Is Childhood Mortality Higher in Urban Poor Than in Rural India?

doi:10.21203/rs.3.rs-965163/v1

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Is Childhood Mortality Higher in Urban Poor Than in Rural India?

https://doi.org/10.21203/rs.3.rs-965163/v1

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The present paper examines the childhood mortality differential among urban poor and rural India using data from two rounds of National Family Health Survey Conducted in 2005-06 and 2015-16. Concentration index (CI), and cox regression were applied to address the research problem. Furthermore predicted probability was used to identify the potential predictors of infant and child mortality after adjusting the predictor variables. The findings suggest a decreasing trend in in infant mortality and child mortality both urban poor and rural India during this period. The economic inequalities respect to child mortality is higher in urban poor than in rural India. Hazard regression suggested that higher risk of child mortality in urban areas, due to poverty, low female literacy, low coverage antenatal care and safe delivery in the community. Even after controlling the possible bio-demographic variables, the study reveals that percentage declined mortality in rural areas higher than the urban poor but inequality is more widened in urban poor in India. The health program should be initiatives a major role to reducing infant and child mortality rates for both urban poor and rural India.

Toxicology

Occupational Medicine

Environmental Policy

Infant mortality

Child mortality

Concentration index

Hazard regression

Economic inequality

Female literacy.

Childhood mortality is one of the important indicators of a country's general medical and public health condition and used summary measure of the quality of life, overall health and country-level socio-economic development. Across the world, children from poor economic background family are at higher risk of dying as compared to rich background family. Infant and child mortality rates are unacceptably high in many developing countries. Globally, around 7 million under-five deaths were recorded in 2011 [1]. Sub-Saharan Africa contributes more than two in five child death below the five age groups [2-3]. High levels of child mortality in sub-Saharan societies are a major contributing factor to low life expectancy which is move through health and mortality transitions [4]. These transitions are pushing mortality risks into the very young and very old cohorts due to the double burden of acute communicable and chronic degenerative diseases [5-6]. Similarly Gaps in child mortality between rich and poor countries substantially wide and growing, and there is evidence of growing inequity within countries [7-8]. The root gap in child mortality indicates the unequal distribution of wealth quintile and the uneven distribution of resources or lack of resources by type of residence.

India is one of the most populous country in the South Asian region, contributes to the highest number of deaths among children under-five in the region (2.1 million deaths in 2006) and one-fifth of under-five deaths worldwide [9]. In addition, before reaching the first year of life more than 18 infant die, and before reaching the age of five more than 13 children were die in India due to various socio-economic and demographic factor respectively [10]. Although infant and child mortality in India both have declined simultaneously over the last three decades, for example an infant mortality rate has declined of 84 to 47 per 1,000 live births from 1990 to 2016 [11-12] and an under-five mortality rate 118 to 66 per 1,000 live births from 1990 to 2016 respectively [12], but tremendous variation in rural-urban mortality across the population groups in the country. For example, the infant mortality rate in the poorest population 2.5 times higher risk than that in the richest population indicating that an infant born in a poor family is more than two times higher risk to die than an infant born in a richest family [10]. These reasons cited for the poor state of infant and child health in India are inadequate neonatal care, insufficient breastfeeding, malnutrition, low immunity and high incidence of communicable diseases [13].

The differential in urban-poor and rural mortality in this context of many developed and developing countries has been major public health issue and challenges [14]. Prior research indicates that analysis of poverty and demographic differentials within cities in the country’s highest lead to unequal morbidity and mortality [15-16]. Van de Poel, O‘Donnell, and Van Doorslaer (2007) research on 47 developing countries respective in wealth quintile and found magnitude difference in the urban-rural gap in child stunting and confirms the higher socioeconomic inequality in stunting and child mortality existence in urban areas as compared to rural areas[17]. The study on Demographic and Health Survey (DHS) data from ten developing countries has been proved that the socioeconomic gradient in childhood undernutrition is higher in urban areas than in rural areas [18]. These studies clearly show that characteristics of urban poverty led to significant intra-urban variation in child morbidity and mortality, and some evidence to suggest an “urban penalty” in the case of child morbidity. Another study, based on cross-sectional data of ‘urban poverty and health inequality’, has found urban poor and slum-dwelling children under age five have higher levels of stunting and mortality than their non-poor and non-slum dwelling urban counterparts, respectively; and the urban poor children are more stunted but not more likely to die than their rural counterparts, but rural children are more likely to be stunted than their slum dwelling counterparts [19]. The higher level deprivations in urban areas are associated with poor living conditions, poor residential conditions, as well as household, commoditized context, while in rural areas lack of accessibility, availability, and affordability led to a higher risk of child mortality than the urban counterpart. Few recent studies conducted in India, suggested that health status, quality of health services, public health services and maternal utilization of healthcare services are lower support among the urban poor than the urban population and has increased the gap over time [20-23]. The factors responsible for the low use of maternal health care services among the poor mainly are increasing prices of drugs, higher cost of health services and unregulated privatization of health sectors etc.[24]. Specifically, poor people are more likely to report health services as unaffordable, unavailable, inaccessible and of low quality [23]. Most of the studies have shown a significant relationship between urban advantage health care facility and the rural-urban gap in child mortality in the countries [21, 25]. Although urban poor community receive better antenatal care and service delivery care than rural residents but the quality of care was worse than non-poor because of higher cost of health services in the larger proportion which led to out of pocket catastrophic expenditure in the urban area [19,26-28].

