Under-Five Mortality in India: A Muddled Trip through Millennium Development Goal-4

The Millennium Development Goal-4 (MDG-4) had a target of reducing the under-fi ve mortality rate (U5MR) by two-thirds, between 1990 and 2015. When compared to 1990 levels, 17,000 fewer children died each day in 2015. In 2012, UNICEF found that, globally, children born in the poorest 20% of households had only half the chance of surviving to their fi fth birthday as children born in the richest 20% of households. Many countries, including India could not attain the MDG-4. The Sustainable Development Goals (SDGs) seeks to build on the Millennium Development Goals (MDGs) and “complete what these did not achieve, “particularly in reaching the most vulnerable. The SDGs are committed to the full realization of all the MDGs, including the off-track MDGs, by providing focused and scaled-up assistance to least developed countries and other countries in special situations, in line with relevant support programs. MDG-4 failed to achieve its single target of reducing child mortality. This review attempts to provide an insight into the under-fi ve mortality in India. Various internet based popular search engines were used to explore data from literature, which includes PubMed, PubMed Central, Google Scholar, Medknow, and Science Direct. Search was made using the key-word combinations “under fi ve mortality” and “millennium development goals” were used. The search was limited to reviews; meta-analyses and assorted reports were retrieved and evaluated. A total of 25 publications were evaluated for this review article. Review Article


Introduction
The under-fi ve mortality rate is a key indicator of child well-being, including health and nutrition status. It is also a key indicator of the coverage of child survival interventions and, more broadly, of social and economic development [1]. Under-fi ve mortality rates fell rapidly from 2000 to 2015, declining by 44 per cent globally, leading to a global under-fi ve mortality rate of 43 per 1,000 live births [1]. Even then about six million children under the age of 5 still died before their fi fth birthday in 2015. The neonatal mortality rate declined from 31 deaths per 1,000 live births in 2000 to 19 deaths per 1,000 live births in 2015. Neonatal deaths represent a larger share (45 per cent) of all under-fi ve deaths as the progress in the rate of survival among children aged 1 to 59 months outpaced advances in reducing neonatal mortality [1].
The Millennium Development Goal-4 (MDG-4) had a target of reducing the under-fi ve mortality rate (U5MR) by two-thirds, between 1990 and 2015. When compared to 1990 levels, 17,000 fewer children died each day in 2015. Since 2000, measles vaccines have averted nearly 15.6 million deaths and 3 out of 4 births were assisted by skilled health-care personnel [2]. Despite improved global progress, a substantial proportion of under-fi ve deaths were in sub-Saharan Africa and Southern Asia, accounting for as much as four out of every fi ve underfi ve child deaths in these regions. Children belonging to poor families and of illiterate mothers have more chances of dying before the age of fi ve when compared to those from wealthier families. In 2012, UNICEF found that, globally, children born in the poorest 20% of households had only half the chance of surviving to their fi fth birthday as children born in the richest 20% of households [3].
The Sustainable Development Goals (SDGs) seeks to build on the Millennium Development Goals (MDGs) and "complete what these did not achieve, "particularly in reaching the most vulnerable. The SDGs are committed to the full realization of all the MDGs, including the off-track MDGs, by providing focused and scaled-up assistance to least developed countries and other countries in special situations, in line with relevant support programs. MDG-4 failed to achieve its single target of reducing child mortality. Goal-3 of SDGs aims to ensure healthy lives and promote well-being for all at all ages. Target 3.2 of SDG-3 is to end preventable deaths of newborn and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births, by 2030 [4]. About half of under-fi ve deaths occur in only fi ve countries: India, Nigeria, Pakistan, Democratic Republic of the Congo and China. Around two-thirds of neonatal deaths occur in just 10 countries, with India accounting for more than a quarter and Nigeria for about a tenth [1].
South Asia has made faster progress than any other region in reducing child deaths and has halved its under-fi ve deaths from 4.7 million in 1990 to 2.1 million in 2012, the total share of global under-fi ve mortality being 6.6 million [5]. With 1.4 million children dying before reaching their fi fth birthday, India had the highest child mortality rate worldwide (56/1000 LB) and compared poorly with even its neighboring countries, Bangladesh (41/1000 LB) or Nepal (42/1000 LB), both having already achieved their respective MDGs-4, unlike India. Public Health is one of the best refl ections of human development in a country. India is one of those countries where the spending on public health in proportion to percentage of GDP is one of the lowest in the world. The important indicators of health in a country are: (1) Infant Mortality Rate (2) Maternal Mortality Rate (3) Life Expectancy at Birth. India is lagging behind on targets for reducing child and maternal mortality. Child mortality rate was 49/1000 live births (LB) in 2013, Infant mortality rate was 40/1000 LB in 2013 [6]. Primary health care (PHC) is equally valid for all countries from the most to the least developed, although it takes varying forms in each of them. The concept of PHC has been accepted by all countries as the key to the attainment of Health for All by 2000 AD.

