Incidence of Low Birth Weight

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Journal of Health & Development. Vol. 3 No. 1 & 2. January – July 2007 data because ... grams at the time of birth in India in 1999 (Blanc and Wardlaw, 2005). The. NFHS-2 .... weight occurred for babies born in the southern region and in UTs than .... (79.7 percent), those who belong to Scheduled Castes/Scheduled Tribes.
RESEARCH

INCIDENCE OF LOW-BIRTH-WEIGHT IN INDIA Regional Variations and Socio-Economic Disparities Ramesh Chellan, Lopamudra Paul and P.M. Kulkarni

OVERVIEW OF THE PROBLEM ow-birth-weight babies have a high risk of neonatal and infant morbidity and hence the proportion of babies with low-birth-weight is considered as a sensitive index of nation’s health and development (WHO, 1980; Ebrahim, 1982; Idris et al., 2000). It becomes an indicator of community health and its periodic monitoring helps to estimate the impact of them on preventive health services in the country. Worldwide, the indicator is noted as a good summary of a multifaceted public health problem of long-term maternal malnutrition, ill health, hard work and poor pregnancy healthcare. The significance and interpretation of low-birth-weight has recently come into prominence, because it indicates the chances of survival, growth, and long-term health, and of impaired cognitive development, diabetes and coronary heart diseases in the later part of their lives (Chase, 1969; Puffer and Serrano, 1973; McCormick, 1995; Blanc and Wardlaw, 2005). The United Nations set up the seven major goals for the current decade, viz., ‘A world fit for children,’ one of which is to reduce the proportion of low-birth-weight babies to one-third by 2010. The reduction of low-birth-weight also forms an important part of Millennium Development Goals for reducing child mortality. The World Health Organization (1992) defines low-birthweight as a weight at birth of less than 2500 grams, irrespective of gestational period, and recommended an additional demarcation of 1500 grams to define very low birth weight. However, the information on gestational age would help to separate infants who are born premature, but this information is rare in developing countries (UNICEF, 2004; Chanon et al., 2006). In most of the developing countries, low-birth-weight data are biased due to majority of births taking place outside the healthcare facilities, and mothers are unable to provide the

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data because infants are mostly not weighed at the time of birth. The World Health Organization (1995) estimated that there is a large gap between the incidence of low-birth-weight babies in developing countries (19 percent) and developed countries (7 percent). According to the UNICEF (2004) estimates, more than 20 million infants are born with low-birth-weight in the world and low-birth-weight babies are concentrated in two regions of the developing world: Asia (72 percent) and Africa (22 percent). India alone accounts for 40 percent of low-birth-weight babies in the overall developing world and more than half of those born in Asia. India, a developing country with high infant mortality rate (60 per thousand live births) is also characterized with substantial number of neonatal deaths (IIPS and ORC Macro, 2000; India, Registrar General, 2005). Lowbirth-weight is probably one of the major causes of neonatal and infant deaths in the country. A study based on the National Family Health Survey (NFHS-2) shows that 70.1 percent of babies were not weighed within two days of birth, and of those weighed, 22.6 percent babies were below 2500 grams at the time of birth in India in 1999 (Blanc and Wardlaw, 2005). The NFHS-2 estimates nearly three quarter births take place in non-institutional set up in India (IIPS and ORC Macro, 2000). Therefore, there is a high probability of not weighing the babies at the time of birth or within two days of birth. Reproductive and Child Health Survey (RCH), 1998–99 also reveals similar results of not weighing of babies. The survey shows a wide variation with background characteristics of respondent with regard to not weighing babies in the country and also babies with low-birth-weight. This calls for further assessment of factors affecting weighing the newborn and low-birth-weight. CONCEPTUALIZATION OF THE PROBLEM Low-birth-weight is a national concern and also has importance in population policies. Therefore, it is also essential to know the percentage of lowbirth-weight babies among who were weighed at the time of birth or within two days of the birth. But the RCH survey, 1998–99, shows 14.9 percent of women could not remember the birth-weight of their babies among who were weighed within two days of the birth. This is a major drawback to carryout further analysis, whereas, the number of weighed babies itself is not large. The factors that affect birth-weight may be biological or socio-economic-demographic and also related to the health services (Figure 1). The biological factors are mainly two major causes, duration of gestation and intrauterine growth rate. Mainly mother’s health condition, history of previous low birth delivery, illness, complication in pregnancy, and past adverse 148

