Estimates of Maternal & Child Mortality in Indianutritionfoundationofindia.org/PPT-2011/Seven17-18teen/...Infant Mortality Rate (IMR) by residence, 1990–2009 80 74 68 58 50 86 80

Estimates of

Maternal & Child Mortality in

India

Office of Registrar General, India 29th August 2011

Sources

• Sample Registration System(SRS)

- National and State level estimates

• Annual Health Survey(AHS)

- State and District level estimates in 8 EAG States and Assam

• National Family Health Survey(NFHS)

- National and State level estimates on child mortality only

• Sample Registration System (SRS) is designed for reliableestimates of fertility and mortality indicators at State andNational level separately for rural and urban areas

• Only source for fertility and mortality data since 1969-70

• One of the largest demographic surveys in the country coveringabout 1.4 million households and 7.01 million population in7597 sample units across 35 States/UTs

• Since 2004, a system of collection of Causes of Death datathrough Verbal Autopsy has also been included under thedomain of SRS

• This system allows for tracking Millennium Development Goals(MDG) on Child Mortality & Maternal Health on a regular basis

Sample Registration System (SRS) – An Introduction

Millennium Development Goals (MDG)

• MDGs are a set of numerical & time-bound targets to measure achievements in human and social development laid down by the UN.

• Of the 8 MDGs, IMR, U5MR and MMR are generated by SRS.

Goal No.

Goals IndicatorsTargets by 2015

4

Reduce infant mortality Infant Mortality Rate (IMR) 28

Reduce child mortality Under 5 Mortality Rate (U5MR) 42

5 Improve maternal health Maternal Mortality Ratio (MMR) 109

INFANT MORTALITY RATE (IMR)

IMR estimates 2009: Highlights

• IMR measures number of infant( < 1 year) deaths per 1000 live births.

• Every 6th death in the country pertains to an infant

• IMR in India has registered a 3 points decline to 50 in 2009 from 53 in 2008

• Maximum IMR in Madhya Pradesh (67) and minimum IMR in Kerala (12)

• Kerala (12) & Tamil Nadu (28) have achieved the MDG target (28 by 2015)

• Delhi (33), Maharashtra (31) and West Bengal (33) are in closer proximity

Infant Mortality Rate (IMR) by residence, 1990–2009

8074

68

5850

8680

74

6455

50 4844

403430

40

50

60

70

80

90

1990 1995 2000 2005 2009

Total Rural Urban

• IMR for the country declined by 30 points (rural IMR by 31 pointsvis-à-vis urban IMR 16 points) in the last 20 years at an annualaverage decline of 1.5 points

• Gap between the rural and urban IMR has declined over the years

• Still, 1 in every 20 infants - National level, 1 in every 18 infants -rural area, and 1 in every 29 infants - urban area die within one year of birth (against 1 in 37 under MDG)

Infant Mortality Rate (IMR) by sex, 1990–2009

80

74

68

58

50

78

73

67

56

49

81

76

69

61

52

45

50

55

60

65

70

75

80

85

1990 1995 2000 2005 2009

Total Male Female

• Female infants continue to experience a higher mortality than male infants

NEO-NATAL MORTALITY RATE (NNMR)

Neo-Natal Mortality Rate (NNMR) by residence, 1990–2009

• Neo-Natal Mortality Rate (<29 days) and Post Neo-Natal Mortality Rate (1 months to 11 months) has declined by 1 point and 2 points respectively during 2009 over 2008.

• NNMR for the country declined by 19 points (rural NNMR by 19 points vis-à-vis urban NNMR 10 points) in the last 20 years at an annual average decline of about 1 point

• Rural-Urban Gap in NNMR is declining.