Methods of Literature Search
The materials for this review were obtained from an extensive search using Medical Subject Headings of electronic databases which included PubMed, PubMed Central, Google Scholar, Medknow, Science Direct and Textbooks were searched until 2016. Literature on the Under-fi ve Mortality in India through Millennium Development Goal was retrieved. The key words used for the literature search included "Under fi ve mortality" and "Millennium development goals". The search was limited to reviews; meta-analyses and assorted reports were retrieved and evaluated from 2005 to 2016 in English. A total of 31 articles were identifi ed. After examining the titles and abstracts, this number was fi nally reduced to 25 articles. A summary of under-fi ve mortality rate of different states of India is depicted in fi gure 1.

Covariates of Infant and under-fi ve mortality
According to Mosley and Chen, 14 intermediate variables directly infl uence the risk of morbidity and mortality grouped into fi ve factors: maternal factors, environmental contamination with infectious agents, nutrient defi ciency, injury and personal illness [7]. Maternal factors include age of mother at the time of birth, birth order, birth interval, son preference, maternal malnutrition (anaemia) and low birth weight; environmental factors include water supply, toilet facilities and use of biomass fuels for cooking; programmatic factors include TT Immunization, full consumption of iron folic acid tablets, delivery in medical facility and delivery by TBA; socioeconomic and demographic factors include income, urban/rural residence and maternal education. Globally 2.6 million still-births (≥28 weeks or ≥1000 g) occur every year, of which more than half (1.45 million) occur during the antepartum period [9]. These stillbirths were not counted in the MDGs and progress has been substantially slower than even that for reductions in newborn mortality.The risk of intrapartum stillbirth is 24 times higher for an African woman than for a woman in a high-income country. Yet these deaths are largely preventable.

Where are the gaps?
Concern has been raised that neonatal death rates in India are not falling at a fast pace [10]. The million death study in India suggested that almost half of India's neonatal deaths are caused by birth asphyxia & birth trauma, sepsis, pneumonia and tetanus -conditions that can be avoided by increases in delivery care and postnatal care [11]. Antibiotic treatment of bacterial pneumonia is highly effi cacious, but may be compromised by increasing resistance of bacteria to inexpensive antibiotics. There is no available treatment or vaccines for important viral causes of lower respiratory illness, such as Respiratory Syncytial Virus. For rotavirus diarrhea, the most important cause of severe childhood diarrhea globally, the vaccine provides only about 50% protection in LMICs. ORS and zinc are effective treatments for diarrhoea, but coverage remains too low [12]. Neonatal mortality is often not addressed  assessment of disease-specifi c mortality rates is not yet possible in many parts of India, either because the underlying cause of the terminal illness was never known or because the relevant information was not recorded. Many low-and middle-income countries lack a systematic approach for reviewing the causes and factors linked to maternal and perinatal deaths and "nearmiss events" occurring in facilities and in the community. The large number of stillbirths and neonatal deaths, particularly in comparison to maternal deaths, presents a challenge to already weak health information systems that are not equipped to capture, let alone review, the quality of services provided to each baby who died.