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pregnancy outcome may cause low-birth-weight (Idris et al., 2000; Kabir, 2002, Rafati et al., 2005). Even outdoor air pollution results in delivery of low-birth-weight babies (Bobak, 2000). Maternal nutritional status is a prime factor of the new born baby’s weight. Nutritional level of mother is also influenced by several socio-economic and demographic factors. Joshi et al., (2005) estimated in Swaroop Rani Nehru Hospital in Allahabad during 2001–2002, that 34.4 percent newborn were low-birth-weight babies. Maternal education, occupational status, and per capita income of the family per month were significantly correlated with birth-weight but not the sex and the religion of the baby. Young mothers, women with low antenatal care, and also with more children, are at relatively higher risk of having low-birthweight babies (Aras et al., 1989; Yasmin et al., 2001). Mothers in deprived socio-economic conditions frequently have low-birth-weight babies. In such conditions, the infant’s low-birth-weight stems primarily from mother’s poor nutrition and health over a long period, including during pregnancy, and the high prevalence of specific infections, or from pregnancy complications, underpinned by poverty. Physically demanding work during pregnancy also causes to poor foetal growth (UNICEF, 2004). Some other studies have simply highlighted the association between social factors and low-birth-weight and suggested that poverty could affect maternal health status at the time of conception through lower physiologic reserves or that unhealthy women are more likely to be concentrated in the lower social classes in the society (Antonovosky and Bernstein, 1977; Lieberman, 1995). Blanc and Wardlaw (2005) estimated from the data of 62 Demographic Health Surveys (DHS) from 42 different countries that percentage of infants not weighed at the time of birth varies from one percent to 96 percent. Overall, 10 percent of mothers do not remember the weight of the infant even if they were weighed at the time of birth. The results show 52 percent of infants weighed at birth resided in urban areas, had educated mothers and were the first birth, and there is no gender discrimination in weighing babies. A study by Channon et al. (2006) also depicts that infants with recorded birth-weights are mostly hospital born, from urban areas, alive at the time of birth, whose parents are educated, and mother had taken prenatal care. Therefore, it is clear that there are various factors that influence the weighing of the babies. The Indian Family Planning Programme aimed at early registration of pregnant women to provide antenatal, natal and postnatal care. The National Population Policy 2000 also laid emphasis on increasing the infant health care and held that the low-birth-weight infants were the most vulnerable and so they required special care (MOHFW, 2000). But to know whether the baby has low-birth-weight or not, it is important to weigh the

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Figure 1

Tentative Model Shows Factors, Effecting Weighing of Babies within Two Days of Birth and Low-Birth-Weight

Socio-economic factors •

Place of residence



Religion



Caste



Education of the mother



Type of house

Demographic factors •

Age of the mother



Birth order



Pregnancy miscarriage*

BABIES WEIGHED AT BIRTH OR NOT Maternal health care facilities •

Full ANC



Institutional de livery

Geographical location •

Note:

Region

LOW BIRTH WEIGHT

* Only for low birth weight.

