Government of India

MORTALITY STATISTICS

IN INDIA 2006

Status of Mortality Statistics Reporting in India

A Report

March 2007

Text Box: Central Bureau of Health Intelligence (CBHI)
Directorate General of Health Services
Ministry of Health & Family Welfare,
Nirman Bhavan, New Delhi - 110011

CBHI website : www.cbhidghs.nic.in CBHI email : dircbhi@nb.nic.in

Government of India

MORTALITY STATISTICS

IN INDIA 2006

Status of Mortality Statistics Reporting in India

A Report

March 2007

Compiled and Edited by

Dr. Ashok Kumar, M.D., Dy.DG & Director

Dr. D.K. Raut, Joint Director

Ms. Pratima Gupta, Assistant Director

Sh. Umed Singh, Assistant Director

Text Box: Central Bureau of Health Intelligence (CBHI)
Directorate General of Health Services
Ministry of Health & Family Welfare,
Nirman Bhavan, New Delhi - 110011

CBHI website : www.cbhidghs.nic.in CBHI email : dircbhi@nb.nic.in

PREFACE

The purpose of preparation of country (India) report on Mortality Statistics is to have complete knowledge on status of mortality statistics of the country (India), which is a crucial aspect for assessing the current health situation in the country. Both the magnitude and distribution of disease burden are important for formulating the policies and programmes for enabling resource allocation to better address health needs and for monitoring the impact of health interventions. The status of mortality statistics shows overall picture of mortality reporting system (system of death registration of the country both in the health institutions and the community) age-wise, sex-wise, as well rural/urban.

It is important to understand the challenges faced by the health sector there is a need to have a correct/latest picture on mortality statistics of the country. Working group was constituted and a meeting with the experts from Registrar General of India, Social Statistics Division of Ministry of Statistics and Programme Implementation, office of the Chief Registrar (Births and Deaths) Delhi, Bureau of Health Intelligence, MCD and Dy. Commissioner (MH) Ministry of Health & Family Welfare to discuss the issues related to status of mortality reporting in India.

ACKNOWLEDGEMENT

We acknowledge with sincere thanks the significant inputs received from office of the Registrar General of India, Statistics Division of Ministry of Statistics and Programme Implementation, Office of the Chief Registrar (Births & Deaths) Delhi, Bureau of Health Intelligence, MCD and Dy. Commission (MH) of Ministry of Health & Family Welfare for their views and valuable advice for preparing the Mortality Report of India.

We are grateful to WHO/SEARO, New Delhi for providing financial support for undertaking this activity.

Contributors

Sh. Harbinder Singh, Dy. Registrar General, O/o. of the Registrar General of India, New Delhi

Sh. Sunil Jain, Dy. Registrar General of India (SRS), O/o. of the Registrar General of India, R.K. Puram, New Delhi

H. Borah, Director, M/o. of Statistics and Programme Implementation, West Block-8, R.K. Puram, New Delhi

S. Chakrabortty, Deputy Director, M/o. of Statistics and Programme Implementation, West Block-8, R.K. Puram, New Delhi

Sh. N.T. Krishna, Dy. Director, O/o. Chief Registrar, (B&D), Room No.148, Old Sectt. Delhi –84

Dr. I.P. Kaur, DC(MH), MOHFW/GOI, Nirman Bhawan, New Delhi

Dr. J. Duggal, MO (IT), Room No. 58, Bureau of Health Intelligence, M.C.D, Town Hall

Mr. V.K. Harnal, Medical Record Officer, Medical Record Department & Training Centre, Safdarjung Hospital, New Delhi

Dr. Ashok Kumar, Director, CBHI

Dr. D.K. Raut, Joint Director, CBHI

Sh. P.K. Mukhopadhyay, Joint Director, CBHI

Ms. Pratima Gupta, Asstt. Director, CBHI

Sh. Umed Singh, Asstt. Director, CBHI

Sh. V.K. Khanna, Asstt. Director, CBHI

Sh. A.K. Chopra, Asstt. Director, CBHI

Ms. R.K. Beniwal, Asstt. Director, CBHI

SELECTED DEFINITIONS USED IN THE CURRENT REPORT

Crude death rate (CDR)	Number of deaths during the year -------------------------------------------------- x 1000 Mid-year population
Age-specific mortality rate (ASMR)	Number of deaths in a particular age-group ---------------------------------------------------------------- x 1000 Mid-year population of the same age-group
Infant mortality rate (IMR)	Number of infant deaths during the year ----------------------------------------------------------- x 1000 Number of live births during the year
Neo-natal mortality rate (NMR)	Number of infant deaths of < than 29 days during the year ------------------------------------------------------------------- x 1000 Number of live births during the year
Early neo-natal mortality rate	Number of infant deaths of < than 7 days during the year ------------------------------------------------------------------- x 1000 Number of live births during the year
Late neo-natal mortality rate	Number of infant deaths of 7 days to < than 29 days during the year -------------------------------------------------------------------- x 1000 Number of live births during the year
Post neo-natal mortality rate(PNMR)	Number of infant deaths of 29 days to < than one year during the year ------------------------------------------------------------------ x 1000 Number of live births during the year
Peri-natal mortality Rate (PMR)	Number of still births and infant deaths of < than 7 days during the year ------------------------------------------------------------------- x 1000 Number of live births and still births during the year
Still birth rate	Number of still births during the year ---------------------------------------------------------- x 1000 Number of live births and still births during the year

CONTENTS

Sl.No.	Items	Page No.
1.	Executive Summary	8
2.	Chapter 1: Indroduction	11
3.	Chapter 2 :Methods of Mortality Statistics Reporting in India	14
4.	Chapter 3: Medical Certification of Cause of Deaths	27
5.	Chapter 4: Status of Mortality Reporting in India	48
6.	Chapter 5: Estimates of Mortality Indicators	60
7.	Chapter 6: Maternal and Infant Mortality	77
8.	References	88
9.	Annexure – I	89
10.	Annexure – II	93
11.	Annexure – III	95
12.	Annexure – IV	105
13.	Annexure – V	127
14.	Annexure –VI	138
15.	Annexure –VII	141
16.	Annexure -VIII	148

EXECUTIVE SUMMARY

Vital Statistics

Sample Registration System (SRS) is the reliable source of nation wide vital statistics. The coverage of vital registration of deaths is 50-69 % through CRS. Cause of death information is most of the times (sometimes) recorded on Civil Registration System (CRS) forms.

The country has adequate capacity to implement data collection, process the data and analyze the data from SRS. Frequency of the assessment of completeness of vital registration is done every year through CRS. Tabulation list ICD 10 is currently in use. Proportion of all deaths coded to ill-defined causes is 11- 19 % (14 % in 2000). Published statistics from SRS are disaggregated by sex, age and geographic region. Sample registration system (SRS) developing and generating timely and accurate data, which is nationally representative. Verbal autopsy (VA) tool validated and questionnaire is publicly available. VA tool is consistent with international standards

Lag time between the statistics from VR /SRS/ DSS were last published and the time that the data were collected is Less than 3 years. Mortality rates from SRS are used for national / sub national analysis and cause of death from Medical Certification of Death (MCD) is used for national reports.

Mortality

Under five mortality (all cause)

Method used to collect the most recent major data point is SRS. For the most recently published estimate (upto 2 years ago) the data were collected through SRS. More than three times the data were collected in last 10 years. No major discrepancies in the data points over time and between sources during last decade noted. Coverage of data upon which the most recently reported estimate is based is sample of deaths. Most recent data point is disaggregated by demographic characteristics (e.g. sex and age) socioeconomic status (e.g. wealth or occupation or education of their parent) and by locality (e.g. urban-rural or major administrative region). SRS is used for country estimates, which is, and transparent well-established method.

Adult mortality (all cause)

Method used to collect the most recent major data point is Sample vital registration. For the most recently published estimate, (upto 2 years ago) the data were collected through this method. Number of data collection rounds in last decade was three or more. Data points in last decade were consistent over time. Coverage of data upon which the most recently reported estimate is based is Sample of deaths. Most recent data point is disaggregated by demographic variables (age and sex), socio-economic status (e.g. by wealth quintiles, level of education, or occupations) and by locality (e.g. urban/rural), major administrative regions). This method of country estimates is transparent well- established.

Maternal Mortality

Data collection method for most recent data point is sample vital registration with verbal autopsy. For the most recently published estimate (upto 2 years ago) the data were collected. More than three data collection rounds were made in last decade. No major discrepancies in data points in last decade over time. Coverage of data upon which the most recently reported estimate is based is sample of deaths. Most recent data point is disaggregated by demographic variables (age), socio-economic status (e.g. by wealth quintiles, level of education, and occupations) and by locality (e.g. urban/rural, major administrative regions). In country estimates transparent well-established method is used.