Besides poverty, other socio-economic and demographic factors have been found to be associated with infant and childhood mortality in the developing countries. Demographic research has suggested that socio-demographic factors such as age of the mother, parity, birth interval, religion, place of residence, and standard of living/economic status have independent as well as the combined effect on child survival [29-32]. Apart from bio-demographic variables, health care factors are major determinants of child mortality in India. The urban poor are always received the of particularly poor quality of health services, because the private providers located in their areas often have little or no medical training, and public providers exert very little effort due to poor incentive structures. Specifically the increasing cost of health care services unaffordable to pay for the urban poor people and marginalized context. Moreover, in less financial support in urban poor family tend to have low quality of reproductive child health outcomes than those who have lived in urban areas for a long time [33]. Thus Intra-urban health disparities are one of the most predictable, troubling and unfair results of the marginalization and exclusion of the urban poor.

Although several studies have examined the rural-urban differential in mortality risks in the country but little is known about the emerging inequality and differentials childhood mortality among the urban poor and rural India. This gap in research is very scanty in the Indian context. Despite the fact that child mortality is one of the important indicators of the socio-economic milieu of any nation and improving child health is a Millennium Development Goal priority; Goal Number 4 is to reduce child mortality. As interest in urban child mortality differentials increases because of rapid urbanization, with a significant proportion of rural-urban migration often settle in squalid living conditions and unfamiliar with health system in urban areas. Markedly, lower child mortality in urban India as compared to that in rural areas comes at a significant cost, and there is minimal to no financial protection for families experiencing catastrophic expenditures on health [19]. Therefore, the present study focus on childhood mortality of urban poor and is also compare with rural residence and examine whether urban poor is better than rural total or not. The analysis has been carried out for India and selected states using the data from two rounds of the National Family Health Survey (NFHS) conducted in India during 2005–2006 and 2015-16.

Data

The data for the present study were taken from two rounds of the National Family Health Survey (NFHS) conducted during 2005-06 and 2015-16. The National Family Health Survey is a large scale, multi-round survey similar to other Demographic Health Survey (DHS) cover more than 99 percent in a representative sample of the household throughout in India. The survey provides the reliable information on fertility, infant and child mortality, the practice of family planning, maternal and child health, reproductive health, nutrition, anaemia, and usage and quality of health and family planning services, as state and national level for both urban and rural sector [10].

The survey carried out two stage sampling design in rural areas and three-stage sampling design in urban areas. In rural areas, villages were selected based on probability proportional to size (PPS) sampling scheme in first stage and second stage using systematics sampling of each household in the villages. In urban areas, first wards were selected based on PPS sampling after that census enumeration blocks (CEB) containing approximately 150–200 households were selected at the second stage and in the final stage systematic sampling technique adopted for selected each household in urban areas. With regards to the urban population third round of National Family Health Survey (2004-05) covered 50,236 households, 56,961women in 15-49 age group and 19,483 children, while in rural areas covered nearly 58,805 households, 67,424 women in 15-49 age and 32,072 children from the five years preceding survey respectively. During the fourth round (2015-16) information was collected nearly 175,946 sample households and 204,753 ever-married women in the 15–49 years age group and 61,379 children five years preceding the survey from the urban area, and in rural areas covered from 425,536 sample households, 494,951 ever-married women and 198,248 children five years preceding survey the same reference periods. The household response rates for eligible women were consistently above 90 % in all two rounds NFHS survey respectively.

Outcome variables

The outcome variables for this study are infant and child mortality that are measured the duration of survival since birth in months. These are defined as the probability of child dead between birth and first birthday (infant mortality) and between age 12 and 59 months (child mortality). The analysis was carried out child-based information and restricted to the last births in the 5 years preceding survey. The outcome variables for the survival analysis compute as binary variables, such as the children’s survival status and the age at death in months as codded 1 (if the child had died) or the last month they were known to be alive as coded 0 (the last month they were known to be alive). Consideration of two durations (0–11 months and 12–59 months) children known to have died (i.e. non-censored) were regarded as the cases, whereas children who were still alive at the time of the survey were considered as right-censored (as appropriate for infant and child mortality) [34].

Exposure variables

The household urban poverty is used main exposure variables in the analysis. The measurement of poverty is a very critical issue because National Family Survey data does not provide direct information on the income or consumption of households. The NFHS only provide information related to ownership of assets, consumer durable variables and infrastructure (sanitation facility and source of water), which can be considered as proxy indicators of the household's wealth quintile. To tackle this issue estimated poverty using officially accepted estimated consumption data on National Sample Survey (NSS) by the planning commission, Government of India. The state-specific poverty cut-off points in both urban and rural areas are defined by the Planning Commission of India taking into account the calories-based estimation and price inflation at each five years. For example, in 2004-05 planning commission of India estimated 27 percent urban population were living below the poverty line. Similarly in 2011-12, the Rangarajan committee estimated that about 26 percent of urban people were residing below the poverty line as compared to 31 percent in rural areas. After that, in rural and urban areas separate wealth index has constructed. Finally, percentile distribution is obtained demarcates the poor and non-poor in urban India and selected states. Urban poor are also compared with rural total in the analysis. The selection of states is based on a sufficient sample size. Those states having a sample size of less than 100 have not been used for the analysis whereas eight north-eastern states have been grouped into one state. A total of 22 states have been used to examine the variation of childhood mortality among the urban poor and rural India. In order to separate regional level analysis, Indian states were grouped into six geographical regions: North, Central, East, West, South and North-east based on NSSO classification.

