International Journal of Community Medicine and Public Health

Bhattacharyya H et al. Int J Community Med Public Health. 2024 Mar;11(3):1397-1400

[Link] pISSN 2394-6032 | eISSN 2394-6040

DOI: [Link]
Review Article

Challenges in the reduction of infant mortality in India: have we

reached a plateau
Himashree Bhattacharyya*, Rashmi Agarwalla

Department of Community and Family Medicine, AIIMS Guwahati, Assam, India

Received: 19 January 2024

Accepted: 21 February 2024

*Correspondence:
Dr. Himashree Bhattacharyya,
E-mail: himashreebhattacharyya@[Link]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

The infant mortality rate is one of the major indicators of a country’s overall health and development. From time to
time, many new initiatives were launched by the government of India to bring down the IMR of the country. Many of
the initiatives launched in the early phases were able to substantially reduce the IMR to 26/100 live births by 2023.
However, the decline has not been uniform and the IMR seems to have reached a plateau. Beyond this it will need
some major changes at the health policy level to bring the IMR to a level which is compatible with the developed
countries. This article attempts to highlight the trajectory of India towards reduction of Infant mortality, the various
initiatives launched from time to time and the challenges in bringing it down further from the present plateau stage.

Keywords: Infant, Mortality, Challenges, Government

INTRODUCTION LITERATURE REVIEW

The infant mortality rate is one of the major indicators of The present article describes the trends in infant mortality
a country’s overall health and development. In 2000, rates in India by comparing with various study reports,
when the UN adopted the millennium development goals, policy and program documents published by the ministry
India had also laid down targets for reduction of infant of health and family welfare, GoI from time to time as
and child mortality. The national health policy 2002, the well as reports and data from the WHO and UNICEF.
national population policy 2000, the national health Also, several studies published in journals on the Infant
mission, all of these had laid down specific targets for mortality trends and its preventive strategies were
reduction of the country’s Infant mortality which was consulted in writing this article which has been duly
more than 25 times than developed countries. Then came mentioned in the reference section. Data bases like
the sustainable development goals (2016-2030) where Embase, MEDLINE, PubMed, Scopus and Web of
one of the targets is to reduce the under-5 mortality to science were searched using appropriate key words
25/1000 live births by 2030. Infant mortality accounts for without any date restrictions to look for the relevant
over 80% of under-5 mortality rate. Despite formulating articles.
so many targets and strategies, the Infant mortality
decline is not the way as it was expected to happen with DISCUSSION
wide disparities across states in India. This article
attempts to highlight the trajectory of India towards India was one of the major contributors to the global
reduction of Infant mortality, the various initiatives infant mortality rates with figures as high as 2.3 million
launched from time to time and the challenges in bringing and infant mortality rate at 88.3/1000 live births in 1990.
it down further from the present plateau stage.1 The first program which was introduced for targeting this

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 Bhattacharyya H et al. Int J Community Med Public Health. 2024 Mar;11(3):1397-1400

issue was the child survival and safe motherhood program Janani Shishu Suraksha Karyakram
launched in 1992.2 Again in 1997, the govt of India
launched the reproductive and child health (RCH) To facilitate zero out of pocket expenditure for maternal
program to reduce infant, child and maternal mortality. In and infant health services through free health care and
the year 2000, India was a signatory to the millennium referral transport entitlements. The package benefits
development goal which had reduction of child mortality extended to all children upto the age of 1 years.10
as its fourth goal.3 India could achieve only a 17%
reduction in neonatal mortality from 1.35 million to 1.12 Rashtriya bal swasthya karyakram
million from 1990 to 2000. The IMR reduced from
88/1000 live births to 68/1000 from the year 1990 to This was a new initiative launched in [Link] major
2000.4 focus was on child health screening and early intervention
services to cover 30 identified health conditions for early
The RCH phase II began from 1st April, 2005. Under the detection, free treatment and management. 11
RCH I and II, several initiatives were launched with focus
on reduction of infant mortality. The major thrust areas in In June, 2012 an important summit on “global child
RCH I and II were: Universal immunization for all survival call to action: a promise to keep” was conducted
vaccine preventable diseases. Essential newborn care in Washington DC to fuel the global fight for reduction of
which includes resuscitation of new borns with asphyxia, child mortality. India was also one of the countries to
prevention of hypothermia and infections and prompt pledge for reduction of child mortality to <20/1000 live
referral of sick newborns. Facility based newborn care by births by 2035. As a call for action in the year 2013, the
equipping the facilities to handle sick newborns referred govt of India launched a strategic approach to
from the periphery. Setting up of new born care corner in reproductive, maternal, newborn, child and adolescent
labour room and OT of all health facilities and special health (RMNCH+A). Since then, it has become a part of
newborn care units at district levels. IMNCI which India’s flagship public health program. This program is
encompasses a range of interventions to prevent and based on provision of comprehensive care through five
manage the common childhood illness.5,6 thematic areas with five high impact cross cutting
interventions. The new born interventions are basically
The programs which were launched with focus on the same as in RCH namely home-based newborn care,
reduction on infant mortality are: essential newborn care and newborn resuscitation
services at all delivery points and special new born care
Home based newborn care units.12

