Child Mortality: Does it actually matter what the middle classes think?

- Ben, EVERY ONE campaign director

A new survey published this week tells us that eight out of ten among the middle-class in cities across India underestimate the levels of child mortality. If you consider yourself middle class then apparently there is a high chance you are unaware that after 20 years of high and sustained economic growth, nearly 2 million Indian children still die every year of conditions like pneumonia and diarrhoea, and of complications related to pregnancy and child birth. Though nearly 60 per cent of those surveyed felt that the problem of child mortality was “very serious” in India, a staggering eight out of ten did not know that nearly 2 million children under the age of five die every year.  This is the highest anywhere in the world. 

This is a crucial insight for Indian organisations like Save the Children who have made it their mission to build a campaign to tackle the high levels of child mortality. But does it actually matter what the middle classes think? Well we think it does. The middle class in any country hold an influential role in society. And at the moment there is very little pressure from this group for action largely because of the lack of awareness of the scale of the problem. There is also little knowledge of how simple the solution is. We do not need a major expensive technological breakthrough for India to tackle the high rates of child mortality. We need skilled personnel available to support mothers during child birth, early postnatal care, preventive and curative treatment for pneumonia, diarrhoea and malaria; and support for nutrition, including exclusive breastfeeding.   Other countries, many of them poorer than India, are making dramatic changes. And the performance of some of India’s states, like Kerala and Tamil Nadu, shows what others could accomplish by pursuing similar approaches.

However those campaigning and working to tackle child mortality in India have yet to gain real traction on the issue among this influential section of society. We might now be saving tigers or turning off our lights once a year but we appear to have still not taken to heart the fate of our own children – this is unusual for a nation that prides itself on its love of children.

For campaigners this is a challenge if we want child survival to become a key metric by which India judges its success in development. We need to bring child and maternal survival in to the discourse on inclusive growth and national pride as rates of mortality are a much more telling indicator of development progress (or the lack of it) than per capita income. We need to be linking the child and maternal survival cause to questions like ‘what are the rewards of economic growth, if not creating a better society?’ or, ‘What kind of India do we want to become?’.  In many ways, India stands at a crossroads in respect to child mortality so can high rates of mortality be consigned to India’s past, or will they remain an indelible stain on its future?

The United Nations Millennium Development Goal Review Summit in September is the right moment for India’s political leaders to affirm decisively that it is the former course that they want to pursue, with high level commitment and with urgency. On the table for discussion will be a proposed Global Strategy for maternal and child health put forward by the UN Secretary General. As the country with the highest number of child deaths anywhere in the world, there remains a particular obligation on the part of India to demonstrate leadership on this issue.

But in the end the Summit in September is but one moment.  The change needs to happen in every village, district and state with high child mortality and there needs to pressure for this to be a national political priority. If the middle classes were to mobilise around this issue for all mothers and children  then faster change is very possible. With the requisite political will and the right policies, India can secure drastic cuts in child and maternal mortality and truly shine in the global arena.

This is why organisations working to tackle child and maternal mortality are working together and targeting politicians, business leaders, media, film makers, celebrities and musicians to take up the issue and make it heard. We are trying to link the more affluent communities to those facing the reality of high child mortality. It is encouraging that when faced with the information about the scale of the problem 74% of those surveyed said they would be somewhat likely or very likely to do something about child mortality and 83% per cent had hope that the situation can be improved and or fully solved.

We are seeing evidence of this already. Save the Children’s own Facebook network in India includes thousands of young supporters, our twitter campaign to help children in Leh was supported by Bollywood stars and generated thousands of hits on our donation pages, schools and colleges are starting their own campaigns about the issue and partnerships with media and businesses are building.

With the spirit for progress that currently exists it is truly possible that India can become a child survival champion and show the rest of the world how to bring about large scale changes that saves the lives of mothers and children.  India is playing an increasingly crucial role on the international stage and now has an opportunity to be a respected player on the world stage in all fields.

