|Year : 2019 | Volume
| Issue : 1 | Page : 33
High under-five mortality rate in Rural Madhya Pradesh, time to identify high-risk districts using National Family Health Survey-4 data with comparison to low under-five mortality rate in Rural Tamil Nadu, India
Kishor Parashramji Brahmapurkar
Department of Community Medicine, LBRKM Government Medical College, Jagdalpur, Chhattisgarh, India
|Date of Submission||24-Mar-2017|
|Date of Acceptance||30-Nov-2017|
|Date of Web Publication||05-Mar-2019|
Kishor Parashramji Brahmapurkar
Department of Community Medicine, LBRKM Government Medical College, Jagdalpur - 494 001, Bastar, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Background: India had highest number of under-five deaths, 1.2 million deaths out of 5.9 million (2015). As per the results from the first phase of National Family Health Survey (NFHS-4), 2015–2016, under-five mortality rate was highest in rural area of Madhya Pradesh (MP), 69/1000 live birth as compared to urban areas, 52/1000 live birth. The objective of the study was to identify potentially high-risk districts (HRD). Methods: This study was carried out from the secondary data of 50 districts of MP State which was available from NFHS-4 with information from 49,164 households. Scoring method was used to identify HRD by comparing variables related to maternal and child health care of rural MP with rural Tamil Nadu. Results: Eleven HRDs were identified with poor maternal and child health care along with high women's illiteracy and high percentage of child marriages in women. Indore division had 3 topmost HRD, Alirajpur, Jhabua, and Barwani followed by Rewa division with 2, Singrauli and Sidhi along with Sagar division. Conclusions: HRDs should be considered for targeted interventions using the strategies for reducing under-five mortality rate in rural MP.
Keywords: Antenatal care, high-risk districts, Madhya Pradesh, postnatal care, under-five mortality rate
|How to cite this article:|
Brahmapurkar KP. High under-five mortality rate in Rural Madhya Pradesh, time to identify high-risk districts using National Family Health Survey-4 data with comparison to low under-five mortality rate in Rural Tamil Nadu, India. Int J Prev Med 2019;10:33
|How to cite this URL:|
Brahmapurkar KP. High under-five mortality rate in Rural Madhya Pradesh, time to identify high-risk districts using National Family Health Survey-4 data with comparison to low under-five mortality rate in Rural Tamil Nadu, India. Int J Prev Med [serial online] 2019 [cited 2019 Jul 23];10:33. Available from: http://www.ijpvmjournal.net/text.asp?2019/10/1/33/253417
| Introduction|| |
In 2015, India had highest number of under-five deaths, 1.2 million deaths out of 5.9 million and was in top rank in total number of under-five deaths.
As per the outcomes from the first phase of the National Family Health Survey (NFHS-4), 2015–2016, U5MR was found irregularly distributed among the states. Tamil Nadu (TN) had lesser U5MR of 27/1000 live births contrasted to Madhya Pradesh (MP), 65/1000 live births., U5MR was higher in rural area, 69/1000 live birth in MP compared to urban area, 52/1000 live births. There is a paucity of information on districts which are potentially high risk for U5MR.
Hence, the present study was planned with the objective of identifying potentially high-risk districts (HRD) in MP and suggesting possible reasons for it and suitable strategies.
| Methods|| |
This study was carried out from secondary data of state MP available from NFHS-4 (2015–2016).,, The details of sampling method, interview schedule, and definitions used were available in NFHS-4 factsheets.,
Inclusion and exclusion criteria
Based on availability of estimates for rural area in district factsheet of Madhya Pradesh.
Districts having 30%–70% or more than 70% rural population were included as estimates for rural area were available in district factsheet.
Districts having <30% rural population were excluded as estimates for rural area were not available in district factsheet.
Hence, out of 50 districts, 48 were included after excluding Bhopal and Indore with <30% rural population and as data were not available for these two districts for rural area in district factsheet of MP in NFHS-4 data factsheet. NFHS-4 fieldwork for MP after excluding Bhopal and Indore was carried out with information from 49,164 households, 59,287 women, and 8950 men of 48 districts and survey schedules, collection of information were available in factsheets of concerned states which was adequate to provide reliable estimates of most indicators for rural areas.,
Operational procedure to identify high risk districts
Scoring was done for positive and negative attributes as shown in [Table 1]. Total score was 40 for district and minimum score of zero by comparison of variables of rural MP with rural TN. Total score was calculated by comparing attributes with that of rural TN as U5MR for rural TN was 31/1000 live births as compared to 69/1000 live births for rural MP, and it was recommended that there is a need to follow the better performer within country to decrease U5MR and it was based on comparison between TN and MP.,,
|Table 1: Scoring method to identify high-risk districts of rural Madhya Pradesh|
Click here to view
Cutoff for labeling a district as very high risk was score of more than or equal to 20 and for HRD it was more than or equal to 14. Those districts having more than equal to 50% (20 and above score) will be topmost HRDs and those having more than equal to 35% (14 and above score) will be HRDs.
