Issues Related to Children in India

Child and Adolescent Labour (prohibition and regulation) Act 1986 defines the child as a person who has not completed the age of 14 years.

India is the country where children’s are considered as the forms of god, but these little God’s are facing very serious problem in social life. India has become one of the fastest growing developing countries along with highest number of child labors in the world.

All metro cities of India are home for the large number of children’s aged between 5-14, who are begging in trains, sleeping on streets, living in slums and working in the most innocent phase of human life. The root cause of child abandonment are poverty, population and non-educational, India also host one of the biggest slum.

Violence against children is widespread and remains a harsh reality for millions of children from all socio-economic groups in India. Both girls and boys in India face early marriage, domestic abuse, sexual violence, violence at home and in school, trafficking, online violence, child labour and bullying. All forms of violence, abuse and exploitation have lifelong consequences on children’s lives. 

Child Issues in India

• Child Labour
• Child Marriage
• Child health & Malnutrition
• Child Abuse
• Child Pornography
• Child Prostitution
• Child Mortality
• Gender bias against girl child
• Street Child
• Forced Begging
• Juvenile Delinquency
• Drugs and Alcoholisms amongst Children
• Lack of access to education, etc.

Child Labour

• Child labour typically means the employment of children in any manual work with or without payment. It is a deep rooted social ill in India.
• Child labour refers to the employment of children in any work that deprives them of their childhood, interferes with their ability to attend regular school, and that is mentally, physically, socially or morally dangerous and harmful.
• The Census of India 2011 reports 10.1 million working children in the age group of 5-14 years, out of whom 8.1 million are in rural areas mainly engaged as cultivators (26%) and agricultural labourers (32.9%).
• Even though there was a decline in the number of working children to 3.9% in 2011 from 5% in 2001, the decline rate is grossly insufficient to meet target 8.7 of the UN Sustainable Development Goals (SDGs), which is to end child labour in all forms by 2025.
• India tops the list when it comes to the number of children still living and working in bonded labour and slave conditions.
• The side-effects of working at a young age are:
  • Risks of contracting occupational diseases like skin diseases, diseases of the lungs, weak eyesight, TB etc.;
  • Vulnerability to sexual exploitation at the workplace;
  • Deprived of education.
  • They grow up unable to avail development opportunities and end up as unskilled workers for the rest of their lives.

Factors leading to Child Labour

• Increase in ‘out of school’ children: UNESCO estimates that around 38.1 million children are “out of school”.
• Economic crisis: The economic contraction and lockdowns lead to income reductions for enterprises and workers, many of them in the informal economy.
• Socioeconomic Challenges: caused by the return of migrant workers has compounded the problem.
• Issues in the Indian Economy: India experienced slower economic growth and rising unemployment even before the pandemic.
• ‘Digital divide’: Lack of access to the internet, Digital devices have forced challenges in distant learning and online learning for children. According to the NSS Report titled ‘Household Social Consumption on Education in India’ only 24% of Indian households had access to an Internet facility.
• Unorganised Sector Growth: Due to stringent labour laws, industries prefer to hire contractual labour than permanent hiring.
• Weak Laws:  Laws are not  updated according to the seriousness of the situation.
• Other reasons: increased economic insecurity, lack of social protection and reduced household income, children from poor households Children are being pushed into child labor.

Impacts of child labour

• Affect childhood: Child labour takes away a child of his/her childhood. It not only denies his/her right to education but also right to leisure.
• Affect adult life: Child labour prevents children from gaining the skills and education they require to have opportunities for decent work when they become an adult.
• Major health and physical risks: as they work long hours and are needed to do tasks for which they are physically and mentally unprepared. Working in hazardous situations adversely impacts a child’s physical and mental health and affects intellectual, emotional and psychological development.
• Poverty: Child labour is both a cause and consequence of poverty. Household poverty makes children enter the labour market to earn money = they miss out on an opportunity to get an education = further continuing household poverty across generations in a vicious cycle.
• Affect country as a whole: Existence of a large number of child labourers has long term effect on the economy and it is a serious obstacle to the socio-economic welfare of the country.

As per the Census of 2011, there are five major states in India that constitute 55% of the total number of child labour in the country.

States	Percentage	Numbers (In million)
Uttar Pradesh	21.5	2.18
Bihar	10.7	1.09
Rajasthan	8.4	0.85
Maharashtra	7.2	0.73
Madhya Pradesh	6.9	0.70

Impact of the Pandemic

• The coronavirus pandemic is forcing India’s children out of school and into farms and factories to work, worsening a child-labour problem that was already one of the direst in the world.
• The Covid-19 crisis has brought additional poverty to these already vulnerable populations and may reverse years of progress in the fight against child labour- ILO
• The nationwide lockdown imposed, pushed millions of people into poverty, which is encouraging trafficking of children from villages into cities for cheap labour.
• School closures have aggravated the situation and many millions of children are working to contribute to the family income. The pandemic has also made women, men and children more vulnerable to exploitation.
• According to the International Labour Organisation (ILO) some 25 million people could lose their jobswith those in informal employment suffering most from lack of social protection during this pandemic.
• As per the Centre for Monitoring Indian Economy’s (CMIE) weekly tracker survey, the impact of COVID-19 has already pushed the urban unemployment rate to 30.9%
• Orphaned children are particularly vulnerable to trafficking and other exploitation like forced begging, or child labour. In such families, there is also the likelihood of older children dropping out of school to support their younger siblings.
• Children are seen as a stop-gap measure to fill jobs left vacant by migrant laborers who fled cities for their rural homes during the lockdown.
• A total of 591 children were rescued from forced work and bonded labour from different parts of India during the lockdown by Bachpan Bachao Andolan, a civil society group on children’s rights

