What the newly released infant mortality rates tell us

Late last month, Kanika and I published an article in scroll.in, discussing the newly released infant mortality rates (IMR). We also used the occasion to discuss the importance of the IMR as a health statistic. I am posting the article in full below, partly because scroll posted only screenshots of our charts, and not the original ones we had created using google api. All the data that we used in this article is available in this spreadsheet.

This month, the Office of the Registrar General of India released data on Infant Mortality Rates (IMR) for 18 states and 5 Union Territories for the year 2014. The numbers show that even as most states made some progress in reducing the number of infant deaths, rich states like Delhi and Gujarat continue to have unreasonably high infant mortality rates. Improvement in rural areas was less impressive. Worryingly, rural Rajasthan and Bihar showed slight increases in infant mortality, while rural Madhya Pradesh and Gujarat made no progress.

These numbers come after a long two year drought of mortality indicators in India. Data for 11 states and all-India estimates are still awaited.

The Infant Mortality Rate measures the number of infant deaths before age 1 year for every 1,000 live births. Along with life expectancy, the Infant Mortality Rate is the most important health statistic in any country. Improvements in overall and adult health are impossible without declines in infant mortality. Despite the relative importance of the IMR, and the release of new health indicators in a long time, this new data has received scant attention and commentary.

These numbers are based on the Sample Registration System (SRS) surveys. Ideally, all births and deaths should be registered, and infant mortality or life expectancies should be calculated based on civil registers of deaths and births. But in countries such as India, where birth and death registration is incomplete, sample registration surveys are used to estimate fertility and mortality.

The release of this data was delayed partly because the SRS re-calibrated its sample based on the results of the 2011 census. Usually, IMR figures are released more periodically: for instance, IMR figures for the whole of India and all states for the year 2013 were available by September 2014.

What the data reveals

Figure 1 shows a comparison between the 2014 and 2013 Infant Mortality Rates for states for which the 2014 data has been released. The states have been arranged in the descending order of their 2014 IMR.

The IMR has declined in all states except Bihar and Manipur, a positive development on the whole. It is highest in Madhya Pradesh, a state which has had the highest IMR in India for a long time, and lowest in the states of Sikkim, Nagaland and Manipur.

Delhi, which is richer than all the states here, lags behind Sikkim, Nagaland and Manipur. One possible reason, among others, for this is the high toll of death among infants caused by the toxicity of Delhi’s air.

States of the Hindi-heartland, as well as Assam and Odisha, have worse IMR than other states. This is along expected lines.

Figure 2 presents the same comparison between IMR for 2013 and 2014, but only for rural areas. While the overall state patterns are similar, rural IMR is generally higher than total IMR, and progress in reducing rural IMR is less sharp.

Out of the 18 states for which 2014 figures are available, IMR in rural areas declined in 12. Madhya Pradesh, Meghalaya, and Gujarat made no progress in reducing rural IMR, while it increased in rural areas of Rajasthan, Bihar, and Manipur. Except Assam, where rural IMR showed a decline from 56 to 52, none of the states saw a steep decline in infant mortality.

Curiously, rural Jharkhand has lower infant mortality than rural Gujarat, while rural Bihar, which is also very poor, has the same level of infant mortality as rural Gujarat. Lower IMR in Bihar (and Jharkhand) and high IMR in Gujarat has been a long puzzle in Indian demography.

Figure 3 shows IMR for these states’ urban areas. Bihar and Uttar Pradesh have the highest infant mortality in urban areas, followed by Odisha, Madhya Pradesh, Uttarakhand, and Meghalaya. Nagaland, Sikkim, Arunachal Pradesh and Manipur have the lowest urban infant mortality rates.

Urban Delhi, which had 20 infant deaths for every 1000 live births, lags behind Nagaland, Sikkim, Arunachal Pradesh and Manipur.

The importance of IMR

Infant mortality is one of the best indicators of the overall health of a population. The first reason for this is that the same things that protect infants from death protect them from disease, and those same things improve the health and productivity of adults too.

A very large literature on “early life health” emphasises that the first 1000 days of life, starting from conception are critical. The brain and body are developing at this stage, and damages due to bad health are often irreversible.

Secondly, the biggest improvements in life expectancy and health come from reduction in infant and child mortality.