This study had used publicly available record available on the website of the following organization: the NFHS-4., Because freely-available database was used in this analysis, no ethical approval was sought.
Data entry were done using Microsoft Office Excel worksheet.
| Results|| |
Women's literacy was lowest in Alirajpur district, 22% followed by Jhabua 24.3% [Table 2]. Maximum prevalence of child marriage was observed in Jhabua, 53.8% and Ratlam district 51.3% [Table 2] and [Table 3]. Out of 11 High Risk Districts (HRD), lowest use of family planning method was seen in Jhabua district, 8.3% followed by Vidisha and Ratlam with 23.8% and 26.4%, respectively [Table 2] and [Table 3].
|Table 2: Distribution of topmost high-risk districts in Madhya Pradesh for maternal and child health care|
Click here to view
|Table 3: Distribution of some high-risk districts in Madhya Pradesh for maternal and child health care|
Click here to view
Full antenatal care (ANC) which was defined as, no less than 4 antenatal visits, one tetanus toxoid injection and consumption of iron folic acid (IFA) tablets for 100 or more days was lowest in district Sidhi 1.9%, Tikamgarh 2.6%, Alirajpur 3.4%, and Jhabua 4.8% [Table 2] and [Table 3].
The percentage of mothers who had received postnatal care (PNC) from health personnel within 2 days of delivery was only 24.5% in Sidhi and 27.8% in Singrauli district [Table 2]. Only 02% of child in Sidhi district received PNC from health personnel within 2 days of delivery followed by Shahdol, 3.8% and Damoh 4.2% [Table 2] and [Table 3].
Skilled birth attendance was lowest in Singrauli and Barwani district, 39.8% and 47.5%, respectively [Table 2]. Anemia in pregnant women and children was higher in Ratlam district, 72.7% and 77.2%, respectively, and Jhabua (more than 70% in both) and Barwani district (68.7% in pregnant women and 83.1% in children) [Table 2] and [Table 3].
Out of 11 HRD, Jhabua and Alirajpur had lowest percentage of full immunization, 19.9% and 22.1%, respectively [Table 2]. The percentage of stunting was highest in Alirajpur, 76.6% followed by Barwani 54.5% [Table 2].
| Discussion|| |
In the present study, an effort has been made to find out potential HRDs for higher U5MR. Eleven HRD were identified.
Overall women's literacy was 51.4% for rural MP. There were various studies, in which women's literacy was found to be significantly associated with utilization of ANC services.,,,,,,,, Sarva Shiksha Abhiyan which is Government of India's flagship program for making free and compulsory Education to the Children of 6–14 years age group, a Fundamental Right, needs to be strengthened.
Another issue is of higher prevalence of child marriages among women which was highest in Jhabua district, 53.8%. Child marriage had been observed to be extensively linked with women's illiteracy and was considerably associated with delay in ANC and incidence of spontaneous abortion, preterm delivery, and low birthweight babies which contributes to higher U5MR.,
As per the Prohibition of Child Marriage Act, 2006, child marriage is a crime and punishable up to 2 years imprisonment and/or a fine up to Rs. 100,000/-and is applicable to all who performs or directs a child marriage.
Full ANC coverage was 8.3% for rural MP. As per NFHS-4, Bihar had the lowest full ANC percentage, 3% in rural area, followed by Tripura (6.8%), Uttarakhand (9.4%), and Assam (16.6%). Singh et 1al. had found 14% of rural adolescent women had full ANC among educated women as compared to 7% among uneducated. Sahu et al. had found association between full ANC and infant mortality, infant mortality was lower in women who had received full ANC as compared to those women who did not receive ANC.
Only 20% women of rural MP had consumed IFA during pregnancy for 100 days, and it was lower in Sidhi, 9.9% which also had higher child marriage (46.4%) and illiteracy (44.7%). Wendt et al. in rural Bihar of India had observed that child marriage and illiteracy among women were associated with poor consumption IFA tablets, 37% during pregnancy.
Mothers who had received PNC from health personnel within 2 days of delivery is an area of concern, as 50% PNC from rural MP had not received it. However, 100% PNC coverage was observed in tribal women who were visited at least twice at their home after delivery for PNC by Junior Public Health Nurse in Kerala.
Even though skilled birth attendant (SBA) at the time of delivery was more than 70% in rural MP, it was only 39.8% in Singrauli district. Titaley et al. had observed a progressive reduction in neonatal mortality as the SBA at delivery increases.
Higher percentage of pregnant women, 75.5% were anemic in Jhabua as compared to 56.4% at state level. Niswade et al. had found that neonatal mortality was positively associated with nonaddition of IFA during pregnancy.
Another issue of concern is PNC visit of child, as only 2% of children had received a health check after birth from health personnel within 2 days in Sidhi district compared to Singrauli district 11.7%. Titaley et al. had observed infants were significantly protected from neonatal death if they had received PNC.