baby after birth. So it is necessary to understand what are the factors effecting parent’s unwillingness to weigh their babies. Is it mainly socio-economic and demographic factors which play an important role (Figure 1)? Moreover, region may play a significant role regarding this issue because India is diverse in its topographical-social and economic features. In India, wide regional variations are observed in infant mortality and maternal mortality, even, maternal and child healthcare also varied over space. It is possibly due to specific cultural factors that prevail in the specific region, which needs to be assessed further. Here, region is taken as an explanatory variable to understand the spatial effect on weighing the newborn and on the birthweight. The States have been grouped into six regions as, Northern: Haryana, Himachal Pradesh, Punjab, Rajasthan, and Jammu and Kashmir; Central: Uttar Pradesh, and Madhya Pradesh; Eastern: Orissa, West Bengal, and Bihar; Northeast: Arunachal Pradesh, Assam, Manipur, Mizoram, Meghalaya, Nagaland, Sikkim, and Tripura; Western: Maharashtra, Gujarat, and Goa; and Southern: Andhra Pradesh, Karnataka, Kerala, and Tamil Nadu. Besides, the union territories are grouped as one region. FOCUS OF THE STUDY The major objectives of the study are: first, to understand the regional dimension of the practice of weighing the newborn; and second, to study the roles of socio-economic-demographic and health factors. It also examines the regional differences in the incidence of low-birth-weight-babies among who 150

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were weighed. Further, it tries to seek the factors (socio-economic-demographic and health factors) that affect low-birth-weight. DATA SOURCE AND METHODOLOGY This paper tries to fulfill the objective of the study by using the Reproductive and Child Health- Rapid Household Survey, 1998–99 (RCH-RHS 1&2) in India, conducted by the International Institute for Population Sciences, Mumbai. The study covered 529,817 households and 474,463 currently married women aged 15–44 years in 504 districts in the country and has a larger sample than the National Family Health Survey-2, 1998–99 (NFHS2). For each birth, which occurred during the period of three years preceding the survey, the mother was asked whether the baby was weighed within two days of birth or not. If weighed, birth-weight was entered in grams. Socio-economic and demographic characteristics of the respondent are also available, and further information regarding utilization of maternal healthcare facilities was also collected. The present study considered 189,236 live births and specifically only the last birth of the respondent, which occurred in the three years preceding the survey in India, to examine the regional dimension of not weighing newborn babies. Besides, 2,545 women who did not remember whether their babies were weighed or not, were also excluded from the analysis. But further analyses (bivariate and multivariate analyses) include 184,895 live births, excluding births from Union Territories (UTs) because they have very special characteristics of their own and the sample size of each UT is very small in number. The multivariate analyses of low-birth-weight, is based on 51,862 births in 25 major States of India, who were weighed within two days of birth. In low-birth-weight analysis, 7,643 births were excluded, since the respondents did not remember the weight of the baby, though they were weighed. But a separate analysis has been carried out to understand the background characteristics of the respondents. The RCH did not collect data on household standard of living or income, therefore, the type of house has been considered as proxy to the economic status. First, the prevalence of not weighing babies is presented for each State and also for regions in India. Then, incidence of low-birth-weight-babies among those who were weighed has been calculated for each State and region. Bivariate analyses have been carried out to understand the variations in babies not weighed and low-birth-weight babies among those who were weighed by selected socio-economic and demographic characteristics and maternal healthcare factors. Finally, multivariate analyses, specially, binary logistic regression has been used to assess net effects of regions as well as socio-economic and

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demographic and maternal healthcare factors on not weighing babies and lowbirth-weight among who were weighed, and later the predicted probabilities of the response are also calculated for each category of predictor variable (for details of methodology see Retherford and Choe, 1993). RESEARCH FINDINGS AND DISCUSSIONS Regional Dimension of Not Weighing New Born The overall picture shows that only 28.4 percent babies were weighed within two days of their birth (Table 1). Therefore, a large number of babies were not weighed and this causes a great concern. Bihar has the worst recoding in this (92.6 percent) and Kerala the best (4.5 percent). There are only four States, viz., Mizoram, Kerala, Goa, and Tamil Nadu, where more than fifty percent babies were weighed within two days after birth. Except, Dadra and Nager Haveli, all UTs have more than fifty percent babies who were weighed. The regional diversity is high regarding weighing the new born in India. There are marginal differences in percentage of babies not weighed in north, central and eastern regions (Figure 2). But higher reporting of birth-

Figure 2

Percentage of Babies Not Weighed and Having Low-Birth-Weight by Geographical Region, India

Babies not weighed/ Low birth weight (in %)

100 90 80 70 60 50 40 30 20 10 0 Northern

Central

Eastern Northeastern Western

Southern

Union Territories

All India

Geographical Regions Babies Not Weighed

Low Birth Weight*

Note: * Among those who were weighed. Source: Computed from RCH-RHS, 1998–99 data file.

