1. IIT DELHIInfant Mortality Rate andMalnourishmentSatna, Madhya Pradesh: A CaseStudyHUC 722Under the guidance of Prof Kamlesh SinghSubmitted by:Avinash Singh Bagri2009MT50541

2. 1Infant mortality rate (IMR) & Malnourishment in SatnaIndexAbstract 3Introduction 4o Key Facts 6o Main Focus 7Literature Survey 8o Worldwide Presence 8o India among the world 12 Key Facts 12 Demographics 14o IMR Case Study Satna 15 Neo Natal Mortality 16 IMR and Malnutrition- Broader Aspects 17Methodology 20o Participants 20o Tools 21o Procedure 22o Analysis 22Results and Discussions 24o Pointing out the malnourishment 24o Surveys/Methods to figure out IMR and Malnourishment 24o Reasons behind high IMR and Malnourishment 25o Suggestive Steps 36o Directions for future Study 39 3. 2Infant mortality rate (IMR) & Malnourishment in SatnaReferences 41Annexures 42o Questionnaire I 42o Questionnaire II 44 4. 3Infant mortality rate (IMR) & Malnourishment in SatnaAbstractThis report briefs about the condition of Infant Mortality Rate andMalnourishment in Satna (Madhya Pradesh) with the help ofvarious available data from the government accompanied by mediareports, non-governmental organisations and surveys. Using theinformation from well-known organisations like UNICEF, WHO,World Bank, definitions and key facts were stated to draw a parallelbetween the situation in the world and Satna. While infantmortality rates have dropped across districts over past ten yearperiod, there still remains a lot of heterogeneity across districts andhence across the states. One of such cases is Satna. It still has anIMR above than any other state in India and most of the countriesin the world. The report starts with reviewing the overall status ofIMR and malnourishment across the globe followed by an overviewon Indian condition. Finally the study is confined to Satna bymentioning stats made available by the Government of MP. Then togo further down in the matter, two surveys meant for two differentclasses of the people namely WCD (Women and ChildDevelopment) officials and non WCD officials were carried out.After the surveys the data was summarized and variousfactors/reasons are pointed out. Then, the steps are suggestedwhich could help in curbing this drastic increase in IMR andmalnourishment in the district. It is notable that the views ofofficials and public are given considerable weightage in the report.Finally with the help of inputs I got from the officials I haveformularized how future study in this direction could be directed. 5. 4Infant mortality rate (IMR) & Malnourishment in SatnaI. IntroductionInfant Mortality Rate is certainly amongst the most significantindicators of the general level of health of a given person or may bea community. It is a measure of the yearly rate of deaths in childrenless than one year old. As per the UNICEF, Infant Mortality Rate isdefined as:The probability of dying between birth and exactly one yearof age expressed per 1,000 live births. (UNICEF, para.2)In the similar terms World Bank term Infant Mortality Rate as:The number of infants dying due to any reason before theage of 1 year, per 1000 live births in a given year. This rate isoften used as an indicator of the level of health in a country.In general words it is termed as the number of deaths ofbabies below one year of age per 1,000 live births.Therefore, the rate in any given place or region is calculatedby dividing the total number of new-borns dying under oneyear of age by the total number of live births during the year,followed by multiplying with 1,000. (Mortality rate, WHO,2011, para. 1)The infant mortality rate is also known as the infant death rate (per1,000 live births). It is generally divided into two categories, i.e.neonatal deaths and post-neonatal deaths. Infants dying under 28days of age constitutes to neonatal death whereas post-neonataldeaths are those deaths occurring in infants older than 28 days butlesser than one year of life (Last, 2001).All the three rates i.e. Infant mortality rate, neonatal death ratesand post-neonatal deaths rates are computed with respect to per1000 live births within a given period in a particular region. 6. 5Infant mortality rate (IMR) & Malnourishment in SatnaThe infant mortality rate (IMR) indicates the state of childs healthand overall development in countries. Better sanitation, cleanwater, improved nutritional measures and easy access to healthcare have contributed heavily in improving infant mortality rates inthose regions which were impoverished, undernourished andunclean. In developing and under developed nations, IMRs are onthe higher side because these basic requirements for infant survivalare scarce or unequally distributed. Diseases which arecommunicable and highly infectious are more common indeveloping or under developed countries as well, though propernutrition and solid sanitary practices would do a lot to preventthem.According The World Health Organization (WHO) 7 out of 10childhood deaths in developing countries are because of five maincauses. Those are: pneumonia, diarrhoea, measles, malaria, andmalnutritionthe latter has been greatly affecting the rest.Malnutrition or Malnourishment has been associated with adecrease or reduction in immune function of the body. A paralyzedor weak immune function often gives birth to an increasedsusceptibility to various sorts of infections. It is a well-establishedfact that infections, no matter how mild, have adverse effects onnutritional status. Conversely, almost any nutritional deficiency willdiminish resistance to disease. Despite the United States spendingmore per capita on health care than any other country, 33 nationshave better IMRs. Some countries have IMRs that are less than halfthe US rate: Singapore, Sweden, and Japan are below 2.80.According to the Centres for Disease Control and Prevention (CDC)(Minio, 2010), The relative position of the United States incomparison to countries with the lowest infant mortality ratesappears to be worsening.There are several factors that affect the IMR of any given region orcountry, for example; preterm births, immunization. Every year, anestimated 15 million babies are born preterm (before 37 completedweeks of gestation), and this number is rising. An estimated 1.1 7. 6Infant mortality rate (IMR) & Malnourishment in Satnamillion babies die annually from preterm birth complications.Preterm birth is the leading cause of new-born deaths (babies in thefirst four weeks of life) and the second leading cause of death afterpneumonia in children under five years. Three-quarters of themcould be saved with current, cost-effective interventions, evenwithout intensive care facilities. Across 184 countries, the rate ofpreterm birth ranges from 5% to 18% of babies born. Pretermbabies have a higher risk of complications that could lead to deathwithin the first year of life. Apart from this nations differ in theirimmunization requirements for infants younger than 1 year. In2009, five of the 34 nations with the best IMRs required 12 vaccinedoses, the least amount, while the United States required 26vaccine doses, the most of any nation.Key factsAs per the official figures available released by WHO (2011):According to 2010 figures every year around 7.6 million childrenunder the age of five die.Most these early child deaths are because of conditions thosecould be avoided or cured or may be prevented with access tosimple, affordable interventions.Leading causes of death in under-five children are pneumonia,preterm birth complications, diarrhoea, birth asphyxia andmalaria. About one third of all child deaths are linked tomalnutrition.Children in low-income countries are about 18 times more likelyto die before the age of five than children in high-incomecountries.Nearly 10 million children under five died worldwide in 2006,according to a new report. That is a daily rate of 26,000 deaths. 