Subnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–17

Rakhi Dandona(University of Washington), G Anil Kumar(University of Washington), Nathaniel J Henry(University of Washington), Vasna Joshua(University of Washington), Siddarth Ramji(University of Washington), Subodh S. Gupta(University of Washington), Deepti Agrawal(University of Washington), Rashmi Kumar(University of Washington), Rakesh Lodha(University of Washington), Matthews Mathai(University of Washington), Nicholas J Kassebaum(University of Washington), Anamika Pandey(University of Washington), Haidong Wang(University of Washington), Anju Sinha(University of Washington), Hemalatha Rajkumar(University of Washington), Rizwan Suliankatchi Abdulkader(University of Washington), Vivek Agarwal(University of Washington), Sandra Albert(University of Washington), Atanu Biswas(University of Washington), Roy Burstein(University of Washington), Joy Kumar Chakma(University of Washington), Devasahayam Jesudas Christopher(University of Washington), Michael L. Collison(University of Washington), Aditya Prasad Dash(University of Washington), Sagnik Dey(University of Washington), Daniel Dicker(University of Washington), William M. Gardner(University of Washington), Scott Glenn(University of Washington), Mahaveer Golechha(University of Washington), Yihua He(University of Washington), Suparna Ghosh‐Jerath(University of Washington), Rajni Kant(University of Washington), Anita Kar(University of Washington), Ajay Khera(University of Washington), Sanjay Kinra(University of Washington), Parvaiz A Koul(University of Washington), Varsha Krish(University of Washington), Rinu P Krishnankutty(University of Washington), Anura V. Kurpad(University of Washington), Hmwe Hmwe Kyu(University of Washington), Avula Laxmaiah(University of Washington), Jagadish Mahanta(University of Washington), P A Mahesh(University of Washington), Ridhima Malhotra(University of Washington), Raja Sriswan Mamidi(University of Washington), Helena Manguerra(University of Washington), Joseph L. Mathew(University of Washington), Manu Raj Mathur(University of Washington), Ravi Mehrotra(University of Washington), Satinath Mukhopadhyay(University of Washington), G. V. S. Murthy(University of Washington), Parul Mutreja(University of Washington), Nagalla Balakrishna(University of Washington), Grant Nguyen(University of Washington), Anu Mary Oommen(University of Washington), Ashalata Pati(University of Washington), Sanghamitra Pati(University of Washington), Samantha Perkins(University of Washington), Sanjay Prakash(University of Washington), Manorama Purwar(University of Washington), Rajesh Sagar(University of Washington), Mari Jeeva Sankar(University of Washington), Deepika Saraf(University of Washington), Deeksha Shukla(University of Washington), Sharvari Shukla(University of Washington), Narinder Pal Singh(University of Washington), V. Sreenivas(University of Washington), Babasaheb V. Tandale(University of Washington), Kavumpurathu R Thankappan(University of Washington), Manjari Tripathi(University of Washington), Suryakant Tripathi(University of Washington), Srikanth Tripathy(University of Washington), Christopher Troeger(University of Washington), Chris M Varghese(University of Washington), Santosh Varughese(University of Washington), Stefanie Watson(University of Washington), Geetika Yadav(University of Washington), Sanjay Zodpey(University of Washington), K. Srinath Reddy(University of Washington), Gurudayal Singh Toteja(University of Washington), Mohsen Naghavi(University of Washington), Stephen S Lim(University of Washington), Theo Vos(University of Washington), Hendrik J Bekedam(University of Washington), Soumya Swaminathan(University of Washington), Christopher J L Murray(University of Washington), Simon I Hay(University of Washington), Rajesh Sharma(University of Washington), Lalit Dandona(University of Washington)
The Lancet
May 1, 2020
10.1016/s0140-6736(20)30471-2
Cited by 224Open Access
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Abstract

BACKGROUND: India has made substantial progress in improving child survival over the past few decades, but a comprehensive understanding of child mortality trends at disaggregated geographical levels is not available. We present a detailed analysis of subnational trends of child mortality to inform efforts aimed at meeting the India National Health Policy (NHP) and Sustainable Development Goal (SDG) targets for child mortality. METHODS: We assessed the under-5 mortality rate (U5MR) and neonatal mortality rate (NMR) from 2000 to 2017 in 5 × 5 km grids across India, and for the districts and states of India, using all accessible data from various sources including surveys with subnational geographical information. The 31 states and groups of union territories were categorised into three groups using their Socio-demographic Index (SDI) level, calculated as part of the Global Burden of Diseases, Injuries, and Risk Factors Study on the basis of per-capita income, mean education, and total fertility rate in women younger than 25 years. Inequality between districts within the states was assessed using the coefficient of variation. We projected U5MR and NMR for the states and districts up to 2025 and 2030 on the basis of the trends from 2000 to 2017 and compared these projections with the NHP 2025 and SDG 2030 targets for U5MR (23 deaths and 25 deaths per 1000 livebirths, respectively) and NMR (16 deaths and 12 deaths per 1000 livebirths, respectively). We assessed the causes of child death and the contribution of risk factors to child deaths at the state level. FINDINGS: U5MR in India decreased from 83·1 (95% uncertainty interval [UI] 76·7-90·1) in 2000 to 42·4 (36·5-50·0) per 1000 livebirths in 2017, and NMR from 38·0 (34·2-41·6) to 23·5 (20·1-27·8) per 1000 livebirths. U5MR varied 5·7 times between the states of India and 10·5 times between the 723 districts of India in 2017, whereas NMR varied 4·5 times and 8·0 times, respectively. In the low SDI states, 275 (88%) districts had a U5MR of 40 or more per 1000 livebirths and 291 (93%) districts had an NMR of 20 or more per 1000 livebirths in 2017. The annual rate of change from 2010 to 2017 varied among the districts from a 9·02% (95% UI 6·30-11·63) reduction to no significant change for U5MR and from an 8·05% (95% UI 5·34-10·74) reduction to no significant change for NMR. Inequality between districts within the states increased from 2000 to 2017 in 23 of the 31 states for U5MR and in 24 states for NMR, with the largest increases in Odisha and Assam among the low SDI states. If the trends observed up to 2017 were to continue, India would meet the SDG 2030 U5MR target but not the SDG 2030 NMR target or either of the NHP 2025 targets. To reach the SDG 2030 targets individually, 246 (34%) districts for U5MR and 430 (59%) districts for NMR would need a higher rate of improvement than they had up to 2017. For all major causes of under-5 death in India, the death rate decreased between 2000 and 2017, with the highest decline for infectious diseases, intermediate decline for neonatal disorders, and the smallest decline for congenital birth defects, although the magnitude of decline varied widely between the states. Child and maternal malnutrition was the predominant risk factor, to which 68·2% (65·8-70·7) of under-5 deaths and 83·0% (80·6-85·0) of neonatal deaths in India could be attributed in 2017; 10·8% (9·1-12·4) of under-5 deaths could be attributed to unsafe water and sanitation and 8·8% (7·0-10·3) to air pollution. INTERPRETATION: India has made gains in child survival, but there are substantial variations between the states in the magnitude and rate of decline in mortality, and even higher variations between the districts of India. Inequality between districts within states has increased for the majority of the states. The district-level trends presented here can provide crucial guidance for targeted efforts needed in India to reduce child mortality to meet the Indian and global child survival targets. District-level mortality trends along with state-level trends in causes of under-5 and neonatal death and the risk factors in this Article provide a comprehensive reference for further planning of child mortality reduction in India. FUNDING: Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

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