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Figure 3

Prevalence of Not Weighing Babies in India: A State-Level Scenario

N

B ab i es No t Wei g h ed More than 70 percent 30-70 percent Less than 30 percent

NOT TO THE SCALE

Note: Map does not show UTs. Source: Computed from RCH-RHS, 1998–99 data file.

weight occurred for babies born in the southern region and in UTs than other regions in India. The map (Figure 3) clearly depicts the north-south divide in weighing babies soon after birth. Low-Birth-Weigh Neonates: A Regional Perspective There is similar picture for the low-birth-weight babies among those who were weighed within two days of delivery (Table 1). Nearly 17 percent of the total weighed babies were low-birth-weight babies in India. The concentration Vol. 3 No. 1 & 2

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Table 1

Percent of Newborn Babies Not Weighed and Incidence of Low Birth Weight by States and Union Territories (UTs), India

State/UT Northern region Haryana Himachal Pradesh Jammu & Kashmir Punjab Rajasthan Central region Madhya Pradesh Uttar Pradesh Eastern region Bihar Orissa West Bengal Northeastern region Arunachal Pradesh Assam Manipur Meghalaya Mizoram Nagaland Sikkim Tripura Western region Goa Gujarat Maharashtra Southern region Andhra Pradesh Karnataka Kerala Tamil Nadu Union territories Andaman & Nicobar Islands Chandigarh Dadra & Nager Haveli Daman & Diu Delhi Lakshadweep Pondicherry All India

percent Babies Not Weighed

Total no. of Births

percent below 2500 gram Birth Weight Babies

Total no. of Weighed Births

78.3 64.4 74.7 71.0 87.4

3203 853 1050 3992 11293

20.3 15.5 22.9 15.1 21.1

696 304 266 1157 1423

83.6 91.9

15148 42032

16.6 16.8

2482 3408

92.6 85.0 64.6

23131 6916 14171

13.9 15.7 22.6

1716 1037 5016

77.0 78.6 69.4 68.5 28.7 86.8 69.6 64.8

257 4649 539 740 188 355 92 361

11.7 11.3 7.3 18.0 9.0 (4.2) (14.8) 21.3

60 995 165 233 134 48 27 127

10.1 57.0 43.8

218 7869 14867

18.5 17.0 18.9

195 3394 8365

52.5 56.7 4.5 22.5

10246 8176 5188 9362

18.1 19.4 14.8 11.1

4864 3542 4952 7253

30.2 34.7

53 75

(74.3) – 33.8 – 9.7 71.6

35 20 1465 11 134 186691

(8.3) 12.0 – – 16.7 – 17.2 16.9

36 50 10 11 971 7 122 53062

Note:

* Among who have been weighed. ( ) Based on less than fifty cases. – Not calculated due to less than 25 observations. Source: Computed from RCH-RHS, 1998–99 data file.

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of low-birth-weight babies are the highest (18.8 percent) in northern States like Haryana, Punjab, Jammu & Kashmir, Himachal Pradesh and Rajasthan. Only nine States have less than 15 percent of babies who were not having low birth-weight, which are either northeastern States or from southern region, except Bihar (Figure 4).

Figure 4

Prevalence of Low-Birth-Weight-Babies in India: A State-Level Scenario

N

Low Birth Weight Babies More than 20 percent 15-20 percent Less than 15 percent NOT TO THE SCALE

Note: Map does not show UTs. Source: Computed from RCH-RHS, 1998–99 data file.

