PROFORMA OF VERBAL AUTOPSY

1. Serial no. :…………………

2. Age : …………………………

3. Sex: (a) male (b) female

4. Religion: (a)Hindu (b) Muslim (c) Christian (d) Others………

5. Mother’s Education: (a) Illiterate (b) Primary (c) Secondary

(d) Pre-university (e) Graduate (f) Post graduate (g) Others…………

6. Gestational age : (a)<37 wks (b)>37 wks

7. Birth weight : (a)<2.5 kg (b) >2.5 kg

8. Family type : (a) Nuclear (b) Joint (c) Three generation

9. Mother’s age at birth of child (years): …………………………

10. Education of head of family : (a) Illiterate (b) Primary (c) Secondary

(d) Pre-university (e) Graduate (f) Post graduate (g) Others………………..

11. Birth spacing : (a) <2yrs (b)>2yrs

12. Socioeconomic class : (a) class I (b)class II (c) class III (d) class IV (e)class V

13. ANC registration : (a) yes (b) no

14. Cause of death : ……………………

15. Period of death :………………………….

16. Parity of mother : (a) primi (b) multipara

17. Type of death : (a) neonatal (b) post-neonatal

18. Others : …………..

Review of Literature

Influence of demographic characteristics on infant mortality

Breast feeding

Breastfeeding claims to improve infant health due to three characteristics.

First, it is nutritious; it can provide all the nutritional requirements for an infant

up to six months. None of its substitutes is as rich or as complete as mother’s

milk. Second, breast milk provides immunity against infections. Third, breast

milk is clean and hygienic since the substances it includes prevents the growth of

bacteria.44

Given these properties the positive effects of breastfeeding on infant

health may depend on the age of the infant and the family’s socio-economic

status.

1. Mother’s milk as a nutrient: As the child grows older, mother’s milk does

not meet all the nutritious requirements of the infant. Also, in cases where

the substitutes for breastfeeding are limited, the importance of

breastfeeding increases.44

2. Breastfeeding to improve immunity: For infants with a greater risk of

being infected breastfeeding is more effective in improving health.

Breastfeeding prevents infants from drinking and eating infected water

and food.44
 3. Mother’s milk as a hygienic food: Breastfeeding has stronger effects

when there is a lack of hygiene. The harmful effects of insufficient water

and sanitation is less the longer breastfeeding lasts.45

4. Despite the lack of medical services and information breastfeeding is

more progressive for the health of the infant.44

The literature on the determining factors of infant mortality indicates a

positive relationship between the termination of breastfeeding and infant

mortality risk.46 Moreover, Jatrana finds the consumption of colostrums as the

most important factor effecting infant mortality in a less developed region of

India, Mewat.47 However, Wolfe and Behrman (1982) could not find a stable

relationship between breastfeeding and child health which they measure using

child mortality, standardized weight, standardized height and standardized biceps

circumference.48

Prenatal Care

Practical studies indicate that improved use of prenatal care results in

better health of infants. In the summing up of the effects of prenatal care

problems, similarities to those of breastfeeding appear. First, prenatal care may

be endogenous. If women who experience challenging pregnancies receive more

prenatal care, ignoring this may lead to an underestimation of the effect of

prenatal care on birth results. On the other hand if women who receive prenatal

care have strong inclinations for healthy children and practice other forms of

healthy behavior, the endogeneity problem may lead to a miscalculation of the

impact of prenatal care on birth outcome. The results of harmful selection are
found in the literature, which means women who are unhealthy start prenatal care

earlier.50 Rosenzweig and Schultz also claim that not taking into account

heterogeneity leads to an underestimation of the effect of prenatal care on the

birth weight of the infant.51 Birth weight is thought to be highly related with

infant mortality.52

In addition to the behavioral reasons, there may also be non-behavioral

reasons of overlooked weakness. This may appear when weakness causes fetal

wastage. Only the fetuses that are healthier will have a chance to survive later

stages of gestation. Thus prenatal care which starts in the later stages of gestation

may lead to lower infant mortality, since these fetuses will be healthier as they

have survived to that period of gestation. Also, the effects of prenatal care may be

underestimated if starting prenatal care earlier suggests unhealthy fetuses to be

born alive that otherwise would not.53

Some studies use TSLS method in order to deal with endogeneity

problem. TSLS involves an assessment of endogenous variables on variables

chosen to be used as a medium. In order to be a valid medium a variable has to be

compared with the endogenous descriptive variable and it also has to be

unconnected with the disregarded or unseen frailty. In the second stage of the

method the variable in question is regressed on exogenous variables as well as on

fitted values of endogenous variables obtained by the first stage regression. Using

data of poor women in Uruguay, Jewell and Triunfo find that advanced usage of

prenatal care will result in increased birth weight which in turn will increase child

health.54 Rosenzweig and Schultz, using US data, find that delay in prenatal care

considerably increases infant mortality risk.51

 Maitra51 and Rous et al.49 use a full-information maximum likelihood

inference approach not only to deal with endogeneity problem but also to control

for the potential biases of sample selection. Sample selection takes place when

the women who decide to give birth are not a random sample of pregnant women.

