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By Elisa Patnaik Orissa has the highest infant mortality rate in the country at 97 per 1,000 live births. Approximately 86,000 infants die in the state each year. Poor healthcare facilities for mother and child, malnutrition, malaria and lack of awareness are major contributing factors. Can the state reduce IMR to the targeted 60/1,000 by 2005?
When 19-year-old Mithila Muduli from Jorhipai, a small village in Orissa's Koraput district, was expecting her second child there was barely enough food for her existing family of three. Mithila herself was anaemic, her first child suffered from malnutrition. As her pregnancy progressed, like most other illiterate women in the village, Mithila did not visit the doctor stationed at the Primary Health Centre (PHC) some 10 km away, at Kakriguma. There was too little money and getting to the PHC was too difficult. Eight months into her pregnancy, Mithila went through prolonged labour and was finally moved to the PHC, where her baby died after undergoing foetal distress. Despite several programmes already in place for women and children, Orissa continues to be plagued by high levels of infant mortality. According to the 1999 National Family Health Survey 2, approximately 86,000 infants die in the state each year, putting Orissa's Infant Mortality Rate (IMR) at 97 per 1,000 live births -- the highest in the country. The state's IMR is not only higher than the national average of 71 per 1,000 live births, it equals the average IMR in Sub-Saharan Africa. Over 60% of infant deaths occur at the neonatal stage -- in the first month of life -- underlining the poor newborn-care facilities provided in the state. The main causes of infant death are poor maternal health, low birth weight, malnutrition, infections and diseases such as diarrhoea and malaria. Since infant mortality often serves as a key development indicator, reflecting the combined effects of socio-economic growth (or the lack of it), Orissa's high infant mortality rate is significant. A large number of people in the state live below the poverty line, and the lack of basic infrastructure facilities like roads and transportation, especially in the interiors, makes the existing healthcare services inaccessible to many. State government interventions, in partnership with voluntary organisations, have achieved little primarily because critical areas such as the protection of antenatals and infants against malaria, and the improvement of newborn-care services were not addressed. Malaria chemoprophylaxis during pregnancy, as a strategy for reducing IMR in Orissa, was introduced only recently as part of the Infant Mortality Reduction Mission (IMRM) launched by the state government in August 2001. Director of health services, Orissa, Dr Niranjan Kar, who heads the IMRM, says: "There were certain lapses in the policies followed earlier which are now being corrected in the IMR Mission." Compared to Kerala, which has the best IMR (14 per 1,000 live births) figures in India, and where almost all deliveries take place in hospitals and private clinics, only 22.6% of births in Orissa are institutional. Relatives and untrained persons attend nearly 66.5% of births (NFHS 2). The reasons for the state's low institutional delivery rate are lack of physical access to institutions, poor facilities available at institutions, and the costs involved in purchasing drugs and undergoing treatment. According to a recent study conducted by the Public Affairs Centre on the state of Orissa's public services, the location of the nearest healthcare centre is a critical element. Though Orissa has 1,351 PHCs and 180 hospitals, only one-fourth of households across rural Orissa (28%) report having a government healthcare provider within a kilometre of their residence.
