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Indian Journal of Community Medicine

Comparative Study of Under-Five Deaths and Family Planning Status in District Ahmedabad

Author(s): (Mrs.) Mrudula K.Lala*, Geeta Kedia*, C.K. Purohit*, B.S. Bhavsar**

Vol. 25, No. 3 (2000-07 - 2000-09)

*Deptt. of P.S.M, B.J. Medical College, Ahmedabad. **Deptt. of P.S.M, Govt. Medical College, Rajkot.

Abstract:

Research question: What is the relationship of under five deaths and family planning status in district Ahmedabad?

Objectives: To study 1. Sex distribution of under five deaths and their causes. 2. Rural-urban comparison of under five deaths and their causes. 3. Rural-urban comparison of FP status. 4. Comparision of F.P. status among couples with and without under five deaths.

Study design: Cross-sectional study, verbal autopsy method used.

Participants: Rural-urban households.

Sample size: 10,100 rural and 10,160 urban population.

Study variables: Age, sex, under five mortality, its causes, rural-urban distribution of under five deaths, pregnancy wastage, contraceptive practice profile.

Outcome variables: Sex-wise and area-wise distribution of under five deaths and their causes, family planning status and its distribution in urban-rural area and among couples with and without underfive (UF) deaths.

Results: Under five mortality rate was more (105.26 per 1000 live birth) in urban area than rural (60.45 per 1000 LB) area of district Ahmedabad. It was more among males. Couple protection rate was more (48.31%) in urban area than rural area (40.43%). Use of contraceptive measures was less (19.23%) among couples with under five deaths than couples without under five deaths (44.8%). The study shows that under five mortality has bearing on FP status. Observed spectrum of under five mortality showed worsening condition in urban area. There is need to strengthen urban health services.

Keywords: Under five mortality, Urban, Rural, Couple protection rate, Interval between last two pregnancies, Couples with and without under five deaths.

Introduction:

Under five mortality is one of the principle indicators used to measure levels of and changes in the well being of children1. High under five mortality rate (U5MR) is mainly correlated with inadequate maternal and child health (MCH) services. Apart from this, it is also related to insufficient nutrition, low coverage by immunization, adverse environment exposure and other exogenous factors2. Estimates of under five deaths are made by different types of surveys1. Our study is one such type of study based on verbal autopsy method to know the causes of under five deaths in urban and rural area of district Ahmedabad. Family planning status has also bearing on under five deaths. Factors associated with low couple protection rate are the factor associated with high under five mortality, e.g. low education status, low economic status, low standard of living, adverse prevalent customs, non availability of health services etc3. Family planning status in urban as well as rural areas gave variable findings4. Our study also tried to explore Family Planning (FP) status in urban and rural areas of district Ahmedabad with and without under five deaths.

Material and Methods:

The clusters were selected in urban and rural areas of district Ahmedabad by using WHO's cluster sampling method. The present study was a preliminary study; detailed study would be carried out in the future. Due to financial constraint, it was not possible to cover all the clusters. Out of chalked out clusters, three clusters were randomly selected covering 10,100 rural and 10,160 urban population. For data collection, schedules were designed and tested in the field. Information about demographic profile of surveyed population was recorded. The cause of under five death was investigated through a schedule for under five deaths which occurred during January to December 1993. Data about family planning status was also obtained. For this a house-to-house survey was done in randomly selected area.

Observations:

A total of 3925 households with population 20,260 were surveyed. Out of these 50.7% were urban and 49.3% were rural households. Average persons per household were 5.16. A total of 663 live births occurred during one year period. It included 397 and 266 births occurring respectively in rural and urban areas. 355 were male and 308 were female births. Under five and infant population constituted 12.66% and 3.12% of total population respectively. 52 under five deaths occurred in the total population of 20,260. Out of these, 26(39.21%) were neonatal deaths, 12(18.1%) were post neonatal deaths, i.e. 38(57.31%) were infant deaths and 14(21.12%) were preschool deaths. Above rates were expressed as per 1000 live births.

Table I: Causes of underfive deaths according to sex.

