1. 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

2. 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

3. 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

4. Nationally representative sample (Sample Registration System)
6,671 of these small areas randomly chosen from all parts of India (each with about people per area)

5. How was the study done?
800 Registrar of General India field workers interviewed 122 thousand families of people who had died in
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)

6. 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

7. How many deaths were studied?
Age
Boys
Girls
Total
First month
6069
4823
10 892
1 to 59 months
5624
6636
12 260
0 to 4 years
11 693
11 459
23 152

8. 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

9. 80% of 1.0 M (10 lakhs) neonatal deaths
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

10. Causes of deaths in children under 5 years in India, 2005

11. 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

12. 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

13. Huge regional variation in specific causes: e.g. neonatal infections
Mortality rate per 1000 livebirths
South 4
Central 15
~ 4 fold difference

14. Huge gender variation in specific causes at ages 1-59 months
Mortality rate per 1000 livebirths
Pneumonia
Girls in Central India 21
Boys in South India 4
Diarrhoea 18
Boys in West India
~ 5 fold difference
~ 4 fold difference

15. 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

16. 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

17. 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

18. 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

19. www.cghr.org/child The Lancet paper and webappendix
Lancet press release
PowerPoint slides

20. Background Slides

21. Distribution of 2.35 million (23 lakhs) deaths at age 0-4 years in India, 2005

22. 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

23. Causes of deaths in children under 5 years (study totals and national estimates)
Note: * See foot-notes in published article

24. Causes of deaths in children under 5 years in India, by gender, 2005

25. Causes of deaths in children under 5 years in India, by state income, 2005

26. Causes of deaths in children under 5 years in India, by region, 2005 (1)

27. Causes of deaths in children under 5 years in India, by region, 2005 (2)

28. Causes of deaths in children under 5 years in India, by region, 2005 (3)

29. Mortality rates for the three leading causes of neonatal death in India, by region, 2005

30. Mortality rates for the two leading causes of death at ages 1-59 months in India, by region, 2005

31. Neonatal mortality due to prematurity & low birthweight in India, by state, 2005

32. Neonatal mortality due to infections in India, by state, 2005

33. Neonatal mortality due to birth asphyxia & birth trauma in India, by state, 2005

34. Mortality due to pneumonia at ages 1-59 months in India, by state, 2005

35. Mortality due to diarrhoea at ages 1-59 months in India, by state, 2005