Published in IIPS Mumbai, ENVIS center, Volume 3, No. 4,  December 2006

 

Relationship between piped water supply and child mortality: Evidences from Madhya Pradesh and West Bengal

Subhra Datta* and Mohua Guha**

Introduction  

After the declaration of the International Drinking Water Supply and Sanitation Decade of the 1980’s, many researchers have made an attempt to study the influence of sanitary reforms, particularly improved water supply, on the reduction in mortality in the nineteenth and the twentieth century. The decline in air-borne diseases, due to nutritional improvements, had been much stronger than the water and food borne diseases, due to advances in the purification of water and sewage disposal. The role played by municipal corporations thus has only been a secondary, reinforcing one (McKeown 1976). Many researchers have tried to test McKeown’s hypothesis by using data at the local level of the municipality and employing more refined statistical techniques, which was responsible for preventive health measures such as improved water supply and sanitation. In general, most of these studies have been conducted in the developed countries while only a handful in India have tried to explore the relationship between piped water supply and child mortality.

During the past decades, several attempts have been made to evaluate the studies describing the effectiveness of water and sanitation interventions on the incidence of morbidity and childhood mortality in the developing countries (Esrey and Habicht 1986; Esrey et al 1991; Pisani 1994). Although evidences were in favour of positive effects of one or more components of water supply, the literature reviews exhibit different results and conclusions. The beneficial health effects following improvements in water supply appear to be more dependent on the type of source of supply, the level of environmental contamination, the presence or absence of certain risk factors and the type of health indicators used. Keeping in view of the above concept, an attempt has been made in this paper to assess whether there is any relationship between provision of piped water facility and child mortality. This gives an evidence of the impact of water on child health.

Methods and materials 

The data for the present study has been derived from the National Family Health Survey (NFHS-2), 1998-99. Two states namely, Madhya Pradesh (including Chattisgarh) and West Bengal have been chosen for the study. Madhya Pradesh has been selected because the child mortality (138 per 1000 live births) has been found to be one of the highest and the percentage of households having piped water1 is comparatively low (63 percent). On the contrary, in West Bengal the percentage of households having piped water is 91 percent (the highest, except in Haryana, Punjab and Delhi) and child mortality is 68 per 1000 live births, which falls in medium category among the major states of India. For this study we have considered those women who have given birth in the last ten years derived from NFHS-2.

The number of respondents in Madhya Pradesh was 5800 and the corresponding figure for West Bengal was 2444. Among the selected group, 60 percent of the women in Madhya Pradesh and 88 percent in West Bengal had piped water supply in their households for drinking and other purpose.

First we have tried to look into the differences in the incidence of child loss2 among women who have piped water facility in their households compared to those who do not have such facilities. Child loss has also been explored by selected background characteristics of the study population. In order to find out the effect of piped water supply on child mortality, logistic regression has been used after controlling for the other known predictors of child mortality. 

Results

 Figure 1 shows the proportion of child loss among women having access to piped water and those not having such facility. In both the selected states child loss is quite high in case of women who do not have access to piped water compared to those who have (27 percent compared to 22 percent in Madhya Pradesh and 15 percent compared to 13 percent in West Bengal).

 * Junior Research Fellow, International Institute for Population Sciences, Deonar, Mumbai – 88, India.

Email: sdiips@rediffmail.com

** Research Scholar, International Institute for Population Sciences, Deonar, Mumbai – 88, India.

Email: gmohua1@yahoo.co.in

 

 

 

 

Risk ratio

 The ratio of proportion of child loss in case of women who have no piped water in their households compared to those having piped water facility has been found to be 1.24 times higher (table not shown) in Madhya Pradesh. Though, the ratio in West Bengal is comparatively low (1.17), nonetheless, it is evident from figure 1 that women residing in households with no access to piped water supply indirectly contribute to child loss. 

Figure 1: Percent of women who have experienced child loss among households having access to piped water facility versus those who do not have such facility, NFHS-2, 98-99

 

   Table 1 presents differentials by the selected background characteristics of the study women who have experienced child loss having piped water in their household compared to those who do not have such facilities and expectedly, the proportion of child loss has been found to be higher in some population groups than in others. In both the states, women residing in rural areas have experienced higher percentage of child loss compared to their urban counterparts. In Madhya Pradesh, the percentage of women who have experienced child loss is 11 times higher  (15 and 26 percent in urban and rural areas respectively) whereas the same in case of West Bengal is 9 and 14 percent respectively.

