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www.cghr.org/child 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. Michaels Hospital, Dalla Lana School of Public Health, University of Toronto prabhat.jha@utoronto.ca Slide 2 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 159 months: pneumonia diarrhoea Huge variation by region or gender Slide 3 www.cghr.org/child Whats 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 Slide 4 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) Slide 5 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 At least two physicians independently examined field reports to attribute a probable cause to each death (e.g., pneumonia) Obtain detailed histories, symptoms, etc. about each deaths and a half page narrative in local language Slide 6 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 Slide 7 www.cghr.org/child How many deaths were studied? AgeBoysGirlsTotal First month 6069482310 892 1 to 59 months 5624663612 260 0 to 4 years 11 69311 45923 152 Slide 8 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 Slide 9 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 80% of 1.0 M (10 lakhs) neonatal deaths 50% of 1.3 M (1.3 lakhs) deaths at ages 1-59 months Slide 10 www.cghr.org/child Causes of deaths in children under 5 years in India, 2005 Slide 11 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 Slide 12 www.cghr.org/child 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 For every 1000 children born, how many died at ages 1-59 months? Slide 13 www.cghr.org/child Huge regional variation in specific causes: e.g. neonatal infections RegionMortality rate per 1000 livebirths South4 Central15 ~ 4 fold difference Slide 14 www.cghr.org/child CauseMortality rate per 1000 livebirths Pneumonia Girls in Central India21 Boys in South India4 Diarrhoea Girls in Central India18 Boys in West India4 ~ 5 fold difference ~ 4 fold difference Huge gender variation in specific causes at ages 1-59 months Slide 15 www.cghr.org/child 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 Slide 16 www.cghr.org/child 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 Slide 17 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 159 months: pneumonia diarrhoea Huge variation by region or gender Slide 18 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. Johns Research Institute, St. Johns 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. Michaels 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 Slide 19 www.cghr.org/child 1. The Lancet paper and webappendix 2. Lancet press release 3. PowerPoint slides Slide 20 www.cghr.org/child Background Slides Slide 21 www.cghr.org/child Distribution of 2.35 million (23 lakhs) deaths at age 0-4 years in India, 2005 Slide 22 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 Slide 23 www.cghr.org/child Causes of deaths in children under 5 years (study totals and national estimates) Note: * See foot-notes in published article Slide 24 www.cghr.org/child Causes of deaths in children under 5 years in India, by gender, 2005 Slide 25 www.cghr.org/child Causes of deaths in children under 5 years in India, by state income, 2005 Slide 26 www.cghr.org/child Causes of deaths in children under 5 years in India, by region, 2005 (1) Slide 27 www.cghr.org/child Causes of deaths in children under 5 years in India, by region, 2005 (2) Slide 28 www.cghr.org/child Causes of deaths in children under 5 years in India, by region, 2005 (3) Slide 29 www.cghr.org/child Mortality rates for the three leading causes of neonatal death in India, by region, 2005 Slide 30 www.cghr.org/child Mortality rates for the two leading causes of death at ages 1-59 months in India, by region, 2005 Slide 31 www.cghr.org/child Neonatal mortality due to prematurity & low birthweight in India, by state, 2005 Slide 32 www.cghr.org/child Neonatal mortality due to infections in India, by state, 2005 Slide 33 www.cghr.org/child Neonatal mortality due to birth asphyxia & birth trauma in India, by state, 2005 Slide 34 www.cghr.org/child Mortality due to pneumonia at ages 1-59 months in India, by state, 2005 Slide 35 www.cghr.org/child Mortality due to diarrhoea at ages 1-59 months in India, by state, 2005