By Leith Greenslade, Co-Chair, Child Health, MDG Health Alliance
Behind every preventable child death is a disempowered mother.
And it is no coincidence that most of the 6.6 million deaths of children under age 5 each year occur in countries with the greatest concentrations of disempowered mothers – India, Nigeria, Democratic Republic of Congo, Pakistan and Ethiopia.
One in every two child deaths occurs to mothers in these countries.
One in every five occurs to mothers in India.
India loses more children under 5 than any other country – an estimated 1,414,000 in 2012.
The causes are well known. 600,000 child deaths occur in the first month of life with prematurity, complications during delivery and infection the leading causes. Next come pneumonia and diarrhea, which together cause another 440,000 deaths. Measles and injuries cause 100,000. Alarmingly, malnutrition is an underlying cause of more than half of all child deaths in India.
The location of these deaths is also well known. Sixty percent of all child deaths occur in just four large northern States in India – Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan.
What is less well known is that these deaths are not randomly distributed. A large body of literature shows that among vulnerable populations, a small minority of mothers experience the majority of child deaths.
The “Death Clustering” Effect
In a 1990 landmark study in rural Punjab, Monica Das Gupta found that 13 percent of mothers accounted for 62 percent of all child deaths. With so many of these mothers experiencing more than two child deaths, she called this phenomenon “the death clustering effect.” Other studies have documented a similar pattern in countries in Africa, Latin America and South Asia, even dating back to the 1800s in western Europe. In northern Nigeria, studies in 2010 found that 20 percent of households accounted for 80 percent of the deaths under age 5.
Das Gupta argued that mothers who lost children differed most from their peers not in income or education, as you might expect, but in their capabilities as mothers. Keeping children healthy in societies where most episodes of sickness are handled within the home places a responsibility on mothers to (a) prevent sickness by properly feeding children and keeping them clean, (b) identify symptoms of serious illness and act quickly to treat, (c) know when and how to seek care outside the home, and (d) negotiate with health providers and complete treatment regimens.
Mothers were more likely to suffer multiple child deaths if they were constrained in these tasks due to ill-health, economic stress, lack of childcare, a large number of children, family violence, low levels of household autonomy, limited mobility or attitudes that restricted care seeking, such as resistance to modern healthcare or preference for sons.
This makes sense when you think about it.
Imagine a mother who has more than four children and no help in raising them; who is poor and uneducated like her neighbors, but who has little or no access to outside information and no autonomy within the household. It should be no surprise that not only are her children at greater risk of falling ill but when they do, it will be hard or impossible for her to get care for them.
India’s Child Survival Challenge
India needs to prevent the deaths of 1 million children by 2015 to achieve Millennium Development Goal (MDG) 4, which calls for reducing by two-thirds the under-5 child death rate globally.
If the literature on child death clustering is right, those 1 million children may belong to just 600,000 mothers.
With about 800 days to achieve MDG 4, what if the health and development community joined forces with the business community in India to put extra focus on those mothers? What if we decided that identifying them and surrounding them with the intensive support they need to raise healthy children is the best strategy for India to achieve its child survival goals?
We would be talking about a plan that prioritizes the most vulnerable mothers in Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan. We would be talking about investing heavily in educating and teaching these mothers how to have safe pregnancies and deliveries. We would be talking about empowering mothers in their own households by raising their incomes, providing access to childcare and working to change the attitudes towards mothers of more powerful family members. We would be rewarding mothers for seeking healthcare outside the home and for participating in mothers’ groups and community activities that provide support, information and power.
Das Gupta concludes that if health workers in her study had used the occurrence of a first child death as a marker for targeting interventions that were successful at preventing all further child deaths, child mortality would have fallen by 41 percent - which is exactly the reduction that India needs to achieve MDG 4.
The great movements for child survival today — including the UN Secretary-General’s “Every Woman Every Child” movement, the Government of India’s “Call to Action for Child Survival and Development” platform and the UN Commission on Life-Saving Commodities for Women and Children — should embrace strategies that target the mothers most at risk of losing a child, with a special focus on mothers who have already lost children. They should prioritize action in India because that is where 25 percent of global child deaths are concentrated. If they did so, India would achieve its child survival goals sooner and prevent so much family devastation and heartbreak.
What Role for Business?
But success won’t be possible without mobilizing the business community in India. It is, after all, corporations that make the vaccines, the zinc and oral rehydration salts, the antibiotics, the food and nutritional supplements, the soap and chlorhexidine and the toilets and household water systems that are essential to raising healthy children.
Further, it is businesses that are in constant communication with mothers through advertising on television, radio, mobile phones and newspapers. The more educated and informed a mother, the less likely her child is to die, so when businesses support campaigns that teach mothers how to raise healthy children, they are making a significant contribution to India’s child survival goals. And we should not forget that small businesses provide most of the healthcare to sick children in India because most vulnerable mothers turn to the vast networks of private medical practitioners, pharmacists and drug shops when they seek care for a sick child.
If we mobilized the leading Indian consumer goods, pharmaceutical, food and beverage and medical device companies to join forces with the advertising, marketing, media and mobile phone companies to reach the most vulnerable mothers with the affordable products, services and information they need to keep their children healthy, child deaths would fall sharply. And if at the same time governments and non-government organizations implemented programs that empowered these mothers, child mortality would fall even more sharply.
The 600,000 mothers in India most at risk of suffering the loss of children over the next two years deserve our attention now. They are in so many ways the most important mothers in the world.
The fate of 1 million children may rest in their hands.
Leith Greenslade is Co-Chair of Child Health at the MDG Health Alliance which works to accelerate global progress towards Millennium Development Goal 4: saving 3.5 million children’s lives by 2015. The Alliance operates in support of Every Woman, Every Child, an unprecedented movement spearheaded by the United Nations Secretary-General to intensify global action to improve the health of women and children.