Child and Infant Mortality and Sexual and Reproductive Health | Sociology Optional for UPSC (Notes) PDF Download

Child and Infant Mortality

• The infant mortality rate (IMR)—probability of dying before one year of age expressed per 1000 live-births and under-five mortality rate (U5MR)—probability of dying between birth and age 5 expressed per 1000 live-births have been used as measures of children’s well-being for many years.
  
  Infant mortality in India is high compared to peers
• Infant and child mortality rates are considered as sensitive indicators of living and socioeconomic conditions of a country. This recognition has made the international organizations as well as National Governments to intensify their efforts to reduce infant mortality and improve child survival. As a result, there have been considerable improvements in the infant and child mortality rates for the world as a whole in recent years.
• In India, evidence of child health inequalities exist along several dimensions. There are huge differentials across states and socio-economic groups in terms of health outcomes, access to health services and utilization of health services. Disparities in health outcomes are explained not only by disparities in utilization of services but also by the differential pace of economic and social development, differentials in the distribution of the benefits of development and the inadequacy of the public health care systems to deliver equitable health services.

Millennium Development Goals (MDGs)

• The Millennium Development Goals (MDGs) adopted by the United Nations in the year 2000 project the efforts of the international community to “spare no effort to free our fellow men, women and children from the abject and dehumanizing conditions of extreme poverty.” The MDGs include eight goals which were framed to address the world’s major development challenges with health and its related areas as the prime focus. In India, considerable progress has been made in the field of basic universal education, gender equality in education, and global economic growth. However there is slow progress in the improvement of health indicators related to mortality, morbidity and various environmental factors contributing to poor health conditions.
• One of the 8 Millennium Development Goals (MDGs) adopted after millennium summit in 2000 is to reduce child mortality (MDG 4). Donors and Development agencies, the United Nations and National Governments around the world committed themselves to the goal of reducing the under -five mortality rates by two-thirds between 1990 and 2015 (UN Millennium Declaration). Two of the key indicators of monitoring progress towards this goal are the under-five mortality rate (U5MR) and the infant mortality Rate (IMR) (UN Development Group, 2003).

