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

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 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 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

* Poorer states are the nine states of Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttarakhand, and Uttar Pradesh. Separate results for the 304 districts in the nine poorer states and 293 districts in the rest of India

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) India’s goals for MDG

Under-5 mortality progress

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 Under-5 mortality results

Districts Lag > 5 year/ Total 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 0/ 35 0/ 19 0/ 32 0/ 20 0/ 14 0/ 12

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

251 districts of 597 districts lag behind the neonatal goal by more than 5 years of these lagging districts are in the poorer states 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 Neonatal and 1-59 month mortality progress

Districts Lag >5yrs/ Total 45/ 50 28/ 33 15/ 18 59/ 71 24/ 30 10/ 24 9/ 22 11/ 27 9/ 23 7/ 26 10/ 38 3/ 12 3/ 19 3/ 20 4/ 30 2/ 21 3/ 35 1/ 13 0/ 32 0/ 14

Districts On track/ Total 32/ 32 14/ 14 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 0/ 71 0/ 33 0/ 30 0/ 18

Districts Lag >5yrs/ Total 49/ 50 36/ 38 19/ 27 49/ 71 14/ 30 13/ 33 9/ 24 3/ 13 3/ 18 4/ 26 2/ 30 1/ 21 1/ 22 1/ 23 0/ 12 0/ 19 0/ 20 0/ 35 0/ 32 0/ 14

Districts On track/ Total 32/ 32 14/ 14 20/ 20 17/ 19 31/ 35 19/ 22 10/ 12 18/ 23 21/ 30 14/ 21 14/ 26 6/ 13 4/ 18 4/ 24 5/ 33 2/ 27 4/ 71 2/ 50 1/ 30 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 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 excess deaths in girls India will meet MDG only around 2020 – richer states by 2015 and poorer states by 2023

More material – 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