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

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

doi:10.1016/s0140-6736(20)30471-2

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

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

Research output: Contribution to journal › Article › peer-review

123 Citations (Scopus)

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.

Original language	English
Pages (from-to)	1640-1658
Number of pages	19
Journal	The Lancet
Volume	395
Issue number	10237
Early online date	12 May 2020
DOIs	https://doi.org/10.1016/s0140-6736(20)30471-2
Publication status	Published - 23 May 2020
Externally published	Yes

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

Access to Document

10.1016/s0140-6736(20)30471-2Licence: CC BY

1-s2Final published version, 4.69 MBLicence: CC BY

Cite this

Dandona, R., Kumar, G. A., Henry, N. J., Joshua, V., Ramji, S., Gupta, S. S., Agrawal, D., Kumar, R., Lodha, R., Mathai, M., Kassebaum, N. J., Pandey, A., Wang, H., Sinha, A., Hemalatha, R., Abdulkader, R. S., Agarwal, V., Albert, S., Biswas, A., ... Dandona, L. (2020). Subnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–17. The Lancet, 395(10237), 1640-1658. https://doi.org/10.1016/s0140-6736(20)30471-2

@article{d7c46445913d42e7babe893b484a7c47,

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

abstract = "Background India has made substantial progress in improving child survival over the past few decades, but acomprehensive understanding of child mortality trends at disaggregated geographical levels is not available. Wepresent a detailed analysis of subnational trends of child mortality to inform efforts aimed at meeting the IndiaNational 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 in5 × 5 km grids across India, and for the districts and states of India, using all accessible data from various sourcesincluding surveys with subnational geographical information. The 31 states and groups of union territories werecategorised into three groups using their Socio-demographic Index (SDI) level, calculated as part of the Global Burdenof Diseases, Injuries, and Risk Factors Study on the basis of per-capita income, mean education, and total fertility ratein women younger than 25 years. Inequality between districts within the states was assessed using the coefficient ofvariation. We projected U5MR and NMR for the states and districts up to 2025 and 2030 on the basis of the trends from2000 to 2017 and compared these projections with the NHP 2025 and SDG 2030 targets for U5MR (23 deaths and25 deaths per 1000 livebirths, respectively) and NMR (16 deaths and 12 deaths per 1000 livebirths, respectively). Weassessed 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 varied5·7 times between the states of India and 10·5 times between the 723 districts of India in 2017, whereas NMR varied4·5 times and 8·0 times, respectively. In the low SDI states, 275 (88\%) districts had a U5MR of 40 or more per1000 livebirths and 291 (93\%) districts had an NMR of 20 or more per 1000 livebirths in 2017. The annual rate ofchange from 2010 to 2017 varied among the districts from a 9·02\% (95\% UI 6·30–11·63) reduction to no significantchange for U5MR and from an 8·05\% (95\% UI 5·34–10·74) reduction to no significant change for NMR. Inequalitybetween districts within the states increased from 2000 to 2017 in 23 of the 31 states for U5MR and in 24 states forNMR, with the largest increases in Odisha and Assam among the low SDI states. If the trends observed up to2017 were to continue, India would meet the SDG 2030 U5MR target but not the SDG 2030 NMR target or either ofthe NHP 2025 targets. To reach the SDG 2030 targets individually, 246 (34\%) districts for U5MR and 430 (59\%) districtsfor NMR would need a higher rate of improvement than they had up to 2017. For all major causes of under-5 deathin India, the death rate decreased between 2000 and 2017, with the highest decline for infectious diseases, intermediatedecline for neonatal disorders, and the smallest decline for congenital birth defects, although the magnitude ofdecline varied widely between the states. Child and maternal malnutrition was the predominant risk factor, to which68·2\% (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 airpollution.Interpretation India has made gains in child survival, but there are substantial variations between the states in themagnitude and rate of decline in mortality, and even higher variations between the districts of India. Inequality betweendistricts within states has increased for the majority of the states. The district-level trends presented here can providecrucial guidance for targeted efforts needed in India to reduce child mortality to meet the Indian and global child survivaltargets. District-level mortality trends along with state-level trends in causes of under-5 and neonatal death and the riskfactors in this Article provide a comprehensive reference for further planning of child mortality reduction in India.",

