Neonatal and child
mortality in India
Million Death Study Collaborators
Registrar General of India (RGI)
Centre for Global Health Research (CGHR)
Keenan Research Centre at the Li Ka Shing Knowledge Institute, St.
Michael’s Hospital, Dalla Lana School of Public Health, University of Toronto
prabhat.jha@utoronto.ca
www.cghr.org/child
Key messages
• 5 causes account for nearly two-thirds of all
2.3 M (23 lakhs) child deaths in India
 3 causes account for 80% of the 1 M (10 lakhs)
deaths in the first month of life:
• prematurity and low birthweight
• neonatal infections
• birth asphyxia and birth trauma
 2 causes account for 50% of the 1.3 M (13 lakhs)
deaths at ages 1–59 months:
• pneumonia
• diarrhoea
• Huge variation by region or gender
www.cghr.org/child
What’s new about this research?
• Most deaths in India occur at home and
without medical attention
• Large, nationally representative sample
of all deaths based on household
interviews with families
• The study results reflect the whole of
India
www.cghr.org/child
Nationally representative sample
(Sample Registration System)
• 6,671 of these
small areas
randomly
chosen from all
parts of India
(each with
about 1000
people per
area)
www.cghr.org/child
How was the study done?
800 Registrar of General India field workers
interviewed 122 thousand families of people who
had died in 2001-2003
Obtain detailed histories, symptoms, etc. about each
deaths and a half page narrative in local language
At least two physicians independently examined
field reports to attribute a probable cause to each
death (e.g., pneumonia)
www.cghr.org/child
How was the study done?
Calculate proportion of deaths by cause within
the study
Combine with national 2005 UN deaths
totals
Produce national (and state) estimates of
number of child deaths by cause
www.cghr.org/child
How many deaths were studied?
Age
Boys
Girls
Total
First
month
6069
4823
10 892
1 to 59
months
5624
6636
12 260
11 693
11 459
23 152
0 to 4
years
www.cghr.org/child
Of the 2.3 M (23 lakhs) child
deaths in India in 2005:
• 1.6 M (16 lakhs) occur in the first year
of life
• 1 M (10 lakhs) occur in the first month
of life
• 0.7 M (7 lakhs) occur in the first week
of life
www.cghr.org/child
Main causes of the 2.3 M (23 lakhs) deaths
in children under 5 years in India, 2005
0.33 M (3.3 lakhs)
Prematurity and low birthweight
0.27 M (2.7 lakhs)
Neonatal infections
0.19 M (1.9 lakhs)
Birth asphyxia or birth trauma
0.37 M (3.7 lakhs)
0.30 M (3 lakhs)
Pneumonia
Diarrhoea
~0.8 M (8 lakhs)
Other causes
www.cghr.org/child
50% of 1.3 M
(1.3 lakhs)
deaths at ages
1-59 months
80% of 1.0 M
(10 lakhs)
neonatal
deaths
Causes of deaths in children under 5 years
in India, 2005
www.cghr.org/child
For every 1000 children born,
how many died in the first month?
• 12 died from prematurity or low
birthweight
• 10 died from neonatal infections
• 7 died from birth asphyxia and
birth trauma
• 37 from all neonatal causes
www.cghr.org/child
For every 1000 children born,
how many died at ages 1-59 months?
• 14 died from pneumonia
 16 girls vs. 11 boys
• 11 died from diarrhoea
 13 girls vs. 9 boys
• 49 from all causes
 57 girls vs. 42 boys
www.cghr.org/child
Huge regional variation in specific
causes: e.g. neonatal infections
Region
South
Central
www.cghr.org/child
Mortality rate per 1000
livebirths
4
15
~ 4 fold
difference
Huge gender variation in specific
causes at ages 1-59 months
Cause
Mortality rate per 1000
livebirths
Pneumonia
Girls in Central India
21
Boys in South India
4
~ 5 fold
difference
Diarrhoea
Girls in Central India
18
Boys in West India
4
www.cghr.org/child
~ 4 fold
difference
Mortality and missing girls
• Most of the “missing” girls at ages 0-6 years in
India arise from selective abortion, and not more
girl deaths
 0.15 M (1.5 lakhs) excess girl deaths at ages 1-59
months (mostly due to neglect or lack of care)
However:
 0.13 M (1.3 lakhs) excess boy deaths in the first month
of life (mostly due to biological reasons)
• States with high selective abortion have high
mortality among girls at ages 1-59 months
