Causes of neonatal and child mortality in India: a nationally representative mortality survey

doi:10.1016/S0140-6736(10)61461-4

The Lancet

Volume 376, Issue 9755, 27 November–3 December 2010, Pages 1853-1860

https://doi.org/10.1016/S0140-6736(10)61461-4 Get rights and content

Summary

Background

More than 2·3 million children died in India in 2005; however, the major causes of death have not been measured in the country. We investigated the causes of neonatal and child mortality in India and their differences by sex and region.

Methods

The Registrar General of India surveyed all deaths occurring in 2001–03 in 1·1 million nationally representative homes. Field staff interviewed household members and completed standard questions about events that preceded the death. Two of 130 physicians then independently assigned a cause to each death. Cause-specific mortality rates for 2005 were calculated nationally and for the six regions by combining the recorded proportions for each cause in the neonatal deaths and deaths at ages 1–59 months in the study with population and death totals from the United Nations.

Findings

There were 10 892 deaths in neonates and 12 260 in children aged 1–59 months in the study. When these details were projected nationally, three causes accounted for 78% (0·79 million of 1·01 million) of all neonatal deaths: prematurity and low birthweight (0·33 million, 99% CI 0·31 million to 0·35 million), neonatal infections (0·27 million, 0·25 million to 0·29 million), and birth asphyxia and birth trauma (0·19 million, 0·18 million to 0·21 million). Two causes accounted for 50% (0·67 million of 1·34 million) of all deaths at 1–59 months: pneumonia (0·37 million, 0·35 million to 0·39 million) and diarrhoeal diseases (0·30 million, 0·28 million to 0·32 million). In children aged 1–59 months, girls in central India had a five-times higher mortality rate (per 1000 livebirths) from pneumonia (20·9, 19·4–22·6) than did boys in south India (4·1, 3·0–5·6) and four-times higher mortality rate from diarrhoeal disease (17·7, 16·2–19·3) than did boys in west India (4·1, 3·0–5·5).

Interpretation

Five avoidable causes accounted for nearly 1·5 million child deaths in India in 2005, with substantial differences between regions and sexes. Expanded neonatal and intrapartum care, case management of diarrhoea and pneumonia, and addition of new vaccines to immunisation programmes could substantially reduce child deaths in India.

Funding

US National Institutes of Health, International Development Research Centre, Canadian Institutes of Health Research, Li Ka Shing Knowledge Institute, and US Fund for UNICEF.

Introduction

Yearly child mortality rates in India have fallen between 1·7%¹ and 2·3%² in the past two decades. Despite this decrease, the United Nations (UN) estimates that about 2·35 million children died in India in 2005. This figure corresponds to more than 20% of all deaths in children younger than 5 years worldwide, which is more than in any other country.1, 3 Large differences in overall child survival between India's diverse regions have been previously documented.4, 5 However, no direct and nationally representative measurement of the major causes of death in neonates (<1 month) and at ages 1–59 months has been done,⁶ and how these causes of death vary across India's regions is unknown. Social preference for boys is strong, as noted by widespread selective abortion of female fetuses⁷ and by lower immunisation rates in girls.⁸ The consequences of boy preference on child mortality remain undocumented. Understanding of the causes of child death might, therefore, help to guide the use of widely practicable interventions for neonatal and child survival.3, 9

Most deaths in India, including of children, are not medically certified since most occur at home, in rural areas, and without attention by a health-care worker.¹⁰ Thus, other sources of information are needed to help to establish the probable underlying causes of death. During the past decade the Registrar General of India (RGI) has introduced an enhanced form of verbal autopsy called RHIME—or routine, reliable, representative, re-sampled household investigation of mortality with medical evaluation¹¹—into its nationally representative sample registration system (SRS), which covered about 6·3 million people and monitored all deaths in 1·1 million homes.⁵ This mortality survey is part of the Million Death Study, which seeks to assign causes to all deaths in the SRS areas during the 13 years from 2001 to 2013.11, 12, 13, 14, 15 In this report we present the results of the causes of child deaths in India, separately for the neonatal period and at ages 1–59 months, for boys and girls, and for each of six major regions of India.

Section snippets

Study setting and procedures

Details of the design, methods, and preliminary results of the Million Death Study have been previously published.11, 12, 13, 14, 15 India was divided into about 1 million areas for the 1991 census, each with about 1000 inhabitants. The RGI chose 6671 of these areas randomly for the SRS in 1993; in each area all individuals and their household characteristics were documented and subsequent births and deaths (but not cause of death) were documented every month by a part-time enumerator resident

Results

Of the 24 841 child deaths surveyed, 93% (23 152) were double-coded by physicians and included in the study (table). Reasons for exclusion were missing information about age or sex (n=191), and non-legible forms, improper scanning of narrative, or incorrect language code (n=1498). Respondents for the 23 152 child deaths were the father (n=5117; 22%), mother (8103; 35%), siblings and other relatives (5047; 22%), grandparents (3612; 16%), or a neighbour or non-relative (1273; 5%). Most child

Discussion

More than three-fifths of all 2·3 million child deaths in India in 2005 were from five causes: pneumonia, prematurity and low birthweight, diarrhoeal diseases, neonatal infections, and birth asphyxia and birth trauma. Each of the major causes of neonatal deaths can be prevented or treated with known, highly effective and widely practicable interventions such as improvements in prenatal care, intrapartum care (skilled attendance, emergency obstetric care, and simple immediate care for newborn

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^‡: Writing committee listed at end of Article and members in webappendix p 7

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ArticlesCauses of neonatal and child mortality in India: a nationally representative mortality survey

Summary

Background

Methods

Findings

Interpretation

Funding

Introduction

Section snippets

Study setting and procedures

Results

Discussion

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World population prospects (2008 revision)

National Family Health Survey (NFHS-3), 2005–06: India

Sample Registration System

Rates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmes

Bull World Health Organ

Gender inequity and age-appropriate immunization coverage in India from 1992 to 2006

BMC Int Health Hum Rights

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Avoidable mortality in India: past progress and future prospects

Natl Med J India

Prospective study of one million deaths in India: rationale, design, and validation results

PLoS Med

Causes of death in India, 2001–2003: Sample Registration System

Adult and child malaria mortality in India: a nationally representative mortality survey

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Causes of neonatal and child mortality in India: a nationally representative mortality survey