This document discusses infant and perinatal mortality. It defines key terms like live birth, fetal death, stillbirth and provides current global and national magnitudes for perinatal mortality rate, neonatal mortality rate and infant mortality rate. The major causes of infant and perinatal deaths are discussed along with the various determinants. Prevention strategies are highlighted including improvements to antenatal, natal and postnatal care. Investigation of infant deaths and methods for surveying to estimate infant mortality rate are also summarized.

1. IMR & PMR – Definition,
Magnitude, Causes & Prevention
of Infant and Perinatal Mortality,
Investigation of Infant Death,
Survey for Estimating IMR
Dr. Roselin
1

2. OVERVIEW
• Definitions
• Mortality in and around infancy
• Current magnitude of PMR, NMR , IMR
• Causes
• Determinants
• Prevention of IMR&PMR
• SDG target
• Investigation of infant death
• Survey of infant death
2

3. LIVE BIRTH
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, such as 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.
3

4. FOETAL DEATH
Death prior to the complete expulsion or extraction from
its mother of a product of conception irrespective of the
duration of pregnancy; the death is indicated by the fact
that after such separation the foetus doesn’t breath or
show any other evidence of life , such as beating of the
heart, pulsation of the umbilical cord, or definite
movement of voluntary muscles.
4

5. 5

6. STILL BIRTH
• WHO recommendation-
foetus born dead, weigh 500 gms , and the birth weight
most frequently associated with a gestational period of
22 weeks.
• International comparison-
foetus born dead, with a boundary of 1000 gms weight,
associated with gestational age of 28 weeks.
6

7. STILLBIRTH RATE
• Death of a foetus weighing 1000g (this is equivalent to 28
weeks of gestation) or more occurring during one year in
every 1000 total births (live births plus still births).
• SBR = Foetal deaths weighing over 1000g at birth ×1000
Total live +stillbirths weighing over 1000g at birth
7

8. CAUSES OF STILLBIRTH
MATERNAL
1. Toxemia
2. Diabetes
3. Infection
4. Rh-incompatibility
5. APH
6. Premature rupture
membrane
FETAL
1. Foetal Malformation
2. Twin, triplets..
3. Cord anomalies
4. Hydramnios
5. Placental anomalies
8

9. MAGNITUDE& PREVENTION
• Global: 3.3 million babies are stillborn/year.
• India:
• Highest in – Karnataka 14/1000
• Lowest in- Bihar & Jharkhand 1/1000
• PREVENTION
early detection and treatment of infectious pathology and
correction of high BP, sugars and other complications.
9
RURAL URBAN TOTAL
INDIA 5 5 5
TN 11 5 8

10. PERINATAL MORTALITY
• Perinatal mortality includes both late foetal deaths
(stillbirths) and early neonatal deaths.
• 8th Revision of ICD: Perinatal period lasts from 28th week of
gestation to seventh day after birth.
• 9th Revision of ICD:
i. Babies should be above 1000 g at birth.
ii. If birth weight unavailable, a gestation period of 28
weeks taken.
iii. If both not known, crown to heel length of atleast 35
cm is taken.
10

11. PMR-PERINATAL MORTALITY RATE
PMR = stillbirth + early neonatal death in one year ×1000
live birth + stillbirth
PMR = stillbirth + early neonatal death in one year ×1000
live birth in a year
International comparison
PMR = stillbirth+ early neonatal death weighing 1000g at
birth ×1000
total live birth weighing over1000 g at birth
11

12. WHY PERINATAL MORTALITY
• Perinatal period accounts only 0.5% of average human
lifespan but more death occur in this period compared to next
30-40 years of life.
• Yardstick for obstetric and pediatric care before and around
the time of birth.
• Also a good indicator for extent of pregnancy wastage and
quality of healthcare available to the mother and newborn.
• SBR and ENMR are combined in PMR because the factors
responsible are almost same.
• To prevent incorrect registration of deaths after birth as
stillbirths.
12

13. MAGNITUDE OF PMR
• 90% of all foetal and infant mortality occurs in the
developed countries.
• PMR according to SRS,2013
• High in Odisha, MP, Chhattisgarh - 36
• Low in Kerala - 10
13
RURAL URBAN TOTAL
31 17 28
TN 24 13 19

