Usha Ram

Causes of neonatal and child mortality in India: a nationally representative mortality survey.

BACKGROUND More than 2·3 million children died in India in 2005; however, the major causes of death have not been measured in the country. We investigated the causes of neonatal and child mortality in India and their differences by sex and region. METHODS The Registrar General of India surveyed all deaths occurring in 2001-03 in 1·1 million nationally representative homes. Field staff interviewed household members and completed standard questions about events that preceded the death. Two of 130 physicians then independently assigned a cause to each death. Cause-specific mortality rates for 2005 were calculated nationally and for the six regions by combining the recorded proportions for each cause in the neonatal deaths and deaths at ages 1-59 months in the study with population and death totals from the United Nations. FINDINGS There were 10,892 deaths in neonates and 12,260 in children aged 1-59 months in the study. When these details were projected nationally, three causes accounted for 78% (0·79 million of 1·01 million) of all neonatal deaths: prematurity and low birthweight (0·33 million, 99% CI 0·31 million to 0·35 million), neonatal infections (0·27 million, 0·25 million to 0·29 million), and birth asphyxia and birth trauma (0·19 million, 0·18 million to 0·21 million). Two causes accounted for 50% (0·67 million of 1·34 million) of all deaths at 1-59 months: pneumonia (0·37 million, 0·35 million to 0·39 million) and diarrhoeal diseases (0·30 million, 0·28 million to 0·32 million). In children aged 1-59 months, girls in central India had a five-times higher mortality rate (per 1000 livebirths) from pneumonia (20·9, 19·4-22·6) than did boys in south India (4·1, 3·0-5·6) and four-times higher mortality rate from diarrhoeal disease (17·7, 16·2-19·3) than did boys in west India (4·1, 3·0-5·5). INTERPRETATION Five avoidable causes accounted for nearly 1·5 million child deaths in India in 2005, with substantial differences between regions and sexes. Expanded neonatal and intrapartum care, case management of diarrhoea and pneumonia, and addition of new vaccines to immunisation programmes could substantially reduce child deaths in India. FUNDING US National Institutes of Health, International Development Research Centre, Canadian Institutes of Health Research, Li Ka Shing Knowledge Institute, and US Fund for UNICEF.

Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the Global Burden of Disease Study 2015

Summary Background The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) provides an up-to-date analysis of the burden of diarrhoeal diseases. This study assesses cases, deaths, and aetiologies spanning the past 25 years and informs the changing picture of diarrhoeal disease worldwide. Methods We estimated diarrhoeal mortality by age, sex, geography, and year using the Cause of Death Ensemble Model (CODEm), a modelling platform shared across most causes of death in the GBD 2015 study. We modelled diarrhoeal morbidity, including incidence and prevalence, using a meta-regression platform called DisMod-MR. We estimated aetiologies for diarrhoeal diseases using a counterfactual approach that incorporates the aetiology-specific risk of diarrhoeal disease and the prevalence of the aetiology in diarrhoea episodes. We used the Socio-demographic Index, a summary indicator derived from measures of income per capita, educational attainment, and fertility, to assess trends in diarrhoeal mortality. The two leading risk factors for diarrhoea—childhood malnutrition and unsafe water, sanitation, and hygiene—were used in a decomposition analysis to establish the relative contribution of changes in diarrhoea disability-adjusted life-years (DALYs). Findings Globally, in 2015, we estimate that diarrhoea was a leading cause of death among all ages (1·31 million deaths, 95% uncertainty interval [95% UI] 1·23 million to 1·39 million), as well as a leading cause of DALYs because of its disproportionate impact on young children (71·59 million DALYs, 66·44 million to 77·21 million). Diarrhoea was a common cause of death among children under 5 years old (499 000 deaths, 95% UI 447 000–558 000). The number of deaths due to diarrhoea decreased by an estimated 20·8% (95% UI 15·4–26·1) from 2005 to 2015. Rotavirus was the leading cause of diarrhoea deaths (199 000, 95% UI 165 000–241 000), followed by Shigella spp (164 300, 85 000–278 700) and Salmonella spp (90 300, 95% UI 34 100–183 100). Among children under 5 years old, the three aetiologies responsible for the most deaths were rotavirus, Cryptosporidium spp, and Shigella spp. Improvements in safe water and sanitation have decreased diarrhoeal DALYs by 13·4%, and reductions in childhood undernutrition have decreased diarrhoeal DALYs by 10·0% between 2005 and 2015. Interpretation At the global level, deaths due to diarrhoeal diseases have decreased substantially in the past 25 years, although progress has been faster in some countries than others. Diarrhoea remains a largely preventable disease and cause of death, and continued efforts to improve access to safe water, sanitation, and childhood nutrition will be important in reducing the global burden of diarrhoea. Funding Bill & Melinda Gates Foundation.

