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Trends in Sex Differential
Childhood Mortality in
Ballabgarh HDSS (1992-2009)
Anand Krishnan, Dwivedi Purva, Yadav Kapil, Nawi Ng, Peter Byass
Ballabgarh HDSSCentre for Community Medicine
The All India Institute of Medical SciencesNew Delhi – 110029, India
Goal 3: Promote gender equality and empower women
NNMR & IMR in Ballabgarh HDSS
• Lower than rest of rural north India
• Gender Differential not studied
Why focus on Gender
• Child mortality rates stagnant for the last decade – Is it related to gender differentials
• Declining sex ratio at birth came to the fore in mid nineties and early 2000.mid nineties and early 2000.
Introduction Introduction Introduction Introduction
to to to to
BallabgarhBallabgarhBallabgarhBallabgarh
Ballabgarh,Haryana
35 Kilometer from AIIMS, Delhi – Mathura Highway
C.R.H.S. Project, BallabgarhRural Intensive Field Practice Area Rural Intensive Field Practice Area –– 87002 in 87002 in
December 2009December 2009
PHCPHCDAYALPURDAYALPUR
Chandawali
Nawada Junehra
Dayalpur
Shahpurkalan
Nirhawali
PHCPHCCHHAINSACHHAINSA
Atali
Fatehpur
BillochNaryala
Chhainsa
Jaya Ladholi
Methods – Data collection
• Birth and death data collected during monthly visits by health worker – service provision like immunization, antenatal care etc.
• Annual Census in December every year to identify additional births and deaths.
• Quality checks by supervisors as well as medical students
Data Storage
• Electronic Database:
• Started since 1988: fully functional since 1992.
• Mainly started for service provision and not • Mainly started for service provision and not for demographic surveillance
– In migration data not captured and stored
– Deaths archived
• Since joining INDEPTH in 2003 have been looking at ways to meet both the ends
– INDEPTH Fellows were very useful
Data Management• Problem: Inability to differentiate between
native born ( and eligible for denominator) and migrated (ineligible) for child mortality rates.
• Would result in a bias of decreasing mortality rates over time.rates over time.
• During Census 2009 all houses visited and in migration year collected for those still living and database corrected.
– Low in migration rates mainly due to marriage
– Unlikely to be a sex differential
• Revised childhood mortality rates calculated.
Data Analysis• Three year moving averages used
– Small denominators : around 1900 live births
– Fluctuating mortality rates
• As census is done and all events are enumerated – confidence intervals not enumerated – confidence intervals not reported.
Current child mortality rates
(2007-2009) (95% C.I.)M F T
NNMR 25.1 23.8 24.5
PNMR 19.0 28.9 23.6PNMR 19.0 28.9 23.6
IMR 44.1 52.7 48.1
1-4 MR 11.6 20.8 15.9
38.0 38.1
34.2 35.2
40.6
45.1
48.2
45.2
48.650.2
53.2
49.8 49.9
46.6 46.848.1
26.927.6 27.3
30.0
40.0
50.0
60.0
Death
Rate
s
Total Death Rates (1992-2009)
9.27.7 8.1 8.6
11.2
14.616.2 17.0 17.0
20.1
22.2 21.9 22.0 21.7
23.724.524.0 24.2
23.2 21.7
26.927.6 27.3
22.021.6
20.8
18.1
15.3 15.7 15.8 16.3 15.9
0.0
10.0
20.0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Death
Rate
s
Year
NMR IMR 1-4DR
17.4
19.618.5
16.4
17.9 17.9
16.3 16.317.2
22.3
25.1
17.9
22.8
27.2
28.529.0
27.3
25.5
23.8