As established in the reviewed literature, numbers of other socio-economic and demographic variables have also been used for a significant effect on infant and child mortality in the analysis [35-40]. The socioeconomic variables included in the models were mother's education (no education; primary; secondary and higher), mother's exposure to media (Radio, Television and News-paper, as exposed; not exposed), religion (Hindu; Muslim; others), and caste (Scheduled Castes; Scheduled Tribes; others) of the household head. The demographic variables included in the models were mother age at birth (15–24; 25–34; 35 years and older), birth interval (less than 24 months, 24 months or longer), birth order (1; 2 and 3+), sex of child (male; female), received antenatal care at least four (yes; no) and place of delivery care (home; public and private).

Statistical Analysis

Infant and child mortality rates (with 95% confidence interval) by urban poor and rural residence for India and its regions in each round of NFHS were estimated using the life table technique available in STATA version 10.0.

Concentration index (CI) was used to examine the extent of economic inequality in infant and child mortality by urban poor and rural residence. The CI is considered as a standard tool for examine the magnitude of socioeconomic inequality in any health outcome [41]. The value of the concentration curve lies between -1 to +1 [41, 42–44]. A negative value implies that the health variable is concentrated among the poor or disadvantaged group and a positive value implies for the richest or advantaged group of people. A zero CI implies a state of horizontal equity. A zero CI implies a state of horizontal equity which is defined as equal treatment for equal needs [45].

At the multilevel analysis, Cox Proportional Hazard regression was performed to examine the effects of socio-economic and demographic characteristics on child survival during infancy and childhood in India. The Cox proportional hazards regression analysis is considered for better analysis of survival data in censored observations. And finally percentage change of predicted probability used for better interpretation on infant and child mortality over the periods 2005-16. This analysis was carried out to percentage change of infant and child mortality in urban poor and rural residence over the periods after controlling some important variables. The some predicted variables that are controlled in the regression analysis, these are mother's age at birth of the newborn, birth order and preceding birth interval, sex of the newborn, mother's schooling, religion, caste, received antenatal care, mother’s exposure to media, and geographic region of residence respectively.

Table 1 Infant and Child mortality rate (per 1000 live births) among the urban poor and rural India, 2005-16

	Infant Mortality				Child Mortality
States/ Region	2005-06		2015-16		2005-06		2015-16
States/ Region	Urban Poor	Rural	Urban Poor	Rural	Urban Poor	Rural	Urban Poor	Rural
India	57	62	44	46	70	83	59	57
North	64	57	47	40	88	75	55	49
Delhi	57	30	40	NC	71	49	60	NC
Haryana	NC	50	41	34	NC	61	53	45
Jammu & Kashmir	NC	47	42	31	NC	55	72	41
Punjab	NC	44	33	35	80	54	33	38
Rajasthan	90	68	39	44	132	88	46	55
Uttarakhand	NC	49	71	38	NC	89	70	49
Central	78	75	62	63	90	106	72	78
Chhattisgarh	32	76	56	56	40	100	60	69
Madhya Pradesh	72	74	57	53	90	104	70	67
Uttar Pradesh	88	75	64	67	98	107	75	84
East	54	61	37	45	60	78	40	55
Bihar	55	64	38	50	61	79	50	61
Jharkhand	91	73	38	46	101	93	40	60
Orissa	30	67	35	43	44	84	47	52
West Bengal	44	49	25	33	52	69	20	41
West	41	53	39	29	59	63	49	36
Goa	17	12	NC	6	17	12	NC	6
Gujarat	55	59	31	38	118	71	58	51
Maharashtra	28	48	33	24	45	58	40	30
South	38	47	33	30	40	59	51	40
Andhra Pradesh	21	64	37	39	31	81	51	43
Karnataka	41	48	38	33	47	59	43	41
Kerala	NC	13	33	5	NC	16	30	5
Tamil Nadu	61	36	17	23	65	44	75	48
Telagana	NA	NA	69	37	NA	NA	91	38
North-Eastern States	78	60	30	44	121	84	38	53

