Childhood is the formative period in human life, subjected to various intrinsic and extrinsic influences affecting their survival, health and disease. State of child health in a community reflects its overall socioeconomic development and health concerns.
Constitutionally, a child has been defined as an individual <18 years of age, though conventionally, a pediatrician in India looks after the health of children fill 12-14 years. In some countries, the scope of pediatrics extends up to 19 years i.e. including the period of adolescence.
From the child health perspectives, childhood is not a homogenous period but includes various phases of growth and development with unique physical, mental and social health dimensions during each phase. (Table 1.1).
According to the National Family Health Survey- II (NFHS-1999), children constitute 40% of India’s population, including 3% infants, 11% preschoolers (1-4 years) and 24% school children <14 years. Another 10% of population is in 15-19 years of age.
Present chapter provides an overview of current status of child health in India and its determinants as well as leading causes of morbidity & mortality and interventional strategies.
Indicators of Child Health
Status of child health in a country is reflected in various morbidity and mortality indicators and their changes over a period of time.
Morbidity indicators: Morbidity indicators are more reliable pointers of community health than mortality indicators. Although community data regarding patterns of childhood morbidity in India is limited due to poor reporting system, hospital data identifies four major causes of post-neonatal morbidity in Indian children — Acute respiratory tract infections (—30%), Malnutrition (—25%), acute diarrheal diseases (—20%) and vaccine preventable diseases e.g. tuberculosis & measles (—20%). Many of these problems are inter-related and co-exist in the same child seeking health care.
Like any other country, morbidity profile is not static in India and keeps on changing with overall development in socioeconomic and environmental status as well as child health care awareness/facilities in the community. Recent years have seen substantial decline in incidence of infectious and nutritional disorders, with simultaneous rise in non-infective illnesses e.g. systemic diseases and accidents due to changing life-style and other ecological factors.
Mortality indicators are relatively better defined and documented. It is estimated that —30-40% of all deaths in India occur during childhood, of which 50% occur in first five years, 33% in first year, 20% in first month and 10% in first week of life.
Considering variable risk of mortality and causative factors in different age groups, many mortality indicators (Table 1.2) are used to assess the status of child health and efficacy of interventional programs, some of which are as follows Perinatal mortality rate (PMR) i.e. a ratio of late fetal and early neonatal deaths compared to all live births in given year, expressed as a rate per 1000 live births, is the best indicator of care available to pregnant mother and her newborn in a given community.
According to National Family Health Survey – III (2006), Current PMR in India is 48.5/1000 live births, with wide geographic variations. Despite the declining trends during recent years, it is still much higher than that in most developed countries (15-20/1000).
Infant mortality rate (JMR) i.e. a ratio of all deaths during first year life and total number of live births, expressed as a rate per 1000 live births, is considered as the single best indicator of child health and effectiveness of health-care system in a community.
According to latest National Family Health Survey – III (2004-2006), current IMR in India is 57/1000 live births, much higher than that in developed countries (<10/1000). Within India too, IMR differs widely in urban vs. rural population (42 & 62 respectively) and from state to state – being lowest in Kerala (15), moderate in Maharashtra (37) and highest in Uttar Pradesh (73).
Neonatal & post-neonatal mortality rate: Infancy includes two crucial phases of human life — neonatal and post-neonatal period, with diverse child health problems. IMR denotes addition of neonatal mortality rate (NMR) and post-neonatal mortality rate (PNMR), which may be computed separately.
Current NMR and PNMR in India is 39/1000 and 18/ 1000 live births, respectively.
Last century has witnessed a sharp fall in 1MR (204 in 1911 to 57 in 2006), predominantly due to declining post-neonatal mortality rate after better control of exogenous factors e.g. infection and malnutrition. Neonatal mortality rate, which is mainly related to biological factors e.g. low birth weight, birth asphyxia and congenital malformations etc. continues to be high in most parts of our country. Interestingly, NIvIR is higher in males (?biologically fragile sex), while PNMR is higher in females due to socio-cultural neglect.
