Indian J. Prev. Soc. Med. Vol. 42 No.2, 2011

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1 ISSN Indian J. Prev. Soc. Med. Vol. 42 No.2, 2011 DETERMINANTS OF CHILDHOOD MORTALITY M. Salman Shah 1, Najam Khalique 2, Zulfia Khan 2 ABSTRACT The objectives of the study were to estimate the mortality rate in children under the age of five years, to find out the socio-biological factors associated with childhood mortality and to establish the causes of deaths in the study population. Methodology: All the deaths in children under the age of five years and live births in one year study period were recorded. The cause of death was ascertained using verbal autopsy procedure. Results: In the study period, there were 700 live births and 82 deaths among under-five children. The main causes of infant deaths were birth asphyxia, diarrhea, pneumonia, prematurity (including Low birth weight) and malnutrition. The deaths in children 1-5 years age group were mainly due to diarrhoea, malnutrition, pneumonia and meningitis. Conclusion: Most of the deaths in children under the age of five years are preventable. Integrated management of neonatal and childhood illness can be utilized for the management of illness at the peripheral level so as to reduce the preventable deaths. Verbal autopsy procedure can assist in the strengthening of Integrated Disease Surveillance Project and reporting of deaths should be made mandatory and according to system. Key words : Childhood mortality, Infant mortality, Verbal Autopsy, Socio-biological factors. INTRODUCTION Under-five mortality is a sensitive indicator of a country s development and telling evidence of its priorities and values. Globally on an average more than 26,000 children under the age of five years die per day mostly from preventable causes. Nearly all of them live in developing countries. More than one-third of these children die during the first month of life usually at home and without access to essential health services 1. Cause-of-death information is needed to prioritize interventions and plan for their delivery, to ascertain the effectiveness of disease specific interventions, and to assess trends in disease burden in relation to national and international aims. The World Health Report 2005 Make every mother and child count summarizes data availability and shows the extent to which estimates of child mortality in developing countries, for recent years, rely on extrapolations 2. Data on childhood mortality is collected by various methods which are not uniform throughout India. Large number of childhood deaths go unreported, and if reported they are misclassified. There is a need for using simpler methods such as verbal autopsy. They can be administered by lay people, and qualified personnel need only to read the forms 3 and interpret. Since, in the local areas there were no recent studies conducted on the estimation of causes of under-five deaths, a population based study was undertaken with the following objectives. (i) to estimate the mortality rate in children under the age of five years (ii) to find out the socio-biological factors associated with childhood mortality and (iii) to establish the causes of deaths in the study population. 1. Assistant Professor, 2. Professor, Dept. of Community Medicine, J.N. Medical College, A.M.U., Aligarh Indexed in : Index Medicus (IMSEAR), INSDOC, NCI Current Content, Database of Alcohol & Drug Abuse, National Database in TB & Allied Diseases, IndMED, Entered in WHO CD ROM for South East Asia.

2 METHODOLOGY The study was undertaken for a period of one year (July 2005 to June 2006) in urban and rural field practice areas of Department of Community Medicine, JNMC, AMU, Aligarh. The urban area is an underserved peri-urban area situated on the outskirts of the city. In the urban area (3 localities) and rural area (7 villages), 1411 children and 2160 children under five years of age were studied respectively. The block head quarter village lies 17kms from Medical College on the Aligarh-Anoopshehar Highway. All the live births and the deaths in under- five children were recorded during the study period. A detailed history of the events of birth of the baby and the circumstances leading to death were elicited from the respondent. The age of the deceased child was ascertained by the date of birth. If the parents could not recall then it was ascertained by or by the religious and the ritual events. Before the investigating the cause of death, the consent of the mother or guardian was taken. The stillbirths were excluded from the study. The cause of death was ascertained using standard verbal autopsy procedure. A verbal autopsy is a method of finding out the causes of a death based on interview with next of kin or other care givers 4. In case of doubt, the cause of death was ascertained after discussion with the consultants of Department of Community Medicine and Department of Pediatrics. RESULTS During the study period, 700 live births and 82 deaths in under- five children were reported. About two-third of under five deaths were in infants. 446 live births and 56 deaths were reported in rural area whereas 256 live births and 26 deaths were reported in the urban area. The neonatal, infant and under five mortality rates were 48.57, and per 1000 live births respectively. In the rural area the above mentioned rates were 48.57, and per thousand live births and 47.24, and per thousand live births in urban area respectively (Table-1). Age group Table-1: Distribution of mortality in children according to age Rural Urban Total 0-28 days days -1 yr yr yrs Sex Total No. * Calculated as per 1000 live birth Table-2: Distribution of mortality in children according to sex Rural Urban 0-5 yrs children 0-5 yrs children Total Percentage Total No. Total Percentage No. % No. % Male Female Total Z = 0.6 (Males) Z = 2.4 (Females) Indian J. Prev. Soc. Med Vol. 42 No.2 119