53 48

44

37 34

57

52 49

41 38

31 29 27 23

21

10

20

30

40

50

60

1990 1995 2000 2005 2009

Total Rural Urban

IMR Vs NNMR Vs PNNMR, 1990–2009

80

74

68

58

50 53 48

44

37 34

27 26 23 22

16

10

20

30

40

50

60

70

80

90

1990 1995 2000 2005 2009

IMR NNMR PNNMR

0

10

20

30

40

50

60

70

1971-75 1976-80 1981-85 1986-90 1991-95 1996-00 2001-05 2006-09

% Share of NNMR & PNNMR in IMR

Neo-natal mortality rate Post-natal mortality rate

• Share of NNMR in the overall IMR is increasing over the years ( 54% in early 70s to 67% now)

• Interventions are required to effectively curb NNMR

UNDER 5 MORTALITY RATE (U5MR)

U5MR estimates 2009: Highlights

• U5MR denotes number of children (0-4 years) who died before reaching their fifth birthday per 1000 live births

• U5MR for the country has declined by 5 points over 2008 (64 in 2009 against 69 in 2008)

• A uniform decline of about 5 points is seen in male and female U5MRs.

• Maximum in Madhya Pradesh (89) and minimum in Kerala (14)

• Kerala (14), Tamil Nadu (33), Maharashtra (36), Delhi (37) & West Bengal (40) have already achieved the MDG target (42 by 2015)

Under 5 Mortality Rate (U5MR) by residence, 1990–2009

118

9785

77

64

128

111

98

85

7171 6755

4941

20

40

60

80

100

120

140

1990 1995 2000 2005 2009

Total Rural Urban

• U5MR for the country declined by 54 points (rural IMR by 57 points vis-à-vis urban IMR 30 points) in the last 20 years at an annual average decline of 2.7 points

• Urban U5MR has already achieved the MDG target (42 by 2015)

• Rural U5MR is still 71

Under 5 Mortality Rate (U5MR) by sex, 1990–2009

118

97

85

77

64

110

96

84

72

60

126

110

95

82

69

50

60

70

80

90

100

110

120

130

1990 1995 2000 2005 2009

Total Male Female

• Male-female mortality differential has narrowed down over the years, yet the gap remains significant

“ Child deaths are falling, but not quickly enough to reach the MDG target”

MATERNAL MORTALITY RATIO (MMR)

MMR estimates 2007-09: Highlights

• MMR measures number of women aged 15-49 years dying due to maternal causes per 1,00,000 live births.

• Decline in MMR estimates in 2007-09 over 2004-06:– For India: 212 from 254 (a fall of about 17%)

– In Empowered Action Group (EAG) states & Assam: 308 from 375 (18%)

– Among Southern States: 127 from 149 (15%)

– In Other States: 149 from 174 (14%)

• States realizing MDG target of 109 have gone up to 3 with Tamil Nadu & Maharashtra (new entrants) joining Kerala

• Andhra Pradesh, West Bengal, Gujarat and Haryana are in closer proximity to achieving the MDG target.

Maternal Mortality Ratio (MMR); India, EAG & Assam, Southern States and

Other States, 2004-06 and 2007-09

India & Major StatesMMR

2004-06

MMR

2007-09

INDIA TOTAL 254 212

Assam 480 390

Bihar/Jharkhand 312 261

Madhya Pradesh/Chhattisgarh 335 269

Orissa 303 258

Rajasthan 388 318

Uttar Pradesh/Uttarakhand 440 359

EAG AND ASSAM SUBTOTAL 375 308

Andhra Pradesh 154 134

Karnataka 213 178

Kerala 95 81

Tamil Nadu 111 97

SOUTH SUBTOTAL 149 127

Gujarat 160 148

Haryana 186 153

Maharashtra 130 104

Punjab 192 172

West Bengal 141 145

Other 206 160

OTHER SUBTOTAL 174 149

Trends in Maternal Mortality Ratio - India

(2004-06)

2009

2007-09 SRS

212

58 000

(2007-09)

Levels of MMR by Regions, 2007-09

Region MMR Life time risk

% share of female Popln.

