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Background: Many studies have been conducted on under-five mortality in India and most of them focused on the associations between individual-level factors and under-five mortality risks. On the contrary, only a scarce number of literatures talked about contextual level effect on under-five mortality. Hence, it is very important to have thorough study of under-five mortality at various levels. This can be done by applying multilevel analysis, a method that assesses both fixed and random effects in a single model. The multilevel analysis allows extracting the influence of individual and community characteristics on under-five mortality. Hence, this study would contribute substantially in understanding the under-five mortality from a different perspective., Method: The study used data from the Demographic and Health Survey (DHS) acquired in India, i.e., the fourth round of National Family and Health Survey (2015-16). It is a nationally representative repeated cross-sectional data. Multilevel Parametric Survival Model (MPSM) was employed to assess the influence of contextual correlates on the outcome. The assumption behind this study is that 'individuals' (i.e., level-1) are nested within 'districts' (i.e., level-2), and districts are enclosed within 'states' (i.e., level-3). This suggests that people have varying health conditions, residing in dissimilar communities with different characteristics., Results: Highest under-five mortality i.e., 3.85% are happening among those women whose birth interval is less than two years. In case of parity, around 4% under-five mortality is among women with Third and above order parity. Further, findings from the full model is that ICC values of 1.17 and 0.65% are the correlation of the likelihood of having under-five mortality risk among people residing in the state and district communities, respectively. Besides, the risk of dying was increased alarmingly in the first year of life and slowly to aged 3 years and then it remains steady., Conclusion: This study has revealed that both aspects viz. individual and contextual effect of the community are necessary to address the importance variations in under-five mortality in India. In order to ensure substantial reduction in under-five mortality, findings of the study support some policy initiatives that involves the need to think beyond individual level effects and considering contextual characteristics., (© 2024. The Author(s).)

Background: Even though the overall infant mortality rate and child mortality rate have considerably declined in India, the marginalised groups-Scheduled Caste, and Scheduled Tribe, continue to have higher mortality rates. This study looks at the changes in IMR and CMR amongst disadvantaged and advanced social groups at the national level and in three states of India., Data and Methods: Data from five rounds of National Family Health Survey spanning nearly three decades have been used to measure IMR and CMR according to the social groups for India and for selected states-Bihar, West Bengal, and Tamil Nadu. The relative hazard curves were drawn to understand which social group's children face a higher risk of dying in the first year of birth and between first year and age four in those three states. Further, a log-rank test was applied to examine whether the differences between the survival curves or distributions of the three social groups are statistically significant. Finally, the binary logit regression model was applied to investigate the effect of ethnicity, and other socio-economic and demographic covariates on the risk of infant and child deaths (1-4 years) in the country and in selected states., Results: Hazard curve shows the probability of death within one year of birth was highest among the children belonging to the ST families, followed by SCs in India. And, the CMR was found to be higher amongst the STs compared to all other social groups as well at the national level. While Bihar had a remarkably high infant and child mortality rates, Tamil Nadu possessed the lowest child death rates irrespective of class, caste, and religion. The regression model revealed that most of the caste/tribe gaps in infant and child deaths might be attributed to the place of residence, mother's level of education, economic status, and the number of children in a family. Notably, the multivariate analysis showed that ethnicity was an independent risk factor, when controlled for socioeconomic status., Conclusion: The study detects the persistence of significant caste/tribe differentials in infant and child mortality in India. Poverty, education and health care access issues could be the possible reasons for the premature deaths of the children from deprived castes and tribes. There is a need to critically analyse the current health programmes aimed at reducing IMR and CMR to make them attuned to the needs of the marginalised communities., (© 2023. The Author(s).)