Rous et al. claims that, in the literature there is evidence of a greater incentive to

give birth rather than abort when the child is expected to be healthy. This is

known as positive fetal selection.49

Maitra (2004) assessed the demand for health inputs, prenatal care and

hospital delivery, and infant mortality jointly. By doing so, he accounts for

unmonitored endogeneity and self-selection. In this study, the demand for health

inputs is related to relative power of the parents. He states that bargaining

between parents cannot directly affect infant health but it affects the demand of

health inputs, which in turn affects child health. The results of the study imply

that a woman’s education has a greater effect on health care usage with respect to

that of her husband, and a woman’s control over resources has a marked positive

effect on demand for prenatal care.49

The second problem of guessing the impact of prenatal care is that the

duration of prenatal care is reduced by the duration of gestation. Prenatal care is

strongly related with the length of gestation duration. Provided that there are

omitted variables which affect infant mortality through gestation length, prenatal

care will be related with infant mortality. This will also be the case even though

there is no relationship between infant health and prenatal care. In this case,

ignoring the reduction problem will result in incorrect approximation of effect of

prenatal care.53
 Prenatal care is usually calculated as the month from which prenatal care

started. Jewell and Triunfu uses this to measure prenatal care.54 However Rous et

al. use the number of doctor visits as a measure of prenatal care, which is also a

usual way to measure.49 On the other hand, Maitra uses prenatal care as a double

variable, whether the women had access to prenatal care or not.50

Previous Birth Interval

Another variable that is accepted to be related to infant survival is the

interval between the previous birth and the next. It is generally thought that

longer birth intervals improve the survival chance of the following infant. 55 Short

preceding birth interval influences infant mortality through three mechanisms.

First, closely spaced births cause weakness in the mother. Second mechanism is

through sibling competition and the third is the movement of infectious diseases

between the closely spaced children.56

The first one is biological and the other two are behavioral effects of short

preceding birth interval. Maternal weakness occurs as a result of repeated and

closely spaced pregnancies. Closely spaced pregnancies do not give the mother

enough time to recover from the harmful physiologic and nutritional demands of

pregnancy.57 The child who is born in such a case suffers from low birth weight,

short duration of gestation and growth retardation.56 This mechanism is effective

in the early stages of life.57 Competition mechanism emerges due to the scarce

resources of the family, including maternal care which has to be divided between

the siblings who are closer in age. The significance of the effect competition on
child mortality changes as the child grows older and according to the level of

resources available to the family.44 The ease in which infectious disease afflicts

and the severity of infection in the families with higher number of children shows

in the third mechanism.57

The length of the preceding birth interval and infant mortality are highly

related. But it will be wrong to look at the effect of the duration of the preceding

birth interval unless the survival status of the previous child and duration of

breastfeeding is not controlled. Firstly, women who breastfeed their children for a

brief period are likely to have shorter birth intervals due to the shorter

suppressing effect of lactation on fertility. Since the children who are breastfed

for a shorter time are more likely to die, the relationship between the short

preceding birth interval and infant mortality may be unauthentic.58 Secondly,

with the death of a child breastfeeding is stopped, which gives way for

conception and shortens the birth interval. Or, replacement and hoaring effects

may be the reason of short birth interval after the death of a child. Strong intra

family relation states the death of the previous child is an indicator of the survival

of the index child, therefore this may also cause a false relation between

preceding birth interval and child mortality.

Studies differ in the way they define previous birth interval. Most of the

studies define it as the inter birth interval, some as inter conception interval, some

as birth to conception interval,51 and the others as average birth interval.57 These

definitions may result in different interval lengths, since premature births and

stillbirths are likely. If inter birth interval is used as a definition of previous birth

interval, a short interval may be the result of premature birth, while a long
interval may involve miscarriage or stillbirth. The problem of premature birth

may be handled by avoiding intervals shorter than nine months; however

miscarriage and stillbirth are difficult to identify. This would be a problem if

miscarriage and stillbirth are related to infant mortality. Ignoring miscarriage and

stillbirth may result in underestimating the effect of preceding birth interval on

infant mortality.55

The literature on the reasons of infant mortality also differentiates by the

way researchers treat the preceding birth interval of the first child, who is not

preceded by any birth. In their article Olsen and Wolpin (1983) take the length of

preceding birth interval as zero and claim that the effect of average preceding

birth interval (effect of previous birth interval times average birth interval) should

be added to the effect of being the first child.59 On the other hand, in order to

evaluate the impact of the previous birth interval on infant mortality some studies

choose to leave out first births from the data used.56,57 Some studies take the first