The main objective is to provide essential new born care With these herculean efforts, however there was a
to all newborns with special care for pre term and sick substantial reduction in neonatal mortality by 33% in
newborns, early identification of complications and 2013 as compared to 2000. The IMR also showed a
provide support and education to the family regarding significant decline from 68/1000 live births to 40/1000 in
newborn care practices. As per this strategy, the ASHA the year 2013. India’s national health policy 2017 had the
will make visits to all newborns (six visits in case of target of reducing the infant mortality rate in the country
institutional delivery and seven visits in case of home to 28/1000 live births by the year 2019.13 However, the
delivery) upto 42 days of life.7 trends in decline of infant mortality have not been
uniform from 1981 to the present. The annual percentage
Navjat shishu suraksha karyakram decrease in the infant mortality was highest during 1988
to 1991 but decreased significantly from 1991 to 1999.
This program aims to train health personnel in basic The decline in infant mortality therefore has not been
newborn care and resuscitation so as to address common uniform. India has not able to keep up the momentum of
problems at birth like prevention of hypothermia, rapid decline of infant mortality as it did during the
prevention of infection and the basic newborn launch of UIP. This was mainly due to changes in the
resuscitation.8 focus towards prevention of maternal mortality through
emergency obstetric care. The major focus of the
Integrated management of neonatal and childhood government shifted to reducing maternal mortality
illness through emergency and comprehensive obstetric care.
The child survival interventions had a setback though it
IMNCI is the one of the key pillars of child health was projected that strengthening of obstetric services
interventions under RCH II strategy. The Indian version would also contribute to reduction of neonatal and infant
has made several adaptations the key highlights of which deaths, but in reality, this did not happen.14 As per the
are inclusion of care of child 0-7 days, incorporation of NFHS III, the full immunization coverage rate increased
National guidelines on malaria, anaemia, Vitamin A by just 1.5% points from 1995-96.15
supplementation and immunization schedule, focus on
skill-based training of health personnel for sick new borns The IMR in the year 2014 was 39 /1000 live births. (SRS)
up to 2 months.9 key thrust was given during this period on setting up sick

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newborn care units, new born stabilization units, New focusses on institutionalized care targeting high risk
born care corners and stabilization units and initiatives infants for providing critical care services. Too much
like navjat shishu suraksha karyakram. Also there has focus on the risk based approach can lead to decline in
been a vast discrepancy in IMR across states. It has been health and well being of infants whereas too much focus
shown to vary from 12 in Kerela to 52 in Madhya Pradesh on community based approach can lead to lack of care in
and 10 in Goa to 46 in Meghalaya.16 The infant mortality critical high risk situations.21 Therefore for effective
rate for India in 2020 was 29.848 deaths per 1000 live reduction of infant mortality a balance has to be struck in
births, a 3.48% decline from 2019.17As per the sample these two approaches. Thus, along with facility based
registration system (SRS) bulletin of registrar general of care, establishment of new born stabilization units etc.,
India (RGI), the Infant Mortality Rate (IMR) has reduced equal focus should also be given to home based new born
from 37 per 1000 live births in 2015 to 30 per 1,000 live care and community based interventions. Preventive
births in 2019 at national level.18 The infant mortality rate interventions like MAA (Mothers absolute affection)
for India in 2021 was 28.771/1000 live births, a 3.61% which encourages exclusive breast feeding for first six
decline from 2020. In 2022, this came down to months, social awareness and actions to neutralize
27.695/1000 with a 3.74% decline and in 2023 the IMR pneumonia successfully (SAANS, defeat diarrhoea
stands at 26.619/1000 live births with a 3.89% decline (D2) initiative implemented for promoting ORS and zinc,
from 2022. It has been observed that the trend in decline RBSK can to a great extent contribute to the reduction of
is indeed slow and it seems to have reached a plateau infant mortality. Another critical factor is the successful
where a further drastic decline would require changes in implementation of these interventions. If country needs to
strategy as well as approaches to the delivery of child make a dent to plateau in infant mortality, government
health care.19 has to ensure that these interventions have to reach out to
masses, be made accessible to them and affordable to
The slow and non-uniform decline and vast discrepancy them. Also, mechanisms for delivery for these services
across states can be attributed to the following factors: needs to be simple and as per felt needs of community. 22
Each state needs to devise a simple service delivery
Differences in income and education across states. mechanism based on local geographical terrains,
Population composition with states/UTs having more knowledge and prevailing customs of people. Adequate
tribal and under privileged populations having higher man power needs to be deployed in poor performing/
rates. This causes discrepancies in access to health care difficult terrain states as the ones working are already
services. overburdened by work load of managing many parallel
programs. Reporting and referral mechanism needs to be
Utilization of health care services by population which is less complex and well outlined. A strong referral linkage
grossly uneven across the country. Lower social, cultural system needs to be built into health care system.23 Infant
and health status of women still exist in many parts of our mortality needs to been given a major focus in health
country. Eliminating gender differences in mortality rates policies and programmes if we are to fulfil goals set by
will significantly reduce overall infant mortality.16 our leaders at national and international levels.

There has been a direct relationship of infant mortality CONCLUSION

with two most crucial indicators: gestational age of the
infant and birth weight with infants having much higher The present article stresses on the fact that though there
risk of dying with early gestational age (less than 37 has been a drastic decline in the Infant Mortality rates in
weeks) and low birth weight (less than 2500 gm). These India in the last decade but somehow the decline in recent
can have a significant impact on infant mortality. Despite years is very slow and seems to have reached a plateau. A
much advocacy work, it has been observed that the strategic combination of public health approaches along
percentage of infants born pre term or low birth weight with facility-based care specifically targeted to high-risk
has continued to rise. Research has shown that a portion infants can go a long way in addressing the gaps in care
of increase in pre term or low birth weight can also be of this vulnerable age group. Issues of accessibility,
due to multiple births which can be attributed to the use availability of quality care, affordability and
of assisted reproductive technologies. Increase in medical accountability needs to be addressed if the country has to
interventions like caesarean section and induction of make a dent in the slow decline of Infant Mortality rates.
labour may also have an effect on the rate of increase in
pre term births.20 Funding: No funding sources
Conflict of interest: None declared
A combined public health as well as risk-based approach Ethical approval: Not required
is required for bringing down the stagnant IMR in India.
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