Initiatives by the Government to Reduce IMR and Child Mortality Rates

• The Government of India aimed to achieve IMR of 60 by the year 2000, after the Alma Ata declaration of 1978. Since then, a lot of efforts have been put into the child survival programmes over the years. The Sixth and Seventh Five-Year Plans had aimed at nationwide programmes to realize this goal.
• The twenty-point programme included rapid improvement in the conditions of women and children. In 1979, the Expanded Programme of Immunization (EPI) was established to provide the tetanus toxoid (TT) vaccine to pregnant women, and BCG, DPT, polio and measles vaccine to children.
• National Health Policy 1983 envisioned significant reduction in IMR, NMR & CMR by 2000. All the child health programmes are directed towards achieving these goals. Universal Immunization Programme against six preventable diseases, namely, diphtheria, pertussis, childhood tuberculosis, poliomyelitis, measles and neonatal tetanus was introduced in the country in a phased manner in 1985, which covered the whole of India by 1990. Significant progress has been made under the Programme in the initial period when more than 90 per cent coverage for all the six immunisation was achieved.
• Universal Immunisation Programme (UIP) become a part of the Child Survival and Safe Motherhood (CSSM) Programme in 1992 and Reproductive and Child Health (RCH) Programme in 1997. Under the Immunisation Programme, infants are immunised against tuberculosis, diphtheria, pertussis, poliomyelitis, measles and tetanus. Universal immunization against six vaccine preventable diseases (VPD) by 2000 was one of the goals set in the National Health Policy (1983).
• The National Population Policy (2000) and National Health Policy (2002) addressed the issue of child survival and maternal health and increase the outreach and coverage of the comprehensive package of RCH services through the government, voluntary and non-government sectors in partnership.
• National Charter for Children, adopted on 9th February 2004, emphasizes Government's commitment to children's rights to survival, development and protection. It also stipulates the duties for the State and the community towards children and emphasizes the duties of children towards family, society and the nation.
• The National Plan of Action for Children, 2005 commits itself to ensure all rights to all children upto the age of 18 years. To ensure child survival, the goals set up in the National Plan of Action for Children were: to reduce infant mortality rate to below 30, child mortality below 31 and neonatal mortality below 18 per 1000 live births by 2010. These goals were to be achieved by: reducing neonatal mortality rate to 26 by 2007; eliminating maternal and neonatal tetanus by 2007; promoting breast-feeding as a measure for ensuring early childhood nutrition; reducing deaths due to measles by half by 2007; ensuring full immunization of all children against vaccine preventable diseases; eradicating poliomyelitis by 2007; reducing deaths due to AARI by one third and due to diarrhea and cholera by 50 percent by 2010.
• In 2005 Government of India launched National Rural Health Mission (NRHM) to improve the availability and quality of accessible health care, especially for those residing in rural areas, including poor, women and children. The Major goals of the mission are to reduce the Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR), improve universal access to public health services such as women’s health, child health, water, sanitation and hygiene, immunization and nutrition; and enhance the prevention and control of communicable and non-communicable diseases. Reproductive and Child Health (RCH) Programme -II was subsumed within NRHM.
• GOI has adopted ambitious targets related  to  children that are in line with, and at times more ambitious than, the MDGs. Centrally-sponsored schemes have increased public resources to key sectors, notably the Reproductive and Child Health Programme II, the National Rural Health Mission and the Integrated Child Development Services. The challenge remains to convert these commitments and resources into measurable results for all children, especially those belonging to socially disadvantaged and marginalized communities.
• Child mortality trends, differentials, and determinants in India have been the subject of many studies. These studies have provided a framework for analysing factors that contributed to it. These included proximate factors (such as nonmedical factors and medical care during the antenatal period, care at birth, and preventive and curative care in the postnatal period); maternal factors (age, parity, and birth intervals); and household- and community-level factors (water, sanitation and housing). These studies concluded that a substantial decline in infant mortality  rate is possible without significant improvement in economic development. They propose increased access to a minimum package of essential services that would significantly reduce high infant mortality rates: reproductive health services; perinatal care; improved breastfeeding practices; immunization; home-based treatment of diarrhoea; and timely introduction of supplementary foods.
• Infant mortality rate (IMR) and under-five mortality rate (U5MR) have been used as measures of children’s well-being for many years.

Levels and trends in infant and under-five mortality rates

• One of the MDG goals is to reduce the mortality rate by two third among children under five between 1990 and 2015. Under-five mortality comprises of infant mortality (death before one year of age) and child mortality (death in the 1-4 year age group). The present Infant mortality rate stands at 40 per 1000 live births in 2013. Infant and child mortality in India have declined substantially over the past two decades. According to SRS data, infant mortality declined by 50% between 1991 and 2013. Though the Infant Mortality Rate is decreasing 2-3 points annually but the slow pace of reduction in the IMR is a major worry for the country as it is still higher than expected and India may not achieve the millennium development goal of 27 per 1000 live births by 2015.
• Infant Mortality Rate comprises of two components - Neonatal Mortality Rate (Number of infant deaths of less than 29 days per thousand live births during the year) and Post Neonatal Mortality Rate (Number of deaths of 29 days to less than one year per thousand live births during the year). Neonatal mortality rate was recorded as 51 in 1991 which declined to 28 in 2013. The present level of neonatal mortality indicates that about two-third of infant deaths occur within the first month of life.
• Between the two components of infant mortality i.e. neonatal and post neonatal mortality, during the period 1991 to 2013, post neonatal mortality rate declined more rapidly than neonatal mortality rate as a decline in post neonatal mortality by 58.6 percent was recorded in comparison to 45 percent decline in neonatal mortality. The level of Neonatal mortality is greatly affected by biological and  maternal factors  including  nutritional status  of  the mother.  Although concerted national efforts have been made to improve child mortality, especially in the post neonatal phase, less attention has been given to determinants of peri-natal and neonatal mortality.
• Early neonatal mortality refers to the deaths in the first week of life. Early neonatal mortality rate (ENMR) is an indicator of quality of peri-natal care. As observed among all the components of the under-five mortality, early  neonatal mortality has been  slowest to decline which has been constantly contributing to slow decrease in IMR over the years.
• Peri-natal mortality rate (PNMR) is the number of fatal deaths after 28 weeks of pregnancy and infant deaths under 7 days of age in given year per 1000 total births in that year. The peri -natal mortality rate has declined from 46 in 1991 to 26 in 2013. From 2001 to 2009, it showed almost stagnant trend, however, after 2009 there was a declining trend.
• The under-five mortality is the probability (expressed as a rate per 1000 live births) that a child born in a specific year or time period will die before reaching the age of five, subject to current age specific mortality rates. Since 1990, a rapid decline was seen in the U5MR and from an estimated level of 125 in 1990, fell to a level of 49 in 2013. Given to reduce under -five mortality rate to 42 per thousand live births by 2015, as per the historical trend, India may be missing the target. However, considering the continuance of the sharper annual rate of decline witnessed in the recent years, India is likely to reach near the target.
• Under-five mortality has declined because of reductions in the neonatal, post neonatal and child mortality rates. Proportionately, child mortality rates has declined more than infant mortality and similarly post neonatal mortality has declined more than neonatal mortality, increasing the relative importance of peri-natal and neonatal mortality.
• Comparison of estimated infant mortality rates based on three rounds of NFHS indicates that the infant mortality rate declined by 22 deaths per 1,000 live births in approximately 13 years. This implies an average reduction of 1.7 infant deaths per year. Neonatal mortality has declined from 49 for the period 1988-92 to 39 for the period 2001-2005 and the post natal mortality declined from 30 to 18 between the same time periods. It is observed that the decline was more in the post neonatal (12) and child mortality (15) as compared to neonatal mortality (10).

