'Child Survival And Safe Motherhood'- The Hard Road Ahead

Shanti Ghosh

Taking cognisance of the pre­vailing high maternal and child mor­tality in the country, India's latest (Eighth)Five Year Plan has adopted an ambi­tious programme for 'Child Survivaland Safe Motherhood (CSSM)'. Themajor objectives of this programmeare the reduction of IMR to 50, under­five mortality to 70, maternal mortalityt~ 200, and crude birth rate (CBR) tonine. The targets for service-cover­age include 100 per cent of antenatalcare as well as child-spacing informa­tion, an effective couple protectionrate of 65 per cent, and 100 per centdeliveries by trained attenGants.

These are laudable objectives.However, the enormity of the effortsthat will be needed to achieve thesegoals must be clearly recognised. Abrief review of the present nationalhealth scene in general and the stateof maternal and child health, in par­ticular, will indicate the magnitude ofthe efforts that will be needed to achievethese targets.

CHILD HEALTH CARE - THEPRESENT PICTURE

According to the 1979 InfantMortality Survey1, only 32 per cent ofchildren in India who died in infancy inrural areas and 65 per cent of thosewho died in urban areas were treatedby a medical practitioner. The figurefor the 1-4 year age group was 51 percent for rural and 77 per cent forurban areas. While lack of awarenessand faith in health services could beresponsible for such a situation, lackof access to health services must surelyalso be an important factor. Only about12 per cent of 0-4 year old children inrural areas and about 29 per cent inurban areas are presently reckonedto have access to health care. Nowthat nearly 14 years have elapsedsince this survey was conducted, it isto be hoped that the conditions todayhave improved.

More recent data show that the

age-specific death rate for 0-4 yearage group is more than thrice thedeath rate for the population as awhole. Significantly, a higher percentageof deaths in rural areas occur in this

age group (48.6 per cent) than inurban areas (36.0 per cent) and morefemales (48.8 per cent) than males(45.3 per cent) die by the age of fiveyears. Forty-eight per cent of femalechildren and 64 per cent of male chil­dren were treated within the first 24hours of their ultimately fatal illness.Infant mortality accounts for one-thirdof total deaths, and under-five mortal­ity accounts for over half of all deaths.

While the post-neonatal mortal­!ty has shown a slow decline resultingIn an IMR of 80 for 1991, perinatal(PNMR) and neonatal mortality (NMR)rates have hardly budged in the pasttwo decades. PNMR was 53.4 in 1971,while it was 50.1 in 1989. NMR was 68in 1970 and 67 in 1983 (RegistrarGeneral of India). The situation re­mains more or less the same till to­day. An estimated 2.5 million infantsand 1.5 million children between oneand five years of age die each year.

A large number of children con­tinue to die of common infectious dis­eases. Diarrhoea claims a million livesand respiratory problems about 600,000lives. There is, however, some heart­ening evidence of reduction in deathsdue to neonatal tetanus (5,776 in 1992,as compared to 11,649in 1988). Tetanustoxoid coverage now is estimated tobe 77.5 percent and the goal is toeliminate neonatal tetanus by 1995.

The Kerala experience: We arenever tired of citing the example ofthe Indian state of Kerala for the revo­lution in health indicators that hastaken place there. Between 1921-1930infant mortality in Kerala was 210,compared to 220 in the whole of India.Life expectancy was 29.5, comparedto India's 26.9. IMR came down to120 in 1951-1960, and now (1991) is17; and the pattern is in line with thatof the developed countries.

Per capita expenditure on healthis highest in Kerala. Private expendi­ture on health exceeds governmentexpenditure. Putting the two together,the proportion of the state incomespent on medical and public healthvaries between 4.5 and 6.4 per cent.Average per capita expenditure on

5

health-care is a little over 7 per cent 01

the total expenditure. There is betterdistribution of health services and be­cause of a vast network of roads (242km of road length per 100 km2 com­pared to 47 km for the country as awhole), access to health services ismuch easier than in other states. Thehigh levels of education contribute toawareness and better utilisation ofhealth services, and also to a higherage of marriage and a low fertilityrate. Kottayam in Kerala has the dis­tinction of 100 per cent literacy, MMRof 0.03/1,000, birth rate of 9.5 andIMR of 9.52.