As anticipated, the percentage of child loss declines sharply as the educational level of the mother increases. Education is expected to reduce child mortality due to multiple reasons. Basic education, especially female education, is now widely considered as one of the most powerful factors in explaining infant and child mortality. As educated mothers are more knowledgeable about nutrition, hygiene and health care, mortality is expected to be lower among the children of the educated mothers. Among the illiterate mothers of Madhya Pradesh child loss is as high as 27 percent whereas in case of the mothers who have completed at least high school it drops down to six percent, a sharp decline by 21 percentage points. The same proportion in case of West Bengal is 17 and 3 percent respectively. In both the states the incidence of child loss declines considerably with increase in household standard of living. For instance, in Madhya Pradesh, 28 percent of the women in low standard of living have lost child in the study population compared to 11 percent of women in high standard of living. Similar situation also prevails in West Bengal where the child loss among the women in the low standard of living is more than twice than those women who are from high standard of living (16 and six percent respectively). Child loss does not vary significantly among the mothers whose body mass index3 (BMI) is less than 18.5 and among those whose BMI is 18.5 or above in both these states. There is no reason to conclude that child loss is less among mothers whose BMI is less than the specified normal, which is 18.5, since the nutritional status of mothers have direct bearing on child survival. The results from West Bengal are more in expected line (14 percent for those women having BMI less than 18.5 and 13 percent for those women having BMI 18.5 or above).

            Women’s autonomy is likely to have a significant impact on the demographic and health seeking behaviour of the couples by altering women’s relative control over fertility and contraceptive use, and also by influencing their attitudes (towards sex composition of the children) and abilities (for example, the ability to obtain health care services for themselves and their children) (Sen and Batliwala 1997). To assess the status of autonomy enjoyed by the women, NFHS-2 asked about women’s participation in household decision-making, their freedom of movement and access to money, which they can spend as they wish. For the present study, we have defined “autonomy”, as, if the respondent decides on obtaining health care or she is allowed to have money set aside or if the respondent herself decides how money will be spent which she earns. It is understood that women’s autonomy defined as above refers to partial autonomy of women and ignores certain other aspects of autonomy.

 

 

 

 

 

 

Table 1: Background characteristics of women who have experienced child loss according to the availability of piped water, NFHS-II, 1998-99

 

 
Characteristics

Madhya Pradesh

West Bengal

Not

piped

Piped

Total

Not piped

Piped

Total
Type of place of residence

Urban

19.3

14.7

15.2

10.5

8.9

9.1

Rural

27.0

24.6

25.9

16.5

14.0

14.3
Educational level

Illiterate

29.0

25.8

27.4

16.1

17.6

17.4

Literate,<middle complete

18.3

17.4

17.9

14.8

10.7

11.0

Middle school

 Complete

8.5

12.9

12.1

20.0

4.8

6.0

High school complete and above

9.5

6.0

6.4

-

3.6

3.3
SLI

Low

28.5

27.7

28.2

15.1

16.2

16.1

Medium

26.9

21.2

23.9

14.9

10.9

11.3

High

11.2

10.8

11.0

25.0

5.0

6.1
BMI

 

 

 

 

 

 

<18.5

27.1

21.5

23.7

13.6

14.1

14.0

>=18.5

26.3

21.7

23.8

18.0

12.2

12.8
Autonomy

No

28.4

24.2

26.3

12.0

14.8

14.5

Yes

24.6

19.8

21.5

17.5

11.4

12.2
Religion

Hindu

26.6

22.1

24.2

15.5

12.4

12.8

Muslim

6.3

17.9

17.3

16.7

14.5

14.5

Others

33.3

14.8

23.0

7.1

13.0

11.7
Age at first birth

<19

27.7

24.9

26.3

16.0

15.1

15.2

>=19

23.7

16.5

18.9

14.3

10.7

11.1
Preceding birth interval

<24

40.6

32.2

35.7

33.3

22.6

24.0

>=24

19.3

16.1

17.6

11.3

9.9

10.0
Parity

<=2

28.4

21.9

24.5

9.1

11.0

10.7

>2

25.2

21.3

23.2

24.8

16.6

17.6
Exposure to media

No

29.2

27.6

28.5

15.9

16.2

16.1

Yes

21.5

16.9

18.5

14.6

10.5

10.9
Mothers working status

Not working

23.7

17.1

19.4

11.0

13.4

13.1

Working

28.1

25.8

27.0

23.7

12.3

14.2

Child wanted (last child)

