Neonatal, 1–59 month, and under-5 mortality in 597 Indian districts, 2001 to 2012: estimates from national demographic and mortality surveys

Lancet Global Health, Sept 19, 2013

Usha Ram, Prabhat Jha, Faujdar Ram, Kaushalendra Kumar, Shally Awasthi, Anita Shet, Joy Pader, Stella Nansukusa, Rajesh Kumar www.cghr.org

Twitter @Cghr_org

Conclusions

• 222 districts of 597 districts are on track to achieve the

MDG of 38 under-5 deaths per 1000 live births by 2015, but an equal number (222) will achieve only after 2020

• The 222 lagging districts are home to 41% of India’s live

births and 56% of all child deaths

• More districts lag behind the neonatal goal (251) than

for 1–59 month mortality goal (197)

• Just 81 (14%) districts account for 37% of under-5 deaths

nationally

• Female mortality at ages 1–59 months exceeded male

mortality by 25% in 303 districts in nearly all states of India, totaling 74 000 excess deaths in girls

India will meet MDG only around 2020 –

richer states by 2015 and poorer states by 2023

How was the study done?

• Divide the 2012 UN sex-specific birth and mortality

totals for India into state totals using relative birth rates and mortality from recent demographic surveys of 24 million people, and divided state totals into totals for the 597 districts using 3 million birth histories.

• Split the results into neonatal and 1–59 month mortality

using data on 109 000 child deaths from six national mortality surveys

• Compare results with the 2001 census for each district • India has 640 districts: results shown for 597 districts,

covering all of India (smaller states/UTs were treated as districts)

Study team

Researchers from:

• Centre for Global Health Research, St Michael’s

Hospital, University of Toronto, Toronto, ON, Canada

• International Institute of Population Science,

Mumbai, India

• King George’s Medical University, Lucknow, Uttar

Pradesh, India

• St John’s Academy of Health Sciences, Bangalore,

India

• School of Public Health, Postgraduate Institute of

Medical Education and Research, Chandigarh, India Funded by DCP 3, CIHR, IDRC, NIH (but funders had no role in data analyses or writing the paper)

What is new about this study?

• The estimates are current (2012), and take

into account the recent improvements in child mortality

• Examines MDG progress between 2001 and

2012 for each of India’s 597 districts for neonatal, 1-59 months and under-5 mortality

• Identifies the hot spots that account for 37%

of national under-5 deaths

• Assesses female disadvantage in 1-59 month

mortality for each districts

Separate results for the 304 districts in the nine poorer states and 293 districts in the rest of India

* Poorer states are the nine states of Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttarakhand, and Uttar Pradesh.

India’s goals for MDG

• Between 1990 and 2015, the under-5

mortality rate (per 1000 live births) to fall from 115 to 38

– Equivalent between 2001 and 2012 is a fall from 81

to 47

• We estimate goals for neonatal (first month of

life) and 1–59 month mortality by 2015

 

Neonatal goal: 20 deaths per 1000 live births (down from 38 in 2001) 1-59 months goal: 18 deaths per 1000 live births (down from 43 in 2001)

Under-5 mortality progress 2001-2012

Under-5 mortality progress 2001-2012

Under-5 mortality results

• Between 2001 and 2012, the number of districts with

>8% risk of newborns dying before 5 years fell from 384 districts to 80 districts

• 222 districts of 597 districts lagged behind the MDG

by more than 5 years

– 194 of these 222 lagging districts are in the poorer states – Number of districts lagging behind has increased in Andhra

Pradesh, Gujarat and Karnataka

– The under-5 mortality in these lagging districts is about the

same as Kenya in 2012 (71 per 1000 live births)

– 90 districts lagged behind by more than 10 years • 222 districts are on track to achieve the MDG; 203

districts are in the richer states

Districts lagging 5+ years to behind under-5 mortality target for 2015 Madhya Pradesh Uttar Pradesh Rajasthan Orissa Chhattisgarh Bihar Assam Jharkhand Gujarat Jammu & Kashmir Uttarakhand Karnataka Andhra Pradesh Haryana Maharashtra West Bengal Tamil Nadu Punjab Kerala Himachal Pradesh 0% 0% 0% 0% 0% 23% 18% 15% 10% 0% 5% 9% 38% 53% 52% 61% 67% 67% Districts 80% Lag > 5 year/ Total 40/ 50 79% 56/ 71 22/ 33 20/ 30 11/ 18 20/ 38 14/ 27 9/ 24 6/ 26 4/ 22 2/ 13 3/ 30 2/ 23 1/ 21 0/ 35 0/ 19 0/ 32 0/ 20 0/ 14 0/ 12

Disrticts on track to meet under-5 mortality target for 2015 Tamil Nadu Kerala 100% 100% Maharashtra Punjab West Bengal 80% 74% 89% Karnataka Jammu & Kashmir 70% 64% Himachal Pradesh 58% Uttarakhand Haryana 54% 52% Gujarat 46% Andhra Pradesh Assam 15% 43% Jharkhand Chhattisgarh Bihar 6% 5% 13% Rajasthan Madhya Pradesh 3% 2% Uttar Pradesh 0% Orissa 0% Districts On track/ Total 32/ 32 14/ 14 31/ 35 16/ 20 14/ 19 21/ 30 14/ 22 7/ 12 7/ 13 11/ 21 12/ 26 10/ 23 4/ 27 3/ 24 1/ 18 2/ 38 1/ 33 1/ 50 0/ 71 0/ 30

Neonatal & 1-59 month mortality progress 2001-2012

Neonatal and 1-59 month mortality progress

• • •

251 districts of 597 districts lag behind the neonatal goal by more than 5 years

- 203 of these lagging districts are in the poorer states - 155 of these districts lag behind by more than 10

years 197 districts of 597 districts lag behind the 1-59 month mortality goals

- 172 of these lagging districts are in the poorer state - 81 of the districts lag behind by more than 10 years

