PB No. 18 An analysis of the seasonal variations in births in Bihar: HMIS data 2017-20

Introduction

Human births are said to follow a seasonal pattern where there are specific periods during which more than average births occur [1]. Birth seasonality is largely a consequence of seasonality in conceptions that have occurred about 9 months earlier. But seasonal variation in live births (or, with appropriate lag, conception) is a multifactor phenomenon [2]. Most studies have documented the importance of environmental and social factors [3-4]. Birth patterns may also vary according to geography. Conception, followed by childbirth is governed by different factors in urban and rural areas. In rural areas, variation of births may be characterized by periods of key agricultural operations and monsoon whereas in urban areas, changes in weather could play an important role [5-6]. Examination of these patterns is important as regular seasonality in births has policy implications. The objective of this policy brief is to examine patterns of birth seasonality in the state of Bihar, and thereby conception and also to examine the role of agro-climatic conditions if any. In addition, the brief also examines gaps in coverage of key vaccines at birth i.e. the birth doses by comparing birth and vaccination coverage data.

We examine birth seasonality and immunization in Bihar – the state having the highest birth and fertility rate in the country – using month-wise data retrieved from the Health Management Information System (HMIS).

The HMIS was established under the National Rural Health Mission (NRHM), a flagship healthcare program under the Ministry of Health and Family Welfare (MoHFW). The policy brief analyzed data between April 2017 to March 2020: a period prior to the onset of the COVID-19 pandemic.

While there are issues with the quality of HMIS data, few sources other than HMIS provide granular-level child birth data. Also, the reporting of live births is fairly robust, at least to the extent of revealing seasonal patterns in births [5].

Even though the policy brief explores the seasonality of births at the state level, patterns below the state level have also been examined. The district-wise extent of variations in births have been examined by calculating and mapping the standard deviations for each district.

Is there a seasonality in births?

The seasonality patterns for the state and districts of Bihar were analyzed between FY 2017-18 to FY 2019-20. It was observed that there is a consistent pattern of seasonality in births in the state. Births peak in the months of August–October and thereafter there is a dip that prolongs from November till June with a sharp peak again in August. Moreover, the regularity in birth peaks is observed in both the urban and rural areas (Fig 1).

  

Source: HMIS

Do agro-climatic factors influence conception ?

Childbirth in Bihar appears to be influenced by monsoon and timing of major agricultural operations. The distinct birth peak in August-October corresponds to conception during the months of November-January and the notable dip in births between April- June corresponds to the previous year’s Kharif season between July-September. Paddy is one of the major crops in Bihar and is largely harvested during October-November. The period following harvesting of this crop appears favorable for conception (December). It also broadly coincides with the main wedding season of October to December for the Hindu marriages in particular. This has an implication on the family planning campaign timings in the state.

Source: BAMETI

Bihar has been classified into four agro-climatic zones based on soil quality and climatic conditions and there were few differences in seasonality (Figure 2). These regions are characterized by alluvial soil hence crops such as rice, wheat, sugarcane, maize, jute and oilseeds are primarily cultivated on it [8]. Figure 3 shows the birth seasonality patterns for the four agro-climatic zones. The HMIS data, reveals that six of eight districts that witnessed a peak in births in the month of August belonged to agro-climatic Zone 1. Most districts in Zone II (seven out of eight) reported a peak in the month of October. A single birth peak in October in Zone II districts suggests that conception was favorable in the period following the sowing of rabi crops between October-December (e.g., wheat, sunflower, maize) and preceding the period during spring, i.e., March to May when kharif crop (jute) is sown.

Source: HMIS

Figure-4 provides the heat map of the standard deviation (SD) based on the moderate (1-1.5 SD), high (1.5-2), and very high (> 2 SD) variations in births. The data shows that most districts in the state had a high to very high standard deviation. Eight districts in the north western alluvial plane Zone I have a moderate SD. This includes a cluster of five districts in Zone I that all have a moderate SD. Five of the eight districts are located on the banks of river Ganga. Three districts in Zone II (North-eastern alluvial plane) and five districts in the two sub zones of Zone III (South Alluvial Plane) had a very high SD.