Mortality Data

Overall mortality regardless of causes of death

India has a national compulsory death registration system under the Registration of Birth and Death Act, 1969.

At the local/individual level, the deaths are reported in the civil registry and at some places local health authorities and police are also involved. At the national level, ministry of home affairs and ministry of health & family welfare are responsible for the final data. The national estimated completeness of overall registered deaths is 50-59% (as per the year 2004). The source of completeness estimate is SRS crude death rate and mid year population (projected/census) in thousands. The information on data collection does not include any overseas territorial units.

Population officially covered by the registration system of the country: All deaths occurring with in the territory of India are included. Military personnel (armed forces) dying with in the country is included, but those dying abroad are not included and Ministry of foreign affairs is responsible for recording these deaths.

Other data

Last census was conducted in the year 2001. The mortality modules included in national census are (i) child ever born and still alive and (ii) sibling survival. These modules were always there since the beginning of census in 1941 and 1971 – 2001.

The number of deaths by age and sex in a specified time period can be derived from the module using P/F (Parity/Fertility) method and Brass method.

For the last ten years the other source of information on adult and /or child mortality is sample vital registration system.

Causes of Death

We have a compulsory national death registration system and the cause of death is part of the information collected. The current International form of Medical Certificate of Cause of Death as recommended by WHO in ICD-10 is used. Three lines are present in Part I of our death certificate (form 4 & 4A). The percentage of registered deaths that are certified in our country by Medical doctors is 15 %. The percentage of registered deaths occurring in a hospital or other medical institution as per CRS report (1995) is 29.4%. The follow-up enquiries to the certifier in case of doubt or inconsistency about the cause of death are undertaken. In order to obtain information on cause of death Verbal autopsy technique is used and 2005 is the last year it was done. The cause-of-death statistics provided to WHO are compiled by date of occurrence. The coding procedure is Decentralized, done at the local/regional level. The underlying cause of death on the medical certificate and assigning of ICD code is done by the certifier. ICD-10 is being used in the country and for deaths due to external causes, dual coding of both the external cause and the nature of injury is done. The death registration form also includes a question on pregnancy at the time of death or pregnancy in the last 12 months.

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Chapter -1

INTRODUCTION

Mortality statistics is the key health indicator to assess quality of life. However reporting of deaths in India has been the challenge for Public Health organizations, Health planners and programmers. Registration of births and deaths is an important source for demographic data for socio-economic development and population control in developing countries. The data on population growth, fertility and mortality serves as the starting point for population projections. Apart from these vital indicators, an adequate evaluation of a number of programs in the health sector, including family planning, maternal and reproductive health, immunization programs, is dependent upon the availability of accurate, up-to-date fertility and mortality data.

It is essential to assess the status of existing Mortality statistics reporting mechanism in India to take appropriate interventions for its improvement. World Health Organisation(WHO) has requested to prepare a report on the mortality statistics coverage, current status of data collection, flow of mortality statistics including cause of death in the country and utilization of the mortality data.

The demographic scenario in the country has been undergoing a change since the inception of SRS; however, the profile and rate of change is not uniform in all the states. Overall, the crude birth rate in the country has come down from 36.9 per one thousand population in 1971 to 23.8 in 2005, whereas the crude death rate has declined from 14.9 to a low of 7.6 in the same period. The infant mortality rate, which is an important indicator of the health status of the country, has registered a significant decline from 129 per one thousand live births in 1971 to 58 in 2005. During the period, the total fertility rate of the country has declined from 5.2 to 2.9. To fulfill its objective of monitoring the changes in vital indicators, the SRS sampling units are retained for about ten years, making it a panel household survey.

The Survey of Causes of Deaths (Rural) has been merged with Sample Registration System from 1st January 1999 to give more impetus covering both rural and urban areas and wider representation of sample villages and urban blocks for Causes of Death. The primary objective of the survey is to build up statistics on “Most Probable Causes of Death” for rural and urban areas using “lay diagnosis reporting (Post Death Verbal Autopsy)” method through post death enquiry based on symptoms, conditions, duration and anatomical site of the disease as observed by family members of the deceased at the time of death. As the collection of causes of death requires knowledge on medical terminologies, symptoms of disease and interview techniques, the supervisors of SRS have been trained by medical professionals in the art of collection of data on causes of deaths. A well-designed VA instrument has been developed and introduced in SRS. Supervisors of all states have been trained with the new VA instrument. To enhance the objectivity of the system, the role of SRS supervisor is restricted to faithfully collect data on sign and symptoms by interviewing the close relative of the deceased. Apart from recording the responses for closed questionnaire, he has to fill up the narrative portion of the VA instrument.

CONSULTATION MEETING FOR PREPARATION OF COUNTRY (INDIA) REPORT ON MORTALITY STATITICS

A working group was constituted to discus the current issues related to Mortality statistics in the country. Representatives from DteGHS, Ministry of Health & Family Welfare GOI, Registrar General of India, Ministry of Statistics and Programme Implementation, Delhi State health information Bureau and Officers of CBHI actively participated in the meeting. The list of the participants is enclosed along with the Programme schedule (Annexure-1).

The consultation meeting of working group was conducted on 8th March 2007 at Niramna Bhawan, New Delhi with the following objective.

To discus and summarise the mortality statistics coverage, current status of data collection, flow of mortality statistics including cause of death in the country and utilization of the mortality data.

The following three sub-groups were formed to discuss mortality specific key issues during the meeting. The groups were requested to perform the following task.

Key issues:

Group 1: Overview of mortality Reporting System in India

Group 2: Reporting Cause of Death

A. Cause of death (COD)

B. Completeness of death registration

Group 3: Maternal and infant mortality statistics.

Methodology: The following methodology adopted during the meeting.

Discussion on the Questionnaire provided by WHO (Annexure-3)

Group work of the all participants from health information & vital registration (including other sectors, e.g. Central Bureau of Statistics, international and national NGOs) so that subjectivity is avoided to the highest extend.

The expert’s view / answers to the questions were obtained by individual discussions with each expert.

Group Task:

Identify group leader and rapporteur

Discus the mortality reporting status in India on following discussion points

Amend (use reference material) and prepare the report

Present salient features.

All three groups had detail discussions on the topics allotted to them and made the draft for the presentation and subsequently the topics were discussed with other colleagues in the respective organisations. Suggestions and modifications on the various topics were again included and final report is updated with latest fact and figures on mortality data especially from SRS, Registrar General of India. The key findings and outcome of the consultation meeting of the working group is compiled and presented in the report.

CHAPTER - 2

METHODS OF MORTALITY STATISTICS REPORTING IN INDIA

INTRODUCTION

In India Registrar General of India collect compile, analyze and publish Mortality statistics for the country under the provisions of Registration of Birth and Death Act (1969) through Civil Registration System (CRS) and Sample Registration System (SRS).

The registration of births and deaths has been made compulsory under the Registration of Births & Deaths (RBD) Act, 1969. The state governments under the rules framed by them are implementing the provisions of this Act. Though more than 30 years have passed since the enactment of the legislation, the level of birth and death registration is not satisfactory in certain parts of the country.

The National Population Policy 2000 has recognized the need for registration of births, deaths and marriages and set the goal of achieving universal registration of these events by 2010. Considering the fact that the level of registration of events under the RBD Act is very low, the National Population Commission appointed a Working Group on Registration of Births, Deaths and Marriages with Registrar General, India as Chairman to look into various issues relating to registration of vital events.

A. Civil Registration System (CRS)

The Civil Registration System Unit of the Office of the Registrar General, India coordinates and unifies the activities of the State Governments on Registration of Births and Deaths in the country. It also provides general direction and guidance to the States/UTs in this matter for effective implementation of the provisions of the Registration of Births and Deaths Act, 1969 and compiles and disseminates the statistical information on vital events based on the registration of births and deaths through various publications.

A.1 Current Status

The Civil Registration System of a country envisages recording each and every incidence of vital event for legal purposes and in the process captures a lot of information on various characteristics of these events, which help in the compilation of a continuous series of vital events. Complete, timely and accurate registration of births and deaths is very crucial for the understanding of population dynamics at the local level and planning of effective health and development programmes. The extent of completeness and accuracy of birth and death registration is by itself an indicator of the modernisation of society as vital statistics belong to the Core Statistics of any National Statistical System.

In India, civil registration was first introduced in the last century mainly as an aid to public health administration for locating and identifying diseases of public health importance and to undertake remedial measures to control mortality. However, registration was kept voluntary and different provinces had different legislations and there was no standardisation of concepts, definitions and classifications. Various Commissions and Committees have reviewed the civil registration based vital statistics system in the past. The enactment of the ‘Registration of Births and Deaths (RBD) Act, 1969’ replacing all diverse laws that existed on the subject, and the Model Rules framed under the Act introduced a uniform piece of legislation to overcome the problems of multiplicity of Acts and Rules that existed in the country. Thus, the Act aimed to have a uniform system of registration and data collection on vital statistics. The Act provides for compulsory registration of births and deaths in the country.