3 Rate Rate M. Salman Shah et al Determinants of childhood mortality In rural area, out of a total of 56 deaths, 18 (32.14%) were males and 38 (67.86%) were females. In the urban area, out of 26 deaths, males and females were 13 (50%) each. The gender difference in deaths in two areas was statistically significant (Table -2). Graph 1: of Children in relation to birth interval Graph2: of Children in relation to Birth Order Rural IMR 100 Rural IMR 80 Rural U5-MR 80 Rural U5-MR < >48 Birth interval Urban IMR Urban U5-MR Total Birth Order Urban IMR Urban U5-MR In Graph-1, the Infant mortality rate as well as the Under-five mortality rate markedly increases when the birth interval is less than 24 months whereas they decrease (2.5-3 times) when the birth interval is more than 48 months. The pattern was similar in the rural and the urban area. The Infant mortality rate and the under-five mortality rate were high in the first order birth and in the birth order fourth and above in both rural and urban areas. A U- shaped pattern could be seen in infant and child mortality (Graph-2). Table-2: Causes of deaths in infants Causes of Prematurity (including LBW) Neonatal Post- Neonatal Rural Urban Total Rural Urban Total No. % No. % No. % No. % No. % No. % Birth asphyxia Congenital malformation Diarrhoea Pneumonia Malnutrition Tetanus Meningitis Neonatal jaundice Neonatal sepsis Others Total The major causes of deaths during the neonatal period were birth asphyxia (47.06%) and prematurity (including Low birth Weight) (26.47%). In the post-neonatal period, the main causes of mortality were diarrhea (39.13%) followed by pneumonia (26.09%) and malnutrition (17.39%) (Table-3).The causes were similar in the rural and urban area. Indian J. Prev. Soc. Med Vol. 42 No.2 120

4 The major causes of death in children in the age group (1-5 years) were diarrhoea (28.0%), malnutrition (24%), pneumonia (20%) followed by measles (8%) and meningitis (10.5%) (Table-4). The five causes of mortality among children in under -five years of age were pneumonia (14.63%), diarrhoea (20.73%), birth asphyxia (19.51%), malnutrition (12.19%) and prematurity including low birth weight (10.97%). These 5 causes accounted for 78% of mortality in children. Table -4 : Causes of death in children (1-5 years) Rural Urban Total Causes of death No. % No. % No. % Diarrhoea Pneumonia Malnutrition Measles Meningitis Accidental drowning Transport accidents Others Total DISCUSSION The aims of the present study were to estimate the mortality rate in children under the age of five years, to find out the socio-biological factors associated with childhood mortality and to establish the causes of deaths in the study population. The diagnosis was mainly symptom based as per the information collected by verbal autopsy. In our study, in the rural area, the neonatal, infant and under five mortality rates were 49.32, and per thousand live births respectively. The findings of our study were higher as compared to other studies 5.6,7,15,18. Similarly, in the present study, the urban area had higher mortality rates in comparison to other studies 5,12,18. Further research is needed at local level to look into various factors for these high mortality rates. Moreover, there was no appreciable difference found between rural and urban due to the fact that the area demarcated as urban is a peri-urban area consisting of population that has migrated from adjoining districts. The health service delivery by the state in this area is almost negligible. Our finding is in conformity with the study by Claeson et al who found that the decline in child mortality in urban areas has been slower than in rural areas as a result; rural-urban differentials have become smaller 8. There is a considerable difference in mortality pattern in males and females in rural areas whereas no difference could be seen in urban areas. No specific individual cause of death could be identified to account for the observed difference between males and females. Similar were the findings by Claeson et al and Howalder and Bhuiyan who observed that the child mortality was higher among female children than males 8,10. However Subramanian et al observed that excess mortality for girls was evident only for the age group 2 to 5 years and the reverse was seen in infancy 9. The reason for this reverse finding was not explained by the author. The neglect of the female child has to be addressed and could be improved by appropriate messages on a short term basis and improving literacy levels especially of mothers as a long term answer. It was observed in the present study that the Infant and under-five mortality decreases as the interval between subsequent births increases. The reason could be that the mothers get enough time to replenish her nutritional stores before next pregnancy and she has time to look after the present child in a proper manner. The findings of our study are in accordance with the findings of the other authors 10,17. The Infant mortality rate and the under-five mortality rate were high at the extremes of birth order in the present study. Similar pattern was reported by other authors 7,14,17. Indian J. Prev. Soc. Med Vol. 42 No.2 121