What interventions are available
A small set of evidence-based and cost-effective interventions focusing on the mother-child dyad can prevent a major part (up to 72%) of neonatal deaths [17]. Over threefi fths of all 2.3 male child deaths in India in 2005 were caused by fi ve conditions: pneumonia, prematurity & low birthweight, diarrhoeal diseases, neonatal infections and birth asphyxia & birth trauma [18]. India is home to 40% of the world's malnourished children. Every year, 2 million children die in India, accounting for one in fi ve child deaths in the world. More than half of these deaths could be prevented if children were well nourished [19]. Health education and motivation of mothers were evidenced to lead to a signifi cant improvement in the nutritional status of malnourished children [20]. Each of the major causes of neonatal deaths can be prevented or treated with known, highly effective and widely practicable interventions such as improvements in prenatal care, intrapartum care (skilled attendance, emergency obstetric care and simple immediate newborn care), postnatal familycommunity care (preventive post-natal care, oral antibiotics management of pneumonia) [21], and tetanus toxoid immunization [22].
In a fi eld trial in Gadricholli, about one-third of the reduction in neonatal mortality was found to be due to sepsis management, a further third to supportive care of neonates with a low birth weight, and around one-fi fth to asphyxia management [23]. From a health system perspective, IMNCI is cost effective strategy for child survival in India, with a 90% probability to be cost effective at a willingness to pay threshold of INR 2300 (USD 51) [24]. However, due to lack of human and fi nancial resources, implementation of IMCI has been slow in many countries. Vaccine-preventable diseases contribute to around 25% of under-5 mortality. Maintenance of room warmth, immediate drying and wrapping, prompt recognition of hypothermia, and re-warming of hypothermic infants averts up to 40% of neonatal deaths. Breastfeeding Immediate (within 1 hour after birth) and exclusive (no prelacteal feeds or other fl uids/food) breastfeeding averts nearly 10% of all neonatal deaths. Skin-to-skin contact between mothers and newborns, by Kangaroo Mother Care (KMC) maintains warmth, encourages nursing, discourages over-handling, and enhances maternal recognition of newborn problems, reducing infection rate by about half.
The most important strategy to reduce stillbirths is improved care at birth, early recognition of danger signs and training skilled birth attendants for emergency resuscitation Evidence-based and cost-effective interventions focusing on the mother-child dyad can prevent a major part (up to 72%) of neonatal deaths. Key interventions for newborns include immediate drying and stimulation at birth; immediate and exclusive breastfeeding; chlorhexidine umbilical cord care, kangaroo mother care [25]. Research may be carried out on the following domains: Evaluating the impact and safety of KMC and other interventions at the community level, early detection of high-risk women, improved and simplifi ed intrapartum monitoring, evaluation of appropriate oral antibiotics for treatment of neonatal sepsis, role of perinatal audits in improving quality of care during labour and childbirth, to discover causal pathways of preterm labour, new tocolytics to delay preterm birth, stable surfactant with easier mode of delivery, and to discover more accurate and affordable ways to detect fetal distress.

Conclusion
Integrated and synergistic efforts of the public, private and civil society to improve outcomes in nutrition, water and sanitation, health, education and other sectors that impact outcomes for women and children, can improve child survival.
Improving maternal nutrition and provision of ante-natal, intra-natal and post-natal care by trained personnel to all pregnant women are areas where priority action is required, directed particularly at the most vulnerable and "at risk" poor, the slum-dwellers and the marginalized is required.
Universal coverage of cost-effective interventions at the community through increased health workforce is the need of the hour, which appears feasible by the National Urban Health Mission. Through investments in domestic production, as well as research and development, the private sector wields enormous infl uence over the availability, affordability and quality of life-saving commodities and medicines. Mobile applications can be made use of for proper monitoring and supervision.
To increase political prioritization of notifi cation and review of stillbirths and neonatal deaths, the Every Newborn Action Plan includes a milestone for developing perinatal mortality audit guidelines. These guidelines will help clarify who is responsible for recording and reviewing stillbirths and neonatal deaths and how to use the information to improve health worker and health system performance.