deaths in a tribal block of south Gujarat. Natl J Community Med 2011;2:399-403.  Back to cited text no. 8
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Kumar C, Singh PK, Rai RK. Under-five mortality in high focus states in India: A district level geospatial analysis. PLoS One 2012;7:e37515.  Back to cited text no. 16
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4]


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