Challenges before policy makers with respect to child labour

• Definitional issue: One of the biggest challenges in eradicating child labour is the confusion around the definition of a child, in terms of age, in various laws dealing with child labour.
• Lack of identification: Age identification of children is a difficult task in India due to the lack of identification documents. Child labourers often lack school registration certificates and birth certificates, creating an easy loophole in the law to exploit. Most often the children of migrant workers working as labourers and those employed in domestic work go unreported.
• Weak enforcement of law and poor governance: Weak enforcement of the law, lack of adequate deterrence and corruption is a major hurdle in eradicating child labour.
• The pandemic is hampering enforcement of anti-child labour laws, with fewer workplace inspections and less vigorous pursuit of human traffickers.
• NGOs point to the fact that the real spike in child labour is yet to come. When economic activity begins accelerating, there is a risk of returning migrants taking children along with them to the cities.
• Children’s access to education, basic nutrition and other critical requirements for their development and wellbeing, have suffered a huge setback and many new children have fallen into the trap of forced labour along with further deteriorated conditions for the existing child labourers.
• Incoherency between laws that prescribe a minimum age for employment and those for completion of compulsory school education. It also means that the expansion of quality universal basic education has to extend beyond the fulfilment of statutory provisions.
• Multiple forms exist: Child labour is not uniform. It takes many forms depending upon the type of work that children are made to do, the age and sex of the child and whether they work independently or with families.
• Due to this complex nature of child labour, there is no one strategy that can be used to eliminate it.
• The absence of national legislation to give effect to global conventions on the employment of children in hazardous industries, as well as on the minimum age of work.
• The lack of harmony between global commitments and domestic priorities.
• Lack of effective labour inspections in the informal economy. Around 71% of working children are concentrated in the agriculture sector, with 69% of them undertaking unpaid work in family units.

Government measures undertaken to eradicate Child labour in India

• Child Labour (Prohibition and Regulation) Act(1986) to prohibit the engagement of children in certain employments and to regulate the conditions of work of children in certain other employments
• Child Labour (Prohibition and Regulation) Amendment Act, 2016 : The Amendment Act completely prohibits the employment of children below 14 years.
• The amendment also prohibits the employment of adolescents in the age group of 14 to 18 years in hazardous occupations and processes and regulates their working conditions where they are not prohibited.
• On World Day Against Child Labour (June 12) in 2017, India ratified two core conventions of the International Labour Organization on child labour.
• National Policy on Child Labour (1987), with a focus more on rehabilitation of children working in hazardous occupations and processes, rather than on prevention.
• Juvenile Justice (Care and Protection of Children) Act2000 and amendment of the JJ Act in 2006: includes the working child in the category of children in need of care and protection, without any limitation of age or type of occupation.
• Section 23 (cruelty to Juvenile) and Section 26 (exploitation of juvenile employee) specifically deal with child labour under children in need of care and protection.
• Pencil: The government has launched a dedicated platform viz. pencil.gov.in to ensure effective enforcement of child labour laws and end child labour.
• The Right to Education Act 2009 has made it mandatory for the state to ensure that all children aged six to 14 years are in school and receive free education. Along with Article 21A of the Constitution of India recognizing education as a fundamental right, this constitutes a timely opportunity to use education to combat child labour in India.
• Amendments made to the Scheduled Castes and Scheduled Tribes (Prevention of Atrocities) Act prescribes severe punishment for people found guilty of retaining bonded labour.
• The amendment stipulates rigorous imprisonment for those who force children to beg, handle or carry human waste and animal carcasses.
• The draft National Policy for Domestic Workers, when goes into force, will ensure minimum Rs.9,000 salary for household helpers.
• Every police station in the country has a separate cell for juvenile, women and child protection.
• Many NGOs like Bachpan Bachao Andolan, CARE India, Child Rights and You, Global march against child labour, RIDE India, Child line etc. have been working to eradicate child labour in India.

Way Forward

• Abolition of child trafficking, elimination of poverty, free and compulsory education, and basic standards of living can reduce the problem to a great extent.
• Strict implementation of labour laws is also essential in order to prevent exploitation by parties or multinational companies
• Strengthening policy and legislative enforcement, and building the capacities of government, workers’ and employers’ organisations as well as other partners at national, State and community levels should be prioritized.

Education:

• Spreading literacy and education is a potent weapon against the practice of child labour, because illiterate persons do not understand the implications of child labour
• The single most effective way to stem the flow of school-aged children into child labour is to improve access to and quality of schooling.

Eradicate Unemployment:

• Another way to stop child labour is to eliminate or rein in unemployment. Because of inadequate employment, many families cannot afford to meet all their expenses. If employment opportunities are increased, they will be able to let their children read and write and become worthy citizens
• Continued progress against child labour requires policies that help mitigate the economic vulnerability of households. Accelerating progress towards universal social protection is key, as social protection helps prevent poor households from having to rely on child labour as a coping mechanism.

Role of Panchayat: As nearly 80% of child labour in India emanates from rural areas, the Panchayat can play a dominant role in mitigating child labour. In this context, panchayat should:

• Generate awareness about the ill-effects of child labour,
• Encourage parents to send their children to school,
• Create an environment where children stop working and get enrolled in schools instead,
• Ensure that children have sufficient facilities available in schools,
• Inform industry owners about the laws prohibiting child labour and the penalties for violating these laws,
• Activate Balwadis and Aanganwadis in the village so that working mothers do not leave the responsibility of younger children on their older siblings.
• Motivate Village Education Committees (VECs) to improve the conditions of schools.

Attitude change:

• It is important that the attitudes and mindsets of people are changed to instead employ adults and allow all children to go to school and have the chance to learn, play and socialize as they should.
• A sector-wide culture of child labour-free businesses has to be nurtured.
• Coordinated policy efforts should be taken to provide employment and income support to all informal sector workers to stimulate the economy and labour demand.
• States should prioritise efforts to continue education for all children, using all available technology.
• Financial support or relaxation of school fees and other related school expenses should be given to those children who wouldn’t be able to return to school otherwise.
• School authorities need to ensure that every student will have free lunches at home until schools open. Special efforts should be taken to identify children orphaned due to COVID-19, and arrangements of shelter and foster care for them should be made on a priority basis.

Integrated Approach: 

• Child labour and other forms of exploitation are preventable through integrated approaches that strengthen child protection systems as well as simultaneously addressing poverty and inequity, improve access to and quality of education and mobilize public support for respecting children’s rights.

Treating Children as Active Stakeholder: 

• Children have the power to play a significant role in preventing and responding to child labour.

Eliminating child labour is firmly placed within Goal 8 of the SDGs. A stronger nexus between the discourse on SDGs and the discourse on eliminating child labour can take the advantage of complementarities and synergies of a wide range of actors engaged in both areas of work. The fight against child labour is not just the responsibility of one, it is the responsibility of all.

