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State of the World's Mothers: India Briefing Global Context More than 1 million babies die on the first day of life globally– making the first 24 hours the most dangerous day for babies in nearly every country, rich and poor alike. This is one of the major findings of Save the Children's 14th annual State of the World's Mothers report. The findings indicate, as never before, that helping babies survive the first day – and the first week – of life represents the greatest remaining challenge in reducing child mortality and meeting the ambitious Millennium Development Goal of reducing child mortality rates by two-thirds by 2015. The world has made unprecedented progress in reducing maternal and child deaths. But we have made much less progress for the children who are the most vulnerable of all – newborns (0-28 days old). In 2011, 3 million babies died globally in their first month of life. This is 43 percent of all deaths of children under age 5 worldwide. Why such slow progress in reducing newborn deaths? We now know that newborn deaths are not inevitable and that low-income countries can make significant progress in reducing newborn mortality. We have identified the three major causes of these deaths – complications during birth, prematurity and infections – and we have developed a set of interventions that can prevent or treat each of these causes. These proven interventions – coupled with stronger health systems and sufficient health care workers who are trained, deployed and supported to tackle the key causes of child mortality – have the potential to reduce newborn deaths by as much as 75 percent.

Where does India stand Today, the world is on the brink of a major breakthrough to ensure newborn babies everywhere survive. If there's one place to trace the seeds of this brewing revolution, it's India. Yet today, India also represents some of the greatest challenges in seeing this revolution through. It has persistently high rates of newborn mortality, and accounts for 29percent of all first day deaths globally –309,000 a year. In the past year, India has begun a major political movement to systematically take on the complex and large-scale problem of newborn and child mortality in the world's second most populous country. Together with the United States and Ethiopia, India co-hosted a Child Survival Call to Action in Washington in June 2012 (A Promise Renewed). It has since recommitted itself to a national policy goal of ending child mortality in a generation and developed a clear road map for success. Many challenges remain, including overlapping government structures, lack of accountability of service providers, inequities in service delivery, health worker shortages and capacities, rapid urbanization and policies that currently prohibit the use of some of the most effective interventions to save babies, such as chlorhexidine, Kangaroo Mother Care and antenatal steroids. But India has already mobilized the most important ingredient to achieve any large-scale change – political will. And, for the first time, newborn survival is a central element of a clear national agenda for improving maternal and child health.

Researchers have made tremendous advances in recent years to pinpoint the causes of newborn mortality. As recently as 2005, global health experts still had many questions about what caused the majority of newborn deaths. Breakdowns of under-5 mortality showed a large percentage of deaths attributed to “newborn causes”. Now we know that the three major causes of newborn mortality are preterm birth, severe infections and complications during childbirth. These three causes together account for more than 80 percent of all deaths among newborn babies globally.

Shafiqul Alam Kiron/Save The Children

Tackling Newborn deaths – the Biggest Challenge

2 State of the World's Mothers: India Briefing India alone accounts for 29 percent of the world's newborn deaths. This forms more than half of all under-5 deaths in the country. These causes are easily preventable. In the context of India, there are other challenges: 1. Cultural practices: In some communities, women give birth in unclean areas of the house; the newborn is placed on the dirt floor immediately after birth, and breastfeeding is discouraged for several days. At some places, the mother and her newborn are often kept in isolation for two weeks or more, for the purpose of fending off evil spirits. This is just one example of cultural practices that are harmful to newborns. 2.

Early marriage and childbearing: This is another factor that heightens the risks for both mothers and babies. According to UNICEF's estimates, 34 million women in South Asia aged 20-24 were married or in union before the age of 18. High rates of child marriage are found in India, where 47 percent of girls marry by the age of 18, although rates vary dramatically across income levels, from a low of 16 percent among girls from the wealthiest families to 75 percent among the poorest. In Afghanistan and Nepal, 40 percent of girls are married before the age of 18. 3.