8. 7Infant mortality rate (IMR) & Malnourishment in SatnaThe United Nations Childrens Fund (UNICEF) has used the latestdata available (2006) on the under-five mortality rate for everycountry in the world. The rate is expressed as the number ofchildren dying before their fifth birthday per 1,000 live births.Main FocusAs per the data available on the webpages on different sections, ofWHO, its clear that infants belonging to following classes are moreendangered than the rest.GeographicOut of all the deaths across the globe most of them occur in regionsof Africa and South-East Asia i.e almost 70 % of it. Within thecountries, it is noted that infant mortality is higher in rural areas,especially the poorer families.NeonatesMore than three million babies die every year in their first month oflife and a similar number are stillborn. Within the first month, onequarter to one half of all deaths happens within the first 24 hours oflife, and 75% occur in the first week. The 48 hours immediatelyfollowing birth is the most crucial period for new-born survival. Thisis when the mother and child should receive follow-up care toprevent and treat illness. 9. 8Infant mortality rate (IMR) & Malnourishment in SatnaII. Literature SurveyWorldwide PresenceOver the years countries suffering with high infant mortality ratehave had major success against it, but mostly they are thedeveloped countries. Under developed or developing countries ofAfrica and Indian sub-continent continue to suffer with the tragichigh numbers of Infant Mortality Rate.As per the literature and data I have collected so far it can be seenthat India is not the only country suffering from it but there aremany other countries which are severely affected. Rathersurprisingly India rank lower than what is being expected afterhaving read the reports of various NGOs and non-governmentalhealth organisation and human right groups. But while lookingaround we find that among all those countries placed above Indiaare highly under developed then India. Moreover, it is notable thatmore or less they are African countries and South-East Asiancountries neighbouring India mostly. This figure does present analarming situation in front of us.We can observe them in the following table:Country name 2007 2008 2009 2010Sierra Leone 121 119 117 114Congo, Dem. Rep. 115 114 113 112Somalia 108 108 108 108Central African Republic 109 108 107 106Afghanistan 104 103 103 103Mali 103 102 101 99Comoros 67 66 64 63 10. 9Infant mortality rate (IMR) & Malnourishment in SatnaCountry name 2007 2008 2009 2010Rwanda 71 66 63 59Malawi 69 65 61 58Swaziland 63 59 57 55Kenya 59 57 56 55Gabon 57 56 55 54Sao Tome and Principe 54 54 54 53Tajikistan 58 56 54 52Zimbabwe 56 54 52 51Myanmar 54 53 52 50Ghana 54 53 51 50Senegal 53 52 51 50India 52 51 50 48Papua New Guinea 49 49 48 47Bolivia 47 45 43 42Nepal 47 45 43 41South Africa 47 45 43 41Singapore 2 2 2 2Luxembourg 3 2 2 2Liechtenstein 2 2 2 2San Marino 2 2 2 2Iceland 2 2 2 2*courtesy: World Bank Indicators 11. 10Infant mortality rate (IMR) & Malnourishment in SatnaAbove table contains only few countries i.e. the countries withhighest and lowest infant mortality rates. I have skipped thecountries lying in middle for now and will cover it later. The abovelist is in decreasing number of death rate of infants in the respectivecountries. It allows us to monitor the impact and spread of thephenomenon across the globe and also gives us the glimpse whichcountries have managed to reduce it over the years. Like in everyfield the name of US comes up here as well. As from 1850 having adeath rate of 217 among 1000 whites and 300+ among 1000 blacksto a meagre 7 is laudable.Following figure depicts the Infant Mortality Rate among thedeveloped countries:*courtesy: Howard Steven Friedman 12. 11Infant mortality rate (IMR) & Malnourishment in SatnaVariation around the globe can be viewed in the picture shownbelow:*courtesy: Global Health FactsIt is evident from the picture that that almost whole of Africa has aserious number of Infant Mortality Rate along with Indian sub-continent led by India and Bangladesh and also a few countriesfrom the Middle East. 13. 12Infant mortality rate (IMR) & Malnourishment in SatnaIndia among the WorldConfining our study on India I would like to quote recent decline infigures along with the Infant Mortality Rates of various stateswhich beat most of the countries in the world. According to an NGOSave the Children indulged in saving the children, every 15seconds one infant dies in the country which amounts to more than4 lakh infants deaths in the first 24 hours of their life. As per thereport, 90 per cent of deaths are because of deadly yet curablediseases like pneumonia and diarrhoea. Moreovermalnourishment/malnutrition is also cited as one of the majorreasons which contribute heavily in increasing the Infant MortalityRate.Key FactsThe UNICEF (2012) in their Indian homepage points out:Averting neonatal deaths is pivotal to reducing child mortality.The New-born period is the period starting from birth andcontinues throughout 28 days of life.Neonatal mortality rate (mortality in the new-born period)stands at 35/1000 lives births, and contributes to 65 per cent ofall deaths in the first year of life.Between 2004-2008, neonatal mortality has moved from37/1000 live births to 35/1000 only.56 per cent of all new-born deaths occur in five states: UP,Rajasthan, Orissa, MP and Andhra Pradesh.Three major causes contribute to about 60 per cent of all deathsin the new-born period: pre-maturity and low birth weight, birthasphyxia and infections. 14. 13Infant mortality rate (IMR) & Malnourishment in SatnaThe high mortality rate also reflects the position of India in publichealth spending as it ranks 171 out of 175 countries in the world.What is worse, its the state in which the child is born that decideshow long he would survive.Following figure shows state-wise distribution of Infant MortalityRate in India:*courtesy: MapsofIndiaFrom the figure we can see the cluster in Northern-Central parthaving the worst IMR as compared to others. Uttar Pradesh leadsthe charts by having rate of 96 deaths in 1,000 births, closely 15. 