Child Marriage

• Child marriage usually refers to a social phenomenon practiced in some societies in India, where a young child (usually a girl below the age of fifteen) is married to an adult man. A second form of practice of child marriage is that in which the parents of the two children (the girl and boy) arrange a future marriage. In this practice, the individuals (the boy and girl) do not meet one another until they reach the marriageable age, when the wedding ceremony is performed.
• It is defined as a marriage of a girl or boy before the age of 18 and refers to both formal marriages and informal unions in which children under the age of 18 live with a partner as if married. The Prohibition of Child Marriage (Amendment) Bill, 2021, fixes 21 years as the marriageable age for women.
• Child marriage is a global issue fuelled by gender inequality, poverty, social norms and insecurity, and has devastating consequences all over the world. High levels of child marriage reflect discrimination and lack of opportunities for women and girls in society.
• Recent analysis by UNICEF points out that one in three of the world’s child brides live in India. It has also warned India against the increase in child marriages owing to the adversaries of COVID-19.  To achieve the commitment of ending child marriages by 2030, it becomes important to integrate the COVID -19 responses with child marriage elimination efforts.
• The factors that encourage its subsistence are usually a combination of poverty, the lack of education, continued perpetration of patriarchal relations that encourage and facilitate gender inequalities, and cultural perspectives that encourage the phenomenon to thrive.

Facts and figures about the prevalence of Child marriage in India

• United Nations Children’s Fund (UNICEF) estimates suggest that each year, at least 1.5 million girls under 18 get married in India, which makes it home to the largest number of child brides in the world – accounting for a third of the global total.
• Child marriage is widespread across India, with nearly half of brides married as girls.
• While there has been a decline in the incidence of child marriage nationally (from 54 per cent in 1992-93 to 33 per cent today) and in nearly all states, the pace of change remains slow, especially for girls in the age group 15-18 years.
• Child marriage is more prevalent in rural areas (48 per cent) than in urban areas (29 per cent).
• There are also variations across different groups, particularly excluded communities, castes and tribes – although some ethnic groups, such as tribal groups, have lower rates of child marriage compared with the majority population.
• Drop out of school, have a low-paid job and limited decision-making power at home. A girl with 10 years of education has a six times lower chance of being pushed into marriage before she is 18.
• 40% of the world’s 60 million child marriages take place in India according to the National Family Health Survey.
• India has the 14th highest rate of child marriage in the world, according to the International Center for Research on Women.
• NFHS-5 data show that about 25% of women aged 18-29 years married before the legal marriageable age of 18.
  • West Bengal has the highest prevalence (42%), followed by Bihar and Tripura (40% each).
  • Oddly, the decline in child marriage has been paltry at best in these high-prevalence States.
  • At the other end of the spectrum are Goa, Himachal Pradesh and Kerala (6% to 7%).
  • 39% of child marriages in India take place among Adivasis and Dalits.
  • The share of advantaged social groups is 17% and the remaining share is of Other Backward Classes.

Factors leading to child marriage in India

• Lack of education: A big determinant of the age of marriage is education. Around 45% of women with no education and 40% with primary education married before the age of 18, according to NFHS-4.
• Seen as a Burden: Economically, child marriages work as mechanisms that are quick income earners. A girl child is seen as a leeway to a large dowry, to be given to her family upon her marriage.
• Poverty: In terms of economic status, women from poor households tend to marry earlier. While more than 30% of women from the lowest two wealth quintiles were married by the age of 18, the corresponding figure in the richest quintile was 8%.
• Social background:Child marriages are more prevalent in rural areas and among Scheduled Castes and Scheduled Tribes.
• Trafficking: Poor families are tempted to sell their girls not just into marriage, but into prostitution, as the transaction enables large sums of money to benefit the girl’s family and harms the girl. There is apathy towards their girls and the money by selling their girls is used for the benefit of their sons
• Girls are often seen as a liability with limited economic role. Women’s work is confined to the household and is not valued. In addition, there is the problem of dowry. Despite the fact that dowry has been prohibited for five decades (Dowry Prohibition Act, 1961), it is still common for parents of girls in India to give gifts to the groom and /or his family either in cash or kind. The dowry amount increases with the age and the education level of the girl. Hence, the “incentive” of the system of dowry perpetuates child marriage.
• The families and girls who might benefit from social protection programmes are not always aware of them and these schemes are often limited to providing cash transfers without the accompanying messages to address the multi-dimensional nature of child marriage.

Interlinkages of poverty and child marriages in India

• Poverty is the main reason behind early marriages in rural areas as most families have large family sizes.
• With such families, most parents are unable or unwilling to take care of their children.
• Early marriages are therefore seen as opportunities to reduce this burden.
• Others who cannot feed or send their children to school, give young girls off marriage to older men.
• Some parents arrange marriages between their children and their creditors as a way of settling debts.
• Without the safety net of schools, the girl child being forced into marriage is cut off from any possible communication with a teacher or counselor.
• Most of them do not have access to child helplines though the government has set these us.
• There was 88 percent increase in child marriages across the country in August 2020 as compared to August 2019, as per a reply by Union Ministry of Women and Child Development to a RTI sought by Rajya Sabha MP.
• Many people in India have lost their jobs and life savings during the pandemic. This has forced parents to marry off their daughters at an early age to reduce the financial burden.
• Apart from poverty, weak law enforcement, patriarchal norms and concern about family honor are factors contributing to early marriage during the COVID- 19 pandemic.
• West Bengal is one of the five states in India that have a high prevalence of early marriages. Though 12% of girls between 15 and 19 years of age are married off nationally, in West Bengal the figure stands at 25.6%.
• Madhya Pradesh recorded 46 child marriages between November 2019 and March 2020, a figure that that jumped to 117 in just three months of the lockdown from April to June 2020, data provided by ChildLine India
• According to ChildLine India, across India 5,214 child marriages were reported in the first four months of lockdown between March to June.
• UNICEF has said that in Madhya Pradesh where child marriages are a constant challenge, economic pressures due to the pandemic has pushed poor parents to marry off girls early.
• As many as 204 child marriages were performed in 25 out of 33 districts in Telangana during the lockdown period from March 24 to May 31 in 2020.