NC: Not Calculated sample size below 100; NA: Not Available in that period

Table 1 presented the infant and child mortality rate among urban poor and rural India. The trends suggested that declined rate in infant and child mortality in both urban poor and rural residence across the states over the last 10 years from 2005-16. The trend in infant mortality was declined significantly from 57 to 44 for urban poor and rural areas it has declined 62 to 46 for per 1000 live births in NFHS-4. The declined rate in infant and child mortality in rural residence slightly faster than the urban poor but the mortality differences between the urban poor and rural residence narrowed down from NFHS-3 to NFHS-4. Between 2005-06 and 2015-16, infant mortality declined by 26 percent in rural areas, compared with 23 percent in urban poor areas. During the same period, the child mortality rate declined by 31 percent in rural areas, compared with 16 percent in urban areas. At a glance, it can also be observed that the majority of the states (ie. 11) experienced higher child mortality among the urban poor than in rural India. It is varying from 132 in Rajasthan to 17 in Goa. States like Delhi, Punjab, Jharkhand, Gujarat, Tamil Nadu and North-eastern states reported higher child mortality among the urban poor than the rural residence. While looking at rural areas states like Chhattisgarh, Madhya Pradesh and Uttar Pradesh reported child mortality of over 100 per 1000 live births in 2005-06. The picture changed gradually over time with a decline in urban poverty sequentially declined in infant mortality (Figure 1). For example, the north-eastern state had declined 78 to 30 per 1000 live births from 2005 to 2016 respectively. The western and southern regions were slightly declined in IMR over the periods. On the other hand, child mortality declined from 70 to 59 per 1000 live births for urban poor and 83 to 57 per 1000 live births for rural India during 2005-2016. State-wise highest mortality found in urban poor residence ware Telagana, Tamil Nadu, Uttar Pradesh while rural residence ware observed Uttar Pradesh, Madhya Pradesh and Chhattisgarh respectively. In the incidence of poverty, infant and child mortality both were clustered in the central and eastern regions of India. The clustered has become more pronounced in the central region and to be a relatively lesser extent in the north-eastern region from 2005-16.

Table 2 Infant and Child mortality rate (per 1000 live births) in bio-demographic and socioeconomic characteristics among urban poor and rural India 2005-16

	2005-06				2015-16
	IMR		CMR		IMR		CMR
Background Characteristics	Urban Poor	Rural	Urban Poor	Rural	Urban Poor	Rural	Urban Poor	Rural
Mother's age at birth
15-24	49	73	60	93	46	49	58	58
25-34	46	53	55	72	42	41	58	52
35+	51	62	71	90	49	59	67	77
Birth order
1	60	76	62	92	47	48	54	56
2	44	52	74	68	34	36	60	46
3	61	60	82	86	50	51	64	68
Preceding birth interval
<24 months	83	90	108	118	60	63	73	81
24-47	44	45	74	64	33	34	53	47
>48	37	38	41	62	36	36	64	48
Mother’s education
No education	63	72	91	100	44	56	71	72
Primary	64	64	70	79	45	51	52	64
Secondary	38	44	40	51	42	37	51	45
Higher		22		22	53	28	65	35
Sex of the child
Male	51	61	70	76	45	49	57	60
Female	54	64	80	90	42	42	52	54
Caste
SC/ST	61	69	92	101	42	49	61	62
OBC	54	61	62	79	48	46	60	58
other	56	57	74	67	41	39	52	46
Religions
Hindu	61	63	83	84	44	46	62	58
Muslim	48	60	55	80	46	45	56	58
Other	35	58	55	84	28	35	33	45
Received Antenatal care
No	46	47	64	70	42	46	65	61
Yes	35	38	47	51	29	27	38	34
Delivery care
Home	63	63	91	87	49	55	65	73
Public	40	48	41	55	39	41	55	51
Private	56	65	62	78	48	42	58	49
Mass media
No	57	67	77	93	45	55	65	71
At least one	56	57	73	70	43	38	57	47

Table 2 presents the bio-demographic and socio-economic differential infant and child mortality among the urban poor and rural India in 2005-16. It was found the maternal age at birth shows a U-shaped relationship with infant and child mortality rates. The infant mortality rate is lowest for mothers age 25-34 years and is substantially higher for mothers age less than 20 years and more than 35 years for both urban poor and rural community. The birth order also shows a similar effect. The infant mortality rate is lowest for births of order 2 and higher for first-order births and the mortality rate increasing steadily with increasing birth order. When birth occurs less than two years after an earlier birth, the infant mortality rate is higher than the interval is 24-47 months. But when the interval is four years or more, the child mortality rate is increased. Considering sex differential infant mortality in India is lower for males (51) than for females (54). As children get older, males are exposed to higher mortality than females due to immunity power. Disparities across social groups SC/ST have the highest infant and child mortality than the other social groups. Coming into pregnancy and delivery related characteristics higher number of an infant died at home without a health facility during delivery and without antenatal care received during the pregnancy. Overall findings suggested that urban areas of the country are observing lower infant and child mortality as compared to rural areas attributing this change to better awareness, higher maternal education and better health care facilities that were easily accessible in the urban area.

Table 3 Concentration indices depicting trends in economic inequalities in infant and child mortality with respect to (a) urban poor (b) rural residence across geographic regions and India, 2005–2016