births as if they are in the most favorable group, the group with the longest

previous birth interval.44 One other possibility is to program a set of dummy

variables for the previous birth intervals and first birth.46

Succeeding Birth Interval

Short subsequent birth interval is found to influence child survival

harmfully in various studies. Explanations about the ways it affects child

mortality are similar to those given for the short previous birth intervals except

maternal weakness.
 In their article Bhalotra and van Soest mention a problem named death

trap. Death trap occurs when the death of a child shortens the interval to the next

birth and shorter previous birth interval increases the mortality risk of the next

child. They find the evidence of death trap in the raw data of India.55 They also

claim that the interference to reduce child mortality or lengthen birth interval

would have increasing effects on infant mortality, since these would also affect

birth spacing and fertility and indirectly infant mortality again. Instead of the

subsequent interval length59 they used number of living children in the family by

age. They also included the number of rooms in the house. These variables were

included in order to measure the disease environment. They removed number of

rooms and children in the house and instead included source of water used by the

family to the analysis in this study as an alternative for the environment where

the child grows up.

Maternal Age at Birth

The impact of maternal age at birth draws attention of many researchers

studying reasons of infant and child mortality. General notion is that; negative

effect of teen maternity on infant mortality is related to reproductive immaturity

of mother. Most of the studies explore a curved relationship between the maternal

age at birth and infant mortality, high risks of infant mortality at very young and

old ages.50,55

The impact of maternal age at birth on infant mortality can be understood

as a biological impact only if all the inputs and child specific frailty endowment

are controlled.53 Otherwise, the effect will include the impact of other behavioral
and non-behavioral factors that influence both infant mortality and maternal age

at birth. This is because women who bear a child at a very young age mostly are

not randomly selected from a population of mothers. Adolescent mothers usually

come from a socioeconomically backward group.

Maitra and Pal (2007) claim that teenage mothers are more likely to be

drop-outs from school, not have steady jobs and have financial problems. They

find that adolescent mothers use health inputs differently from other women.

Also they themselves select health inputs. Ignoring the self-selection prejudice

they approximate the effects of early child bearing on infant mortality. After

removing the unmonitored heterogeneity the harmful effect of teenage maternity

disappears. If adolescent mothers’ are provided adequate health input the

negative impact of early child bearing can be reduced.60

Mother’s Education Level

Maternal education is an important factor of infant and child mortality and

is mostly used as a substitute for socio-economic status of mother. Less educated

mothers are found to experience higher child mortality.46

There are several reasons given as to how which maternal education

influences child health. More educated women adopt simple health knowledge

rather than accept negative health outcomes; they adopt alternatives in child care

and recent treatments. They can feed their children and practice child care better.

Educated women are more capable of handling the modern world.

Communication with doctors and nurses is easier for educated women. Educated
women may change the traditional balance of family relationships. In different

countries education impacts child health differently.61

Also educated mothers may use health inputs more productively and

effectively, may have better information of best usage of health inputs, may have

more family resources as a result of marrying wealthier men or working outside,

and may have different preferences for child health. All these may improve child

health. However more educated women may allocate more value to their time and

may spend less time with their children, which would lead to poorer infant

health.62

In another study conducted by Hobcraft, the survival chances of children

born to educated mothers are maintained to be greater due to several demographic

reasons. Educated mothers tend to marry and have children later and/or have

fewer children; therefore the extra risk of infant mortality for teenage mothers is

reduced. Also educated mothers experience lower maternal mortality and per

birth maternal mortality because of greater usage of health services, avoiding

risky pregnancies and/or experiencing fewer pregnancies. Also, children without

mothers are less likely to survive.63

The results of this study conducted by Hobcraft means that net effect of

maternal education after controlling other socioeconomic variables are very

similar to its gross effect. Despite this, the influence of maternal education on

infant health is found to be weak in sub-Saharan African countries in several

studies that Hobcraft has discussed. In an attempt to explain this result he has

several suggestions. Firstly, the greater independence of women in sub-Saharan

Africa than in many Asian and Muslim societies may lead to an ineffective

relation. Secondly, interaction of traditional practices with maternal education

may result in higher infant survival rates of mothers with no education than

mothers with a few years of education. Thirdly, weak health infrastructure in sub-

Saharan Africa may prevent more educated mothers to take advantage of their

knowledge; there may be a maximum limit of social development to benefit from

education level.63

Education of the mother is claimed to impact the survival chances of

children also beyond the first year of life. Longer breastfeeding durations used by

educated mothers may lead to this long lasting effect.63

Impact of child health will also influence the fertility decision of parents.

To explain the effect of education of a mother on infant health; firstly, the

probability of giving birth and then the effect of the education on mortality,

uncertainty on being born has to be estimated. Maternal education may influence

infant health directly and indirectly through fertility, since education of the

mother is found to reduce fertility.55

Maternal education may be prejudiced if change in education level causes

changes in the share of fertility of the children with different natural healthiness.