Under-five mortality rate (U5MR) differs by rural-urban place of residence and mother's education; however, the rural-urban gap in U5MR by mother's educational attainment is unclear in the existing literature. Using five rounds of the national family health surveys (NFHS I-V) conducted between 1992-93 and 2019-21 in India, this study estimated the main and interaction effects of rural-urban and maternal education on U5MR. The mixed effect Cox proportional hazard (MECPH) model was used to predict the risk of under-five mortality (U5M). The finding shows that unadjusted U5MR remained 50 per cent higher in rural areas than in urban areas across the surveys. Whereas, after controlling for demographic, socioeconomic, and maternal health care predictors of U5M, the MECPH regression results indicated that urban children had a higher risk of death than their rural counterparts in NFHS I-III. However, there are no significant rural-urban differences in the last two surveys (NFHS IV -V). In addition, increasing maternal education levels were associated with lower U5M in all surveys. Though, in recent years, primary education has had no significant effect. The U5M risk was additionally lower for urban children than rural children whose mothers had secondary and higher education by NFHS-III; however, this additional urban advantage was no longer significant in recent surveys. The higher impact of secondary education on U5MR in urban areas in the past may be attributed to poor socio-economic, healthcare conditions in rural areas. Overall, maternal education, particularly secondary education, remained a protective factor for U5M in both rural and urban areas, even after controlling for predictors. Therefore, there is a need to increase the focus on secondary education for girls for a further decline in U5M., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: With 8,82,000 deaths in the under-five period, India observed varied intra-state and inter-regional differences across infant and child mortality in 2018. However, scarce literature is present to capture this unusual concentration of mortality in certain families by examining the association of the mortality risks among the siblings of those families along with various unobserved characteristics of the mother. Looking towards the regional and age differential in mortality, this paper attempts to provide evidence for the differential in mortality clustering among infants (aged 0-11 months), children (12-59 months) and under-five (0-59 months) period among mothers from the Empowered Action Group (EAG) and non-EAG regions of India., Methods: The study used data from the National Family Health Survey (2015-16) which includes all the birth histories of 475,457 women aged 15-49 years. Bivariate and multivariate analyses were used to fulfil the objectives of the study. A two-level random intercept Weibull regression model was used to account for the unexplained mother (family) level heterogeneity., Results: About 3.3% and 5.9% of infant deaths and 0.8% and 1.6% of childhood deaths were observed in non-EAG and EAG regions respectively. Among them, a higher percentage of infant and child death was observed due to the death of a previous sibling. There were 1.67 times [95% CI: 1.55-1.80] and 1.46 times [CI: 1.37-1.56] higher odds of infant and under-five mortality of index child respectively when the previous sibling at the time of conception of the index child was dead in the non-EAG regions. In contrast, the odds of death scarring (death of previous sibling scars the survival of index child) were 1.38 times [CI: 1.32-1.44] and 1.24 times [CI: 1.20-1.29] higher for infant and under-five mortality respectively in the EAG regions., Conclusion: The extent of infant and child mortality clustering and unobserved heterogeneity was higher among mothers in the non-EAG regions in comparison to their EAG region counterparts. With the growing situation of under-five mortality clustering in non-EAG states, region-wise interventions are recommended. Additionally, proper care is needed to ameliorate the inter-family variation in mortality risk among the children of both EAG and non-EAG regions throughout their childhood., (© 2021. The Author(s).)

Background: The conventional indicators of infant and under-five mortality are aggregate deaths occurring in the first year and the first five years, respectively. Monitoring deaths by <1 month (neonatal), 1-11 months (post-neonatal), and 12-59 months (child) can be more informative given various etiological causes that may require different interventions across these three mutually exclusive periods. For optimal resource allocation, it is also necessary to track progress in robust estimates of child survival at a smaller geographic and administrative level., Methods: Data on 259 627 children came from the 2015-2016 Indian National Family Health Survey. We used a random effects model to account for the complex survey design and sampling variability, and predicted district-specific probabilities of neonatal, post-neonatal, and child mortality. The resulting precision-weighted estimates are more reliable as they pool information and borrow strength from other districts that share the same state membership. The Pearson correlation and Spearman's rank correlation were assessed for the three mortality estimates, and the Moran's I measure was used to detect spatial clustering of high burden districts for each outcome., Results: The majority of under-five deaths was disproportionately concentrated in the neonatal period. Across all districts, the predicted probability of neonatal, post-neonatal, and child mortality varied from 6.0 to 63.9 deaths, 3.8 to 47.6 deaths, and 1.7 to 11.8 deaths per 1000 live births, respectively. The overall correlation between district-wide probabilities of mortality for the three mutually exclusive periods was moderate (Pearson correlation = 0.47-0.58, Spearman's rank correlation = 0.58-0.64). For each outcome, a relatively strong spatial clustering was detected across districts that transcended state boundaries (Moran's I = 0.61-0.76)., Conclusions: Sufficiently breaking down the under-five mortality to distinct age groups and using the precision-weighted estimations to monitor performances at smaller geographic and administrative units can inform more targeted interventions and foster accountability to improve child survival., Competing Interests: Competing interests: The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author), and declare no conflicts of interest., (Copyright © 2020 by the Journal of Global Health. All rights reserved.)