No

18.8

14.9

16.2

13.3

8.2

8.6

 Yes

24.2

19.9

21.8

12.3

9.9

10.1

Total

26.8

21.7

23.8

15.3

13.1

13.4

In both the states, child loss varies substantially among women who do not have any autonomy compared to those who have some autonomy, the percentage being 26 and 15 respectively in case of Madhya Pradesh and West Bengal for the former group compared to 22 and 12 percent respectively in the later category. Child loss by religion depicts different picture in Madhya Pradesh and West Bengal. Religion has been grouped into three categories, Hindu, Muslim and others, which include those other than Hindus and Muslims. In Madhya Pradesh the incidence of child loss is higher among Hindus compared to Muslims (24 and 17 percent respectively) whereas in West Bengal, Hindu women experience fewer child loss compared to Muslim women (13 and 15 percent respectively). Mortality differentials by religion also reflect influences other than religion itself. For example, larger proportions of Muslims than Hindus live in urban areas where child mortality is low in general. It is possible that larger proportion of Muslims live in urban areas in case of Madhya Pradesh compared to West Bengal. Pandey et al 1998 using NFHS-1 data has shown that child mortality rates among Hindu and Muslim children reduces considerably after controlling other demographic and socio-economic variables.

            Age at birth is bound to have an impact on child mortality. If the age at first birth is less than 19 years then the incidence of child loss is much more higher as is evident in case of Madhya Pradesh and West Bengal (26 and 15 percent respectively) compared to those who had first birth at 19 years or above (19 percent and 11 percent respectively). The result is likely since before the age of 19 years, the mother’s body is physiologically not well developed to bear child and hence it may result in low weight at birth resulting in high neonatal mortality. Also pregnancy before age 19 will have adverse effects on the health of mothers. 

 

 

 

 

 

Preceding birth interval is yet another important determinant of child loss. It is observed that if birth interval is less than 24 months then child death is higher, both in case of Madhya Pradesh and West Bengal. In fact in Madhya Pradesh, child loss increases from 18 percent in case if preceding birth interval is 24 months or more to 36 percent if preceding birth interval is less than 24 months. The difference in West Bengal is more (10 and 24 percent respectively). The length of previous birth interval is likely to affect child mortality directly. Also a substantial portion of the association between birth interval and mortality risk may reflect the effect of factors that are correlated with birth intervals. For example, shorter birth intervals are likely to occur in large families, and large families tend to live in rural areas where medical facilities and other survival enhancing resources are less readily available. Child loss is also more among women of higher parity in case of West Bengal where the proportion increases from 11 percent in women of at most two parities to 18 percent in women of more than two parities. Parity does not show similar effect in Madhya Pradesh. Similarly, child loss is more among women who are not exposed to mass media4. Child loss is more by ten percentage points in case of Madhya Pradesh if women have no exposure to mass media – 29 percent in case of no exposure and 19 percent in case of any exposure. The effect of mass media in reducing child mortality is less in West Bengal where it reduces by 5 percentage points (16 to 11 percent) in case of those having exposure to mass media compared to the non-exposed group. The incidence of child deaths is also higher in case of working mothers, which holds true for both the states considered in this paper. The chance of child death is almost more than seven percentage points in case of Madhya Pradesh for working women – 19 percent for not working and 27 percent for working women. In West Bengal it increases from 13 percent to 14 percent in the two categories.

On the whole, in Madhya Pradesh, child loss was observed to be more among women who do not have access to piped water except in case of Muslim women and those having completed middle school. On the contrary in West Bengal, no such specific trend was found, where child loss has

been observed to be lower among the women who

do not have access to piped water even in case of

those who are illiterate, belong to low SLI, whose BMI is less than 18.5, have parity less than equal to two, enjoy no autonomy, belong to religion other than Hindus and Muslims and fall in the non-working category.