While many healthcare centres in rural areas manage without regular doctors, lack of proper facilities like hygienic labour rooms and a shortage of medicines and equipment prevent existing doctors from pursuing the essential line of treatment. In Orissa, an infant's problems begin as soon as it is conceived. The most important cause of infant death is maternal malnutrition and lack of antenatal care for mothers. Maternal malnutrition and the absence of antenatal care lead to the birth of underweight (less than 2,500 gm) babies who are more susceptible to infections and diseases. Most deliveries in the interior tribal districts of Koraput, Nawrangpur, Malkangiri and Mayurbhanj are self-deliveries. During delivery, women are forced to undergo prolonged labour either due to the lack of health facilities or certain cultural barriers that prohibit women from delivering in the presence of doctors and auxiliary nurse midwives (ANMs) whom they do not consider part of the community. Says Pratima Sabat, an ANM based in Mayurbhanj district: "Faith in traditional healers in these areas dissuades many people from accessing the existing healthcare facilities, besides harmful community practices during pregnancy and childbirth." Malnutrition among children is also widely prevalent in Orissa and is an underlying and contributing factor in infant mortality. While 46.7% of under-threes in the country are moderately or severely malnourished, in Orissa the figure is 54.4%. The lack of appropriate antenatal care adds to the problem. According to NFHS 2, only 47% of women had three or more check-ups; only 34% had a check-up during the first trimester. Only 21.4% of women receive all the recommended aspects of antenatal care (three or more check-ups, with at least one in the first trimester, two or more TT injections or booster, IFA tablets for three months or more). Of the 77% home deliveries, only 14% are attended by health professionals (ANMs, LHVs, midwives, nurses or doctors). While nearly 29% of deliveries are attended by a trained birth attendant (TBA) (the rest, by untrained attendants like relatives and friends), only 19% of women have been seen by a healthcare provider within two months of delivering. Even if the child is healthy, not enough emphasis is given to growth promotion. Only 24% of babies are breastfed within an hour of birth, according to NFHS 2, and the period of exclusive breastfeeding lasts only 1.8 months. Poor recognition of danger signs in newborns and infants by community and health providers, a poor or non-functional referral system and the lack of drugs and paediatric preparations are some of the key obstacles in the care of sick children in this state. Endemic malaria is a major contributor to the IMR in Orissa. According to the National Malaria Eradication Programme (NMEP) report of 1998, 28.6% of all malaria cases and 62.4% of all malaria deaths reported in India are from Orissa. Malaria in infants and children can cause illness and malnutrition, even death. In Orissa, the majority of infant deaths occur in the drought-prone regions of Kalahandi, Bolangir, Koraput, Phulbani and Keonjhar, which are also malaria endemic zones. Pregnant women from these parts experience a variety of medical problems ranging from malaria, maternal anaemia and morbidity to abortion, stillbirth, pre-term and low birth weight (LBW) babies and intra-uterine growth retardation. The social, cultural and health conditions related to the low status of women in Orissa also have a negative impact on child survival. Girl-children experience a higher level of child morbidity and mortality than boys, from the age of one month to five years. They also receive less healthcare and food. Though in the first month, congenital and other causes increase mortality among boys, after one month of age, environmental and behavioural factors including care-seeking behaviour during illness are disadvantageous to girl-children. One of the most significant detrimental outcomes of low birth weight is growth retardation in young girls, perpetuating a cycle of female malnutrition through adulthood and into the next generation. Although the government-sponsored ICDS (Integrated Child Development Scheme) has managed to generate greater awareness, the effects have been far from adequate. Though anganwadi workers (AWWs) play a major role in persuading pregnant women, adolescent girls and their family members to access healthcare facilities, they and other ICDS staff are not trained or equipped to care for LBW babies or sick newborns. The lack of data and analyses on several key areas is another problem that has not been taken seriously by state government authorities. There is considerable variation in the IMR for different parts of Orissa. The causes of infant deaths are likely to be different in different regions in Orissa. What is needed is a district-specific action plan. Though policy-makers agree that the decade-old ICMR data on inter-district variations, conducted in 1993, and the ranking of the earlier 13 districts (now 30), have changed, no recent data on district-wise IMR is available. Still, despite the existing high IMR in Orissa, experts believe there's a lot to cheer about. The government's strategy seems to be paying off as the state witnessed a five-point reduction in IMR in 2001, as compared to previous years. According to the 2001 Sample Registration Survey (SRS), the IMR in Orissa has come down to 90 per 1,000 live births, though it remains the highest in the country. The Mission's goal is to reduce Orissa's IMR to 60 per 1,000 live births by 2005.
(Elisa Patnaik is a Bhubaneswar-based journalist) InfoChange News & Features, July 2003
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