Vital statistics of Birth and Death

                 Health Status of the country

The  health  of  a  nation  is  an  essential  component  of  development,  vital  to  the  nation‟s  economic growth and internal stability. Assuming the minimum level of health care to the  population  is  a  critical  constituent  of  the  development  process.  Many  countries  in  the  course of development  gone through what is known as an “epidemiologic transition”, where  the  initial  high  burden  of  disease  and  mortality  due  to  infectious  diseases  and  maternal  and  child  mortality,  declines  and  gives  way  to  non-communicable diseases,  injuries  and  geriatric  problems  as  the  main  burden  of  disease.  India‟s Epidemiologic  Transition, however is marked by three challenges in disease control, all of which need to  be managed concurrently.First,  India  has  to  complete  its  unfinished  agenda  of  reducing  maternal  and infant  mortality as  well as communicable diseases such as TB, Vector-borne disease  of  malaria,  Kala-azar  and  Filaria,  water  borne  diseases  such  as cholera,  diarrhoeal  diseases,  leptospirosis,  and  vaccine-preventable  measles and tetanus.Second,  India  has to contend with the rising epidemic of non communicable diseases  including  cancers,  diabetes,  cardiovascular  diseases,  chronic obstructive pulmonary diseases and injuries.Third,  developing  systems  to  cope  with  the  new  and  re-emerging  infectious diseases like HIV, Avian influenza, SARS and very recent H1N1 influenza.Since independence, India has built up a vast health infrastructure and health personnel and considerable achievements have been made over the last six decades to improve  key health  indicators  such  as  life  expectancy,  child  mortality  and  infant  mortality  and maternal mortality.India, with a population of more than 1 billion people, has many challenges in improving the health and nutrition of its citizens. Even though there is a steady decline in fertility, maternal,  infant  and  child  mortalities  and  the  prevalence  of  severe  manifestations  of nutritional deficiencies, the pace is slow and falls short of national and MDG targets. The likely  explanations  include  social  inequities,  disparities  in  health  systems  between  and within  states  and  consequences  of  urbanization  and  demographic  transition.  In  2005, India  launched  in  a  big  way  the  National  Health  Mission  (NRHM),  an  extraordinary effort to strengthen the rural health care delivery systems. However, coverage of priority interventions  remains  insufficient,  and  the  content  and  the  quality  of  existing interventions are sub optimum.

India in the International Scenario in terms of key health indicators

The  comparative  picture  with  regard  to  key  health  indicators  such  as  Life  Expectancy, Maternal  Mortality  Rate,  Infant  Mortality  Rate  and  Total  Fertility  Rate  points  that countries placed  in almost same situations such as Indonesia, Sri  Lanka and China have performed much better than India.Life expectancy in India has more than  doubled in  years  the last sixty years. It increased from  around  30  years  at  the  time  of  independence  to  over  63.5  years  in  2002-2006. India‟s life expectancy is lower than the global average of 67.5 years and the average of most of countries that won their independence from colonial rule at about the same time like China, Vietnam, Srilanka and so on.India‟s Infant Mortality Rate too has shown a steady decline from 129 deaths per 1000 live births in 1971 t o  47  in 2010. The rate of decline has been slowing  from 9 points in the 1970s to 16 points in the current decade. Currently,  the urban IMR is  31  ascompared  to  the  rural  IMR  of  51.India  is  not  in  an  appreciable  situation  when compared with the countries of the same region.The problem of estimating MMR has been the fixing of a reliable denominator due to the comparative  rarity  of  the  event,  necessitating  a  large  sample  size.  However,  given  this constraint, data suggests that India had a MMR of 400  in 1997-98  to 301 in 2001-03 declining to 254 deaths per 100000 live births in 2004-2006 and 212 in 2007-09.On the maternal mortality front,  South Asian nations except Sri  Lanka do worse than India, and  South  Asia  as  a  region  has  poor  record  of  maternal  mortality  in  the  world,  very significantly affecting the global effect to achieve the MDG set for 2015.The  population stabilization  is indicated through  TFR, which is the average number of children that a woman would bear over her lifetime if she were to experience the currentage-specific  fertility  rates.  Total  Fertility  Rate  has  reduced  from  5.2  in  1971  to  2.6  in 2008. India‟s record compares poorly  with that of Japan, China and United States which have TFR of 1.3, 1.7 and 2.1 respectively.TFR varies significantly with female literacy, mean age of women at marriage, percentage of females working in non primary sectors, infant and child mortality, type of housing, and level of urbanization. The TFR declines significantly  with  the  level  of  education  of  mother,  and  income/wealth.  Population stabilization is also includes the maintenance of gender balance.