Discussion and conclusion 

Using data from NFHS-2 for the states of Madhya Pradesh and West Bengal, we have tried to investigate the relationship between piped water supply and child mortality. Even after controlling some known indicators of child mortality such as parity, education of mother, preceding birth interval etc, piped water supply significantly reduces child deaths in case of West Bengal. But it does not exert similar effect on child loss in the state of Madhya Pradesh. Among the selected predictors, piped water supply, mother’s education, BMI and preceding birth interval has significant effect on the incidence of child loss in West Bengal whereas religion, mother’s educational level, working status, standard of living and child wanted or not has significant effect on child loss in case of Madhya Pradesh.

Now we will discuss whether the condition in Madhya Pradesh was such that no effect of water supply could be expected at all. Several factors may have played a role here. The conditions prevailing before the introduction of the piped water supply may have been such that only a minor or no effect could be expected. The ‘threshold-saturation theory’ points out that there is not only an upper limit of saturation where further investments in sanitation do not result in further improvement of health status, but also a threshold of socio-economic and health status below which no health benefits can be achieved by investing in sanitation (Cvjetanovic 1986). With a high level of environmental contamination, the beneficial effect on health due to improved water supply may be greatly reduced or even nullified (Masse et al 1993). Given the mortality situation and further the socio-economic characteristics, both are plausible. Similarly in areas, where breastfeeding was not universal or of short duration, water and sanitation facilities could be expected to produce a large health effect.

Several misclassifications can also be imagined in case of our study. First of all uncontaminated water may become polluted during inappropriate transport and storage leading to the ingestion of contaminated water (Esrely and Habicht 1986). Household characteristics too were

measured at a time, which did not correspond with that of birth or death of the child. Improvement in household water supply is a necessity but not a sufficient pre-condition for improved health status. Improvements in hygiene and sanitary conditions are also required, particularly to attain a reduction in diarrhoeal diseases, which is reported to be 23 percent in Madhya Pradesh compared to eight percent in West Bengal among the children within two weeks before the survey.

 

 

 

 

 

 

References 

Cvjetanovic, B (1986) Health effects and impact of water supply and sanitation. World Health Statistics Quarterly 39: pp 105-117. 

Esrey, S. A. and J. P. Habicht (1986) Epidemiologic evidence for health benefits from improved water and sanitation in developing countries. Epidemiologic Reviews 8: pp 117-127. 

Esrey, S. A, J. B. Potash, L. Roberts and C. Shiff (1991) Effects of improved water supply and sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma. Bulletin of the World Health Organization 69 (5): pp 609-621. 

Massee Bateman, O. S. Smith and P. Roark (1993) A comparison of the health effects of water supply and sanitation in urban and rural areas of five African countries. Washington DC: US Agency for International Development. 

McKeown, T (1976) The modern rise of population. London: Edward Arnold. 

Pandey, Arvind, Minja Kim Choe, Norman Y. Luther, Damodar Sahu, and Jagdish Chand (1998) Infant and child mortality in India. National Family Health Survey Subject Reports No. 11 Mumbai: International Institute for Population Sciences; and Honolulu: East-West Center. 

Pisani, V (1994) Improving personal and domestic hygiene: does it reduce diarrhoeal disease? M. Sc Public health in developing countries, University of London. 

Retherford, Robert D, Minja Kim Choe, Shyam Thapa, and Bhakta B. Gubhaju (1989) To what extent does breastfeeding explain birth-interval effects of early childhood mortality? Demography 26 (3): pp 439-450. 

Sen, Gita and Srilatha Batliwala (1997) Empowering women for reproductive rights: Moving beyond Cairo. Paper presented at the Seminar on female empowerment and demographic processes: Moving beyond Cairo, IUSSP, Lund, Sweden, 21-24 April.

1 Piped water is defined as if water is piped into residency/yard/plot or water is taken from public hand pump or public tap or if there is hand pump in residency/yard/plot.

2 Child loss has been defined as the death of a child before attaining his/her fifth birthday, i.e., under age five. 

3 Calculated as the ratio of the weight in kilograms to the square of the height in metres (Kg/m2). 

4  Exposure to mass media is defined as whether the respondent reads newspaper once a week or watches TV every week or listens to radio every week or goes to cinema or watches a movie at least once a week.