Inter- State Differentials in IMR and U5MR

• Among the states, Kerala, Tamil Nadu, Delhi, Punjab, Maharashtra, Goa, Manipur, Nagaland, Sikkim and Tripura, in 2013 the IMR have been estimated below the Millennium Development Goal (27) set for the year 2015. Also, Karnataka (31), West Bengal (31), Arunachal Pradesh and Uttarakhand (32) are likely to achieve the reduction of IMR to the level of MDG by the year 2015. In the States of Assam (54), Madhya Pradesh (54), Odisha (51), Uttar Pradesh (50), Rajasthan (47), Chhattisgarh (46), Bihar (42), Meghalaya (47) and Haryana (41) the IMR was recorded more than the national level (40) in the year 2013 which is far away from the target. In Andhra Pradesh, Jammu & Kashmir, Jharkhand, Gujarat, Himachal Pradesh and Mizoram, the infant mortality  rates were recorded between 35 and 40 and may not achieve the target by 2015. In all the Union Territories, IMR has been recorded below 27 except Dadra & Nagar Haveli (31) which is likely to achieve the target by 2015.
• The under-five mortality rate as per SRS was estimated 49 at national level in 2013 and there were considerable inter-state variations. Among the bigger States, highest U5MR was in Assam (73) and lowest in Kerala (12). Assam (73), Madhya Pradesh (69), Odisha (66), Uttar Pradesh (64), Rajasthan (57), Bihar (54) and Chhattisgarh (53) have U5MR higher than the national average (49). The States of Kerala (12), Tamil Nadu (23), Maharashtra & Delhi (26), Punjab (31), Karnataka and West Bengal (35), Jammu & Kashmir (40), Andhra Pradesh and Himachal Pradesh (41) have already achieved the given national level MDG target to reduce U5MR to 42 per thousand live births by the year 2015. Gujarat and Haryana (45) are likely to achieve the national target by 2015.