Figure 4 shows age-specific mortality rates for all ages in India, for the years 1971, 1991, and 2013, based on the Sample Registration System. The age-specific mortality rate is calculated by the SRS as the number of deaths in a particular age group divided by the mid-year population in that age group. All figures are per 1000 population.

The figure shows a pattern well known to demographers and public health experts: mortality is high in the very young ages, low during adolescence and the middle years of life, and rises quickly with the onset of old-age. It also shows declines in mortality at all ages between 1971 and 2013.

But what is even more dramatic is that the big declines in mortality happened at the youngest ages: in the 0-4 years age interval. Child Mortality declined from 52 deaths per 1,000 in 1971 to 27 deaths in 1991, to 11 deaths in 2013.

Adult mortality declined too, but the magnitude of the decline was less: from 109 deaths per 1000 in the 70+ age group in 1971 to 91 deaths in 1991 and 79 deaths in 2013. The children whose lives were saved had many more years to live than the older adults whose survival also increased.

Consequently, in the life expectancy improvements in this period, which was 50 years in the period 1970-75, 60 years in the period 1991-95 and 67.5 years in the period 2009-2013, reduction in child mortality had a much larger role than declines in any other age.

Neglect of health in public discussions

Infant mortality, and these new rates, deserve much more careful scrutiny. The lack of attention accorded to these speaks volumes about the overall neglect of health as an important topic of public discussion and debate in India.
Jean Dreze and Amartya Sen, in their 2013 book, An Uncertain Glory: India and its Contradictions, analysed more than 5,000 op-eds in the last six months of 2012 in all the leading english language papers. They found that just 1% dealt with health related matters.

This neglect, which seems to continue, is tragic. The reasons why Gujarat or Delhi has such high infant mortality given their incomes reiterate the dissociation between India’s growth story and other development indicators. Similarly, India now has higher infant mortality than both Bangladesh and Nepal, even though these countries are much poorer than India. Slow progress, or stagnation and reversals in infant health in some states are also causes of worry.

India’s GDP numbers, which are released quarterly, create a splash in the front pages of all newspapers. Consequently, governments feel that they are constantly monitored and are pressurised to act. Health indicators are released much less frequently. When they are, they generate hardly any debate and discussion, let alone any action.

Progress on the health front in India is unlikely to accelerate unless this changes.

Jai Bhim, Kajubai!

Aashish and I recently visited SEARCH at Gadchiroli. There we met Kajubai, who showed us how healthcare can be democratised. We wrote a small article about her, which was published by scroll.in. I am posting the original here.

Democratizing health, one hand-wash at a time

When it was time to leave, we said namaste to Kajubai. She returned the greeting without much emotion. We then asked her, “aap kya bolte hain?” (how do you greet one another?). To this, she enthusiastically replied, “Jai Bhim!”

Kajubai turned 64 this 1st July. She remembers her age well, which is rare for older people in rural India. For the last 21 years, Kajubai Undirwade has been successfully saving babies from suffocation, bacterial infections and fevers. As some girls walked by her house, she proudly pointed out the one she resuscitated just after her birth. This girl is eighteen years old now.

Kajubai is not a doctor or a nurse. She did not even complete eight years of schooling. But in 1994, she trained to be an Arogyadoot (Health Ambassador) with the Society for Education, Action and Research in Community Health (SEARCH), a pioneering rural health organisation set up in 1986 in Gadchiroli.

Photo 4

The basic features of SEARCH’s Home Based New-born Care (HBNC) model are well known and have been widely reported, in both scientific journals and popular media. SEARCH’s interventions helped bring the Infant Mortality Rate down from 76 deaths of babies aged less than one year per 1,000 live births in 1993-95 to 31 deaths per 1,000 live births in 2001-03. In control areas, this IMR remained essentially unchanged: IMR was 77.1 infant deaths per 1,000 live births in 1993-95, and 75.8 in 2001-03 in control areas where Arogyadoots were not functioning. After the publication of these results, SEARCH’s Arogyadoots transitioned from a research to a service orientation, continuing to bring child mortality down.

Arogyadoots are trained to provide care for low birth-weight babies, babies with birth asphyxia and those with infectious diseases such as sepsis and pneumonia. According to the Million Deaths Study conducted by the Registrar General of India, these four causes together account for 78% of total neonatal mortality or the deaths of infants younger than 1 month. It is in the neonatal period that babies are the weakest, and most vulnerable to diseases and death. Often, these conditions occur together.

