Mapping neonatal and under-5 mortality in India
Authors: Praveen Kumar, Nalini Singhal
Journal: The Lancet (2020)

India is one of the world's largest and most populous countries, made up of more than 700 diverse districts. Variations in mortality in the country are known at the macro level, and now the India State-Level Disease Burden Initiative Child Mortality Collaborators1India State-Level Disease Burden Initiative Child Mortality CollaboratorsSubnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–17.Lancet. 2020; (published online May 12.)https://doi.org/10.1016/S0140-6736(20)30471-2Google Scholar have mapped neonatal and under-5 mortality rates from 2000 to 2017 for every district in India, going down to geospatial grids as small as 5 km × 5 km. In The Lancet, the study authors report that the under-5 mortality rate (U5MR) in India decreased from 83·1 deaths (95% uncertainty interval 76·7–90·1) in 2000 to 42·4 deaths (36·5–50·0) per 1000 livebirths in 2017, and the neonatal mortality rate (NMR) decreased from 38·0 deaths (34·2–41·6) to 23·5 deaths (20·1–27·8) per 1000 livebirths. U5MR varied 5·7 times between the various states and 10·5 times between the 723 districts in 2017, whereas NMR varied 4·5 times across the states and 8·0 times across the districts. Child and maternal malnutrition was the main risk factor, contributing to 68·2% (65·8–70·7) of under-5 deaths and 83·0% (80·6–85·0) of neonatal deaths in India in 2017, while 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. The authors found substantial variations between the states in the magnitude and rate of decline in neonatal and under-5 mortality, with higher variations between the districts. Additionally, inequality between districts has increased within the majority of the states. The underlying system-based causes of neonatal and under-5 mortality need to be better understood. One size cannot fit all, especially in such a large country. Contextual microplanning is required at the lowest administrative unit level, which should be based on real data of deaths and their causes, available resources, and coverage and quality of services. The Article1India State-Level Disease Burden Initiative Child Mortality CollaboratorsSubnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–17.Lancet. 2020; (published online May 12.)https://doi.org/10.1016/S0140-6736(20)30471-2Google Scholar describes important differences in local outcomes that can inform the designing of strategies with local stakeholders in areas such as education, provision of equipment (eg, incubators, neonatal radiant warmers, neonatal resuscitation bag and masks, autoclaves), and transportation of mothers and neonates to health facilities to accelerate the decrease in NMR and U5MR. Local health-care providers understand the challenges their areas face and thus might be able to provide solutions for sustainable improvements. A district-level perinatal–neonatal care model driven by local coordination committees composed of all stakeholders has been proposed.2Bhakoo ON Kumar P Current challenges and future prospects of neonatal care in India.Indian J Pediatr. 2013; 80: 39-49Crossref PubMed Scopus (7) Google Scholar Quality care, knowledge translation to caregivers, and local implementation for delivery of health care are all key to survival of children and mothers.3Ersdal HL Singhal N Msemo G et al.Successful implementation of Helping Babies Survive and Helping Mothers Survive programs—an Utstein formula for new-born and maternal survival.PLoS One. 2017; 12e0178073Crossref PubMed Scopus (34) Google Scholar Focusing on local changes using local data can lead to improved outcomes, as has been shown in Canada.4Lee SK Beltempo M McMillan DD et al.Outcomes and care practices for preterm infants born at less than 33 weeks' gestation: a quality-improvement study.CMAJ. 2020; 192: E81-E91Crossref PubMed Scopus (22) Google Scholar Health is a state responsibility; however, in India planning typically occurs at the central level with very little involvement of lower level providers. This study1India State-Level Disease Burden Initiative Child Mortality CollaboratorsSubnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–17.Lancet. 2020; (published online May 12.)https://doi.org/10.1016/S0140-6736(20)30471-2Google Scholar provides valuable information to highlight the importance of standardised national perinatal–neonatal surveillance data that can be turned into actionable information for end users at the lowest administrative unit. The authors have brought attention to the fact that, with current trends, India is unlikely to achieve the Sustainable Development Goal (SDG) 2030 NMR targets or either of the National Health Policy 2025 targets.1India State-Level Disease Burden Initiative Child Mortality CollaboratorsSubnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–17.Lancet. 2020; (published online May 12.)https://doi.org/10.1016/S0140-6736(20)30471-2Google Scholar 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 2017.1India State-Level Disease Burden Initiative Child Mortality CollaboratorsSubnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–17.Lancet. 