Cost of health care: Two im­

portant considerations, namely, (a)universal access to health care and(b) containing the cost of health care,have guided health policies of manycountries. In delivering health' ser­vices, cost, outreach and quality areof prime importance. The tremendousincrease in the cost of delivery ofhealth care, which is one of the directconsequences of its increasing de­pendence on high technology, hasfurther aggravated the inadequacy ofaccess to health care.

DRUG POLICY

In a relatively small outlay onhealth, an inordinately large propor­tion of India's present health budgetis being spent on drugs. A rationalpolicy on the use of drugs, if imple­mented, would decrease expenditureon drugs while not adversely affectingthe quality of coverage of health care.

The prevailing mismatch in pro­duction and distribution of drugs inIndia is highlighted by the indepen­dent assessment of two different UNagencies. UNIDO puts India in Cat­egory 4, which means that the countryis technologically developed to be to­tally self-reliant in drugs (as a matterof a fact, India is one of the leaders indrug export). However, WHO puts In­dia in Group A, which means that lessthan 30 per cent of its population hasregular access to essential drugs! Inactual figures, the health sector ex­penditure was Rs 3,105 crore in 1986­90. Out of this, 35 per cent was spenton drugs, which is a large percentageof a small budget. There are over50,000 drug preparations in the mar­ket, while WHO recommends that about1,500 preparations of about 250 enti­ties are mo~e than adequate to takecare of 95 per ,cent of the illnesses.

Table 1: Percentage of births by type ofattention at birth, rural/urban, India, 1993Rural

UrbanTotal

Institutionai

12.6~~3Attended by a trained person16.3

Attended by untrained person71.129.::> 62.7

Source: Sample Registration Bulletin

The poorest 40 per cent of ruralhouseholds spend, on an average, Rs157 for an illness episode, when re­ceiving care from government doc­tors and Rs 131 when purchasing carefrom private doctors (42nd round ofthe National Sample Survey (NSS)­1987). Medical care cost is only nextto dowry expenses as a cause of ruralindebtedness. Several reports3 haveassessed that 7-9 per cent of a ruralhousehold income is spent on healthcare which is often of poor quality andby 'doctors' usually untrained. A studyon diarrhoea in rurallndia4 found that

65 per cent of diarrhoea cases go formedical consultation. Of these 80 percent go to private practitioners andonly 10 per cent go to governmenthealth facilities. Almost 62 per cent of'private doctors' had no formal medi­cal qualifications. Even the poor ruralpopulation is more than willing to paya reasonable amount for efficient healthservices. In fact, they value serviceswhich they have paid for.

While the medical pr.ofession isoften guilty of prescribing drugs un­necessarily, a large number of drugsare self-prescribed and sold withoutprescription. Toxicity of drugs usedirrationally is being increasingly seen.Drug resistance is becoming common.The National Drug Policy, announcedin 1978, had recommended that un­necessary combinations of drugs wou Idnot be marketed; that 116 essentialdrugs would always be available inabundance; and that drugs would bemarketed by their generic names. Theserecommendations have not been ef­fectively implemented.

MALNUTRITION

Protein energy malnutrition (PEM)and micronutrient deficiencies are stillwidespread, the former affecting halfthe children under six years. Anaemiais almost universal. While iodine defi­ciency in eJstwhile endemic areas hasnot been brought effectively undercontrol, new goitre endemic areas havebeen identified in the irrigated plains.Vitamin A deficiency, even though muchless in evidence than before, still mani­fests in milder forms in large numbersof children.

Malnutrition is, in many respects,the common denominator of the dis­eases and deprivation processes thatreduce child survival. Moderate to se­vere undernutrition affects nearly halfthe children and contributes directly

or indirectly to 60 per cent of all childdeaths. Those severely malnourishedhave 20 times greater chances of dy­ing than their normally nourished peers.And yet the Eighth Plan hardly makesadequate reference to practical waysof combating undernutrition. It wouldseem that for a malnourished childevery infection is a potentially fatalillness. Several studies and reportshave shown a higher rate of malnutri­tion among girls compared to boyswhich would contribute to a highermortality among the girls5. The cyclegoes on - today's malnourished girlgrows up to a malnourished mother,who in turn gives birth to a small,undernourished baby.

