2. Question
(A)Define Infant Mortality Rate (IMR) and
indicate the current data in India.
(b) Enumerate common causes for IMR in
India and mention interventional programmes
available to combat it.
(2+1+3+2=8)
2
3. Definition and components of IMR
• Infant mortality rate - Probability of dying between birth
and exactly one year of age expressed per 1,000 live births.
Number of infant deaths during the year
------------------------------------------------------ x 1000
Number of live births during the year
• Infant mortality:
1. Neo-natal mortality:
• Early neo-natal mortality rate
• late neo-natal mortality rate.
2. Post neo-natal mortality.
3
4. Formulas
1. Neo-natal mortality rate (NMR)
Number of infant deaths of 28 completed days during the year
--------------------------------------------------------------------------------- x 1000
Number of live births during the year
2. Early neo-natal mortality rate
Number of infant deaths of < than 7 days during the year
-------------------------------------------------------------------------------- x 1000
Number of live births during the year
3. Late neo-natal mortality rate
Number of infant deaths of 7 days to < than 29 days during the year
--------------------------------------------------------------------------------------------- x 1000
Number of live births during the year
4. Post neo-natal mortality rate(PNMR)
Number of infant deaths of 29 days to < than one year during the year
---------------------------------------------------------------------------------------------- x 1000
Number of live births during the year
4
5. Live birth
• Live birth refers to the complete expulsion or extraction from
its mother of a product of conception, irrespective of the
duration of the pregnancy, which, after such separation,
breathes or shows any other evidence of life - e.g.
– beating of the heart,
– pulsation of the umbilical cord or
– definite movement of voluntary muscles - whether or not
the umbilical cord has been cut or the placenta is attached.
• Each product of such a birth is considered live born.
• Period of viability:
• fetus having birth weight >500 g (or gestation >22 weeks
or crown heel length >25 cm) or more.
5
6. Sources of data
• National Family Health Survey (NFHS)
• Demographic and Health Surveys (DHS)
• Indian Sample Registration System (SRS)
• Public health reporting system
6
7. Perinatal mortality
• PERINATAL PERIOD: Commences from 22 weeks (154
days) of gestation (the time when the birth weight is
500 g), and ends at 7 completed days after birth.
• Perinatal mortality rate=
(Early neonatal deaths + stillbirths) x 1000
Total births
• The Perinatal ratio is the number of perinatal deaths
per 1,000 live births.
• PMR of India in 2007 is 33/1000 total births
7
8. Values of IMR from DPH Chennai:
• Tamilnadu: SRS 2008-09 statistics per thousand
livebirths
• IMR 35
– NNMR 23
– Post Neonatal DR 12
• Perinatal MR 8.4
• CMR or U5 mortality 26
• Neonatal mortality rate is 34/1000 LB
8
9. • Under-five Mortality Rate:
• (U5MR) is measured in terms of death of number of
children (under five years of age) taking place per
1000 live births. The U5 MR declined from 69 in 2008
to 59 in 2010.
• Maternal Mortality Ratio (MMR):
• MMR has reduced from 254 per 100000 live births in
2004-06 to 212 per 100000 live births in 2007-09
(SRS),
9
11. States
1. Kerala has the lowest IMR (12 /1000 live
births) and
2. Orissa the highest (65 per 1000 live births)
3. Puducherry 22/1000 live births;
4. Tamil nadu 28 - (SRS 2009)
11
12. Current figures
• India Latest IMR (SRS data 2012):
• All india: 44/ 1000 live births; urban 29;
rural 48
• Tamil nadu: 22/1000 urban 19 rural 24
• Puducheri 19/1000
• Neonatal mortality rate is 34/1000 LB
12
13. World
Country Name Value
Angola 176
Afghanistan 149
Somalia 106
India 48
China 16
United States 6
United Kingdom 5
Sweden 3
Singapore 2
Japan 3 13
17. • Neonatal mortality (2005-06) is 39/ 1000
livebirths;
• About 40% of neonatal deaths occur in the
first day of life.
• Nearly 3/4th of neonatal deaths occur within
7 days of life.
17
18. Components
India 2003
Mortality Total Rural Urban
Infant mortality rate 60 66 38
Neo-natal mortality rate 37 41 22
Early neo-natal mortality rate 25 28 12
Late neo-natal mortality rate 12 13 10
Post neo-natal mortality rate 23 25 16
18
19. Importance of IMR
• Infant and child mortality rates refect a
country's level of socio-economic development
and quality of life and are used for monitoring
and evaluating population, health programs
and policies.