Associations between Early Marriage and Young Women's Marital and Reproductive Health Outcomes: Evidence from India

CONTEXT Little evidence from India is available regarding the ways in which early marriage may compromise young womens lives and their reproductive health and choices. METHODS Data from 8,314 married women aged 20-24 living in five Indian states, obtained from a subnationally representative study of transitions experienced by youth, were used to compare marital, reproductive and other outcomes between young women who had married before age 18 and those who had married later. Logistic regression analyses were conducted to identify associations between timing of marriage and the outcomes of interest. RESULTS Young women who had married at age 18 or older were more likely than those who had married before age 18 to have been involved in planning their marriage (odds ratio, 1.4), to reject wife beating (1.2), to have used contraceptives to delay their first pregnancy (1.4) and to have had their first birth in a health facility (1.4). They were less likely than women who had married early to have experienced physical violence (0.6) or sexual violence (0.7) in their marriage or to have had a miscarriage or stillbirth (0.6). CONCLUSIONS Findings underscore the need to build support among youth and their families for delaying marriage, to enforce existing laws on the minimum age at marriage and to encourage school, health and other authorities to support young women in negotiating with their parents to delay marriage.

Neonatal, 1–59 month, and under-5 mortality in 597 Indian districts, 2001 to 2012: estimates from national demographic and mortality surveys

BACKGROUND India has the largest number of child deaths of any country in the world, and has wide local variation in under-5 mortality. Worldwide achievement of the UN 2015 Millennium Development Goal for under-5 mortality (MDG 4) will depend on progress in the subregions of India. We aimed to estimate neonatal, 1-59 months, and overall under-5 mortality by sex for 597 Indian districts and to assess whether India is on track to achieve MDG 4. METHODS We divided the 2012 UN sex-specific birth and mortality totals for India into state totals using relative birth rates and mortality from recent demographic surveys of 24 million people, and divided state totals into totals for the 597 districts using 3 million birth histories. We then split the results into neonatal mortality and 1-59 month mortality using data for 109,000 deaths in children younger than 5 years from six national surveys. We compared results with the 2001 census for each district. FINDINGS Under-5 mortality fell at a mean rate of 3·7% (IQR 3·2-4·9) per year between 2001 and 2012. 222 (37%) of 597 districts are on track to achieve the MDG 4 of 38 deaths in children younger than 5 years per 1000 livebirths by 2015, but an equal number (222 [37%]) will achieve MDG 4 only after 2020. These 222 lagging districts are home to 41% of Indias livebirths and 56% of all deaths in children younger than 5 years. More districts lag behind the relevant goal for neonatal mortality (251 [42%]) than for 1-59 month mortality (197 [33%]). Just 81 (14%) districts account for 37% of deaths in children younger than 5 years nationally. Female mortality at ages 1-59 months exceeded male mortality by 25% in 303 districts in nearly all states of India, totalling about 74,000 excess deaths in girls. INTERPRETATION At current rates of progress, MDG 4 will be met by India around 2020-by the richer states around 2015 and by the poorer states around 2023. Accelerated progress to reduce mortality during the neonatal period and at ages 1-59 months is needed in most Indian districts. FUNDING Disease Control Priorities 3, Canadian Institutes of Health Research, International Development Research Centre, US National Institutes of Health.