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Not Weighing Neonates in India: Do Regional-Socio-EconomicDemographic and Maternal Healthcare Factors Matter? In India (excluding UTs), 72.0 percent babies were not weighed within two days of birth. But there is a wide variation across socio-economic categories and with demographic characteristics of the mother. Moreover, maternal healthcare factors also show wide differentials. Babies from rural areas (79.7 percent), those who belong to Scheduled Castes/Scheduled Tribes (80.5 percent), and babies of mothers with low age at marriage (80.0 percent) and living in kachcha houses (86.7 percent) are less likely to be weighed. With increase in educational level of the mother, the incidence of not weighing of babies decreases. There are marginal variations by sex of the child and age of the mother, not weighing is high among adolescent mothers. Babies with higher birth order are less likely to be weighed by their parents (Table 2). Maternal healthcare services play an important role. Over eighty percent of women, who did not receive full ANC (Ante Natal Care) care (at least three ANC visits + at least one Tetanus Toxoid injection + Iron and Folic Acid tablets) have not weighed their babies compared to only thirty percent women who did. Even, in cases of institutional delivery, 21.7 percent babies were not weighed within two days of birth. This is surprising since, facility survey data shows that infant-weighing machines are easily available (more than 90 percent) in different health set-ups in India (IIPS, 2005). Besides, even among those whose babies were weighed, a considerable percentage of women (14.7 percent) do not remember the baby’s weight (Table 2). Women from rural areas, belonging to Scheduled Caste/Scheduled Tribe (SC/ST), Muslim women, women with no schooling, low standard of living, higher birth order, older women, and who had non-institutional birth are more likely to not remember the baby’s weight. Sex of the baby does not seem to matter much. This shows that certain sections of the society are not paying much attention to the neonates, as they deserve. So far we have discussed the gross differentials, which examine one variable at a time, in not weighing babies by selected socio-economic-demographic, regional and maternal healthcare factors. However, many of these variables may be interrelated, e.g., mother’s level of education is associated with caste, religion, place of residence etc. Hence, to examine the net effect of individual variables, a multivariate analysis was carried out employing the logistic regression analysis technique since the dependent variable, a baby weighed or not, is dichotomous in nature. Table 3 presents the results of logistic regression in terms of predicted probabilities. Instead of merely presenting the logistic regression coefficients, 156

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percentage of Newborn Babies Not Weighed, Weighed but Table 2 Weight Not Remembered and Low Birth Weight Babies (below 2500 grams) by Background Characteristics, India Background characteristics

Percent babies not weighed

Total no. of births

Residence Rural 79.7 148890 Urban 40.1 35912 Religion Hindu 72.6 147272 Muslim 74.3 27888 Others 55.4 9735 Caste OBC 73.0 66836 SC/ST 80.5 53424 Others 64.2 64608 Mother’s education (year of schooling) 0 schooling 87.9 109951 1–5 71.4 19786 6–10 46.8 41079 11 + 21.4 14080 Type of house Kachcha 86.7 81143 Semi-pucca 67.8 57739 Pucca 51.1 45880 Sex of the child Boy 71.0 96049 Girl 72.2 83991 Age of mother 15–19 67.6 60694 20–24 74.0 13649 25–29 69.1 61042 30–34 76.8 30534 35 + 85.8 18973 Age at first cohabitation Less than 18 years 80.0 139901 18–20 57.8 25651 21 + years 32.8 19342 Birth order 1 55.4 44223 2 63.1 46526 3 75.7 34466 4+ 89.0 54537 Pregnancy wastage No N. A N. A Yes N. A N. A Full ANC care No 81.8 149167 Yes 30.0 34658 Institutional birth No 98.6 123701 Yes 21.7 61192 Total No. of births 72.0 184895

Percent babies weighed but weight not remembered

Percent birth weight (below 2500 grams)