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

year = "2020",

month = may,

day = "23",

doi = "10.1016/s0140-6736(20)30471-2",

language = "English",

volume = "395",

pages = "1640--1658",

journal = "The Lancet",

issn = "0140-6736",

publisher = "Elsevier B.V.",

number = "10237",

}

Dandona, R, Kumar, GA, Henry, NJ, Joshua, V, Ramji, S, Gupta, SS, Agrawal, D, Kumar, R, Lodha, R, Mathai, M, Kassebaum, NJ, Pandey, A, Wang, H, Sinha, A, Hemalatha, R, Abdulkader, RS, Agarwal, V, Albert, S, Biswas, A, Burstein, R, Chakma, JK, Christopher, DJ, Collison, M, Dash, AP, Dey, S, Dicker, D, Gardner, W, Glenn, SD, Golechha, MJ, He, Y, Jerath, SG, Kant, R, Kar, A, Khera, AK, Kinra, S, Koul, PA, Krish, V, Krishnankutty, RP, Kurpad, AV, Kyu, HH, Laxmaiah, A, Mahanta, J, Mahesh, PA, Malhotra, R, Mamidi, RS, Manguerra, H, Mathew, JL, Mathur, MR, Mehrotra, R, Mukhopadhyay, S, Murthy, GVS, Mutreja, P, Nagalla, B, Nguyen, G, Oommen, AM, Pati, A, Pati, S, Perkins, S, Prakash, S, Purwar, M, Sagar, R, Sankar, MJ, Saraf, DS, Shukla, DK, Shukla, SR, Singh, NP, Sreenivas, V, Tandale, B, Thankappan, KR, Tripathi, M, Tripathi, S, Tripathy, S, Troeger, C, Varghese, CM, Varughese, S, Watson, S, Yadav, G, Zodpey, S, Reddy, KS, Toteja, GS, Naghavi, M, Lim, SS, Vos, T, Bekedam, HJ, Swaminathan, S, Murray, CJL, Hay, SI, Sharma, RS & Dandona, L 2020, 'Subnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–17', The Lancet, vol. 395, no. 10237, pp. 1640-1658. https://doi.org/10.1016/s0140-6736(20)30471-2