The RBD Act has provided for a hierarchical set-up for the registration machinery in the country, headed by the Registrar General of India at the Centre, The Chief Registrar of Births and Deaths is the chief executive authority in the State for implementing the provisions of the Act. There are District Registrars in the districts and Registrars and Sub-registrars for registering births and deaths occurring in the area allotted to them within a district. The States with the approval of the Central Government have made Rules in accordance with the Model Rules to implement various provisions of the Registration of Births and Deaths Act.

A.2 DEFICIENCIES

It is estimated that 26 million births and 9 million deaths occur in India every year and based upon the reports received, only 53 percent of births and 48 percent of deaths are registered. About 10 million births, which are about 25 percent of the unregistered births in the world and about 4 million deaths, are not registered. The poor registration in the rural areas of the country is the main reason for incomplete registration. On the basis of births registered in rural and urban areas, assuming that these births have taken place to the population living in these areas, the estimated birth rate works out to 12 and 24 per thousand respectively against 28 and 20 per thousand estimated from Sample Registration System during 1995. Even if it is taken that a sizable proportion, say 35-40 per cent of the births registered in the urban areas come from the population living in the rural areas, the birth rate of the rural areas could be estimated at around 14 to 15 per thousand, which shows that the level of registration in the rural areas may be around only 50 per cent. Further, the levels of registration of births and deaths vary widely across the States. Thus, the Civil Registration System suffers from incomplete coverage and the problem is more acute in a few States, which account for a big chunk of this incomplete coverage. Given the complete coverage, the CRS has the potential to provide estimates of vital rates such as birth rate, death rate, infant mortality rate and other related fertility and mortality indicators even at the district and below levels and will be of immense importance for micro level planning for development. However, due to incomplete coverage of the system, these estimates are made available at the State level only through the Sample Registration Scheme (SRS). However, even the estimates of infant mortality rate for small States and UTs are not reliable due to the small sample size.

There are more than 200,000 reporting units in the country and more than 100,000 local registrars doing the actual work of registration. Monitoring the receipt of statistical returns from each and every registration unit on a monthly basis is a challenging task. Other requirements are of training, supervision and maintenance of a timely supply of forms and registers in the registration units.

A combination of administrative factors is responsible for the poor registration levels of vital events. Except for a few States and UTs, generally multiple agencies are involved in the registration work at the sub-national level. This poses immense problems of coordination, monitoring and supervision, which directly affect the quality and timeliness of data. Though high -level inter-departmental committees exist, they have remained ineffective in improving the situation in most of the States. Further, the registration functionaries at all levels do the work of registration in addition to their other normal duties in an honorary capacity generally, without any incentive. This is why the work of registration, preparation and submission of statistical returns do not get due attention and priority. The quality of data becomes a major casualty. The number of Registration centres has also been a contentious issue. If this number is too small there are problems of accessibility. On the other hand, a large number of registration centres pose huge problems of control, management and supervision. Lack of adequate budget for supplying material resources such as forms and registers, for meeting training and supervisory requirements and publicity efforts put a constraint on the system to perform better. With regard to the registration of marriages, though legislations exist in some States, however, there is no uniform legislative enactment in the country. Some of the existing enactments are applicable to specific religious groups. There is also no provision for registration of divorces.

Even in States that have achieved high levels of registration, there is a considerable delay in reporting of statistics from the local registrars, eventually delaying the compilation of vital statistics at the State and National levels. A lot of paper work required and pending at the level of Registrar is one of the major reasons for the delay in submission of returns. Different States have different arrangements for processing the data on civil registration, depending on the number of registration centres, availability of manpower in offices where tabulation is done and the level of computerisation at the State headquarters. Varying lengths of time taken for intermediate tabulation at the district and town/municipality levels seriously affect the tabulation work at the State level resulting in the failure of States to meet the time limit prescribed under the law for publication of statistical reports.

The other factors that lead to incomplete registrations are a general lack of awareness in the public about the statutory requirements and procedures of registration, lack of demand of birth and death certificates in rural areas, acceptance of alternate documents as proof of death, and lack of perception of any benefits of registration by the people. Further, the registration centres are not always easily visible. Around 75 percent of births and 80 percent of deaths are domiciliary in nature and the statutory reporting of the events lies with the household.

A.3 RECOMMENDATIONS

The National Statistical Commission working group has given following recommendations for improvement of Civil Registration System in India.

The Civil Registration System (CRS), which is capable of providing vital rates not only at the district but also lower level, is deficient in most of the States and UTs. The justification for improvement in the system of civil registration and vital statistics would usually be based on a demonstration of the potential of such a system to create individual records that are useful for legal and administrative purposes and also to aggregate them into usable statistics. The CRS in the country has so far not served the needs for which it was set up and therefore; it attracts low priority and attention not only by the Government but also by also potential users. The Commission observes that incomplete registrations and delays in the upward movement of the registration data have been major problems for timely processing and publication of the results of the Civil Registration System and this has undermined the its utility. At present it is a passive system, in which most people do not realise the importance of reporting births and deaths. Where ANMs and other village level workers have been given the responsibility of reporting births and deaths to the Registrar there has been a positive impact. Inspite of demands for publication of the absolute number of births, deaths, infant deaths, etc., such figures are not available. There is growing need for district level vital statistics, which is a major lacuna in the way of decentralised planning. Recently, released provisional results of the Census 2001 have revealed that the population has grown at a faster rate than estimated and the sex ratio in the age group 0-6 years has declined considerably during the last decade form 945 to 927. Had the Civil Registration System in the country been efficient in covering all births and deaths and bringing out data in time, it would have been possible to introduce necessary preventive measures in time. The results of Census 2001, once again stress the need for an efficient Civil Registration System. The Commission also recognises the goal of attaining of complete registration of vital events namely, births, deaths, marriages and pregnancy as one of the 14 socio-demographic goals to be attained by the year 2010 in the recently announced National Population Policy, 2000, and therefore recommends:

(i) There should be a more pro-active Civil Registration System in place of the existing passive system. In rural areas, panchayats, local bodies and other basic and primary workers apart from Auxiliary Nurses, Midwives, Village Watchmen should play an active role in informing the Registrar about the occurrence of vital events. They should collect birth and death information from households and deliver the same to the Registrar. All States should implement this as a part of strategy to improve the registration. This can be achieved by giving the local level workers the responsibility for informing and collection of reports of events and getting them registered.

(ii) Within a State, as far as possible, only one department of the Government should be responsible upto the district level for implementing the provisions of the RBD Act. Where multiple departments are involved, inter-departmental coordination committees should ensure effective and periodic reviews to propose measures for improving registration levels and provision of registration services by drawing up a plan of action. This requires tight monitoring and supervision of the registration work at the field level.

(iii) Recognising the increasing role of local self-governance in the light of the 73^rd and 74^th Constitutional Amendments and considering the fact that quite a few States in the country have already taken initiative in this direction, the panchayats in the rural areas and Municipalities in the urban areas should gradually be given the responsibility for registration of births, deaths and marriages.

(iv) Sufficient resources should be provided to the agencies implementing the Registration of Births and Deaths (RBD) Act. The Planning Commission should provide funding to the States for this purpose. Further, to improve the availability of required forms and registers used for registration of vital events, the Central Government should bear the expenditure on this account.

(v) Regular training programmes should be organised by the States for Registration officials at all levels. The ‘Registrar’s Manual for Registration of Births and Deaths’ being prepared by RGI should be made available to all concerned, and training programmes should be conducted to impart training to all Registrars in the use of the manual.

(vi) The revamped system of registration of births and deaths in the country introduced by Registrar General of India, mainly with a view to strengthen the statistical functions of the CRS and to reduce paper work at the level of the local Registrar, by facilitating computerised data entry, easy retrieval of records and reducing storage requirements of records, should be vigorously implemented in all the States. There should be special emphasis on the monitoring and supervision of the system particularly for poorly performing States in order to enhance their performance.

(vii) Production of birth and death certificates should be encouraged for various purposes, as it will help in improving the overall registration of vital events. For example, the production of birth certificates should be made mandatory for entering the name of new-born child in the ration card, school admission, etc., and death certificates for settling insurance claims and for inheritance of property by legal heirs, in case it is not so already in any State and UT.

(viii) Considering the stated goal in the National Population Policy of 100 per cent registration of marriages by 2010, sustained efforts should be made to achieve this goal through the Civil Registration System by suitably amending the RBD Act for registration of all marriages and divorces.