Only in Kerala have all the districts achieved the neonatal and 1-59 months mortality goals

Districts lagging 5+ years behind neonatal mortality target for 2015 Madhya Pradesh Rajasthan Chhattisgarh Uttar Pradesh Orissa Jharkhand Jammu Kashmir Assam Andhra Pradesh Gujarat Bihar Himachal Pradesh West Bengal Punjab Karnataka Haryana Maharashtra Uttarakhand Tamil Nadu Kerala 0% 0% 16% 15% 13% 10% 9% 8% 27% 26% 25% 42% 41% 41% 39% Districts 85% 90% Lag >5yrs/ Total 45/ 50 28/ 33 83% 15/ 18 83% 59/ 71 80% 24/ 30 10/ 24 9/ 22 11/ 27 9/ 23 7/ 26 10/ 38 3/ 12 3/ 19 3/ 20 4/ 30 2/ 21 3/ 35 1/ 13 0/ 32 0/ 14

Districts on track to meet neonatal mortality target for 2015 Tamil Nadu Kerala Punjab Karnataka Uttarakhand Maharashtra Himachal Pradesh Jammu Kashmir West Bengal Gujarat Haryana Andhra Pradesh Assam Jharkhand Bihar Madhya Pradesh Uttar Pradesh Rajasthan Orissa Chhattisgarh 2% 0% 0% 0% 0% 22% 19% 17% 11% 38% 33% 65% 63% 62% 60% 47% 58% 55% 100% 100% Districts On track/ Total 32/ 32 14/ 14 13/ 20 19/ 30 8/ 13 21/ 35 7/ 12 12/ 22 9/ 19 10/ 26 7/ 21 5/ 23 5/ 27 4/ 24 4/ 38 1/ 50 0/ 71 0/ 33 0/ 30 0/ 18

Districts lagging 5+ years behind 1-59 month mortality target for 2015 Madhya Pradesh Bihar Assam Uttar Pradesh Orissa Rajasthan Jharkhand Uttarakhand Chhattisgarh Gujarat Karnataka Haryana Jammu Kashmir Andhra Pradesh Himachal Pradesh West Bengal Punjab Maharashtra Tamil Nadu Kerala 0% 0% 0% 0% 0% 0% 7% 5% 5% 4% 17% 15% 23% 39% 47% 38% 70% 69% 98% 95% Districts Lag >5yrs/ Total 49/ 50 36/ 38 19/ 27 49/ 71 14/ 30 13/ 33 9/ 24 3/ 13 3/ 18 4/ 26 2/ 30 1/ 21 1/ 22 1/ 23 0/ 12 0/ 19 0/ 20 0/ 35 0/ 32 0/ 14

Districts on track to meet 1-59 month mortality target for 2015 Tamil Nadu Kerala Punjab West Bengal Maharashtra Jammu Kashmir Himachal Pradesh Andhra Pradesh Karnataka Haryana Gujarat Uttarakhand Chhattisgarh Jharkhand Rajasthan Assam Uttar Pradesh Madhya Pradesh Orissa Bihar 7% 6% 4% 3% 3% 22% 17% 15% 46% 54% 70% 67% 89% 89% 86% 83% 78% 100% 100% 100% Districts On track/ Total 32/ 32 14/ 14 20/ 20 17/ 19 31/ 35 19/ 22 10/ 12 18/ 23 21/ 30 14/ 21 14/ 26 6/ 13 4/ 18 4/ 24 5/ 33 2/ 27 4/ 71 2/ 50 1/ 30 1/ 38

81 districts are home to 37% of the national deaths in children < 5 years

68 of these 81 districts are in poorer states

Girl disadvantage in 1-59 month mortality

• Nationally: for every 100

boys who died at 1-59 months, 131 girls died.

• Female mortality at these

ages exceeds male mortality by more than 25% in 303 districts

• Excess female mortality is

seen in nearly all states including Kerala and Tamil Nadu

• Nationally: about 74 000

excess deaths in girls at these ages

Comparison with other estimates

• At the state level, the means and the

errors of under-5 and neonatal mortality are similar between the Annual Health Survey (AHS) and our study

• The numbers of districts lagging behind

MDG by more than 5 years were similar between the AHS and our results

What can be done?

• Much faster progress in reducing under-5 mortality is

needed in all districts

• Focus resources on the 81 districts accounting for 37%

of all under-5 deaths

• More districts lag behind the neonatal goals than the

1–59 month mortality goals in both richer and poorer states, suggesting a need for renewed national attention on strategies to reduce neonatal deaths

• All districts could benefit from better accountability

and assessment of their performance, including the causes of neonatal death

Conclusions

• 222 districts of 597 districts are on track to achieve the

MDG of 38 under-5 deaths per 1000 live births by 2015, but an equal number (222) will achieve only after 2020

• The 222 lagging districts are home to 41% of India’s live

births and 56% of all child deaths

• More districts lag behind the neonatal goal (251) than

for 1–59 month mortality goal (197)

• Just 81 (14%) districts account for 37% of under-5 deaths

nationally

• Female mortality at ages 1–59 months exceeded male

mortality by 25% in 303 districts in nearly all states of India, totaling 74 000 excess deaths in girls

India will meet MDG only around 2020 –

richer states by 2015 and poorer states by 2023

More material

www.cghr.org/child

– Lancet Paper and Web appendix – PowerPoint slides – Frequently asked questions – Earlier work:

• Causes of neonatal and child mortality in India: a

nationally representative mortality survey. Lancet

2010; 376: 1853–60