Maternal Mortality in India: Causes and Healthcare Service Use Based on a Nationally Representative Survey

Background Data on cause-specific mortality, skilled birth attendance, and emergency obstetric care access are essential to plan maternity services. We present the distribution of Indias 2001–2003 maternal mortality by cause and uptake of emergency obstetric care, in poorer and richer states. Methods and Findings The Registrar General of India surveyed all deaths occurring in 2001–2003 in 1.1 million nationally representative homes. Field staff interviewed household members about events that preceded the death. Two physicians independently assigned a cause of death. Narratives for all maternal deaths were coded for variables on healthcare uptake. Distribution of number of maternal deaths, cause-specific mortality and uptake of healthcare indicators were compared for poorer and richer states. There were 10 041 all-cause deaths in women age 15–49 years, of which 1096 (11.1%) were maternal deaths. Based on 2004–2006 SRS national MMR estimates of 254 deaths per 100 000 live births, we estimated rural areas of poorer states had the highest MMR (397, 95%CI 385–410) compared to the lowest MMR in urban areas of richer states (115, 95%CI 85–146). We estimated 69 400 maternal deaths in India in 2005. Three-quarters of maternal deaths were clustered in rural areas of poorer states, although these regions have only half the estimated live births in India. Most maternal deaths were attributed to direct obstetric causes (82%). There was no difference in the major causes of maternal deaths between poorer and richer states. Two-thirds of women died seeking some form of healthcare, most seeking care in a critical medical condition. Rural areas of poorer states had proportionately lower access and utilization to healthcare services than the urban areas; however this rural-urban difference was not seen in richer states. Conclusions Maternal mortality and poor access to healthcare is disproportionately higher in rural populations of the poorer states of India.

Timing of first sex before marriage and its correlates: evidence from India

While several studies have documented the extent of pre-marital sexual experience among young people in India, little work has been done to explore the factors that are correlated with the timing of pre-marital sexual initiation. This paper examines age at initiation of pre-marital sex, circumstances in which first sex was experienced, nature of first sexual experience and correlates of age at initiation of pre-marital sex. Life table estimates suggest that pre-marital sexual initiation occurred in adolescence for 1 in 20 young women and 1 in 10 young men. For the majority of these young people, their first sex was with an opposite-sex romantic partner. First sex, moreover, was unprotected for the majority and forced for sizeable proportion of young women. A number of individual, family-, peer- and community-level factors were correlated with age at first pre-marital sex. Moreover, considerable gender differences were apparent in the correlates of age at first pre-marital sex, with peer- and parent-level factors found more often to be significant for young women than men.

Socio-Economic Differentials in Impoverishment Effects of Out-of-Pocket Health Expenditure in China and India: Evidence from WHO SAGE.

Background and Objectives The provision of affordable health care is generally considered a fundamental goal of a welfare state. In addition to its role in maintaining and improving the health status of individuals and households, it impacts the economic prosperity of a society through its positive effects on labor productivity. Given this context, this paper assesses socioeconomic-differentials in the impact of out-of-pocket-health-expenditure (OOPHE) on impoverishment in China and India, two of the fastest growing economies of the world. Data and Methods The paper uses data from the World Health Organisation’s Study on Global Ageing and Adult Health (WHO SAGE), and Bivariate as well as Multivariate analyses for investigating the socioeconomic-differentials in the impact of out-of-pocket-health-expenditure (OOPHE) on impoverishment in China and India. Results and Conclusions Annually, about 7% and 8% of the population in China and India, respectively, fall in poverty due to OOPHE. Also, the percentage shortfall in income for the population from poverty line due to OOPHE is 2% in China and 1.3% in India. Further, findings from the multivariate analysis indicate that lower wealth status and inpatient as well as outpatient care increase the odds of falling below poverty line significantly (with the extent much higher in the case of in-patient care) due to OOPHE in both China and India. In addition, having at least an under-5 child in the household, living in rural areas and having a household head with no formal education increases the odds of falling below poverty line significantly (compared to a head with college level education) due to OOPHE in China; whereas having at least an under-5 child, not having health insurance and residing in rural areas increases the odds of becoming poor significantly due to OOPHE in India.