Impact of child marriage on Indian economy

• Child marriage negatively affects the Indian economy and can lead to an intergenerational cycle of poverty.
• Girls and boys married as children more likely lack the skills, knowledge and job prospects needed to lift their families out of poverty and contribute to their country’s social and economic growth.
• Early marriage leads girls to have children earlier and more children over their lifetime, increasing economic burden on the household.
• Child marriage is estimated to cost economies at least 1.7 percent of their GDP.
• It increases total fertility of women by 17 percent, which hurts developing countries battling high population growth.
• As per IRCW study, the welfare benefit in ending child marriage is estimated to be $22.1 billion globally in the first year (2015). This number increases to $566 billion annually by 2030, for a cumulative welfare benefit of more than $4 trillion. Considering how one out of three such marriages happen in India, this impact is huge on India.
• Decreased household sizes would lead to an increased availability of funds which then could be used to pay for food, education, health care and other expenses for other members of the household.

Government measures, Laws and Policies to curb Child Marriages in India

• The Child Marriage Restraint Act, 1929.
  • The object is to eliminate the special evil which had the potentialities of dangers to the life and health of a female child, who could not withstand the stress and strains of married life and to avoid early deaths of such minor mothers.
  • It extends to the whole of India except the State of Jammu and Kashmir and it applies also to all citizens of India within and beyond India.
• Prohibition of Child Marriage Act, 2006
  • This Act replaced the Child Marriage Restraint Act, 1929 which was enacted during the British era.
  • It defines a child to mean a male below 21 years and female below 18 years.
  • “Minor” is defined as a person who has not attained the age of majority as per the Majority Act.
  • It envisages preventing child marriage with punishments of rigorous imprisonment for two years and/ or fine of Rs. 1 lakh.
  • The Act also provides for the appointment of Child Marriage Prohibition Officer whose duties are to prevent child marriages and spread awareness regarding the same.
• Hindu Marriage Act, 1956: Under Hindu Marriage Act, there are no certain provisions for punishing the parents or people who solemnized the marriage.
  • A girl can get the marriage annulled only if she wants to get married before attaining the age of fifteen years and she challenges the marriage before turning eighteen.
• Muslim Personal Law: Under the Muslim Laws, there is no bar to child marriage. The couple after marriage has an “option of puberty” known as Khayar-ul-bulugh in which they can repudiate the marriage after attaining the age of puberty. 
• The Protection of Children from Sexual Offences Act, 2012: which aim at protecting children from violation of human and other rights. 
• A parliamentary standing committee is weighing the pros and cons of raising the age of marriage for women to 21, which has been cleared by the Union Cabinet. 
• State Governments are requested to take special initiative to delay marriage by coordinated efforts on Akha Teejthe traditional day for such marriages;
• Advertisements in the press and electronic media educating peoples about the issue of Child Marriage etc are also being taken up.
• Platforms such as the International Womens Day and the National Girl Child Day are used to create awareness on issues related to women and to bring to the centre stage issues such as child marriage.
• Through the Sabla programme of Women and Child Ministry, adolescent girls in the age group of 11 to 18 years are imparted training with regard to legal rights of women which also includes the Prohibition of Child Marriage Act, 2006.

Measures needed to prevent Child Marriages

Education

• It is one of the most effective strategies to protect children against marriage.
• When girls are able to stay in school an attitudinal change can also occur towards their opportunities within the community.

Congregating child protection workers:

• One way of keeping a check on child marriages during the pandemic would be to ensure that there is a strong cohort of child protection workers among essential health workers.
• India has a robust system of grassroots workers who have done commendable work in ensuring that health and other social security services reach people on in these dire times.
• If such workers were incorporated into the system, they could keep a check on girl children at risk of early marriage and take steps to avert these.
• This could be in the form of awareness counseling and helping some benefits reach the family concerned.

Gender sensitization programs:

• Gender training programs should be spread throughout the district for police and NGOs. Government of India along with organizations like UNICEF and NGOs should make the efforts for the implementation of the convergent national strategy, which includes:

Law enforcement:

• Capacity-building on laws, support mechanisms such as a child marriage telephone hotline should be implemented in true letter and spirit. E.g: Odisha Child Marriage Resistance Forum.

Girls’ empowerment:

• Imparting Life skills, protection skills, higher education and employment opportunities should be ensured to each and every girl child.
• Primary and secondary education for girls should be promoted.

Community mobilization:

• Working with influential leaders, oaths and pledges, counselling, folk and traditional media.
• Government’s partnerships with civil society organizations and communities are key to supporting community mobilization efforts and mindset changes and partnerships with the media are very important for raising awareness of child marriage.

Promoting convergence:

• programs and sectors at all levels should be converged, in particular with education and social protection schemes and programmes.
• Government of India has already enacted laws like Child marriage prohibition act 2006 and started many initiatives like Beti Bachao Beti Padhao, Sukanya Samriddhi Yojana to incentivize the people to give equal treatment to their daughters as their sons.

Incentives:

• Conditional Cash Transfer schemes addresses issues more towards the individual rather than the household, which is the focus of the government.
• Certain national schemes, is, related to maternity benefits and the survival and education of the girl child which addresses the problem of child marriage directly or indirectly. E.g.: Dhanalakshmi, Rajiv Gandhi Scheme for Empowerment of Adolescent girls (SABLA)
• CCTs have benefits of legal protection of the marriage as well as ensuring education of girls.

Government of India has the biggest responsibility towards ensuring better childhood of every child. Every child irrespective of socio-economic status is entitled to the quality education, health facilities and freedom and space to enjoy childhood.

Malnutrition

• Malnutrition, in all its forms, includes undernutrition (wasting, stunting, underweight), inadequate vitamins or minerals, overweight, obesity, and resulting diet-related noncommunicable diseases.
• The term malnutrition addresses 3 broad groups of conditions:
  • Undernutrition, which includes wasting (low weight-for-height), stunting (low height-for-age) and underweight (low weight-for-age)
    • Together, the stunted and wasted children are considered to be underweight, indicating a lack of proper nutritional intake and inadequate care post-childbirth.
  • Micronutrient-related malnutrition, which includes micronutrient deficiencies (a lack of important vitamins and minerals) or micronutrient excess; and
  • Overweight, obesity and diet-related noncommunicable diseases (such as heart disease, stroke, diabetes and some cancers).
• It is a chronic problem and a longstanding challenge for the public administration of India.
• Malnutrition in India accounts for 68% of total under-five deaths and 17% of the total disability- adjusted life years. India is home to about 30% of the world’s stunted children and nearly 50 per cent of severely wasted children under the age of five. Besides, India is home to nearly half of the world’s “wasted or acute malnourished” (low weight for height ratio) children in the world.