www.cghr.org/child
Implications
Most child deaths are avoidable
• Top 5 causes can be avoided with effective
and widely practicable interventions:
•
•
•
•
•
•
•
www.cghr.org/child
Prenatal care
Skilled delivery
Emergency obstetric care
Newborn care and postnatal care
Oral antibiotics
Pneumonia and diarrhoea treatment
Immunisation, especially newer antigens (Hib,
pneumococcus, rotavirus) at ages 1-59 months
Key messages
• 5 causes account for nearly two-thirds of all
2.3 M (23 lakhs) child deaths in India
 3 causes account for 80% of the 1 M (10 lakhs)
deaths in the first month of life:
• prematurity and low birthweight
• neonatal infections
• birth asphyxia and birth trauma
 2 causes account for 50% of the 1.3 M (13 lakhs)
deaths at ages 1–59 months:
• pneumonia
• diarrhoea
• Huge variation by region or gender
www.cghr.org/child
Million Death Study Collaborators
Indian Academic Partners (in alphabetical order):
1. Clinical Epidemiology Resource and Training Centre, Trivandarum: KB Leena, KT Shenoy (until 2005)
2. Department of Community Medicine, Gujarat Medical College, Ahmedabad: DV Bala, P Seth KN Trivedi
3. Department of Community Medicine, Kolkatta Medical College, Kolkatta: SK Roy
4. Department of Community Medicine, Regional Institute of Medical Sciences, Imphal: L Usharani
5. Department of Community Medicine, S.C.B. Medical College, Cuttack, Orissa: Dr. B Mohapatra
6. Department of Community Medicine, SMS Medical College, Jaipur: AK Bharadwaj, R Gupta
7. Epidemiological Research Center, Chennai: V Gajalakshmi, CV Kanimozhi
8. Gandhi Medical College, Bhopal: RP Dikshit, S Sorangi
9. Healis-Seskarhia Institute of Public Health, Mumbai: PC Gupta, MS Pednekar, S Sreevidya
10. Indian Institute of Health & Family Welfare, Hyderabad: P Bhatia
11. Institute of Health Systems Research, Hyderabad: P Mahapatra (until 2004)
12. St. John’s Research Institute, St. John’s Academy of Health Sciences, Bangalore: A Kurpad, P Mony, M Vaz, R Jotkar, S Rao-Seshadri, A Shet, S Srinivasan
13. King George Medical College, Lucknow: S Awasthi
14. Najafgarh Rural Health Training Centre, Ministry of Health, Government of India, New Delhi: N Dhingra, J Sudhir, I Rawat(until 2007)
15. National Institute of Mental Health and Neurosciences, Bangalore: G Gururaj (until 2004)
16. North Eastern Indira Gandhi Institute of Regional Medical Sciences, Shillong, Meghalaya: FU Ahmed (until 2005), DK Parida
17. Regional Medical Research Center, ICMR Institute, Bhubaneshwar: AS Karketta, SK Dar
18. School of Preventative Oncology, Patna: DN Sinha
19. School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh: N Kaur, R Kumar, JS Thakur
20. Tata Memorial Hospital, Mumbai: RA Badwe, RP Dikshit, K Mohandas
Lead Partners:
1. Office of the Registrar General of India, RK Puram, New Delhi, India: C Chandramouli (Registrar General of India [RGI]), RC
Sethi, B Mishra, S Jain (until 2008), DK Dey (until 2009), AK Jha, AK Saxena, MS Thapa, N Kumar, JK Banthia and DK Sikri (former RGIs)
2. Million Death Study Coordinating Centre, Centre for Global Health Research (CGHR), Li Ka Shing Knowledge Institute,
Keenan Research Centre, St. Michael’s Hospital, Dalla Lana School of Public Health, University of Toronto, Canada: DG Bassani,
P Jha (Principal Investigator), R Jotkar, R Kamadod, B Pezzack, S Rao-Seshadri, P Rodriguez, J Sudhir, C Ramasundarahettige, W Suraweera
Affiliated Partners:
1. Indian Council of Medical Research, New Delhi, India: VM Katoch (Director General [DG] from 2008), NK Ganguly (DG to 2008), L Kant, B Bhattacharya
2. School of Population Health, The University of Queensland, Australia: AD Lopez, C Rao
3. World Health Organization. Geneva and SEARO Office, New Delhi: T Boerma, T Evans, A Fric, S Habayeb (former WHO Representative-India), S Khanum,
C Mathers, DN Sinha, N Singh, P Singh (Deputy Regional Director)
4. Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, UK: N Bhala, J Boreham, Z Chen, R Collins, R Peto, G Whitlock
www.cghr.org/child
www.cghr.org/child
1. The Lancet paper and webappendix