14. AT RISK FACTORS FOR PMR
1. Low socio economic status
2. High maternal age (35 yrs or more)
3. Low maternal age (under 19 yrs)
4. High parity ( 5th and more) in short intervals
5. Smoking ( 10 or > cigarettes daily)
6. Maternal Height – < 145 cms
7. Poor past obstetric history
8. Malnutrition and severe anemia
9. Multiple pregnancy
14

15. CAUSES OF PERINATAL MORTALITY
ANTENATAL CAUSES:
1. Maternal diseases
2. Pelvic diseases – endometriosis, ovarian tumor
3. Anatomical defects – Uterine, Cervical anomalies
4. Endocrine imbalance
5. Blood incompatibilities
6. Malnutrition
7. Toxemias of pregnancy
8. APH
9. Congenital defects
10. Advanced maternal age
15

16. CAUSES CONT.
INTRANATAL CAUSES:
1. Birth injuries
2. Asphyxia
3. Prolonged effort time
4. Obstetric complications
POSTNATAL CAUSES:
1. Prematurity
2. Respiratory distress syndrome
3. Infections
4. Congenital anomalies
Unknown causes
16

17. Perinatal Death- Form
17
Source:www.who.int/classifications ICD-10

18. PREVENTION OF PERINATAL DEATH
Before & during pregnancy:
Delay child birth
Birth spacing
Healthy mother
No drug abuse
TT and Rubella immunization
Female education
During pregnancy
Birth preparedness
Prevention &Rx of anemia
Prevention &Rx of infection
Good diet
18

19. PREVENTION OF PERINATAL DEATH
Soon after delivery
Hospital delivery.
Early detection & prompt treatment of complication.
Newborn resuscitation.
Newborn care.
Early initiation of exclusive breastfeeding.
Counseling on homecare, danger sign & care seeking.
19

20. NMR-NEONATAL MORTALITY RATE
• Deaths occurring during the neonatal period, commencing at
birth and ending 28 completed days after birth – Neonatal
deaths
• NMR is the ratio of no. of neonatal deaths in a given year per
1000 live births in that year.
• NMR = no. of death of children under 28 days of age ×1000
total live birth
20

21. MAGNITUDE OF NMR
GLOBAL
• 2.8 million newborn die each year.
• Half of them die within 24 hours.
• 98% occur in developing countries.
• Accounts for 44% of under 5 death.
• NMR is 6.5 times lower in high income countries.
INDIA
21
RURAL URBAN TOTAL
INDIA 33 16 29
TN 18 11 15

22. 22
Source: UNICEF child survival progress report 2015

23. 23

24. 24Source: Annual health survey report- vital health indicators- census of India

25. MEASURES TO PREVENT NMR- TN
25

26. POSTNEONATAL MORTALITY RATE
• Deaths occurring from 28 days of life to under one year – post
neonatal deaths.
• PNMR – ratio of post neonatal deaths in a given year to the
total no. of live births in the same year; expressed as a rate per
1000
• PNMR = No. of deaths of children between 28 days
and 1 year of age in a given year ×1000
total live birth in same year
26

27. MAGNITUDE OF PNMR
• Highest in Assam- 27
• Lowest in Kerala- 5, TN- 6
27
RURAL URBAN TOTAL
INDIA 14 12 13
TN 7 6 6

28. INFANT MORTALITY RATE
• Ratio of infant deaths registered in a given year to the
total number of live births registered in the same year;
expressed as a rate per 1000 live births.
• IMR = no. of death of children less than 1 year
of age in a year ×1000
no. of live births in the same year
28

29. SIGNIFICANCE OF IMR
• Largest single, age-category of mortality.
• Peculiar set of diseases and conditions.
• Affected rather quickly and directly by specific health
programs.
• Hence, IMR is the most important indicator of
 Health status of community
 Level of living of people
 Effectiveness of MCH services
• Used in Quality of life indices eg. PQLI
29

30. IMR MAGNITUDE
• GLOBAL
• World average of IMR varies from 5/1000 to 61/1000.
• The average in south Asian countries 43/1000
• 2013 global IMR – 34/1000
• INDIA
30
RURAL URBAN TOTAL
INDIA 43 26 39
TN 23 16 20

31. 31Source: census of India 2011

32. 32Source: Annual health survey report- vital health indicators- census of India

