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Objectives: This paper analyses the patterns and trends in the mortality rates of infants and children under the age of 5 in India (1992-2016) and quantifies the variation in performance between different geographical states through three rounds of nationally representative household surveys., Design: Three rounds of cross-sectional survey data., Setting: The study is conducted at the national level: India and its selected good-performing states, namely Haryana, Kerala, Maharashtra, Punjab and Tamil Nadu, and selected poor-performing states, namely Bihar, Chhattisgarh, Madhya Pradesh and Uttar Pradesh., Participants: Adopting a multistage, stratified random sampling, 601 509 households with 699 686 women aged 15-49 years in 2015-2016, 109 041 households with 124 385 women aged 15-49 years in 2005-2006, and 88 562 households with 89 777 ever married women in the age group 13-49 years in 1992-1993 were selected., Results: Through the use of maps, this paper clearly shows that the overall trend in infant and child mortality is on a decline in India. Computation of relative change shows that majority of the states have witnessed over 50% reduction in both infant and under-5 mortality rates from National Family Health Survey (NFHS)-I to NFHS-4. However, the improvements are not evenly distributed, and there is huge variation in performance between states over time. Funnel plots show that the most populous states like Uttar Pradesh Bihar and Madhya Pradesh have underperformed consistently across the survey period from 1992 to 2016. Regression analysis comparing high-performing and low-performing states revealed that female infants and women with shorter birth intervals had greater risk of infant deaths in poor-performing states., Conclusion: Attempts to reduce infant and child mortality rates in India are heading in the right direction. Even so, there is huge variation in performance between states. This paper recommends a mix of strategies that reduce child and infant mortality among the high-impact states where the biggest improvements can be expected, including the need to address neonatal mortality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Relating Information on causes of deaths to implementation of health interventions provides vital information for program planning and evaluation. This paper from Ballabgarh Health and Demographic Surveillance System (HDSS) site in north India looks at temporal trends and gender differentials in the causes of death among under-five children. Methods: Data on causes of death for 1972-74, 1982-84, 1992-94, 2002-04 were taken from existing HDSS publications and database. Physicians' assigned causes of death were based on narratives by lay health worker till 1994 and later by verbal autopsy. Cause Specific Mortality Fractions (CSMF) and Cause Specific Mortality Rates (CSMR) per 1000 live births were calculated for neonatal (<1 month) and childhood (1-59 months) period. Gender difference was estimated by calculating ratio of CSMR between girls and boys. Available information on coverage of childhood interventions in the HDSS was retrieved and compiled. Results: The CSMF of prematurity and sepsis was 32% and 17.6% during neonatal period in 2002-04. The share of infections in all childhood deaths decreased from 55.2% in 1972-74 to 43.6% in 2002-04. All major causes of mortality (malnutrition, diarrhea and acute lower respiratory infection) except injuries showed a steep decline among children and seem to have plateued in last decade. Most of disease specific public health interventions were launched in mid eighties. . Girls reported significantly higher mortality rates for prematurity (RR 1.52; 95% CI 1.01-2.29); diarrhea (2.29; 1.59 - 3.29), and malnutrition (3.37; 2.05 - 5.53). Conclusions: The findings of the study point out to the need to move away from disease-specific to a comprehensive approach and to address gender inequity in child survival through socio-behavioural approaches. [ABSTRACT FROM AUTHOR]

Background: Verbal autopsy (VA) has been proposed to determine the cause of death (COD) distributions in settings where most deaths occur without medical attention or certification. We develop performance criteria for VA-based COD systems and apply these to the Registrar General of India's ongoing, nationally-representative Indian Million Death Study (MDS)., Methods: Performance criteria include a low ill-defined proportion of deaths before old age; reproducibility, including consistency of COD distributions with independent resampling; differences in COD distribution of hospital, home, urban or rural deaths; age-, sex- and time-specific plausibility of specific diseases; stability and repeatability of dual physician coding; and the ability of the mortality classification system to capture a wide range of conditions., Results: The introduction of the MDS in India reduced the proportion of ill-defined deaths before age 70 years from 13% to 4%. The cause-specific mortality fractions (CSMFs) at ages 5 to 69 years for independently resampled deaths and the MDS were very similar across 19 disease categories. By contrast, CSMFs at these ages differed between hospital and home deaths and between urban and rural deaths. Thus, reliance mostly on urban or hospital data can distort national estimates of CODs. Age-, sex- and time-specific patterns for various diseases were plausible. Initial physician agreement on COD occurred about two-thirds of the time. The MDS COD classification system was able to capture more eligible records than alternative classification systems. By these metrics, the Indian MDS performs well for deaths prior to age 70 years. The key implication for low- and middle-income countries where medical certification of death remains uncommon is to implement COD surveys that randomly sample all deaths, use simple but high-quality field work with built-in resampling, and use electronic rather than paper systems to expedite field work and coding., Conclusions: Simple criteria can evaluate the performance of VA-based COD systems. Despite the misclassification of VA, the MDS demonstrates that national surveys of CODs using VA are an order of magnitude better than the limited COD data previously available.

