Community based retrospective study of sex in infant mortality in India
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7407.126 (Published 17 July 2003) Cite this as: BMJ 2003;327:126All rapid responses
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Dear Sirs
There are demographic implications of the sex bias in infant
mortality in India reported by R Khanna et al (BMJ 19 July 2003:327). The
sex ratio at birth and the higher infant mortality for girls reported for
India both imply a higher family size required for the human population in
India to replace itself.
In a developed country, the replacement level is around 2.08 Total
Fertility Rate. This allows for a sex ratio at birth of 1.05 boys to 1
girl and for mortality of around 3 per thousand among girls before they
reach the age of having children.
In India, the authors report a ratio at birth of 3752 boys to 3260
girls i.e. 1.15 boys to 1 girl and high infant mortality of 72 per
thousand among girls. With an allowance of 4 per thousand among Indian
girls between infancy and the age they have children, we arrive at a
replacement level of 2.28 for India.
When average family size falls below that in India there will be no
surplus population for emigration to countries like the UK.
Yours faithfully
Patrick Carroll
Director of Research
PAPRI Pension And Population Research Institute,
35 Canonbury Road,
London N1 2DG
e-mail papriresearch@btconnect.com
charity registration number in England 327942
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
Gender difference in infant mortality in India
Gender differences in infant mortality have been the subject of previous international comparison and discussion1 and Khanna et al’s2 results provide confirmation.
I examined whether similar gender differences exist in England and Wales using, unpublished ONS data on births and infant deaths by mother’s country of birth. In the absence of national data by ethnic origin, the data for children born to first generation migrants provide the closest proxy to outcomes for minority populations in England and Wales.
For the 19,663 births registered between 1996 and 1998 to mothers born in India, infant mortality for both genders was 5.49 per 1000 births an odds ratio of 1.00 which is not significantly different from the overall England & Wales ratio of 0.80 (see Table).
For the 37,947 births registered in the same period to mothers born in Pakistan female mortality was higher than that for males with an odds ratio of 1.09, significantly higher (p<_0.05 than="than" the="the" overall="overall" england="england" _="_" wales="wales" ratio.="ratio." p="p"/>For no other country of birth group was such an effect observed. Also noteworthy are the much higher infant mortality rates for this group when compared with births to other South Asian-born mothers.
Ian Dawson
Birchington,
Kent
CT7 9HX
1 “Too young to die: genes or gender” United Nations Department of Economic and Social Affairs, Population Division. United Nations New York (1998)
2 Community based retrospective study of sex in infant mortality in India
R Khanna, A Kumar, J F Vaghela, V Sreenivas, and J M Puliyel
BMJ 2003; 327: 126-0.
England and Wales – 1996 to 1998
Mother's Country of Birth |
Live Births |
Infant Deaths |
Infant Death Rate |
Odds Ratio |
Odds Ratio |
||||
per 1000 live births |
|||||||||
M |
F |
M |
F |
M |
F |
F: M |
95% CI |
||
United Kingdom |
858,282 |
815,237 |
5,429 |
4,026 |
6.33 |
4.94 |
0.78 |
0.75 |
0.81 |
|
|||||||||
England and Wales |
839,481 |
797,168 |
5,321 |
3,934 |
6.34 |
4.93 |
0.78 |
0.75 |
0.81 |
Scotland |
14,138 |
13,593 |
80 |
68 |
5.66 |
5.00 |
0.88 |
0.64 |
1.22 |
Northern Ireland |
4,123 |
3,958 |
25 |
20 |
6.06 |
5.05 |
0.83 |
0.46 |
1.50 |
Outside the United Kingdom |
130,184 |
123,780 |
931 |
798 |
7.15 |
6.45 |
0.90 |
0.82 |
0.99 |
Irish Republic |
7,366 |
7,164 |
55 |
33 |
7.47 |
4.61 |
0.62 |
0.40 |
0.95 |
Other European Union |
15,189 |
14,347 |
84 |
62 |
5.53 |
4.32 |
0.78 |
0.56 |
1.08 |
Rest of Europe |
6,212 |
5,739 |
29 |
30 |
4.67 |
5.23 |
1.12 |
0.67 |
1.86 |
Commonwealth |
|||||||||
Australia, Canada, New Zealand |
5,082 |
4,803 |
20 |
23 |
3.94 |
4.79 |
1.22 |
0.67 |
2.21 |
New Commonwealth |
70,669 |
67,337 |
604 |
525 |
8.55 |
7.80 |
0.91 |
0.81 |
1.02 |
Bangladesh |
10,947 |
10,714 |
80 |
66 |
7.31 |
6.16 |
0.84 |
0.61 |
1.17 |
India |
10,194 |
9,469 |
56 |
52 |
5.49 |
5.49 |
1.00 |
0.69 |
1.46 |
Pakistan |
19,503 |
18,444 |
213 |
219 |
10.92 |
11.87 |
1.09 |
