Department of PSM, Maulana Azad Medical College, New Delhi.
Research question: What is the status of Reproductive and Child Health (RCH) in Delhi?
Objectives: 1. To study the current state and trends in RCH in Delhi. 2. To study MCH service coverage separately for slums and rest of Delhi. 3. To assess the adequacy of health services for RCH service coverage and lacunae if any.
Study design: Cross-sectional through secondary data.
Setting: National capital of Delhi.
Study variables: Infant, child and maternal mortality, common morbidities, RCH services and coverage.
Statistical analysis: Percentages and rates.
Results: Delhi, the National Capital faces the challenge of very high population growth, mainly due to immigration from other states. Slums accommodate about one third of its population and are characterised by poor MCH service coverage. IMR, Child MR, MMR and CBR are still high. Health services need to be population based. Abortion and delivery services need to be augmented. Priority and special strategies for health services and IEC efforts are required for slum population.
Keywords: RCH status, Service coverage, RCH services.
RCH programme was launched in India in October, 1997 replacing Family Welfare and Child Survival and Safe Motherhood Programme. The programme focusses on overall reproductive health of women as well as health and survival of children and not merely on birth control. Contraceptive method specific targets that were decided centrally in the Family Welfare Programme have been replaced by decentralised approach of community needs assessment and progress monitoring by RCH indicators. The present study was an attempt to pool together data on various aspects of RCH so as to know the current status and trends.
Data on infant, child and maternal mortality, fertility, RTIs, STIs, nutritional status of under fives, organisation and delivery of MCH services was collected from documents obtained from Census 1991, Registrar - Births and Deaths, Bureau of Economics and Statistics, Directorate of Health Services, Directorate of Family Welfare, reports of surveys carried out recently and through personal communication. Data was tabulated to study the trends and service coverage in slums and rest of Delhi and component-wise adequacy of MCH services1-4.
There has been a slow decline in birth rate from 28.7 in 1988 to 24.6 in 1997 (based on registration of births). SRS estimates indicate a greater decline of birth rate to 21.1 in 19975.
Birth order: The proportion of birth order 3 and above has also declined from 38.20% in 1988 to 24.81% in 19975.
Age at marriage and child bearing: More than one third women are married before the legal age of marriage i.e. 18 years. About two fifth have their first pregnancy before 20 years of age and more than two third deliveries have birth intervals of less than three years6-7.
There is an urgent need to focus the efforts on empowerment of women to ensure right age at marriage and improve use of family planning methods among the women <30 years to time and limit the births.
Maternal health: Reporting of maternal deaths is highly inadequate as only 38 maternal deaths and 2,88,776 births were reported in 19975. This may be due to difficulty in certifying death due to maternity and related causes. Probably for the same reason Maternal Mortality Rate (MMR) is also not computed by SRS also. Maternal Mortality Rate based on a study among high risk pregnancies in 1982-83, has been reported to be 4.21 per thousand live births8. It was higher among women from rural and urban slum areas. A working paper at the state planning workshop for CSSM Programme reported MMR of 2.4 per 1000 deliveries in Delhi in 1992, based on data collected from 12 major hospitals in Delhi. (Directorate of Family Welfare, Govt. of Delhi, 1993).
Reported direct causes of maternal deaths are abortions (18.0%), sepsis (17.3%), haemorrhage (12.8%), ruptured uterus (8.3%) and other causes (8.3%). Indirect causes include hepatitis (15.8%), anaemia (7.5%), heart disease (6.0%) and others (12.0%), in comparison to haemorrhage (23.7%), anaemia (19.4%), toxaemia (15.2%, abortions (12%) and sepsis (8%) for India as a whole9.
More than half (58.1%) of women suffer from anaemia during pregnancy9.