14Infant mortality rate (IMR) & Malnourishment in Satnafollowed by Madhya Pradesh at 94, Orissa at 91 and 85 inRajasthan. It is notable that these parts of India have significantnumber of tribals and economically undeveloped population.Demographics*courtesy: IndexmundiIn the figure above we can see the changes in IMR in last decade. Aswe can see in 2008-09 India touched its lowest at 30 but again in2010-11 it rose to 47.57 again.While looking for apparent reasons for this variance I went throughseveral papers and found an interesting piece. In whichArulampalam and Bahlotra (2006) argue that: 16. 15Infant mortality rate (IMR) & Malnourishment in SatnaAlthough socio-economic reasons have big role to play inthe varying IMR across the country but we cant actuallyattribute it to them only. They support it by mentioningvarying GDP across the states but the ratios of IMR were notproportionate. Similarly, talking about the social conditionsthere were not very consistency in apparent reasons exceptson-preference. Apart from them demographics covariateshave the major role to play in varying IMR among the states(P 31).In order to improve health standards and get the IMR under aproper check NRHM has laid down various blue prints. The NRHMhas set its aim to reduce the infant mortality from 50 to 30 per1,000 births by 2012 and the ICDS programme focuses on providingnutrition supplement to children under the age of five.Shireen Miller, Policy Head, Save the Children, states that:Highest rate of malnutrition are in four of five states inIndia. Clearly the National Rural Health Mission (NRHM) andIntegrated Child Development Services (ICDS) have failed toreach those for whom it has been designed (MaryaShakil, CNN-IBN, 2009, para. 4).IMR Case Study SatnaAccording to first time released Annual Health survey 2010-11,Infant mortality rate in Madhya Pradesh is 67, which is worse thanBangladesh (41), Ghana (47), Zimbabwe (56), Myanmar (57),Botswana (43), and other Saharan countries, and it is equal toEthiopia.Panna ranks highest among all districts with 93 deaths per thousandlive births. First five districts having highest IMR are Panna (93),Satna (90), Damoh (80), Guna & Ashoknagar (79) and Raisen (78). 17. 16Infant mortality rate (IMR) & Malnourishment in SatnaMandla and Sidhi (37) have lowest among all the districts ofMadhya Pradesh.The main reason for highest IMR of Satna may be because itsgeographical location. It shares its boundaries with UP on north andPanna (Bundelkhand) on its east. Its pertinent to mention thatthese regions are among the most backward regions and also theseborders are Dacoit marred areas. Many villages in Satna still arepredominantly feudal, have high levels of caste and genderdiscrimination, and also prone to drought. It has been an uppercaste dominated, Dacoit-infested region where girl-child is verymuch neglected, at times to the extent of infanticide. This regionhas been in need for larger socio-political-economic intervention forimproving the status of child health indicators and malnutrition.Distress migration due to consecutive drought in the region in last10 years has become a regular phenomenon in the life of Satna.Satna has an IMR of 90 which more than the IMR of almost 3/4thcountries of the world. Among them, males have an IMR of 87,whereas the females have higher IMR with 94.Neo Natal MortalityAccording to Annual Health survey 2010-11, Neonatal mortality rateof Madhya Pradesh is 44 which is worse than Bhutan (33), Angola(42), Bangladesh (30), Burundi (42) and Ethiopia (36) and almostequal to Chad and Chile (45).As per the Annual Health Survey report (2011), Panna again rankshighest among all districts with 66 NMR closely followed by Satnaand Damoh with 63 and 61 respectively. With comparison to othercountries Panna, Satna and Damoh ranks highest with 66, 63 and 61NMR respectively in all over world. In rural areas the Neonatalmortality rate is 49 where as in urban area it is 32. Out of every 10infant deaths 6 -7 pertains to Neo Natal Deaths. Rural NMR indistricts is significantly higher than the urban. 18. 17Infant mortality rate (IMR) & Malnourishment in SatnaSatna has an NNMR of 67. If we distinguish between male andfemale, it becomes 47 and 63 respectively.Here we have to note that the rate for death of female infants isway higher than male infants. It again put the socio-economicsituation of the district under scrutiny.IMR and Malnutrition- Broader AspectsIn 2008 April, when Satna came in limelight for such severe casesfor infant death and heavy malnutrition, several probes were setup. According to Right to Food campaign reportThere were at least 163 children died of severe malnutritionin four months in four districts of Madhya Pradesh Satna(69), Khandwa (47), Shivpuri (32) and Sheopur (15). All thechildren belonged to tribal/indigenous communities Kol,Mawasi, Saheriya and Korku. It was stated that MP has spentonly 0.86 per cent of its total budget through the ICDS forchildren aging below six and only 1.51 per cent of the Statesbudget is allocated for the Department of Women and ChildDevelopment. In money terms, the allocation is Rs.590 crore,up from Rs.190 crore last year. But only Rs.222 crore hasbeen allocated for the implementation of the ICDS in 2008-09 against the need of Rs.799 crore (Mahaprashasta, TheHindu, 2009, para.8 & 20)All the 1.078 crore children under six years of age in the Stateshould be covered through universalisation of the ICDS, theSupreme Court had ruled in PUCL vs. Union of India and others. Forthis purpose, only 67,000 anganbadi centres are functional,whereas, according to informed sources, the actual need is for 1.26lakh centres. 19. 18Infant mortality rate (IMR) & Malnourishment in SatnaThe Seventh Report of the Commissioners of the Supreme Courtstates that as per Census 2001 as many as 6.6 million children areenrolled in anganbadis run under the ICDS in Madhya Pradesh, butonly 3.89 million, or 35.9 per cent, get supplementary nutritionfrom the State through anganbadis.Satna district, where the deaths of infants were first highlighted,presents a darker picture. Even the Women and Child DevelopmentDepartments figure for Grade 3 and Grade 4 malnutritionedchildren in 28 villages in the district is more than 4,000, but fromJanuary to August 2008 only 435 children were brought to nutritionrehabilitation centres (NRCs).In the 11th edition of the six-monthly report published byDepartment of WCD under the Bal Sanjeevani Abhiyan, thegovernment committed a blunder. The report (2007) says that:3,18,371 children were weighed and only 2,941 of themwere found to be malnourished. It says that the severelymalnourished in Satna district form 0.92 per cent, whichwould be 2,557 children (page 29). 20. 