Infant and Under-five Mortality in EAG States and Assam

• AHS was conducted in 2010-11 with baseline survey and followed by two updating rounds in 2011-12 and 2012-13 in 8 Empowered Action Group (EAG) states and Assam. AHS provided data on infant and child mortality for 9 States.
• Among the EAG States and Assam, the infant mortality rate was highest in Uttar Pradesh (68) and lowest in Jharkhand (36) in 2012-13. The percentage of decrease in IMR from 2010-11 to 2012-13 was lowest (4.2%) in Uttar Pradesh which indicates the lower performance of NRHM and other health interventions in the state. Chhattisgarh, Bihar and Jharkhand have recorded a decrease of 13.2 percent, 12.7 percent and 12.2 percent respectively in IMR from 2010-11 to 2012-13 showing the better progress in these three States. More attention is required in the States of Madhya Pradesh, Rajasthan, Odisha and Assam besides Uttar Pradesh for success of various health interventions including NRHM.
• Highest under-five mortality rate in 2012-13 was estimated in Uttar Pradesh (90) followed by Madhya Pradesh (83), Odisha (75), Rajasthan (74), Assam (71), Bihar (70) and Chhattisgarh (60). The national target set by the Government to reduce under-five mortality to 42 by 2015 is far away from the current level of U5MR in these states except the states of Uttarakhand (48) and Jharkhand (51) where it is closer to the target.
• Annual Health Surveys also indicate that the infant and child mortality rates are higher in rural areas as compared to urban areas. Maximum difference in rural and urban areas is seen in Assam where the mortality rates in rural areas are nearly double of the urban areas.

Maternal Determinants of Infant and Child Mortality

• The demographic characteristics of both mother and child like age at marriage, mother’s age at child birth, birth order of the child, birth interval, and child’s weight/size at birth and sex of the child have been found to play an important role in the survival probability of children. As per SRS data, the percentage of effective marriage below the legal age of marriage i.e. 18 has declined from 20.3 percent in 1993 to 2.2 percent in 2013.
• Age of the mother at the time of child birth has an important bearing on the survival of the child as children born to adolescent mothers are at higher risk. Infant and under-five mortality rates are highest among mothers below 20 years of age, whereas children born to mothers aged 35 and above are likely to have the increased risk of mortality.
• The effect of maternal age on mortality is highest during the neonatal period, and progressively diminishes during the post-neonatal and 1-4 year age-group. Based on NFHS-3, the effect of young age of a mother (<20 years) on neonatal mortality was 1.58 times higher than the child born to mothers whose age was between 20 and 30 years. Similarly the children born to mothers above 40 years of age have 1.25 times higher risk of death within first month of birth in comparison to mothers of age 20-29 years.
• As per NFHS-3, 2005-06, the first order children have 57 percent higher risk of dying in the first month of life as compared to birth order 2 and 3. There is no increased risk of dying for first order birth beyond the neonatal period. In fact, child mortality is lowest among first order births and increased with the order births. Fourth to sixth order children have 37 percent higher risk of dying in the neonatal period, 26 percent in the post neonatal period and 53 percent during 1 -4 year age as compared to birth order 2 and 3. Children in birth order 7 or more have 86 percent higher chances of dying before fifth birthday. According to DLHS-3, 2007-08 more than two third children of fourth and higher order were born to mothers whose age was above 35 years. Though declining trend in percentage of fourth and higher order births have been seen as it decreased from 24.2 percent in 1991 to 10.5 percent in 2013, but more efforts in implementation of the family planning programme are required. With higher birth order, decreased utilization of health services by mothers and children like ANC, delivery in a health facility, vaccination and vitamin A supplementation has been observed.
• The interval between two births shows a strong effect on infant and child mortality rates. The shortest birth interval, less than two years, carries the greatest risk of mortality and the risk of mortality decline with increased birth interval. Mothers whose births are spaced too closely may not recover their health before becoming pregnant and this can hinder the growth and development of the foetus and a child born too soon after the first may divert time, attention and resources of the caretakers from the first child.
• According to Sample Registration System, among the children born in the year 2013, 31 percent were with previous birth interval less than 24 months and another 30 percent with an interval of 24-36 months. Among the children born between 2001 and 2005, the infant mortality rate was 2.9 times higher for the children with previous birth interval below 24 months and 1.7 times higher for the interval 24-35 months than the birth interval 36-47 months. It is revealed that previous birth interval is one of the important determinants of IMR and U5MR. The IMR and U5MR is considerably low when the previous  birth  interval is  36-48 months, therefore,  the IMR and U5MR can be  reduced significantly by spacing births.
• Any birth when the mother’s age is less than 18 years or  more than 34 years; where the previous birth interval is less than 2 years or the birth order is more than three can be categorized as high risk. Total 46 percent births in the preceding five-year from NFHS-3 (approximately from 2001 to 2005) were in an avoidable risk category. These births had nearly twice the risk of dying than those which were not in any high risk category. Among the avoidable high risk category, 35 percent births were in single high risk category and 11 percent of the births in multiple high-risk category.
• Neonatal and post neonatal mortality was found highest when the deliveries were conducted at home by traditional birth attendants. NFHS data revealed that neonatal mortality is lowest among the children delivered at home by health professionals. Thus maximizing the number of deliveries assisted by trained health personnel can be helpful in minimizing the risk of dying in neonatal and post neonatal period.
• Mother’s nutritional status affects the nutritional status of babies and the infant mortality. The risk of having a baby with low birth weight is also higher for mothers who are short. Based on NFHS3, 11 percent women in the age group 15-49 had height below 145 centimeter, 16 percent were moderately/severely thin (BMI <17.0), 20 percent mildly thin (BMI 17.0-18.4) and 13 percent were overweight/obese. Fifty five percent of women whose haemoglobin level was tested were found to be anaemic. Thirty-nine percent women were mildly anaemic, 16 percent were moderately anaemic and two percent were severely anaemic.