REPRODUCTIVE HEALTH

Many paediatricians now realisethe vital role that women's health,empowerment and decision-makingpower play in child health and in childsurvival; and barriers between disci­plines are breaking down. Paediatriciansare as concerned with maternal health

and fertility regulation as obstetriciansand indeed, demographers and so­cial scientists. Limiting reproductionand increasing spacing is really es­sential for the health of women andchildren, and ultimately of the nation.

'Reproductive health care' shouldnot be equated just with 'family plan­ning'. The scope of reproductive healthcare should be expanded to includeall aspects of women's health. Repro­ductive tract infections are an impor­tant reason for the poor acceptanceand low continuation rates of contra­ceptive methods such as IUD and yet,there is no provision for their man­agement in family planning program­mes6. A study from Bangladesh? re­vealed high morbidity among familyplanning acceptors. Women's viewson health care have been largely missingfrom policy debates and should beincorporated in any health policy af­fecting women,family planningbeing an impor­tant one. Wo­men must beempowered tomake informedchoices and notconsidereddumb recipientsof a benevolentgovernment pro­gramme.

6

Maternal health, nutrition andeducation are important for the sur­vival and well-being of women in theirown right and are key determinants ofthe health and well-being of the child.High rates of infant mortality, espe­cially neonatal mortality, are linked tountimely pregnancies, unsafe deliv­eries, low-birth-weights and pretermbirths, high fertility rates, etc. Theseare also major causes of maternalmortality. There is an added benefit ofpromoting maternal and child healthprogrammes and family planning to­gether in that, acting synergistically,these activities help accelerate thereduction of both mortality and fertil­ity and contribute more to roweringrates of population growth than eithertype of activity alone.

Maternal mort~lity: Maternalmortality is the health indicator whichshows the greatest differential betweendeveloped and developing countries.The life-time risk of death related topregnancies and child-bearing is esti­mated to be 500 times higher for womenin Africa and large parts of Asia thanfor those of the developed countries.A majority of deaths occur around thetime of delivery. Resorting to unsafeabortion of unwanted pregnancies isanother contributing factor. Maternalmortality accounts for 2.5 per cent ofall female deaths and 12.5 per cent ofdeaths among rural women in the 15to 45 year age group (Office of theRegistrar General, 1988).

, Dais are being trained in Indiafor the last several dec?des but alarge number of deliveries are stillbeing conducted by untrained dais orfamily members, as shown'in Table 1.

In a study by the Indian Councilof Medical Research (ICMR) and bythe Maulana Azad Medical College,the proportion of deliveries attendedby untrained persons in urban slumswas found to be around 60 per cent.The Sample Registration System does

Figure: Girl Child Mortality- Regional Distribution

Between the third and the fifthyear, a female child is exposed tomuch greater risk of death than amale child. It is an interesting obser­vation that a straight line drawn fromthe city of Bharuch in the west toBirbhum in the east would neatly di­vide the country into two parts - thenorthern with an excess of femalechild mortality and the southern withfemale child mortality lower than malemortality, the only exceptions with re­spect to the latter would be Salem inTamil Nadu, Gulbarga in Karnataka,Kurnool in Andhra Pradesh and Ganjamin Orissa9 (Figure). The reason forthis peculiar distribution of gender dis­crimination is not clear.

•KURNOOL

work for eight to 12 hours a day. Morethan a quarter suffer from health prob­lems, with poor access to medicalfacilities, and are constantly exposedto poor environment, dirt, smoke andextremes of temperature, in additionto poor bathing or toilet facilities

In 1986, the Government of In­dia adopted the Child Labour (Prohi­bition and Regulation Act) to protectchildren under 14 years from hazard­ous jobs. The Act only covers childrengoing to work under identifiable em­ployers, thereby denying protectionto many female children who work asfamily help. Also the age cannot al-

Table2: Age specificdeath rate by genderAGE

MF

0-4

39.543.0

5-9

3.64.6

10-14

1.62.0

15-19

2.02.8

20-24

2.83.9

25-29

2.83.8

30-34

3.23.5

Source: Sample Registration Bulletin

XXI No 1, Office of the RegistrarGeneral of India, New Delhi, 1987

~HIGH

The gender gap in survival is thegreatest during the first five years oflife when girl-child mortality is about20 times greater than that of any otherfive-year age group. Deaths of younggirls exceed those of young boys byalmost one-third of a million everyyear. Only after 35 years of age, whenwomen have passed their child bear­ing years, do female mortality ratesdrop below male rates (Table 2).