• It is an outcome rather than a cause and hence
directly measures results of the distribution and
use of resources.
19
20. Differentials
• Infant mortality has declined by 35 percent
during the past fifteen years.
• Urban rural divide: Infant mortality rates in
urban (34/1000 live births) and rural areas
(55/1000 live births) (SRS2009).
• Sex differentials: In rural population IMR of
female children are relatively more due to
gender issues such as son preference and
neglect of female children.
20
21. GOALS:
• Our goal was to achieve an Infant Mortality
Rate of 45/1000 live births by 2007 (as per the
Tenth Plan) and to achieve an Infant Mortality
Rate of 30/1000 live births by the year
2010(as per the National Health Policy 2002).
21
22. The trends
• The rapid decline and static trends in IMR:
• There was significant reduction min IMR after
the introduction of programs like EPI, ORT,
pneumonia control, vit.A prophylaxis etc.
• The contribution of neonatal mortality to IMR
remained static as they required different
interventions
22
23. • Out of total IMR more than 50% occur in
neonatal period and out of the neonatal
period more than 50 % of deaths occur in
early neonatal period
23
24. Exogenous and endogenous causes of IMR
• Bourgeois-Pichat (1964) indentified two types of factors
viz. ‘endogenous’ and ‘exogenous’ that affect infant
mortality.
• Exogenous factors:
• vaccine preventable diseases
• respiratory diseases
• diarrheal disease.
– occur in the post-neonatal period
– they are easier to control.
24
25. • Eendogenous causes:
1. More biological in nature
2. Include deaths due to congenital malformations
and birth process.
3. They occur in the neonatal period (less than 1
month of age of infant)
4. The are difficult to control
25
26. Common causes of IMR
• The causes are classified as Direct and indirect
• Direct causes:
• Infant mortality:
– Perinatal causes 46%
– ARI 22%
– ADD 10%
– Other infections 8%
– Cong.defects 3.1%
– Nutritional deficiency 2%
– Injuries 1.4%
– Malaraia 1.1%
26
28. Indirect causes
Maternal causes.
• Mother:
– Age:
• The pattern of infant mortality follows a U-
shaped curve with the age of mother
• Teen age, grand multi and elderly primi have
increased chances of infant mortality
28
29. Pregnancy
• Birth Order:
– The pattern of infant mortality by order of birth seems to
follow a U-shaped curve
– Mortality is more in 1st and 4th and above birth orders
• Birth Interval
– shorter birth interval (below 18 months)
• Prenatal Care
– 2 doses of TT, high risk identification, Iron folic acid and
feeding programs had a relatively lower risk of death
29
30. Birthing process
• Place of birth: Home delivery carries high IMR as
compared to institutional deliveries
• Birth attendant: delivery conducted by untrained
relatives and traditional birth attendants (Dhais)
cary high mortality in contrast those conducted by
VHNs and medical professionals
30
31. Social causes
1. Poverty:
2. Social status:
3. Cultural beliefs:
4. Son preference:
5. Female literacy
6. Female empowerment
7. Female infanticide
31
32. Health system factors
1. Inadequate doctor patient ratio
2. Inadequate specialists
3. Lack of tertiary care in nearer places
4. Problems of transport during emergencies
5. Lack of dedication
3 delays:
1. Delay in referral
2. Delay in transport
3. Delay in treatment
32
33. Interventions for reducing IMR
• Life cycle approach: Attention to female child
to improve the nutrition (height and weight)
and anemia, prevention of RTI etc
• Women: Strategy to prevent teen marriage
and pregnancy, multiparity, elderly pregnancy,
short pregnancy intervals etc
33
34. Antenatal
• Antenatal care: for high risk screening, TT
immunization, feeding, iron folic acid
• Antenatal fetal monitoring - FM
• Institutional delivery
• Appropriately skilled birth attendant
• Planned transport for reaching institution in
time
34
35. • Intranatal:
– Fetal monitoring (partogram)
– Emergency obstetric care
– Resuscitation of NB
• Post natal:
– Preterm/LBW care
– Colostrums and exclusive breast feeding
– Warm chain
– Prevention of sepsis
35
36. Infancy
• Immunization
• Exclusive breastfeeding
• Vit.A prophylaxis
• Care of the female child
• ARI control
• ORT
• Cultural beliefs and practices
36
37. Strategies by Government
• Implementation of Integrated management of
neonatal and childhood illness
• Establishment of first referral hospitals,
Comprehensive Emergency Obstetric and
Newborn Care (CEmONC) and basic service at
PHC: BEmONC
37
38. • Establishment of tertiary care hospitals
• MTP act to regulate unwanted pregnancies
• Women empowerment
• Extended Maternity leave
• Pregnancy- financial aids
• Smokeless Chula
• Cradle Baby scheme
• Doctor – patient ratio
38
39. Strengthening of referral system
• In all home deliveries AWW worker checks the
birth weight as soon after delivery as possible
and refer those neonates with birth weight less
that 2.2 kg to hospitals where there is a
pediatrician is available and FRU/ CHCs honour
the referrals.