Cause Male Female Total
No. (Rate) No. (Rate) No. (Rate)
Pre-maturity 2 (5.63) 4 (12.99) 6 (9.05)
Birth injury 4 (11.27) 2 (6.49) 6 (9.05)
Asphyxia 1 (2.82) -   1 (1.51)
Neonatal tetanus 1 (2.82) 1 (3.25) 2 (3.02)
Congenital causes 3 (8.45) -   3 (4.52)
Fever with convulsion 2 (5.63) 2 (6.49) 4 (6.03)
Diarrhoea 2 (5.63) 1 (3.25) 3 (4.52)
Pneumonia -   2 (6.49) 2 (3.02)
Measles 6 (16.9) 6 (19.48) 12 (18.1)
TBM 1 (2.82) 2 (6.49) 3 (4.52)
Rh. incompatibility 2 (5.63) 1 (3.25) 3 (4.52)
Typhoid 1 (2.82) -   1 (1.51)
Jaundice 1 (2.82) -   2 (1.51)
Unknown 5 (14.08) -   5 (7.54)
All causes 31 (87.32) 21 (68.18) 52 (78.43)

Rate per 1000 live births

Under five MR per 1000 live births (LB) was 87.32 amongst males and 68.18 amongst females. Sex differential indicated that amongst males; measles (16.9), birth injury (11.27) and congenital causes (8.45) were leading causes of deaths, while amongst females they were measles (19.48) and prematurity (12.99). Disease rates were calculated per 1000 live births.

Table II: Causes of under five deaths according to area.

Cause Urban Rural Total
No. (Rate) No. (Rate) No. (Rate)
Pre-maturity 6 (22.56) -   6 (9.05)
Birth injury 2 (7.52) 4 (10.08) 6 (9.05)
Asphyxia 1 (3.76) -   1 (1.51)
Neonatal tetanus 1 (3.76) 1 (2.52) 2 (3.02)
Congenital causes 2 (7.52) 1 (2.52) 3 (4.52)
Fever with convulsion 4 (15.04) -   4 (6.03)
Diarrhoea 2 (7.52) 1 (2.52) 3 (4.52)
Pneumonia 1 (3.76) 1 (2.52) 2 (3.02)
Measles 3 (11.28) 9 (22.67) 12 (18.1)
TBM 2 (7.52) 1 (2.52) 3 (4.52)
Rh. incompatibility -   3 (7.56) 3 (4.52)
Typhoid 1 (3.76) -   1 (1.51)
Jaundice 1 (3.76) -   2 (1.51)
Unknown 2 (7.52) 3 (7.56) 5 (7.54)
All causes 28 (105.26) 24 (60.45) 52 (78.43)

Rate per 1000 live births

Total U5MR was 78.43 per 1000 LB. It was 105.26 in urban area and 60.45 in rural area. Leading causes of deaths in urban area were prematurity (22.56), fever with convulsions (15.04), measles (11.28) followed by birth injury, diarrhoea, TBM and unknown causes (7.52 each). The leading causes of under five deaths in rural area were measles (22.67), birth injury (10.08), Rh. incompatibility (7.56), unknown causes (7.56) followed by neonatal tetanus, congenital causes, diarrhoea, pneumonia and TBM (2.52 each).

Table III: Pregnancy wastage in surveyed population according to area.

Pregnancy wastage Urban Rural Total
No. (Rate) No. (Rate) No. (Rate)
Abortion 40 (150.38) 37 (93.20) 77 (116.14)
Still births 3 (11.28) 6 (15.11) 9 (13.57)
M.T.P. 17 (63.91) 14 (35.26) 31 (46.76)
Total 69 (225.57) 57 (143.57) 117 (176.47)

Rate per 1000 live births

Pregnancy wastage occurred due to medical termination of pregnancy, abortion and still births. Total pregnancy wastage rate was 176.47 per 1000 live births. It was 1.57 times more in urban area (225.57) than in rural area (143.58). The pregnancy wastage due to abortion was maximum (116.14) followed by MTP (Medical termination of pregnancy - 46.76) and still births (13.57). Rates for MTP and abortion were more in urban area (63.91) and (150.38) than in rural area (35.26) and (93.20) respectively. Rate for still births was more in rural area (15.11) as compared to urban area (11.28).

Table IV: Contraceptive practice profile.

Cause Urban Rural Total
No. % No. % No. %
Reproductive couples (RCs) 1776 (50.6) 1734 (49.4) 3510 (100)
RCs/1000 population 174.80 171.68 173.25
Couples protected 858 (48.31) 701 (40.43) 1559 (44.41)
Contraceptive practice
Permanent 631 (35.53) 627 (36.16) 1258 (35.84)
Reversible 227 (12.78) 74 (4.27) 301 (8.57)
Natural/rhythm 70 (3.94) 27 (1.56) 97 (2.76)
Not practiced 848 (47.75) 1006 (58.01) 1854 (52.82)
Interval in last two pregnancies
>3 years 400 (22.52) 299 (17.24) 699 (19.91)
<3 years 927 (52.20) 871 (50.23) 1798 (51.22)
Not possible 449 (25.28) 564 (32.53) 1013 (28.86)
First pregnancy 278 (25.65) 271 (15.63) 549 (15.64)
No issue 68 (3.83) 91 (5.25) 159 (4.53)
Newly wed 103 (5.80) 202 (11.65) 305 (8.69)