The Lives Saved Tool (LiST) has been used to estimate the impact of scaling up intervention coverage on undernutrition and mortality. Evidence for the model is largely based on efficacy trials, raising concerns of applicability to large-scale contexts. We modelled the impact of scaling up health programs in India between 2006 and 2016 and compared estimates to observed changes. Demographics, intervention coverage and nutritional status were obtained from National Family and Health Survey 2005-6 (NFHS-3) for the base year and NHFS-4 2015-16 for the endline. We used the LiST to estimate the impact of changes in coverage of interventions over this decade on child mortality and undernutrition at national and subnational levels and calculated the gap between estimated and observed changes in 2016. At the national level, the LiST estimates are close to the actual values of mortality for children <1 year and <5 years in 2016 (at 41 vs 42.6 and 50 vs 56.4, respectively, per 1000 live births). National estimates for stunting, wasting and anaemia at are also close to the actual values of NFHS-4. At the state level, actual changes were higher than the changes from the LiST projections for both mortality and stunting. The predicted changes using the LiST ranged from 33% to 92% of the actual change. The LiST provided national projections close to, albeit slightly below, actual performance over a decade. Reasons for poorer performance of state-specific projections are unknown; further refinements to the LiST for subnational use would improve the usefulness of the tool., (© The Author(s) 2019. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Background: India had the largest number of under-5 deaths of all countries in 2015, with substantial subnational disparities. We estimated national and subnational all-cause and cause-specific mortality among children younger than 5 years annually in 2000-15 in India to understand progress made and to consider implications for achieving the Sustainable Development Goal (SDG) child survival targets., Methods: We used a multicause model to estimate cause-specific mortality proportions in neonates and children aged 1-59 months at the state level, with causes of death grouped into pneumonia, diarrhoea, meningitis, injury, measles, congenital abnormalities, preterm birth complications, intrapartum-related events, and other causes. AIDS and malaria were estimated separately. The model was based on verbal autopsy studies representing more than 100 000 neonatal deaths globally and 16 962 deaths among children aged 1-59 months at the subnational level in India. By applying these proportions to all-cause deaths by state, we estimated cause-specific numbers of deaths and mortality rates at the state, regional, and national levels., Findings: In 2015, there were 25·121 million livebirths in India and 1·201 million under-5 deaths (under-5 mortality rate 47·81 per 1000 livebirths). 0·696 million (57·9%) of these deaths occurred in neonates. There were disparities in child mortality across states (from 9·7 deaths [Goa] to 73·1 deaths [Assam] per 1000 livebirths) and regions (from 29·7 deaths [the south] to 63·8 deaths [the northeast] per 1000 livebirths). Overall, the leading causes of under-5 deaths were preterm birth complications (0·330 million [95% uncertainty range 0·279-0·367]; 27·5% of under-5 deaths), pneumonia (0·191 million [0·168-0·219]; 15·9%), and intrapartum-related events (0·139 million [0·116-0·165]; 11·6%), with cause-of-death distributions varying across states and regions. In states with very high under-5 mortality, infectious-disease-related causes (pneumonia and diarrhoea) were among the three leading causes, whereas the three leading causes were all non-communicable in states with very low mortality. Most states had a slower decline in neonatal mortality than in mortality among children aged 1-59 months. Ten major states must accelerate progress to achieve the SDG under-5 mortality target, while 17 are not on track to meet the neonatal mortality target., Interpretation: Efforts to reduce vaccine-preventable deaths and to reduce geographical disparities should continue to maintain progress achieved in 2000-15. Enhanced policies and programmes are needed to accelerate mortality reduction in high-burden states and among neonates to achieve the SDG child survival targets in India by 2030., Funding: Bill & Melinda Gates Foundation., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background and Objective: India contributes the highest global share of deaths among the under-fives. Continuous monitoring of the reduction in the under-five mortality rate (U5MR) at local level is thus essential to set priorities for policy-makers and health professionals. In this study, we aimed to provide an update on district-level disparities in the neonatal mortality rate (NMR) and the U5MR with special reference to Sustainable Development Goal 3 (SDG3) on preventable deaths among new-borns and children under five., Data and Methods: We used recently released population-based cross-sectional data from the National Family Health Survey (NFHS) conducted in 2015-2016. We used the synthetic cohort probability approach to analyze the full birth history information of women aged 15-49 to estimate the NMR and U5MR for the ten years preceding the survey., Results: Both the NMR and U5MR vary enormously across Indian districts. With respect to the SDG3 target for 2030 for the NMR and the U5MR, the estimated NMR for India for the period studied is about 2.4 times higher, while the estimated U5MR is about double. At district level, while 9% of the districts have already reached the NMR targeted in SDG3, nearly half (315 districts) are not likely to achieve the 2030 target even if they realize the NMR reductions achieved by their own states between the last two rounds of National Family Health Survey of India. Similarly, less than one-third of the districts (177) of India are unlikely to achieve the SDG3 target on the U5MR by 2030. While the majority of high-risk districts for the NMR and U5MR are located in the poorer states of north-central and eastern India, a few high-risk districts for NMR also fall in the rich and advanced states. About 97% of districts from Chhattisgarh and Uttar Pradesh, for example, are unlikely to meet the SDG3 target for preventable deaths among new-borns and children under age five, irrespective of gender., Conclusions: To achieve the SDG3 target on preventable deaths by 2030, the majority of Indian districts clearly need to make a giant leap to reduce their NMR and U5MR., Competing Interests: The authors have declared that no competing interests exist.

