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PAPERS: R Khanna, A Kumar, J F Vaghela, V Sreenivas, and J M Puliyel Community based retrospective study of sex in infant mortality in India BMJ 2003; 327: 126 [Abstract] [Full text]

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infant mortality should improve

R Durai   (19 July 2003)

Mother who rocks the cradle ameliorates the community

himmatrao saluba Bawaskar   (1 August 2003)

Gender difference in infant mortality in India

IAN DAWSON   (4 August 2003)

Demographic Implications of Sex Bias in Infant Mortality in India

Patrick S Carroll   (4 August 2003)

Gender bias, Poverty or SIDS?

Zubair Kabir   (7 August 2003)

infant mortality should improve 19 July 2003
R Durai, SSHO surgery North Middlesex University Hospital ,london Send response to journal: Re: infant mortality should improve	It is a pity to hear that there are a lot of infant deaths due to diarrhoea is still going on. Diarrhoea occurs because of overcrowding and poverty .Poor people has no access to good water supply.The poor think that male child is going to look after them well .The tradition in India is men go to work and women look after kids and cooking.So male child is looked after well in comparison to female.Usually the femaleside has to bear the expenses of arranged marriage.So having a female child is considered as a burden in an uneducated family. With better income and education this will change. India is such a big country.So it is not possible make a sudden change.The infant mortality is different in different regions.It may be more than what was published is some places. so the essence is overcrowding,poverty,illiteracy ,lack of good drinking water and poor sanitaion all contributes to increased infant mortality due to infectious diseases Competing interests:   None declared
Mother who rocks the cradle ameliorates the community 1 August 2003
himmatrao saluba Bawaskar, clinician Bawaskar hospital and research center Mahad raigad maharashtra ndia 402301 Send response to journal: Re: Mother who rocks the cradle ameliorates the community	Mother who rocks the cradle ameliorates the community Sir, Khanna R and his colleagues addressed the vital subject of female child fatality in India. (1). 175000 infants die every year in Maharashtra state, India, alone. Sex disparities in health and education are higher in south Asia than anywhere else in the world. 40% more girls than boys are likely to die before the age of five (2). Over the past forty years a wide range of developing countries have successfully developed models of primary health care promoted by the World Health Organization. In the year 1960 transient decreases in infant mortality were reported by introduction of bare foot doctors in China. But at present infant fatality is 88%. Today, 60% of Chinese have hepatitis B due to improper sterilized needles of bare foot doctors.(3) SEARCH (Society for Education, Action, and Research in Community) reported 83% infant deaths due to pre-maturity, birth asphyxia, birth injury and sepsis from rural Maharashtra (3). With the help of trained semiliterate women called health messengers (arogya doot) for home–based neonatal care and management of sepsis they achieved reduction in case fatality by 14% and infant mortality by 62%. (3) In India illiteracy is the root cause of population explosion, poverty, malnutrition, maternal mortality, infectious and ischemic heart disease. Child mortality is 18.8 per 1000 births in Kerala state and is achieved because of 100% literacy, whereas it remains 137.6 per 1000 in Madhya Pradesh due to illiteracy. Communities like that in India “health for all” can be easily achieved by abolishing illiteracy, rather than giving training and authorizing semi-literate women and exposing poor illiterate people to the extra risk of infections such as hepatitis (3). It is high time now charitable health institutes, health trusts and non-government organization should divert their funds and energy to rectify the root cause, which is illiteracy than its effects. Improvement of per capita income (2). Every one should attempt to make this world a safe haven for women and new comers. Long term follow up of infants is crucially important for the possibility of development of insulin dependent diabetes and childhood cancer due to routine administration of cows' milk and injection vitamin K by SEARCH trained health messengers (4). Good long term supervision is vital, while incorporating home based neonatal care in an illiterate community by semi-literate women (4). Otherwise there will be no time to transform health messengers (arogye doot) to official disease spreaders (Rog doot), as China experienced in the recent past (2). Pharmaceutical industries from developing countries like India should divert their funds to improve child fatality and should avoid sponsorship of free lunches, conferences and arranging tours abroad for doctors. In India there is rampant corruption in the health department, health trusts and even in funding agencies. To avoid injustice to a female child, the conception, mother, and growing fetus till the age of five should be registered as wealth of a nation and be provided with all health facilities and be protected from all consequences or handing them over to a nursing staff by establishing a new department(5). Thanking you Yours sincerely H.S. Bawaskar Bawaskar hospital and research center Mahad Dist – Raigad 402301, Maharashtra, India E-mail- himmatbawaskar@rediffmail.com References 1-Khanna R, Kumar A, Vaghela JF, Sreenivas V and Puliyel Jm. Community based retrospective study of sex in infant mortality in India . BMJ. 2003;327:126-30. 