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

[email protected]

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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

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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

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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)

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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)

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How was the study done?

Calculate proportion of deaths by cause within the study Combine with national 2005 UN deaths totals

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Produce national (and state) estimates of number of child deaths by cause

How many deaths were studied?

Age First month 1 to 59 months 0 to 4 years Boys 6069 5624 11 693 Girls 4823 6636 11 459 Total 10 892 12 260 23 152

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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

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Main causes of the 2.3 M (23 lakhs) deaths in children under 5 years in India, 2005

0.33 M (3.3 lakhs) 0.27 M (2.7 lakhs) 0.19 M (1.9 lakhs) 0.37 M (3.7 lakhs) 0.30 M (3 lakhs) ~0.8 M (8 lakhs) Prematurity and low birthweight Neonatal infections Birth asphyxia or birth trauma Pneumonia Diarrhoea 50% of 1.3 M (1.3 lakhs) deaths at ages 1-59 months Other causes 80% of 1.0 M (10 lakhs) neonatal deaths

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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

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For every 1000 children born, how many died at ages 1-59 months?

• 14 died from pneumonia

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16 girls vs. 11 boys • 11 died from diarrhoea

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13 girls vs. 9 boys • 49 from all causes

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57 girls vs. 42 boys

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Huge regional variation in specific causes: e.g. neonatal infections

Region South Central Mortality rate per 1000 livebirths 4 15 ~ 4 fold difference

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Huge gender variation in specific causes at ages 1-59 months

Cause Pneumonia Girls in Central India Boys in South India Diarrhoea Girls in Central India Boys in West India

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Mortality rate per 1000 livebirths 21 4 18 4 ~ 5 fold difference ~ 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

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Implications

Most child deaths are avoidable • Top 5 causes can be avoided with effective and widely practicable interventions: • 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

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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

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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

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1. The Lancet paper and webappendix 2. Lancet press release 3. PowerPoint slides

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Background Slides

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-lower income states are known as the Empowered Action group States plus Assam (EAGA) states

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Causes of deaths in children under 5 years (study totals and national estimates) Cause Neonatal ( <1 month)

Prematurity & low birthweight * Infections † Birth asphyxia & birth trauma Other noncommunicable diseases Congenital anomalies Diarrhoeal diseases Tetanus Injuries Other causes

All causes (%) 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 (%) 0 to 4 years All causes (%) Study deaths, 2001-03 Boys / Girls / Total Rural area Died in a health facility Two coders immediately agreed

2012 / 1619 / 3631 1544 / 1339 / 2883 1219 / 316 / 213 175 / / 854 243 146 162 / / / / 2073 559 359 337 149 27 / / 115 20 / / 264 47 414 / 325 / 739

6069 / 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%)

1542 / 1890 / 3432 1184 / 1532 / 2716 308 418 / / 450 433 / / 758 851 400 262 232 141 / / / / 357 325 209 201 / / / / 757 587 441 342 147 143 / / 213 182 / / 360 325 847 / 844 / 1691

5624 / 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%) 11 693 / 11 459 / 23 152 21 062 (91·0%) ‡ 3877 (16·7%) ‡ 14 410 (62·2%) Mortality rate per 1000 livebirths Boys / Girls / Total All India, 2005 Total deaths (thousands) Boys / Girls / Total (99%CI)

13·0 / 10·8 / 12·0 10·3 / 8.0

2.0

1·4 1·2 / / / / 9·4 5·9 1·6 1·0 1·2 / / / / / 9·9 7·0 1·8 1·2 1·2 1·3 0·2 / / 1·0 0·1 / / 1·2 0·2 2·7 / 2·5 / 2·4

40·1 / 33·5 / 36·9

185 / 142 / 327 (309 –345) 145 / 123 / 268 (253 –286) 113 / 77 / 190 (176 –206) 28 20 / / 21 13 / / 49 33 (42 –58) (28 –42) 17 18 3 39 / / / / 15 14 2 33 / / / / 32 32 5 72

568 / 440 / 1008

(26 –40) (26 –39) (3 –8) (61 –81) – 11·2 / 16·0 / 13·5 8·9 / 13·4 / 11·1 2·5 3.0

/ / 4·2 3·5 / / 3·3 3·2 2·9 1·7 1·9 1·1 / / / / 2·9 2·4 1·9 1·9 / / / / 2·9 2·0 1·9 1·5 1·1 1·0 / / 1·8 1·5 / / 1·4 1·2 6·4 / 7·2 / 6·9

41·7 / 56·7 / 48·9 81·8 / 90·2 / 85·8

159 / 210 / 369 (348 –390) 126 / 176 / 302 (283 –323) 36 42 / / 56 46 / / 92 88 (79 –104) (77 –100) 42 24 27 16 / / / / 38 32 25 25 / / / / 80 56 52 41 (68 –92) (47 –65) (43 –62) (34 –51) 15 14 91 / / / 23 19 95 / / 38 33 (31 –47) (27 –41) / 186 (170 –203)

592 / 745 / 1337

–

1160 / 1185 / 2345

– Note: * See foot-notes in published article

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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