Child Determinants of Infant and Child Mortality

• As per SRS data, in the year 1991, the IMR was marginally higher for male as compared to female but after that the IMR for female was higher than male and in the year 2013, the IMR was 39 for male and 42 for female. It is observed that mortality rate for female was lower than male during neonatal period as per three rounds of National Family Health Survey which can be attributed to biological advantage of girls, however, during this period the narrowing gap in neonatal mortality between male and female has been seen. The data shows the reverse trend of increasing mortality rate among female children after neonatal period and the difference between male and female is more in the age group 1-4 years.
• A variety of cultural and traditional factors may be responsible for the higher mortality among girls beyond neonatal period as the parental care of the child affects the mortality beyond this period. Traditionally, preference is given to sons over daughters in terms of food, prevention of dise ases and treatment of illness resulting in higher post neonatal and child mortality among girls.
• The vaccination received by male and female children of 12-23 months, based on NFHS and CES, revealed that a little higher percentage of male children received all vaccinations, whereas, among the children who did not receive any vaccine percentage of female was comparatively higher.
• As per NFHS-3, almost half of children under five years of age (48%) were stunted and 43 percent were underweight. The proportion of children who were severely undernourished (below -3SD from the median of the reference population) was also notable – 24 percent according to heightfor-age and 16 percent according to weight-for age. Wasting was also quite a serious problem in India, affecting 20 percent of children under five years of age. Under nutrition was substantially higher in rural areas than in urban areas. Even in urban areas, 40 percent of children were stunted and 33 percent were underweight.
• National Family Health Survey, 2005-06, reveal that 70 percent of the children below 5 years were anaemic, including 26 percent mildly anaemic, 40 percent moderately anaemic and 3 percent severely anaemic.