If rise in education decreases the fertility of the infants which have weaker

natural healthiness proportionately, ignoring the fertility selection may lead to

overestimation of the education effect. On the other hand, if the number of

healthier infants born reduces more than the other infants, the impact of maternal

education will be underestimated. Results of the study indicate underestimation

of fertility selection and maternal education on infant health in 11 of the

countries. However the bias is small probably because of high fertility rates of

sub-Saharan Africa.64

Gender

Gender is an exogenous variable except in the case of selective abortion.

Including all the inputs in case of relationship between the inputs and gender of

the baby, will lead to effects of gender to be only biological.51 Relation between

inputs and gender will be the case if families have preferences for the survival of

boys vs. girls, and differentiate the blend of inputs after being aware of the sex of

the child.

Rosenzweig and Schultz have a different point of view. They study the

factors of sex-specific discrepancies of survival rates of rural India, other than

biological effects. They propose that the more economically fruitful is a gender

the more resources are assigned to him/her and therefore the survival chance of

that gender is higher. The female employment rate is used as a substitute for the

probable contribution of girls, and a rise in the female employment rate decreases

survival discrepancies in favour of girls. An increase of 37% employment rate of

females would remove the difference in the survival rates of girls and boys.

Another interesting finding of the study is; increase in the wealth level is

the other variable to improve survival of girls vis-a vis boys.51

Income
 Income or financial resources available to a family, does not have an

impact over infant mortality directly. Income may affect infants’ health through

the inputs available to the family. Therefore the only way it can influence infant

health is through the absent variables in the model or the relation of income with

the unmonitored frailty.53

In an attempt to guess the effects of health inputs on a health mix, health

equations are formed, which include one or two health inputs and prices and

income variables, because of the data curbs on health inputs.51 However, such a

mixed model described is hard to interpret. Change in use of some health inputs

will have impact on other behavior through changing economic resources left for

other inputs. Therefore the impact of health inputs will not reflect only their own

effect; they will include the effects of other behaviors that change.53

Income that is included in infant health equation does not always refer to

income at household level. Some studies include income per capita in order to

determine the facts causing differences in child survival. Factors measuring

structural rather than individual situation, such as the extent of family support or

income inequality, are usually not found to exercise any impact due to lack of

variation in these factors in one country and at a point in time. To study the

probable effects of income per capita time series analysis or cross-country

studies, or combinations of these methods are used.65

For example improvement in nutrition, which is stated as one of the most

important explanatory variables to pull down infant mortality, is associated with

income growth.66
 It is found that not only the level of income but also income distribution

effect infant mortality. Countries with more equal income distribution experience

lower infant mortality rates than the countries with similar per capita income

levels but unequal distribution. Infant mortality is mostly a concern among poor

people because children and infants are very vulnerable to bad living conditions.

Hence, increase in inequality cause the poor to be poorer, which results in

increasing infant mortality.65

Another remarkable claim made by Waldmann is that, increase in income

share going to the richest 5 percent of the country increases infant mortality even

after holding the income going to the poor constant. Probable explanations of this

result are possibility of a larger fraction of babies are born to poor families in the

countries with a high rich share, governmental policies that affect both the infant

mortality and rich share, and unclear preferences and judgment of the poor by

large rich share.67

Public Policy

Infant mortality is considered to be a sign of deprivation that is used to

measure the development levels of societies.68 Therefore, it is of great importance

to reduce infant mortality rate. This is the reason why child health is one of the

central issues of public policy on health in developing countries, where infant

mortality is a concern.

Increasing income per capita does not solely improve infant mortality,

other factors and policies have to be taken into consideration. Examples of poor
countries that has a better performance of infant mortality than middle income

countries proves this.69

Wang in his study conducted for both national level and separately for

rural and urban level determinants of infant and child mortality finds that, besides

income per capita access to electricity, vaccination in the first year of infants’

lives, public per capita health expenditure, and access to piped water and

sanitation are considerable at national level in decreasing child mortality. These

results alter some when considered separately for rural and urban areas. Access to

electricity becomes the most major determinant in urban areas whereas in rural

areas vaccination is the only major factor.70

The link between the Sudden Infant Death Syndrome (SIDS) and smoking

is claimed to be forceful by Markowitz. Postnatal smoking by mother and other

household members besides prenatal smoking is tied to SIDS. Therefore any

effort to decrease cigarette consumption is expected to decrease infant mortality.

In the article it is found that strict policies on smoking decreases SIDS. The most

significant policy effecting infant mortality is taxation of cigarettes. Also

restrictions on smoking in public areas lead to a leading decline in infant

mortality.71

Result

Verbal autopsy

Table 8. Distribution of infants according to their religion

 Distribution (n=20)
Religion
Number Percentage

Hindu 14 70

Buddhism 6 30

Total 20 100.00

Graph 8. Distribution of infants according to their

religion

30.00%

70%

Hindu Busshism

In this study most of the infant deaths were seen among Hindus (70%). In

the remaining 30% the infants belonged to the Buddhism community.