Although full immunization coverage at state level was 50.2% among children aged 12–23 months, it was lowest in Jhabua district, 19.9% followed by Alirajpur 22.1%. It was observed that those women who were educated are more likely to immunize their children.,
Breastfed within 1 h of birth was lowest in Ratlam district, 8.3% followed by Jhabua district, 21.6%, whereas it was more than 34% in all HRD. Immediate breastfeeding protects the newborn from diseases and malnutrition.
The reasons for higher child mortality in rural MP could be those highlighted above. These HRDs need to be focused at state, regional, and district level review meetings with objective to sensitize concerned staff regarding each and every under-five death occurring in particular district. Intersectoral coordination needs to be strengthened to prevent child marriages and to improve the women's literacy in district-level task force meetings. Furthermore, there is need to identify high-risk blocks by conducting further research in HRDs to identify the needs and actions required to meet the demands identified accordingly.
As the datasets for the NFHS-4 were not available at Demographic and Health Survey, detailed analysis for the association of factors related to higher U5MR was not done.
| Conclusions|| |
HRDs should be considered for targeted interventions using the strategies for reducing under-five mortality rate in rural MP as limited resources are available. The Ministry of Health and Family Welfare need to expand the services to unreached rural communities and support intersectoral coordination to improve women's education and prohibit child marriages. Another area of center of attention is to increase in the percentage of SBA at the time of delivery along with health check after birth from health personnel within 2 days during PNC visits to reduce under-five mortality.
The author is grateful to the Ministry of Health and Family Welfare, Government of India, and International Institute for Population Sciences, Mumbai, for the data for research purpose from 2015–2016 (NFHS-4). The author is also appreciative to Dr. Vaishali K Shrote for her support in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mumbare SS, Rege R. Ante natal care services utilization, delivery practices and factors affecting them in tribal area of North Maharashtra. Indian J Community Med 2011;36:287-90.
] [Full text]
Jose JA, Sarkar S, Kumar SG, Kar SS. Utilization of maternal health-care services by tribal women in Kerala. J Nat Sci Biol Med 2014;5:144-7.
Regassa N. Antenatal and postnatal care service utilization in Southern Ethiopia: A population-based study. Afr Health Sci 2011;11:390-7.
Deshmukh V, Lahariya C, Krishnamurthy S, Das MK, Pandey RM, Arora NK, et al.
Taken to health care provider or not, under-five children die of preventable causes: Findings from cross-sectional survey and social autopsy in rural India. Indian J Community Med 2016;41:108-19.
] [Full text]
Nath L, Kaur P, Tripathi S. Evaluation of the universal immunization program and challenges in coverage of migrant children in Haridwar, Uttarakhand, India. Indian J Community Med 2015;40:239-45.
] [Full text]
Acharya AS, Kaur R, Prasuna JG, Rasheed N. Making pregnancy safer-birth preparedness and complication readiness study among antenatal women attendees of a primary health center, Delhi. Indian J Community Med 2015;40:127-34.
] [Full text]
Islam S, Mahanta TG, Sarma R, Hiranya S. Nutritional status of under 5 children belonging to tribal population living in riverine (Char) areas of Dibrugarh district, Assam. Indian J Community Med 2014;39:169-74.
] [Full text]
Pandya YP, Bhanderi DJ. An epidemiological study of child marriages in a rural community of Gujarat. Indian J Community Med 2015;40:246-51.
] [Full text]
Saxena D, Vangani R, Mavalankar DV, Thomsen S. Inequity in maternal health care service utilization in Gujarat: Analyses of district-level health survey data. Glob Health Action 2013;6:1-9.
Sarva Shiksha Abhiyan. Department of School Education and Literacy. Ministry of Human Resource Development, Government of India. Available from: http://www.mhrd.gov.in/sarva-shiksha-abhiyan
. [Last accessed on 2016 Jul 08].
Singh PK, Rai RK, Alagarajan M, Singh L. Determinants of maternity care services utilization among married adolescents in rural India. PLoS One 2012;7:e31666.
Sahu D, Nair S, Singh L, Gulati BK, Pandey A. Levels, trends & predictors of infant & child mortality among scheduled tribes in rural India. Indian J Med Res 2015;141:709-19.
] [Full text]
Wendt A, Stephenson R, Young M, Webb-Girard A, Hogue C, Ramakrishnan U, et al.
Individual and facility-level determinants of iron and folic acid receipt and adequate consumption among pregnant women in rural Bihar, India. PLoS One 2015;10:e0120404.
Titaley CR, Dibley MJ, Agho K, Roberts CL, Hall J. Determinants of neonatal mortality in indonesia. BMC Public Health 2008;8:232.
Niswade A, Zodpey SP, Ughade S, Bangdiwala SI. Neonatal morbidity and mortality in tribal and rural communities in central India. Indian J Community Med 2011;36:150-8.
] [Full text]
[Table 1], [Table 2], [Table 3]