Motherhood at Peril

By Priya Subramanian, Save the Children Media Manager. This article also appeared in The Hindu.

Are the mothers of India safe? A vast majority of them do not have access to basic health care...

Thirty-year-old Naseem Bano is a mother of five who makes a living rolling beedis at home in Tonk district of Rajasthan. Naseem's last child was born in a hospital. Her first four children were delivered at home. She had one miscarriage before her last son was born. According to Naseem, “she was too scared to go to a hospital for delivering her first four children.” Crucially, her husband would not allow her to go to a hospital with a male gynaecologist.

Naseem's story is shared by millions of women in India and across the developing world. Today, the world over, a day has been dedicated to celebrate the mother. Underlying the warm eulogies of the woman donning different roles as mother, sister, wife, etc, there is another subaltern narrative of the woman who has never been to school, who has no control over resources in her own home, and who will be dictated to by her husband and the elders in the family on whether she can go to hospital to deliver her child.

No infrastructure

Every year, 50 million women in the developing world give birth at home with no professional help whatsoever. And every year, nearly 350,000 women die during pregnancy or childbirth. Almost all these deaths happen not because of untreatable complications but because these mothers do not have access to basic health care services or if these are available, they are of very poor quality.

Most of these deaths could be prevented if skilled and well-equipped health care workers were available to serve the poorest, hardest to reach mothers. However, there is a very strong link between whether a woman can access skilled health care and her level of education. Poorer and less educated women, and especially those living in rural areas, are far less likely to give birth in the presence of a skilled health worker than better educated women who live in wealthier households.

A UNESCO report says worldwide, 39 million girls are not attending school and millions more complete only a year or two of schooling. In India, female literacy stands at a disappointing 53.67 per cent. Women like Naseem with little or no schooling lack the confidence and authority to make decisions for their own health and the health of their children.

Moreover, social and cultural barriers often prevent women like Naseem from visiting health providers. Typically, in rural areas, husbands and elder family members often decide whether a woman may go for health care outside the home and women themselves often choose to forego health care if the provider is male due to social stigma. In such circumstance, the presence of a skilled female health care provider could mean the difference between life and death for the mother and her newborn child.

Experience in many countries has shown that modest investments in female community health workers can have a strong impact on mothers surviving in rural communities. Between 1990 and 2008, Bangladesh has cut its maternal mortality rate dramatically by 53 per cent. In 1997, the government launched a safe motherhood initiative aimed at improving emergency obstetric care and training 17,000 skilled birth attendants to work at the community level. Though still more than 116,000 mothers die each year in Bangladesh mainly because of inadequate care during childbirth, a vibrant home-grown NGO sector has shown that health workers with limited education and training can have a significant impact on the survival of mothers.

Recent findings presented in The Lancet indicating a 1.5 per cent yearly rate of decline in maternal mortality since 2005 is good news. In India, the National Rural Health Mission has completed five years this year. Despite good schemes, their implementation leaves a lot to be desired. A recent Comptroller and Auditor General report found that institutional deliveries have not really taken off due to several irregularities in the States where maternal mortality and infant mortality rates are high. Only 47 per cent of women give birth attended by skilled health attendants.

Poor health care

In 2000, India, along with 189 Heads of State and government committed to reducing the numbers of mothers dying by 2015 in their Millennium Declaration. Despite a decline in maternal mortality rate, the question arises if we are doing enough to save the lives of thousands of mothers who are still dying because there is no health care provider nearby to spot complications early on and intercede on behalf of these mothers before it is too late.

A worldwide survey done recently by Save the Children finds India at 73 out of 77 middle-income countries in terms of the best country to be a mother. To paraphrase Nehru, you can tell the condition of a nation by looking at the status of its women. In a country that has glorified women in mythology and fiction, it is incongruous to have a reality where women have no control over their destiny and indeed their lives and, are dying because they cannot access basic health care.