Low birthweight: This is the major contributor to newborn deaths in the country. An estimated 28 percent of infants in India are born too small. Most likely these are underestimates as many newborns are not weighed at birth.


Stunting: It is estimated that 11 to 13 percent of women are stunted in the country, which puts them at higher risk of complications during delivery and of having small babies. Twenty to 40 percent of women are also excessively thin, which compounds the risk of poor pregnancy outcomes. It is believed that half of the child stunting occurs in the utero underscoring the importance for better nutrition for women and girls.


1 in 5 deaths of children under 5 in India –19 percent -- take place on the day a child is born and 53 percent take place within the first month of birth. his means that the majority of under-5 deaths are those of babies in their first month of life.

❖ Since

1990, India has cut the rate of deaths of children under 5 by 46 percent –or almost half. However, with an average annual rate of reduction of only 3.0% of under 5 mortality rates, India is lagging behind in terms of MDG 4 and reducing 1990 child mortality rates by two thirds by 2015.

❖ From

1990-2011, newborn mortality rates (death rates within the first month) declined by 31% - compared to 47% in Nepal and 49% in Bangladesh. By focusing on newborns and their survival during the first few days of life, India can make significant progress i reducing the deaths of all children under 5. Newborn health is the last frontier of children' health in India.

❖ Close

up on equity: Of the four countries in the region with available data (Bangladesh, India, Nepal and Pakistan), the greatest newborn mortality gap between rich and poor is found in India, where babies born into the poorest 20% of families are more than twice as likely to die in their first month (NMRs are 56 vs. 26) compared to babies born into the wealthiest 20% of families. Closing the equity gap in India (i.e. if the poorest 80% of families had the same NMR as the richest 20% of families), would cut newborn mortality by 41% and save the lives of 358,400 newborns each year.

Where are NEWBORNS dying According to Government of India's Sample Registration Survey (SRS 2011) Madhya Pradesh has the highest burden of early newborn deaths (0-7 days) at 32, followed closely by Uttar Pradesh and Odisha (30). Other states with high burden are Rajasthan and Chhattisgarh, Bihar, Jharkhand and J&K (refer figure 1) Kerala is the leader in reducing neonatal mortality by a wide margin, while Tamil Nadu, Delhi and Maharashtra too have bucked the national rate.

State of the World's Mothers: India Briefing 3

And just as there are variations among states in reducing child deaths, there are wide disparities within states (Districts and Blocks) as well indicating that we now need to move to state specific goal posts and look at percentage decline instead of point decline.

Figure 1. Distribution of Early Neonatal Mortality in Selected Indian States

Inequity Clearly, all babies born in India do not get an equal chance of survival. Inequities are persistent and widening .According to Save the Children's flagship report State of the World's Mothers, children born in socially and economically disadvantaged families have a higher newborn mortality level. disparities: Babies born to the poorest families have a much higher risk of death compared to babies from the richest families. If all newborns in India experienced the same survival rates as newborns from the richest Indian families, nearly 3,60,000 more babies would survive each year. Children from poor households are more likely to be exposed to diseases and have lower resistance because of malnutrition. They are also less likely to receive to receive preventive interventions and their families have limited resources and capacity to cope with illnesses.

Wealth ●

disparities: The highest regional inequality in early neonatal mortality is in EAG region which is the most backward in terms socio-economic and health indicators such as Bihar, Chhattisgarh, Jharkhand, Uttar Pradesh, Rajasthan and Madhya Pradesh.

● Inter-state

divide: As per the graph below rural areas distinctively show higher newborn mortality than urban centres. However, we must acknowledge that SRS data does not take into account the disaggregated data on urban Figure 2. Early Neonatal Mortality rates in Indian States poor. Recent evidence shows that health indicators among the urban poor are equally bad, sometimes even worse.

● Rural-Urban

Another inequity exists in the level of education and age of the mother. For successive years neonatal mortality rate among children born to illiterate mothers has been consistently higher than those born to mothers with some education.