% to total maternal

deaths

EAG states

308 1.1% 48.0 61.6

Southern states

127 0.3% 21.0 11.4

Other states

149 0.4% 31.0 27.0

India 212 0.6% 100 100

Levels of MMR by Regions, 1999-2009

35%

38%

33%327

301

254

212

461438

375

308

206

173

149127

229

199

174

149

100

150

200

250

300

350

400

450

500

1999-2001 2001-03 2004-06 2007-09

India EAG & Assam States Southern States Other States

35%

Decline over last 10 years

ANNUAL HEALTH SURVEY (AHS)

Objective of AHS

“ To yield benchmarks of core vital andhealth indicators at the district level andto map changes therein on an annualbasis”

Background

• Conceived at the behest of NationalCommission on Population , PMO andPlanning Commission

• Entrusted to ORGI in view of its expertise inimplementing Sample RegistrationSystem(SRS)

• Scheme is sponsored by Ministry of Health &Family Welfare(MOHFW)

NEED FOR AHS 9 AHS States namely, Rajasthan, Uttar Pradesh,

Uttarakhand, Bihar, Jharkhand, Orissa, Madhya Pradesh, Chhattisgarh and Assam constitute:

• 48 percent of country’s Population

• 59 percent of Births

• 70 percent of Infant Deaths

• 75 percent of Under 5 Deaths

• 62 percent of Maternal Deaths

There is large inter-district variations in these States.

In the absence of District level vital data, State level estimates from Sample Registration System (SRS) are used for formulating district level plans.

Annual Health SurveySelected States

Orissa

Chhattisgarh

JharkhandMadhya Pradesh

Bihar

ASSAM

Rajasthan

Uttar Pradesh

Uttarakhand

Key Features

• Coverage- All the 284 districts of 8 EAG States and Assam

• Sample Units- 20,694 statistically selected sample units (Census

Enumeration Blocks in urban areas and Villages in rural areas)

• Sample Population- About 18.2 million

• Sample Households- 3.6 million households

• Average Sample households per district- About 13 thousand

Largest Sample Survey in the World

Key Features

• Sample Size- District level sample size is based on Infant Mortality

Rate

• Conduct of Field Work- Hybrid approach wherein fieldwork has

been outsourced and supervision done by the ORGI

• Third Party Audit- Third Party Audit was implemented under AHS

to verify the correctness of data through an independent

arrangement. This was over and above the regular supervision by

ORGI

StateNo. of

District

Sample

Population

per district

Total Sample

Population

No. of Sample

Units

No. of

Households*

Uttarakhand 13 141,898 1,844,670 2,501 368,934

Rajasthan 32 50,678 1,621,710 1,841 324,342

Uttar Pradesh 70 49,564 3,469,464 3,927 693,893

Bihar 37 59,361 2,196,340 2,356 439,268

Assam 23 71,216 1,637,967 1,784 327,593

Jharkhand 18 104,862 1,887,520 2,109 377,504

Madhya Pradesh 45 48,937 2,202,161 2,557 440,432

Chhattisgarh 16 70,371 1,125,940 1,255 225,188

Orissa 30 71,377 2,141,319 2,364 428,264

Total 284 18,127,089 20,694 3,625,418

* No. of households estimated using 5.0 as average household size

Allocation of Sample


0

10

20

30

40

50

60

70

80

IMR - AHS States

Jharkhand and Uttarakhandare at the bottom of the list whereas, MP and UP tops

IMR in rural area is significantly higher than that of urban area across AHS States. In UP, rural IMR is 74 compared to 54 in urban

More female infants die as compared to males. In UP, female IMR is 72 compared to 69 for males


State

Total no.

of

districts

Districts with

minimum IMR

Districts with

maximum IMRRange

UTTARAKHAND 13 Rudraprayag (19) Haridwar (72) 53

RAJASTHAN 32 Kota (36) Jalor (79) 43

UTTAR PRADESH 70 Kanpur Nagar (36) Shrawasti (103) 67

BIHAR 37 Patna (39) Madhepura (71) 32

ASSAM 23 Dhemaji (44) Kokrajhar (76) 32

JHARKHAND 18 Purbi Singhbum (26) Godda (64) 38

ORISSA 30 Baleshwar (49) Balangir (100) 51

CHHATTISGARH 16 Durg (43) Raigarh (65) 22

MADHYA PRADESH 45 Indore (40) Panna (93) 53

IMR across 284 districts ranges between 19 (Rudraprayag; Uttarakhand) & 103 (Shrawasti, UP) – a variability of 5 times!