Background: Excess female mortality causes half of the missing women (estimated deficit of women in countries with suspiciously low proportion of females in their population) today. Globally, most of these avoidable deaths of women occur during childhood in China and India. We aimed to estimate excess female under-5 mortality rate (U5MR) for India's 35 states and union territories and 640 districts., Methods: Using the summary birth history method (or Brass method), we derived district-level estimates of U5MR by sex from 2011 census data. We used data from 46 countries with no evidence of gender bias for mortality to estimate the effects and intensity of excess female mortality at district level. We used a detailed spatial and statistical analysis to highlight the correlates of excess mortality at district level., Findings: Excess female U5MR was 18·5 per 1000 livebirths (95% CI 13·1-22·6) in India 2000-2005, which corresponds to an estimated 239 000 excess deaths (169 000-293 000) per year. More than 90% of districts had excess female mortality, but the four largest states in northern India (Uttar Pradesh, Bihar, Rajasthan, and Madhya Pradesh) accounted for two-thirds of India's total number. Low economic development, gender inequity, and high fertility were the main predictors of excess female mortality. Spatial analysis confirmed the strong spatial clustering of postnatal discrimination against girls in India., Interpretation: The considerable effect of gender bias on mortality in India highlights the need for more proactive engagement with the issue of postnatal sex discrimination and a focus on the northern districts. Notably, these regions are not the same as those most affected by skewed sex ratio at birth., Funding: None., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Under the prevailing conditions of imbalanced life table and historic gender discrimination in India, our study examines crossover between life expectancies at ages zero, one and five years for India and quantifies the relative share of infant and under-five mortality towards this crossover., Methods: We estimate threshold levels of infant and under-five mortality required for crossover using age specific death rates during 1981-2009 for 16 Indian states by sex (comprising of India's 90% population in 2011). Kitagawa decomposition equations were used to analyse relative share of infant and under-five mortality towards crossover., Findings: India experienced crossover between life expectancies at ages zero and five in 2004 for menand in 2009 for women; eleven and nine Indian states have experienced this crossover for men and women, respectively. Men usually experienced crossover four years earlier than the women. Improvements in mortality below ages five have mostly contributed towards this crossover. Life expectancy at age one exceeds that at age zero for both men and women in India except for Kerala (the only state to experience this crossover in 2000 for men and 1999 for women)., Conclusions: For India, using life expectancy at age zero and under-five mortality rate together may be more meaningful to measure overall health of its people until the crossover. Delayed crossover for women, despite higher life expectancy at birth than for men reiterates that Indian women are still disadvantaged and hence use of life expectancies at ages zero, one and five become important for India. Greater programmatic efforts to control leading causes of death during the first month and 1-59 months in high child mortality areas can help India to attain this crossover early.

Background & Objectives: The level of infant and child mortality is high among Scheduled Tribes particularly those living in rural areas. This study examines levels, trends and socio-demographic factors associated with infant and child mortality among Scheduled Tribes in rural areas., Methods: Data from the three rounds of the National Family Health Survey (NFHS) of India from 1992 to 2006 were analysed to assess the levels and trends of infant and child mortality. Univariate and multivariate Cox proportional hazard model were used to understand the socio-economic and demographic factors associated with mortality during 1992-2006., Results: Significant change was observed in infant and child mortality over the time period from 1992-2006 among Scheduled Tribes in rural areas. After controlling for other factors, birth interval, household wealth, and region were found to be significantly associated with infant and child mortality. Hazard of infant mortality was highest among births to mothers aged 30 yr or more (HR=1.3, 95% CI=1.1-1.7) as compared with births to the mother's aged 20-29 yr. Hazard of under-five mortality was 42 per cent (95% CI=1.3-1.6) higher among four or more birth order compared with the first birth order. The risk of infant dying was higher among male children (HR = 1.2, 95% CI=1.1-1.4) than among female children while male children were at 30 per cent (HR=0.7, 95% CI=0.6-0.7) less hazard of child mortality than female children. Literate women were at 40 per cent (HR=0.6, 95% CI=0.50-0.76) less hazard of child death than illiterate women., Interpretation & Conclusions: Mortality differentials by socio-demographic and economic factors were observed over the time period (1992-2006) among Scheduled Tribes (STs) in rural India. Findings support the need to focus on age at first birth and spacing between two births.