5 In our study we found that the major causes of deaths during the neonatal period were birth asphyxia, prematurity (including Low Birth Weight), pneumonia, diarrhoea, tetanus, neonatal sepsis, neonatal jaundice and congenital malformation were the other causes of neonatal deaths. The chief causes of neonatal deaths reported in similar studies were Low Birth Weight, prematurity, birth asphyxia, hypothermia and pneumonia 6,11,12.In our study there was only one child who died of tetanus. This may be due to high level of coverage against tetanus in the recent years. In the post neonatal pe riod, in our study the main causes of death were diarrhoea, pneumonia and malnutrition.. In another study from Aligarh, it was found diarrhoea, pneumonia and malnutrition were the main causes of death in the post- neonatal period 7.The other authors are in agreement with the findings of our study 6,14,15.According to the present study, the major causes of death in children in the age group (1-5 years) were diarrhoea, malnutrition, pneumonia and meningitis. Other authors reported similar findings 6,11,13,15. In a study from urban east Delhi, measles was found to be an important cause of death along with diarrhoea and pneumonia in children (1-5) years age group 16. CONCLUSION Majority of the deaths in children under the age of five years are preventable. Integrated management of neonatal and childhood illness can be utilized for the management of illness at the peripheral level so as to reduce the preventable deaths. Verbal autopsy procedure can assist in the strengthening of Integrated Disease Surveillance Project. Reporting of vital events should be made mandatory. The urban poor should not be neglected in policy attention and resource allocation. Verbal autopsy tool can be conveniently used by the peripheral health worker who acts as the first contact at or around the time of bereavement. Although attaining good quality vital registration data should be a long-term goal, alternative methods of ascertaining and estimating cause-of death distributions at the population should be used in the interim. REFERENCES 1. UNICEF, State of the World s Children, 2008, New York: UNICEF World Health Organization. World health report 2005 Make every mother and child count. Geneva: WHO; Garenne M, Fauveau V. Potentials and limits of verbal autopsy. Bull World Health Organ 2006;84(3). 4. WHO/CDS/CSR/ISR/99.4. A standard verbal autopsy method for investigating causes of death in infants and children. 5. National Family Health Survey (Uttarpradesh). Ministry of Health and Family Welfare, Government of India. 6. Nandan D, Mishra SK, Jain M et al. Social Audits for Community Action: A tool to initiate community action for reducing child mortality 2005;30(3): Khalique N, Sinha SN, Yunus M et al. Certain aspects of Infant - a prospective study in a rural community Indian J Mater n Child Health 1992; 3 (3): Cleason M, Bos Er, Mawjit et al. reducing child mortality in India in the new millennium. Bull World Health Organ 2000; 78: Subramanian S.V. Nandy S, Irving M et al, Am J Public Health 2006;96: Howalder AA and Bhuiyan MU. Mothers seeking behaiviour and infant mortality in Bangladesh. Trop Med Inter Health 1999;4: Nongkynrih B, Anand K, Kapoor S.K. Use of Verbal autopsy by health workers in under five children. Indian Pedia 2001; 38: Vaid A, Mammen A, Primose B et al. Infant mortality in an urban slum. Indian Journal of Pediatrics ; Awasthi S, Pande VK. Cause specific mortality in under fives in the urban slums of Lucknow, North India. J Trop Paed 1998; 44: Reddaiah VP, Kapoor SK. Sociobiological factors in under five deaths in a rural area. Indian J Pediatr 1992; 59 (5): Hirve S, Ganatra B. In a prospective cohort study on the survival experience of under-five children in rural western India. Indian Pediatrics 1997; 34: Awasthi S, Agarwal S. Determinants of Childhood mortality & morbidity in urban slums in India. Indian Pediatrics 2003; 40: Syamala TS. Relation ship between sociodemographic factors and child survival: Evidences from Goa, India. J.Hum. Ecol 2004; 16(2): Registrar General, India. Sample Registration System Bulletin New Delhi, India ---- Indian J. Prev. Soc. Med Vol. 42 No.2 122