2-Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D et al. Applying an equity lens to child health and mortality : more of the same in not enough. Lancet 2003; 362:23. 3-Elisabeth R. Chines Doctors dirty needles spread hepatitis. New York times service the international herald tribune 8-22-1 4-Bang A, Bang R, Baitule SB, Reddy MH and Deshmukh MD. Effects of home –based neonatal care and management of sepsis on neonatal mortality: field trial in rural India . Lancet 1999;354:1155-61 5- Bawaskar H. Child survival in India. Lancet 2003;362: 26th July( debate). Competing interests:   None declared
Gender difference in infant mortality in India 4 August 2003
IAN DAWSON, N/A Kent Send response to journal: Re: Gender difference in infant mortality in India	Dear Sir, Gender difference in infant mortality in India Gender differences in infant mortality have been the subject of previous international comparison and discussion1 and Khanna et al’s2 results provide confirmation. I examined whether similar gender differences exist in England and Wales using, unpublished ONS data on births and infant deaths by mother’s country of birth. In the absence of national data by ethnic origin, the data for children born to first generation migrants provide the closest proxy to outcomes for minority populations in England and Wales. For the 19,663 births registered between 1996 and 1998 to mothers born in India, infant mortality for both genders was 5.49 per 1000 births an odds ratio of 1.00 which is not significantly different from the overall England & Wales ratio of 0.80 (see Table). For the 37,947 births registered in the same period to mothers born in Pakistan female mortality was higher than that for males with an odds ratio of 1.09, significantly higher (p<0.05) than the overall England & Wales ratio. For no other country of birth group was such an effect observed. Also noteworthy are the much higher infant mortality rates for this group when compared with births to other South Asian-born mothers. Ian Dawson Birchington, Kent CT7 9HX 1 “Too young to die: genes or gender” United Nations Department of Economic and Social Affairs, Population Division. United Nations New York (1998) 2 Community based retrospective study of sex in infant mortality in India R Khanna, A Kumar, J F Vaghela, V Sreenivas, and J M Puliyel BMJ 2003; 327: 126-0. Male and female infant mortality rates by mother’s country of birth England and Wales – 1996 to 1998 Mother's Country of Birth Live Births Infant Deaths Infant Death Rate Odds Ratio Odds Ratio per 1000 live births M F M F M F F: M 95% CI United Kingdom 858,282 815,237 5,429 4,026 6.33 4.94 0.78 0.75 0.81 England and Wales 839,481 797,168 5,321 3,934 6.34 4.93 0.78 0.75 0.81 Scotland 14,138 13,593 80 68 5.66 5.00 0.88 0.64 1.22 Northern Ireland 4,123 3,958 25 20 6.06 5.05 0.83 0.46 1.50 Outside the United Kingdom 130,184 123,780 931 798 7.15 6.45 0.90 0.82 0.99 Irish Republic 7,366 7,164 55 33 7.47 4.61 0.62 0.40 0.95 Other European Union 15,189 14,347 84 62 5.53 4.32 0.78 0.56 1.08 Rest of Europe 6,212 5,739 29 30 4.67 5.23 1.12 0.67 1.86 Commonwealth Australia, Canada, New Zealand 5,082 4,803 20 23 3.94 4.79 1.22 0.67 2.21 New Commonwealth 70,669 67,337 604 525 8.55 7.80 0.91 0.81 1.02 Bangladesh 10,947 10,714 80 66 7.31 6.16 0.84 0.61 1.17 India 10,194 9,469 56 52 5.49 5.49 1.00 0.69 1.46 Pakistan 19,503 18,444 213 219 10.92 11.87 1.09 0.90 1.31 East Africa 7,413 6,940 45 35 6.07 5.04 0.83 0.53 1.29 Southern Africa 1,897 1,829 9 7 4.74 3.83 0.81 0.30 2.16 Rest of Africa 9,605 9,375 119 80 12.39 8.53 0.69 0.52 0.91 Far East 2,806 2,578 12 11 4.28 4.27 1.00 0.44 2.26 Mediterranean 2,331 2,173 19 14 8.15 6.44 0.79 0.40 1.57 Caribbean 4,012 3,930 41 34 10.22 8.65 0.85 0.54 1.33 Rest of the New Commonwealth 1,961 1,885 10 7 5.10 3.71 0.73 0.28 1.91 Rest of the World and not stated 25,666 24,390 139 125 5.42 5.13 0.95 0.74 1.20 All 988,466 939,017 6,360 4,824 6.43 5.14 0.80 0.77 0.83 Source: Office for National Statistics (unpublished) Competing interests: None declared
Demographic Implications of Sex Bias in Infant Mortality in India 4 August 2003
Patrick S Carroll, Director of Research, PAPRI PAPRI, 35 Canonbury Road, London N1 2DG Send response to journal: Re: Demographic Implications of Sex Bias in Infant Mortality in India	Dear Sirs There are demographic implications of the sex bias in infant mortality in India reported by R Khanna et al (BMJ 19 July 2003:327). The sex ratio at birth and the higher infant mortality for girls reported for India both imply a higher family size required for the human population in India to replace itself. In a developed country, the replacement level is around 2.08 Total Fertility Rate. This allows for a sex ratio at birth of 1.05 boys to 1 girl and for mortality of around 3 per thousand among girls before they reach the age of having children. In India, the authors report a ratio at birth of 3752 boys to 3260 girls i.e. 1.15 boys to 1 girl and high infant mortality of 72 per thousand among girls. With an allowance of 4 per thousand among Indian girls between infancy and the age they have children, we arrive at a replacement level of 2.28 for India. When average family size falls below that in India there will be no surplus population for emigration to countries like the UK. Yours faithfully Patrick Carroll Director of Research PAPRI Pension And Population Research Institute, 35 Canonbury Road, London N1 2DG e-mail papriresearch@btconnect.com charity registration number in England 327942 Competing interests:   None declared