Background: The United Nations Millennium Development Goals include targets for the health of children under five years old. Poor health is linked to poverty and microfinance initiatives are economic interventions that may improve health by breaking the cycle of poverty. However, there is a lack of reliable evidence to support this. In addition, microfinance schemes may have adverse effects on health, for example due to increased indebtedness. Rojiroti UK and the Centre for Promoting Sustainable Livelihood run an innovative microfinance scheme that provides microcredit via women's self-help groups (SHGs). This pilot study, conducted in rural Bihar (India), will establish whether it is feasible to collect anthropometric and mortality data on children under five years old and to conduct a limited cluster randomized trial of the Rojiroti intervention., Methods/design: We have designed a cluster randomized trial in which participating tolas (small communities within villages) will be randomized to either receive early (SHGs and microfinance at baseline) or late intervention (SHGs and microfinance after 18 months). Using predesigned questionnaires, demographic, and mortality data for the last year and information about participating mothers and their children will be collected and the weight, height, and mid upper arm circumference (MUAC) of children will be measured at baseline and at 18 months. The late intervention group will establish SHGs and microfinance support at this point and data collection will be repeated at 36 months.The primary outcome measure will be the mean weight for height z-score of children under five years old in the early and late intervention tolas at 18 months. Secondary outcome measures will be the mortality rate, mean weight for age, height for age, prevalence of underweight, stunting, and wasting among children under five years of age., Discussion: Despite economic progress, marked inequalities in child health persist in India and Bihar is one of the worst affected states. There is a need to evaluate programs that may alleviate poverty and improve health. This study will help to inform the design of a definitive trial to determine if the Rojiroti scheme can improve the nutrition and survival of children under five years of age in deprived rural communities., Trial Registration: Clinicaltrials.gov (study ID: NCT01845545). Registered on 24 April 2013.

Studies that have separately examined the consequences of gender based violence upon women, use of solid fuel for cooking, and mother and father's use of tobacco on child health have concluded that they serve as risk factors for maternal and child health. Some authors have implied that these studies may have run the risk of overestimating the burden of disease of one factor over another. In this paper, we included all four factors in the same model to estimate their adjusted effects on child mortality, controlling for the demographic factors. The data come from 2005 to 2006 National Family Health Survey of India that interviewed a nationally representative sample of 39,257 couples. Of the four factors, mothers' use of tobacco presented the highest risk for child mortality (OR = 1.42; CI = 1.27-1.60) followed by fathers' use of tobacco (OR = 1.23; CI = 1.12-1.36), households' use of solid fuel for cooking (OR = 1.23; CI = 1.06-1.43), and physical abuse upon mothers (OR = 1.20; CI = 1.10-1.32). Among the households that used solid fuel for cooking, improved cookstoves users experienced 28 % lower odds of child mortality (OR = 0.72; CI = 0.61-0.86) compared to nonusers of improved cookstoves. Additionally, increase in age of mothers at birth of first child, parents' education, and household wealth served as protective factors for child mortality. To prevent child death, programs should focus on reducing couple's use of tobacco, protecting women from physical abuse, and helping households switch from solid to liquid fuel. Moreover, a significant reduction in child death could be attained by improving girls' education, and delaying their age at marriage and first birth.

Background: Violence against women may have an impact on infant and child mortality. We aimed to determine whether domestic violence is a risk factor for infant and child death., Methods: Eighty infant and child deaths (under 5 years of age) were identified from a central register of a comprehensive community health programme in rural southern India; controls were matched for age, gender and street of residence., Results: Domestic violence during the lifetime (OR 2.63, 95% CI 1.39-4.99), which was severe (OR 4.00, 95% CI 2.02-7.94) and during pregnancy (OR 5.69, 95% CI 2.03-15. 93) and father's smoking status (OR 3.81, 95% CI 1.92-7.55) were significantly related to infant and child death while immunization being completed for age (OR 0.04, 95% CI 0.01-0.19) and having at least one boy child in the family (OR 0.29, 95% CI 0.14-0.59) were protective. These variables remained statistically significantly associated with outcome after adjusting for other determinants using conditional logistic regression., Conclusion: There is evidence for an association between domestic violence in mothers, and infant and child death., (Copyright 2013, NMJI.)

Background: This paper examines if, when controlling for biophysical and geographical variables (including rainfall, productivity of agricultural lands, topography/temperature, and market access through road networks), socioeconomic and health care indicators help to explain variations in the under-five mortality rate across districts from nine high focus states in India. The literature on this subject is inconclusive because the survey data, upon which most studies of child mortality rely, rarely include variables that measure these factors. This paper introduces these variables into an analysis of 284 districts from nine high focus states in India., Methodology/principal Findings: Information on the mortality indicator was accessed from the recently conducted Annual Health Survey of 2011 and other socioeconomic and geographic variables from Census 2011, District Level Household and Facility Survey (2007-08), Department of Economics and Statistics Divisions of the concerned states. Displaying high spatial dependence (spatial autocorrelation) in the mortality indicator (outcome variable) and its possible predictors used in the analysis, the paper uses the Spatial-Error Model in an effort to negate or reduce the spatial dependence in model parameters. The results evince that the coverage gap index (a mixed indicator of district wise coverage of reproductive and child health services), female literacy, urbanization, economic status, the number of newborn care provided in Primary Health Centers in the district transpired as significant correlates of under-five mortality in the nine high focus states in India. The study identifies three clusters with high under-five mortality rate including 30 districts, and advocates urgent attention., Conclusion: Even after controlling the possible biophysical and geographical variables, the study reveals that the health program initiatives have a major role to play in reducing under-five mortality rate in the high focus states in India.