(ix) Public campaigns should be launched to create awareness among the general public about the need and importance of registration of births and deaths. Also steps should be taken to improve customer services by making registration centres more visible, prompt issue of birth and death certificates, simplifying the procedure, making registration in big hospitals more efficient and proper preservation and maintenance of records of vital events.

(x) Acknowledging the fact that an efficient Civil Registration System is the lasting solution to produce a regular series of vital rates e.g., fertility, mortality, etc. specific for age, sex, and educational level upto the district and even lower levels, the ultimate goal should be to put in place the Civil Registration System in the next 10 years and to use the Sample Registration System (SRS) as a source of data for longitudinal study of the social dynamics of the country and as a means of validating the CRS data.

(xi) Recourse to Information Technology (IT) should be taken for establishment of an effective system of civil registration that would provide prompt service to the public and help in quick retrieval of information for both administrative requirements and statistical purposes. As the costs of hardware and network communications will come down in the coming years, decentralised data entry and data transmission at the Registration level should be the goal to be achieved within a few years. Sustained efforts should be made for adoption of IT in modernising the CRS. The computers provided by the Department of Family Welfare, Government of India may be utilised for this purpose as well.

B. SAMLE REGISTRATION SYSTEM

In India, the need for dependable demographic data was felt soon after independence heralding the era of five year planning. The registration of births and deaths started on voluntary basis and there was no uniformity in statistical returns resulting in both under-registration and incomplete coverage. In order to unify the civil registration activities, the Registration of Births & Deaths Act, 1969 was enacted. Despite having the registration of birth & death compulsory under the statute, the level of registration of births and deaths under the Act has continued to be far from satisfactory in several states/UTs. With a view to generate reliable and continuous data on these indicators, the Office of the Registrar General, India, initiated the scheme of sample registration of births and deaths in India popularly known as Sample Registration System (SRS) in 1964‑65 on a pilot basis and on full scale from 1969‑70. The SRS since then has been providing data on regular basis.

B.1 Objectives:

The main objective of SRS is to provide reliable estimates of birth rate, death rate and infant mortality rate at the natural division level for the rural areas and at the state level for the urban areas. Natural divisions are National Sample Survey (NSS) classified group of contiguous administrative districts with distinct geographical and other natural characteristics. It also provides data for other measures of fertility and mortality including total fertility, infant and child mortality rate at higher geographical levels.

B.2 Methodology:

The SRS in India is based on a dual record system. The field investigation under Sample Registration System consists of continuous enumeration of births and deaths in a sample of villages/urban blocks by a resident part‑time enumerator, and an independent six monthly retrospective survey by a full‑time supervisor. The data obtained through these two sources are matched. The unmatched and partially matched events are re-verified in the field to get an unduplicated count of correct events. The advantage of this procedure, in addition to elimination of errors of duplication, is that it leads to a quantitative assessment of the sources of distortion in the two sets of records making it a self‑evaluating technique.

The revision of SRS sampling frame is undertaken in every ten years based on the results of latest census. While changing the sample, modifications in the sampling design; wider representation of population; overcoming the limitations in the existing scheme; meeting the additional requirements are taken into account. The first replacement was carried out in 1977-78 and the last being in 2004. Whereas the replacement of samples in earlier years was undertaken in phases spread over 2-3 years, the replacement in 2004 was completed within a year. The following table provides the sample size in different replacement period.

Table 2.1
Number of sample units at different replacement period
Residence	1969-70	1977-78	1983-85	1993-95	2004
Rural	2432	3684	4176	4436	4433
Urban	1290	1738	1846	2235	3164
Total	3722	5422	6022	6671	7597

The earlier sample was based on the reliability of birth rate at the state level, whereas the 2004 sample is estimated using IMR and reliability at natural division level.

B.2.1 Structure of the Sample Registration System

The main components of SRS are:

(i) Base‑line survey of the sample units to obtain demographic details of the usual resident population of the sample areas;

(ii) Continuous (longitudinal) enumeration of vital events pertaining to usual resident population by the enumerator;

(iii) Independent retrospective half‑yearly surveys for recording births and deaths which occurred during the half‑year under reference and up‑dating the House list, Household schedule and the list of women in the reproductive age group along with their pregnancy status by the Supervisor;

(iv) Matching of events recorded during continuous enumeration and those listed in

course of half‑ yearly survey;

(v) Field verification of unmatched and partially matched events; and

(vi) Filling of Verbal Autopsy Forms for finalized deaths (Annexure-7)

B.2.1.1 Baseline Survey:

The base‑line survey is carried out prior to the start of continuous enumeration. This involves preparation of a notional map of the area to be surveyed, house numbering and house listing and filling‑in of a household schedule. The supervisor prepares a notional map with the help of the enumerator showing important landmarks and location of the houses to be covered in the sample unit. He then prepares a list of houses/households covered by the sample in the House List (Form-1) and fills‑in the Household Schedule (Form-2) wherein he records the residential status and other demographic particulars of each individual residing in the household viz. identification code, name, sex, date of birth, age, educational/marital status and relation to head of household, etc. The inmates of public institutions like hotels, inns, schools and hospitals are excluded, but households living permanently within the compound of such institutions are covered. A list of all women in the reproductive span along with their pregnancy status is also prepared in Form 3 at the time of the base line survey.

B.2.1.2 Continuous enumeration:

The enumerator maintains a Birth Record (Form 4) and a Death Record (Form 5) in respect of his area. The enumerator is expected to record all births and deaths occurring within the sample unit, as well as those of the usual residents occurring outside the sample unit. The events in respect of visitors occurring within the sample unit are also listed, but these are not taken into account while calculating rates. Thus, the events to be netted by the enumerator are those pertaining to: (i) usual residents inside the sample unit; (ii) usual residents outside the sample unit; (iii) inmigrants present; (iv) inmigrants absent; and (v) visitors inside the sample unit.

For ensuring complete netting, the enumerator uses different sources to get information of the occurrence of vital events in the sample unit. These include the help of the village priest, barber, village headman, midwife and such other functionaries. The enumerators maintain contact with these informants at frequent intervals and collects information about the occurrence of births and deaths. On being informed about the occurrence of an event, he visits the concerned household and records the prescribed particulars. He also keeps in touch with other socially important persons and visits local or nearby hospitals, nursing homes, cremation or burial grounds, at frequent intervals to keep himself updated about the occurrence of events. He maintains and updates a list of all women in the reproductive span along with their pregnancy status, which helps him in netting of all the births. Despite all these efforts, the enumerator may miss information about some of the events. Therefore, he is required to visit all the households once in each quarter in rural areas and once a month in urban areas, so as to ensure that all the events have been recorded.

B.2.1.3 Half‑yearly survey:

Half-yearly survey is carried out independently in each sample unit by a full‑time supervisor. The supervisor belonging to the statistical cadre of the State Census Directorates (either a Compiler or a Sr. Compiler or Statistical Investigator or any suitable official) visits each household in the sample unit and records the particulars of births and deaths in Forms 9 & 10 respectively in respect of all the usual residents and visitors (only those occurring within the sample unit) which had occurred during the half‑yearly period (January‑June or July‑December) under reference. Simultaneously, he updates the house-list, the household schedule and the pregnancy status of women by making entries of changes, if any. While carrying out this survey he does not have access to the birth and death records of the enumerator for the same periods which are withdrawn from the field before the supervisor’s visit for the half yearly survey.

B. 2.1.4 Matching:

On completion of the half‑yearly survey, the Forms 9 & 10 filled‑in by the supervisors are compared with those in the Forms 4 & 5 (filled‑in by the enumerators). This is done at the office of Directorate of Census Operations for all states except for rural areas of Kerala and Maharashtra, where it is done at the office of Directorate of Economics and Statistics of the respective states. Selected important entries in the enumerator's and supervisor's record are matched item by item and events are classified as fully matched, partially matched and unmatched. The items generally considered for matching are: Identification code of the head of Household and mother, Relationship of the mother to head, date of live birth, month in case of still birth/abortion, sex in case of live birth /still birth (for birth) and identification code of the head of household and mother in infant death, relationship of the deceased to head, date of death and sex in case of death.

B.2.1.5 Field verification of unmatched and partially matched events:

Every unmatched or partially matched event is verified by a visit to the concerned household. This is done either by a third person or jointly by the supervisor and the enumerator, depending upon the availability of staff.