19Infant mortality rate (IMR) & Malnourishment in SatnaIII. MethodologyIn order to collect variety of data concerning the Infant MortalityRate, the poll was conducted on variety of crowd. It had peoplefrom almost all parts of the society ranging from a Doctor, agovernment officer to a farmer residing from backward village. Ialso happened to get hold of a few reporters from local newspapersand also members of NGO working on this very cause. I was luckyenough to be a part of a workshop held in District Panchayatheadquarters on 25thof October which covered all the followingissues. In the workshop my topics were raised and discussed withzeal and due seriousness. In order to complete the survey I took asample of 50 persons but from different field, so that I get variety indata depending upon thinking of almost all sections of society.There were two questionnaires addressed for different variety ofpeople. Questionnaire 1 was directed towards the officials ofdistrict administration at different levels. The questionnaire wasmeant to have a policy-wise view on the problem. The questionswere framed in a way which could enable us to understand theworking of the administration in this very direction. It was intendedto know the possible reasons of high IMR according to them whichcould pass our thoughts without having been looked upon.Other questionnaire was prepared for the women and childrendevelopment officers of the district Satna and seven blocks. Withthe help of the questionnaire, I intended to get the idea of how thelocal factors have affected Infant Mortality Rate and the impact ofMalnourishment/Malnutrition in the region. As I had mentionedearlier that there are some specific local reasons varying fromsocio-economic causes to the geographical location of the regionwhich have impacted the rate immensely.Through these short surveys I intended to get the stand ofgovernment as well as the view of common man. After collecting 21. 20Infant mortality rate (IMR) & Malnourishment in Satnathe data from both surveys the findings are listed below. I havetried to draw a parallel between the two different views.ParticipantsThere were two types of questionnaires aimed towards differentclass of people. For the 1stquestionnaire I surveyed 15 persons butthey all were members of Public Health Committee Satna. Out ofwhich there were only 2 women and 13 men. Standard deviation ofthe age of the participants in the survey was 50-55 years. Fewimportant names, who play important role in policy and decisionmaking of the district, were District President of BJP, President ofcommittee on WCD, Health and PHE, District Council, District WCDofficer, Chief Medical and Health officer etc. All of them took aninteractive part in the survey. Opinion of the 4thpole of democracyi.e. media was also sought. Editor of the daily Nav-Swadesh alsotook part in survey.Talking of the 2ndquestionnaire, it was meant for the general publicbelonging mostly to various fields. The survey was conducted over asample of 50 persons only. Out of 50 participants 15 were women.Most of them were housewives coming from different socio-economic backgrounds. There were few exceptions as well, 4women were playing active role in public life in different capacityviz. Chairperson Zila Parishad, Project Officer Zila Parishad, Directorof NGO Vasundhara Mahila Mandal, etc. Most of the maleparticipants were graduates however women were mostly 12thpassed.Given the socio-economic profile of the district around 70% of theparticipants have a connection with the rural profile of the district.Most of them were active in public life in different roles of vitalimportance. Standard deviation of the age of the participants in thesurvey was 53-55 years.Almost 90% of the participants came from middle class background. 22. 21Infant mortality rate (IMR) & Malnourishment in SatnaToolsData and figures were mostly collected from internet, EconomicSurvey 2012, India Year Book 2012, HUNGaMA report, few mediareports, RTI in office of Zila Panchayat and office of Women andChild Development.Opinions and responses were sought in form of a questionnaire.Questionnaire comprises objective and subjective questions both.Participants were supposed to fill the questionnaire on their own.Few discussions with few other eminent people of the district werealso done.During the survey, I went through minutes of meeting of committeeon WCD, Health and PHE, District Council and also attended aworkshop organized by an NGO in District Council office only. Tripto the Nagod Block of the district which is the bordering region ofBundelkhand region of the state was also made. Few importantpublic representatives of the district belonged to this Block only.ProcedureQuestionnaire was handed over to the participants. No help wasprovided by the surveyor in answering the queries. No constraintwas put in answering the questions. Two types of surveys wereprepared, one for government officials i.e. those who wereexpected to focus upon current official status and efforts beingmade to address the problems. The other survey was meant forpeople who were not a part of the government or state machinery,for e.g. media persons, NGOs, social workers, politicians, etc.Most of the male and female participants didnt need any sort ofhelp in filling up the questionnaire however few participants(mostly women) needed a little help in understanding the spirit ofthe questions. 23. 22Infant mortality rate (IMR) & Malnourishment in SatnaThe prime motive of the questionnaire was if the victims of theproblem are aware of the problem at all. And if yes, then what dothey perceive as the root cause of the issue. Was they are generalagreement on the root cause. What was the role of local factors inaggravating a global problem? What was the role of traditionalfactor like culture and norms in the problem? What was the role ofmodern factors like poverty in the problem, etc? What was the levelof penetration of government run programs and schemes and theirimpact?AnalysisThe data collected after the survey was analysed thoroughly and isrepresented graphically. Since there were two types of questions sothe way of analysis was different as well. For example thequestionnaire 1 comprises completely of subjective and open-ended questions, so they are analysed in more detailed andcomprehensive manner. The inputs given by the people have beendiscussed and mentioned under various columns later in the paper.Moreover, the paper tried to look into the details of the cause andalso the possible prevention which also comes later. Apart from thisthere were objective questions meant to give a direction to mystudy which have been analysed slightly differently. Such questionswere asked by the general public in the 2ndquestionnaire. I wentthrough the answers thoroughly and compiled the perceptions ingraphical way. Depending upon the type of questions, the stats aredemonstrated either through bar graphs or pie charts. Moreover,they are followed by little descriptions as well, wherever required.The enthusiastic participation and general perception in the surveysindicated that the questions asked in the survey were very muchclose to the actual thinking of the public especially belonging to therural section and also the officials. As the survey was mostlyconcerned about seeking the pattern in increasing number of suchcases and the probable causes, people put in some importantpoints which were left out while preparing the survey. For example, 24. 