Gender bias, Poverty or SIDS? 7 August 2003
Zubair Kabir, Epidemiologist St, James's Hospital, Dublin 8. Send response to journal: Re: Gender bias, Poverty or SIDS?	Dear Editor, I appreciate Khanna and his colleagues for attempting to address an important social issue from a ‘local’ perspective for an ‘international’ audience. This study raised many questions than answering any! The topic is not only interesting, but also sensitive. However, I am concerned about its simple study design, a straightforward analysis and more importantly, a sketchy explanation of the observations. I offer a few comments, which may help provide further insights into the study findings for the readers and authors alike, as well as motivating future investigators to conduct a better study with additional information. Delhi has a sizeable proportion of economic migrants (almost 40% of the general populations!) from the poorest states of independent India, such as Bihar, who are forced to eke out their livelihoods in urban slums, as resettlement colonies (1) It is beyond dispute that child mortality across different age groups is most likely to be the consequence of social deprivation or underlying poverty (2). As for infant deaths, not only the proximal causes are profound in such populations, but also the distal determinants of infant deaths, such as social inequality or poverty (3). In addition, the proximal causes of neonatal deaths are distinctly different from those contributing to post-neonatal deaths. Recently, a study in rural India in a relatively stable homogenous population also demonstrated that low socio-economic conditions contribute to a higher likelihood of post-neonatal deaths, as opposed to neonatal deaths (4). This may be consistent with the observed higher proportion of diarrhoeal deaths (95/442) in Khanna et al’s study (table III). Hence, the potential inconsistencies in findings looking at infant deaths by gender without controlling for socio-economic status, especially among socially deprived populations, such as an urban slum community. However, an observed association in relation to infant death by gender is most likely due to the residual confounding of an underlying socio-economic status. The present study has faltered on this very important issue, and goes on associating the excess ‘treatable and preventable’ infant deaths with gender bias, which seems unlikely for many other potential reasons. First, the investigators could have taken the opportunity of designing a better study. My understanding is that the existing computerised database system of the Community Medicine department is accurate, reliable and complete, although no such commitment has been made. Given the validity of such a database, a rigorous computerised matching programme could have been utilised for selecting individual controls (living children) matching to some potential confounders. This study design for data collected prospectively, as in the present study, followed by a retrospective analysis of all the relevant socio-demographic data presumably collected routinely during the health workers’ domiciliary visits, could have certainly minimised inherent biases, such as selection and recall biases, as well as reducing type II error. In addition, the findings would have been more robust and less confusing. Second, in the presentation of results, an extra table showing the distribution of the causes of neonatal and post-neonatal deaths separately would have been more explanatory for the general audience (bmj.com has no dearth of space!). However, sub-group analysis is always an issue for an apparently inadequate sample size testing a hypothesis of a relatively low prevalence. For example, 44% of the infant deaths are attributed to perinatal and neonatal causes (immaturity, birth asphyxia, congenital anomalies, septicaemia), as opposed to 36% of the causes (diarrhoea, malnutrition, acute respiratory infection) commonly attributed to post- neonatal deaths (table III). In other words, this study may have a higher proportion of neonatal deaths than post-neonatal deaths, but did not have adequate power to give a statistical significance across the ‘less preventable and less treatable’ causes. In summary, the majority of the causes for infant deaths in this study population were more likely to be ‘less treatable or less preventable’, thereby increasing the possibility of type II error. Nonetheless, revisiting the same issue after a few more years with the similar study design would be more convincing. Third, per-capita income is just one of the few proxy