B.2.2 Sample design

The Sample design adopted for SRS is a uni-stage stratified simple random sample without replacement except in stratum II (larger villages) of rural areas, where two stages stratification has been applied. In rural areas of bigger states (population with ten million or more as per Census 2001), natural division is the first geographical stratification or in rural areas of a smaller states, the stratification has been done on size of villages with villages having population less than 2,000 forming Stratum I and villages with population 2,000 or more forming Stratum II. Smaller villages with population less than 200 are excluded from the sampling frame in a manner that the total population of villages so excluded did not exceed 2 per cent of the total population of the concerned natural division in the state. The number of sample villages in each state is allocated to the substrata proportionally to their size (population). The villages within each size stratum are ordered by the female literacy rate based on the Census 2001 data, and three equal size substrata are established. The sample villages within each substratum are selected at random with equal probability. In the case of villages of Stratum 2, each sample village with a population of 2,000 or more is subdivided into two or more segments in a way that none of the segments cut across the Census Enumeration Blocks (CEBs) and the population of each segment formed by grouping the contiguous CEBs is approximately equal and do not exceed 2000. A frame of segments are prepared and selection of one segment is done at random at the second sampling stage for the SRS enumeration.

In urban areas, the categories of towns/cities have been divided into four strata based on the size classes in contrast to the six strata in the earlier sampling frame. Towns with population less than one lakh have been placed under stratum I, towns/cities with population one lakh or more but less than 5 lakhs under stratum II, towns/cities with population 5 lakh or more under stratum III and four metro cities of Delhi, Mumbai, Chennai and Kolkata as separate strata viz. stratum IV. The sampling unit in urban area is a Census Enumeration Block. The Census Enumeration Block within each size stratum is ordered by the female literacy rate based on the Census 2001 data, and three equal size substrata are established. The sample Census Enumeration Block within each substratum is selected at random with equal probability. A simple random sample of these enumeration blocks are selected within each sub-strata without replacement from each of the size classes of towns/cities in each State/Union Territory.

B.2.3 Sample size

The Infant Mortality is the decisive indicator for estimation of sample size at Natural Division, the ultimate level for estimation and dissemination of indicators for rural areas. The permissible level of error is taken as 10 prse (percentage relative standard error) at Natural Division level for rural areas and 10 prse at state level for urban areas, in respect of major states having population more than 10 million as per Census 2001. For minor states, 15 prse has been fixed at the total state level. Usually, the above criteria is followed, however, there have been a few exceptions, on account of operational constraints. Based on the above criteria, the number of units has been increased from 6671 to 7597 with 4433 in rural and 3164 in urban areas. Table 2.2 shows the number of sample units and population covered in 2005, separately for rural and urban areas of all the states and union territories.

B.3 Estimation procedure

Estimates of population, births, deaths and infant deaths for natural division in rural areas for bigger states and at state level for smaller states separately for rural/urban areas for all states/UTs are obtained using unbiased method of estimation. The estimates of birth, death and infant death rates are obtained as the ratios of the ‘estimated births to estimated population’, ‘estimated deaths to the estimated population’ and ‘estimated infant deaths to estimated births’ respectively expressed in terms of per thousand.

Table: 2.2
Number of sample units and population covered India, States and Union territories, 2005

India/States/Union territories	Number of sample units			Population covered (in'000)
India/States/Union territories	Total	Rural	Urban		Total	Rural	Urban
1	2	3	4		5	6	7
India	7,597	4,433	3,164		6,830	3,513	3,318
Bigger States
1. Andhra Pradesh	375	235	140		394	199	195
2. Assam	300	90	210		195	101	94
3. Bihar	330	200	130		334	175	159
4. Chhattisgarh	130	40	90		99	51	48
5. Delhi	200	10	190		142	77	65
6. Gujarat	365	215	150		351	181	170
7. Haryana	210	100	110		202	108	94
8. Jammu & Kashmir	260	150	110		213	111	102
9. Jharkhand	170	60	110		112	59	53
10. Karnataka	480	330	150		431	216	215
11. Kerala	250	150	100		333	161	172
12. Madhya Pradesh	340	220	120		305	159	146
13. Maharashtra	485	250	235		398	204	194
14. Orissa	405	290	115		324	163	161
15. Punjab	250	150	100		235	124	111
16. Rajasthan	350	250	100		317	166	151
17. Tamil Nadu	465	250	215		448	225	223
18. Uttar Pradesh	500	350	150		537	284	253
19. West Bengal	555	310	245		555	286	269
Smaller States
1. Arunachal Pradesh	60	45	15		30	16	15
2. Goa	85	43	42		76	38	38
3. 3. Himachal Pradesh	190	140	50		92	46	46
4. Manipur	150	110	40		129	65	64
5. Meghalaya	120	90	30		61	30	30
6. Mizoram	40	20	20		29	15	15
7. Nagaland	45	33	12		36	19	17
8. Sikkim	60	45	15		57	29	27
9. Tripura	80	60	20		102	52	50
10. Uttaranchal	150	100	50		108	56	52
Union Territories
1. Andaman & Nicobar Islands	50	34	16		33	17	16
2. Chandigarh	35	5	30		30	17	13
3. Dadra & Nagar Haveli	30	22	8		37	20	17
4. Daman & Diu	20	13	7		26	15	12
5. Lakshadweep	12	6	6		14	7	7
6. Pondicherry	50	17	33		44	22	22

Note: Rural-Urban population may not add up to total due to rounding
B.4 Organization and Supervision

From 1995, the SRS is being implemented mainly through the Directorates of Census Operations in both rural and urban areas. However, in the states of Kerala and Maharashtra the implementation of fieldwork and their monitoring for rural units has been entrusted to the Directorate of Economics & Statistics and the urban units to the Directorate of Census Operations.

For continuous enumeration, there is an enumerator for each sample unit, who is usually a anganwadi/resident teacher employed on a part‑time basis and is paid honorarium for this purpose. For supervision and conduct of half‑yearly surveys, there are full‑time supervisors at the state headquarters. One supervisor is usually assigned a set of 10 to 12 sample units for conducting half‑yearly surveys. Each state headquarters have a complement of staff necessary for planning and organizing various field operations, training of the field staff, effecting proper supervision and control, ensuring regular flow of returns from the field, forwarding of various returns to the Office of the Registrar General, India and for undertaking certain minimum tabulations.

At the national level, the Vital Statistics Division of the office of the Registrar General, India coordinates the implementation work, formulates and prescribes necessary standards, provides necessary instructions and guidance, undertakes tabulation, analysis and dissemination of data.

Supervision of the field work is an important component of SRS. This is undertaken by the supervisory level officials such as the Investigator, Assistant Director, Deputy Director, Joint Director and Director. Officers at the state headquarters undertake visits to sample units and inspect the work at the field level. Officers of Vital Statistics Division in the headquarters also undertake surprise checks and visits in SRS units for control of the quality of work.

B.5 SRS Forms and their flow

For collecting information on population and vital events various forms/schedules have been prescribed under the SRS. Depending upon various operations under the system, the following 17 types of forms are in use:

A. Baseline Survey Forms

Form 1: House List

Form 2: Household Schedule

Form 3: Pregnancy Status of women

B. Continuous Enumeration Forms

Form 4: Outcome of Pregnancy recorded by Enumerator (January‑June/July‑December)

Form 5: Deaths recorded by Enumerator (January‑June/July‑December)

Form 6: Monthly report of Outcome of Pregnancy

Form 7: Monthly report of Deaths

C. Half yearly Survey Forms

Form 9: Outcome of Pregnancy recorded by Supervisor (January‑June/July‑December)

Form 10: Deaths recorded by Supervisor (January‑June/July‑December)

Form 15: Distribution of usual resident population by age, sex and marital status

(as on 1st July/1st January)

Form 16: Distribution of Female population by broad age groups and levels of

education (as on 1st July of the year)

Form 17: Number of females who got married

by age at effective marriage (January‑June/July‑December)

D. Compilation/Tabulation Forms

Form 8: Consolidated monthly report on births and deaths

Form 11: Finalised list of Outcome of Pregnancy (January‑June/July‑December)

Form 12: Finalised list of Deaths (January‑June/July‑December)

Form 13: Results of the HYS for Outcome of Pregnancy (January‑June/July‑December)

Form 14: Results of the HYS for Deaths (January‑June/July‑December)

Every enumerator records all births and deaths events (Forms 4 and 5) on a continuous basis and retains with him for six months prior to initiation of the next half yearly surveys. He is required to send to the state headquarters in the first week of the following month a monthly report on births and deaths (Forms 6 and 7). He copies down the relevant entries of birth and death records in monthly report from six monthly records and sends to the state headquarter. On the basis of the monthly reports received from the sample units, the state headquarters are required to prepare a consolidated monthly report (Form 8) and forward the same to the Office of the Registrar General, India by the end of the following month. The monthly reports for the individual units remain at the state headquarters. The supervisor records details of each birth and death event occurring during the six-month reference period in Forms 9 and 10 respectively. After matching of each birth and death event recorded in Forms 4 and 5 with those in Forms 9 and 10 and verification of partially and unmatched events in the field, finalized forms 11 and 12 are prepared after necessary corrections and inclusion of additional events recorded during the survey. These forms are sent to the Office of the Registrar General, India along with the half‑yearly survey results in Forms 13, 14, 15, 16 and 17. Efforts are being made to computerize the entire system of period report including matching report and generation of specific tables thereon.

cHAPTER - 3

MEDICAL CERTIFICATION of Cause of DEATHs

1. Introduction:

At the national level, the Registrar General of India (RGI) is responsible for collection, collation and publication of cause of death statistics. At the state level, the Vital Statistics Division of the Directorate of Health deals with cause of death statistics. It is of vital importance to know the leading causes of deaths, as they are essential for prioritizing Public Health Initiatives and various National Health Programmes.