23Infant mortality rate (IMR) & Malnourishment in Satnathe point of being a Dacoit prone area and its effect was not thatmuch evident as predicted earlier. Also, poorer areas have lesserIMR than those areas which have a mixed blend of people i.e. notvery poor but not even middle class. But, as far as malnutrition isconcerned the case is exact opposite.After collecting the data many new things came up in the light andfew went into the backend as they did not seem that importantafterwards. The further summarized data is mentioned in nextchapter describing all the aspects of the survey and the views of theparticipating people. 25. 24Infant mortality rate (IMR) & Malnourishment in SatnaIV. Results and DiscussionsAfter talking to the officials and getting to their views about theproblem of high infant mortality rate and malnutrition in Santa, Itried to summarize the finding in following manner:Pointing out the malnourishmentAccording to the most of the officials, they primarily point out themalnourished infants by looking at their health. Its pretty straightforward as they pick those who apparently do not appear healthy.For example if some child is thinner than he should at his age theymark him or the children whose skeleton is visible or those whodevelop some kind of disparity because of staying hungry for quitesome time. They also figure it out by holding them by theirshoulders and measuring the shoulders. After marking them, theyweigh them to ensure their prediction. When they find them fallingin the criterion they finally pen it down. Thats how they completetheir survey.Surveys and Methods to figure out IMR andMalnourishmentThroughout the nation the surveys at various levels are done tocollect the data in this regard. However, it is not easily accessible topublic but it can be accessed through RTI. The surveys are done atBlock level by further distributing them to Gram Panchayat leveland are mostly carried out by the Anganbadi karyakarta orAsha. They work in local Anganbadis or dispensaries and have theresponsibility of villages health issues. 26. 25Infant mortality rate (IMR) & Malnourishment in SatnaReasons behind high IMR and MalnourishmentIlliteracy:It is rather surprising to notice that Satna has a considerably goodliteracy rate. In Satna this rate is 70% which is well above nationalaverage of 56%. But if we divide it gender wise, we can spot thedifference very clearly. Male literacy rate 76% is well clear of femaleliteracy rate of 62%. But, in order to make our study more justifiedif we leave the city apart which has a literacy rate of 91% and gotowards the rural area the rate dips quite alarmingly. So, thishampers the growth of the society, family and thus affects theinfants ultimately.Poverty:As mentioned earlier despite having slew of cement industries andmines, Satna does not have a pleasant economic condition. Peoplein rural belt still depend upon agriculture for their day to day living.The conditions around the city do not present a good picture as faras agriculture is concerned. As discussed earlier Satna does nothave many rivers and those it has are seasonal only. So, the farmershere depend entirely upon the heavens to rain good, but to theirbad luck it has not been fair with them over the years. As a resultthey find it difficult to sustain the requirements of the familyespecially the infants as they need more care. It leads to fatalexercises of having them killed before they are born or immediatelyafter the births.Lack of Sustainable Resources:Satna lacks the resources required to create a healthy environmentfor the residents by all means. As per the government officialsbecause of this lack of resources it becomes really difficult to helppeople motivate and inspire them for better living standards. 27. 26Infant mortality rate (IMR) & Malnourishment in SatnaTalking about availability of sustainable resources required for adecent life in the district, Mr C. P. Tiwari, Assistant Project Officer,Zila Panchayat, Satna had this view: | i.e. the literacy rate in Satna isrelatively lower than other cities and it also lacks thesustainable resources needed for a decent life.Due to some unfortunate circumstances the people with extremelylow income or pay develop tendencies of giving up easily instead offacing the situation. Killing of infants and increasing number offeticides is among the examples of such practices. They tend tochoose this path when they feel tired of their condition and dontreceive of kind of help needed desperately from the government tosustain their lives.Insufficient Health Services:As per the survey I conducted most people feel the health serviceswhich include hospital or dispensary or anganbadi. For that matterSatna does not have any decent hospital either. There are twodecently big hospitals but their infrastructure lack the ability tosuffice the needs of the patients they encounter. Moreover, thisinfrastructure problem grow graver with the level of hospitals, i.e.in block level the government hospitals cant even accommodate 10patients simultaneously whereas anganbadi and SamudayikSwasthya Kendra dont even see the face of doctors for many days.As a result very often there comes up the case of deaths of bothmother and child while delivering the baby.Scarce of Nutritious and quality food:It is a problem spread across the state. The food served in Mid-DayMeal scheme run by the government of Madhya Pradesh is ofextremely low standard and consequently the children bear the 28. 27Infant mortality rate (IMR) & Malnourishment in Satnaresults in long run. Although this is a state wide problem butincreasing number of Mafias in Satna gaining control over thedistribution of food under the scheme has made the condition evenworse.Commenting on the same point Dr. G. P. Mishra, District Ayush(Ayurved) Officer said: i.e.due to the lack of nutritious food schemes, themalnourishment has grown further among the children in thedistrict.Higher Birth Rate:According to Dr Mishra higher birth rate across the district is onegood reason as well. He said: , i.e among other reasons Higher Birth Rate is aprominent one as well.On interviewing further he made some intriguing and sparklingobservations which really provide an insight to this problem. This isquite amazing and alarming to find out that there are numerousfamilies which have 7-8 children. They still have the mentality thatby having more children they will have more helping hands andeventually will help them expanding their income. But,unfortunately this practice has proven very futile as the economyhas gotten better over the years and the number of people to feedbecome more than they can afford. Apart from this there arefamilies which after a birth of girl child go for another child hopingfor a boy. But, if they dont get it in 2ndchance they tend to gofurther till they get one or they get more than enough number ofgirl children. In the meantime the killings of girl child happen very 29. 