Under-Five mortality rate is a sensitive indicator of the overall development of the community, as majority of its causes e.g. malnutrition and infection, depend on the socio-economic status, environmental hygiene and child health awareness in population. It is defined as the ratio of annual deaths <5 years of age and total live births in the same year, expressed as a rate per 1000 live births.
In India, Under-five mortality has shown marked decline during last few decades (242 in 1960 to 74 in 2006), due to overall socioeconomic development, easier access to child health care and control of infectious diseases.
CAUSES OF CHILDHOOD MORBIDITY & MORTALITY
Etiology of childhood morbidity and mortality varies with age and may be divided into two major groups — endogenous causes e.g. low birth weight, predominantly responsible for neonatal morbidity; and exogenous causes e.g. infections and malnutrition, which usually affect beyond the neonatal period.
Rapid improvement in mortality indicators during the last century is largely attributable to better control of exogenous factors. Endogenous causes are more difficult to control and need holistic strengthening of antenatal, intranatal and postnatal services.
With relative control of common illnesses, new causes are emerging as important contributors of childhood morbidity and mortality in India e.g. congenital malformations, immunological disorders, newer infections e.g. HIV/AIDS and mental health problems.
DETERMINANTS OF CHILD HEALTH
Child health in a community is influenced by various environmental factors, which account for geographic and demographic differences in morbidity and mortality. Important adverse factors for child-health in India include —
a) Maternal factors e.g. young matemal age, maternal malnutrition and illnesses, repeated pregnancies, short birth spacing etc.
b) Socioeconomic factors e.g. poverty, urbanization, large family size, female illiteracy, girl child, illegitimate pregnancies etc.
c) Cultural factors e.g. early marriage, improper infant feeding practices e.g. top feeding, harmful child-care customs/taboos etc.
d) Environmental factors e.g. Overcrowding, unsafe water supply & excreta disposal, poor personal & environmental hygiene, stressful family environment e.g. broken families etc.
e) Health-care factors e.g inadequate antenatal care, unsafe/untrained deliveries, poor immunization coverage, inadequate access to health services etc., specially in rural areas.
Three most important determinants of poor child health in India and other developing countries are also denoted as PPE spiral i.e. Poverty, Population-explosion and Environment.
INTERVENTIONAL STRATEGIES for child health
Since independence, a plethora of targeted child health programs were launched in India with periodic reviews and modifications. While earlier programs were largely uni-sectorial, inter-sectorial coordination is hallmark of current strategies in child health care. Some important aspects of these efforts are as follows —
a) General population measures: Socio-economic development, Population control (Family planning), Environmental sanitation, Promotion of female literacy.
b) Reproductive female health measures: Nutritional health care of reproductive females, Adequate birth spacing
c) Antenatal care: Regular antenatal care, ‘At-risk approach’ for high-risk pregnancies
d) Perinatal care: Safe/clean delivery by trained attendants, Essential newborn care, Promotion of breast feeding
e) Postnatal care: Universal immunization, Growth monitoring & promotion (GMP), Early diagnosis & treatment of common illnesses, Promotion of low-cost tools e.g. ORS
f) Strengthening of heath-care system: Low-cost medical care, General health programs e.g. RCH, ICDS, Disease- targeted programs e.g. malaria control, Group-targeted programs e.g street children
To conclude, the child health in India is currently at the crossroads. Despite all efforts, status of the Indian child is still far behind than that of a child in developed countries. Country has largely failed to achieve child health targets set under health for all by the year 2000 AD.
Government of India has revised some of these targets under National health policy 2002 and National population policy 2000, to be achieved by the year 2010. Although lessons have been learnt from the past and strategies are being revised accordingly, achievement of these targets remains a function of political will, community participation, efforts of child health workers and above all, the acceptance of these interventions by the recipients.
• Safe water supply
