Economic Survey 2015-16: Mother and Child
It is argued that some of the highest economic returns to public investment in human capital in India lie in maternal and early-life health and nutrition interventions. The investigation on the macro relationship between infant health and economic growth suggests that countries with better maternal and infant health “at take-off” grew faster over the subsequent 20 years.
Evidence from epidemiology and economics suggest that events which occur while a child is in utero (in the womb) or very young (below the age of 2) cast a long shadow over cognitive development and health status even in adulthood. A healthy mother is more likely to give birth to a healthy baby who learns better and stays on in school longer as a result.
The returns to investment are highest for programs that target young children and in-utero health. Programs targeting younger children are also relatively cheap in comparison to investments made in older children. For example, Iodine supplementation is relatively cheaper compared to improving teacher quality or re-designing institutions to raise school accountability, and also arguably requires less service delivery capacity from the state. Thus, on both the benefit and the cost side, early-life investments represent a real opportunity for fiscal and capacity-constrained governments.
Height-for-age in rural and urban India
Height is a good proxy for early-life conditions, and a predictor of later-life outcomes, because both height and cognitive development are partly determined by early-life environment and net nutrition. The data on height-for-age suggests that: first, there has been improvement over time in both urban and rural India; Second, there is a persistent rural-urban height gap which has not closed over the past decade; Third, despite the progress made, India remains a negative outlier – our children are on average 2 standard deviations shorter than the healthy average.
The state of maternal health
A Child’s “critical period” of physical and cognitive development is first 1000 days of the child on earth. A child’s health during this period ultimately depends on his mother’s health. The main causes of mortality in the first month of life differ substantially from the determinants of demise in the subsequent 11 months.
Relative to its level of economic development, India has a high neonatal mortality rate. Out of all the infants who die in India, 70 per cent die in the first month. A leading cause of this is low birth weight. Babies with low birth weight are more prone to dying in the first few days of life.
Data suggests that 42.2 per cent of Indian women are underweight at the beginning of pregnancy. By contrast, only 35 per cent of non-pregnant women of childbearing age are underweight. So, pregnant women are perversely more likely to be underweight. Not only are Indian women too thin when they begin pregnancy, they also do not gain enough weight during pregnancy to compensate for low pre-pregnancy body mass. Women in India gain only about 7 kilograms during pregnancy, which is substantially less than the 12.5-18 kg gain that the WHO recommends for underweight women. Women from richer households in India start pregnancy heavier, but do not gain more weight during pregnancy.
Another reason for poor maternal health is that social norms accord young women low status in joint households. A recent study shows that children of younger brothers in joint family households are significantly more likely to be born underweight than children of their older brother. This is attached in part to the lower status of younger daughter-in-laws in families.
Improving maternal health in India
Investing in maternal health could become a top policy priority of the government. The National Food Security Act 2013, legislating a universal cash entitlement for pregnant women of at least Rs. 6000 is a promising opportunity to improve nutrition during pregnancy. The Survey recommended pairing cash transfers with education about pregnancy weight gain. The cash transfer should be given in a single, lump-sum payment early in pregnancy to avoid delays, reduce administrative costs, and ensure that it is possible for the household to spend the money on better food during pregnancy.
The issue of open defecation
One significant and internationally unique source of early life disease in India is open defecation, especially in rural India. Open defecation in India is much more common than in even much poorer countries. India has the largest rural open defecation rate in South Asia by a very large margin. According to WHO and UNICEF Joint Monitoring Programme estimates, 61 per cent of rural Indians defecate in the open in 2015, compared with only 32 per cent of rural people in sub-Saharan Africa.
In India, income constraints may not be the main determinants of open defecation. Research suggests that rural Indian households reject the types of latrines promoted by the World Health Organization and the Indian government partly because their pits needed to be emptied every few years. Latrine pit emptying, which is routine in other countries, is substantially complicated by rural India’s history of untouchability- work of disposing of human faeces is associated with severe forms of social exclusion and oppression.
Evidence suggests that open defecation leads to child stunting, diarrhoea and environmental enteropathy. The Prime Minister’s Swachh Bharat Mission has raised the profile of the problem of open defecation. In the last year alone, the government has built over 80 lakh toilets. The next challenge in rural India is behavioural.
Breast-feeding
The breast-feeding example illustrates how some investments by the state can lead to tangible changes in social norms in a relatively short period of time. Programs like Janani Suraksha Yojana and other schemes under the Integrated Child Development Scheme delivered via Anganwadi program has increased the proportion of breast feeding mothers to 62%.