28Infant mortality rate (IMR) & Malnourishment in Satnaoften as the frustrated family tends to lose hope and gets worriedabout feeding them in long run.Social and traditional Values:Satna is still very backward as far as its social and traditional valuesare concerned. Like the Khap Panchayats in Haryana they havesimilar way of traditional mind-set over here. The society here isstill male dominated and male biased. They still want and prefer amale child over a female one. When a girl child is born in the poorfamilies, they often worry about their futures and think of thedowry they will have to pay at the time of marriage. Talking ofmarriage, people in this part see a boy as an investment. Theyconsider him as a commodity on whose exchange they can getmoney in the form of dowry during the marriage.Unawareness:Unawareness is problem which is present all over the country and isprimarily a reason for the failures of all the schemes run by thegovernments for the welfare of the public. Dr J. H. Pandey, DistrictHealth Officer, Satna raised a very valid point about unawarenessamong the people of Satna. It was not meant only for the peoplecoming from rural background but the city residents as well. Hesaid: , , , | i.e. There are veryimportant reasons like illiteracy, backwardness but one I would liketo point out is lack of awareness as there are several schemes beingrun by the state for this very cause but people have not been awareenough to take advantage of them. 30. 29Infant mortality rate (IMR) & Malnourishment in SatnaUnavailability of Clean Drinking water:Satna, barring for winters, deals with a severe shortage of drinkingwater supply. As mentioned earlier in the report the rivers in Satnamostly have water only during rainy and following season which isnot very drinkable either. Before being utilised it needs to betreated chemically so that it does not harm the public. Butunfortunately Satna does not have those kinds of resources andpeople residing nearby them use that water anyways. Moreover,the ground water table is pretty low as well and whats moreconcerning is the quality of water coming out from them. Actuallysoil in Satna is full of minerals and also has components of limestones which pollute the water colossally.Inability to accustom with modernization:As mentioned earlier the people in Satna are socially and culturallyvery traditional and tend to stick to their ancient values they find ithard to change themselves with time. Dr Gaurav Sharma, ProjectOfficer, Zila Parishad/Panchayat, Satna echoed the same. He stated: | i.e. people here find it difficult toaccustom with modernization.One example which comes in view cementing this thought andwhich also concerns our problem is, the efforts made by stategovernment to limit the children per family which have beensevered and rejected out-rightly by the people. These methods arenot outrageous to say but they havent gone down well with thepublic given their traditional and unwilling state of mind.Regional Imbalance:The regional imbalance refers to the difference between the fartherpoints of the district. For example on east side its fully coveredwith mountains having infested by myriad Dacoits over the years 31. 30Infant mortality rate (IMR) & Malnourishment in Satnawhereas on north-eastern part we have its boundary shared withone of the most backward area of the state i.e. Bundelkhand. Thisimbalance is apparent on the status of development of therespective areas which directly have an effect on the status offamilies residing in those parts and consequently on the problemwe are dealing with. Its like a chain reaction; everything leads toanother and thus playing their roles in aggravating this problem.This point was pointed out by Dr Gaurav Sharma, he said: , i.e. Satna is a big district and hence have a regionalimbalance. Villages on farther side have diverse conditionsand it becomes difficult to manage them properly.These views were echoed by Mr Ashok Sen, Tehsilsdar, Amarpatandivision in a different way: | i.e. Satna being a backward city itself is also surroundedby highly backward areas like Bundelkhand, Tarai etc. 32. 31Infant mortality rate (IMR) & Malnourishment in SatnaFollowing are the observations and summary of the data I was ableto collect from questionnaire 2:Among the others, most prominent was Poverty. Satna is anindustrial city per se but still large chunk of people reside in villagesand like rest of India, feed themselves on Agriculture. But, as Satnais a drought hit area Agriculture has not been a very profitablebusiness over the years and its impact has been evident inincreasing IMR, feticides and malnourishment.38%22%26%14%Reason behing high IMR in SatnaIlliteracyInsufficient HealthResourcesOld fashioned thinkingOthers 33. 32Infant mortality rate (IMR) & Malnourishment in SatnaOne question which will remain pertinent perhaps for good 20more years is the biasedness towards the boy child. The datacollected clearly show that even after 65 years of independenceand despite all the efforts put in by all kind of state machineriessociety has still not been able to weigh a girl child and a boy childequally. In cities and may be in larger part of country this problemmight have been reduced but it has not vanished yet. Be it Haryanaor Rajasthan or even Satna. Although Satna does not see that muchamount of female feticides as does Haryana or Rajasthan but it stillremains a big problem and contributes to increasing IMR heavily.90%10%Society favours boy over girl?Yes No 34. 33Infant mortality rate (IMR) & Malnourishment in SatnaTo eradicate this problem along with other health issues the stategovernment has been putting in lots of efforts. There are schemeslike Janani Suraksha Yojana, Ladali Laxmi Yojana etc meant tominimise the female feticides and casualities during delivery, butsomehow the results are not that encouraging and more than 55%people think that these efforts are failure so far.44%56%Schemes by Government, a failure?YesNo26%32%42%Fear of Dacoits Poverty OthersReasons behind Female feticides inTARAI Regions 35. 34Infant mortality rate (IMR) & Malnourishment in SatnaAmong others there were some sparkling developments as I wastold female feticides in Tarai regions are less than those of areashaving upper caste people. According to Miss Vidya Pandey whoruns an NGO especially dedicated towards Female Feticides anddevelopment of Infants around the district this rate is considerablelow in tribal areas like Tarai and other parts of Satna. In fact the sexratio in Majhgawan block which encircles this region is best amongother blocks in Satna. According to almost 20% of the people Isurveyed the lack of literacy is the main reason behind femalefeticides in the region.0510152025A little A lot Not at all Cant SayImpact of Bundelkhand 36. 35Infant mortality rate (IMR) & Malnourishment in Satna86%14%Reason of higher IMR amongst thepoorLack of appropriatehealth servicesDelivery in a scarceand lackingenvironment18%15%67%0%Reason behind MalnourishmentInsufficient schemes Corruption Lack of Knowledge Cant say 37. 