0.90 |
1.31 |
East Africa |
7,413 |
6,940 |
45 |
35 |
6.07 |
5.04 |
0.83 |
0.53 |
1.29 |
Southern Africa |
1,897 |
1,829 |
9 |
7 |
4.74 |
3.83 |
0.81 |
0.30 |
2.16 |
Rest of Africa |
9,605 |
9,375 |
119 |
80 |
12.39 |
8.53 |
0.69 |
0.52 |
0.91 |
Far East |
2,806 |
2,578 |
12 |
11 |
4.28 |
4.27 |
1.00 |
0.44 |
2.26 |
Mediterranean |
2,331 |
2,173 |
19 |
14 |
8.15 |
6.44 |
0.79 |
0.40 |
1.57 |
Caribbean |
4,012 |
3,930 |
41 |
34 |
10.22 |
8.65 |
0.85 |
0.54 |
1.33 |
Rest of the New Commonwealth |
1,961 |
1,885 |
10 |
7 |
5.10 |
3.71 |
0.73 |
0.28 |
1.91 |
Rest of the World and not stated |
25,666 |
24,390 |
139 |
125 |
5.42 |
5.13 |
0.95 |
0.74 |
1.20 |
All |
988,466 |
939,017 |
6,360 |
4,824 |
6.43 |
5.14 |
0.80 |
0.77 |
0.83 |
Source: Office for National Statistics (unpublished)
Competing interests:
None declared
Competing interests: Male and female infant mortality rates by mother’s country ofbirth
Mother who rocks the cradle ameliorates the community
Sir,
Khanna R and his colleagues addressed the vital subject of
female child fatality in India. (1). 175000 infants die every year
in Maharashtra state, India, alone. Sex disparities in health and
education are higher in south Asia than anywhere else in the world. 40% more
girls than boys are likely to die before the age of five (2).
Over the past forty years a wide range of developing countries have
successfully developed models of primary health care promoted by the
World Health Organization. In the year 1960 transient decreases in
infant mortality were reported by introduction of bare foot doctors in China. But at present infant fatality is 88%. Today, 60% of Chinese have
hepatitis B due to improper sterilized needles of bare foot doctors.(3)
SEARCH (Society for Education, Action, and Research in Community) reported 83% infant deaths due to pre-maturity, birth asphyxia, birth
injury and sepsis from rural Maharashtra (3). With the help of trained semiliterate women called health messengers (arogya doot) for home–based neonatal care and management of sepsis they achieved reduction in case fatality by 14% and infant mortality by 62%. (3)
In India illiteracy is the root cause of population explosion, poverty, malnutrition, maternal mortality, infectious and ischemic heart disease.
Child mortality is 18.8 per 1000 births in Kerala state and is achieved
because of 100% literacy, whereas it remains 137.6 per 1000 in Madhya
Pradesh due to illiteracy. Communities like that in India “health for
all” can be easily achieved by abolishing illiteracy, rather than giving training and authorizing semi-literate women and exposing poor illiterate people to the extra risk of infections such as hepatitis (3). It is
high time now charitable health institutes, health trusts and non-government organization should divert their funds and energy to rectify the root cause, which is illiteracy than its effects. Improvement of per capita income (2). Every one should attempt to make this world a safe haven for women and new comers.
Long term follow up of infants is crucially important for the possibility of development of insulin dependent diabetes and childhood cancer due to routine administration of cows' milk and injection vitamin K by SEARCH trained health messengers (4).
Good long term supervision is vital, while incorporating home based neonatal care in an illiterate community by semi-literate women (4).
Otherwise there will be no time to transform health messengers (arogye doot) to official disease spreaders (Rog doot), as China experienced in the recent past (2).
Pharmaceutical industries from developing countries like India should divert their funds to improve child fatality and should avoid sponsorship of free lunches, conferences and arranging tours abroad for doctors.
In India there is rampant corruption in the health department, health trusts and even in funding agencies. To avoid injustice to a female child, the conception, mother, and growing fetus till the age of five should be registered as wealth of a nation and be provided with all
health facilities and be protected from all consequences or handing them over to a nursing staff by establishing a new department(5).
Thanking you
Yours sincerely
H.S. Bawaskar
Bawaskar hospital and research center Mahad Dist – Raigad 402301,
Maharashtra, India
E-mail- himmatbawaskar@rediffmail.com
References
1-Khanna R, Kumar A, Vaghela JF, Sreenivas V and Puliyel Jm. Community
based retrospective study of sex in infant mortality in India . BMJ.