Variation of health indicators across the states

The  special  concern  and  challenge  is  the  wide  variance  in  health  indication  across  the states.  Life  expectancy  is  74  years  in  Kerala  whereas  the  life  expectancy  of  states  like Assam, Bihar, Madhya Pradesh, Orissa,  Rajasthan  and Uttar Pradesh is in the range of 58-62 years, a level achieved during the period of 190-75 in Kerala. Similarly, Kerala and Tamil  Nadu  reporting  an  MMR  of  95  and  111  respectively  lower  than  Assam  (480), Bihar/Jharkhand (312), Madhya Pradesh/ Chattisgarh (335), Orissa (303), Rajastan (388) and Uttar Pradesh/Uttar khand (440). Further,  TFR  of  Uttar  Pradesh,  Bihar,  Jharkhand,  Rajasthan,  Madhya  Pradesh,  and Chhattisgarh that account for over 40% of India‟ population and have a TFR in the range of 3.0 to 3.9 – a level that Kerala and Tamil Nadu had in the early 1970s.The  nine  states  Assam,  Bihar/  Jharkhand,  Madhya  Pradesh  /  Chhattisgarh,  Orissa, Rajasthan, Uttar Pradesh /  Uttar khand  account for 47% of India‟s population represent the  core  of  our  poor  performance  on  all  four  indicators  that  is  Life  expectancy,  IMR,MMR and TFR.

Maternal Health – Antenatal Care

Maternal  care  involves  three  stages  antenatal  care  (period  of  pregnancy),  delivery  care and  post  natal  care  (care  after  the  delivery  of  the  baby)  Even  though  every  stage  is significant for the health of mother as well as child, antenatal care takes more emphasis as it assures a safe delivery, less chances of neonatal deaths / infant deaths or maternal deaths. Ante natal care involves timely appropriate checkups,  taking Iron and Folic Acid supplements  and Tetanus  toxin  vaccines and delivery at  hospital.According  to NFHS-3,  less  than  half  of  the  women  received  antenatal  care  during  thefirst  trimester  of pregnancy,  22%  had  their  first  visit  during  the  fourth  or  fifth  month of  pregnancy  and 51% of mothers had three or more antenatal visits. Rural women are less likely to receive three or more visits than urban women.  65% of the mothers received IFAsupplements, but  only  23%  consumed  them  for  the  recommended  90  days  or  more.Three  in  Four mothers have received the prescribe dose of TT vaccination.

Delivery Care

Delivery  at  health  facility  in  the  presence  of  health  professionals  with  the  required medical  facility  is  recommended  for  safe  delivery.  Three  out  of  every  five  delivery  in India  take  place  at  home.  Only  two  births  out  of  five  takes  place  in  a  Health  facility. However, the percentage of birth in health facility has increased steadily since NHFS-1. According  to  NHFS-3,  Deliveries  at  home  are  more  common  in  among  women  who received  no  antenatal checkups, older women, women with no education, women in the lowest quintile and women with more than three previous births.

Postnatal Care

Early  postnatal  care  for  a  mother  helps  safeguard  her  health  and  can  reduce  maternal mortality.  Only  37%  of  mothers  had  a  postnatal  checkup  within  2  days  of  birth,  as  is recommended. Most women receive no postnatal care at all. Postnatal care is common following  births  in  a  medical  facility,  however,  about  one  in  five  births  in  medical facilities  were  not  followed  by  a  postnatal  checkup  of  the  mother.  Only  15%  of  home deliveries were followed by a postnatal checkup.

Maternal Mortality Rate

Maternal death is  an important indicator of the reach of effective clinical health services to  the  poor,  and  is  regarded  as  one  of  the  composite  measure  to  assess  the  country‟s progress. Reliable estimation of levels and trends of maternal mortality is thus extremely essential.  Deaths  due  to  pregnancy  and  child  birth  are  common  among  women  in  the reproductive  age  groups.  Reduction  of  mortality  of  women  has  thus  been  an  area  of concern and governments across the globe have set time bound targets to achieve it. The Millennium Development Goals (MDG) have  set the target of achieving 109  per lakh of live births by 2015.The MMR during 2001–03 has been 301 per 100000 live births. And 254 in 2006, 212  in 2009 .  Levels of maternal  mortality vary greatly across the regions due to variation in access to emergency obstetric care (EmOC), prenatal care, and anemia rates among women, education level of women, and other factors. There has been a substantial decline during the seven year period of 1997–2003. However, the pace of decline is insufficient. At the present rate of decline, it will be difficult to achieve the goal of 109  by 2015.  The major causes of these deaths have been identified as  Hemorrhage(both  ante  and  post  partum)  (37%),  toxemia  (hypertension  during  pregnancy)  (5%),obstructed labour  (5%), puerperal sepsis (infections after delivery and unsafe condition)(11%), abortions (8%), anemia and other conditions (34%).It is very clear that delivery care  remains an  important determinant of maternal health outcomes.  This reinforces that rapid  expansion  of  skilled  birth  attendance  and  EmOC  is  needed  to  further  reduce maternal  mortality  in  India.  The  trend  for  undertaking  an  institutional  delivery  is  on increase as desired in India but differentials exist in different parts.

