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

Dandona, Rakhi, Kumar, G Anil, Henry, Nathaniel J, Joshua, Vasna, Ramji, Siddarth, Gupta, Subodh S, Agrawal, Deepti, Kumar, Rashmi, Lodha, Rakesh, Mathai, Matthews ORCID:, Kassebaum, Nicholas J, Pandey, Anamika, Wang, Haidong, Sinha, Anju, Hemalatha, Rajkumar, Abdulkader, Rizwan S, Agarwal, Vivek, Albert, Sandra, Biswas, Atanu, Burstein, Roy, Chakma, Joy K, Christopher, D J, Collison, Michael, Dash, A P, Dey, Sagnik, Dicker, Daniel, Gardner, William, Glenn, Scott D, Golechha, Mahaveer J, He, Yihua, Jerath, Suparna G, Kant, Rajni, Kar, Anita, Khera, Ajay K, Kinra, Sanjay, Koul, Parvaiz A, Krish, Varsha, Krishnankutty, Rinu P, Kurpad, Anura V, Kyu, Hmwe H, Laxmaiah, Avula, Mahanta, Jagadish, Mahesh, P A, Malhotra, Ridhima, Mamidi, Raja S, Manguerra, Helena, Mathew, Joseph L, Mathur, Manu R, Mehrotra, Ravi, Mukhopadhyay, Satinath, Murthy, G V S, Mutreja, Parul, Nagalla, Balakrishna, Nguyen, Grant, Oommen, Anu M, Pati, Ashalata, Pati, Sanghamitra, Perkins, Samantha, Prakash, Sanjay, Purwar, Manorama, Sagar, Rajesh, Sankar, Mari J, Saraf, Deepika S, Shukla, D K, Shukla, Sharvari R, Singh, Narinder P, Sreenivas, V, Tandale, Babasaheb, Thankappan, Kavumpurathu R, Tripathi, Manjari, Tripathi, Suryakant, Tripathy, Srikanth, Troeger, Christopher, Varghese, Chris M, Varughese, Santosh, Watson, Stefanie, Yadav, Geetika, Zodpey, Sanjay, Reddy, K Srinath, Toteja, G S, Naghavi, Mohsen, Lim, Stephen S, Vos, Theo, Bekedam, Hendrik J, Swaminathan, Soumya, Murray, Christopher J L, Hay, Simon I, Sharma, R S and Dandona, Lalit (2020) 'Subnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–17'. Lancet, Vol 395, pp. 1640-1658.

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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
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.

Item Type: Article
Subjects: WA Public Health > Health Problems of Special Population Groups > WA 320 Child Welfare. Child Health Services.
WA Public Health > Health Problems of Special Population Groups > WA 395 Health in developing countries
WA Public Health > Statistics. Surveys > WA 900 Public health statistics
WS Pediatrics > By Age Groups > WS 440 Preschool child
Faculty: Department: Clinical Sciences & International Health > International Public Health Department
Digital Object Identifer (DOI):
Depositing User: Rachel Dominguez
Date Deposited: 14 May 2020 09:36
Last Modified: 04 Jun 2020 10:52


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