2003;327:126-30.
2-Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D et al. Applying an
equity lens to child health and mortality : more of the same in not
enough. Lancet 2003; 362:23.
3-Elisabeth R. Chines Doctors dirty needles spread hepatitis. New York
times service the international herald tribune 8-22-1
4-Bang A, Bang R, Baitule SB, Reddy MH and Deshmukh MD. Effects of
home –based neonatal care and management of sepsis on neonatal mortality:
field trial in rural India . Lancet 1999;354:1155-61
5- Bawaskar H. Child survival in India. Lancet 2003;362: 26th July(
debate).
Competing interests:
None declared
Competing interests: No competing interests
It is a pity to hear that there are a lot of infant deaths due to
diarrhoea is still going on.
Diarrhoea occurs because of overcrowding and poverty .Poor people has
no access to good water supply.The poor think that male child is going to
look after them well .The tradition in India is men go to work and women
look after kids and cooking.So male child is looked after well in
comparison to female.Usually the femaleside has to bear the expenses of
arranged marriage.So having a female child is considered as a burden in an
uneducated family. With better income and education this will change.
India is such a big country.So it is not possible make a sudden
change.The infant mortality is different in different regions.It may be
more than what was published is some places.
so the essence is overcrowding,poverty,illiteracy ,lack of good
drinking water and poor sanitaion all contributes to increased infant
mortality due to infectious diseases
Competing interests:
None declared
Competing interests: No competing interests
Gender bias, Poverty or SIDS?
Dear Editor,
I appreciate Khanna and his colleagues for attempting to address an
important social issue from a ‘local’ perspective for an ‘international’
audience. This study raised many questions than answering any! The topic
is not only interesting, but also sensitive. However, I am concerned about
its simple study design, a straightforward analysis and more importantly,
a sketchy explanation of the observations. I offer a few comments, which
may help provide further insights into the study findings for the readers
and authors alike, as well as motivating future investigators to conduct a
better study with additional information.
Delhi has a sizeable proportion of economic migrants (almost 40% of
the general populations!) from the poorest states of independent India,
such as Bihar, who are forced to eke out their livelihoods in urban slums,
as resettlement colonies (1) It is beyond dispute that child mortality
across different age groups is most likely to be the consequence of social
deprivation or underlying poverty (2). As for infant deaths, not only the
proximal causes are profound in such populations, but also the distal
determinants of infant deaths, such as social inequality or poverty (3).
In addition, the proximal causes of neonatal deaths are distinctly
different from those contributing to post-neonatal deaths. Recently, a
study in rural India in a relatively stable homogenous population also
demonstrated that low socio-economic conditions contribute to a higher
likelihood of post-neonatal deaths, as opposed to neonatal deaths (4).
This may be consistent with the observed higher proportion of diarrhoeal
deaths (95/442) in Khanna et al’s study (table III). Hence, the potential
inconsistencies in findings looking at infant deaths by gender without
controlling for socio-economic status, especially among socially deprived
populations, such as an urban slum community. However, an observed
association in relation to infant death by gender is most likely due to
the residual confounding of an underlying socio-economic status. The
present study has faltered on this very important issue, and goes on
associating the excess ‘treatable and preventable’ infant deaths with
gender bias, which seems unlikely for many other potential reasons.
First, the investigators could have taken the opportunity of
designing a better study. My understanding is that the existing
computerised database system of the Community Medicine department is
accurate, reliable and complete, although no such commitment has been
made. Given the validity of such a database, a rigorous computerised
matching programme could have been utilised for selecting individual
controls (living children) matching to some potential confounders. This
study design for data collected prospectively, as in the present study,
followed by a retrospective analysis of all the relevant socio-demographic
data presumably collected routinely during the health workers’ domiciliary
visits, could have certainly minimised inherent biases, such as selection
and recall biases, as well as reducing type II error. In addition, the
findings would have been more robust and less confusing.
Second, in the presentation of results, an extra table showing the
distribution of the causes of neonatal and post-neonatal deaths separately
would have been more explanatory for the general audience (bmj.com has no
dearth of space!). However, sub-group analysis is always an issue for an
apparently inadequate sample size testing a hypothesis of a relatively low
prevalence. For example, 44% of the infant deaths are attributed to
perinatal and neonatal causes (immaturity, birth asphyxia, congenital
anomalies, septicaemia), as opposed to 36% of the causes (diarrhoea,
malnutrition, acute respiratory infection) commonly attributed to post-
neonatal deaths (table III). In other words, this study may have a higher
proportion of neonatal deaths than post-neonatal deaths, but did not have
adequate power to give a statistical significance across the ‘less
preventable and less treatable’ causes. In summary, the majority of the
causes for infant deaths in this study population were more likely to be
‘less treatable or less preventable’, thereby increasing the possibility
of type II error. Nonetheless, revisiting the same issue after a few more
years with the similar study design would be more convincing.