Source: HMIS

These patterns of conception are also corroborated in literature. Studies indicate that conception is usually the highest during the colder and dry winter months [2]. The similarity in urban-rural birth patterns is notable but some studies observe that climate is also a key factor that influences conception in urban areas [9]. The chances of conception are generally known to be the lowest especially in rural areas when households are engaged in strenuous farm activity of sowing field crops such as paddy which primarily occurs in Bihar between June-July and kharif harvesting which primarily occurs between September-October [6, 10]. Studies have also found that the frequency of conceptions may operate through the mechanism of food supply [4, 9]. The period following harvesting of important crops like paddy during December-January is also a period of abundance with a good availability of food and low necessity for exertion and could hence be favorable for conception from an economic point of view as well.

Gap in coverage of Immunization at birth:

Seasonality in births should logically reflect in the seasonality in birth-dose vaccination coverage. Figure-5 compares month-wise data of births and coverage of birth doses of 4 vaccines for FY 2017-18-FY 2019-20 period. It is observed that the variations in the coverage of the four vaccines follow the variations in birth with a peak during August-October, and a decline thereafter with significant dip between April-June.

Source: HMIS

In terms of coverage of birth doses, the largest gap existed for vitamin K1 dose and Hepatitis B – birth doses. The total number of Bacillus Calmette-Guérin (BCG) administered exceeded that of children born through the period of interest indicating significant over-reporting and double counting. The gap between number of births and oral poliovirus vaccine (OPV) was low. The data also indicated that the timelines of the birth doses of the four vaccines were important. The earlier the deadline to administer the vaccine, the higher the chances of missing the birth dose of the given vaccine. As per the immunization guidelines [11-12], the birth dose of BCG could be given to the infant latest by the first year of life whereas OPV could be administered within the first 15 days of life compared to vitamin K1 and Hepatitis B which should be given within 24 hours of birth.

Key Takeaways and Policy Implications

The study of birth seasonality in Bihar is important due to the implications these patterns have on the health service delivery. The identification of peak months of births will support local planning of maternal and child health services in a state like Bihar which has the highest birth and fertility rates in the country [13]. For instance, birth seasonality can help health care workers focused on improving obstetric care. It is important to also meet the unmet contraceptive needs of women in order to avoid unwanted conception during the peak conception months. The regularity of birth peaks in the months of August to October prescribe a need to improve dissemination of family planning messages and increase reach of contraception services in the months of December to February in Bihar. Scholars have observed that the sexual behaviour of people also has an effect on the variation of births [1]. A study in Bihar found that women with migrant husbands were about 50% less likely to use modern contraceptive methods [14]. Given that migration among males is common in Bihar, especially in rural areas [15], it is imperative that family planning programs in Bihar prepare migration specific implementation strategies.

Birth data can also help health systems to ensure adequate stock of birth vaccine doses (BCG, Vitamin K1, Hepatitis B and OPV) during birth peak months. The findings suggest poor coverage of Hepatitis B and Vitamin K1 birth doses. The gaps in Vitamin K1 have been largely attributed to insufficient supply and poor awareness of health workers [16]. While government guidelines mandates administration of Vitamin K1 prophylaxis at birth, the national immunization schedule has not included the vaccine which indicates a need for sensitization of health care workers [11-12]. Similarly, factors like poor stock management, incomplete recording and incomplete knowledge amongst health functionaries about vaccination schedule have resulted in the low uptake of hepatitis B birth dose. Studies have also observed fear of high vaccine wastage for Hepatitis-B birth dose where health care workers often refrained from opening a new 10 dose vial of the vaccine for a low number of deliveries [17]. While the Open Vial Policy has helped scale up Hepatitis B vaccination, there is significant need for more training of health care workers [18]. More analysis may be needed to further examine birth seasonality patterns and their implications in Bihar.

