Formative research on infant mortality rate in Manipur

INTRODUCTION

Infant Mortality Rate (IMR) is the number of deaths per 1,000 live births of children under one year of age. IMR is universally regarded as the most important indicator of the health status of a community and the effectiveness of Maternal and Child Health services in particular. It is also an excellent indicator of the socio-economic development of a country.¹ This statistical index not only indicates the quantity and number of deaths, but is also indicative of life quality.² Infant mortality is the result of a complex web of determinants at different levels. Lancet neonatal survival series has shown that scaling up of peri-conceptional folic acid supplementation to reduce the incidence of neural tube defects, calcium supplementation to reduce eclampsia, detection and treatment of asymptomatic bacteriuria, community-based pneumonia management, and extra care for low birth weight infants, including Kangaroo mother care will lead to reduction in neonatal mortality.³

Among the developing countries, India alone contributes to one‑third of the five million children who die before reaching their first birthday.⁴ However, India has seen a decline in IMR over the years.

The IMR was reduced by 28% between 2015 and 2016 (National Family Health Survey‑4 [NFHS‑4]) as compared to 2005-2006 (NFHS‑3), from 57/1000 to 41/1000 live births. The target fixed by the Government of India for IMR in 2019 is 28/1000 live births (National Health Policy, 2017).⁵ However, the distribution of these gains is uneven across states. For example, at the national level, IMR varies from 38 in rural areas to 23 in urban areas.⁶ To a large extent, India’s underperforming states and its approach to reducing neonatal mortality will determine its success or failure in reducing infant and child mortality in the future.⁷ The success of Kerala state in reducing IMR has been attributed to its overall development characterised by (a) high female literacy, (b) higher status of women in the society, (c) good accessibility of health services even in rural areas, (d) equitable distribution of wealth resulting from land reforms. This is despite the lack of any industrial or agricultural development in the state.⁸ According to the Sample Registration System (SRS) 2017: The national IMR is 34 deaths per 1000 births. Manipur reported one of the lowest IMR at 11 deaths per 1000 live births.

The key reasons behind the state's success in this regard, according to officials, are better medical facilities, proper and effective immunization, dedicated doctors and health workers, high health consciousness, a tremendous increase in institutional deliveries, women empowerment.

Swift reduction in IMR accompanies the progress of female literacy beyond the 65-70% range.⁹ Literacy rate in Manipur has seen upward trend and is 76.94 percent as per 2011 population census. Of that, male literacy stands at 83.58 percent while female literacy is at 70.26 percent. Sometimes, physicians may feel compelled to underreport infant death statistics if they are pressured to reach statistical targets. In the case of Cuba, for example, Hirschfeld (2007b) and Hirschfeld (2007a) document such instances of underreporting.¹⁰ Understated mortality statistics might lead to an improper allocation of funds.

This misallocation of funds, in turn, may result in less than necessary resources for infant and prenatal health care.¹⁰ It is therefore imperative to analyse the statistics that are currently seen in Manipur through a finer lens with a wealth of information from different sources at different levels of healthcare. It is with this background in mind that the present study was carried out to confirm data triangulation of Infant Mortality Rate in Bishnupur district of Manipur.

METHODS

A formative research was conducted in Bishnupur area of Manipur in November-December 2017. The study population included Medical Officers, Programme Officers, ANMs, ASHAs and Village leaders of Bishnupur area. Those who refuse to participate in the study were excluded. Purposive sampling strategy was used to recruit the participants. The sample size was not calculated but participants were recruited until a level of saturation was reached. In depth interview was conducted with the participants and only one question was asked to the participant i.e. “IMR in Manipur is very low. Do you agree?, If yes, why? If no, why?” A tape recorder was used during the interview.

Before the interview, the purpose of the study was explained and permission to tape record the whole conversation was taken. A quiet and isolated place was chosen for conducting the interview. Participants were explained about the purpose of the study. Feedbacks from the participants were solicited and the whole interview was tape recorded. All the interviews were transcribed and analysed with qualitative content analysis. Transcription was done using the recorded audio of the interviews.