	Infant Mortality				Child Mortality
India/ Regions	2005-06		2015-16		2005-06		2015-16
	CI^a	SE^b	CI^a	SE^b	CI^a	SE^b	CI^a	SE^b
a
India	-0.010	0.0503	0.030	0.0268	-0.031	0.0225	0.012	0.0233
North	0.156*	0.1094	0.040	0.0676	0.072	0.0650	0.022	0.0638
Central	0.053	0.0668	-0.068**	0.0355	0.025	0.0628	-0.080**	0.0311
East	-0.157*	0.0962	0.064	0.0707	-0.186*	0.0961	0.050	0.0671
West	-0.005	0.1405	-0.052	0.0917	-0.136*	0.1174	-0.061	0.0862
South	-0.190	0.1645	0.090	0.0715	-0.147	0.1327	0.043	0.0654
North-East	0.010	0.0857	-0.158*	0.0991	-0.022	0.0680	-0.193**	0.0685
b
India	-0.096***	0.0155	-0.139***	0.0081	-0.121***	0.0139	0.008***	0.0077
North	-0.121***	0.0422	-0.138***	0.0187	-0.145***	0.0349	-0.162***	0.0181
Central	-0.071***	0.0240	-0.069***	0.0112	-0.103***	0.0208	-0.089***	0.0105
East	-0.043	0.0343	-0.126***	0.0164	-0.059**	0.0318	-0.139***	0.0154
West	-0.148***	0.0551	-0.101**	0.0423	-0.180***	0.0501	-0.102***	0.0396
South	-0.078*	0.0465	-0.177***	0.0314	-0.101**	0.0422	-0.181***	0.0302
North-East	-0.113**	0.0502	-0.152***	0.0239	-0.123***	0.0407	-0.152***	0.0230

Significant at ***p<0.01; **p<0.05; *p<0.10

^aConcentration index, ^bStandard error

Table 3 present trends in concentration indices in infant and child mortality with respect to urban poor and rural residence across the geographic regions for the two rounds of survey in India. The negative values indicate that child mortality indicators are concentrated among the disadvantaged group, while a positive value indicates that the concentrated among the advantaged group. The results show a rising trend of economic inequalities among the disadvantaged group. The central, western and north-eastern regions are more economic inequality in the disadvantaged group for both infant and child mortality from 2005-06 to 2015-16. In addition, the findings show economic inequalities more concentrated among the disadvantageous groups in rural residence as compared to urban poor. The degree of economic inequality varied across the geographic region over the periods. For example, southern and western regions have higher level of socio-economic inequalities but the lower rates of infant and child mortality respectively. . It is due to, children in the southern and western regions belonged to richest background family and uses better access of maternal and child health services, thus lower rick of child death than those are belonged in central region in India, [46].

The result of the Cox Proportional Hazard model (95 % confidence intervals) for infant and child mortality across the selected bio-demographic and socio-economic characteristics by urban-poor and rural residence in India, 2005-16 are presented in Table 4. It was observed hazard risk of infant and child mortality both are higher among the urban poor population than the rural population. Mother age at birth, birth order and preceding birth interval were significantly associated with infant and child mortality for both urban poor and rural India. Irrespective of the birth order birth interval less than 24 months had a higher risk of newborn mortality in infancy than newborns with a birth interval of 24 months or more. Mother's education was significantly associated with infant and child mortality in India. Children's mothers who were more educated had a lower risk of child death than children's mothers who are not educated respectively. When we consider the level of secondary and higher education of mother result suggested significant state risk of infant and child deaths higher in rural as compared to urban poor mother with respect to 95 percent confidence interval. Moving with the sex of the child and considering the males as the reference level, the risk of the female child had a higher chance of infant death among the urban poor in statically significant with 95 percent confidence interval than the rural residence.

Now going on caste status with the reference level of scheduled caste and tribe result indicate the degree of varied hazard risk of infant and child death among the other backward caste and other caste in urban poor and rural residence. Moving to religious factor with Hindus are considered as the reference population, in Muslims community risk of infant deaths relatively lower with respect to other religious with 95% confidence interval at significant state. Coming to pregnancy-based characteristics, those mothers who received at least four antenatal care during pregnancy relatively lower risk of infant and child death than those who had not received any antenatal care. The hazard risk of infant and child death both were declined due to received antenatal care among the urban poor compare to rural from 2005 to 2016 respectively. The risk of infant mortality is higher among infant’s mothers who have given birth at home than the infant who have born to women access to health care facility. On the other hand risk of infant and child mortality were lower in urban poor mother as compare to rural mother due to exposure to mass media and better knowledge of child survival.

Table 5 presents the results of the Cox Proportional Hazard model for infant and child mortality in urban poor and rural residence across the geographic region in India in 2005-16. The result suggested the patterns of inter-state disparity in child mortality are very similar to those observed for infant mortality. The hazard risk of child death has been declined from 2005-2016 to the entire geographic region except for the western region in India among the urban poor. This could be a possible explanation for the highest number of slum dwellers are residing in the western part (Mumbai in Maharashtra) and also widening the economic inequality in the infant as well as child mortality as trends to prevail in urban setting as significant cost and catastrophic health expenditure. On the contrary Eastern, Western and Southern regions the hazard risk of infant and child mortality relatively lower in rural residence as compare to the urban poor community. Overall hazard risk of infant and child mortality in India for urban poor 1.14 and 1.11 times were higher than the rural residence with respect to 95% confidence interval state.

Table 4 Hazard ratios (95 % confidence intervals) for infant and child mortality across selected bio-demographic and socio-economic characteristics by urban-poor and rural residence in India, 2005-16.