References

1. Tembon, A. C. (1990). Seasonality of births in the North West Province, Cameroon: implications for family planning programme. Central African Journal of Medicine, 36(4), 90-93.
2. Ogum, G. E. O., & Okorafor, A. E. (1979). Seasonality of births in south-eastern Nigeria. Journal of Biosocial Science, 11(2), 209-217.
3. Cancho-Candela, R., Andrés-de Llano, J. M., & Ardura-Fernandez, J. (2007). Decline and loss of birth seasonality in Spain: analysis of 33 421 731 births over 60 years. Journal of Epidemiology & Community Health, 61(8), 713-718.
4. Ferguson, A. G. (1987). Some aspects of birth seasonality in Kenya. Social Science & Medicine, 25(7), 793-801.
5. Nambiar, A., Chowdhury, D., & Agnihotri, S. B. (2022). Seasonal Variations in Childbirth A Perspective from the HMIS Database (2017–20). Economic & Political Weekly, 7(17).
6. Bernard, R. P., Bhatt, R. V., Potts, D. M., & Rao, A. P. (1978). Seasonality of birth in India. Journal of Biosocial Science, 10(4), 409-421.
7. BAMETI. (n.d.). Status of Agriculture in Bihar. Retrieved from https://www.bameti.org/wp-content/uploads/2021/02/State-Profile.pdf
8. Dwevedi, A., Kumar, P., Kumar, P., Kumar, Y., Sharma, Y. K., & Kayastha, A. M. (2017). Soil sensors: detailed insight into research updates, significance, and future prospects. In New pesticides and soil sensors (pp. 561-594). Academic Press.
9. Kosambi, D. D., & Raghavachari, S. (1951). Seasonal variation in the Indian birth‐rate. Annals of eugenics, 16(1), 165-192.
10. Government of India. (2018). New Crop Calendar. Pradhan Mantri Fasal Bima Yojana. Ministry of Agriculture and Farmers Welfare. Retrieved from https://pmfby.gov.in/pdf/New_Crop_Calendar_20.09.18.pdf

11. MOHFW. (2018). National Immunization Schedule. National Health Mission.Retrieved from https://nhm.gov.in/New_Updates_2018/NHM_Components/Immunization/report/National_%20Immunization_Schedule.pdf
12. Government of India. (2014). Operational Guidelines. Injection of Vitamin K Prophylaxis at Birth (In Facilities). Ministry of Health & Family Welfare . Retrieved from https://nhm.gov.in/images/pdf/programmes/child-health/guidelines/Vitamin_K_Operational_Guidelines.pdf
13. Government of India. (2011). Population Projections for India And States 2011 – 2036, Census of India 2011. Report of the Technical Group on Population Projections. Retrieved from: https://nhm.gov.in/New_Updates_2018/Report_Population_Projection_2019.pdf
14. Mahapatra, B., Saggurti, N., Mishra, R., Walia, M., & Mukherjee, S. (2020). Migration and family planning in the state with highest total fertility rate in India. BMC public health, 20(1), 1-9.
15. Keshri, K., & Bhagat, R. B. (2010). Temporary and seasonal migration in India. Genus, 66(3), 25-45.
16. Bora, K. (2021). Gaps in the coverage of vitamin K1 prophylaxis among newborns in India: insights from secondary analysis of data from the Health Management Information System. Public Health Nutrition, 24(17), 5589-5597.
17. Lahariya, C., Subramanya, B. P., & Sosler, S. (2013). An assessment of hepatitis B vaccine introduction in India: Lessons for roll out and scale up of new vaccines in immunization programs. Indian journal of public health, 57(1), 8.
18. UNICEF. (2021). A report on assessment of Open Vial Policy Implementation in India. National Cold Chain and Vaccine Management Resource Centre. Retrieved from https://www.unicef.org/india/reports/assessment-open-vial-policy-implementation-india

Authors

Marian Abraham, Krritika R Patel, Prof. Satish B Agnihotri & Prof. Sarthak Gaurav

Marian Abraham is a Senior Research Analyst at the Koita Centre For Digital Health, IIT Bombay.

Krritika R Patel has completed her M.Tech in Technology and Development at CTARA, IIT Bombay.

Prof Satish B Agnihotri is Emeritus Fellow CTARA at IIT Bombay and works, inter alia, on Child Malnutrition, Health and Nutrition Policy.

Prof. Sarthak Gaurav is an Associate Professor at Shailesh J. Mehta School of Management, IIT Bombay.

Suggested citation: Abraham, M., Patel, K., Agnihotri, S. B., & Gaurav., S. (2024). An analysis of the
seasonal variations in births in Bihar: HMIS data 2017-20. Nutrition Group, IIT Bombay