Total no. of babies weighed

16.7 11.9

17.3 16.3

30304 21518

14.9 16.7 9.7

17.2 15.7 15.9

40351 7172 4341

13.1 17.1 14.9

15.5 19.2 16.9

17454 10440 23969

25.6 18.3 10.8 7.6

18.6 18.5 16.7 14.3

13289 5662 21852 11059

21.2 13.7 12.5

19.4 17.3 15.3

10813 18576 22417

14.4 14.9

15.7 18.0

27838 23344

13.8 18.3 14.0 14.8 21.7

18.1 21.2 15.7 15.7 14.0

19646 3550 18873 7098 2697

18.6 12.6 8.3

18.0 16.2 15.1

28037 10830 12996

11.6 12.4 18.2 25.8

18.4 15.6 16.5 16.4

19728 17187 8363 6549

15.0 13.3

16.8 17.5

44663 7198

19.5 9.2

17.7 16.1

27207 24249

28.2 13.6 14.7

18.2 16.8 16.9

3949 47911 51862

Note:

*: Women who had delivered their last live births during three years period to survey. N.A: Not Applicable. Source: Computed from RCH-RHS, 1998–99 data file.

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Predicted Probabilities (in percent) for Newborn Babies Not Table 3 Weighed and Low Birth Weight Babies (below 2500 grams) by Background Characteristics, India Predicted probabilities Background Characteristics

Babies not weighed

Region South@ North Central East Northeast West Residence Rural@ Urban Religion Hindu@ Muslim Others Caste Others (Non SC/ST/OBC)@ OBC SC/ST Mother’s education (year of schooling) 0 schooling@ 1–5 6–10 11+ Type of house Kachcha@ Semi-pucca Pucca Sex of the child Boy@ Girl Age of mother 20–24@ 15–19 25–29 30–34 35 + Birth order 1@ 2 3 4+ Pregnancy wastage No@ Yes Full ANC care@ No@ Yes Institutional birth No@ Yes

Low birth weight babies#

65.5 77.7** 81.7** 72.5** 62.8** 45.2**

17.1 23.6** 24.5** 16.9 10.8** 16.5

72.9 66.9**

17.0 16.8

72.1 74.1** 69.5**

17.0 16.9 16.5

71.7 73.0** 71.4

17.0 15.5** 18.4**

73.4 76.5** 69.9** 58.2**

18.0 19.7** 17.1** 14.4**

72.6 72.7 69.6**

17.6 17.8 15.8**

71.5 72.6**

16.3 17.7**

73.0 76.7** 71.5** 70.4** 70.8**

17.2 20.6** 16.6 16.5 14.5**

69.8 67.5** 71.0** 76.6**

17.2 16.2** 17.2 17.5

N.A. N.A.

16.8 17.3*

73.2 64.5**

17.0 16.8

72.0 26.1**

17.6 16.8*

Source: Computed from RCH-RHS, 1998–99 data file. Note: @ Reference category. # Among who have weighed and weight remembered. N.A: Not Applicable. ** Significant level at 1 percent. * Significant level at 5 percent.