	2005-06				2015-16
	IMR		CMR		IMR		CMR
Background Characteristics	Urban Poor	Rural	Urban Poor	Rural	Urban Poor	Rural	Urban Poor	Rural
Mother's age at birth
15-24®
25-34	0.71^a (0.41,1.22)	0.75^c (0.53,1.08)	0.84 (0.52,1.38)	0.86 (0.63,1.17)	0.74^a (0.62,0.88)	0.76^a (0.62,0.91)	0.85^a (0.60,1.22)	0.76^a (0.64,0.90)
35+	0.83 (0.38,1.84)	0.78 (0.47,1.29)	1.15 (0.59,2.25)	0.86 (0.56,1.29)	0.97 (0.78,1.22)	1.04 (0.81,1.31)	1.25 (0.81,1.94)	1.04 (0.84,1.27)
Birth order
1®
2	2.0^a (1.19,3.45)	1.13 (0.78,1.62)	1.42^c (0.90,2.25)	1.17 (0.82,1.60)	1.84^a (1.57,2.14)	1.78^a (1.50,2.10)	1.78^a(1.35,2.35)	1.79^a (1.55,2.07)
Preceding birth interval
<24 months®
24-47	0.69^a (0.42,1.14)	0.54^a (0.39,0.74)	0.86 (0.55,1.33)	0.60^a (0.46,0.78)	0.67^a(0.57,0.77)	0.65^a (0.55,0.75)	0.64^a(0.56,0.72)	0.63^a(0.55,0.71)
>48	0.80 (0.44,1.49)	0.62^b (0.41,0.96)	0.75 (0.43,1.31)	0.58^a (0.41,0.83)	0.39^a(0.57,0.82)	0.72^a (0.59,0.87)	0.48^a(0.38,.67)	0.71^a(0.60,0.83)
Mother’s education
No education®
Primary	1.75^b (0.97,3.15)	0.56^b (0.35,0.89)	1.18 (0.70,1.99)	0.61^a (0.41,0.89)	0.86^a(0.59,1.32)	0.71^a(0.58,0.87)	0.87^a(0.62,1.22)	0.73^a(0.61,0.86)
Secondary	0.88 (0.48,1.62)	0.48^a (0.31,0.74)	0.69 (0.42,1.17)	0.52^a (0.36,0.75)	0.66^a(0.58,0.81)	0.71^a (0.59,0.84)	0.59^a (0.43,0.75)	0.67^a (0.57,0.78)
Higher	0.29^a (0.06,1.38)	0.41 (0.09,1.76)	0.16^b (0.04,0.72)	0.33^c (0.80,1.40)	0.36^a (0.18,0.68)	0.67^c (0.43,1.04)	0.39^a (0.24,0.66)	0.58^a(0.39,0.87)
Sex of the child
Male®
Female	1.47^b (0.94,2.27)	1.28^c (0.96,1.72)	1.54^b (1.05,2.25)	1.56^a (1.23,1.98)	1.50^a (1.14,1.97)	1.17^b (1.02,1.33)	1.44^a(1.14,1.83)	1.17^a(1.04,1.30)
Caste
SC/ST®
OBC	0.85 (0.49,1.50)	1.25 (0.88,1.79)	0.80 (0.49,1.30)	1.04 (0.78,1.40)	1.00 (0.91,1.23)	1.03(0.88,1.21)	0.98(0.72,1.33)	0.99 (0.86,1.13)
other	0.75 (0.46,1.99)	1.31^c (0.91,2.11)	0.81 (0.48,1.37)	1.10 (0.78,1.56)	1.38 (0.92,2.06)	0.99(0.78,1.23)	1.10 (0.77,1.58)	0.99 (0 .81,1.19)
Religions
Hindu®
Muslim	0.81 (0.45,1.47)	0.81 (0.49,1.31)	0.79 (0.47,1.32)	1.0 (0.68, 1.47)	0.98 (0.72,1.08)	0.92 (0.73,1.14)	0.92^c (0.68,1.24)	0.89 (0.73,1.07)
Other	0.96 (0.46,1.99)	1.35^c (0.90,2.11)	1.16 (0.63,2.16)	1.23 (0.86,1.75)	1.42^a(1.18,1.71)	1.36^b (1.11,1.65)	1.66^c ( 1.15,2.39)	1.27^c (1.07,1.50)
Received Antenatal care
No®
Yes	1.03 (0.55,1.94)	0.92 (0.67,1.28)	0.84 (0.50,1.36)	0.81^c (0.63,1.05)	0.78^b (0.55,1.13)	0.87^b (0.74,1.01)	0.80^a (0.58,1.08)	0.84^a (0.74,0.95)
Delivery care
Home®
Public	0.94 (0.55,1.61)	0.69 (0.41,1.16)	0.81 (0.50,1.32)	0.74 (0.48,1.15)	1.08^b (0.74,1.56)	0.82^a(0.70,0.95)	1.12^a (0.82,1.54)	0.82^a (0.72,0.93)
Private	0.86 (0.45,1.64)	1.07 (0.64,1.78)	0.96 (0.55,1.67)	1.06 (0.68,1.64)	1.16 (0.76,1.79)	0.88 (0.69,1.10)	1.07 (0.73,1.57)	0.89 (0.72,1.08)
Mass media
No®
At least one	1.13 (0.83,2.71)	1.50 (0.82,1.56)	0.98 (0.82,2.11)	1.01 (0.75,1.29)	1.03 (0.72, 1.68)	1.14 (0.88,1.19)	0.97 (0.74,1.41)	1.02 (0.85,1.09)

Significant at ^ap<0.01; ^b p<0.05; ^cp<0.10

Table 5: Hazard ratio’s (95 % confidence intervals) of Infant and Child mortality for urban poor vs. rural of different region in India, 2005-16