We assessed the prevalence of childhood acute malnutrition and under-five mortality rate (U5MR) in Darbhanga district, India, using a two-stage 49-cluster household survey. A total of 1379 households comprising 8473 people were interviewed. During a 90-day recall period, U5MR was 0.5 [95% confidence interval (CI), 0.2-1.4] per 10,000 per day. The prevalence of global acute malnutrition among 1405 children aged 6-59 months was 15.4% (NCHS) and 19.4% (2006 WHO references). This survey suggests that in Darbhanga district, the population is in a borderline food crisis with few food resources. Appropriate strategies should be developed to improve the overall nutritional and health status of children.

This review relates to achieving the Millennium Development Goals (MDGs), especially MDGs 4 and 5, by India by the year 2015. India contributes the maximum number of maternal deaths (68,000) to the global estimate of 358,000 maternal deaths annually. Infant mortality rate (IMR) is also high at 50 per 1000 (2009). Low budgetary spending on health, poverty, lower literacy, poor nutritional status, rural-urban divide and lack of trained workers in the health sector are cited as reasons for a high maternal mortality ratio and IMR. Increased spending by the Government of India on the health sector has started to show encouraging results. Recent assessments by world bodies like the World Health Organisation have given hope that MDGs 4 and 5 are achievable., (© 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOG.)

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., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Objective: To assess associations between maternal child marriage (marriage before age 18) and morbidity and mortality of infants and children under 5 in India. Design Cross-sectional analyses of nationally representative household sample. Generalised estimating equation models constructed to assess associations. Adjusted models included maternal and child demographics and maternal body mass index as covariates. Setting India. Population Women aged 15-49 years (n=124 385); data collected in 2005-6 through National Family Health Survey-3. Data about child morbidity and mortality reported by participants. Analyses restricted to births in past five years reported by ever married women aged 15-24 years (n=19 302 births to 13 396 mothers)., Main Outcome Measures: In under 5s: mortality related infectious diseases in the past two weeks (acute respiratory infection, diarrhoea); malnutrition (stunting, wasting, underweight); infant (age <1 year) and child (1-5 years) mortality; low birth weight (<2500 kg). Results The majority of births (73%; 13 042/19 302) were to mothers married as minors. Although bivariate analyses showed significant associations between maternal child marriage and infant and child diarrhoea, malnutrition (stunted, wasted, underweight), low birth weight, and mortality, only stunting (adjusted odds ratio 1.22, 95% CI 1.12 to 1.33) and underweight (1.24, 1.14 to 1.36) remained significant in adjusted analyses. We noted no effect of maternal child marriage on health of boys versus girls. Conclusions The risk of malnutrition is higher in young children born to mothers married as minors than in those born to women married at a majority age. Further research should examine how early marriage affects food distribution and access for children in India.

Objective: The goal was to test the association between maternal intimate partner violence (IPV) victimization and child death., Methods: Information was collected regarding 39096 children <60 months of age in the nationally representative 2005-2006 National Family Health Survey of India. The exposures were maternal reports of physical, sexual, psychological, and any IPV. Outcomes included infant (0 to <12 months), older child (12 to <60 months), and any child (0 to <60 months) deaths., Results: Maternal experience of physical IPV was associated with increased mortality rates among all children (risk ratio [RR]: 1.21 [95% confidence interval [CI]: 1.13-1.30]), infants (RR: 1.24 [95% CI: 1.01-1.53]), and older children (RR: 1.25 [95% CI: 1.00-1.56]). Sexual and psychological IPV were less strongly associated with child death. The associations between maternal IPV and death did not differ according to the child's gender., Conclusion: The robust association between exposure to household IPV and infant and child death could be attributable to the mother's inability to care for her child, psychological stress associated with witnessing violence, and the use of maternal violence victimization as a proxy for child violence victimization.

Background: Although socioeconomic position is generally found to be related to health, the associations can be different for different measures of socioeconomic position. We examined the association between adult education and child mortality, and the influence of other socioeconomic markers (caste, household wealth, and urbanization) on this association., Methods: Data were drawn from the 1998-1999 Indian National Family Health Survey, conducted in 26 states and comprising 66,367 children age 5 years or under. Adult education, for the head of household and spouse, was categorized into 0, 1-8, and 9 or more years of schooling. We used logistic regression to estimate associations between education and child mortality in analysis adjusted for other socioeconomic markers. Effect modification by caste, household wealth, and urbanization was assessed by fitting an interaction term with education., Results: Compared with those who had no education, 9 or more years of education for the head of household and for the spouse were associated with lower child mortality (odds ratio [OR] = 0.54; 95% confidence interval [CI] = 0.48-0.62 and OR = 0.44; 95% CI = 0.36-0.54, respectively) in analyses adjusted for age, sex, and state of residence. Further adjustments for caste and urbanization attenuated these associations slightly; when adjustments were made for household wealth the associations were attenuated more substantially. Nevertheless, in fully adjusted models, 9 or more years of education for the head of household (OR = 0.81; 95% CI = 0.70-0.93) and the spouse (OR = 0.75; 95% CI = 0.60-0.94) remained associated with lower child mortality. There was no effect modification of this association by caste, household wealth, and urbanization., Conclusion: Adult education has a protective association with child mortality in India. Caste, household wealth, and urbanization do not modify or completely attenuate this association.