Table 9. Distribution of mothers according to age at delivery

Distribution (n=20)
Age group (Years)
Number Percentage

16-22 10 50
 23-26 7 35

27-30 3 15

>30 0 0

Total 20 100.00

Graph 9. Distribution of mothers according to age at

delivery

60%
50.00%
50%
Distribution (%)

40% 35.00%

30%

20% 15.00%

10%
0.00%
0%
16 to 22 23 to 26 27 to 30 >30
Age group (Years)

In this study, most of the mothers whose infants died were aged 16 to 22

years (50%) followed by 23 to 26 years (35%).

Table 10. Distribution of mothers according to educational status

Distribution (n=20)
Education
Number Percentage

Primary 8 40

Secondary 5 25
 Graduate 0 0

Pre-university 0 0

Others 2 10

Illiterate 4 20

Total 20 100.00

Graph 10. Distribution of mothers according to

educational status

45% 40.00%
40%
35%
Distribution (%)

30% 25.00%
25% 20.00%
20%
15% 10.00%
10%
5% 0.00% 0.00%
0%
Secondary

Graduate

Pre-university

Others

Illiterate
Primary

Education

In the present study 40% of the infants who died were born to mothers’

with primary education and 25% to mothers with secondary education.

Table 11. Distribution of head of family according to educational status

Distribution (n=20)
Education
Number Percentage

Primary 4 20

Secondary 7 35
 Graduate 2 10

Pre-university 0 0

Others 4 20

Post graduate 0 0

Illiterate 3 15

Total 20 100.00

Graph 11. Distribution of head of family according to

educational status

40%
35.00%
35%
30%
Distribution (%)

25%
20.00% 20.00%
20%
15.00%
15%
10.00%
10%
5%
0.00% 0.00%
0%
Secondary

Graduate

Pre-university

Others
Primary

Illiterate
Post graduate

Education

In this study, most of the family heads (35%) studied upto Seconday and

20% upto Primary. 10% did Graduate, management and teachers’ training

courses. 20% were Others.

Table 12. Distribution of families according to socio economic class

Distribution (n=20)
Socio economic class
Number Percentage

I 5 25
 II 6 30

III 2 10

IV 4 20

V 3 15

Total 20 100.00

Graph 12. Distribution of families according to socio

economic class

35%
30.00%
30%
25.00%
25%
Distribution (%)

20.00%
20%
15.00%
15%
10.00%
10%

5%

0%
I II III IV V

Socio economic class

In the present study 30 % infants belonged to Class II socio economic

group according to modified B. G. Prasad’s classification. Class IV socio

economic strata was noted in 20%, Class I in 25% and 20% belonged to Class IV.

However 10% of infants belonged to Class III socioeconomic strata.

Table 13. Distribution of mothers according to ANC registration

Distribution (n=20)
Registration
Number Percentage
 Yes 20 100

No 0 0

Total 20 100.00

Graph 13. Distribution of mothers according to ANC

registration

0.00%

100.00%

Yes No

In this study 100% mothers of infants who died were registered for

antenatal care whereas 0% did not register for antenatal care.

Table 14. Distribution of families according to the type

Distribution (n=20)
Type
Number Percentage
 Joint 14 70

Nuclear 6 30

Total 20 100.00

Graph 14. Distribution of families according to the

type

30.00%

70.00%

Joint Nuclear

In the present study 70% of infants who died belonged to the joint family

system whereas 30% infants were from nuclear families.

Table 15. Distribution of mother according to the parity

Distribution (n=20)
Parity
Number Percentage
 Primi 14 70

Multi 6 30

Total 20 100.00

Graph 15. Distribution of mother according to the

parity

30.00%

70.00%

Primi Multi

In this study 70% mothers whose infant died had primi para whereas 30%

mothers were multiparous.

Table 16. Distribution of mothers according to the birth spacing

Distribution (n=20)
Birth spacing
Number Percentage
 < 2 years 16 60

More than 2 years 8 40

Total 20 100.00

Graph 16. Distribution of mothers according to the

birth spacing

4.00%

60.00%

< 2 years > 2 years

In the present study 60% infant who died had birth spacing of less than

two years whereas 40% babies had more than two years.

Table 17. Distribution of infants according to type of death

Distribution (n=20)
Type
Number Percentage
 Neonatal 13 65

Post natal 7 35

Total 20 100.00

Graph 17. Distribution of infants according to type of

death

35.00%

65.00%

Neonatal Postnatal

In the present study 65% were neonatal deaths and 35% were postnatal

deaths.