Multi-dimensional determinants of malnutrition

Mother’s health:

• Scientists say the initial 1,000 days of an individual’s lifespan, from the day of conception till he or she turns two, is crucial for physical and cognitive development.
• But more than half the women of childbearing age are anaemic and 33 per cent are undernourished, according to NFHS 2006. A malnourished mother is more likely to give birth to malnourished children.

Social inequality:

• For example, girl children are more likely to be malnourished than boys, and low-caste children than upper-caste children.

Sanitation:

• Most children in rural areas and urban slums still lack sanitation. This makes them vulnerable to the kinds of chronic intestinal diseases that prevent bodies from making good use of nutrients in food, and they become malnourished.
• Lack of sanitation and clean drinking water are the reasons high levels of malnutrition persists in India despite improvement in food availability.

Lack of diversified food:

• With the increase in diversity in food intake malnutrition (stunted/underweight) status declines. Only 12% of children are likely to be stunted and underweight in areas where diversity in food intake is high, while around 50% children are stunted if they consume less than three food items.

Lack of food security:

• The dismal health of Indian women and children is primarily due to lack of food security.
• Nearly one-third of adults in the country have a body mass index (BMI) below normal just because they do not have enough food to eat.

Failure of government approaches:

• India already has two robust national programmes addressing malnutrition the Integrated Child Development Service (ICDS) and the National Health Mission but these do not yet reach enough people.
• The delivery system is also inadequate and plagued by inefficiency and corruption. Some analysts estimate that 40 per cent of the subsidized food never reaches the intended recipients

Disease spread:

• Most child deaths in India occur from treatable diseases like pneumonia, diarrhoea, malaria and complications at birth.
• The child may eventually die of a disease, but that disease becomes lethal because the child is malnourished and unable to put up resistance to it.

Poverty:

• The staff of ICDS places part of the blame of malnutrition on parents being inattentive to the needs of their children, but crushing poverty forces most women to leave their young children at home and work in the fields during the agricultural seasons.
• Regional disparities in the availability of food and varying food habits lead to the differential status of under-nutrition which is substantially higher in rural than in urban areas.
• This demands a region-specific action plan with significant investments in human resources with critical health investments at the local levels.

Lack of nutrition:

• Significant cause of malnutrition is also the deliberate failure of malnourished people to choose nutritious food.

An international study found that the poor in developing countries had enough money to increase their food spending by as much as 30 per cent but that this money was spent on alcohol, tobacco and festivals instead.

Covid-19 impact on malnutrition in children in India

• While the deteriorating facets of malnutrition continue to remain a matter of grave concern, the emergence of COVID-19 has only worsened it.
• The partial closure of Anganwadi Centres (AWCs) along with disruptions in supply chains due to subsequent lockdowns has resulted in halting of mid-day meals scheme, reduced access to take home ration (a nutritional measure to supplement some portion of a child’s calorie needs) and restricted mobility to health care services.
• According to a study published in journal Global Health Science 2020, the challenges induced by COVID-19 are expected to push another four million children into acute malnutrition.
• This is also evident from India poor ranking, an abysmal 107, out of 121 countries on the Global Hunger Index 2022.

Government effort to fight malnutrition

• Pradhan Mantri Matru Vandana Yojana (PMMVY): 6,000 is transferred directly to the bank accounts of pregnant women for availing better facilities for their delivery.
• POSHAN Abhiyaan: aims to reduce stunting, under-nutrition, anaemia and low birth weight babies through synergy and convergence among different programmes, better monitoring and improved community mobilisation.
• National Food Security Act (NFSA), 2013, aims to ensure food and nutrition security for the most vulnerable through its associated schemes and programmes, making access to food a legal right.
• Mid-day Meal (MDM) scheme aims to improve nutritional levels among school children which also has a direct and positive impact on enrolment, retention and attendance in schools.
• Integrated Child Development Services (ICDS), with its network of 1.4 million Anganwadi Centres, reaching almost 100 million beneficiaries who include pregnant and nursing mothers and children up to 6 years;
• Public Distribution System (PDS) that reaches over 800 million people under the National Food Security Act.
• Additionally, NITI Aayog has worked on a National Nutrition Strategy (NNS), isolated the 100 most backward districts for stunting and prioritised those for interventions.
• The National Nutrition Strategy (NNS) has set very ambitious targets for 2022 and the Poshan Abhiyaan has also specified three-year targets to reduce stunting, under-nutrition and low birth weight by 2% each year, and to reduce anaemia by 3% each year.
• IYCF (Infant and Young child feeding), Food and Nutrition, Immunization, Institutional Delivery, WASH (Water, Sanitation and Hygiene), De-worming, ORS-Zinc, Food Fortification, Dietary Diversification, Adolescent Nutrition, Maternal Health and Nutrition, ECCE (Early Childhood care and Education), Convergence, ICT-RTM (Information and Communication. Technology enabled Real Time Monitoring), Capacity Building.

Measures needed to Address the malnutrition

According to National Family Health Survey (NFHS)-4 conducted in 2015-16, 21 per cent of children in India under-5 suffered from Moderate Acute Malnourishment (MAM) and 7.5 per cent suffered from Severe Acute Malnourishment (SAM).

• Reduce the burgeoning burden of acute malnutrition and ensure early identification and treatment of SAM children to stop them from further slipping into the vicious cycle of malnutrition.
• Enrol such children in Nutrition Rehabilitation Centres.
• The second step is, treatment of SAM children without any complications at community level through Village Child Development Centre (VCDC) by using different centrally and locally produced therapeutic food.
• These energy-dense formulations are often at the core of nourishing the children since they are fortified with critical macro- and micro-nutrients. It ensures that the target population gains weight within a short span of six to eight weeks.
• Follow up of such children is needed to prevent relapse of malnutrition and ensure adequate food supply to the target population.
• ASHA workers must be given adequate remuneration to be able to carry out this responsibility with more rigour.

Nutrition is not a peripheral concern rather a central to our existence; a pro-equity agenda that mainstreams nutrition into food systems and health systems, supported by strong financing and accountability is the greatest need. Only five years are left to meet the 2025 global nutrition targets, while the time is running out, the focus should be on an action that provides the maximum impact.

Gender bias against girl child

The demographic transition in India has brought along an ugly unintended consequence – a historically strong preference for sons over daughters in these societies has strengthened with the decline in fertility, thus worsening the female-male sex ratio at birth.