Socio-Economic Determinants of Infant and Child Mortality

• Despite substantial progress in reducing under-five deaths, children from rural and poorer households remain disproportionately affected. The SRS data for the year 2013 shows that children in rural areas are about 1.6 times more likely to die before their first birthday and 1.9 times more likely to die before fifth birthday than those in urban areas. During the period 1991 to 2013, neonatal mortality declined by 53 percent in urban areas as compared to 44 percent in rural areas. In 2013, the neonatal mortality rate was about double in rural areas as compared to urban areas.
• As per NFHS-3, in rural areas 28 percent mothers did not receive any ANC as compared to 9 percent mothers in urban areas. Among the women who delivered during 12 months preceding CES, 2009, in urban areas 82.7 percent women received more than three ANCs, 89.4 percent received two doses of TT injections and 39.7 percent women areas consumed IFA tablets/syrup for 100+ days as compared to 63.3 percent, 85.9 percent and 27.6 percent respectively in rural areas. Full ANCs were received by 26 percent women in rural areas and 36 percent in urban areas.
• Urban women (70.4%) were more likely to receive ANC in the first trimester than rural women (54.9%). About 12 percent women in rural areas and 4 percent in urban are as did not receive any antenatal checkup. A significant increase in institutional deliveries from 28.9 percent (NFHS-3, 2005-06) to 68 percent (CES, 2009) has been observed in rural areas which may be attributed to interventions like NRHM, JSY and JSSK.
• It was observed that higher percentage of children in urban areas received vaccination and vitamin A supplementation than in rural areas. Though the immunization coverage increased in subsequent surveys but still more efforts are required to cover all children.
• Mother’s education is often just a good indicator of other socioeconomic factors that affect under-five mortality directly. A mother’s education is important because it facilitates her integration into a society impacted by traditional customs, exposes her to information about better nutrition, spacing births, childhood illnesses and treatment.
• The data revealed that children born to a mother with secondary or higher education have lowest rates for all types of childhood mortality. IMR and U5MR among children born to illiterate mothers have been consistently higher than those born to mothers with any education. Under -five mortality was highest (94.7) among children whose mothers were uneducated which decreased with each higher level of education and was lowest (29.7) among children of mothers who completed 12 years or more education.
• It was observed that the level of utilization of health services like ANC, assistance of skilled health personnel during delivery, immunization of children etc. depended on educational level of mother.
• Some of the effect of religion on mortality may be due to differences in life -style based on traditions and beliefs. Such differences may include customary practices related to childbirth, infant feeding, and health care. According to NFHS-3, highest rate of infant mortality was found among Hindus and it was lowest among Christians. Though, the level of complete antenatal care was low among all religious groups, it was seen that Christian mothers were more aware of receiving antenatal care. Majority of children belonging to Hindu, Muslim and Sikh religion received prelacteal feed (something other than breast milk during the first three days of life). Immunization of children and vitamin A supplementation was lowest among Muslims.
• Besides socio-economic differences, the cultural patterns of unique social groups can be quite varied and different groups may be at different stages of transition in the process of cultural change. In general, scheduled caste and schedule tribe children have higher levels of under-five mortality than others. The infant mortality rate was 36 percent higher among scheduled castes, 27 percent higher among scheduled tribes and 16 percent higher among other backward classes as compared to others. Between NFHS-1 (1992-93) and NFHS-3 (2005-06), about 37 percent decline in infant mortality was recorded among Other Castes and Scheduled Castes but during the same period only 21 percent decline was recorded among Scheduled Tribes.
• Under-five mortality rate was 49 percent higher among scheduled castes, 62 percent higher among scheduled tribes and 23 percent higher among OBCs in comparison to others. Although scheduled tribes had a lower infant mortality rate (62) than scheduled castes (66), the child mortality rate (1-4 years of age) was higher among scheduled tribes (36) than among scheduled castes (23).
• Lowest proportion of ST women received ANC, assistance during delivery and post natal check up followed by SCs and OBCs. As observed, among the Scheduled Tribes, least proportion of children received all vaccines and the Under-five mortality rate among them is highest and on the other side among other caste children, most children received all vaccines and U-5MR is least among them. It emphasizes the role of immunization in reducing child mortality particularly in the age group 1-4 years. More efforts are required to encourage the women particularly those who belong to Scheduled Castes and Tribes to avail antenatal care services, institutional deliveries and to get their children fully immunized.
• Wealth Index or Economic status (as measured by Standard of Living Index) affects the infant and child mortality directly. As observed, Under-five mortality and its components vary inversely with economic status of the household, as measured by the Standard of Living Index (SLI): children born in low SLI households had the highest mortality rates, and those born in high SLI households had low mortality rates. The infant mortality rate is 70 among children in households in the lowest wealth quintile, 58 in the middle wealth quintile households, and only 29 in the highest wealth quintile households. Households in the highest wealth quintile experience the under-five mortality rate only one-third of households in the lowest quintile.
• As observed, the level of utilization of health services like antenatal care, deliveries assisted by skilled health personnel, early initiation of breast feeding, immunization of children, and vitamin A supplementation depended on the economic status of the household.