India lacks nationwide cancer registration and systematic death registration. Gaining insight into the magnitude of the cancer problem in India depends mainly on 14 population based cancer registries, which provide relatively accurate statistics although the area and population cover by these registries is minimal at about 7% (20% Urban and 1 % Rural). With estimation of cancer burden from other sources, paucity of adequate data on the one hand and the complex pathogenesis of disease on other makes for complexity in dealing with rural populations. However, surveys of cause of death do reveal some interesting patterns that may very well be of use for international comparisons. In this paper an attempt has been made to estimate the cancer burden in rural India using the information available from surveys of cause of death for rural populations conducted by the Government of India.

When plague epidemics swept India in the second half of the 19th century, there was an epidemiological need for mortality statistics; as a result, vital event registration systems were established. However, despite the existence of multiple sources of mortality statistics in many ministries/departments of the government, neither the number of deaths nor the causes of deaths reported annually are complete yet. Multilateral international organisations have supported modelling for the generation of mortality statistics in developing countries rather than supporting and funding the development of real-time mortality data. With specific initiatives for decentralising the registration process to primary health centres and sub-health centres, the civil registration system despite its flaws, can be improved for gathering accurate data on mortality, including the causes of deaths. [ABSTRACT FROM AUTHOR]

Objective To determine the association of different feeding patterns for infants (exclusive breastfeeding, predominant breastfeeding, partial breastfeeding and no breastfeeding) with mortality and hospital admissions during the first half of infancy. Methods This paper is based on a secondary analysis of data from a multicentre randomized controlled trial on immunization-linked vitamin A supplementation. Altogether, 9424 infants and their mothers (2919 in Ghana, 4000 in India and 2505 in Peru) were enrolled when infants were 18-42 days old in two urban slums in New Delhi, India, a periurban shanty town in Lima, Peru, and 37 villages in the Kintampo district of Ghana. Mother-infant pairs were visited at home every 4 weeks from the time the infant received the first dose of oral polio vaccine and diphtheria-pertussis-tetanus at the age of 6 weeks in Ghana and India and at the age of 10 weeks in Peru. At each visit, mothers were queried about what they had offered their infant to eat or drink during the past week. Information was also collected on hospital admissions and deaths occurring between the ages of 6 weeks and 6 months. The main outcome measures were all-cause mortality, diarrhoea-specific mortality, mortality caused by acute lower respiratory infections, and hospital admissions. Findings There was no significant difference in the risk of death between children who were exclusively breastfed and those who were predominantly breastfed (adjusted hazard ratio (HR) = 1.46; 95% confidence interval (CI) = 0.75-2.86). Non-breastfed infants had a higher risk of dying when compared with those who had been predominantly breastfed (HR = 10.5; 95% CI = 5.0-22.0; P < 0.001) as did partially breastfed infants (HR = 2.46; 95% CI = 1.44-4.18; P = 0.001). Conclusion There are two major implications of these findings. First, the extremely high risks of infant mortality associated with not being breastfed need to be taken into account when informing HIV-infected mothers about options for feeding their infants. Second, our finding that the risks of death are similar for infants who are predominantly breastfed and those who are exclusively breastfed suggests that in settings where rates of predominant breastfeeding are already high, promotion efforts should focus on sustaining these high rates rather than on attempting to achieve a shift from predominant breastfeeding to exclusive breastfeeding. [ABSTRACT FROM AUTHOR]