Recently, the United Nations Population Fund (UNFPA) has released the State of the World Population 2020 report, titled ‘Against my will: defying the practices that harm women and girls and undermine equality’. It highlights at least 19 human rights violations against women and focuses on the three most prevalent ones, Female Genital Mutilation (FGM), extreme bias against daughters, in favour of sons and child marriage.

Key findings of the report in India

• One in three girls missing globally due to sex selection, both pre- and post-natal, is from India, i.e. 46 million out of the total 142 million.
• India has the highest rate of excess female deaths at 13.5 per 1,000 female births or one in nine deaths of females below the age of 5 due to postnatal sex selection.
• In India, around 460,000 girls went missing at birth, which means they were not born due to sex-selection biases, each year between 2013 and 2017.
• India (40%) along with China (50%) account for around 90% of the estimated 1.2 million girls lost annually to female foeticide.
• One in nine females below the age of 5 die due to postnatal sex selection.
• It tends to be higher among wealthy families, but percolates down to lower-income families over time, as sex selection technologies become more accessible and affordable.
• The skewed ratio causes the number of prospective grooms to outnumber prospective brides, which further results in human trafficking for marriage as well as child marriages.
• However, the positive news is according to the report, advances in India have contributed to a decline in child marriages in South Asia. This corroborates the NFHS data which had said that child marriage in India fell from 47% in 2005-’06 to 26.8% in 2015-’16.

Government Measures undertaken

• In order to arrest the problem of sex-selection and female foeticide, the government in 1994 introduced the Prenatal Diagnostics Techniques Act.
• In 2003, PDT act was amended to become the Prenatal Conception and Prenatal Determination Act (PCPNDT) which regulates sex selection before or after conception.

Measures needed

• There are many loopholes in the implementation of the PCPNDT Act, namely, under-utilization of funds, non-renewal of registration leading to automatic renewal of registration, non-maintenance of patients’ details and diagnostic records, non-maintenance of records by the authorities, absence of regular inspection of ultrasonography (USG) centres, lack of documentation of inspection report, lack of mapping and regulation of USG equipment, and so on. They need to be addressed at the earliest.
• Countries that have ratified international treaties such as the Convention on the Rights of the Child, have a duty to end the harm, whether it’s inflicted on girls by family members, religious communities, health-care providers, commercial enterprises or State institutions themselves.
• Governments must fulfil their obligations under human rights treaties that require the elimination of these practices and rituals.
• Dowry is also one of the main causes of low sex ratio. The trend of taking and giving of dowry which takes place mostly in educated and upper class homes can be discouraged by laws and awareness among the peoples.
• Children should be taught to uphold morals and refrain from practices of dowry, female foeticide, and gender bias. The vulnerable minds of the children should be so influenced that they grow up as adults who consider practicing dowry and female foeticide as immoral.
• Women should also be socialized from early childhood to consider themselves as equal to men. This would be a positive influence on the coming generations as today’s girl child would be tomorrow’s mother as well as mother in-law.
• The major barrier in the way towards the balanced gender structure is gender inequality based on the socio-cultural issues. The systematic discrimination of the females needs to be tackled from our society.
• In order to marshal support of various groups and channelizing the efforts in a focused manner, government must take a lead in establishing a mission for balancing the sex ratio by the next census operation through a coordinated mix of reinforcement programmes and support mechanism.

Way forward

• A radical shift in the approach moving from protection of girl child to promotion of women as a category is the need of the hour.
• This is done not just by improving the image of the girl child but increasing the value of the girl child.
• A rights-based lifecycle approach with focus on nutrition, health, education, equal entitlements in property rights, employment and income generation is the need of the day.
• Finally, only an over-arching gender sensitization programme focusing at the individual level through education, at the institutional level, public and private, at societal level through professional behavioural campaign is the only way to not add more to the shameless inventory of ‘Missing Millions’.

To choose on the basis of gender and eliminate new life if the gender is not ‘favourable’ can easily be among humanity’s worst moments. It is time again for the government to ramp up awareness building exercises, and this time use technology to monitor every single pregnant woman right down to taluk levels until at least one year after birth. While punitive aspects might offer a measure of deterrence, true change can only be brought about by a change in attitude. As Amartya Sen argued: while at birth boys outnumber girls, ‘after conception, biology seems on the whole to favour women’. The weapon that the government needs to use now is one that will be powerful enough to eliminate the perversion of son preference from people’s minds.

Child Abuse

Child Abuse is defined as “injury, sexual abuse, sexual exploitation, negligent treatment or maltreatment of a child”. This abuse can be of several kinds according to the World Health Organisation (WHO) – physical, mental, emotional, psychological or in the form of neglect or exploitation. Child abuse, in its various forms can be found everywhere in India -in cities and rural homes, in the homes of the rich and the poor, and in the streets and schools.

Constitutional Provisions to safeguard children

• The Constitution of India contains a number of provisions for the protection and welfare of the children.
• It has empowered the legislature to make special laws and policies to safeguard the rights of the children.
• Articles 14, 15, 15(3), 19(1) (a), 21, 21(A), 23, 24, 39(e) 39(f) of the Constitution of India contain provisions for the protection, safety, security and well-being of all it’s people, including children.

Child Abuse in India

• Child abuse in India is often a hidden phenomenon especially when it happens in the home or by family members.
• Focus with regards to abuse has generally been in the more public domain such as child labour, prostitution, marriage, etc.
• In 80-85 per cent cases of child rapes in our country, the offender is a known person.
• They can be a neighbour, someone from the local community, a relative or even a family member.
• A sexual offence by a known person is one of the worst things that can happen to a child.
• Many a time, when the offender is a family member, the victims don’t report due to fear of social stigma.
• Sometimes minors do not even understand that they are being wronged.
• This data from the National Crime Records Bureau shows even the best of police systems and toughest of laws cannot ensure prevention of sexual violence against children.
• Police can punish the perpetrator after the crime is committed. However, by then the damage is already done.
• A jail sentence to the accused comes after years of legal battle, and hardly helps the victim in dealing with lifelong trauma.
• In many such incidents, victims are forced to change their statements in court just because the matter has been ‘amicably settled’ among the elders.
• Many rapes take place in urban slums, because children are left alone or with some person known to the parents.

Impacts of child abuse

• It brings about circumstances causing harm to a child’s health, welfare, and safety.
• It can also result in lasting lifelong physical and psychological trauma.
• Families and society also experience this trauma.
• As adults, victims of childhood abuse are more vulnerable to mental health trauma.