	2005-06				2015-16
Regions	IMR		CMR		IMR		CMR
Regions	Urban Poor	Rural	Urban Poor	Rural	Urban Poor	Rural	Urban Poor	Rural
North	1.36 (0.54,2.15)	0.68^b (0.44,1.04)	2.57^c (0.56,11.29)	0.81 (0.57,1.13)	1.02 (0.45,2.3)	1.07 (0.89,1.28)	1.05 (0.56,1.99)	1.03 (0.87,1.20)
Central	1.86 (0.56,6.61)	1.19 (0.85,1.68)	2.04^c (0.52,10.89)	1.24^c (0.94,1.64)	0.86 (0.51,1.44)	1.35^a (1.17,1.57)	0.86 (0.54,1.37)	1.45^a (1.28,1.64)
East	1.05 (0.65,1.94)	1.09 (0.75,1.58)	1.61 (0.42,4.69)	0.98 (0.72,1.34)	0.93 (0.23,3.74)	0.83^b (0.70,0.97)	0.81 (0.28,2.67)	0.77^a (0.67,0.89)
West	1.00 (0.82,1.24)	0.71 (0.36,1.40)	0.82 (0.35,1.85)	0.65 (0.36,1.17)	3.08^c(0.69,13.72)	0.53^a (0.35,0.80)	3.14^c (0.74,13.6)	0.59^a (0.42,0.82
South	2.27 (0.51,12.58)	0.86 (0.50,1.47)	2.64 (0.79,14.25)	0.82 (0.52,1.30)	1.82 (0.59,5.61)	0.68^b (0.48,0.97)	2.16^c (0.89,5.24)	0.72^b (0.54,0.97)
North-East	2.33^b (0.71,14.26)	1.40^c (0.89,2.20)	2.28^c (0.65,13.29)	1.31^c (0.90,1.91)	1.35 (0.68,2.69)	1.01 (0.79,1.30)	1.08 (0.56,2.06)	1.00 (0.81,1.23)
India	1.57^c (1.26,3.21)	1.05 (0.96,1.15)	1.92^a (0.45,7.65)	1.01 (0.94,1.10)	1.14^a (0.83,1.57)	0.93^a (0.88,0.98)	1.11 (0.84,1.47)	0.93^a (0.89,0.97)

Significant at ^a p<0.01; ^b p<0.05; ^c p<0.10

Table 6 Percentage change in the predicted probability of (a) infant mortality (b) child mortality by urban-poor and rural residence in India, 2015-16

	2005-06	2015-16	2005-16
a
Urban-poor	17.4	8.3	21.5
Rural	25.6	1.8	28.9
b
Urban-poor	18.9	9.2	25.6
Rural	32.6	3.8	32.6

The models have been adjusted for mother’s age at birth of the newborn, birth order and preceding birth interval, sex of the newborn, mother’s schooling, religion, caste, received antenatal care, mother’s exposure to media, and geographic region of residence.

Table 6 a, b shown the percentage change in the set of predicted probabilities for infant and child mortality among children belonged to urban poor and rural households over the period 2005-16 in India. Findings suggest that, for children belonged to the poorest household in urban residence, the probability of dying during infancy declined by about 22 % points, whether in rural residence declined by about 29 % points over the same period during 2005-16. The corresponding declines in child mortality among urban poor and rural areas were 26 and 33 % points respectively. Overall findings suggested that the economic disparities in infant and child mortality between the urban poor and rural residence both have widened during 2005-16. However, the economic inequality gap has more widened in the urban area as compared to rural India.

The study attempts to understand the urban poor and rural differentials in infant and child mortality in India and selected states. As a first step, the separate wealth index is computed for urban and rural samples in India and states. The urban poor and non-poor are classified using the official cut-off point of poverty estimates by the Rangarajan committee in 2011of the country and states based on uniform recall period. The results obtained using NSS poverty estimates were similar to those obtained from using poverty estimates generated using NFHS 3 and 4 datasets. After defining the urban poor and non-poor based of cut-off points, the differentials infant and child mortality have been examined among the groups. Urban poor are also compared with total rural residence in the analysis. Results suggested that the infant and child mortality rate has declined considerably in both urban poor and rural India during 2005-06 and 2015-16 respectively. The declined rate in infant and child mortality both are faster in rural areas as compare to urban areas. This could be happen rapid economic growth rate, new Economic policy, agriculture development, medicine, information technology, Reproductive child health programs etc. [47]. But overall higher infant and child mortality in rural India indicates an unequal distribution of wealth and use of the different types of resources. Substantial mortality disadvantages in rural areas were found in both socioeconomically advanced states (Andhra Pradesh, West Bengal) and disadvantaged states (Madhya Pradesh, Uttar Pradesh, Bihar and Orissa). Another interesting finding is that some advanced states like Delhi, Punjab, Gujarat and Tamil Nadu were child mortality higher among the urban poor than in rural India. This may reflect their proximity to health services, which are essential during a particularly severe during infancy. Another point of view the density of health providers in urban areas is high and access to health services may be less of a concern than in rural areas, the cost and quality of the services provided present significant issues in the urban area [19]. Because the urban poor received low quality of care from the private sector due to significant cost and no financial protection for families’ experiencing in catastrophic expenditure on health. But the rural-urban gap in infant and child mortality has remained the same over the last two decades.

