Inequality apparent in District-level child mortality and growth failure

BY ADITI ROY 

New Delhi, May 12  Two recent research papers published by the India State-Level Disease Burden Initiative has highlighted 68 percent of the under-5 deaths in India can be attributed to child and maternal malnutrition, 83 percent of the neonatal deaths to low birth weight and short gestation.

The paper in ‘The Lancet’ reports the first comprehensive estimates of district-level trends of child mortality in India from 2000, and the paper in ‘EClinicalMedicine’ reports detailed district-level trends of child growth failure. The findings show that although the child mortality and child growth failure indicators have improved substantially across India from 2000 to 2017, the inequality between districts has increased within many states, and that there are wide variations between the districts of India.

The child mortality and child growth failure trends reported in these papers utilized all accessible georeferenced survey data from a variety of sources in India, which enabled more robust estimates than the estimates based on single sources that may have more biases, says the research.

The under-5 mortality rate (U5MR) and neonatal mortality rate in the first month of life (NMR) have dropped substantially in India since 2000, but there is a 5-6 fold variation in the rates between the states and 8-11 fold variation between the districts of India. While U5MR and NMR have been decreasing in almost all districts of India, the progress in this decline has been highly variable because of which the inequality in these rates has increased between districts within many states, it adds.

Adding, if the trends observed up to 2017 were to continue, India would meet the SDG (Sustainable Development Goals) 2030 U5MR target but not the SDG 2030 NMR target; 34 percent of the districts in India would need higher U5MR reduction and 60 percent districts would need higher NMR reduction to individually meet the SDG targets.

“This is India’s first comprehensive consolidated and detailed analysis of sub-national trends of child mortality and growth failure for all the districts and states in India. It is reassuring news for India that with the various governmental and other efforts under-five mortality rate has halved from 2000 to 2017. The district-level trends reported in these papers provide useful guidance for identifying priority districts in each state that need the highest attention. This approach can facilitate further reduction in child mortality in India,” said Balram Bhargava, Secretary to the Government of India, Department of Health Research, Ministry of Health & Family Welfare, and Director General, ICMR.

District-level child mortality variations

* U5MR varied 10.5 times between the 723 districts of India in 2017, ranging from 8 to 88 per 1000 livebirths, and NMR varied 8.0 times, ranging from 6 to 46 per 1000 livebirths. The highest district-level U5MR and NMR in 2017 were comparable to the highest rates globally among some Sub-Saharan Africa countries.

* U5MR was 40 or more per 1000 livebirths in 88 percent of the districts in the less developed (low SDI or Sustainable Development Index) states, but only in 2 percent of the districts in the more developed (high SDI) states.

* Similarly, NMR was 20 or more per 1000 livebirths in 93 percent of the districts in the low SDI states, but only in 13 percent of the districts in the high SDI states.

* The annual rate of change 2010-2017 varied widely among the districts from 9.0% reduction to no significant change for U5MR, and from 8.0 percent reduction to no significant change for NMR.

* Inequality between the districts within the states, measured as coefficient of variation, varied extensively in 2017, ranging 11-fold for U5MR and 13-fold for NMR among the states.

* Despite the decrease in U5MR and NMR in most of the districts from 2000 to 2017, the inequality in these rates increased in 74 percent of the states for U5MR and in 77 percent states for NMR.

* The highest increases in inequality between districts within states were in Assam and Odisha among the low SDI states, in the small north-eastern states of Meghalaya and Arunachal Pradesh, and in Haryana among the middle SDI states.

“These studies clearly indicate that, nationally, India has made impressive and substantial progress in reducing the rates of under-5 mortality, however, there remain discrepancies in those rates among and within district-level geographies,” said Prof Christopher J L Murray, Director of the Institute for Health Metrics and Evaluation at the University of Washington’s School of Medicine.

Causes of child mortality

* Lower respiratory infections (17�9 percent), preterm birth (15�6 percent), diarrhoeal diseases (9�9 percent), and birth asphyxia and trauma (8.1 percent) were the leading causes of under-5 death in India in 2017.

* Preterm birth (27�7 percent), birth asphyxia and trauma (14�5 percent), lower respiratory infections (11.0 percent), and congenital birth defects (8.6 percent) were the leading causes of neonatal deaths in India in 2017. 80 percent of the neonatal deaths were in the early neonatal period of 0�6 days.

* There were wide variations in the percentage of under-5 deaths due to various causes across the states even within the same SDI group. For example, within the low SDI states, the percentage for lower respiratory infections ranged from 15 percent in Odisha to 27 percent in Rajasthan, for diarrheal diseases from 6% in Chhattisgarh to 16% in Bihar, and for preterm birth from 11% in Bihar to 19% in Chhattisgarh.

* The rates for most causes of under-5 death in India were lower in the more developed states than in the less developed states.

* The death rate for all major causes of under-5 death reduced in India from 2000 to 2017, with the highest decline in measles (82 percent), followed by diarrhoeal diseases (69 percent), and lower respiratory infections (57%) and least for congenital birth defects (15 percent). There were wide variations in the magnitude of decline between the states, even within the same SDI group.

Identification of priority districts in states

* Priority districts for child growth failure reduction were identified within states as those that fell in the category of high prevalence of stunting, wasting or underweight in 2017 and low annual rate of reduction from 2010 to 2017 for their distribution within the states. Using this approach, priority districts for the nationwide distribution of the prevalence of stunting, wasting and underweight and the rate of reduction were also identified to enable a complimentary understanding of the standing of each district with respect to all districts in the country.

* In Odisha, which had the highest inequality between districts for all the three CGF indicators in 2017, the districts in the highest priority category of high prevalence and low annual rate of reduction for stunting, wasting and underweight included a cluster of three districts in the south-west handle of the state (Kalahandi, Koraput, and Rayagada), and additionally for underweight and wasting in the neighbouring three districts (Nuapada, Nabarangapur and Malkangiri), and for stunting and underweight in Balangir district.

* In Uttar Pradesh, which had the highest stunting prevalence and medium level of inequality in 2017, the districts in the highest priority category of high prevalence and low rate of reduction for stunting included a cluster of 13 districts in the northern part (Pilibhit, Shahjanpur, Lakhimpur Kheri, Sitapur, Bahraich, Sharavasti, Balrampur, Siddharth Nagar, Gonda, Barabanki, Faizabad, Basti, and Maharajganj).

* Based on the nationwide district-level distribution of the prevalence of CGF indicators, all 38 districts in Bihar were in the high tertile of stunting and none were in the high tertile for their rate of reduction, while in Uttar Pradesh, 97 percent of the districts fell in the high tertile for stunting and only 12 percent were in their high tertile for the rate of reduction.

* Interestingly, for wasting, 60 percent of the districts in the Odisha were in the high nation-wide tertile in 2017, while 67 percent in Uttar Pradesh were in the low tertile, indicating the contrast even within the less developed (low SDI) states.

“These research findings have shown that India has made positive strides in protecting the lives of new-borns over the last two decades. Introduction of contextually relevant multi-sectorial actions by the Government of India and the State Governments like maternal nutrition programmes during pregnancy, access to skilled health providers during childbirth, and family/community-based care through postnatal home visits have shown to have made a difference. The district level data from this study will help in the planning and implementation of local action plans and set the course for further improvements in child mortality and child growth failure in India,” said Vinod Paul, Member, NITI Aayog.

(Aditi Roy can be contacted at aditi.r@ians.in)