Medical Certification of cause of Death is an important tool of obtaining authentic & scientific information regarding causes of mortality. The Scheme is formulated by Office of the Registrar General, India is a big step towards the establishment of a system in the country for obtaining data on causes of death. The Scheme had undergone phase-wise implementation in the State, starting from medical college hospitals. In second phase, District hospitals, specialized hospitals were covered. The office of the Registrar General had given necessary administrative guidelines regarding coverage of MCCD Scheme in both urban & rural area. Attempts are being made to cover all private & govt. hospitals since 1998. A brief overview of the cause of death reporting systems in India is given below.

2. Flow of MCCD Data

Cause of death reports originate from lay reporters in rural areas and medical attendants in urban areas. The reports reach the State Vital Statistics office through the primary health centre, in case of rural areas, and the municipal health office for urban areas.

The data of MCCD flows from Hospitals/medical institutions of the notified areas to the Registrar (B&D) who has the functional jurisdiction. Thereafter it gets channelized to the District level and in turn to the o/o Chief Registrar of the concerned State for the preparation of Annual Report. The state reports will be consolidated into national level report on MCCD. A novel system of reporting of vital events is in vogue in NCT of Delhi (Area under Municipal Corporation of Delhi) wherein all registered health institutions furnish data “online” as they have been provided with unique “user-id” and “password”. This modal is likely to be replicated in other states in the future which will enhance the accuracy and reduce the time lag.

Tabulation is usually done at the state level but the statistics are published by the RGI. Until December 1998, cause of death data for the rural areas used to be collected under the Survey of Cause of Death Rural (SCD-Rural) scheme, from a sample of villages by a lay diagnosis and reporting system.

A paramedical person from the PHC is designated as the field agent who undertakes the primary survey. (S)he identifies key informants and maintains liaison with them. A household register is drawn up and updated on a half yearly basis. For each death occurring in the village, the field agent identifies one or more persons having knowledge of the circumstances of death, interviews them and records the symptoms and circumstances of death in Form-7.

A structured questionnaire is used to investigate cause of death using the symptoms and circumstances of death. The structured questionnaire is supplemented by a check list. The field agent arrives at a probable cause of death by applying the structured questionnaire to symptoms and circumstances recorded in Form-7. The check list entry against the probable cause of death is tallied with the symptoms and circumstances of death. The cause of death thus arrived is reported in Form-3. The PHC statistician is designated as the recorder of events reported by the field agent. Half-yearly verification of the household list is done by the recorder. Medical officer of the PHC is expected to check and certify the correctness of cause of death assignment by the field agent. Assignment of cause of death is done by the field agent based on a structured interview with a member of concerned household. The structured questionnaire currently in use was adopted after taking into account five years of field experience with a provisional questionnaire. The non medical list (NML) of causes of death was last revised in 1983 to correspond to ICD ninth revision (RGI, 1991). SCD-Rural used verbal autopsy (VA) to arrive at cause of deaths using paramedical personnel.

Since January 1999 a cause of death component has been added to the SRS (RGI, 1999).

Two more columns have been added to SRS Form-5 (Columns 16-17) and Form-10 (columns 12-13). The SRS part-time enumerator (PTE) records cause of death in column 16 and the code in column 17 of the revised Form-5. The SRS supervisor records similar information in columns 12 and 13 of the revised Form-10. A major departure from the SCD-Rural design is doing away with the symptom record (SCD-Rural Form-7). Another departure from the SCD-Rural is the elimination of the structured questionnaire. Instead the instructions contain a list of causes, related symptoms for some, and the corresponding ICD-10 code.In case of the urban areas, a medical certification of cause of death (MCCD) scheme is operational. This scheme has been acceded legal sanction under the Registration of Births and Deaths (RBD) Act. All medically attended deaths are expected to be registered (Form-2) along with cause of death reports in a format (Form-4) which is similar to what is prescribed by the WHO for International Classification of Cause of Death (ICD). The responsibility for reporting cause of death rests with the doctor / health care provider who last attended on the deceased. Reports are sent to the municipal health authorities, who forward them to the concerned state vital statistics office. The medical attendant is required to follow guidelines contained in the Physician's manual on medical certification of cause of death (RGI, 1992). This manual prescribed the WHO form for reporting cause of death according to the current version of ICD. Coding and tabulation is done according to the National List which is an adaptation of the ICD basic tabulation list. Since the MCCD essentially implements ICD coding and guidelines, the design of the system is considered satisfactory.

3. Characteristics of a usable cause of death reporting system:

Ruzicka and Lopez (1990) have listed five criteria used by the World Health Organisation to assess fitness of country-level cause of death data for inclusion in its compilations. Firstly, the proportion of all deaths attributed to residual categories such as "Symptoms, signs and ill defined conditions" is within limits, say less than 10%. Secondly, the proportionate distribution of deaths by cause is consistent with the estimated mortality level for that country. Thirdly, no cause of death with a clear age-sex dependency has been incorrectly assigned. Fourthly, the age-sex distribution for major causes is consistent with what one may expect for each cause. Finally, data generated by the system are consistent with previous years. Note that these are basically plausibility checks. A data set failing these criteria is more likely to be biased. A data set satisfying these criteria may still not be usable, on account of poor statistical power of the generated estimates, and biases that are not readily noticeable.

4. Statutory Frame-work

The scheme on Medical Certification of Cause of Death (MCCD) being implemented by the office of the Registrar General, India aims to provide a reliable database for generating mortality statistics, which forms an integral part of the vital statistics system. Statistics on causes of death is obtained through the Civil Registration System under the Registration of Births and Deaths Act, 1969. Section 10(2) empowers the states to implement this scheme in any given area while taking into account the level of health infrastructure where as Section 10(3) of the Registration of Births & Death Act, 1969 fixes the onus for the issuance of a certificate as to the cause of death on the medical practitioners who attended the deceased at the time of death. However, the Act provides for maintaining the confidentiality of individual information by forbidding its disclosure under section 17(1).

The scheme of Medical Certification of Cause of Death is being implemented in most of States/UTs in a phased manner to provide reliable data on cause of death. The Offices of the Chief Registrar of Births and Deaths are tabulating data on MCCD in conformity with the International Classification of Diseases (ICD)-Tenth Revision. The statistical report generated by analysis of the data collected is published in the annual publication ‘Medication Certification of Cause of Death’.

5. Level of Registration of COD

The quality of mortality data and the reliability of cause analysis in respect of medically certified deaths, to a great extent, depend on the level of registration of deaths. The current level of registration of births and deaths in the country is far from complete. Continuous efforts are being made by the Office of the Registrar General, India to bring about improvements in the system.

The proportion of medically certified Deaths in the total deaths is highly un-even among states of India. During the year 2000 it varied from as high as 94%in the state of Goa to a very low of less than 1% in case of the state of Utter Pradesh. Scheme implementation as per the Sample Registration Scheme (SRS) estimates, implemented by Registrar General of India, the level of death registration in the country is about 50%. Further, the proportion of medically certified deaths is abysmally low of 14.5% during the year 2000. The time series data for the years 1998-2000 is presented in the table 3.1. The diagrammatic presentation also gives the status of level of registration in the country in a vivid manner.

Table 3.1: Profile of Death Registration in India

Year	Number of Registered Deaths	Crude Death Rate (per1000 population)	Level of Death Registration	Medically Certified Deaths	% of Medically Certified Deaths to Total
1998	3,353,703	9.0	49.7	498586	14.9
1999	3,603,741	8.7	51.8	488619	13.6
2000	3,528,338	8.5	49.8	510580	14.5

6. Medical Certification of Cause of Death

During the year 2000, the total number of 510580 medically certified deaths were registered in India under the civil registration system. The cause analysis revealed that about 73.33% of the total medically certified deaths that has taken place in the year 2000 were under five major causes viz. Diseases of the circulatory system (I00-I99)(24.34%), Infectious and Parasitic Diseases (A00-B99)(15.72%), Symptoms, Signs and abnormal clinical & Laboratory finding not elsewhere classified (R00-R99)(14.21%), Injury, poisoning and certain other consequences of external causes (S00-T98)(11.28%), Certain conditions originating in the prenatal period (P00-P96)(7.79%) and the remaining 26.66% certified deaths were classified under the other causes. The MCCD data in terms of 19 major categories for the years 1998-2000 is presented in table 3.2 gender-wise.