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we have computed the predicted probabilities of weighing a newborn for each category of explanatory factor holding other variables constant at the respective means. These are similar to the adjusted values in Multiple Classification Analysis and allow simpler interpretation than the logistic coefficients. It is seen that regions have great impact on weighing babies in India. Babies from north, central and east are significantly less likely to be weighed and babies from northeast and west are more likely to be weighed than southern region in the country. It gives a clear picture that geographical diversity plays an important role in India, even when other socio-economic-demographic and maternal healthcare factors are controlled. The study reveals that respondents from urban areas, and living in pucca houses are significantly more likely to weigh their babies after controlling the other socio-economic factors. There is significant reduction in not weighing of babies with the increase in educational attainment of the mother. There is even sex preference towards male child to be weighed after birth. Adolescent mothers are more reluctant to weigh the babies whereas women in higher age groups are less likely to do so than the mothers of age group 20–24 years. Maternal healthcare is an important factor in this regard, as women with full ANC care and those who had institutional deliveries were more likely to weigh their neonates, which shows that utilization of maternal healthcare promote the practice of weighing a newborn. Low-Birth-Weight: Do Disparities Persist among Regional-SocioEconomic-Demographic and Maternal Healthcare Factors? Nearly 17 percent babies (among those who were weighed) were low-birthweight-babies in India (Table 2). There are marginal differentiations in low birth-weight across the place of residence, religion, caste, sex of the child, birth order, and age of the mother except the adolescent mother where lowbirth-weight incidence is high. However, the incidence of low-birth-weight babies decreases with increase in the mother’s level of education, age at marriage and rise in the standard of living (type of house taken as proxy). Institutional birth reduces the propensity of low-birth-weight-babies; however, only a small proportion of deliveries occurred in institutions. There is almost no variation in low-birth-weight babies with history of adverse pregnancy outcomes of the mother. Logistic regression results show that mother’s education and caste have the highest impact on low-birth-weight babies (Table 3). However, primarily the effect of education is seen only at the high school level. Women in higher age groups and who are living in pucca houses are less likely to give birth to low-birth-weight babies. It shows that experience of earlier pregnancy and

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economic status play a major role, which may indirectly be related with nutritional status and proper antenatal care of the women during pregnancy. On the other hand, adolescent mothers were probably not aware of the proper care of pregnancy and related issues. Women who had institutional deliveries and received full ANC care were at a low risk to have low-birth-weight babies. Geographical regions have mixed impact on the low-birth-weight. Babies from the northern and central regions are significantly more like to have low-birth-weight and from northeast are less likely to have low-birthweight than the babies from southern region in India after controlling socioeconomic and demographic factors. CONCLUSIONS The present study reveals that a majority of babies were not weighed at, or soon after, birth. It is known that a large number of births take place at home and weighing is generally not possible for these. However, even among institutional deliveries 21.7 percent babies were not weighed. As a result, in many cases the incidence of low-birth-weight may not be recognized and thus the babies may not get the requisite special care. Among socio-economic factors, education of woman and urban residence show influences in the expected direction, but effects of other factors are generally not large. On the other hand, regional variations are very conspicuous; weighing of newborn is less common in the central, northern, and eastern States than the western, northeastern, and southern States. The occurrence of low-birth-weight babies (among those weighed) is also high in northern and central States in India even when controlled for other socio-economic and demographic factors. Mother’s education has played an important role and higher educational attainment of mother reduces the incidence of low-birth-weight babies. Living conditions also matter; naturally incidence of low birth falls as the level of living rises. Further analysis shows that babies from socially disadvantaged sections such as the scheduled castes and tribes are more likely to have low-birth-weight than others. Note that this is the case even after effects of other factors, including mother’s education and standard of living, are controlled. Given that the scheduled castes and tribes are also more likely to be poor and less educated than others, the disadvantage is compounded. The public health programmes in India do seek to provide care to the newborn and also to work towards equity in such care so that the deprived sections are also assured of at least the minimum required care. Yet, the issue of low-birth-weight, so well recognized by the public health community, does not receive a prominent mention in the programme literature. Besides, as the evidence shows, the programme has not been successful even at the basic 160

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step of identifying low-birth-weight babies. Though programmes are implemented to provide to safe motherhood and care for neonates, is it a question of accessibility or discrimination in services, which prevent the poorer sections of the society from utilising these? Moreover, the goal of equity is far from being achieved. In spite of a programme that ostensibly has a very wide reach, and is designed to cater to the needs of the weaker sections of the society, whether in economic or social terms, the deprivation persists. Overall, the effect of geographical regions is very prominent, so more focus should be paid to regional development with special care. Clearly, a more affirmative strategy is called for and its implementation needs to be ensured. ACKNOWLEDGEMENT We are highly indebted to the International Institute for Population Sciences, Mumbai, for providing data for research purposes.

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Journal of Health & Development Vol. 3 No. 1 & 2

January – July 2007