Background: Haemoglobinopathies, including sickle-cell disease and thalassaemia syndrome, are a group of blood diseases mostly confined to tropical and subtropical regions of the world. The spectrum of haemoglobin variants is a group of commonly encountered genetic conditions, with an average frequency of 19.32% in Orissa, varying from region to region and from community to community depending upon the type of mating practices., Aim: For the first time, the infant mortality rate (IMR), i.e. the number of deaths under 1 year of age (in a given year) per thousand live births in a particular area, was studied to find the cause of the high IMR and to relate it to different genotypes of haemoglobinopathies., Results: IMR was found to be higher in couples with sickle-cell trait (75.9), beta-thalassaemia (184.2), and sickle cell/beta-thalassaemia (70.2) compared to normal couples (26.3). The reproductive wastage (abortions, stillbirths and neonatal deaths) and the number of deaths of offspring below 1 year of age (infant mortality) and below 10 years of age (childhood mortality) among affected couples in such families were also statistically significantly higher compared to normal parents., Conclusions: The progeny of sickle-cell trait, beta-thalassaemia trait, and sickle cell/beta-thalassaemia couples contributes substantially to the high neonatal/IMR in the coastal state of Orissa in Central-Eastern India. This study has revealed that in comparison to normal couples, couples who were carriers of haemoglobinopathies had a greater reproductive wastage. Screening and genetic counselling could be an important factor in reducing IMR in rural India. The traits/carriers of haemoglobinopathies should, specifically, avoid marriages and mating for the better health of subsequent generations.

Objective: We examined the effect of physical violence during pregnancy on perinatal and early-childhood mortality., Methods: We estimated the prevalence of domestic violence during pregnancy among a population-based sample of 2199 women in Uttar Pradesh, India. We used a survival regression model to examine the risks for perinatal, neonatal, postneonatal, and early-childhood (aged 1-3 years) mortality by mother's exposure to domestic violence, after we controlled for other sociodemographic and maternal health behavior risk factors., Results: Eighteen percent of the women in our study experienced domestic violence during their last pregnancy. After we adjusted for other risk factors, births among mothers who had experienced domestic violence had risks for perinatal and neonatal mortality that were 2.59 (95% confidence interval [CI]=1.35, 4.95) and 2.37 (95% CI=1.21, 4.62) times higher, respectively, than births among mothers who had not experienced violence. We found no significant associations between domestic violence and either postneonatal or early-childhood mortality., Conclusions: Domestic violence is a significant risk factor for perinatal and neonatal mortality.

About 2.1 million Indian children under 5 years of age die each year. In spite of reductions in child mortality rate over the past two decades, the rate remains high at 87 per 1000 live births. The main causes are diarrhoea, pneumonia, and for deaths among the neonates asphyxia, pre-term delivery, sepsis and tetanus. The major underlying cause of death is undernutrition. Child survival interventions of proven impact, feasible for use at high coverage in India were identified, and their effect on child mortality was calculated if high coverage were to be achieved. Exclusive breastfeeding, oral rehydration therapy, and adequate complementary feeding were among the most effective interventions. If these interventions would be applied universally 57% of mortality among pre-schoolers could be prevented. No cause specific mortality data were available from individual Indian states. Nevertheless, the range of child mortality, as well as the proportion of neo-natal deaths, occurring across the states, suggests that at state level 50-70% of deaths can be prevented. The results show that the targets set in the millennium development goals as well as in the Tenth Five Year plan can be reached.