TY - JOUR

T1 - Subnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–17

AU - Dandona, Rakhi

AU - Kumar, G Anil

AU - Henry, Nathaniel J

AU - Joshua, Vasna

AU - Ramji, Siddarth

AU - Gupta, Subodh S

AU - Agrawal, Deepti

AU - Kumar, Rashmi

AU - Lodha, Rakesh

AU - Mathai, Matthews

AU - Kassebaum, Nicholas J

AU - Pandey, Anamika

AU - Wang, Haidong

AU - Sinha, Anju

AU - Hemalatha, Rajkumar

AU - Abdulkader, Rizwan S

AU - Agarwal, Vivek

AU - Albert, Sandra

AU - Biswas, Atanu

AU - Burstein, Roy

AU - Chakma, Joy K

AU - Christopher, D J

AU - Collison, Michael

AU - Dash, A P

AU - Dey, Sagnik

AU - Dicker, Daniel

AU - Gardner, William

AU - Glenn, Scott D

AU - Golechha, Mahaveer J

AU - He, Yihua

AU - Jerath, Suparna G

AU - Kant, Rajni

AU - Kar, Anita

AU - Khera, Ajay K

AU - Kinra, Sanjay

AU - Koul, Parvaiz A

AU - Krish, Varsha

AU - Krishnankutty, Rinu P

AU - Kurpad, Anura V

AU - Kyu, Hmwe H

AU - Laxmaiah, Avula

AU - Mahanta, Jagadish

AU - Mahesh, P A

AU - Malhotra, Ridhima

AU - Mamidi, Raja S

AU - Manguerra, Helena

AU - Mathew, Joseph L

AU - Mathur, Manu R

AU - Mehrotra, Ravi

AU - Mukhopadhyay, Satinath

AU - Murthy, G V S

AU - Mutreja, Parul

AU - Nagalla, Balakrishna

AU - Nguyen, Grant

AU - Oommen, Anu M

AU - Pati, Ashalata

AU - Pati, Sanghamitra

AU - Perkins, Samantha

AU - Prakash, Sanjay

AU - Purwar, Manorama

AU - Sagar, Rajesh

AU - Sankar, Mari J

AU - Saraf, Deepika S

AU - Shukla, D K

AU - Shukla, Sharvari R

AU - Singh, Narinder P

AU - Sreenivas, V

AU - Tandale, Babasaheb

AU - Thankappan, Kavumpurathu R

AU - Tripathi, Manjari

AU - Tripathi, Suryakant

AU - Tripathy, Srikanth

AU - Troeger, Christopher

AU - Varghese, Chris M

AU - Varughese, Santosh

AU - Watson, Stefanie

AU - Yadav, Geetika

AU - Zodpey, Sanjay

AU - Reddy, K Srinath

AU - Toteja, G S

AU - Naghavi, Mohsen

AU - Lim, Stephen S

AU - Vos, Theo

AU - Bekedam, Hendrik J

AU - Swaminathan, Soumya

AU - Murray, Christopher J L

AU - Hay, Simon I

AU - Sharma, R S

AU - Dandona, Lalit

PY - 2020/5/23

Y1 - 2020/5/23

N2 - Background India has made substantial progress in improving child survival over the past few decades, but acomprehensive understanding of child mortality trends at disaggregated geographical levels is not available. Wepresent a detailed analysis of subnational trends of child mortality to inform efforts aimed at meeting the IndiaNational 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 in5 × 5 km grids across India, and for the districts and states of India, using all accessible data from various sourcesincluding surveys with subnational geographical information. The 31 states and groups of union territories werecategorised into three groups using their Socio-demographic Index (SDI) level, calculated as part of the Global Burdenof Diseases, Injuries, and Risk Factors Study on the basis of per-capita income, mean education, and total fertility ratein women younger than 25 years. Inequality between districts within the states was assessed using the coefficient ofvariation. We projected U5MR and NMR for the states and districts up to 2025 and 2030 on the basis of the trends from2000 to 2017 and compared these projections with the NHP 2025 and SDG 2030 targets for U5MR (23 deaths and25 deaths per 1000 livebirths, respectively) and NMR (16 deaths and 12 deaths per 1000 livebirths, respectively). Weassessed 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 varied5·7 times between the states of India and 10·5 times between the 723 districts of India in 2017, whereas NMR varied4·5 times and 8·0 times, respectively. In the low SDI states, 275 (88%) districts had a U5MR of 40 or more per1000 livebirths and 291 (93%) districts had an NMR of 20 or more per 1000 livebirths in 2017. The annual rate ofchange from 2010 to 2017 varied among the districts from a 9·02% (95% UI 6·30–11·63) reduction to no significantchange for U5MR and from an 8·05% (95% UI 5·34–10·74) reduction to no significant change for NMR. Inequalitybetween districts within the states increased from 2000 to 2017 in 23 of the 31 states for U5MR and in 24 states forNMR, with the largest increases in Odisha and Assam among the low SDI states. If the trends observed up to2017 were to continue, India would meet the SDG 2030 U5MR target but not the SDG 2030 NMR target or either ofthe NHP 2025 targets. To reach the SDG 2030 targets individually, 246 (34%) districts for U5MR and 430 (59%) districtsfor NMR would need a higher rate of improvement than they had up to 2017. For all major causes of under-5 deathin India, the death rate decreased between 2000 and 2017, with the highest decline for infectious diseases, intermediatedecline for neonatal disorders, and the smallest decline for congenital birth defects, although the magnitude ofdecline varied widely between the states. Child and maternal malnutrition was the predominant risk factor, to which68·2% (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 airpollution.Interpretation India has made gains in child survival, but there are substantial variations between the states in themagnitude and rate of decline in mortality, and even higher variations between the districts of India. Inequality betweendistricts within states has increased for the majority of the states. The district-level trends presented here can providecrucial guidance for targeted efforts needed in India to reduce child mortality to meet the Indian and global child survivaltargets. District-level mortality trends along with state-level trends in causes of under-5 and neonatal death and the riskfactors in this Article provide a comprehensive reference for further planning of child mortality reduction in India.