Environmental Determinants of Infant and Child Mortality

• It is acknowledged that availability and distribution of water is essential for good health status of people. There have been many policies that have helped in proper distribution and accessibility of water in India. As per Census, 2011, at the National level, only 32 percent households are availing tap water from treated sources, whereas 33.5 percent using water from handpumps, 8.5 percent from tubewells and 1.6 percent from covered wells. Also, 46.6 percent households have source of drinking water within the premises and 17.6 percent were bringing the water from a distant place.
• In Bihar, Nagaland, Assam, Odisha, Jharkhand and Lakshdweep only upto 10 percent households and in Uttar Pradesh, Tripura, Chhattisgarh, West Bengal, Madhya Pradesh and Kerala 10 to 25 percent households were using tap water from a treated source in 2011.
• Access to an improved toilet (flash or pit) is potentially an important determinant of in fant and child mortality in India. Roughly, 53 percent houses were without latrine facility within the premises. Among them 3 percent households were using public latrine and 50 percent were still going to an open place for defecation. There have been various governmental policies like Nirmal Bharat Abhiyan that have helped in increasing toilet facilities for rural and urban populations but much more efforts have to be made to provide improved toilet facility for having a good health status of the people and specifically to reduce child mortality.
• Studies have revealed that the type of cooking fuel used in a household could affect under -five mortality  as the use of cooking  fuel that emits harmful smoke could  elevate their risk of respiratory disease and children born to mothers who have exposure to smoke during pregnancy are more likely to be low birth weight and therefore at a higher risk of death. As per census 2011, firewood was used for cooking purposes by 49 percent households, 9 percent households were using crop residue and another 8 percent used cowdung cake. LPG and kerosene were used by 28.6 percent and 2.9 percent households respectively.
• In conclusion, this analysis confirms the hypothesis that the infant and under-five mortality and associated determinants vary among different States and households with different socioeconomic background. To enhance child survival, many determinants such as age at marriage, age at child birth, intensive antenatal and delivery care to pregnant women, spacing the birth interval, complete immunization of children, nutritional status of women and children and child care practices can be modified by child survival programs.
• Factors contributing to slow decline include the lower social, cultural and health status of women in India. Thus, improving female education and nutrition, as well as increasing the use of health services during pregnancy and delivery, would lower child mortality. The level of child morbidity and mortality is higher for girls aged one month to 5 years than for boys. Eliminating gender differences in mortality rates would significantly reduce infant and child mortality overall. An initiative by Government of India 'Beti Bachao Beti Padhao' aims to create awareness among masses to eliminate discrimination to girl child at all stages.
• Child health policies should be reviewed to sustain the achievements that have already been made, enhance quality and efficiency and address specific gaps in neonatal care. Existing child health programmes and strategies, including initiatives for the eradication of vaccine-preventable childhood diseases, and specific health and nutrition interventions, need to be examined in the context of socioeconomic and State specific approaches. It is revealed from the above discussion that the economic status of the household is an important factor of the infant and child mortality rates. To reduce infant and child mortality not only the health services, water and sanitation facilities be improved by proper implementation of the programmes but also the poverty elimination programmes be implemented effectively.

Sexual and Reproductive Health

• Sexual and reproductive health was given an international consensus definition at the International Conference on Population and Development (ICPD) in 1994. At its core is promotion of reproductive health, voluntary and safe sexual and reproductive choices for individuals and couples, including decisions on family size and timing of marriage. Sexuality and reproduction are vital aspects of personal identity and are fundamental to human well being fulfilling  relationship within diverse cultural contexts.
• Sound reproductive health is integral to the vision that every child is wanted, every birth is safe, every young person is free from HIV, and every girl and woman is treated with dignity. Implicit in this vision is the idea that men and women will be able to exercise their rights to information on and access to safe, affordable and acceptable methods of fertility regulation as well as quality health care services. The latter will enable women to experience safe pregnancy and childbirth, across the world.
• Poor women, especially in developing countries, suffer disproportionately from unintended pregnancies, maternal death and disability, sexually transmitted infections including HIV, gender based violence and other problems related to their reproductive system and sexual behavior.
• There are several reproductive health concerns in India which need to addressed in order to improve reproductive health status of people. In the following paragraphs, an attempt has been made to highlight some of the major concerns.