Background: Machine learning (ML) algorithms have been successfully employed for prediction of outcomes in clinical research. In this study, we have explored the application of ML-based algorithms to predict cause of death (CoD) from verbal autopsy records available through the Million Death Study (MDS).Methods: From MDS, 18826 unique childhood deaths at ages 1-59 months during the time period 2004-13 were selected for generating the prediction models of which over 70% of deaths were caused by six infectious diseases (pneumonia, diarrhoeal diseases, malaria, fever of unknown origin, meningitis/encephalitis, and measles). Six popular ML-based algorithms such as support vector machine, gradient boosting modeling, C5.0, artificial neural network, k-nearest neighbor, classification and regression tree were used for building the CoD prediction models.Results: SVM algorithm was the best performer with a prediction accuracy of over 0.8. The highest accuracy was found for diarrhoeal diseases (accuracy = 0.97) and the lowest was for meningitis/encephalitis (accuracy = 0.80). The top signs/symptoms for classification of these CoDs were also extracted for each of the diseases. A combination of signs/symptoms presented by the deceased individual can effectively lead to the CoD diagnosis.Conclusions: Overall, this study affirms that verbal autopsy tools are efficient in CoD diagnosis and that automated classification parameters captured through ML could be added to verbal autopsies to improve classification of causes of death. [ABSTRACT FROM AUTHOR]

Background: Longitudinal/ follow-up studies of older adults are a tough task as sample attrition rates due to mortality and other factors may be high in this particular group. However, such studies are very much needed to assess the outcome of health status as well as explore preventive, protective, interventional aspects, as well as risk factors. Given this, a follow-up study was planned and carried out. Aim: To discuss the rate of sample loss as well as the reasons over 9 years. Methods: An Indian Council of Medical Research (ICMR) supported follow-up study of urban and rural elderly was done during June, 2016–May, 2017; these subjects were studied in 2007-09 through two independent ICMR supported studies. Similar methodology and assessment tools were applied in these studies. During follow-up a semi structured proforma was developed to get the information of study cohort, obtained data was analyzed and presented applying percentage statistics. Results: The sample attrition rate was reported to be comparatively high in urban 52.1% (n= 633) cohort than their rural counterparts 36.3% (n= 457). Conclusion: Over a period of 9 years chances of cohort loss due to mortality is about 32%–35%. [ABSTRACT FROM AUTHOR]

Background: Schizophrenia is a life-shortening disease. Although the rate of mortality of persons with schizophrenia in India is established to be more compared to that in the general population, there is a little exploration of the causes for the same. Aim: The aim of this study is to explore the causes of death in two rural cohorts of schizophrenia. Materials and Methods: In-person interviews of primary caregivers of 53 deceased persons with schizophrenia were conducted using the World Health Organization's verbal autopsy 2014 instrument. Physician-based method was used to determine the causes of death. Results: Average age of 53 deceased schizophrenia patients was 50.45 ± 13.65 years with almost equal gender ratio. Just more than two-thirds of patients were married, just more than one-third are educated up to primary school and also had no formal education each. Noncommunicable diseases (NCDs) were the most common causes of death (30, 56.6%) in this sample, followed by communicable disease (7, 13.2%), and then unnatural deaths (suicide – 8, 15%, and road traffic accidents – 3, 5.6%). Conclusions: It is the first study in India to explore the causes of death in schizophrenia. NCDs being the most common cause of death in schizophrenia suggests to the need of integration of schizophrenia care into general health care. [ABSTRACT FROM AUTHOR]

Objectives: The present study aimed to estimate the age and cause-specific mortality in Ballabgarh Health and Demographic Surveillance System (HDSS) site for the years 2009 to 2012, using a probabilistic model (InterVA-4). Methods: All Deaths in Ballabgarh HDSS from January 1, 2009, to December 31, 2012, were included in the study. InterVA-4 model (version 4.02) was used for assigning cause of death (COD). Data from the verbal autopsy (VA) tool were extracted and processed with the InterVA-4 model. Cause-specific mortality rate (CSMR) per 1,000 person-years was calculated. Results: A total of 2,459 deaths occurred in the HDSS during the year 2009 to 2012. Among them, 2,174 (88.4%) valid VA interviews were conducted. Crude death rate ranged from 7.1 (2009) to 6.4 (2012) per 1,000 population. The CSMR per 1,000 person-years over the years (2009-2012) for non-communicable diseases, communicable diseases, trauma, neoplasm, and maternal and neonatal diseases were 1.78, 1.68, 0.68, 0.49, and 0.48, respectively. The most common causes of death among children, adults, and the elderly were infectious diseases, trauma, and non-communicable diseases, respectively. Conclusions: Overall, non-communicable diseases constituted the largest proportion of mortality, whereas trauma was the most common COD among adults at Ballabgarh HDSS. Policy-makers ought to focus on prevention of premature CODs, especially prevention of infectious diseases in children, and intentional self-harm and road traffic accidents in the adult population. [ABSTRACT FROM AUTHOR]