36Infant mortality rate (IMR) & Malnourishment in SatnaSuggestive Steps:Increasing literacy in rural areasLiteracy is a major factor in improving IMR and MMR figures. Sateslike Kerala with almost 100% literacy rate have the IMR (13) andMMR (27) figures as good as of the North American or Scandinaviannations whereas states like UP or Bihar has poor IMR and MMRfigures. Literacy would help in bringing a general awarenessregarding healthy practices. For e.g. as per HUNGaMa report only9% of mothers use soap to wash their hands before taking a meal.Government schemes like Total Sanitation Campaign (TSC) nowrechristened as Nirmal Bharat Abhiyan (NBA), Janani SurakshaYojana (JSY), and Janani Shishu Suraksha Yojana (JSSY) would get abetter penetration among the target group with increased literacy.Yes No42%58%Enough no. of hospitals in the locality 38. 37Infant mortality rate (IMR) & Malnourishment in SatnaSpreading awareness and advertising governmentspoliciesAwareness follows literacy automatically and is a key factor totackle the socio-economic problems of the country. Success indealing with most of these problems is a direct function ofawareness among the people. 60% of all open defecation takesplace in India alone. Despite of government funding for evenprivate toilets penetration of TSC was not satisfactory as people arenot aware of the graveness of the matter and the scheme. While onthe other hand JSY has got tremendous success by doubling thefigures of institutional delivery from 39% to 78%. Awareness amongthe people viz-a-viz the scheme and its importance was a key factorin deciding its success. Given the importance of awarenessgovernment started spending heavily in different awarenessprogrammes through various means. For e.g. advertisement ofgovernment schemes on national TV, radio, vernacular and nationalnewspapers, posters on public transport, Hoardings on streets,paintings on wall of government building like Panchayat Bhawan,Anganbadi, school, etc. New interactive means like street-play;IVRS, etc. are also being employed.Providing good quality foodQuality of food provided to targeted group by state machineryunder different schemes like PDS, Antyoday Anna Yojana (AAY),Mid-Day-Meal (MDM), ICDS etc. is not up to the mark and thenutritional value of the food served is also not satisfactory viz-a-vizour peers across the globe like Brazil, Mexico, etc. Improving onthese two aspects would be of a great help. It has been quoted asone of the reasons for high IMR and low CSR by HUNGaMa as well.Improving infrastructure in AnganbadisWe are lagging in infrastructure of Anganbadi centres andAnganbadi workers. As per need and government regulations thereshould be one Anganbadi centre/250 people but we are still pretty 39. 38Infant mortality rate (IMR) & Malnourishment in Satnafar from achieving this figure which on ground varies from onecentre/300 to 1000 people. Number of workers required is alsoalmost half. Taking note of the issue government has decided todouble the number of workers in 12thFive year plan and increasedhealth expenditure to tackle malnutrition and IMR.Necessity of Need Based ProgrammesIndia is a country with all type of diversity. Geographically,linguistically, economically, culturally India is highly diverse. Thisdiversity leads to different social issues in a different degree orextent in different regions. Given this diversity a uniformcentralized top-down approach cant be practiced and we need tomove towards a bottom-up localized approach to tackle differentsocial evils. For e.g. Ladli Laxmi Yojana might be of great significancefor a state like Madhya Pradesh but not for Kerala or Nagaland. Onone hand main problem for malnutrition in Orissa is acute povertyand lack of understanding of tribal culture but for regions like Indo-gangetic problems in-proportionate allocation of resources is themain problem. We need programmes which can cater the specificneeds and issues of the concerned community instead of somegeneric approach.Focus on Comprehensive Human DevelopmentSocial problems dont exist in isolation and more than often areinterrelated and aggravate each other. For e.g. poverty leads toilliteracy and illiteracy leads to poverty and thus creates a vicioustrap. Similarly, problem of malnutrition and declining sex ratio isrelated with many other issues like illiteracy, poverty, existingmalpractices on the name of tradition in a patriarchal society, etc.Understanding the crux of problem government has started tofocus on concept of Comprehensive Human Development. MillionDevelopment Goals of UN is a major milestone in this direction.Focus is needed on all inter-related aspects of HumanDevelopment. Health, Education and employment opportunities are 40. 39Infant mortality rate (IMR) & Malnourishment in Satnakey factors to decide human development. Improved educationwould lead to improved awareness about the problem ofmalnutrition and an increased purchasing power of common peoplewould help in fighting the menace of malnutrition.Constant follow up and monitoring of health services byMinistry/Department of Woman and ChildrenDevelopment (WCD)Ministry of Woman and Child development is the nodal ministry tooversee comprehensive development of children. It has a majorrole to play in coordinating with other concernedministries/departments like Ministry of HRD, Ministry of Health andFamily planning, Ministry of Social Welfare, Ministry of TribalWelfare, Ministry of Minority affairs etc. apart from this horizontalcoordination the Ministry of WCD also need to do verticalcoordination with different state governments and Zila Panchayats,etc. This coordination and overseeing mechanism is imperative inensuring efficient execution of different schemes and eradicatingthe problems. The Min. of WCD also needs to take appropriateaction on report of Woman Commission and Commission forProtection of Child Rights. Apart from distributing resources todifferent agencies ministry also has a major role to play in ensuringaccountability in use of the resources allocated.Directions for future StudyAs per the advice of the officials the study should be directedtowards the socioeconomic conditions of the district. Satna despitebeing an industrial city is not as developed as one should expect itto be. The geographical location does not support its conditioneither. Satna is a drought hit area and does not have rivers either.There are only two small rivers running across the district alongwith a few streams but none of them have water for even half ofthe year. So, agriculture being the mostly followed occupation isnot helped by this fact. As a result there is a grave situation in 41. 