2020; (published online May 12.)https://doi.org/10.1016/S0140-6736(20)30471-2Google Scholar Simply knowing the causes is not enough. Structural deficiencies remain, with glaring bottlenecks. To provide adequate care, India needs 20 000–30 000 level 3 neonatal intensive care unit (NICU) beds and 75 000–100 000 level 2 special newborn care beds.2Bhakoo ON Kumar P Current challenges and future prospects of neonatal care in India.Indian J Pediatr. 2013; 80: 39-49Crossref PubMed Scopus (7) Google Scholar, 5Karthik NN Razak A Current status of neonatal intensive care in India.Arch Dis Child Fetal Neonatal Ed. 2016; 101: F260-F265Crossref PubMed Scopus (9) Google Scholar, 6Neogi S Malhotra S Zodpey S Mohan P Is the number of beds in special care newborn units in India adequate?.Natl Med J India. 2014; 27: 102-104PubMed Google Scholar However, the numbers of beds available, especially level 3 NICU beds, are grossly inadequate.2Bhakoo ON Kumar P Current challenges and future prospects of neonatal care in India.Indian J Pediatr. 2013; 80: 39-49Crossref PubMed Scopus (7) Google Scholar, 5Karthik NN Razak A Current status of neonatal intensive care in India.Arch Dis Child Fetal Neonatal Ed. 2016; 101: F260-F265Crossref PubMed Scopus (9) Google Scholar, 7Sundaram V Chirla D Panigrahy D Kumar P Current status of NICUs in India: a nationwide survey and the way forward.Indian J Pediatrics. 2014; 81: 1198-1204Crossref PubMed Scopus (18) Google Scholar It remains common in government hospitals to have up to five sick newborn babies sharing a cot.6Neogi S Malhotra S Zodpey S Mohan P Is the number of beds in special care newborn units in India adequate?.Natl Med J India. 2014; 27: 102-104PubMed Google Scholar In such scenarios, quality improvement efforts that target process improvement alone do not achieve their full potential benefits. The Indian Government's flagship insurance scheme—the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana—holds great promise of rapidly expanding the pool of hospital beds by enrolling existing private health-care facilities. However, the effect on availability of level 3 NICU beds is yet to be seen. Upgrading and operationalising the underused newborn stabilisation unit beds across the country along with a functional back-referral system could substantially augment the number of level 2 beds available.2Bhakoo ON Kumar P Current challenges and future prospects of neonatal care in India.Indian J Pediatr. 2013; 80: 39-49Crossref PubMed Scopus (7) Google Scholar The variation in district-wise mortality and its relationship to social development has caught the attention of planners. The Aspirational Districts Programme launched in 2018 focuses on the 115 lowest-performing districts for all-round development through convergence, collaboration, and competition. Intersectoral and centre-state convergence addresses education, skills development, financial inclusion, water, air, infrastructure, and other determinants of health. Apart from state-wise and district-wise differences, another source of huge variation is urban slums. The mortality indicators in urban slums are even worse than in rural areas and they have their own unique set of problems.8Kyu HH Shannon HS Georgiades K Boyle MH Association of urban slum residency with infant mortality and child stunting in low and middle income countries.Biomed Res Int. 2013; 2013604974Crossref PubMed Scopus (14) Google Scholar, 9Bhandari N Bahl R Taneja S Martines J Bhan MK Pathways to infant mortality in urban slums of Delhi, India: implications for improving the quality of community- and hospital-based programmes.J Health Popul Nutr. 2002; 20: 148-155PubMed Google Scholar The growing inequalities shown in this study1India State-Level Disease Burden Initiative Child Mortality CollaboratorsSubnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–17.Lancet. 2020; (published online May 12.)https://doi.org/10.1016/S0140-6736(20)30471-2Google Scholar between 2000 and 2017, against a global aim of equity, are of concern and reflect the widening gap between the rich and the poor. Finally, the estimates of the causes of neonatal deaths in the country need to be more robust for good planning. The study authors point out the limitations of verbal autopsy methods.1India State-Level Disease Burden Initiative Child Mortality CollaboratorsSubnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–17.Lancet. 2020; (published online May 12.)https://doi.org/10.1016/S0140-6736(20)30471-2Google Scholar However, the medical certification of cause of death is not always credible, given the expertise of medical officers in the districts with limited laboratory support.10Garg A Singh SV Gupta VK Accuracy of medical certification of the cause of death in a rural non-teaching hospital in Delhi.Natl Med J India. 2012; 25: 185-186PubMed Google Scholar The authors make a strong case for local implementation and provide guidance to address gaps. In this direction, the Indian Government has launched programmes to improve nutritional outcomes for children, pregnant women, and lactating mothers; clean water and sanitation; and hygiene in public health facilities. With local input and planning, both U5MR and NMR can be brought down. We declare no competing interests. Subnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–17India 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. Full-Text PDF Open Access