Out of total 3510 couples, 1951(55.58%) couples did not practice any contraceptive. It included 97(2.76%) couples who believed in natural or rhythm method of contraception. Total couple protection rate (CPR) was 48.31% in urban area while it was 40.43% in rural area. 52.82% couples did not practice any method while 35.84% used permanent method followed by reversible method (8.57%) and natural/rhythm method (2.76%). Couple protection rate was 41.99% in rural area while it was 52.25% in urban area. It was statistically significant (p<0.05 - including natural method). The use of permanent method was little more (36.16%) in rural area as compared to urban area (35.53%). Use of reversible method was three times more in urban area (12.78%) than rural area (4.27%). The use of natural/rhythm method was also higher in urban area (3.94%) than in rural area (1.56%).

The information about interval between last two pregnancies was possible in 2497(71.14%) couples. Among 72.01% couples, this interval was less than three years. Interval of more than 3 years was in 22.52% couples in urban and 17.24% in rural area while interval less than 3 years was 52.2% in urban and 50.23% in rural area.

Table V: Contraceptive practice profile in families with under five deaths.

  No(%) (%) No(%) (%) Total No (%)
Contraceptive practice
Permanent 3 (10.71) 6 (25.00) 9 (17.31)
Reversible -   1 (4.17) 1 (1.92)
Not practiced 25 (89.29) 17 (70.83) 42 (80.77)
Interval in last two pregnancies
>3 years 22 (78.57) 15 (62.50) 37 (71.15)
baby born died so not possible 3 (10.71) 3 (12.50) 6 (11.54)

Out of 52 couples (Parents of 52 deceased under fives), 19.23% were using contraceptives. They were 29.17% in rural and 10.71% in urban area. Out of these no one was using reversible method in urban area while 4.17% i.e. only one couple in rural area was using reversible method. 89.29% couples in urban area were not practicing any method as compared to 70.83% couples in rural area. Total 80.77% couples were not using any method of contraception.

Among 17.31% couples the interval between last two pregnancies was more than 3 years while in 71.15%, the interval was less than 3 years. The interval of more than 3 years was more in rural couples (25%) than in urban couples (10.71%). The interval of less than 3 years was more in urban couples (78.57%) than in rural couples (62.50%).

Table VI: Comparison of contraceptive practices in couples with and without underfive deaths.

Cause Absent No(%) Underfive deaths
Present No.(%) Relative ratio
Present/Absent
Contraceptive practice
Permanent 1249 (36.12) 9 (17.31) 0.48
Reversible 300 (08.67) 1 (01.92) 0.22
Not practiced 1909 (55.20) 42 (80.77) 1.46
Interval in last two pregnancies
>3 years 690 (28.15) 9 (19.57) 0.70
<3 years 1761 (71.85) 37 (80.43) 1.12

Among the couples with under five deaths, 19.23% were using contraceptive method as compared to 44.8% couples without under five deaths (p<0.05). 36.12% and 8.67% couples without under five deaths were using permanent method and reversible methods as compared to 17.31% and 1.92% couples with under five deaths respectively.

The interval of more than 3 years between last two pregnancies was present in more couples without under five deaths (28.15%) than in couples with under five deaths (19.57%). The interval of less than 3 years was in 80.43% couples with under five deaths while it was 71.85% in couples without under five deaths.

Discussion:

Computed under five mortality rate in rural and urban Ahmedabad in the present study was 60.45 and 105.26 per 1000 live births. In different studies, it was found that U5MR is more in rural areas than in urban areas5. In India and in Gujarat, for the year 1994, rural U5MR is more than urban rate5. Reason may be gradual change in urban area, due to establishment of more slums in cities. In these slums most of the people come from rural areas in search of jobs6. These slums are in every respect similar to rural areas. They are plagued with high mortality, high morbidity, low socio-economic conditions, illiteracy, overcrowding, bad environmental sanitation and high fertility status7.

Sex-wise distribution of U5MR is more among males (87.32) than females (68.18). In India and Gujarat (1993) the rate was more in females8. In our study, it may be due to the fact that equal attention now a days is given to both sexes. The causes of mortality in urban and rural area in our study are well compared with causes in rural and urban India and Gujarat5 for the year 19939.

