Why So Many Child Deaths?

[The following is an edited translation of my op-ed piece in the Bengali daily, Sakalbela, published a few months ago. I am thankful to Priyanka Nandy for her help in editing the language of the translation.]

There was a hue and cry for several deaths of children in West Bengal few months back. The issue of child mortality became almost regular news for the print as well as the electronic media. The Chief Minister (who is the Health Minister as well) of West Bengal raised the issue of under-nutrition of children in this regard. She mentioned the problem of low weight at the time of birth of children. Whatever may be the political significance of the words of the Chief Minister, these issues are noteworthy. According to the UNICEF’s 2008 report on the State of the World’s Children, under-nutrition remains as an area of key concern, as it is associated with up to 50 per cent of child deaths. It has been found in India that the areas having higher rates of child mortality are also facing greater child under-nutrition. West Bengal is not an exception from it. The relation of child mortality with the child nutrition level is a universally accepted fact. The relationship of under-nutrition with the child mortality is found to be relevant in West Bengal from the National Family Health Survey (NFHS) data. There is progress in West Bengal in this respect but those have not been sufficient till now. The recent National Sample Survey (2009-10) data shows that the number of households not getting adequate calorie (food) are increasing both in rural and urban areas in India. This trend naturally has had some negative bearing on the nutrition level of children. The development in the economic condition of the people is the basic solution, but a programme like Integrated Child Development Service (ICDS) could have also done a lot in this regard if it had been implemented seriously. Unfortunately, this programme is neglected in West Bengal, just as it is in many other states in India. The problem in conceptual clarity, the lack of political will and some other factors are responsible for this neglect, adding to the persistence of child mortality in West Bengal.

Though the detail of child deaths in West Bengal in the contemporary period is unknown, but newspaper reports made it appear that there were children of various age groups – including neo-natal (age within one month) – amongst those that were dying. As per NFHS (2005-06), the rate of mortality of child under-five was 60 in West Bengal for per 1000 live births. Uttar Pradesh was at the top and Kerala was at the bottom in India in this regard (the corresponding figures for them were 96 and 16 respectively). Most of the children (38) out of the 60 child deaths in West Bengal died at the neo-natal stage, like in the other states. These ratios were slightly higher for the rural areas in West Bengal – neo-natal deaths were 40, and deaths of children under-five was 64.

The problem of under-nutrition of the children in the neo-natal stage may occur mainly in two ways: firstly, the low weight of the child at the time of birth – a result of under-nutrition in the pregnant mother – provides a strong base for the under-nutrition of the child. Secondly, the unavailability of breast milk causes under-nutrition of children. Although the issue of breast milk appears to be less relevant for West Bengal. As per NFHS (2005-06), the proportion of children (under 2 months) deprived of breast milk was only 2 per cent in West Bengal, and 79 per cent of the children were exclusively breastfed. These ratios were 3 and 69 per cent respectively for the whole country. Thus it seems that the birth-weight of a child is vital to its level of nutrition in the neo-natal stage: a child with low birth-weight usually remains under-nourished during this period.
According to an estimate, one third of the children of the world are born with a lower weight than normal. Although the under nutrition of the pregnant mother is not the only reason behind the low weight of any child, it is certainly an important reason behind it.

The percentage of women, as per NFHS (2005-06), in the age group of 14-49 years who were victim of under nutrition (body mass index below the normal) was 39 in West Bengal. The ratio was 46 for the rural areas and 58 for the people of lowest wealth index. This proportion was found to be 50 per cent among the women in the age group of 15-19 years. Alarmingly, 25 per cent of women in this age group also became pregnant, according to the NFHS (2005-06). Thus the data of under-nutrition of women is showing an important link for the under nutrition of the children in West Bengal. In addition to this, if the question of anaemia among women – a dire 63 per cent women, as per NFHS (2005-06), was suffering from anaemia – is taken into consideration, the situation for child under-nutrition looks more serious. So to tackle the problem of under-nutrition of children the problem of under-nutrition amongst pregnant and lactating mothers must be eradicated.

The relation of nutrition of a child with nutrition level of his/her mother becomes less relevant after the child completes first six months of his/her life. Semi-solid food besides breast-milk becomes very important for the child then. Many people from lower ranks of the society fail to provide balanced, nutritious food to their children at this stage. From the NFHS survey it was found that the proportion of children having the problem of under-nutrition was maximum in the lowest wealth index, and minimum in the highest wealth index. According to its 2005-06 survey, 59 per cent of the children in West Bengal (under the age of five years) coming from the lowest wealth index was found to be stunted (low height for age) and 50 per cent of the children of the same category was found to be underweight (low weight for age). The extent of the problem of under nutrition amongst the children of West Bengal’s lower economic strata can be easily understood from this data. Thus, to remove the problem of under nutrition, it is vital to supply balanced, nutritious food to children above six months.

Those who admit the relationship of nutrition with child mortality know very well how closely the reduction in the rate of child mortality is linked to the eradication of the problem of under-nutrition of pregnant mothers, lactating mothers and children. The ICDS (Anganwadi) can take a very important role for removing this problem. There is provision of food for pregnant/lactating mothers and for children under six years for 300 days in a year. For the pregnant/lactating mothers the provision of food is equivalent to 600 calories for each woman each day, and for a child of under six years it is equivalent to 500 calories. For a severely malnourished child the amount of food is equivalent to 800 calories instead of 500 calories. But unfortunately this scheme is found to be neglected in West Bengal.

The data provided by the Ministry of Women and Child Development, Govt. of India, shows that as of March 2012, West Bengal was at the top in terms of number of projects not in operation, although sanctioned. There were 100 projects in West Bengal which were not in operation on March 2012, despite being sanctioned. The figure for the entire country was 167 then. It is true that there may be a huge gap in being formally operational, and the good functioning of any project. Thus, there are many areas where the ICDS scheme is functional, but performing very poorly. With the realisation of the importance on the early child health some scholars focused on the improvement in infant feeding practices in the age group of six months to two years, and raised questions regarding the ways in which the ICDS functions for these age groups. But if the project does not operate then the question of good functioning does not arise at all. In the absence of proper action of the State as well as the Central government, the ICDS scheme is stumbling instead of walking. Had the State dedicated itself to creating a positive example out of the supplementary nutrition scheme in West Bengal, child mortality and the under-nutrition of pregnant/lactating mother and children under six years could have been significantly reduced.

According to the 2004-05 survey of National Sample Survey Organisation, the proportion of rural households ‘not having enough food everyday in some months’ was highest in West Bengal. It has already been mentioned that the number of households not getting adequate calories (food), as per National Sample Survey (2009-10), are increasing both in rural and urban India. In a survey conducted among the children of Class I in four districts of West Bengal in last year by the Department of School Education, Government of West Bengal, found that 9 children out of 10 were the victim of under-nutrition. At the same time there is tremendous neglect in the implementation of the Anganwadi scheme. The programme of supplementary nutrition was executed for 242 days in 2009 in West Bengal, even though the provision is for 300 days. Is the new Government of West Bengal considering the Integrated Child Development Scheme seriously?