Table 18. Distribution of infants according to age

Distribution (n=20)
Age
Number Percentage
 Upto 1 day 9 45

2 to 3 days 2 10

4 to 7 days 3 15

8 to 28 days 2 10

29 days to 1 years 4 20

Total 20 100.00

Graph 18. Distribution of infants according to age

50%
45.00%
45%
40%
35%
Distribution (%)

30%
25%
20.00%
20%
15.00%
15%
10.00% 10.00%
10%
5%
0%
Upto 1 dya 2 to 3 days 4 to 7 days 8 to 28 days 29 days to 1 year

Age

In this study most of the deaths (45%) were recorded within a day from

the birth followed by 20% between 29 days to 1 year.

Table 19. Distribution of infants according to sex

Sex Distribution (n=20)

 Number Percentage

Male 14 70

Female 6 30

Total 20 100.00

Graph 19. Distribution of infants according to sex

30.00%

70.00%

Male Female

In the present study infant mortality was high among male babies (70%)

as compared to female babies (30%).

Table 20. Distribution of infants according to place of death

Distribution (n=20)
Place
Number Percentage
 Hospital 17 85

Home 3 15

Total 20 100.00

Graph 20. Distribution of infants according to place of

death

15.00%

85.00%

Hospital Home

In this study majority of the infant deaths occurred in hospital (85%) and

the remaining at home (15%).

Table 21. Distribution of infants according to cause of death

Distribution (n=68)
Causes
Number Percentage
 Premature 3 15

Low birth weight 2 10

Diarrhoea 1 5

Birth asphyxia 4 20

Pneumonia 2 10

Septicemia 8 40

Total 20 100.00
 Graph 21. Distribution of infants according to cause
Causes
of death

Septicemia 40.00%

Pneumonia 10.00%

Birth asphyxia 20.00%

Diarrhoea 5.00%

Low birth weight 10.00%

Premature 15.00%

0% 10% 20% 30% 40% 50%

Distribution (%)

In the present study the most common cause of infant death was

septicemia (40%), birth asphyxia (20%) followed by prematurity (15%),low birth

weight (10%), , pneumonia (10%), Diarrhoea (5%).

Discussion

VERBAL AUTOPSY

In the present study, to enhance the record based information, primary

information regarding the causes of infant death was gathered by interviewing

32% of the mothers whose infants had died from Dhulikhel Municipali Ward no

6,7,9 and 10.

Demographic characteristics

In this study most of the Population were Hindus so infant deaths were

seen among Hindus (70%) and the Buddhism community (30%).

Maternal age

Most of the mothers whose infants died were aged 18 to 22 years

(64.71%) followed by 23 to 26 years (32.35%). The infant mortality statistics

from USA by CDC82 showed that, infant mortality rates vary with maternal age.

In 2008, infants of teenage mothers (9.59) and mothers aged 40 and over (8.07)

had the highest mortality rates. The lowest rates were for infants of mothers in

their late 20s and early 30s. Teenage pregnancy and motherhood burdens the girl,

who is not fully mature and therefore is not capable of enduring the nutritional

and metabolic stresses of these events, thereby affecting infant survival largely.

In a study74 from Bhavnagar among 15% cases, Mother’s age at birth of deceased

child was <20 years and in 6.25% cases, it was ≥30 years. Another study from

India,81 shows distribution of deliveries by age of mother displayed a sharp

increase in perinatal mortality rate (77.3%) from the age group below 20 years.
Educational status

In the present study 35.29% of the infants who died were born to a mother

with a primary education and 26.47% to mothers with a secondary education.

Most of the family heads (30.88%) studied upto primary and 26.47% upto pre-

university. 16.18% did a diploma, management and teachers’ training course and

13.24% were graduates.

In a study73 from Pakistan among factors affecting morbidity, 65 (43.3%)

fathers were literate while 85(56.7%) illiterate; 33(22%) mothers were literate

while 117(78%) illiterate. In another study78 from Gujarat characteristics of head

of family showed 44.8% were illiterate, while education up to primary and higher

secondary & above in 40.6% and 14.6% respectively.

Socio economic status

In the present study 30.88% infants belonged to Class III socio economic

group according to a modified B. G. Prasad’s classification.75,83 Class IV socio

economic strata was noted in 26.47%, Class II in 23.53% and 14.71% belonged

to Class I. However 4.41% of infants belonged to Class V socioeconomic strata.

In a study73 from Pakistan family income in 61.3% was <5000 Pakistani

Rupees/month and >5,000 in 58(38.7%). A study74 from Gujarat based on

Kuppuswamy’s socioeconomic classification, 61.5% from upper lower social

class (class IV), while the rest (38.5%) were from the lower (class V) which was

similar to various other studies.82,94

Type of family
 In the present study 66.18% of infants who died belonged to the joint

family system whereas 33.82% infants were from a nuclear family. In a similar

study78 from Gujarat based on family type, it was found that majority (51.0%) of

the families was of Joint type, 34.4% families was Nuclear and 14.6% was of the

Three-generation type.