Child health in urban slums:The problem of urbanisation is ac­quiring increasing proportions. Thirty­three million children and women areliving below the poverty line in thecities and towns ofIndia. Children alonenumber 18 million,of which a consid­erable number in thebig cities are streetchildren.

Considerableinformation is avail­able now about streetchildren. Seventy­one million live inurban areas of which18 million live inslums. A recent studycarried out in 14 cit­

ies by the Ministryof Welfare, Govern­ment of India,showed that street­children from urban

slums were engagedas porters, sh6e­shine boys, news­paper sellers, loadcarriers and aboutone-third as shop as­sistants. Most ofthem were found to

not include slums in the urban sample.

When a mother is seriously ill ordies as a result of child-birth, the in­fant has to be abruptly weaned fromthe breast, and generally may notsurvive. A recent study in Bangladesh8found that more than one-third of theinfants, whose mothers died post­partum, died themselves during theneonatal period. Other children uncaredfor might become sick or die. Be­cause of maternal deaths, older girlsare prematurely burdened with housework and child care and cannot go toschool.

Age at marriage: The propor­tion of girls who are at obstetric risk issignificantly reduced at 18 years ascompared to at 14 years. Maternalmortality rates are reported to be fivetimes higher in 12-14 yearolds than in20-24 yearolds (WHO,UNFPAlUNICEF,1989). Raising the age at marriagecould, therefore, pay dividends in bet­ter pregnancy outcome and bettermaternal, foetal and infant survivaleven in the current context of povertyof our rural and disadvantaged urbancommunities. Children born to ado­lescent mothers are about 40 per centmore likely to die during the first yearof life than those born to women in

their 20s and are at even greater riskduring the second year.

Three of the most important strat­egies now available for reducing childdeaths - the education of women,spacing of births and breast-feeding- also happen to be among the mostdirect methods of reducing child births.Breast-feeding prevents more preg­nancies than any other method.

Child-mortality - the genderdifference: There are ample data ondiscrimination against the female startingeven at birth and going on till thegrave. Foeticide has been claimed tobe increasing rapidly and there areallegations of an unholy nexus be­tween some laboratories, radiologistsand gynaecologists in this regard. Thereare also alarming reports about fe­male infanticide in some parts of thecountry. Even allowing for some de­gree of exaggeration and sensationa­'jsation, these reports must causeL.)ncern. In most of the northern andnorth-eastern states, males outnum­ber femaies by almost 10 per cent.The only Sth. ' in which the sex ratio isabove 1,000 .> ':erala - with a figureof 1,040.

ways be verified in the absence ofbirth registration.

There is very little informationon the health problems of these chil­dren. The three main occupations ­making matches, gem polishing usingsilicon and glass, and metal works ­are health hazards and cause ill-healthand shorten lives. Since by the timethese children reach adulthood theirhealth is so impaired as to disablethem from hard work, they, in turn,send their own children to work in thesame professions. So the vicious cyclecontinues.

In order that the goals set out inthe the Eighth Five year Plan for 'ChildSurvival and Safe Motherhood' arerealised it will be necessary to takedue note of the formidable problemsdiscussed above and to institute spe­cific action programmes to combatthem successfully within a reason­able time-frame. The Kerala and TamilNadu experiences provide hearten­ing evidence that the attainment ofthese goals is not impossible. What isneeded is deep commitment at alllevels and efficient management anddevelopment of material and man­power resources already available withinthe country.

The author is Senior Consultant, Maternal/ChildHealth.

References

1. Survey of Infant Mortality, Registrar General's

Office Report, 1979.

2. Alphons, K.J.: Kottayam, Kerala's first literatetown. Times of India, December 17,1993

3. Bhat, R.: The private health care sector in India.

In: Paying for India's Health Care. Eds: Berman,Peter and Khan, M.K., Sage Publications, New

Delhi/Newbury Rock/London, 1993.