Challenges

• Due to societal norms, there is hardly any discussion on sex—including safety—in the household.
• The perceived stigma attached to a victim has functioned as an escape tool for offenders.
• Poorer kids are more at risk than rich kids.
• In India a rising concern is the pressure children feel to perform well in school and college examinations, which can be seen as a form of emotional stress and abuse.
• Manufacturers exploit children as inexpensive labour.
• High incidence of malnourishment, child stunting and wasting.

Government initiatives undertaken

POCSO Act

• The Protection of Children from Sexual Offences (POCSO) Act, 2012 address the crimes of sexual abuse and sexual exploitation of children through stringent legal provisions.

POCSO e-Box

• Online complaint management system for easy and direct reporting of sexual offences against children and timely action against offenders.

NCPCR

• The National Commission for Protection of Child Rights (NCPCR) ensure that all Laws, Policies and Programmes are in consonance with the Child Rights perspective as enshrined in the Constitution of India and the UN Convention on the Rights of the Child.

Integrated Child Protection Scheme

• Aimed at building a protective environment for children in difficult circumstances through Government-Civil Society Partnership.

Operation Smile

• Operation Smile also called as Operation MUSKAAN is an initiative of the Ministry of Home Affairs (MHA) to rescue/rehabilitate missing children.

Child Pornography

The POCSO Act, 2019 defines Child Pornography as Any visual depiction of sexually explicit conduct involving a child which includes a photograph, video, digital or computer-generated image indistinguishable from an actual child. India Child Protection Fund (ICPF) has come out with a report which indicates a sharp rise in demand for online child pornography during the lockdown.

Currently, there is no law banning watching pornography in personal space. After the Supreme Court’s order, the Department of Telecommunication banned several websites containing child pornographic material. As per the Information Technology (IT) Act, 2002, it is punishable to show children any pornographic content.

The Ad-hoc Committee of the Rajya Sabha was instituted recently by the Chairman of the House to examine and report on the issue of child pornography and the prevalence of its horrific consequences. The Committee has also recommended important amendments to the Protection of Children from Sexual Offences (POCSO) Act, 2012 and the Information Technology Act, 2000 besides initiating changes at technological, institutional, social, educational and state-level initiatives.

Impact of Pornography on Children and Society

• Psychological impact: Porn creates a psychological impact on children. It is associated with depression, anger and anxiety. It can lead to mental distress. It also impacts day to day functioning of children, their biological clock, their work, and their social relationship.
• Impact on sexuality: When seen regularly, it gives a sense of sexual gratification and sexual obsession, which leads to a willingness to do the same things in real life.
• Sexual addiction: According to some experts, pornography is like an addiction. It produces a similar effect on the brain as produced by consumption of drug or alcohol on a regular basis.
• Behavioural impact: Adolescent pornography use is associated with stronger beliefs in gender stereotypes, particularly for males. Male adolescents who view pornography frequently are more likely to view women as sex objects.
  • Pornography may strengthen attitudes supportive of sexual violence and violence against women.

Other Impacts

• Pornography can influence a young person’s expectations about sex. There is some evidence that exposure to pornography can increase the likelihood of an earlier first-time sexual experience.
• Pornography is also associated with unsafe sexual health practices such as not using condoms and unsafe anal and vaginal sex.
• Both male and female consumers of pornography had increased levels of self-objectification and body surveillance.
• The content of pornography may reinforce double standards of active male sexuality and passive female receptacle.

Challenges to ban child pornography

• The effect of pornography is different in children belonging to the lower class compared to children belonging to the high class. A single approach won’t be able to handle the issue effectively.
• Lack of sex education courses and workshops in the school curriculum.
• In India, sex is seen as negative (something which should be hidden). There is no healthy family dialogue regarding sex. It leads the child to learn this from outside which led to an addiction to pornography.
• It’s very difficult for agencies to detect the activities of child pornography and monitor them effectively.
• Availability of obscene content on regular websites and OTT (over the top) services make it difficult to differentiate between the non-vulgar content and vulgar content.

Efforts Undertaken

• Agencies across the world are sharing information to combat child pornography. New technologies and methods are being adopted.
• Coordination between police and ordinary people to identify the hotspots of child pornography.
• The Uttarakhand High Court asked the Centre to strictly implement the ban on pornographic websites, after the reports that a girl was gang-raped in a Dehradun school by her fellow students after they watched porn clips.

Way forward

• Parents can make a vast and positive difference by talking with their children. Like sexuality education in general, the topic of pornography is not one big talk but rather a series of discussions that easily can arise from the content of songs, music videos, video games, movies and unintended or intended exposure to sexually explicit images.
• Parents can help their children develop a critical eye when viewing media, so they see the lies, and differentiate that fiction from the joy in loving equitable and respectful relationships.
• National Cyber Crime Reporting Portal shall be designated as the national portal under-reporting requirements in the POCSO Act in case of electronic material
• Union Government shall be empowered through its designated authority to block and/or prohibit all websites/intermediaries that carry child sexual abuse material
• Law enforcement agencies should be permitted to brake end to end encryption to trace distributors of child pornography. Apps that help in monitoring children’s access to pornographic content shall be made mandatory on all devices sold in India. Such Apps or similar solutions to be developed and made freely available to ISP, companies, schools and parents.
• Ministry of Electronics and IT and Ministry of Home Affairs shall coordinate with Blockchain analysis companies to trace identities of users engaging in cryptocurrency transactions to purchase child pornography online. Online payment portals and credit cards are prohibited from processing payments for any pornographic website.
• All social media platforms should be mandated with minimum essential technologies to detect Child Sexual Abuse Material besides regular reporting to law enforcement agencies in the country.
• On-streaming platforms like Netflix and social media platforms like Twitter, Facebook etc. should have a separate adult section where under-aged children could be disallowed.
• The National Crime Records Bureau (NCRB) shall mandatorily record and report annually cases of child pornography of all kinds.
• A national Hotline Number should be created where child sexual abuse, as well as the distribution of child pornographic material, can be reported by concerned citizens.
• Ministries of Women and Child Development and Information and Broadcasting shall launch campaigns for greater awareness among parents to recognize early signs of child abuse, online risks and improving online safety for their child.
• Schools shall undertake training programmes for parents at least twice a year, making them aware of hazards for children of free access to smartphones, internet at an early age. Based on the experiences of other countries, a proper practicable policy for restricting the use of smartphones by under-aged kids needs to be considered.