2. Lancet press release
3. PowerPoint slides
www.cghr.org/child
Background Slides
www.cghr.org/child
Distribution of 2.35 million (23 lakhs) deaths
at age 0-4 years in India, 2005
www.cghr.org/child
Livebirths and deaths in children under 5 years
in India, by region, 2005
* These-lowerincome states are
known as the
Empowered Action
group States plus
Assam (EAGA)
states
www.cghr.org/child
Causes of deaths in children under 5 years
(study totals and national estimates)
Study deaths, 2001-03
Cause
Boys / Girls / Total
Rural
area
All India, 2005
Died in a Two coders
health immediately
facility
agreed
Mortality rate
per 1000 livebirths
Boys / Girls / Total
Total deaths (thousands)
Boys / Girls / Total (99%CI)
Neonatal ( <1 month)
Prematurity & low birthweight *
Infections†
Birth asphyxia & birth trauma
Other noncommunicable diseases
Congenital anomalies
Diarrhoeal diseases
Tetanus
Injuries
Other causes
All causes
(%)
2012
1544
1219
316
213
175
149
27
414
6069
/ 1619 / 3631
/ 1339 / 2883
/ 854 / 2073
/ 243 / 559
/ 146 / 359
/ 162 / 337
/ 115 / 264
/ 20 / 47
/ 325 / 739
/ 4823 / 10 892
3265
2694
1869
502
304
318
255
43
665
9915
(91·0%)
988
346
631
118
139
26
14
8
147
2417
(22·2%)
2381
1804
946
251
202
227
180
15
329
6335
(58·2%)
13·0
10·3
8.0
2.0
1·4
1·2
1·3
0·2
2·7
40·1
/ 10·8 / 12·0
/ 9·4 / 9·9
/ 5·9 / 7·0
/ 1·6 / 1·8
/ 1·0 / 1·2
/ 1·2 / 1·2
/ 1·0 / 1·2
/ 0·1 / 0·2
/ 2·5 / 2·4
/ 33·5 / 36·9
185
145
113
28
20
17
18
3
39
568
/ 142 / 327 (309–345)
/ 123 / 268 (253–286)
/ 77 / 190 (176–206)
/ 21 / 49 (42–58)
/ 13 / 33 (28–42)
/ 15 / 32 (26–40)
/ 14 / 32 (26–39)
/ 2 / 5 (3–8)
/ 33 / 72 (61–81)
/ 440 / 1008 –
1 to 59 months
Pneumonia
Diarrhoeal diseases
Measles
Other noncommunicable diseases
Injuries
Malaria
Meningitis/encephalitis
Nutritional diseases
Acute bacterial sepsis & severe infections
Other infectious diseases
Other causes
All causes
(%)
1542
1184
308
418
400
262
232
141
147
143
847
5624
/ 1890 / 3432
/ 1532 / 2716
/ 450 / 758
/ 433 / 851
/ 357 / 757
/ 325 / 587
/ 209 / 441
/ 201 / 342
/ 213 / 360
/ 182 / 325
/ 844 / 1691
/ 6636 / 12 260
3146
2480
687
772
689
562
396
303
324
298
1490
11 147
(90·9%)
404
293
64
142
91
43
94
18
50
43
218
1460
(11·9%)
2546
2146
374
490
673
354
183
190
117
120
882
8075
(65·9%)
11·2
8·9
2·5
3.0
2·9
1·7
1·9
1·1
1·1
1·0
6·4
41·7
/ 16·0 / 13·5
/ 13·4 / 11·1
/ 4·2 / 3·3
/ 3·5 / 3·2
/ 2·9 / 2·9
/ 2·4 / 2·0
/ 1·9 / 1·9
/ 1·9 / 1·5
/ 1·8 / 1·4
/ 1·5 / 1·2
/ 7·2 / 6·9
/ 56·7 / 48·9
159
126
36
42
42
24
27
16
15
14
91
592
/ 210 / 369 (348–390)
/ 176 / 302 (283–323)
/ 56 / 92 (79–104)
/ 46 / 88 (77–100)
/ 38 / 80 (68–92)
/ 32 / 56 (47–65)
/ 25 / 52 (43–62)
/ 25 / 41 (34–51)
/ 23 / 38 (31–47)
/ 19 / 33 (27–41)
/ 95 / 186 (170–203)
/ 745 / 1337 –
21 062
3877
(91·0%)‡ (16·7%)‡
14 410
(62·2%)
81·8 / 90·2 / 85·8
0 to 4 years
All causes
(%)
www.cghr.org/child
11 693 / 11 459 / 23 152
Note: * See foot-notes in published article
1160 / 1185 / 2345 –
Causes of deaths in children under 5 years
in India, by gender, 2005
www.cghr.org/child
Causes of deaths in children under 5
years in India, by state income, 2005
www.cghr.org/child
Causes of deaths in children under 5 years
in India, by region, 2005 (1)
www.cghr.org/child
Causes of deaths in children under 5 years
in India, by region, 2005 (2)
www.cghr.org/child
Causes of deaths in children under 5 years
in India, by region, 2005 (3)
www.cghr.org/child
Mortality rates for the three leading causes
of neonatal death in India, by region, 2005
www.cghr.org/child
Mortality rates for the two leading causes of death
at ages 1-59 months in India, by region, 2005
www.cghr.org/child
Neonatal mortality due to prematurity & low
birthweight in India, by state, 2005
www.cghr.org/child
Neonatal mortality due to infections in India,
by state, 2005
www.cghr.org/child
Neonatal mortality due to birth asphyxia &
birth trauma in India, by state, 2005
www.cghr.org/child
Mortality due to pneumonia at ages 1-59
months in India, by state, 2005
www.cghr.org/child
Mortality due to diarrhoea at ages 1-59
months in India, by state, 2005
www.cghr.org/child