Ten interviews conducted in Manipuri were translated and cross-checked by two members. Process of content analysis consisted of: selecting the unit of analysis (coding unit), grouping the codes into sub themes, developing a theme. In the first step, groups of words/statements that reflect the same central meaning were grouped as a coding unit. In the second step, all the codes were categorised into subthemes which refer to a group of content that share a commonality. All the categories were gathered together to develop a theme that showed the underlying meaning of the text. Ethical Approval was obtained from the Research Ethics Board, RIMS, Imphal. Informed verbal consent was taken from the participants before data collection. Data collected were kept secured under lock and key. Data collected were made accessible only to the investigators. Identifiers like name and address were not collected to maintain confidentiality.

RESULTS

A total of 15 in-depth interviews were taken and the findings are presented in this section. The findings are organised into two sections.

Demographic details of the participants (Table 1), themes with sub-themes (Table 2).

Supporting statements of the participants (Table 3).

DISCUSSION

This study gives an insight into the status of Infant Mortality Rate in Manipur through the eyes of the health care workers. According to World Health Organisation (WHO), improvement of hospital-based care can have an impact of up to 30% in reducing Infant Mortality Rate. Provision of round the clock availability of skilled medical care may reduce hospital based infant mortality.¹¹

The doctors in this study are of the opinion that the health services in Manipur are well-equipped in terms of facilities as well as health professionals who are able to effectively cater to needs of the people in their village. There is also the availability of 24 hours service of the Primary Health Centres as well as the Community Health Centres.

Health care systems with a strong primary care orientation are more likely to provide better population health and more equitable outcomes.¹² This can be achieved when the workers work effectively for the health of the public. All the interviewees believed that it is through the efficient work by the health workers that has led to a significant reduction of the IMR. The work of the Accredited Social Health Activist (ASHA) has been praised by ANMs, nurses and doctors alike through their active participation in ante natal check-ups of the pregnant women, advocating institutional deliveries, and immunisation. Education is considered as an important social determinant of health and there is abundant evidence of the positive relationship between education and health status of the people.¹³ Kerala’s literacy rate is 93.91% and its IMR is only 10 per 1000 live births. Providing education to the parents, particularly to mothers is critical to reduce infant mortality rates and its regional variations in India.¹³

The interviewees believed that the awareness among the parents in Manipur is also a contributing factor in the low IMR in the state. According to them, the parents are acquainted with the benefits of regular ante natal check-ups, timely immunisation, institutional deliveries, etc. They also have good health seeking behaviour.

Underreporting of deaths remain an issue across the globe.¹⁴ It hampers the accurate estimation of the numbers of infant deaths. A study conducted in Haryana discovered that many of the frontline field workers involved in the review system appear to have very heavy workloads and little time for the detailed documentation of deaths. This problem may have been exacerbated by a lack of awareness about the importance of accurate reporting and inconsistencies in community access to local health-care services.¹⁵

Only 2 of the health care workers in our study believed that records might not be properly maintained. They also highlighted that there might be some difference in the reporting of infant deaths from the private sector. Whether this statement is true remains to be seen and need further evaluation to come to a decisive conclusion.

It has been shown that there exists a degree of imbalance in the distribution of development entitlements between the hill and valley districts whereby the more inaccessible hill districts in which several of the tribes live are deprived in terms of the non-implementation of various developmental programmes.¹⁶ There is the belief that the terrain of the hilly areas makes its accessibility difficult for the health care workers especially in terms of immunisation. There is the problem of transportation and communication as well. The traditional home delivery is still prevalent according to some of the interviewees and the facilities are not as well developed as compared to other parts of Manipur.

The Government of India has introduced many schemes in relation to maternal and child health. These programmes like Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK), Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), Integrated Management of Childhood Illnesses (IMNCI) and Mission Indradhanush have been functional in Manipur and the health care workers believed that these schemes have led to the reduction of IMR in the state. The provision of monetary incentives as well as free health care for the pregnant women and their children has also been instrumental.

CONCLUSION

From the perspective of the health care workers, they are in agreement with the low IMR statistics in Manipur. The most common reason they stated was because of the efficiency of the health workers. There is a belief that there is a disparity between the hilly and plain areas. Further studies need to be conducted in different parts of Manipur to gain insight in the different districts especially the hilly areas.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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