Antenatal indicators

Parity

In this study 55.88% of the mothers whose infant had died had primi para

whereas 44.12% of the mothers were multiparous. A study74 from Gujarat

reported maximum deaths (38.5%) in first parity. Similar findings reported in

another study from India and a study done in Nepal which showed highest

mortality among primiparous women. CDC report from USA in 2008 showed

that, higher parities and, therefore, the highest-order births (fifth child and higher)

are more likely to be linked with older maternal age, multiple births, and lower

socioeconomic status.

Birth spacing

In the present study 57.89% of the infants who died had birth spacing of

less than two years whereas 42.11% babies had more than two years. Infant

mortality rates were normally higher for first births than for second births, and

then usually increased as birth order increased. A similar study73 from Pakistan

reported 50.7% had 1-2 years birth spacing and 30% more than 2 years. In a

study74 from Gujarat regarding birth spacing and infant deaths it was found that
53.7% of the deaths were among babies born with a spacing of less than 2 years

which was comparable with NFHS 381 showing 65.7% mortality in birth spacing

less than 2 years. Studies from different regions also revealed similar findings.

Antenatal care

In this study 66.18% mothers of infants who died were registered for

antenatal care whereas 33.82% were not registered. Almost one third of the

women did not receive ANC care during pregnancy. Health related activities of

women especially during pregnancy plays an important role in the health of the newborn.

Important factors for reduction in infant mortality may be: a wider coverage area for

ante-natal care, iron folic supplements and tetanus toxoid vaccine provided under the

RCH programme.

Infant characteristics

In the present study 72.06% were neonatal deaths and 27.94% were

postnatal deaths. Infant mortality was high among male babies (66.18%) as

compared to females (33.82%). Most of the deaths (48.53%) were recorded

within a day from the birth followed by 20.59% between 29 days to 1 year.

A study from Gujarat reported constant prevalence of male deaths

(57.3%) in overall infancy as compared to females (42.7%). A study done in an

urban slum of Tamil Nadu also shows 54.7% male and 45.3% female infant

deaths. Another study in which 53% infant deaths in female and 47% deaths in

male infants showed a reversal as compared to our study. Considering NFHS-3

data as a whole, it is seen that IMR is marginally higher in females (58%) than

males (56%). However, in the neonatal period, like elsewhere, mortality in India

is lower in female (37%) than male (41%) which corresponds to our study.78 As

children get older, females are exposed to higher mortality than males in the post

neonatal period which was also revealed in a study from Gujarat. It showed

26.8% females died in postnatal period whereas only 21.9% in case of infant

males. In another study from Aligarh, on infant deaths, about 60% were in the

neonatal period whereas 40% died in the post-neonatal age group. The neonatal,

post neonatal and infant mortality rates were 49.4, 33.6 and 83.0 per thousand

live births respectively. There were more female deaths in the neonatal and post-

neonatal age groups.

Majority of the infant deaths occurred in hospital (82.35%) and the

remaining at home (17.65%). The majority of deaths in hospital could be ascribed

to delayed care due to which lives could not be saved.

Causes of death

In the present study the most common cause of infant death was birth

asphyxia (29.41%) followed by septicemia (17.65%), low birth weight (16.18%),

prematurity (11.76%), pneumonia (8.82%), heart disease (5.88%), diarrhoea

(4.41%), jaundice (2.94%), congenital defects and tuberculosis (1.47% each).

Data assessed in London in the year 200073 from 44 countries with vital

registration (96,797 neonatal deaths) and from 56 studies (29 countries, 13 685

neonatal deaths) met inclusion criterias. The distribution of reported causes of

death varied significantly between countries and across studies. Based on 193
countries, the major causes of neonatal death globally was said to be infections

(sepsis/pneumonia, tetanus, and diarrhoea, 35%), preterm birth (28%), and

asphyxia (23%). The study also mentioned the importance of regional variation

and substantial uncertainty surrounding these estimates. Using different

approaches, deaths in the year 2000 have been estimated at 220000 for neonatal

tetanus, at 940000 for asphyxia, and at 1.33 million for prematurity, although the

latter includes deaths attributed to preterm birth up to the age of 5 years.

In a study from Aligarh, the major causes of deaths during the neonatal

period were birth asphyxia (40.9%), prematurity (including LBW) (27.27%).

Pneumonia, diarrhoea, tetanus, neonatal sepsis, neonatal jaundice and congenital

malformation were the other causes of neonatal deaths (4.55% each). In the post-

neonatal period, the main causes of mortality were diarrhoea and pneumonia

(80%). In a study on the use of verbal autopsy by health workers in under-five

children, authors found birth asphyxia, prematurity, low birth weight and

septicemia as the main cause of death in the neonatal period. Another study100

also reported that the neonatal deaths were mainly due to perinatal asphyxia,

prematurity and aspiration pneumonia or acute respiratory distress. The findings

of the present study with respect to causes of neonatal deaths are in accordance

with these reports and others.

In a study from Delhi 143 deaths occurred among under-five-children in

the CRHSP population during 2008 of which, 65 deaths occurred in the neonatal

period (0-28 days); 60% of these deaths in the early neonatal period (0-7 days).