Third, per-capita income is just one of the few proxy measures for
socio-economic status. Hence, a proportionately greater ‘unexplained’
death in higher per-capita income households is less conclusive for
excluding ‘extreme poverty’ as a probable explanation (table V). In such a
community, “caste” would have been a better indicator, which not only
reflects material wealth, but also suggests social/ethnic background.
Tables I and IV provide indirect evidence of this observation. For
example, crude infant mortality rate is higher among Muslim households
(whose per-capita income is relatively low), but the cause-specific death
rates, including unexplained deaths, are lower compared to Hindu
households. Thus, the observed variations in infant deaths by gender is
more likely to be modified by religion or socio-cultural practices in
presence of an underlying poverty, which is a potential confounder for the
association examined.
Fourth, the families under study are mostly economic migrants from a
couple of far-flung poor states; not only their socio-ethnic background is
heterogenous, but also born and brought up in a culture quite different
from those practised in the wealthy states of the Punjab or Haryana. These
are the two significant states with the dubious distinction of systematic
female foeticides and lower sex ratio, as well as mushrooming of illegally
operated sex-identification mobile clinics. In addition, these clinics
operate on a hefty price between fifty and hundred Euros! However, I am
not aware of any sex-identification mobile clinics clandestinely operating
in urban slum communities of Delhi suburbs based on my personal experience
in such resettlement colonies. So, is it paradoxical that households with
a paltry per-capita income of ‘eleven Euros’ can be the innocent victims
of such extortions time and again, or even if a handful of such clinics do
operate, the likelihood of their overall impact on the study population,
and consequently the hypothesis in question? In other words, the study
findings can neither be generalised nor strong conclusions can be drawn
based on events/practices elsewhere.
Fifth, the elusive higher proportions of sudden ‘unexplained’ deaths
observed in this study. The authors’ stated that 50% of the unexplained
deaths were neonates, and 86% of these were females. I wonder if they are
more likely to be associated with conditions, such as SIDS (Sudden Infant
Death Syndrome), rather than speculating foeticide alone as a probable
explanation. SIDS is an emerging condition in developed countries.
Unfortunately, prevalence data on such conditions are virtually non-
existent in less-developed countries, including India, but this does not
imply that the possibility of SIDS is less unlikely. More importantly, all
the known risk factors for SIDS are very much prevalent among such urban
slum communities, and they are also relatively more common among socially
deprived populations (5). It would be worth considering such outcomes in
the future, before attributing an apparent innocent poor family or a
community at large to sexual discrimination and committing socially
unacceptable crimes, such as infanticides.
Finally, the investigators comment on the ‘adverse’ sex ratio both at
the local and national level. It is always important to observe any
significant patterns emerging across potential child survival indicators,
such as sex ratio or infant mortality rate (IMR) by gender, both at the
local and national level. It is encouraging that an improvement in the
overall sex ratio from 1991 to 2001 is observed at the national level. In
addition, the figures for female IMR in the study population suggest that
the female death rates are declining at a rate of –5.5% on an annual
basis. This annual change would have been more apparent had the authors
computed the annual sex ratio over the study period instead of a summary
sex ratio. All these observations indicate that practices, which are
extremely localised and culture-centric, are increasingly becoming rare
over the past decade. It is high time that the social scientists, as well
as international organisations, stop being carried away by a tunnel vision
based on prejudiced ideas, and start contemplating the bigger picture. We
also need to echo the sentiments, as well as the ordeal of Trupti Patel
and her family, which are still fresh in our memories!
References
1. Kabir Z. Child labour and urban slum experience. Indian J Pediatr 2003;
70: 447.
2. Blakely T, Atkinson J, Kiro C, Blaiklock A. D’Souza A. Child mortality,
socio-economic position, and one-parent families: independent associations
and variation by age and cause of death. Int J Epidemiol 2003; 32: 410-18.
3. Victora CG, Wagstaff A, Schellenberg JA, et al. Applying an equity lens
to child health and mortality: more of the same is not enough. Lancet
2003; 362: 233-41.
4. Kabir Z. Demographic and socio-economic determinants of post-neonatal
deaths in a special project area of rural northern India. Indian Pediatr
2003; 40: 653-9.
5. Fleming PJ, Blair PS, Platt MW, et al. Sudden infant death syndrome and
social deprivation: assessing epidemiological factors after post-matching
for deprivation. Paediatr Perinat Epidemiol 2003; 17: 272-80.
Competing interests:
I worked as a Senior Resident of Community Medicine at the AIIMS, New Delhi
Competing interests: No competing interests