Infant Mortality Rate

One  of  the  most  sensitive  indicators  of  the  health  status  of  a  population  is  Infant Mortality Rate. The IMR in India is steadily decreasing,  which is 50  per 1000 live births. It is  34  in  urban areas far lower than 55  of the rural area  during 2009.Further,  it  also varies across states with Kerala has the lowest IMR with 12 and the highest is in Madhya Pradesh with IMR of 67. It  is  observed  from  the  National  Family  Household  Survey-3  and  District  Level Household  Survey  -3  that  the  higher  rates  of  antenatal,  institutional  deliveries  and postnatal  are  associated  with  lower  IMR.Infant  mortality  in  rural  areas  is  50% higher than in the urban areas. Children whosemothers have no education are more than twice  as  likely  to  die  before  their  first  birthdayas  children  whose  mothers  have completed  at  least  10  years  of  school.  In  addition,children  from  scheduled  castes  and scheduled tribes are at greater risk of dying than otherchildren. The risk is high in case of mother‟s age is less than 20 or above 30.It  is  also  important  to  note  that  IMR  constitutes  significant  portion  of  Neo-natal Mortality. Neo-natal Mortality in India varies between 60 to 75% in various states.The causes  of  IMR  in  India  comprise  of  Acute  Respiratory  Infections,  Diarrhea,  Sepsis, Asphyxia, Prematurity and others.In  spite  of  much  effort  only  46.6  %  deliveries  are  assisted  by  Trained  Health  Care Personnel of which 38.7% are  Institutional deliveries. This indicates that concerted efforts will be required under Home Based Newborn Care(HBNC) to reduce the  IMR and Neo-natal Mortality Rate (NMR) further.Also inverse relationship is observed with higher education status of mothers and higher standard of living index.

Maternal and Child Health Programmes in India

India has a long history of  Maternal and Child Health Programmes  since independence, which have undergone significant shifts in their emphasis over time. The 5-year phase of RCH II was launched in 2005 with a vision to bring about outcomes as  envisioned  in  the  MDGs,  the  National  Population  Policy  2000,  the  National  Health Policy  2002  and  The  Tenth  Five  Year  Plan,  minimizing  the  regional  variations  in  the areas  of RCH and  population stabilization through  an integrated, focused, participatory programmes  meeting  the  provisions  of  assured,  equitable,  responsive  quality  services. The implementation of the RCH II was strengthened with its integration into the NRHM, where improved programme implementation and health system development was seen as mutually reinforcing processes.  In the five years since the launch of the NRHM in 2005, institutional deliveries have increased rapidly witnessing a remarkable ump in coverage from 7.39 to 90.37 lakh beneficiaries in 2008-09. Also quality of antenatal and postnatal care  is  also  being  strengthened,  while  the  ASHA  providing  support  for  increasing utilization.

Major initiatives in Child Health under RCH II:

The  strategy  for  child  health  care  aim  to  reduce  under  5  child  mortality  through interventions at every level of service delivery and through improved child care practices and child nutrition. One major component of the strategy was training to the AWWs and ANMs for early diagnosis and referral to facilities. At the facility level, the focus  was on strengthening capacity to cope with essential newborn care in newborn corners in every facility and promptly treat or refer sick newborns and sick children to more specialized newborn stabilization units or special newborn care units  at the district hospital. 213 sick newborn care units have been set up so far.IMNCI  strategy  encompasses  a  range  of  interventions  to  prevent  and  manage  5  major childhood illnesses  –  ARI, Diarrhea,  Measles, Malaria and Malnutrition with the major causes of neonatal mortality  –  prematurity and sepsis. In addition, IMNCI teaches about nutrition  including  breast  feeding  promotion,  complimentary  feeding  and micronutrients.It  focuses  on  preventive,  promotive,  a  curative  service  i.e.  it  gives  a holistic outlook to the programme. Major components of the strategy are:(a)  Strengthening the skills of the health care workers(b)  Strengthening the health care infrastructure(c)  Involvement of the communityThe first two components are facility based IMNCI and the third one is community based IMNCI.

The major features of the IMNCI  are:

  • Focus  on  the  newborn  care  and  young  infant-  since  a  significant  proportion  of child mortality is centered in the first few months of life
  • Development of protocol and algorithm for home visits by field functionaries like ANMs and AWWs for all newborns in the first week of life.
  • Ensuring  harmonization  between  existing  health  interventions  and  programmes like ICDS and anti Malaria programmes implemented by agencies other than the Department of Family Welfare that impact child health.
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