Table 4.2 : Level of registration of deaths - States/Union territories, 1996-2004

	India/State/Union	Level of registration of deaths
	Territories	1996	1997	1998	1999	2000	2001	2002	2003	2004

	India	47.3	46.3	49.7	51.8	49.8	51.7	54.1	56.8	58.1
	Total¹	51.9	56.6	61.8	59.8	55.4	59.4	62.3	62.5	65.9

	States
1.	Andhra Pradesh	34.8	34.0	40.0	37.6	56.7	57.8	58.9	59.8	67.7
2.	Arunachal Pradesh	30.6	27.5	26.1	28.4	23.1	28.7	n.a.	n.a.	n.a.
3.	Assam²	10.2	14.1	11.9	20.7	20.1	na	n.a.	28.2	n.a.
4.	Bihar³	18.0	na	na	na	9.4	11.0	12.0	13.5	18.1
5.	Chhattisgarh⁴	--I.i Madhya Pradesh--			70.0	66.1	66.6	72.8	72.6	75.7
6.	Goa⁶	104.5	95.7	100.5	108.0	100.5	100.3	n.a.	n.a.	n.a.
7.	Gujarat	69.9	65.1	59.6	54.8	60.4	62.9	58.3	64.3	74.3
8.	Haryana	71.4	67.5	72.8	73.1	72.2	70.6	75.5	81.1	83.0
9.	Himachal Pradesh	60.7	61.6	66.1	72.5	74.3	80.7	77.1	84.3	84.5
10.	Jammu & Kashmir	nc	nc	72.8	61.7	49.5	41.0	48.7	49.5	50.4
11.	Jharkhand⁴	---------I.i Bihar-----------			23.0	22.8	23.8	29.4	32.6	34.7
12.	Karnataka	90.1	92.4	93.5	87.5	86.4	90.7	91.8	91.7	90.3
13.	Kerala⁶	90.4	86.7	93.0	92.8	88.1	86.4	89.5	100.2	99.5
14.	Madhya Pradesh	58.6	53.8	59.2	53.6	48.1	47.9	49.4	52.4	52.0
15.	Maharashtra	69.3	62.5	72.3	68.1	71.5	72.4	78.1	83.2	84.1
16.	Manipur	19.7	17.0	24.0	26.1	25.3	23.0	43.6	33.3	42.3
17.	Meghalaya	37.5	41.9	45.5	43.5	51.6	38.7	47.8	49.4	n.a.
18.	Mizoram⁶	99.5	82.1	73.1	80.9	77.7	103.0	101.4	100.5	96.7
19.	Nagaland	nc	nc	nc	nc	nc	nc	n.c.	n.c.	78.8
20.	Orissa	58.5	58.2	64.8	63.8	61.4	61.6	67.1	67.6	64.1
21.	Punjab	87.9	86.7	84.8	88.6	82.5	89.3	87.6	93.3	91.9
22.	Rajasthan	28.6	32.8	42.5	42.7	45.6	55.1	62.4	59.1	70.4
23.	Sikkim	15.0	19.1	35.4	36.6	41.4	54.9	74.9	92.1	88.5
24.	Tamil Nadu	78.3	78.2	78.4	78.5	73.0	80.8	82.9	86.7	84.8
25.	Tripura	37.1	40.6	42.4	37.0	64.9	75.1	49.5	62.6	75.8
26.	Uttar Pradesh⁵	na	na	na	na	na	na	n.a.	n.a.	n.a.
27.	Uttaranchal^4,5	--- I.i Uttar Pradesh---			na	na	na	n.a.	n.a.	37.9
28.	West Bengal	30.3	33.2	38.7	54.0	53.4	56.2	59.3	59.1	58.0

	Union territories
1.	A. N. Islands6	70.4	64.5	73.2	57.3	61.9	73.3	71.2	72.3	110.0
2.	Chandigarh⁶	209.8	214.2	236.1	231.9	238.7	264.4	293.3	261.7	321.8
3.	Dadra & Nagar Haveli	62.0	59.7	63.2	57.3	56.1	60.3	56.9	77.5	82.1
4.	Daman & Diu⁶	77.6	118.9	85.7	98.2	85.4	83.0	79.9	76.6	80.5
5.	Delhi⁶	115.0	109.3	121.2	126.3	116.3	114.0	117.2	n.a.	118.9
6.	Lakshadweep	79.4	80.6	84.7	81.9	85.3	93.1	95.0	99.8	64.9
7.	Pondicherry⁶	125.7	108.3	113.9	122.8	136.3	133.3	144.3	153.8	119.1
	Notes:
	1. Total refers to the States/Union territories for which data are available for respective year
	2. The report of Assam for the year 1996 is based on only 16 out of 23 districts.
	3. The report of Bihar for the year 1996 is based on only 36 out of 54 districts.
	4. Newly formed states. The SRS rates for these three newly formed states are estimated
	for the year 1999 and hence the level of registration also.
	5. Complete and reliable information is not available
	6. Includes delayed registration,death occuring to outside residents of states/UT's
	na : Data not available; nc : Not calculated as the SRS rates are not available

Table 4.3: States Classified by Levels of Registration

Level of Registration (Per cent)

EVENT

Birth

Death

Above 80

Arunachal Pradesh, Goa, Gujarat, Haryana, Himachal Pradesh, Karnataka, Kerala, Maharashtra, Mizoram, Nagaland, Orissa, Punjab, Sikkim, Tamil Nadu, Tripura, West Bengal, A&N Islands, Chandigarh, Daman & Diu, Delhi and Pondicherry.

(16 States and 5 UTs)

Goa, Haryana, Himachal Pradesh, Karnataka, Kerala, Maharashtra, Mizoram, Punjab, Sikkim, Tamil Nadu, A & N Islands, Chandigarh, Dadra & Nagar Haveli, Daman & Diu, Delhi and Pondicherry.

(10 States and 6 UTs)

60-80

Andhra Pradesh, Jammu & Kashmir, Manipur, Uttaranchal, Dadra & Nagar Haveli and Lakshadweep

(4 States & 2UTs)

Andhra Pradesh, Chhattisgarh, Gujarat, Nagaland Orissa, Rajasthan, Tripura and Lakshadweep

(7 States and 1 UT)

40-60

Assam, Chhattisgarh, Madhya Pradesh, Meghalaya and Rajasthan

(4 States)

Jammu & Kashmir, Madhya Pradesh, Manipur, Meghalaya and West Bengal

(5 States)

Below 40

Bihar, Jharkhand and Uttar Pradesh

(3 States)

Arunachal Pradesh, Assam, Bihar, Jharkhand, Uttar Pradesh and Uttaranchal

(6 States)

Source: Office of Registrar General and Census Commissioner, India

8. Level of public awareness and enforcement

The current level of registration of births and deaths in the country is far from complete. Continuous efforts are being made by the Office of the Registrar General, India to bring about improvements in the system. Various activities pursued during1999-2000 to achieve the goal are given below:

Large-scale publicity measures have been launched to create awareness among general public about the importance of registration of births and deaths and the procedure for registration. For this various media like television, radio, postal stationery, cinema slides, video film, etc., have been utilised. Efforts have been made to reach directly to the rural masses by distributing the stickers in the schools in rural areas. Video and audio spots in different language are also being produced for publicity through Doordarshan and All India Radio.

The states of Andhra Pradesh, Assam, Bihar, Rajasthan and Uttar Pradesh are having the lowest level of registration in the country. The Registrar General, India held a review meeting exclusively with the Chief Registrars of Births and Deaths in these states for accelerated improvement in the registration of births and deaths.

To facilitate easy registration and ensure quicker flow of records from registration centres to state and national level tabulation offices forms and procedure for registration have been simplified for adoption from January 1, 2000. The computation capacity in these centres is also being enhanced.

One of the main causes of low level registration is the lack of awareness about the need, importance and benefits of registration and the procedure thereof among the general public and also lack of procedural knowledge among the registration functionaries across all levels, particularly at the lower level.

In order to create awareness, the Office of the Registrar General, India has been undertaking several publicity measures, which include -

Ø release of advertisements on Birth / Death registration through the electronic media, viz., Doordarshan, Private T.V., and All India Radio

Ø release of advertisements on Birth / Death registration through the mass print media, viz., leading local newspapers during school admission time and on special occasions (Children’s Day, Independence Day, Republic Day, World Population Day, State Formation Day, etc)

Ø publicity through conventional modes, viz., hoardings, wall hangers, wall paintings, calendars, paintings on public utilities, pamphlets, posters, Meghdoot postcards

Ø publicity targeting school children through supply of name label stickers to be used on note-books & text books/school bags/geometry boxes/foot rules bearing civil registration messages / slogans, spread of messages on civil registration in the students’ assembly, prayers and other congregations, quiz contests for children, etc.

