AnnNelson Mandela said that “there can be no greater revelation of the soul of a society than the way it treats its children”. Two global reports released on January 10, 2023 – on child mortality and stillbirth – prompt us to ponder whether India is doing enough to ensure the health and survival of every child.
Report on child mortality – Levels and trends in child mortalityGlobally, five million children are expected to die before their fifth birthday in 2021 (the under-five mortality rate) – by the United Nations Inter-Agency Group for Child Mortality Estimation (UNIGME). Of these, more than half (2.7 million) occurred in children aged 1–59 months, while the remainder (2.3 million) occurred in just the first month of life (neonatal deaths).
India’s share of these child deaths was estimated to be 7,09,366 under the age of five; 5,86,787 infant deaths (death before first birthday); and 4,41,801 neonatal deaths. Many of these are preventable. Furthermore, the Sample Registration System (SRS) released in September 2022 showed wide inter-state variation in child mortality rates in India. For every 1,000 live births, the infant mortality rate in Madhya Pradesh was six times the rate in Kerala. Child mortality in rural parts is much higher than that of their urban counterparts in any age subgroup.
two neglected challenges
Two neglected challenges are at the root of many child deaths. The first challenge is babies born ‘too early’ (preterm birth), meaning they are born alive before 37 weeks of pregnancy have been completed. This is a challenge because these ‘preterm babies’ have a two to four times higher risk of death after birth than those born after 37 weeks’ gestation. Globally, one out of every 10 births is premature; In India, one out of every six to seven births is premature. India has a high burden of prematurity, which means that newborns in the country are at higher risk of complications and mortality. Studies have shown that premature birth contributes to one out of five out of every six child deaths. However, three out of every four deaths due to complications related to premature birth are preventable.
The second challenge is that of stillbirths, the subject of another report by UNIGME titled ‘Never Forgotten’. A baby who dies any time after 22 weeks of pregnancy, but before or during birth, is classified as a stillborn. Globally, an estimated 1.9 million stillbirths will occur in 2021. In 2021, the absolute estimated number of stillbirths in India (2,86,482) was more than the number of deaths of children aged 1-59 months (2,67,565). The rate and number of both premature births and stillbirths are unacceptably high and lead to the upward trend in neonatal, infant and child mortality rates in India. Thus, they seek immediate intervention.
One of the reasons for the lack of proper attention to premature birth and still birth is the lack of detailed and reliable data. For decades, while countries have strengthened mechanisms for tracking child mortality, data on stillbirths and premature births have been scarce. Globally too, the first report on stillbirth was released in October 2020 itself. In India, SRS reports on stillbirths fail the ‘smell test’. Its stillbirth estimate is less than the low end of the confidence interval by all other credible estimates, including a recent peer-reviewed analysis using government data from health management information systems. Experts believe that the problem is the lack of timely, detailed data on stillbirths from the block, district and state levels.
Known and Proven Remedy
Most stillbirths and premature births can be prevented by scaling up known and proven interventions and improving the quality of health services. To reduce both stillbirth and premature birth, the focus should be on: increasing access to family planning services; improving antenatal services such as health and nutrition, including iron folic acid intake by expectant mothers, providing counseling on the importance of a healthy diet and optimal nutrition; and identification and management of risk factors. Measures to prevent, detect and manage diseases that put mothers at high risk, such as diabetes, hypertension, obesity and infections, will also help reduce premature birth and stillbirth. And by ensuring early initiation of kangaroo mother care and exclusive breastfeeding, among other things, it is possible to reduce future neurological complications for preterm infants.
Half of stillbirths are due to antepartum causes before delivery and the remainder occur during delivery (intrapartum). Monitoring of labor and functional referral linkage and improving the quality of health care services will prevent stillbirth.
However, interventions can be best delivered if premature birth and stillbirth data are better recorded and reported. Maternal and perinatal mortality surveillance guidelines need to be implemented effectively and the International Classification of Diseases definition for perinatal mortality should be adopted. Use of this classification would help standardize the reasons for stillbirth reporting. Simultaneously, India needs to identify hot spot clusters of stillbirths and preterm births for localized and targeted interventions.
In mid-2022, the Foundation for People-Centric Health Systems, a Delhi-based non-profit, drafted a report that was endorsed by seven other organizations and professional associations, including the Federation of Obstetric and Gynecological Societies of India and the Indian Association of Preventive and Social Medicine. It underlined the need for multi-stakeholder collaboration and flagged the need for better data. It is time for all stakeholders to work together and for health policy makers to take note of these challenges and initiate interventions.
policy solution
Three weeks from now, the Union Budget will be presented in Parliament. The government is likely to list its achievements in the health sector. While achievements should be celebrated, it is equally important that policymakers pause to reflect on neglected challenges. Stillbirth and prematurity are highly sensitive ‘tracer indicators’ of the quality of maternal and child health services in particular and overall health services in general. In the National Health Policy of 2017, the government committed to invest 2.5% of GDP on health by 2025. In the six years since then, the government’s allocation for health has increased marginally. Even by the best estimate, it is about 1.5% of GDP. The Indian government’s investment on health is among the lowest in the world. Yet, there doesn’t seem to be any urgency on his part to increase funding for health. There are many reasons why India’s health system needs more government funding: children continue to die from preventable causes; pregnant women do not receive good quality care; Total mortality hides inequalities in health outcomes and those inequalities are borne by the poorest and most marginalized households; and the primary healthcare system is underfunded, and even a few cosmetic changes are not enough to improve health outcomes; among others. Two recent reports are a reminder that the time has come for the government to allocate more money to health, starting with the upcoming budget.
Chandrakant Lahariya is a consultant physician and public policy and health systems specialist. He is the primary author of the report ‘Stillbirths in India: A call to action’ (2022).