Using her simple and localised medical kit, Kajubai showed us how to detect these conditions and what to do about them. As soon as a baby is born, she checks if the baby is crying, breathing, and not gasping. If any of this doesn’t happen, she starts what the World Health Organisation calls bag-and-mask ventilation, after clearing the airways in the baby’s mouth, ears and nostrils. She makes sure that, following WHO guidelines, she starts this process within the first minute of the birth. Until she can see that the baby is breathing without difficulty, Kajubai continues to ventilate.

Kajubai took us to Laksh’s house, who was born on 1st June in a nearby sub-centre. After saying hello to the mother, she proceeded to wash her hands after removing her bangles. Every time she is seeing a baby, Kajubai removes her bangles, washes her hands thoroughly, and then holds them out, so as to air-dry them completely. She joked that if she is ever seen without her bangles on the village road, people ask her, “Who just delivered?”

“Information asymmetry” is the polite term used by economists to describe massive hierarchies in knowledge between providers and recipients that characterise fields such as medicine and law. These inequalities of information, along with an unresponsive health system in a society riddled with hierarchies of gender, caste, wealth, age and education present particularly insurmountable challenges for improvements in well-being in India.

Because of her demonstrations over and over again, and quiet insistence on following guidelines, the logic behind these simple methods has percolated into wider village consciousness. By following the exact same set of procedures for all babies in the village, Kajubai is also able to keep other forces of inequality, such as those of gender and caste, at bay.

For all babies, Kajubai has simple and easy to understand recommendations: wrapping the baby in a warm cloth, keeping it warm by giving the baby body heat through their parents’ bodies, adequate and exclusive breastfeeding, and avoiding infections by washing hands and maintaining hygienic conditions. These help improve health and survival of all babies, but are especially useful for babies who are born before the completion of 38 weeks of pregnancy, and those with birthweights less than 2.5 kilograms at birth. These are both common occurrences in India.

Another intervention that Kajubai excels at is giving Vitamin K injections to the babies in her village within the first hour of their birth. Her track-record with these inoculations, as well as of all the other Arogyadoots, is flawless. So much so that a new doctor in a nearby health centre brought his own daughter to Kajubai, just to make sure that everything was done as it should be done.

In all this, Arogyadoots like Kajubai and SEARCH have demystified a jargon-ridden profession while also using medical advances to save local lives. Kajubai’s skills and her explanations are remarkable, but even more remarkable is the way Arogyadoots have democratised the technical field of medicine.

In these interventions, and as a Dalit woman, Kajubai understood the importance of Dr. B.R. Ambedkar’s words to the Constituent Assembly: “On the 26th of January 1950, we are going to enter into a life of contradictions. In politics we will have equality and in social and economic life we will have inequality.” In her life and her work, Kajubai continues to defy precisely these disparities.

Jai Bhim to her!

Still I rise

This is my first blog post and I wanted it to be one of my favourite poems. As I’m trying to recover from a bad bout of illness ( about that in another post), I dedicate these beautiful lines from Maya Angelou to all those who are struggling for a healthier tomorrow. We shall over come!


You may write me down in history

With your bitter, twisted lies,

You may tread me in the very dirt

But still, like dust, I’ll rise.


Does my sassiness upset you?

Why are you beset with gloom?

‘Cause I walk like I’ve got oil wells

Pumping in my living room.


Just like moons and like suns,

With the certainty of tides,

Just like hopes springing high,

Still I’ll rise.


Did you want to see me broken?

Bowed head and lowered eyes?

Shoulders falling down like teardrops.

Weakened by my soulful cries.


Does my haughtiness offend you?

Don’t you take it awful hard

‘Cause I laugh like I’ve got gold mines

Diggin’ in my own back yard.


You may shoot me with your words,

You may cut me with your eyes,

You may kill me with your hatefulness,

But still, like air, I’ll rise.


Does my sexiness upset you?

Does it come as a surprise

That I dance like I’ve got diamonds

At the meeting of my thighs?


Out of the huts of history’s shame

I rise

Up from a past that’s rooted in pain

I rise

I’m a black ocean, leaping and wide,

Welling and swelling I bear in the tide.

Leaving behind nights of terror and fear

I rise

Into a daybreak that’s wondrously clear

I rise

Bringing the gifts that my ancestors gave,

I am the dream and the hope of the slave.

I rise

I rise

I rise.