Pregnancy wastage of 176.47 in our study, is well compared with that for India and Gujarat for 19934. Pregnancy wastage in our study was due to abortion, followed by MTP and still births. Total pregnancy wastage rate for abortion and MTP were more in urban Ahmedabad; while still birth rate was more in rural area. These findings are well matched with findings for India and Gujarat for 199310.

Couple protection rate (CPR) was 44.41% in district Ahmedabad; more in urban (48.31%) than in rural area (40.43%) (p<0.05). Use of various methods was highest for permanent method (35.84%) followed by reversible method (8.57%) and natural rhythm method. Same pattern was seen in India and Gujarat for 1992-934.

Area-wise distribution of use of FP measures in our study showed that use of permanent method was little more in rural area (36.16%) than in urban area (35.53%). For the year 1992-93 in India and Gujarat the use of permanent method was double in rural than in urban area. It may be due to intensive target oriented approach in rural area and more emphasis given to permanent methods in National Family Planning Programme4. In our study, it was observed that use of reversible method and natural rhythm method was three times in urban area than in rural area. But for India and Gujarat for the year 1992-93 use of IUCD was three times in rural area than in urban area.

Likewise use of the oral contraceptive and conventional contraceptive was more in rural area4. In our study in urban Ahmedabad 22.52% couples had pregnancy interval more than 3 years as compared to 17.24% in rural Ahmedabad. For India (1990), it was 30.2% for urban couples and 28.5% for rural couples. But for the year 1992-93 it was more in rural couples than in urban couples4. In our study, the results may have been influenced by less sample size but gradual change in favour of rural couples was seen.

Contrary to the findings of total couples, among couples with U5 deaths, CPR, percentage of couples with pregnancy interval more than 3 years and percentage of couples using permanent method were two times in rural area than in urban area. These findings matched with findings of total couples for India and Gujarat (1992-93). In our study CPR and pregnancy interval may have been affected due to availability of FP services even to very low socio-economic group4.

In the present study, when FP status was compared in couples with and without U5 death, it was observed that CPR and percentage of couples with pregnancy interval more than 3 years were more in couples without U5 death (44.79% and 28.15%) as compared to couples with U5 deaths (19.23% and 19.57%) (p<0.05) and well compared with other findings11.

In our study, U5 mortality and FP status had inverse relationship. It has been known that infant and child mortality and birth rate (BR) are directly related and BR in turn dependent on CPR11. Other factors like low age at marriage, universal marriage, low socio-economic conditions and low female literacy rate are also related to BR, so also related to low CPR.

Conclusion:

In our study, U5MR and CPR were more in urban area. Use of permanent method was more in rural area but use of reversible method was little more in urban area. Amongst couples with U5 deaths, CPR and percentage of couples with pregnancy interval more than 3 years were more in rural area. Comparison showed that CPR and percentage of couples with pregnancy interval more than 3 years were more among couples without U5 deaths.

Recommendations:

  1. Health services in urban areas should be improved.
  2. Health programmes related to communicable diseases should be strengthened.
  3. Urban FP programme should be strengthened.
  4. More emphasis should be given to urban slums.
  5. In rural area female literacy should be improved so that community participation can be encouraged in FP programme and manpower can be diverted to urban slums.

Acknowledgement:

We are thankful to Commissionerate of Health, Medical Services & Medical Education and Research for financing our project.

References:

  1. James P. Grant (UNICEF): The state of World's children, 1993: 1.
  2. Park J.E.: Text book of P.S.M., Banarsidas Bhanot Publication, 1997: 20.
  3. Hobcraft J: Does FP save children's lives? Technical background paper prepared for 'The international conference on better health for women and children through FP' Nairobi, Kenya, October 1987.
  4. Year book: Family planning programme in India, Ministry of Health and Family Welfare, Deptt of Family Welfare, GOI, India 1992-93: 133-90.
  5. Survey of causes of death (Rural) India: Annual Report, Published by Vital Statistics division, Office of Registrar General India, Ministry of Home affairs, New Delhi 1994: series 3,No. 27: 15-25.
  6. 'The urban health challenge': Nutrition, NIN, ICMR publication, July 1996, Vol. 30, No. 3: 3-18.
  7. 'New Reproductive Health Focus' Population Report, Series J No.45, Vol. XXIV, No. 3: 7-9.
  8. Publication of Foundation for Research in Health System (FHRS) 'Health Monitor' 1995: 84.
  9. FHRS publication 'Health Monitor' 1993: 16.
  10. FHRS publication 'Health Monitor' 1994: 139.
  11. "Health Benefits of FP" Publication of FP and Population Division of Family Health, WHO, 1995: 1-27.
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