33. MORTALITY PATTERN
• AGE: death 0-1 year 13% of total death.
within 1st month - 68.5%
out of it within 1st week -51.6%
• SEX: Early neonatal deaths and Stillbirths –M>F
Post neonatal deaths – India – F>M
33

34. IMR – SEX DISTRIBUTION
34
Source: Maternal & Child Mortality and Total Fertility Rates(SRS)
Office of Registrar General, India 2011

35. IMR TRENDS
35
Source:Infant and Child Mortality in India Levels trends and determinants – factsheet
UNICEF

36. IMR IN INDIAN STATES
36Source: Infant and Child Mortality in India Levels trends and determinants – factsheet
UNICEF

37. ENMR&PNMR
37
Source: Infant and Child Mortality in India Levels trends and determinants – factsheet
UNICEF

38. CAUSES OF INFANT MORTALITY
Neonatal mortality( 0-4 weeks) Post-neonatal mortality(1-12
months)
Low birth weight & prematurity Diarrhoeal diseases
Birth injury & difficult labour ARI
Sepsis Other communicable diseases
Congenital anomalies Malnutrition
Hemolytic disease of newborn Congenital anomalies
Placental cord anomaly Accidents
Diarrhoea
ARI
Tetanus
38

39. PRINCIPAL CAUSES OF IMR IN
INDIA
1. Low birth weight – 57%
2. Respiratory infections – 17%
3. Diarrhoeal diseases – 4%
4. Congenital malformations – 5%
5. Cord infection – 2%
6. Birth injury – 3%
7. Unclassified - 18%
39

40. FACTORS AFFECTING INFANT
MORTALITY
BIOLOGICAL FACTORS
• Birth weight - <2.5 & >4 kgs
• Age of the mother - <19 & >30
• Birth order - First, after 3,4,5<later
• Birth spacing - < 1 yr
• Maternal nutrition
• Multiple births
• Family size
• High fertility
40

41. FACTORS AFFECTING INFANT
MORTALITY
Socioeconomic factors
CULTURAL FACTORS
• Breast feeding
• Religion and caste
• Early marriages
• Sex of the child
• Quality of mothering
• Maternal education
• Quality of health care
• Broken families
• Illegitimacy
• Brutal habits and customs
• The indigenous dai
• Bad environmental
sanitation
41

42. PREVENTIVE & SOCIAL MEASURES
1. PRENATAL NUTRITION
- Improve maternal nutrition
- 500kcal and 10g protein extra
- Food supplementation programme
2. PREVENTION OF INFECTION
- Immunization
- Universal immunization programme- 1985
- Provide protection against 6 vaccine preventable disease
42

43. PREVENTIVE & SOCIAL MEASURES
3. BREAST FEEDING
- Lowers LBW babies
- Exclusive breastfeeding
- BPHI -1992
Protect ,promote and support breastfeeding practices
43

44. BFHI
TEN STEPS:
i. Maintain written breastfeeding policy to be communicated
to health care staff.
ii. Train the staff to implement this policy.
iii. Inform pregnant women about benefits of breastfeeding.
iv. Help mother to initiate breastfeeding within half hour.
v. Show mother how to breastfeed and maintain lactation
even baby is separated.
44

45. BFHI
vi. No food or drink other than breast milk
vii. Rooming in
viii. Demand feeding
ix. No artificial teats, pacifiers, dummies to breastfeeding
infants
x. Refer to breastfeeding support groups
45

46. PREVENTIVE & SOCIAL MEASURES
4. GROWTH MONITORING
- Growth chart maintenance.
- Identify children at risk of malnutrition.
5. FAMILY PLANNING
- Health educate about limited family size
- Birth spacing.
6. SANITATION
- Good housing and sanitation plays role in reducing IMR.
46

47. PREVENTIVE & SOCIAL MEASURES
7. PRIMARY HEALTH CARE
- Obstetrician to the local dai should collaborate and work as a
team.
- Detection of high risk mothers.
- Proper referral services.
8. SOCIO-ECONOMIC DEVELOPMENT
- Provision of safe water
- Improve basic sanitation
- Female literacy
- Housing condition
- Growth of agriculture and industry
47