78 deaths occurred in the period from 29-days to <5 years; 58% of these deaths

were between 29 days to <1 year. Most neonates died in hospital (56%) or on
way to the hospital (38%), whereas only 22% of the 29-days to <5 year-olds died

at hospital and 65% died at home. There were more males (58%) among neonatal

deaths in the 29-days to <5 year-olds (50%). Low birth weight was the most

common cause of death in both early and late neonatal period. Birth asphyxia was

another common cause of death in the early neonatal period. However it was an

infrequent cause of death in the late neonatal period. Pneumonia in the early

neonatal period was 5.1% and 19.2% in the late neonatal period. The congenital

malformation was 7.7% in the early neonatal period, and 7.7% in the late

neonatal period. In children aged 29-days to <1 year, diarrhoea was the cause of

death in 42.2% children.

Conclusion

The verbal autopsy revealed similar pattern of infant mortality cause. The most

common cause of infant death was birth asphyxia (29.41%) followed by

septicemia (17.65%), low birth weight (16.18%) and prematurity (11.76%). The

other causes were pneumonia (8.82%), heart disease (5.88%), diarrhoea (4.41%),

jaundice (2.94%), congenital defects and tuberculosis (1.47% each).

Methodology

METHODOLOGY

Study participants

Data were collected from the Dhulikhel Hospital, Dhulikhel Kavre. In

order to supplement the record based information, primary information regarding

the causes of infant death was gathered by interviewing 20% of the mothers

whose infants had died.

Sample size and sampling method

Infant death related information was collected primarily through a

household survey in Dhulikhel Municipality Ward No 6, 7 , 9 and 10 among

20% of the mothers of death cases. These 20% cases were selected by snow ball

sampling method.

Selection criteria

Inclusion criteria
  All the data retrieved from Dhulikhel Hospital on infant mortality in

during the study period was included in this study.

Exclusion criteria

 Incomplete records.

Ethical Clearance

The ethical clearance was obtained from Institutional Ethics Committee,

Dhulikhel University Hospital, Dhulikhel.

Consent

An informed verbal consent was taken from the study participants.

Method of Data Collection

Infants who had died during 2013 to 2015 and their causes were retrieved

from Hospital by using the death certificates maintained at Hospital. The data

regarding age, sex, cause of death, educational status, income, type of family etc

were collected by using predesigned and pretested proforma (Annexure ………).

Statistical Analysis

The data was tabulated and a master chart was prepared (Annexure

………….). Data was analysed using Microsoft Excel software. Results were

presented in diagram, tabular and narrative form while percentages were applied

wherever required.

Definition of variables
Age of the mother: Age was recorded to the nearest completed year.

Religion: The subject’s religion was noted and was grouped as “Hindu”,

“Buddhism”, and “Others” (Muslim and Christian etc).

Type of family

Nuclear family: Married couples, along with their unmarried children living in

the same house.

Joint family: Many married couples and their children who live in the same

household. Males are blood relatives and females of the family are related by

either marriage or blood relation.

Educational status of parents: The subjects were asked about their educational

qualifications and were grouped into following categories.

Illiterate: A person who could not read and write with understanding in any

language.

Primary school education: A person who had studied up to 7th standard.

Secondary education: A person who had studied from 8th to 10th standard.

Pre-university: A person who had studied up to pre-university.

Graduate: A person who had a bachelor’s degree in any field.

Post-Graduate: A person who had a master’s degree in any field.

Others : A person who had studied higher secondary and/or pre-university with

some other degrees. Graduation and post graduation such as diploma, industrial

training, teachers training were considered as others.

Socioeconomic status: Information on family size along with of total monthly

income of the family in rupees was obtained. Per capita monthly income in

rupees was calculated, and then the family was classified using modified B. G.

Prasad’s classification.75

Average Consumer Price Index for the year 2012 = 96981

Modifications were done with the aid of Multiplication Factor (M.F),

which was obtained as below:

Average Consumer Price Index for study period

M. F. = X 4.93
100

969
M. F. = X 4.93
100

= 47.77 ≈ 48

Modified B. G. Prasad’s Classification

Modified Prasad's
Prasad's classification classification in the
Socioeconomic
(1961) per capita study period (2012)
class
income in Rs/ month80 Per capita income in
Rs/month81
I 100 & above 4800 and above

II 50 – 99 2400 to 4799

III 30 –49 1440 to 2399

 IV 15 – 29 720 to 1439

V below 15 Below 720

Type of death: The type of death was ascertained from the death certificate from

District Health Office.75

Neonatal death: Neonatal deaths were deaths that occurred during the neonatal

period starting at birth and ending at 28 completed days after birth.75

Post neonatal death: Deaths that occurred from 28 days of life to under one year

were defined as post neonatal death.75

Cause of death: The cause of death was classified according to the death

certificate maintained at District Health Office.