This high morbidity and mortality is largely explained by poor service coverage. Only about two third of women get three or more antenatal visits. Although more than 70% women were getting IFA tablets during pregnancy, only 8.0% consumed these for at least 100 days10. Long interruption in IFA supplies maybe partly responsible for this situation. Only about half of the deliveries are institutional and 24-30% are conducted by untrained personnel. Data from registration of birth and deaths shows higher proportion of deliveries to be institutional and by trained personnel. This may be due to non-registration of many home deliveries which have been represented in Multi-Indicator Survey, by home visits.
Infant mortality rate has declined by 50.2% between 1981 and 1997, being 25.95 per 1000 live births in 19974,5. However, the decline has been only in post-neonatal mortality rate and neonatal mortality shows almost no decline5. IMR and under five mortality rate in Delhi are higher than urban India6. Causes of infant mortality (institutional) reported in 1997 were - small for date or pre-maturity (36.43%), hypoxia/birth asphyxia and other respiratory conditions (6.34%), septicemia (5.75%), pneumonia (5.15%), meningitis (3.92%), other causes in perinatal period (10.20%) and others (18.25%)5. Neonatal tetanus which was a major cause of neonatal deaths in urban slums, is declining substantially11.
Two week incidence of diarrhoea and ARI among children less than four years has been reported to be 9.8% and 4.8% respectively6.
ICMR task force collaborative study of high risk pregnancies has shown incidence of low birth weight babies (wt. <2500 gm) to be quite high (26.0%)8.
Malnutrition is common among under fives as about half of the children suffer from various grades of malnutrition. Six percent even suffered from severe grades of malnutrition7.
Supplementary nutrition is provided mostly through Anganwadis, but this is highly unsatisfactory on account of quality of supplies and that too erratic.
Practice of breast feeding was nearly universal (99.2%). However, feeding was mostly initiated late. It was initiated in only 8.3% children within one hour, 30.9%, within four hours and 62.5% within 24 hours of birth. Others were initiated on second or third day.
The practice of exclusive breast feeding, i.e. giving breast milk only and not even water till first four months of life was negligible. More than four fifth of mothers (85.2%) started giving water or other fluid to their infants by three months of age and 60.8% had even begun it in the first month of life.
Solid and meshy foods were started late i.e. after six months of age in 36.8% cases and in 3.8% these were begun earlier than three months of age7. NFHS (1992-93)6 has also shown that harmful feeding practices for infants are widely prevalent.
In most episodes of diarrhoea affecting young children, they were taken to private doctors (76.9%)7. Home management was low (15.3%). In most cases (71.6%) fluids are either decreased or even withheld. Decrease or withholding of food was reported in 51.6%. ORT use rate was just 28.4% and is below the national average (38.0%).
More than half of the mothers took their children for treatment in case of cough. This was irrespective of the other symptoms or signs. Fast/difficult breathing as a reason for taking their children for treatment was reported by 34.8%7.
Coverage evaluation surveys carried out in 1998 show that only 75.3% children 12-23 months of age are fully immunised in Delhi, exclusive of JJ clusters12.
Although 91.0% children have come in contact with the health care system as is evident from BCG coverage, there is high drop-out rate of 14.5% between DPT1 and DPT3. Low coverage with measles (77.1%) has resulted in a drop-out rate of 29.4% between BCG and measles12.
Situation is pathetic in JJ clusters where only 44.6% children are fully immunised13.
Only 37.8% children are reported to have been given first dose of vitamin A7.
R.C.H. household survey carried out recently (1998-99) shows that RTIs and STI are common in Delhi although the reported prevalence (M-6.3% and F-14.5%) is lower than that of country as a whole14. A qualitative study has brought out very high prevalence (72.0%) among the slum women14.
Common RTIs are bacterial vaginosis (41.5%), chlamydia infection (28.7%), candidiasis (18.6%), trichomoniasis and infection with Human Pappiloma viruses. Awareness about HIV and AIDS was more among males (84.4%) than females (75.4%)14.
This aspect has hardly been studied in Delhi. One study from a slum area has reported anaemia (55.45%), goitre (28.3%) and dental caries (37.2%) to be major problems. Teenage pregnancy is a common problem as 41.6% women had their first pregnancy before 20 years of age15.