6 districts viz. Purbi Singhbhum & Dhanbad (Jharkhand); Chamoli, Rudraprayag, Pithoragarh & Almora (Uttarakhand) have already achieved MDG-4 National target of 28 by 2015

Another 4 districts i.e. Bokaro & Ranchi(Jharkhand) and Bageshwar & Nainital(Uttarakhand) are in closer vicinity

Female infants experience higher mortality than males

IMR in rural areas is significantly higher than that in urbanareas



StateFrequency Range

15 - 29 30 - 44 45 - 59 60 - 74 75 - 89 90 - 104

UTTARAKHAND 4 7 2

RAJASTHAN 1 15 15 1

UTTAR PRADESH 2 18 22 23 5

BIHAR 1 27 9

ASSAM 1 13 8 1

JHARKHAND 3 6 8 1

ORISSA 17 8 4 1

CHHATTISGARH 1 10 5

MADHYA PRADESH 1 9 28 5 2

Total 7 20 117 98 34 8

76 % of districts fall in range 45-59 and 60-74 of IMR

Infant Mortality Rate

Top Five Districts in AHS States

Uttarakhand

Uttar Pradesh

Rajasthan

Assam

Bihar

Madhya Pradesh

Jharkhand

Chhattisgarh

Orissa


0

10

20

30

40

50

60

NNMR - AHS States

Jharkhand & Uttarakhandrecords NNMR under 30 whereas for MP & UP, it is 44 & 50 respectively

NNMR is more acute in rural areas than urban areas across all 9 AHS States. In UP, rural NNMR is 53 compared to 36 in urban

NNMR across 284 districts ranges between 11 (Rudraprayag; Uttarakhand) & 75 (Balangir, Orissa) – a variability of 7 times!

Out of every 10 infant deaths, 6-7 pertains to neonates

NNMR in rural areas of districts is significantly higher than that in urban areas


State

Total

no. of

districts

Districts with

minimum NNMR

Districts with

maximum NNMRRange

UTTARAKHAND 13 Rudraprayag (11) Haridwar (50) 39

RAJASTHAN 32 Kota (25) Jalor (58) 33


BIHAR 37 Patna (22) Madhepura (49) 27

ASSAM 23 Dhemaji (27) Dhubri (50) 23

JHARKHAND 18 Purbi Singhbum (17) Lohardaga (41) 24

ORISSA 30 Anugul (31) Balangir (75) 44

CHHATTISGARH 16 Durg (29) Raigarh (45) 16




10 - 19 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79

UTTARAKHAND 5 6 1 1

RAJASTHAN 1 15 14 2

UTTAR PRADESH 4 15 17 19 12 3

BIHAR 7 20 10

ASSAM 1 12 9 1

JHARKHAND 2 8 7 1

ORISSA 17 10 2 1

CHHATTISGARH 3 5 8


Total 7 33 100 92 33 15 4

68% of districts fall in range 30-39 & 40-49 of NNMR

Uttarakhand

Uttar Pradesh

Rajasthan Assam

Bihar

Madhya Pradesh

Jharkhand

Chhattisgarh

Orissa

Neo-Natal Mortality Rate


UNDER FIVE MORTALITY RATE (U5MR)

0

10

20

30

40

50

60

70

80

90

100

U5MR - AHS States U5MR for Uttarakhand is in the 50s while for UP, it is in the 90s

Across all 9 AHS states, U5MR in rural areas is significantly higher than that of urban areas. In UP, rural U5MR is 101 compared to 68 in urban

Gap between male-female mortality differential is significant. In UP, male-female gap is 9


State

Total no.

of

districts

Districts with

minimum U5MR

Districts with

maximum U5MRRange

UTTARAKHAND 13 Pithoragarh (24) Haridwar (94) 70

RAJASTHAN 32 Kota (45)Jalor (99)

Banswara (99)54


BIHAR 37 Patna (53) Sitamarhi (106) 53

ASSAM 23 Dhemaji (52) Kokrajhar (103) 51

JHARKHAND 18 Purbi Singhbum (36) Godda (93) 57

ORISSA 30Balasore (58)

Jharsuguda (58)Kandhamal (145) 87

CHHATTISGARH 16 Durg (52) Surguja (103) 51


U5MR ranges between 24 (Pithoragarh, Uttarakhand) & 145 (Kandhamal, Orissa) - a variability of 7 times!