40Infant mortality rate (IMR) & Malnourishment in Satnavillages as far as economic condition is concerned. This lead to thedrastic measure they take when faced by some severe problems.Number of children is a part of it. Generally people in Satna havemore children than they should have in proportion to their wealthand property. So, going in the same direction when they feel theycant afford more this kind of killings happen. This is not the solereason but is among the most prominent ones as this is a commonphenomenon across the lengths and breadths of the district andsame kind of explanation has been given by the local authoritieswhich seem pretty sensible too.Given the fact that Satna has always been socially a backward place,one may easily be convinced with the current scenario of thedistrict. Historically Satna is not a very rich city; it does not boast bignames or richness like other parts of India or may be even MadhyaPradesh. So, it goes way back and ever since freedom this place hasnot seen much of development despite being one of the politicaland industrial hubs of the state.Satna is one of the leading cement producers in India. It has everybig cement industry in its vicinity which in turn has had its impacton the district. Theoretically it should give rise to myriad jobopportunities for the locals and also provide them a decent living bybuying raw products from the locals. Apart from the cementindustries Satna is hub of many limestone and few bauxite minesbut instead of giving an earning opportunities to the local they havecaused such environmental pollution which in turn as created anuneasy ambience for living. 42. 41Infant mortality rate (IMR) & Malnourishment in SatnaReferences1. Annual Health Survey, Madhya Pradesh (2011), Census of India.Retrieved fromhttp://censusindia.gov.in/vital_statistics/AHSBulletins/files/03-Madhya_Pradesh_AHS_Bulletin.pdf2. Arulampalam, W. and Bhalotra, S.,(2006), Persistence in InfantMortality: Evidence for the Indian States. Retrieved fromhttp://ftp.iza.org/dp2488.pdf3. Census of India (1991), MapsofIndia. Retrieved fromhttp://www.mapsofindia.com/maps/india/india-map-infant-mortality-rate.jpg4. Demographics, Infant Mortality Rate, India (2012). Retrieved fromhttp://www.indexmundi.com/g/g.aspx?c=in&v=295. Friedman, H.S., US Infant Mortality Rate Higher Than OtherWealthy Countries (2011). Retrieved fromhttp://www.huffingtonpost.com/howard-steven-friedman/infant-mortality-rate-united-states_b_1620664.html6. HUNGaMA (Hunger and Malnutrition) Survey Report 2011. Read onhttp://hungamaforchange.org/HungamaBKDec11LR.pdf7. Infant Mortality Rate (Total Deaths per 1,000 Live Births) (2012),Global Health Facts. Retrieved fromhttp://www.globalhealthfacts.org/data/topic/map.aspx?ind=918. Last JM, (2001) A Dictionary of Epidemiology, 4th ed. New York,Oxford University Press9. Level & Trends in Child Mortality Report (2011), World Bank.Retrieved fromhttp://data.worldbank.org/indicator/SP.DYN.IMRT.IN10. Marya Shakil, CNN-IBN (2009), Infant mortality rate highest inIndia. Retrieved fromhttp://content.ibnlive.in.com/article/05-Oct-2009india/infant-mortality-rate-highest-in-india-report-102751-3.html11. Mahaprashasta,A. A., The Hindu (2009), Dying of hunger.Retrieved fromhttp://www.hindu.com/thehindu/thscrip/print.pl?file=20081107252205200.htm&date=fl2522/&prd=fline& 43. 42Infant mortality rate (IMR) & Malnourishment in Satna12. Minio, Arialdi M., M.P.H., and Sherry L. Murphy, B.S (2010),NCHS Data Brief. Retrieved fromhttp://www.cdc.gov/nchs/data/databriefs/db99.htm13. Seventh Report of the Commissioners of the Supreme Court, in thecase: PUCL v. UOI & Ors. Writ Petition (Civil) No. 196 of 2001,(November, 2007). Retrieved fromhttp://www.righttofoodindia.org/data/comm2007seventhreport.pdf14. UNICEF, (2009), Basic Indicators. Retrieved fromhttp://www.unicef.org/infobycountry/stats_popup1.html15. UNICEF (2011), Health. Retrieved fromhttp://www.unicef.org/india/health.html16.11th edition, Bal Sanjeevani Abhiyan report (November 2007) 44. 43Infant mortality rate (IMR) & Malnourishment in SatnaAnnexuresQuestionnaire I ?__________________________________________________ (How does the government point out if the child ismalnourished?)__________________________________________________ ?__________________________________________________ (Do you perform some sort of survey to collect data in thisregard?)__________________________________________________ (Infant Mortality Rate) , ?__________________________________________________ (If yes, can you please let me have the questionnaire/surveyrelated to IMR and Malnourishment)__________________________________________________ 45. 44Infant mortality rate (IMR) & Malnourishment in Satna , ?__________________________________________________ (If I want to get into the reasons why Satna has more IMRthan any other district in Madhya Pradesh, rather India, thenin which direction shall I motivate my study?)__________________________________________________ , ?__________________________________________________ (Also Satna has more number of malnourished children thentribal belts of Odhisha and Chhattisgarh and MadhyaPradesh, what could possibly be the reasons behind that?)__________________________________________________ , ( ) ?__________________________________________________ (How do you collect information/date in this regard and canyou share the detailed report of your department with me?)__________________________________________________ 46. 45Infant mortality rate (IMR) & Malnourishment in SatnaQuestionnaire II , ?a) b) c) d) __________________________________________________ What could be the reason behind Satna having highest IMR?a) Illiteracyb) Insufficient health servicesc) Traditional way of thinkingd) Others , ?a) b) In Satna death rate of girl child is more than that of malechild, do we still want a boy instead of a girl?a) Yesb) No ?a) 47. 46Infant mortality rate (IMR) & Malnourishment in Satnab) Do we still care and treasure a boy child more than a girlchild?a) Yesb) No ?a) b) Are the Janani Suraksha Yojna and Asha Aganbari karykartaschemes failures for the state government in this direction?a) Yesb) No ?a) b) What could be the main reason behind increasing femalefeticides?a) Fear of dacoitsb) Poverty ?a) 48. 47Infant mortality rate (IMR) & Malnourishment in Satnab) c) d) Being adjacent to relatively backward Bundelkhand region isa disadvantage?a) A lotb) A littlec) Not at alld) Cant say ?a) b) What could be the main reason of higher IMR amongst thepoor?a) Lack of appropriate health servicesb) Delivery in an scarce and lacking environment ?a) b) , c) d) What is the main reason of malnourishment?a) Not sufficient number of schemes from government 49. 48Infant mortality rate (IMR) & Malnourishment in Satnab) Corruption, which hinders public to take advantage of suchschemesc) Lack of knowledge among the peopled) Cant say / ?a) b) According to you, your locality has either a dispensary or ahospital with enough beds to suffice the local crowd?a) Yesb) No ?____________________________________________ What according to you is the biggest reason of disparity insex ratio?____________________________________________ ?____________________________________________ 50. 49Infant mortality rate (IMR) & Malnourishment in Satna According to you, what steps are necessary to minimize theinfant mortality rate?__________________________________________________ / ?__________________________________________________ What necessary steps must be taken towards thedevelopment and nourishment of girl infants?__________________________________________________:, ?__________________________________________________ Finally according to you, what could be the main reasonbehind the increasing Infant Mortality Rate in Satna?__________________________________________________