Objective:Medical audit is a widely promoted strategy in hospitals, but experience within community settings is scant. Community neonatal death audit is a form of audit, which involves a systematic analysis of the quality of care provided in the home, danger sign recognition and care seeking decision making for neonatal illness. This research was conducted in Uttar Pradesh, India, to investigate the feasibility and cultural acceptability of community neonatal death audits.Study Design:During November–December 2004, we conducted three in-depth interviews with family members of deceased neonates, and six focus group discussions with family and community members. Three approaches were evaluated: in-depth interview with the family before engaging them in an audit with the community; preliminary meeting to build rapport with the family and community before conducting an audit; and audit with the family and community in a single focus group. Approaches were interactive processes, involving the community, to identify avoidable factors in a particular death and discuss solutions.Result:Carried out in a culturally sensitive and non-punitive manner, community neonatal death audit was found to be acceptable and feasible. All approaches provoked formal investigation by community members, and stimulated sharing of views, leading to the self-discovery that community perception was a cumulatively amplified effect of individual perceptions. Presence of an educated/experienced community member or health worker served as a catalyst. No one optimal approach was identified.Conclusion:Community neonatal audit is an acceptable approach that shows promise as an effective intervention for improving neonatal health outcomes.Journal of Perinatology (2007) 27, 556–564; doi:10.1038/sj.jp.7211788; published online 19 July 2007 [ABSTRACT FROM AUTHOR]

Objectives: This study was carried out to evolve a method to improve the registration of cancer mortality data in Chennai (Madras, India).Methods: Data on cancer deaths have been collected from the Vital Statistics Department (VSD) by a population-based cancer registry (PBCR) in Chennai only since 1982. The low mortality-to-incidence ratio during 1982-84 suggested under-registration of mortality data. Since 1985, the PBCR has taken special effort to ascertain the vital status of cancer cases by sending reply-paid postcards and/or making house visits. The data on all deaths occurring in Chennai, irrespective of stated cause of death in the death certificate, have been collected from the VSD since 1992.Results: Deaths that occurred in Chennai and obtained by sending reply-paid postcards and/or making house visits were registered in VSD as non-cancer causes of death; hence, these data were not collected from VSD. The sensitivity and positive predictive values of death certificates on cancer diagnosis based on 1992 and 1993 mortality data were 57 percent and 99.5 percent, respectively.Conclusion: Since the accuracy of death certificate information on cancer diagnosis is relatively low in a developing country such as in India, collecting data on all deaths will improve the mortality data registration in PBCRs. [ABSTRACT FROM AUTHOR]

Background: India contributes the highest share of under-five and neonatal deaths and stillbirths globally. Diagnostic autopsy, although useful for cause of death identification, have limited acceptance. Minimally invasive tissue sampling (MITS) is an alternative to autopsy for identification of the cause of death (CoD). A formative research linked to pilot MITS implementation was conducted to document the perceptions and attitudes of the healthcare professionals and the barriers for implementation.Methods: This exploratory qualitative study conducted at a tertiary care hospital in New Delhi, India included the hospital staffs. In-depth interviews were conducted with the doctors, nurses and support staffs from pediatrics, neonatology, obstetrics and forensic medicine departments. Inductive data analysis was done to identify the emerging themes and codes.Results: A total of 26 interviews (doctors, n = 10; nurses, n = 9 and support staffs, n = 7) were conducted. Almost all professional and support staffs were positive about the MITS and its advantage for CoD identification including co-existing and underlying illnesses. Some opined conduct of MITS for the cases without clear diagnosis. All participants perceived that MITS would be acceptable for parents due to the non-disfigurement and preferred by those who had unexplained child deaths or stillbirths in past. The key factors for MITS acceptance were appropriate communication, trust building, involvement of senior doctors, and engagement of the counselor prior to deaths and training of the personnel. For implementation and sustenance of MITS, involvement of the institute authority and government stakeholders would be essential.Conclusions: MITS was acceptable for the doctors, nurses and support staffs and critical for better identification of the causes of death and stillbirths. The key facilitating factors and challenges for implementing MITS at the hospital in Indian context were identified. It emphasized on appropriate skill building, counseling, system organization and buy-in from institution and health authorities for sustenance of MITS. [ABSTRACT FROM AUTHOR]