7 districts viz. Pithoragarh, Almora, Rudraprayag, Chamoli, Nainital & Bagheswar (Uttarakhand) and Purbhi Singhbum (Jharkhand) have already achieved MDG National level target of 42

Another 10 districts viz. Dhanbad, Bokaro, Kodarma, Hazaribagh & Giridih (Jharkhand) and Kota (Rajasthan) and Champawat, Udham Singh Nagar, Dehradun & Uttarakashi are in closer vicinity

More no. of females die before reaching age 5 years than males

U5MR in rural areas is significantly higher than that in urban areas




21 - 40 41 - 60 61 - 80 81 - 100 101 - 120 121 - 140 141 - 160

UTTARAKHAND 6 5 1 1

RAJASTHAN 1 18 13

UTTAR PRADESH 2 13 30 19 5 1

BIHAR 1 23 9 4

ASSAM 2 12 8 1

JHARKHAND 1 9 4 4

ORISSA 3 13 9 4 1

CHHATTISGARH 2 12 1 1


Total 8 44 104 81 38 7 2

66 % of districts fall in range 61-80 and 81-100 of U5MR

Under Five Mortality Rate


Uttarakhand

Uttar Pradesh

Rajasthan

Assam

Bihar

Madhya Pradesh

Jharkhand

Chhattisgarh

Orissa


Uttarakhand has the lowest MMR whereas, Assam has the highest

Maternal Deaths under AHS are based on response of relatives of the deceased

There is a move to introduce tools of Verbal Autopsy under AHS

0

50

100

150

200

250

300

350

400

MMR - AHS States

MMR has been published for 62 administrative divisions (Commissionraits) in 9 AHS States

It ranges between 183 (Kumaon HQ, Uttarakhand) & 451(Faizabad Mandal, UP)

MMR for Uttarakhand along with its two divisions is lower than the National Average (212)


State

Total no.

of

Admin.

Division

Admin. Division

with minimum MMR

Admin. Division with

maximum MMRRange

UTTARAKHAND 2 Kumaon HQ (183) Garhwal HQ (190) 7

RAJASTHAN 7 Bharatpur (292) Udaipur (364) 72

UTTAR PRADESH 18 Jhansi Mandal (241)Faizabad Mandal

(451)210

BIHAR 9 Patna (258) Purnia (377) 119

ASSAM 4Hills & Barak Valley

(342)Upper Assam (430) 88

JHARKHAND 5Uttari Chota Nagpur

(208)Santal Paragana (325) 117

ORISSA 3 Northern (253) Southern (311) 58

CHHATTISGARH 4 Raipur (243) Bastar (312) 69

MADHYA PRADESH 10 Gwalior (262) Shahdol (435) 173

Maternal Mortality Ratio

By Administrative Divisions in

AHS States

Uttarakhand

Uttar Pradesh

Rajasthan

Assam

Bihar

Madhya Pradesh

Jharkhand

Chhattisgarh

Orissa

MMR

250 and below

251 - 350

351 - 400

401 and above

Administrative Divisions

CONCLUSION

Top 100 districts in order of IMR constitute about 50 percent of total Infant Deaths across 9 States

Top 25 Administrative Divisions (comprising 104 districts) in order of MMR constitute 41 percent of the total Maternal Deaths

Top 100 districts in order of U5MR account for 63 percent of total child deaths.

57 districts are in common – Hot Spots

Orissa

Chhattisgarh

Jharkhand

Madhya Pradesh

Bihar

AssamRajasthan

Uttar Pradesh

Uttarakhand

Infant Mortality Rate

Top 100 Districts in AHS States

Orissa

Chhattisgarh

Jharkhand

Madhya Pradesh

Bihar

Assam

Rajasthan

Uttar Pradesh

Uttarakhand

Maternal Mortality Ratio

Top 25 Administrative Divisions in

AHS States

MMR

Top 25

Administrative Divisions

Rajasthan- 5

Assam- 7

MP- 11

UP- 34

THANK YOU

Documents

Estimates of Maternal & Child Mortality in Indianutritionfoundationofindia.org/PPT-2011/Seven17-18teen/...Infant Mortality Rate (IMR) by residence, 1990–2009 80 74 68 58 50 86 80