Infant mortality rate indetail abt causes too from spm

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Infant Mortality Rate (IMR) - Park's Textbook of Preventive and Social Medicine

Definition

Infant Mortality Rate (IMR) is defined as "the ratio of infant deaths registered in a given year to the total number of live births registered in the same year; usually expressed as a rate per 1000 live births."

Formula:

IMR = (Number of deaths of children < 1 year of age in a year / Number of live births in the same year) × 1000

Importance of IMR

IMR is universally regarded as:

The most important indicator of health status of a community
An indicator of the level of living of people in general
A measure of effectiveness of MCH (Maternal & Child Health) services

Reasons why infant mortality is given separate treatment by demographers:

(a) Infant mortality is the largest single age-category of mortality
(b) Deaths at this age are due to a peculiar set of conditions to which adults are less exposed or vulnerable
(c) Infant mortality is affected quickly and directly by specific health programmes and may change more rapidly than the general death rate

International Comparisons

Infant Mortality Rate in selected countries (1990 vs 2018):

Country	IMR 1990	IMR 2018
India	88	32
Sri Lanka	18	6
Bangladesh	100	25
Pakistan	106	57
China	42	7
Nepal	99	27
USA	9	6
UK	8	4
Japan	5	2
World average	63	29

Developed countries: ~4 per 1000 live births
Least developed countries: ~46 per 1000 live births
South Asian average: 35 per 1000 live births

IMR in India

Kerala has the lowest IMR (7/1000) with the highest female literacy (91.98%) and lowest birth rate
Madhya Pradesh has the highest IMR (48/1000) with lower female literacy and highest birth rate
India's current IMR = 32 per 1000 live births (2018)

Mortality Pattern

(a) Age distribution:

Deaths in 0-1 year account for 10.5% of total deaths in India
About 71.7% of infant deaths occur within the first month (neonatal period)
Of neonatal deaths, 54.6% occur in the first week of birth
Risk is greatest in the first 24-48 hours after birth

(b) Sex:

In developed countries: male death rates are higher than female
In India: after age 1 month (post-neonatal period), female deaths are higher than male - attributed to social factors unfavourable to females in India
Neonatal death rate is higher for males; post-neonatal death rate is higher for females

Medical Causes of Infant Mortality (Table 26 - Park's)

Neonatal Mortality (0-4 weeks)	Post-neonatal Mortality (1-12 months)
1. Low birth weight and prematurity	1. Diarrhoeal diseases
2. Birth injury and difficult labour	2. Acute respiratory infections
3. Sepsis	3. Other communicable diseases
4. Congenital anomalies	4. Malnutrition
5. Haemolytic diseases of newborn	5. Congenital anomalies
6. Conditions of placenta and cord	6. Accidents
7. Diarrhoeal diseases
8. Acute respiratory infections
9. Tetanus

Principal causes of infant mortality in India (percentage-wise):

Low birth weight: 57%
Respiratory infections: 17%
Congenital malformations: 5%
Diarrhoeal diseases: 4%
Birth injury: 3%
Cord infection: 2%
Unclassified: 18%

In developing countries: High IMR mainly due to - low birth weight + infection (diarrhoea, respiratory) + malnutrition

In developed countries: Mainly due to - congenital anomalies, anoxia, and hypoxia

Factors Affecting Infant Mortality

1. Biological Factors

(a) Birth weight - Single most important determinant

Babies < 2.5 kg (LBW) and > 4 kg are at special risk
Virtually all infants weighing < 1000 g succumb
Major cause of LBW = poor maternal nutrition

(b) Age of the mother

IMR is greatest when mother is < 19 years or > 30 years
Very young mothers tend to be poorer and less educated

(c) Birth order

Highest mortality: first born and 5th or later children
Lowest mortality: second born
Risk escalates after the 3rd birth
Nutritional deficiency deaths are 3-4 times higher for 5th+ birth order

(d) Birth spacing

IMR highest for infants born after interval of 1 year
IMR lowest for infants born after interval of 4 years (Khanna Study, India)
Risk is 2-4 times higher for babies born within 1 year of each other vs those born >2 years apart

(e) Multiple births

Greater risk due to higher frequency of LBW

(f) Family size

IMR increases with family size
Diarrhoea, malnutrition, respiratory infections all increase with family size
Duration of illness also longer in larger families

(g) High fertility

High fertility and high infant mortality go together

2. Economic Factors

Socio-economic status is the most important variable - both directly and indirectly
IMR is highest in slums and lowest in richer localities
Quality of health care and child's environment are closely linked to socio-economic status

3. Cultural and Social Factors

(a) Breast-feeding - Early weaning and bottle-fed infants under poor hygienic conditions are more prone to die

(b) Religion and caste - Differences attributed to socio-cultural patterns of living, age-old habits, customs, traditions affecting cleanliness, eating, clothing

(c) Early marriages - Baby of a teenage mother has the highest risk for neonatal and post-neonatal mortality

(d) Sex of the child - Female infants receive far less attention than males in most parts of India; female IMR is higher overall

(e) Quality of mothering - Even in extreme poverty, an efficient mother can reduce infant mortality

(f) Maternal education - Illiteracy is the greatest barrier to health improvement; mother's education level is a key determinant of child health within the same socio-economic class. Kerala experience demonstrates this clearly.

(g) Quality of health care - Inadequate prenatal care; high percentage of deliveries attended by untrained persons in rural India; only ~47% of deliveries attended by trained birth attendants

(h) Broken families - Infant mortality is high when mother or father has died or separated

(i) Illegitimacy - Illegitimate child is unwanted; does not receive adequate nutrition or medical care

(j) Brutal habits and customs

Depriving baby of colostrum (first milk)
Frequent purgation
Branding the skin
Application of cowdung to the cut end of umbilical cord
Faulty feeding practices and early weaning

(k) The indigenous dai - Untrained, illiterate midwife with unhygienic delivery practices is a major cause of high IMR in India

(l) Bad environmental sanitation - Lack of safe water, poor housing, bad drainage, overcrowding, insect breeding all increase risk

Preventive and Social Measures to Reduce IMR

A multipronged approach is required since the aetiology is multifactorial.

Prenatal nutrition - Supplementation of mother's diet; even 500 kcal + 10 g protein extra in last 4 weeks raises birth weight by ~300 g (ICDS programme)
Prevention of infection - Immunization (Universal Immunization Programme, 1985); protection against 9 vaccine-preventable diseases
Breast-feeding - Most effective measure; safeguard against GI and respiratory infections and PEM
Growth monitoring - Low-cost technology to reduce infant mortality
Family planning - Limiting family size and spacing births; reduces risk substantially
Sanitation - Safe water, proper housing, basic hygiene; risk of dying closely related to the environment
Provision of primary health care - Prenatal care to detect high-risk mothers; special care baby units for babies < 2000 g; proper referral services
Socio-economic development - Female literacy, nutritional standards, safe water, sanitation, housing, agriculture, industry
Education - Especially female education; Tamil Nadu example: mid-day meal programme + improved health care for women reduced IMR from 90 (1984) to 57 (1991) per 1000 live births

Source: Park's Textbook of Preventive and Social Medicine, Chapter on Demography and Vital Statistics

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