Another important finding of the study is the measure of economic inequalities across the six geographic regions with respect to infant and child mortality in India. Findings in this study suggested infant and child mortality was a more resolute among the disadvantage group in rural residence. While the extent of economic inequality was considerably higher in urban compared with rural India. For example among the six geographic regions, the Southern and western regions are more socio-economic and demographic advanced region in India. But the economic inequalities in infant and child mortality were also the highest in these two regions. In addition the highest extension in socio-economic inequality was in the north-east region over the two survey rounds. This finding may be attributed to spatial inequality in social and economic development between region [48], inequality in distribution, and use of health facilities [49-52], difference maternal education between and across the regions and different use of preventive health care services [53]. Prior study Arokiasamy and Pradhan (2010) suggests that child deaths in southern and western regions were disproportionately concentrated among the poor households [54].

Apart from region of residence, other socio-economic characteristics found to exert significant effects on infant and child mortality in India include mother’s education, caste, religious, delivery care and mass media. Considering the place of residence, for instance, infant and child mortality is likely to be higher in the regions that are predominantly urban poor compared with rural residence. This is perhaps partly due to the differentials in the distribution of health care facilities between rural and urban communities [49-50]. Also, bio-demographic attributes such as mother’s age at birth, birth interval, birth order, child’s sex, maternal education, and place of delivery were important predictors of infant and child mortality in India. For instance, the children of mothers aged 25–34 had lower risks of death compared with children of younger mothers, thus lending credence to the findings of earlier studies [55-56]. Children of mothers aged 25–34 are likely to better care for their children than the children of younger mothers because the younger mother is generally inexperienced about child-rearing, they are mostly uneducated and often marry too early [34]. In addition, children whose mothers have no education are more risky to die before their first birthday as compared to whose mothers have completed at higher education. Also, children from scheduled castes and tribes are at greater risk of dying than other children.

Another interesting finding of the study is that distinct patterns of risks of death during infancy and childhood due to the individual level and the community level characteristics in different geographic regions in India. The results indicate a significant variation in infant and child mortality across the six regions of the country (p < 0.001). The western and southern regions shown higher risks of infant and child mortality among the poor, it was lowest in the eastern region. Similarly, in rural areas, it was highest in the central region and lowest in the western region. The distribution of infant and child mortality across the six regions suggests that child death was generally more pronounced during infancy in rural area. Thus, this study has established that individual- and community-level factors are important in explaining regional variations in infant and child mortality in India. For example, southern and western regions were the highest number of the urban poor population residing in a community where there was low utilization of prenatal care service and hospital delivery and higher-level socio-economic inequality. While in central region residing in communities with a high proportion of rural households and community poverty level appears high thus risks of death during childhood was significantly higher in this region compared with the south-east region.

Predicted probability results suggest that declined rates for infant and child mortality both were faster in the rural area as compared to urban poor. Because the disparity between urban poor and rich is much more higher than the disparity between rural poor and rich. The unequal distribution of maternal education and wealth status has tended to widen the rural-urban gap in infant mortality in India [14].

The study concluded that children belonged to economically poor household’s family higher isk of death than those have come from rich household family respectively. Although the substantial decline in infant and child mortality for both urban and rural areas, the economic inequality in childhood mortality in urban poor is much higher than in rural India. One of the advantages point in rural areas that some untrained doctors without medical specialists are available and they provide some medicine with minimum cost, while in urban poor people apart from this type of benefit. Although better care health care facilities are available in urban areas, but urban poor cannot be aware of this advantage due to the high significant cost, might explain the greater economic inequality in child health in urban areas. These findings have implied special attention to need policy implications. To address regional disparities in infant and child mortality in India, it is important to look beyond individual-level attributes. Policies that aim to improve the health condition of urban poor and rural counterparts. In urban areas, greater attention needs to be given to southern and western regions to reduce socio-economic inequalities with respect to infant and child mortality and provide equitable services to all people. The Mahatma Gandhi National Rural Employment Guarantee Scheme is a welcome step in arresting poverty, especially in the rural areas of the country [57]. In addition to strengthening MCH programs in rural areas, substantial efforts must also be made to improve household wealth and female education (including literacy). It is necessary to identify this fact and frame the policies and programs and to provide the specific needs for eliminate the poverty and improve the child survival of the states in the different geographic regions of India.

Ethics approval and consent to participate: Not applicable.

Consent for publication: Not applicable.

Availability of data and materials: Data used in this study for analysis is publicly available and can be obtained from: http://rchiips.org/NFHS/index.shtml.

Competing interests: The authors declare that they have no competing interests.

Funding: The authors received no specific funding for this work.

Author’s Contribution: Conceptualization U.D. and D.C.; Data curation UD; Formal analysis U.D. and D.C.; investigation DC; Methodology U.D. and D.C. All authors have read and agreed to publish version of the manuscript.

Acknowledgements: Not applicable.

Author details

¹ Research Scholar, Department of public health and mortality, International Institute for Population Sciences, Mumbai, Govandi Station Road, ORCID: 0000-0002-3791-4805

²Assistant Professor Bankura Christian College, Dept. of Geography India Email: [email protected]

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Is Childhood Mortality Higher in Urban Poor Than in Rural India?

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