4. Viswanathan, H. and Rodhe, J.E.: Diarrhoea in

rural India. A nation-wide study of mothers and

practitioners, New Delhi, Vision Books, 1990.

5. Ghosh S: The female child in India - A struggle

for survival. NFl Bulletin 8(4). 1987.

6. Bang, R. et al: High prevalence of gynaecologicaldiseases in rural Indian women. Lancet, January,

pp 85-88,1989.

7. Wasserheit, G.N. et al: Reproductive tract infec­

tions in family planning population in rural Bangladesh.

Studies in Family Planning, Volume 20(2) March/

April 1989.

8. Koenig, M.A., Fauvean, V., Chowdhary, A.I.,

Chakraborty, J. and Khan, H.A.: Maternal mortality

in Matlab, Bangladesh: 1976-85. Studies in FamilyPlanning 19(2). March-April, 1988.

FOUNDATIONNEWS

* Evaluation of the project on "Edu­cation for Better Living of Rural Ado­lescent Girls" carried out in Gwalior(MP), Bharatpur (Rajasthan), andVaranasi (UP), is now nearing comple­tion. Dr Shanti Ghosh and Dr SarammaMathai Visited these centres as exter­nal evaluators.

* The Annual General Body Meetingof the Foundation was held on March29, 1994 at the India InternationalCentre, New Delhi.

* Dr C. Gopalan, President of theFoundation, has been nominatedMember, Planning Board,MadhyaPradesh government. It is expectedthat a major programme designed tomobilise youth (especially adolescentgirls) will be initiated in the state. Thevolunteers who will be imparted ap­propriate training will act in the inter­face between the provider (govern­ment) and the consumer (community);and will promote optimal utilisation ofavailable resources for health/nutri­tion upliftment. Meaningful commu­nity participation and involvement inhealth and nutrition programme couldthus be ensured.

Lectures by the President,Dr C. Gopalan

* "Changing Profile of Malnutrition inthe Developing World" at the Interna­tional Symposium on Clinical Nutri­tion, at the All India Institute of Medi­cal Sciences, New Delhi, on January6, 1994.

* The Second Shri AvinashilingamMemorial Lecture on "Education andEmpowerment of Women for NationalDevelopment" at the AvinashilingamInstitute for Home Science, Coimbatore,on January 13, 1994.

* Key-note address on "Public health:The Need for a New Direction", at theInternational Conference of MedicalParliamentarians in Bangkok on Feb­ruary 7, 1994.

the Eighth Asian Congress of Paediatricsin New Delhi on February 11, 1994.

Fund-raising

* The Foundation had recently is­sued an Appeal for Funds to scien­tists from within India and abroad aspart of its fund raising drive. Donorswho respond positively to the appealwill be listed in the Bulletin from timeto time in the chronological order inwhich their donations are received.

The Foundation deeply appreci­. ates donations already received from

the following scientists:

Dr David Rush (USA); Dr R.K.Chandra (Canada); Dr James Olson(USA); Dr A.S. Prasad (USA);Dr ShubhKumar (USA); Dr Margaret Biswas(UK).

New WHO (SEARO)Publication

* "Nutrition Research in South­East Asia - The Emerging Agendaof the Future" by Dr C. Gopalan,just published by WHO (SEARO),broadly outlines a possible agendafor nutrition research in the coun­tries of South-East Asia for theturn of the century. It deals withsome of the major nutrition andnutrition-related research issuesthat may need special attentionin the coming decades. Copiesof the book (135 pp, priceRs 125) can be obtained fromthe WHO (SEARO) office, Indra­prastha Estate, New Delhi.

Erratum

In the January issue's (Vol15 No 1) paper on "Diet in RenalDisease" on page 5, in the sev­enth para, third line "Amino ac­ids release glucagon from thekidneys"must be read as "Aminoacids release glucagon from thepancreas".

We are grateful to UNICEF fora matching grant towards the

cost of this publication

9. Registrar General's Report. Occasional Paper * Plenary Lecture on "The ChangingNo 5,1988. Picture of Child Nutrition in Asia" at

Edited by Harvinder Kaur for the Nutrition Foundation of India, B-37 Gulmohar Park. Designed and produced by Media Workshop. Tel 6410474,6416570. Printed by Vashima Printers.