Child Mortality

India’s under-five mortality rate now matches the global average (39 deaths per 1,000 live births), but the number of infant and neonatal deaths–and the performance of India’s poorer neighbours–indicate that tackling new-born health remains a formidable challenge.

The report on child mortality —Levels and Trends in Child Mortality, by the United Nations Inter-agency Group for Child Mortality Estimation —Globally, five million children died before their fifth birthday in 2021. Over half of these occurred among children aged 1-59 months, while the remainder occurred in just the first month of life (neonatal deaths).

• India’s share – 7,09,366 under-five deaths; 5,86,787 infant deaths (death before first birthday); and 4,41,801 neonatal deaths.
• For every 1,000 live births, the infant mortality rate in Madhya Pradesh was six-fold of the rate in Kerala.
• Higher deaths are seen in rural than urban.

Causes for child mortality

• Household food insecurity and Illiteracy specially in women. Children in the poorest households are nearly twice as likely to die before the age of five as those from the richest, as well as those whose mothers lack any secondary or higher education.
• Lower access for girls to effective prevention and treatment health services are likely responsible for the marked gender differences in mortality.
• Poor access to health services. In 2017, 2.9 million children in India under one year of age had not been vaccinated with the first dose, according to UNICEF.
• Lack of availability of safe drinking water. within India, large disparities between states on health indicators such as infant mortality show high levels of inequality in access to healthcare and sanitation levels.
• Early marriages of girls. High rates of anaemia (affecting 50% of pregnant women nationally), low nutrition levels (23% of mothers are underweight) and over-burdened government and private health facilities are part of the challenge in delivering healthy children.
• Teenage pregnancies resulting in low birth weight of the new-borns.
• Poor breastfeeding practices
• Poor complementary feeding practices
• Ignorance about nutritional needs of infants and young children and repeated infections further aggravate the situation.
• Children being ‘born too early’ (preterm births), which means they are born alive before 37 weeks of pregnancy are completed. They are two to four times at higher risk of death after birth in comparison to those born after 37 weeks of gestation. Globally, one in every 10 births is preterm; in India, one in every six to seven births is preterm. 3 out of every 4 deaths due to preterm birth-related complications are preventable.
• Another important neglected challenge is of stillbirths. A baby who dies any time after 22 weeks of pregnancy, but before or during the birth, is classified as a stillborn. In 2021, the absolute estimated number of stillbirths in India (2,86,482) was greater than the death amongst children in 1-59 months of age (2,67,565).
• Number of other factors such as environmental, geographical, agricultural, and cultural including various other factors have contributive effects resulting in malnutrition.
• In India, the first dose of measles vaccine is given at nine-12 months of age and the second dose is given at 16-24 months of age through the national immunisation programme. But it appears that millions of children in India do not receive measles vaccine through routine immunisation activities.

Government initiatives

The steps being taken by the government to further combat infant mortality and increase vaccine coverage under the National Health Mission are as under:

• Promotion of Institutional deliveries through cash incentive under Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakaram (JSSK) which entitles all pregnant women delivering in public health institutions to absolutely free ante-natal check-ups, delivery including Caesarean section, post-natal care and treatment of sick infants till one year of age.
• Strengthening of delivery points for providing comprehensive and quality Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) Services, ensuring essential newborn care at all delivery points, establishment of Special Newborn Care Units (SNCU), Newborn Stabilization Units (NBSU) and Kangaroo Mother Care (KMC) units for care of sick and small babies. Home Based Newborn Care (HBNC) is being provided by ASHAs to improve child rearing practices.
• India Newborn Action Plan (INAP) was launched in 2014 to make concerted efforts towards attainment of the goals of “Single Digit Neonatal Mortality Rate” and “Single Digit Stillbirth Rate”, by 2030.
• Early initiation and exclusive breastfeeding for rest six months and appropriate Infant and Young Child Feeding (IYCF) practices are promoted in convergence with Ministry of Women and Child Development.
• Village Health and Nutrition Days (VHNDs) are observed for provision of maternal and child health services and creating awareness on maternal and child care including health and nutrition education.
• MAA-Mothers’ Absolute Affection programme in August 2016 for improving breastfeeding practices (Initial Breastfeeding within one hour, Exclusive Breastfeeding up to six months and complementary Breastfeeding up to two years) through mass media and capacity building of health care providers in health facilities as well as in communities.
• Universal Immunization Programme (UIP) is being supported to provide vaccination to children against many life threatening diseases such as Tuberculosis, Diphtheria, Pertussis, Polio, Tetanus, Hepatitis B and Measles. Pentavalent vaccine has been introduced all across the country and “Mission Indradhanush” has been launched to fully immunize children who are either unvaccinated or partially vaccinated;
• Measles Rubella Campaign is being undertaken in select States for children from 9 months to 15 years of age with the aim of eliminating Measles by 2020.
• Name based tracking of mothers and children till two years of age (Mother and Child Tracking System) is done to ensure complete antenatal, intranatal, postnatal care and complete immunization as per schedule.

Way forward

• Achieving the ambitious child survival goals requires ensuring universal access to safe, effective, high-quality and affordable care for women, children and adolescents.
• Measures should be taken to ensure early registration of pregnancies, and for early detection of high risk cases, improving institutional deliveries, providing skill development training to health staff.
• Education campaign should be taken up to aware the mother of the merits of antenatal care, institutional delivery, importance of exclusive breast feeding, immunization, home care for diarrhoea; all these are meant to create awareness among family members to provide support to women during pregnancies and deliveries.
• India continues to show impressive decline in child deaths. The investment on ensuring holistic nutrition under the POSHAN campaign and national commitment to make India open defecation-free by 2019 are steps that will help in accelerating progress further.
• Mortality rates among children and young adolescents are not only key indicators for child and young adolescent well-being, but, more broadly, for sustainable social and economic development.
• SDG goal 3 calls for an end to preventable deaths of newborns and children under 5 years of age and specifies that all countries should aim to reduce neonatal mortality to at least as low as 12 deaths per 1,000 live births and under-five mortality to at least as low as 25 deaths per 1,000 live births by 2030.
• Tackling the diseases and conditions associated with the quality of care around the time of childbirth will help tackle newborn deaths. This will depend on strengthening health services and ensuring more births take place in hospitals and are attended to by trained staff.