Measles mortality in high and low burden districts of India: Estimates from a nationally representative study of over 12,000 child deaths

BACKGROUND Direct estimates of measles mortality in India are unavailable. Our objective is, to use a nationally-representative study of mortality to estimate the number and distribution of, measles deaths in India with a focus on 264 high burden districts. METHODS We used physician coded verbal autopsy data from the Million Death Study which surveyed, over 12,000 deaths in children aged 1 month to under 15 years from 1.1 million nationally, representative households in 2001-2003. RESULTS We estimate there were 92,000 (99% CI 63,000-137,000) measles deaths in children 1-59, months of age in India in 2005, representing a mortality rate of 3.3 (99% CI 2.3-5.0) per 1000 live, births and about 6% of all 1-59 month deaths. In children under 15 years of age, there were 107,000, (99% CI 74,000-158,000) measles deaths. The measles mortality rate was nearly 70% greater in girls, than in boys, and 60% of the deaths were in three populous states Uttar Pradesh, Bihar, and Madhya, Pradesh. The 1-59 month measles mortality rate in high burden districts was 4.48 (99% CI 3.94-5.02) compared to 2.40 (99% CI 2.28-2.52) per 1000 live births in other districts. CONCLUSION Measles killed over 100,000 children in India in 2005 and girls were at higher risk than boys. The majority of measles deaths occurred in a few states and high burden districts. The results of this study highlight the importance of focusing measles supplementary immunization activities in high burden districts.

Gender Socialization: Differences between Male and Female Youth in India and Associations with Mental Health

This paper describes patterns of gender socialization among youth in India and evaluates how these patterns are associated with their mental health. Data come from the Youth in India: Situation and Needs Study (), a subnationally representative survey conducted during 2006–2008. Descriptive results underscored the gendered nature of socialization experiences, showing that male and female youth inhabit different social worlds. Female youth expressed more gender-egalitarian attitudes than male youth but reported greater restrictions to their independence than male youth. Male youth recognized more gender-discriminatory practices within their households than did the female youth. Poisson models revealed that female youth experienced more mental health problems when their households engaged in practices that favoured males over females, even as these same practices were associated with fewer mental health problems among male youth. Family violence and restrictions to independence were associated with mental health problems for both male and female youth. When males and females engaged in behaviours contravening sex-specific gender norms, there were corresponding increases in mental health problems for both sexes. Together, these findings suggest that gender inequality permeates family life in India, with corresponding consequences for the mental well-being of male and female youth.

Age-specific and sex-specific adult mortality risk in India in 2014: analysis of 0·27 million nationally surveyed deaths and demographic estimates from 597 districts

BACKGROUND As child mortality decreases rapidly worldwide, premature adult mortality is becoming an increasingly important contributor to global mortality. Any possible worldwide reduction of premature adult mortality before the age of 70 years will depend on progress in India. Indian districts increasingly have responsibility for implementing public health programmes. We aimed to assess age-specific and sex-specific adult mortality risks in India at the district level. METHODS We analysed data from five national surveys of 0·27 million adult deaths at an age of 15-69 years together with 2014 demographic data to estimate age-specific and sex-specific adult mortality risks for 597 districts. Cause of death data were drawn from the verbal autopsies in the Registrar General of Indias ongoing Million Death Study. FINDINGS In 2014, about two-fifths of Indias men aged 15-69 years lived in the 253 districts where the conditional probability of a man dying at these ages exceeded 50%, and more than a third of Indias women aged 15-69 years lived in the 222 districts where the conditional probability of a woman dying exceeded 40%. The probabilities of a man or woman dying by the age of 70 years in high-mortality districts was 62% and 54%, respectively, whereas the probability of a man or woman dying by the age of 70 years in low-mortality districts was 40% and 30%, respectively. The roughly 10-year survival gap between high-mortality and low-mortality districts was nearly as extreme as the survival gap between the entire Indian population and people living in high-income countries. Adult mortality risks at ages 15-69 years was highest in east India and lowest in west India, by contrast with the north-south divide for child mortality. Vascular disease, tuberculosis, malaria and other infections, and respiratory diseases accounted for about 60% of the absolute gap in adult mortality risk at ages 15-69 years between high-mortality and low-mortality districts. Most of the variation in adult mortality could not be explained by known determinants or risk factors for premature mortality. INTERPRETATION Indias large variation in adult mortality by district, notably the higher death rates in eastern India, requires further aetiological research, particularly to explore whether high levels of adult mortality risks from infections and non-communicable diseases are a result of historical childhood malnutrition and infection. Such research can be complemented by an expanded coverage of known effective interventions to reduce adult mortality, especially in high-mortality districts. FUNDING National Institutes of Health, Canadian Institutes of Health Research, University of Toronto.