measures for socio-economic status. Hence, a proportionately greater ‘unexplained’ death in higher per-capita income households is less conclusive for excluding ‘extreme poverty’ as a probable explanation (table V). In such a community, “caste” would have been a better indicator, which not only reflects material wealth, but also suggests social/ethnic background. Tables I and IV provide indirect evidence of this observation. For example, crude infant mortality rate is higher among Muslim households (whose per-capita income is relatively low), but the cause-specific death rates, including unexplained deaths, are lower compared to Hindu households. Thus, the observed variations in infant deaths by gender is more likely to be modified by religion or socio-cultural practices in presence of an underlying poverty, which is a potential confounder for the association examined. Fourth, the families under study are mostly economic migrants from a couple of far-flung poor states; not only their socio-ethnic background is heterogenous, but also born and brought up in a culture quite different from those practised in the wealthy states of the Punjab or Haryana. These are the two significant states with the dubious distinction of systematic female foeticides and lower sex ratio, as well as mushrooming of illegally operated sex-identification mobile clinics. In addition, these clinics operate on a hefty price between fifty and hundred Euros! However, I am not aware of any sex-identification mobile clinics clandestinely operating in urban slum communities of Delhi suburbs based on my personal experience in such resettlement colonies. So, is it paradoxical that households with a paltry per-capita income of ‘eleven Euros’ can be the innocent victims of such extortions time and again, or even if a handful of such clinics do operate, the likelihood of their overall impact on the study population, and consequently the hypothesis in question? In other words, the study findings can neither be generalised nor strong conclusions can be drawn based on events/practices elsewhere. Fifth, the elusive higher proportions of sudden ‘unexplained’ deaths observed in this study. The authors’ stated that 50% of the unexplained deaths were neonates, and 86% of these were females. I wonder if they are more likely to be associated with conditions, such as SIDS (Sudden Infant Death Syndrome), rather than speculating foeticide alone as a probable explanation. SIDS is an emerging condition in developed countries. Unfortunately, prevalence data on such conditions are virtually non- existent in less-developed countries, including India, but this does not imply that the possibility of SIDS is less unlikely. More importantly, all the known risk factors for SIDS are very much prevalent among such urban slum communities, and they are also relatively more common among socially deprived populations (5). It would be worth considering such outcomes in the future, before attributing an apparent innocent poor family or a community at large to sexual discrimination and committing socially unacceptable crimes, such as infanticides. Finally, the investigators comment on the ‘adverse’ sex ratio both at the local and national level. It is always important to observe any significant patterns emerging across potential child survival indicators, such as sex ratio or infant mortality rate (IMR) by gender, both at the local and national level. It is encouraging that an improvement in the overall sex ratio from 1991 to 2001 is observed at the national level. In addition, the figures for female IMR in the study population suggest that the female death rates are declining at a rate of –5.5% on an annual basis. This annual change would have been more apparent had the authors computed the annual sex ratio over the study period instead of a summary sex ratio. All these observations indicate that practices, which are extremely localised and culture-centric, are increasingly becoming rare over the past decade. It is high time that the social scientists, as well as international organisations, stop being carried away by a tunnel vision based on prejudiced ideas, and start contemplating the bigger picture. We also need to echo the sentiments, as well as the ordeal of Trupti Patel and her family, which are still fresh in our memories! References 1. Kabir Z. Child labour and urban slum experience. Indian J Pediatr 2003; 70: 447. 2. Blakely T, Atkinson J, Kiro C, Blaiklock A. D’Souza A. Child mortality, socio-economic position, and one-parent families: independent associations and variation by age and cause of death. Int J Epidemiol 2003; 32: 410-18. 3. Victora CG, Wagstaff A, Schellenberg JA, et al. Applying an equity lens to child health and mortality: more of the same is not enough. Lancet 2003; 362: 233-41. 4. Kabir Z. Demographic and socio-economic determinants of post-neonatal deaths in a special project area of rural northern India. Indian Pediatr 2003; 40: 653-9. 5. Fleming PJ, Blair PS, Platt MW, et al. Sudden infant death syndrome and social deprivation: assessing epidemiological factors after post-matching for deprivation. Paediatr Perinat Epidemiol 2003; 17: 272-80. Competing interests:   I worked as a Senior Resident of Community Medicine at the AIIMS, New Delhi