High unwanted fertility

• As per the National Family Health Survey III - 2005-2006 (NFHS-III), nearly 21% pregnancies are either unwanted or mistimed.
• Total fertility refers to mean number of children born per woman in the age group of 15-49 years. Total wanted fertility represents the level of fertility that will result theoretically, if all unwanted births are prevented. Total wanted fertility rate in urban areas is 1.6 and in rural areas 2.6, while total fertility rate is 2.06 in urban areas and 2.98 in rural areas.
• Unmet need for family planning is an important indicator for assessing potential demand for family planning in India There is a high unmet need for family planning, with 6.2 % for spacing and 6.6% for limiting  methods among  currently  married women.  Unmet need is also high amongst the illiterate and in the lowest wealth quintile.
• Male participation in sharing responsibility for contraception is low. As per NFHS –III, male sterilisation was accepted by only 1% of currently married couples.

High maternal mortality

India’s maternal mortality ratio is unacceptably high at 230 per 100,000 live births (2008) as per UN estimates. Nearly 63,000 Indian women, accounting for almost 18 per cent of estimated global maternal deaths, die every year due to causes related to pregnancy and childbirth. The lifetime risk of maternal mortality is 1 in 70; i.e. one in every 70 pregnant women is at risk of death, even as she gives birth. Available data also indicates that a significant proportion of women suffer from obstetric morbidities.

Sexually Transmitted Infections/Reproductive Tract Infections

Several studies highlight the widespread prevalence of sexually transmitted and reproductive tract infections. In a nation-wide community-based study, prevalence was nearly 6% in the 15-50 years age group. The problem is further compounded by the prevailing culture of silence, as women are generally reluctant to seek medical treatment for these symptoms.

Government policies/programmes

In 1951, India became the world’s first nation to launch a family planning programme. Decades later, when the International Conference on Population  and Development (Cairo,  1994) prompted  a paradigm shift in population programmes, with the advocacy of client-centered and quality-oriented reproductive health approaches, India formulated appropriate policy and programmatic responses:

• The National Population Policy was formulated in the year 2000. It affirms the government’s commitment to promote voluntary and informed choice, and continuation of the target-free approach in family planning service delivery.
• The National Rural Health Mission (NRHM) was launched in 2005. It aims to revamp the public healthcare delivery system and seeks to provide accessible, affordable and quality healthcare to rural population
• A national level Reproductive and Child Health Programme II (RCH II) was introduced in 2005 and focuses on addressing reproductive health needs of the population through evidence-based technical intervention through wide range of service delivery network. There is implicit emphasis on addressing the equity dimension in coverage, while maintaining focus on quality.
• Conditional Cash Transfer schemes like Janani Suraksha Yojana (for promoting institutional deliveries) were introduced to help address economic barriers for access to services.

Better access to services is the key

• Reproductive health programmes must place emphasis on improving access to quality reproductive health services by gender sensitive providers. Maternal death and disability can be reduced dramatically if every woman has access to health services throughout her lifecycle, especially during pregnancy and childbirth. The highest priority needs to be given to ensuring that women have access to skilled birth attendants at the time of giving birth and that women who develop life -threatening complications during pregnancy, childbirth or post partum can immediately access treatment at adequately-equipped facilities.
• The focus needs to be on eliminating delays in decision- making to seek services, ensuring timely transportation to proper facilities and enabling prompt treatment on arrival at facilities.
• The importance of Family Planning: The number of unwanted and closely spaced births can be drastically reduced by providing access to quality contraceptive services. It is vital that services are available to  women and men from lower income quintiles, especially in  rural areas,  which are currently under serviced.
• Moreover, a set of emerging issues, such as infertility, reproductive cancers, morbidities such as prolapse and gender based violence, need to be studied and addressed.
• In addition, programmes need to focus on preventing and treating reproductive tract and sexually transmitted infections and meeting unmet reproductive health needs of underserved groups, such as adolescents and people living with HIV/AIDS with special reference to information, counseling and services.