The aim of this study was to develop a single comprehensive index of child mortality for longitudinal assessment of health status of children. The need for such a comprehensive index arose from conflicting trends in different child mortality indicators. The data for the study was taken from the Sample Registration System (SRS) reports of the Registrar General of India. SRS is known to provide reliable estimates of births and deaths at the State and the National level. The study included five child mortality indicators, namely, under five mortality rate (U5MR), infant mortality rate, neonatal mortality rate, perinatal mortality rate and still birth rate. These were available for fifteen states of India over the years 1972-1988. To develop this index we modified an earlier method based on factor analysis. Factor analysis of data on various indicators of child mortality revealed two factors which together explained 78% to 93% of the total variation in different years. The first factor was identified as representing mortality after birth and the second as before and during birth. The comprehensive index was obtained as a linear combination of these two factors. The resultant index thus fairly represented all five mortality indicators and provided a comprehensive and reasonably correct picture of child mortality. The lower the magnitude of this index, the better was the child health status. Trends in the index showed that the highest decline in the magnitude was in the state of Kerala followed by Punjab, Andhra Pradesh, Gujarat and Maharashtra in that order. This indicates steady improvement of the child health status over years in these states. In the State of Jammu and Kashmir, the index remained more or less constant over the years though the magnitude was low in the cross-sectional comparison with other states. Thus the comprehensive index developed by using factor analysis of the various mortality indicators can be used for the longitudinal monitoring of child health status in the states of India.

There are few studies of the interrelationships among breastfeeding, child spacing, and child mortality in traditional societies that incorporate extensive controls for social and demographic characteristics of the mother and child. In this paper, we investigate the impact of breastfeeding and the length of the preceding birth interval on early child mortality (defined as a death in the first two years of life) using data from a traditional society of India. Multivariate hazards models are used to analyze the data. Most prior analyses related the impact of breastfeeding duration to the duration of child survivability by taking breastfeeding as a fixed covariate. The present study has a methodological focus in the sense that breastfeeding information from retrospective survey data is treated as a time-dependent covariate both as a status variate as well as a duration--with empirical findings compared across the two specifications. The effects of postpartum amenorrhoea and various other demographic and socioeconomic characteristics of mother and child are also studied. The results suggest that breastfeeding duration has a strong impact in reducing the relative risk of early child mortality; but it does not explain the effect of the length of the preceding birth interval on early child mortality.

"The social and cultural practices prevalent in various parts of [India] resulted in the neglect of the female child...[in general, and] probably more so in the Punjab. Moreover, female mortality significantly exceeded male mortality in years of epidemics and famines. This paper tries to examine the socio-cultural and economic factors, namely, the system of land holdings and inheritance strategies, structured customs in different parts of the province, and notions of honour and status which probably have been at the back of neglect of the girl child. Among certain caste groups even female infanticide might not have been uncommon.", (excerpt)

As Asia becomes increasingly urbanized the effect of new industrial development on child mortality becomes of increasing interest. In India, considerable investment has been made in the social infrastructure of industrial new towns. This survey of Durgapur steel town in West Bengal shows that although the average level of child mortality in the working class population is favourable in comparison with other Indian cities, considerable differentials, that can be related to social, economic and environmental differences within the population, have arisen since the creation of the city in the late 1950s. The paper argues that the undertaking of selective sanitary interventions to improve access to drinking water (in particular) would be administratively feasible in these industrial new towns, of immediate impact, and indeed necessary if the differentials in mortality are to be eliminated.

Mortality associated with diarrhea was investigated in a longitudinally followed cohort of children under 6 years of age in rural North India. During the followup, 1663 episodes of diarrhea and 23 diarrhea-related deaths were recorded in 1467 children followed up for 20 months. The case fatality rate was 0.56% for acute watery diarrhea, 4.27% for dysentery, and 11.94% for non-dysenteric persistent diarrhea. Most of the episodes lasted less than a week; 5.2% became persistent (duration 14 days). The case fatality rate was similar in episodes of 1 and 2 weeks duration (0.64% and 0.8%) and increased to 13.95% for persistent episodes. Of the total 86 persistent episodes, 22.1% were dysenteric; the case fatality rate for such dysenteric persistent episodes was 21.1% and for watery persistent diarrhea 11.4%. Diarrheal attack rates were similar among different nutritional groups, but diarrheal case fatality rates progressively increased with increasing severity of malnutrition; these were 24 times higher in children with severe malnutrition (7.48%) compared to those normally nourished (0.31%). With availability and use of oral rehydration therapy, dysentery and persistent diarrhea emerge as major causes of diarrhea-related mortality, with underlying malnutrition as a key associated factor.

Studies of infant and child mortality have evolved to distinguish between two sets of explanatory variables-factors related to reproductive or maternal characteristics and socioeconomic factors, generally described as characteristics of the family or household. Almost all multivariate analyses include variables from each of these two sets, but there has been little consideration of the relationship between them. We examine how these two sets of variables jointly affect mortality. We test first for confounded effects by examining socioeconomic effects while excluding and then including reproductive variables in nested multivariate models. Next, we look for age-dependent effects among the explanatory variables and find that reproductive and socioeconomic factors affect mortality at differing ages of children. Finally, we examine interactive effects of the two sets of variables. We conclude that the higher mortality observed among the low status groups is not a result of greater concentration of poor reproductive patterns in those groups. Instead, higher status groups probably have more resources available for combating the negative effects of the same high-risk reproductive patterns.