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Report on Under-Five Child Health in India

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India has the world's highest percentage (21%) of under-five deaths, estimated at 1726000 in 2009 owing to its large population1. The country has managed to reduce the under-five mortality rate from 118 per 1000 live births in 1990 to 63 per 1000 live births in 2010. This average annual rate of decline at 3.1% is considered insufficient to achieve the Millennium Development Goal 4 of reducing under-five mortality to 39 per 1000 live births by 20152. These figures however do not reveal the huge inequities in mortality rates across the country, within States and between them, as well as between children in urban and rural areas3. In India, states such as Assam, Arunachal Pradesh, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh have higher under-five mortality than the rest of India. On account of the unacceptably high fertility and mortality indicators, these states which constitute 48% of India population, have been designated as the ‘High Focus States’ by the Government of India. This report aims to discuss the three major causes of under-five mortality in these high focus states and suggest interventions to combat the same.
Diarrhea is one of the leading causes of under-five mortality among the high focus states accounting for about 15-17% of deaths among children under five4. Maternal factors, nutrient deficiency and environmental hygiene are some of the distal determinants of this leading cause. Some of the proximal determinants are lack of immunization, delay in seeking care, access to healthcare and personal hygiene6. Poor knowledge of proper treatment of diarrhea is one of the major causes contributing to deaths caused by diarrhea. Research in the past have established that education is a proxy for health knowledge5 and thereby implementing programs to improve the literacy of women in these states can significantly reduce the deaths due to diarrhea. Other interventions to be considered include (1) Child health programs supplementing essential nutrients such as zinc, vitamin A, (2) Improving immunization coverage, (3)Programs to improve sanitation and hygiene by building toilets, provision of clean source of water and proper disposal of human waste6, (4) Expanding campaigns to accentuate the importance of ORS as treatment for dehydration rather than for stopping diarrhea6,(5) Campaigns providing education about proper feeding practices, promoting hand washing and proper storage of water, (6) Promoting public healthcare facilities as available resources of treatment is also a major intervention6.
Acute respiratory infection including pneumonia is another cause of under- five mortality among these states. Pneumonia is singly responsible for almost 13% of total mortality in this vulnerable age group4. Air pollution, overcrowding and maternal transmission of HIV are some of important proximal determinants while under nutrition, lack of breastfeeding, late recognition of danger signs are some of the distal determinants7. Interventions to address these determinants include (1) Controlling tobacco use and providing alternatives for solid fuel use within the house hold can help to reduce indoor pollution, (2) Promoting exclusive breastfeeding and appropriate timing of complementary feeding, (3) Strategies to prevent mother-to-child transmission of HIV and to improve the management of HIV infection and P. jiroveci pneumonia prophylaxis in children, (4) Expanding immunization coverage and (5) Community based programs to treat pneumonia by community workers. Third important cause of under- five mortality is neonatal infections contributing to about 6-9% of under-five deaths in these states. Some of the key proximal determinants of this cause include maternal health, cultural beliefs, short birth intervals and key distal determinants include unsafe delivery practices, low birth weight and improper newborn care. Interventions suggested are (1) Promoting community based education on improved maternal and newborn care such as cord care, thermal care, recognizing signs of sepsis (2) Home-based treatment for newborn infections, (3) Providing intensive antenatal care for young women and women with high parity and short birth intervals, (4) Improving utilization of family planning services, (5) Nutritional supplementation and immunization programs for low birth weight babies and premature babies.

The regional inequality in the distribution of under-five mortality in India suggests that specific interventions might be priorities for different regions. Overall the child survival can be improved by increasing the awareness among caregivers about the potential risk factors and interventions that are available. This report helps to identify the three major causes of under-five mortality among the high focus states and also suggests some interventions to address these causes.

References:
1 Kumar C, Singh PK, Rai RK. Under-five mortality in high focus states in India: a district level geospatial analysis. Baradaran HR, ed. PloS one. 2012;7(5):e37515. Available at: http://dx.plos.org/10.1371/journal.pone.0037515. Accessed December 5, 2012. 2 UN, General assembly, 56th session. Road Map towards the implementation of the United Nations Millennium declaration: report of the Secretary-General. New York: United Nations, 2001.
3 Subramanian SV, Nandy S, Irving M, Gordon D, Lambert H, et al. The mortality divide in India: the differential contribution of gender, caste and standard of living across the life course. American Journal of Public Health 96. 2006. (p): 826–833
4 The Million Death Study Collaborators. Causes of neonatal and child mortality in India: a nationally representative mortality survey.The Lancet, Volume 376, Issue 9755, 27 November–3 December 2010, Pages 1853–1860
5 Desai S, Alwa S. Maternal Education and Child Health: Is there a Strong Causal Realitionships?. Demography, 35(1), 71 - 81
6 Pneumonia and Diarrhea: Tackling the Deadliest Diseases for World's Poorest Children. Statistics and Monitoring Section – Division of Policy and Strategy. United Nation's Children's Fund. June 2012.
7 Varinder Singh. The burden of pneumonia in children: an Asian perspective Paediatric Respiratory Reviews, Volume 6, Issue 2, June 2005, Pages 88–93

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