AB - Background India has made substantial progress in improving child survival over the past few decades, but acomprehensive understanding of child mortality trends at disaggregated geographical levels is not available. Wepresent a detailed analysis of subnational trends of child mortality to inform efforts aimed at meeting the IndiaNational 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 in5 × 5 km grids across India, and for the districts and states of India, using all accessible data from various sourcesincluding surveys with subnational geographical information. The 31 states and groups of union territories werecategorised into three groups using their Socio-demographic Index (SDI) level, calculated as part of the Global Burdenof Diseases, Injuries, and Risk Factors Study on the basis of per-capita income, mean education, and total fertility ratein women younger than 25 years. Inequality between districts within the states was assessed using the coefficient ofvariation. We projected U5MR and NMR for the states and districts up to 2025 and 2030 on the basis of the trends from2000 to 2017 and compared these projections with the NHP 2025 and SDG 2030 targets for U5MR (23 deaths and25 deaths per 1000 livebirths, respectively) and NMR (16 deaths and 12 deaths per 1000 livebirths, respectively). Weassessed 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 varied5·7 times between the states of India and 10·5 times between the 723 districts of India in 2017, whereas NMR varied4·5 times and 8·0 times, respectively. In the low SDI states, 275 (88%) districts had a U5MR of 40 or more per1000 livebirths and 291 (93%) districts had an NMR of 20 or more per 1000 livebirths in 2017. The annual rate ofchange from 2010 to 2017 varied among the districts from a 9·02% (95% UI 6·30–11·63) reduction to no significantchange for U5MR and from an 8·05% (95% UI 5·34–10·74) reduction to no significant change for NMR. Inequalitybetween districts within the states increased from 2000 to 2017 in 23 of the 31 states for U5MR and in 24 states forNMR, with the largest increases in Odisha and Assam among the low SDI states. If the trends observed up to2017 were to continue, India would meet the SDG 2030 U5MR target but not the SDG 2030 NMR target or either ofthe NHP 2025 targets. To reach the SDG 2030 targets individually, 246 (34%) districts for U5MR and 430 (59%) districtsfor NMR would need a higher rate of improvement than they had up to 2017. For all major causes of under-5 deathin India, the death rate decreased between 2000 and 2017, with the highest decline for infectious diseases, intermediatedecline for neonatal disorders, and the smallest decline for congenital birth defects, although the magnitude ofdecline varied widely between the states. Child and maternal malnutrition was the predominant risk factor, to which68·2% (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 airpollution.Interpretation India has made gains in child survival, but there are substantial variations between the states in themagnitude and rate of decline in mortality, and even higher variations between the districts of India. Inequality betweendistricts within states has increased for the majority of the states. The district-level trends presented here can providecrucial guidance for targeted efforts needed in India to reduce child mortality to meet the Indian and global child survivaltargets. District-level mortality trends along with state-level trends in causes of under-5 and neonatal death and the riskfactors in this Article provide a comprehensive reference for further planning of child mortality reduction in India.

U2 - 10.1016/s0140-6736(20)30471-2

DO - 10.1016/s0140-6736(20)30471-2

M3 - Article

SN - 0140-6736

VL - 395

SP - 1640

EP - 1658

JO - The Lancet

JF - The Lancet

IS - 10237

ER -

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

Abstract

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