• Ambulance services
39
40. Under five children
1. 15% of population
2. Period of growth and development
3. Prone for malnutrition
4. More deaths due to PEM, Pneumonias , ADD and
tuberculosis, measles, Pertusis and other VPDs
5. Behavior and developmental disorders
6. Nephrotic syndrome
7. Febrile fits
8. CHDs and other defects
41. U5 clinic
• The concept of under five clinics was proposed by
David Morley in South Africa.
• Concept : comprehensive system of health care
within the resources available, making use of non-
professional auxiliaries, :
a. Prevention: immunization
b. Treatment: minor ailments
c. Health supervision: routine check up
d. Nutritional surveillance: Growth chart
e. Health education: Child to child ; child to family
f. Available to a larger proportion of children
42. David Morley
Published a book, Paediatric Priorities in the Developing
World, which challenged the concept of hospitals as
"disease palaces".
He clearly showed the impact of simple, community-based
technologies and healthcare systems in contrast to hospital
based approaches
David Morley started Under-Fives
Clinics and he devised the ‘Road to
Health’ growth chart
44. Aims and Objectives
Symbol of under 5 clinic
Care in
illness
Growth
monitoring
Preventive
care
Family planning
45. Care in illness
• This is a mother’s “felt need”.
• Studies have shown that 70-90 percent of the care of sick
children can be handled skilfully by trained health
personnel
• The illness care for children will comprise:
1.Diagnosis and treatment of:
1. Acute illness
2. Chronic illness including physical, mental congenital and
acquired abnormalities
3. Disorders of growth and development
2.X-ray and laboratory services
3.Referral services
46. Preventive care
1. Immunization
a. Immunization is the world’s greatest public heath
tool.
b. In the context of HFA/2000,one of the health goal
was to immunize the all children against the “big six”
disease
c. Together these diseases kill about 5 million children
in a year and disable another 5 million worldwide.
47. Nutritional surveillance
• Common nutritional disorders in U5:
– PEM,
– anaemia,
– rickets,
– Vit.A deficiency
– Nutritional surveillance is extremely important for
sub clinical nutrition as it tends to be over looked.
– Growth chart and referral
– The ICDS
48. Health check -ups
1. Physical examination
2. Appropriate laboratory tests;
3. Provided every 3-6 months.
4. The child health card provides a check list for
these examinations;
5. Are in use in all ICDS projects.
6. Useful in identifying ‘at risk’ children so that
they can be given special attention
49. Oral rehydration
• On an average, child in the developing
country, suffer from ADD 2-6 times in a year
• Sets in vicious cycle of infection-malnutrition
• risk of death from dehydration.
• The home use of ORT has opened the way to
the drastic reduction of child deaths and
malnutrition.
50. Family planning
• In the centre of the symbol is the symbol of
family planning triangle of in India.
• This puts the topic in the centre of concern for
the health and well-being of the child.
• It is possible to conduct family planning
programmes through these clinics, as the mother
can receives counselling about family planning.
51. Health education
• Around the whole symbol is a border that
touches all the other areas.
• This simply represents health education that
mother automatically receives when she goes
with her baby.
• She is taught about how to keep baby clean,
about feeding, immunizations, hand washing,
nutritious diet etc
52. Growth monitoring
1. weigh the child:
1. every monthly during the first year,
2. every 2 month during the second year
3. every 3 months thereafter
2. This is plotted on o growth chart
3. Detect early onset of growth failure due to:
1. failure of breast feeding,
2. intestinal parasites etc.
3. Inter current illness
4. Cultural beliefs and customs