20.0
25.0
30.0
35.0
NM
R
Neonatal Mortality Rate
9.48.5 8.4 8.1
12.4
16.4 16.3 16.317.2
8.7
6.87.8
9.29.9
11.312.2
15.1
0.0
5.0
10.0
15.0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
NM
R
Year
Male Female
25.526.4
23.124.4
25.5
21.9 22.223.3 23.6 23.0
32.7
35.4
32.9
34.8
37.037.6
39.9
35.8
42.541.1
39.9
32.833.9
32.331.6
28.9
25.0
30.0
35.0
40.0
45.0
PN
MR
Post Neonatal Mortality rate
20.3 19.7
21.9 22.2
20.518.9
16.3
19.0
0.0
5.0
10.0
15.0
20.0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
PN
MR
Year
Male Female
41.8
45.0
40.438.5 38.5
41.139.8 39.3 38.6
44.141.5 42.2
40.7
44.0
46.948.9
52.151.0
60.4
63.9
67.1
61.362.9
59.657.1
52.7
40.0
50.0
60.0
70.0
80.0
IMR
Infant Mortality Rate
34.9 34.9
28.7 27.8
35.4
38.5 38.5 39.3
36.238.6
0.0
10.0
20.0
30.0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
IMR
Year
Male Female
33.3
34.3
32.631.2
40.140.5 39.0
28.8
28.528.0
24.725.0
30.0
35.0
40.0
45.0
4yrs
DR
1-4 yrs Death Rate
16.0
15.815.2
13.6
15.5 16.6
17.516.5 15.8
14.6
12.411.6
12.7
12.3
12.7
11.7
19.619.5 20.1
20.920.9
0.0
5.0
10.0
15.0
20.0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
1-4
yrs
DR
Year
Male Female
50.9 50.7 51.0
58.5
62.6
56.954.3 53.1 53.5
51.5 51.9
48.351.2
55.7
74.976.6
73.375.2
86.989.2
90.9
79.8
88.991.8 91.7
80.982.5
79.978.0
73.5
50.0
60.0
70.0
80.0
90.0
100.0
Un
5M
R
Under Five Mortality Rate
43.941.4
48.3
0.0
10.0
20.0
30.0
40.0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Un
5M
R
Year
Male Female
43.2
65.7
53.1
40.0
50.0
60.0
70.0
80.0
IMR
Infant Mortality Rate 1993-2008
43.2
0.0
10.0
20.0
30.0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
IMR
Year
Male Female Total Log. (Male) Log. (Female) Log. (Total)
Was it always like this?
Year NNMR IMR 1-4 MR
1966-69
M
F
43.7
41.4
91.6
123.6
NR
1972-74 NR1972-74
M
F
NR
42.5
57.5
31.0
69.0
1982-84
M
F
NR
43.7
56.4
32.1
62.9
From published sources
What about other parts of India?
One million death study 2005
Fig 1. - Framework for explaining Gender differences in child survival
Behavioral
Technological
•Role of ultrasound
•Vaccines
Economic
•Poverty driven
choices
Social
•Dowry system
•Male preference
•Inheritance rulesBiological
Governmental
•One child norm
•Financial incentives
for girl child
Gender difference
in child survival
Behavioral
•Sex determination
•Health seeking
•Child rearing
•Inheritance rules
•Female literacy
Biological
•Immunity
•Differential
response to vaccines
for girl child
•PNDT Act
•Vaccination Policy
• Social mobilization
Key Messages
• Girl Children have higher mortality rates at all levels and even at neonatal period in Ballabgarh HDSS population.
• With low sex ratio at birth this appears a continuum.continuum.
• MDG goals unlikely to be reached unless gender differential is addressed.
• Major socio-cultural issues involved which need to be understood better and subsequently tackled.
What needs to be done
• At Site Level– Address neonatal mortality – being done in collaboration with Unicef India
– Understand issue better – Part of PhD work with Umea
– Social Mobilization for Gender discrimination – being done
• INDEPTH Level• INDEPTH Level– Part of Equity working group
– Report all data by sex as a rule
• National / Global Level– Advocacy for gender