● Education:

of mother: NFHS 3 data also shows that neonatal death is directly related to the mother's age at birth. Lower the age, lesser will be her baby's chance of survival.

● Age

difference: Children born to schedule caste and schedule tribe families have a higher risk of dying than others. While there has been a decline in child mortality in all other social groups, the decline among these two groups has been much lower – widening the gap.

● Caste

The lowest inequality in early newborn mortality is observed in southern India where information on birth preparedness, recognition of danger sign, education of pregnant women and caretakers about antenatal care, maternal nutrition security, safe delivery practices and home based neonatal care is found to be high.

4 State of the World's Mothers: India Briefing


Nilayan Datta/ Save the Children

In 1993, Dr. Abhay Bang, who spent his early childhood in a Gandhi ashram and is now an internist and a public health expert trained at Johns Hopkins University, set out to address the biggest challenge facing pregnant women in rural India – no access to health clinics or hospitals to give birth. Together with his wife, Dr Rani, Dr. Bang pioneered a system of training community volunteers in 39 villages of a tribal, insurgent, rural and poor district of Gadchiroli in central India to provide home based newborn care. This included essential newborn care, management of birth complications (asphyxia management) and management of newborn sepsis. Their efforts produced dramatic local improvements to newborn survival. Since then, some of the world's poorest countries have adapted Dr. Bang's model and achieved remarkable results. In recent years, health workers in Nepal, Bangladesh and Malawi have likely prevented hundreds of thousands of newborn deaths. In India, this model has not scaled up because of lack of intensive supervision and training of health workers within the government system. Though Abhay Bang's newborn package has been adopted by the government – two critical elements for newborn survival – birth asphyxia management and gentamicin injections to prevent infections – have not been integrated. Thus it has not had the same impact.

Recommendations Clearly, overall Under-5 mortality cannot be reduced unless issues of newborn and maternal mortality are addressed. In 2006, India started one of its biggest flagship programme Janani SurakshaYojna that offers financial incentives to rural women to encourage deliveries at health facilities. Despite an increase in facility births, newborn survival rates have not reduced commensurately. Access to healthcare still remains one of the biggest challenge for India's poor both urban and rural. Despite well-meaning schemes, services and programmes, both coverage and quality of antenatal and postnatal careis lacking. Additionally, training, supervision and capacity of frontline health workers needs attention. Key Programme Recommendations These proven interventions – coupled with stronger health systems and sufficient health care workers who are trained, deployed and supported to tackle the key causes of child mortality – have the potential to reduce newborn deaths significantly: ● Every mother and every newborn must have access to high impact care that will save their lives through a continuum of care approach. ● Frontline health workers need training, motivation, supplies and appropriate facilities to prevent and respond to complications from preterm birth and help them breathe. ● Clean cord care, including chlorhexidine cord cleaning and newborn/pediatric doses of antibiotics, could prevent and treat simple but deadly infections. ● Immediate and exclusive breastfeeding and “kangaroo mother care” cost virtually nothing, but could save hundreds of thousands of babies' lives each year. Yet few frontline workers are trained to support mothers for this care. ● We need to address the underlying causes of newborn mortality, especially inequality and malnutrition. Key Policy Recommendations With the Call to Action on Child Survival, the government of India has demonstrated a high level of commitment and political will towards ensuring child survival. India has the technical know-how; what is required is a greater urgency to ongoing efforts. In keeping with momentum, we recommend: ● Include Civil Society Organisations in the oversight of the National Health Accounts, thus facilitating greater accountability and governance for improving maternal and child health in India; ● Expedite the National Family Health Survey-IV so that current data necessary for decisionmaking is available this year (the last NFHS was in 2005/4 worth mentioning) ● Encourage Members of Parliament to engage with the multi-party coalition for RMNCH+A

Notes: This report is to be read in conjunction with Save the Children' State of the World' Mothers 2013 report. The additional information cited in this report has been taken from NHFS III and SRS 2011.

State of the World's mothers: India briefing