A deadly difference

Infant mortality rates are high in India, particularly in some areas. But what’s the cause, and what should be done to address it? Pradeep Kumar Choudhury offers some thoughts.

Infant mortality rate (IMR) – defined as the death of infants less than one year old per thousand live births – is a sensitive indicator of a country’s living and socio-economic conditions. A high IMR in a country indicates unmet health needs, unfavourable environmental factors, and low health and socio-economic status in its population.

It was also one of the indicators in the Millennium Development Goals (MDGs), which aimed to reduce the child mortality by two-thirds between 1990 and 2015.

The 2012 mortality estimates for India indicate an IMR of 44,  higher than the global figure of 35 in the corresponding year. Further, within India it varies widely across regions and states. In 2011, the IMR was 48 in rural areas and 29 in urban areas. Similarly, it varies from 12 in the state of Kerala (one of the educationally advanced states) to 59 in Madhya Pradesh (a state with low educational achievement).

Although several studies have examined the pattern and determinants of infant mortality in India, systematic attempts to understand the factors that explain the regional variations in infant mortality are limited. Education and health studies have largely focused on examining the role of mothers’ education in reducing the morbidity and mortality of their children, but there is very little investigation on the impact of fathers’ education and the parents’ combined education on the issue.

Also, there have been hardly any attempts to understand the effect of a mother’s exposure to mass media, and her socio-economic empowerment (which is closely linked with education) on infant mortality at the regional level in India.

Additionally, although some studies have placed particular emphasis on rural-urban disparities in infant mortality and the factors contributing to it, no attempt has been made to examine its differences by Empowered Action Group (EAG) and non-EAG states, which is an important classification of the Indian states made by the Indian Government on the basis of crucial socio-economic and health indicators.

The recently-released public draft National Health Policy has a focus on inequities in health outcomes (including IMR) in the regions and states. In particular, it has considered the differences between rural and urban regions and states with good performance and greater challenges in health outcomes. Interestingly, all the states with weak health outcomes (specifically IMR) listed in the draft policy document (Madhya Pradesh, Assam, Odisha, Rajasthan) are the EAG states.

My recent study in Asia & the Pacific Policy Studies looked at the role of parents’ education and other related factors in reducing infant mortality, and how it differs significantly between regions, classified here as Empowered Action Group (EAG)-non-EAG states, and rural-urban.

Given the lack of evidence on a specific relationship between education and child health at the regional level in India, the study systematically examines the role of parental education and the related factors (mother’s exposure to mass media, and her socio-economic empowerment) in explaining the variations in infant mortality between rural and urban regions and also between EAG and non-EAG states in India. The aim is to understand this by controlling the potential confounding factors that are broadly categorised as socio economic (caste, economic status of the household measured in terms of wealth index, and mother’s working status); drinking water and sanitation (sources of drinking water, availability of toilet facilities in the household); demographic (mother’s age, birth order of the child, household size, and child’s sex); and ability to access healthcare services. The study used the latest round of the National Family Health Survey (NFHS-3) data collected during 2005-2006 – an important source of information on population, health and nutrition for India and its states.

The study found that while the overall infant mortality is 57 in major states of India, it varies enormously by parental education and regions. Both a mother’s and a father’s education are significantly associated in reducing the infant mortality across the regions and major states of India, although the relative effect of different levels of education of the parents varies between EAG-non-EAG states and rural-urban regions.

It is also evident that children born to mothers who have any kind of exposure to mass media have a lower probability of death in their infant stage, compared to the children born to mothers having no mass media exposure – a feature that is even more pronounced in underdeveloped regions such as EAG states and rural areas.

This suggests the low level of female education is a major hindrance to reducing infant death, especially in rural India and the EAG states.

The clear implication for the country’s policymakers is to provide more and better education to parents, particularly to mothers in backward regions or states. Attempts should also be made to increase exposure to mass media and create higher levels of socioeconomic empowerment among mothers.  A focus on these steps could play a big role in reducing infant mortality in India.

This article is based on the author’s paper in Asia & the Pacific Policy Studies, ‘Explaining the role of parental education in the regional variations in infant mortality in India‘.