Seema Kol, who is five months pregnant, has to travel nearly 32 kilometres to reach the district hospital for her check-up. "There are no other doctors or clinics in my village," Seema, who hails from Bahri village in Sidhi district of Madhya Pradesh, said.
Three years ago, Seema lost her first baby just two days after giving birth.
As per the National Health Mission 2020-21 report, Madhya Pradesh has the country's highest infant mortality rate (IMR) of 48 in 2018. This means 48 children out of 1,000 live births died in the state within one year. In rural areas, the IMR is at 52 and 36 in urban areas.
India has an average infant mortality rate of 32 deaths per 1,000 live births, with 36 occurring in rural areas and 23 in urban areas.
Madhya Pradesh has maintained its top position in this list for the last 10 years. The next highest rate, 43, is in Uttar Pradesh, and the lowest rate, 7, is in Kerala.
Compare this to some of the African nations that have the worst health systems in the world — Rwanda (28), Sudan (42), Tanzania (36) — they still have a lower infant mortality rate than Madhya Pradesh in 2018.
Is The Infant Mortality Rate (IMR) Reliable?
The infant mortality rate, as defined by the World Health Organization (WHO), is the probability of a child born in a particular year or period dying before turning one, based on the age-specific mortality rates in that time-frame. The infant mortality rate is strictly a probability of death that is derived from a life table and expressed as a rate per 1000 live births.
However, many experts question the methodology used for measuring IMR.
Dr Anthony K.R., Independent Monitor, National Health Mission, Government of India explained how the infant mortality rate for states is calculated based on the data generated using a survey methodology known as the Sample Registration System (SRS).
"As this is an independent survey conducted by the Registrar General of Census India, there is no counter-checking procedure by the Health Department of the States," he said. He said that although the sampling units are picked randomly from a particular village or urban ward, not necessarily can "we assume that those sampling units truly represent the entire state".
"There is no information on what proportion of tribal and non-tribal, rural, and urban families are included in these surveys," he said.
Dr Anthony K.R. said that to make the IMR data truly representative and more reliable, there needs to be involvement of demographic and statistical experts. As an independent monitor, Dr Anthony evaluates the implementation of several health programs implemented under the National Health Mission.
"When all the sampling units are changed at one go there can be significant variation in IMR which affects comparability over several years," he said, adding that the trend was observed in Chhattisgarh.
Madhya Pradesh's Healthcare Infrastructure? Poor
Under the National Rural Health Mission, Indian Public Health Standards (IPHS) are a set of standards that are aimed at improving the quality of healthcare in India. There are 51 district hospitals in Madhya Pradesh, 324 community health centres (CHCs) and 1170 Primary Health Centers (PHCs).
Amulya Nidhi, a health expert based in Indore who is associated with Jan Swasthya Abhiyan said, "As per IPHS norms, there should be at least one gynaecologist, one paediatrician, and an intensive care unit (ICU) in every community health centre (CHC). However, many of these CHCs lack staff, adequate facilities, and a regular supply of essential medications."
According to the Annual Health Report of Madhya Pradesh 2020-21, 33,221 posts were sanctioned, out of which 11,432 are vacant in the health department. There were 8,350 posts for Auxiliary Nursing Midwifery (ANM) and 5,770 posts for staff nurses sanctioned, but 32 per cent of ANM posts and 53 per cent of staff nurse posts remain vacant.
Why Is MP's IMR Not Improving Despite The Efforts?
In 2005, the Government of India began the National Health Mission and one of the key goals of the program was to control the Infant Mortality Rate. "The goal of the initiative was to improve health infrastructure at the grassroots level," Amulya Nidhi said.
"After 2014, the Narendra Modi government began focusing exclusively on insurance-based health care, leading to the destruction of basic healthcare at its core," he said.
The Pradhan Mantri Jan Arogya Yojana (PMJAY) was launched in 2018 to provide health insurance to 10 crore poor families in the country. It is part of the Indian government's National Health Policy, which was launched by the Ministry of Health and Family Welfare. The PMJAY, also known as Ayushman Bharat Yojana, is the largest health scheme in the world, aiming to provide health coverage to 50 crore people.
Amulya Nidhi wonders how free healthcare works if the infrastructure cannot be trusted. Amulya Nidhi has been working on primary health care issues for the last 20 years. A large part of his work is to train Asha workers, as well as other grassroots workers. He is a member of the State Mentoring Committee on Community Action in Madhya Pradesh. The health department of Madhya Pradesh formed this committee to facilitate the implementation of Asha programmes.
According to Dr Antony, a low birth weight and premature delivery are the two leading causes of high infant mortality along with newborn sepsis. "Premature babies have weakened immune systems, making them more likely to succumb to complications. Malnourished mothers have low birth weight babies."
Dr Manish Singh, a paediatrician based in Shahdol, a tribal district of Madhya Pradesh, said, "A lot of PHCs and CHCs have been set up in the rural areas, but they do not function. Women sometimes travel 50 to 60 kilometres to district hospitals or give birth at home. The government must make all the local health centres functional to improve IMR."
Last year, the Madhya Pradesh government formed Cooperation Committees called 'Matru Sahyogini Samiti', which consists of 10 mothers at each Anganwadi, representing their concerns under Integrated Child Development Services/National Nutrition Mission. As part of the scheme, six services are offered, including supplementary nutrition, medical services including vaccination, as well as early education.
A senior health official noted that most of these programs are failing at implementation due to rampant corruption and a lack of enthusiasm among lower-level officials.
What Could Madhya Pradesh Do To Improve Its IMR?
"The government does not have a proper policy for improving health infrastructure in tribal areas or providing care to pregnant women. For example, in hilly areas, lots of women have low haemoglobin levels and the government does not have any policy to provide care to such women. Without addressing the underlying problem, it is obvious that IMR will not improve in such areas," said Amulya Nidhi.
He explained that a classification of areas is needed, including urban versus rural, developed versus not developed, and tribal versus not tribal.
The government provides free iron tablets for 100 days to prevent anaemia and tetanus injections to prevent neonatal tetanus. Antenatal check-ups that prevent high blood pressure and preterm deliveries are also offered by the government. However, Dr Antony said that only "few people trust free medications and services from the government."
People in rural areas often choose home delivery over hospitals, said Dr Antony, explaining how the unhygienic conditions can lead to newborns developing sepsis and succumbing to it. "There is a need to raise awareness about institutional delivery to prevent neonatal deaths," he added.
Keeping their bodies warm is also an important factor as low-birth-weight babies are at the risk of hypothermia.
In the case of Chhattisgarh, the IMR dropped to 41 in 2018 from 54 in 2009. The IMR improving significantly was a result, Dr Antony said, of training nearly 60,000 ASHAs in Chattisgarh, called Mitanins, to detect sepsis and better home-based care of low birth weight babies.
A health ministry official on condition of anonymity said that Madhya Pradesh is planning to introduce a High Risk Infant Tracking System to reduce infant mortality. "Children of 0 to 1 year of age will be tracked. Health-related monitoring will be conducted for a year after the birth of the children in the online software," he said.
The author is a freelance journalist based in Madhya Pradesh.
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