Infectious diseases are still major causes of death for children under five in poorer Indian states, a study has said, advocating scaling up vaccine coverage, improving childbirth and neonatal care, especially in states where mortality rates remain high.
India in 2015 had more deaths among children under five than any other country, the study published in The Lancet Global Health said.
Though India made great progress from 2000 to 2015 in reducing annual mortality among children under five, large disparities existed across states, according to the study led by researchers at the Johns Hopkins Bloomberg School of Public Health.
Among 25 major states, the highest under-5 mortality rates were observed in the northeast region (63·8 deaths per 1000 livebirths) and central region (60·6 deaths per 1000 livebirths), both more than twice that of the south region (29·7 deaths per 1000 livebirths).
After the south region, the lowest rates were observed in the west and north (35·2 deaths per 1000 livebirths) regions, increasing to 49·3 deaths per 1000 livebirths in the east region.
For example, the highest mortality rate, in Assam, a state in northeastern India, was more than seven times that in the western state of Goa.
Assam is followed by Madhya Pradesh and Odisha in having the highest under-5 mortality rates, whereas Kerala and Tamil Nadu registered the lowest rates besides Goa.
Most (57.9 percent) of deaths among Indian children under five in 2015 occurred in the first four weeks of life--the neonatal period.
Preventable Infectious Diseases
Although most under-five deaths were due to preterm complications, preventable infectious diseases featured prominently as causes of death in higher-mortality states, according to study co-lead author Li Liu, assistant professor in the Department of Population, Family and Reproductive Health at the Bloomberg School.
The research team included scientists from the Bloomberg School, the London School of Hygiene & Tropical Medicine, World Health Organization (WHO), Indian government health and vital records agencies and other institutions.
To accelerate India's progress against child mortality, the team recommends more extensive use of childhood vaccines, particularly against pneumonia- and meningitis-causing Streptococcus and H. influenzae bacteria.
India’s Ministry of Health and Family Welfare launched Mission Indradhanush (MI) in 2014, to target underserved, vulnerable, resistant, and inaccessible populations. This was followed by the launch of Intensified Mission Indradhanush (IMI), an ambitious plan to accelerate vaccination progress, in 2017.
Fake News and Anti Vaxxers
An analysis of India’s Intensified Mission Indradhanush strategy highlights factors, such as large mobile and isolated populations that are difficult to reach, and low demand from underinformed and misinformed populations who fear side effects and are influenced by anti-vaccination messages, in limiting vaccination coverage.
Asked on spread of fake news on vaccines and cultural and religious beliefs as barriers to vaccine coverage in the country, Liu told FIT:
India is not alone experiencing such challenges. Both the UK and US have suffered from vaccine fake news. As a result, measles have been on the rise globally.
“Cultural and religious beliefs are different. Certainly working with key opinion leaders to promote the correct information would be a first step. We’d also need to allow time for ideology diffusion as well,” Liu added.
Liu and colleagues also advocate--especially for higher-mortality regions--a scaling up of standard care strategies for newborns, including "kangaroo care" in which the baby rests against the mother's skin, thermal care to reduce hypothermia and early initiation of breastfeeding.
Child survival is also intrinsically linked to nutrition status of mothers.
Age at birth and marriage, are critically important for improving maternal and neonatal health. The biological mechanisms could include physiological, nutritional, and psychological readiness of the mothers associated with age and experience.Li Liu, Assistant Professor, Bloomberg School
In addition, there are social mechanisms. For example, delayed marriage and childbirth may increase women’s education and potential employment opportunities and hence independence, therefore empowering women in many ways to improve her and her babies’ health. This is particularly powerful in the context of India, Liu emphasised.
Teen Mothers and Nutrition
A recent study by researchers at International Food Policy Research Institute (IFPRI) found that prevalence of undernutrition was more in children born to teen mothers than in children born to adult mothers.
“We found that stunting and underweight were 11 percentage points more prevalent in children born to adolescent mothers compared with children born to adult mothers,” said IFPRI Senior Research Fellow and study co-author, Purnima Menon.
The researchers suggest interventions at ending early marriage could help improve maternal and child nutrition in India.
The nutrition community needs to align with policy communities working on reducing early marriage and early childbearing and accelerate actions in areas where early marriage and early childbearing are more prevalencePurnima Menon
Expanding further, Menon said India’s POSHAN Abhiyaan policy community must align strongly with the policy communities working on reducing early marriage and early childbearing and accelerate joint actions in areas where early marriage and early childbearing are more prevalent.
“Beti Bachao-Beti Padhao are already linked to the nutrition mission but the actions on the ground need to go beyond the campaign and focus on the context-specific drivers of early marriage and early childbearing,” Menon told FIT.
India is home to the more stunted children than any other country and is one of the ten countries with the largest burden of teenage pregnancy.
Although marriage before the age of 18 years is illegal in India, the 2016 National Family and Health Survey (NFHS)-4 revealed that 27 percent of girls are married before their 18th birthday and further, 31 percent of married Indian women gave birth by the age of 18 years.
Government of India has piloted different cash transfers conditional on education, with complementary programming meant to encourage investment in girls’ human capital, and several adolescent health programmes are ongoing under different ministries in India, the study notes.
However, there are strong cultural barriers, the authors said, to efforts to delaying early marriage. At the same time, the problem of early marriage in India isn’t geographically uniform.
“It’s hard to say what policies or programs would tackle the variability that is seen across India in teen pregnancies or in stunting. The fact is that there is a reason to this geographic variability – it speaks to the multiple determinants of teenage pregnancy in the different states and the effectiveness of state policies and programs,” Menon explained.
So a state-focused review of the current challenge of early pregnancy is important, along with a review and possible evaluation of efforts undertaken in those states, she added.
(Sahana Ghosh is a microbiologist-turned-journalist. She writes on science and environment and is interested in science in remote areas.)
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