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
Districts
Lag > 5 year/ Total
Madhya Pradesh
80%
Uttar Pradesh
79%
Rajasthan
67%
Orissa
67%
Chhattisgarh
61%
Bihar
53%
Assam
52%
Jharkhand
38%
Gujarat
23%
Jammu & Kashmir
18%
Uttarakhand
15%
Karnataka
10%
Andhra Pradesh
9%
Haryana
5%
40/ 50
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
Maharashtra
0%
0/ 35
West Bengal
0%
0/ 19
Tamil Nadu
0%
0/ 32
Punjab
0%
0/ 20
Kerala
0%
0/ 14
Himachal Pradesh
0%
0/ 12
Disrticts on track to meet under-5 mortality target for 2015
Tamil Nadu
100%
Kerala
100%
Maharashtra
89%
Punjab
80%
West Bengal
74%
Karnataka
70%
Jammu & Kashmir
64%
Himachal Pradesh
58%
Uttarakhand
54%
Haryana
52%
Gujarat
46%
Andhra Pradesh
43%
Assam
15%
Jharkhand
13%
Chhattisgarh
6%
Bihar
5%
Rajasthan
3%
Madhya Pradesh
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
Districts
Lag >5yrs/ Total
90%
45/ 50
Madhya Pradesh
Rajasthan
85%
28/ 33
Chhattisgarh
83%
15/ 18
Uttar Pradesh
83%
59/ 71
Orissa
80%
24/ 30
Jharkhand
42%
10/ 24
Jammu Kashmir
41%
9/ 22
Assam
41%
11/ 27
Andhra Pradesh
39%
9/ 23
Gujarat
27%
7/ 26
Bihar
26%
10/ 38
Himachal Pradesh
25%
3/ 12
West Bengal
16%
3/ 19
Punjab
15%
3/ 20
Karnataka
13%
Haryana
10%
4/ 30
2/ 21
Maharashtra
9%
3/ 35
Uttarakhand
8%
1/ 13
Tamil Nadu
0%
0/ 32
Kerala
0%
0/ 14
Districts on track to meet neonatal mortality target
for 2015
Districts
On track/ Total
Tamil Nadu
100%
32/ 32
Kerala
100%
14/ 14
Punjab
65%
Karnataka
63%
Uttarakhand
62%
Maharashtra
60%
Himachal Pradesh
58%
Jammu Kashmir
55%
West Bengal
47%
Gujarat
38%
Haryana
33%
Andhra Pradesh
22%
Assam
19%
Jharkhand
17%
Bihar
Madhya Pradesh
11%
2%
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
Uttar Pradesh
0%
0/ 71
Rajasthan
0%
0/ 33
Orissa
0%
0/ 30
Chhattisgarh
0%
0/ 18
Districts lagging 5+ years behind 1-59 month
mortality target for 2015
Districts
Lag >5yrs/ Total
Madhya Pradesh
98%
Bihar
95%
Assam
70%
Uttar Pradesh
69%
Orissa
47%
Rajasthan
39%
Jharkhand
38%
Uttarakhand
23%
Chhattisgarh
17%
Gujarat
15%
Karnataka
7%
49/ 50
36/ 38
19/ 27
49/ 71
14/ 30
13/ 33
9/ 24
3/ 13
3/ 18
4/ 26
2/ 30
Haryana
5%
1/ 21
Jammu Kashmir
5%
1/ 22
Andhra Pradesh
4%
1/ 23
Himachal Pradesh
0%
0/ 12
West Bengal
0%
0/ 19
Punjab
0%
0/ 20
Maharashtra
0%
0/ 35
Tamil Nadu
0%
0/ 32
Kerala
0%
0/ 14
Districts on track to meet 1-59 month mortality
target for 2015
Districts
On track/ Total
Tamil Nadu
100%
32/ 32
Kerala
100%
14/ 14
Punjab
100%
20/ 20
West Bengal
89%
17/ 19
Maharashtra
89%
31/ 35
Jammu Kashmir
86%
Himachal Pradesh
83%
Andhra Pradesh
78%
Karnataka
70%
Haryana
67%
Gujarat
54%
Uttarakhand
46%
Chhattisgarh
22%
Jharkhand
17%
Rajasthan
Assam
Uttar Pradesh
15%
7%
6%
19/ 22
10/ 12
18/ 23
21/ 30
14/ 21
14/ 26
6/ 13
4/ 18
4/ 24
5/ 33
2/ 27
4/ 71
Madhya Pradesh
4%
2/ 50
Orissa
3%
Bihar
1/ 30
3%
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
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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