48. PREVENTIVE & SOCIAL MEASURES
9.EDUCATION
- High literacy rate in women – low maternal and infant
mortality.
- Study in 1991 in India says mid day meal programme-
improved health care of women and their babies,
increased immunization and drastic fall in IMR.
48

49. SDG
• SDG target 3.2: by 2030, end preventable death of newborns
and children under 5 years of age, with all countries aiming to
reduce neonatal mortality to atleast as low as 12/ 1000 live
births and under-five mortality to atleast as low as 25/1000
live births.
- 5.9 million under 5 die every year globally
- Out of it 45% were neonatal death.
• ACHIEVING THE 2030 TARGET
rapid progress is required to meet the SDG targets for under-
five and neonatal mortality. 79 countries did not meet the
2030 SDG targets and 24 countries have rates 2-3 times
higher.
49

50. SDG
NEONATAL PERIOD
• Scaling up the priority intervention area to address major
gaps.
• Better prevention and management of preterm births.
• Inpatient supportive care of ill and small newborn babies.
• Management of severe infection.
• Promotion of kangaroo mother care.
POSTNEONATAL PERIOD
• Scale up Vaccine coverage.
• Treatment coverage for diarrhoea and pneumonia.
• Prevention and treatment of injuries.
50

51. INVESTIGATION OF INFANT DEATH
• Reducing infant mortality is one of the key goals under NHM.
• Analysis of child deaths provides information about the
medical causes of death, helps to identify the gaps in health
service delivery and social factors that contribute to child
deaths.
• This information can be used to adopt corrective measures
and fill the gaps in community and facility level service
delivery.
51

52. INVESTIGATION OF INFANT DEATH
• Child death review by ministry of health and family welfare.
• Community Based Child Death Review (CBCDR) ƒFacility
Based Child Death Review (FBCDR)
• Step 1 – notification of death
• Step 2 – investigation of death
• Step 3 – data transmission
• Step 4 – analysis of data followed by action plan
52

53. 53

54. 54

55. SURVEY FOR ESTIMATING IMR
• In each district, the survey should be done on a minimum of 3
lakh population.
2 lakh - from rural
1 lakh -from urban
• For rural survey - 40 HSC selected at random.
• For urban survey - the population is divided by no. wards or
streets and required no. selected at random.
• The population is contacted by Household survey and
information on births, deaths, infant deaths are recorded.
• Matching is done with other source of available data.
55

56. SURVEY FOR ESTIMATING IMR
• The infant deaths are classified as per sex and age (days) -
<1, 1-6, 7-27, 28-364 days and summed up.
• Then Age and Sex distribution of deaths including maternal
and infant deaths are tabulated in each of the HSCs.
• From the above data the proportion of infant deaths among all
age group can be found out.
• In the DANIDA vital events survey, the causes of infant death
was classified into 40 and the cause of each infant death is
coded accordingly.
56

57. CAUSES OF IMR
57
AIDS Congenital
malformation
Jaundice Neonatal
tetanus
Septicemia
Accident Diarrhoea Low birth wt PUO Severe under
nutrition
Poisoning Diphtheria Malaria Pertusis Snake bite
ARI Dysentery Measles Pneumonia Social cause
Birth asphyxia Encephalitis MAS Polio Surgical cause
Birth injury Fits Meningitis Prematurity TB
Cholera Heart disease Mumps Rubella Typhoid
Coma Hypothermia Neonatal
convulsion
Scorpion sting Other cause

58. SUMMARY
58

59. REFERENCE
• Park textbook of preventive and social medicine 23rd edition.
• Community medicine with recent advances AH Suryakantha
• AFMC textbook by Rajvir Bhalwar
• Committing to Child Survival: A Promise Renewed Progress
Report 2015
• SRS BULLETIN - Sample Registration System Registrar
General, India July 2016
• Save the Child Public Health Foundation of India 2014
• Infant and Child Mortality in India Levels trends and
determinants – factsheet UNICEF
59

60. REFERENCE CONT.
• Neonatal and perinatal mortality : country, regional and global
estimates.- WHO
• NFHS -4 Tamilnadu Factsheet.
• SDG -child mortality.
• Child death review operational guidelines august 2014-
ministry of health & family welfare Gov. of India.
• ICD-10 , second edition.
60

61. THANK YOU
61