The National Population Policy, 2000 has set the goal of achieving cent per cent registration by the year 2010. This is a national endeavour. The Ministries of Health and Women & Child Development shall also play important role in this endeavour to create awareness among the general public about the need and importance of registration by including the civil registration slogans in their health-related advertisements like Pulse Polio, HIV/AIDS, Dengue, etc., which have a wider reach among the people. Besides, these Ministries can think of re-defining the role of Aanganwadi Workers / Health workers / ANMs/ASHA, who are in constant touch with the rural masses. Their services could be utilized in educating the rural masses, especially the expectant mothers and mothers whose post-natal care are attended to by them. The Aanganwadi centre is another point where the Aanganwadi Workers come into contact with children till they go to regular school. These functionaries can also act as interface between the local Registrar of Births & Deaths and the local people and ensure registration of all birth and death events, institutional as well as domiciliary, and issuance of birth/death certificates.

9. Recommendations

The present system of data collection through the Ministry of Health and Family Welfare, through MCCD or surveys conducted by RGI and NFHS on morbidity and mortality are unable to meet the data requirements of public health planners, medical scientists, epidemiologists and researchers. Further, there are hardly any estimates available at the district and below level, which is a serious handicap in planning the preventive action at these levels. The Commission strongly feels that the situation needs to be corrected by taking necessary interventions and recommends:

(i) There should be periodic sample surveys of households on morbidity in the country, by trained investigators taking in to account the seasonal variations in diseases. These data should be analysed as quickly as possible and the morbidity patterns in the country should be published regularly. The National Statistical System should bring out regularly the morbidity and mortality patterns in the different age groups at least at the district/regional levels including for the diseases like T.B. and AIDS.

(ii) The morbidity and mortality surveys should be conducted in two stages. While at the first stage, the data could be collected on a fairly large sample; at the second stage, data from a sub-sample may be collected and verified by trained medical functionaries on certain specific aspects like causes of death, maternal mortality audit, etc.

(iii) As recommended by the Khusro Committee, the quality of data on infant, child mortality and maternal mortality can be greatly improved by conducting comprehensive sample surveys of pregnant women and by a follow up of these over one or more years after childbirth. Such surveys can be conducted on a small scale at local levels.

(iv) There should be a procedure for medical certification of the cause of death to be implemented at least on a sample basis throughout the country regularly, in order to have a better understanding of the causes or factors underlying deaths in the country. The death records should include symptom-based information on the possible cause of death.

(v) The scheme of Medical Certification of Cause of Death (MCCD) envisaged under the Registration of Births and Deaths Act, 1969 should be strengthened. The State Governments should attach a high priority to the implementation of this scheme both in the rural and urban areas. There should be a system for prompt reporting of deaths due to certain diseases, like cholera, polio, malaria, diphtheria, etc. so that immediate preventive and curative measures can be taken.

(vi) The statistical system in all hospitals, nursing homes and other treatment facilities and dispensaries including those in the private sector should necessarily include certain basic information on each patient and this information in prescribed formats should flow to Health Statistical System within a fixed time frame. Computerisation of birth, morbidity and mortality records should be done in phases and should be coded with ICD-10 codes to facilitate processing.

CHAPTER – 5

ESTIMATES OF MORTALITY INDICATORS

Mortality is one of the basic components of population change and essential for demographic studies and public health administration. It is the principal ingredient for population projections and life tables. Information on death events recorded in SRS is used to estimate mortality indicators. The various measures of mortality are Crude Death Rate (CDR), Infant Mortality Rate (IMR) and its components, Age Specific Mortality Rates (ASMR), Still Birth Rate (SBR) and Peri-Natal Mortality Rate (PMR).

SRS has continued to provide data for estimating various mortality measures since its inception. The crude death rate (CDR) at all India level has declined significantly from 14.9 to 12.5 during 1971 to 1981 and thereafter from 9.8 to 7.6 during 1991 to 2005. The decline has been steeper in rural areas as compared to urban areas. The infant mortality rate, which plays an important role in health planning, has shown a considerable decline from 129 per 1000 live births in 1971 to 110 in 1981 and from 80 in 1991 to 58 in 2005. The child mortality rate has depicted a perceptible decline from 51.9 in 1971 to 41.2 in 1981 and from 26.5 in 1991 to 17.3 in 2005. In 2005, slightly more than one-fourth of the deaths were institutional and three-fourth received medical attention other than institution.

Apart from the all India scenario, this chapter presents data on mortality indicators for bigger states by sex, residence and broad age groups. It includes data on infant mortality and its component viz., neo-natal mortality and post neo-natal, peri-natal mortality and their changes over the last decade. It also includes data on medical attention before death.

Apart from the mortality indicators at state and national levels, the SRS sample from 2004 onwards also provides estimates of death rates at sub-state, viz. NSSO Natural Division Level in rural areas. NSSO natural divisions have been formed taking into consideration the geography of the state and by grouping continuous districts having similar topography, population density, cropping pattern and rainfall etc. The Table at annexure-6 of this report contains data on death rate and infant mortality rate besides birth for 56 Natural Divisions of bigger states. The Table also contains data on death rate and infant mortality rate besides birth death for four metro cities viz. Chennai, Delhi, Kolkata and Mumbai.

Table 5.1
CDR (Crude death rates) by residence, India and bigger states, 2005

India and bigger states	Total	Rural	Urban
India	7.6	8.1	6.0

Andhra Pradesh	7.3	7.9	5.9
Assam	8.7	9.2	5.6
Bihar	8.1	8.3	6.6
Chhattisgarh	8.1	8.4	6.9
Delhi	4.6	5.5	4.5

Gujarat	7.1	8.0	5.8
Haryana	6.7	7.0	5.8
Himachal Pradesh	6.9	7.1	4.7
Jammu & Kashmir	5.5	5.7	5.0
Jharkhand	7.9	8.4	5.7

Karnataka	7.1	7.9	5.6
Kerala	6.4	6.3	6.5
Madhya Pradesh	9.0	9.8	6.1
Maharashtra	6.7	7.4	5.7
Orissa	9.5	9.9	7.0

Punjab	6.7	7.2	5.8
Rajasthan	7.0	7.2	6.2
Tamil Nadu	7.4	8.2	6.2
Uttar Pradesh	8.7	9.1	6.8
West Bengal	6.4	6.3	6.6

Crude Death Rate (Table 5.1) at the national level for 2005 was 7.6 per thousand populations and it varies from 8.1in rural areas to 6.0 in urban areas. Among the bigger states it varies from 4.6 in Delhi to 9.5 in Orissa. The states having death rate higher than national level are Assam (8.7), Bihar (8.1), Chhattisgarh (8.1), Jharkhand (7.9), Madhya Pradesh (9.0), Orissa (9.5) and Uttar Pradesh (8.7).

Table 5.2 given below shows the percentage change in the level of crude death rate between the period 1993-95 and 2003-05 for India and bigger states. During this period crude death rate in India has declined by 16.3 per cent. Among the bigger states, decline in crude death rate varies from only 23.8 per cent in Bihar to 7.4 per cent in Tamil Nadu. In Kerala, average crude death rate have shown marginal increase during 1993-95 to 2003-05 period, which could be possibly due to the changes in age structure of the population.

Table 5.2

Percent change in average crude death rate between 1993-95 and 2003-2005, by residence, India and bigger states

India and bigger states	Total			Rural			Urban
	1993-95	2003-05	% Change	1993-95	2003-05	% Change	1993-95	2003-05	% Change

India	9.2	7.7	-16.3	10.2	8.3	-18.6	6.4	5.9	-7.8

Andhra Pradesh	8.4	7.4	-11.9	9.3	8.2	-11.8	6.0	5.4	-10.0
Assam	9.7	8.9	-8.2	10.0	9.3	-7.0	6.9	5.7	-17.4
Bihar*	10.5	8.0	-23.8	11.0	8.3	-24.5	6.5	5.8	-10.8
Gujarat	8.2	7.2	-12.2	8.9	8.0	-10.1	6.6	5.9	-10.6
Haryana	8.0	6.8	-15.0	8.5	7.1	-16.5	6.7	5.9	-11.9
Himachal Pradesh	8.6	6.9	-19.8	8.9	7.1	-20.2	5.8	4.7	-19.0
Karnataka	8.0	7.1	-11.3	9.1	7.8	-14.3	5.6	5.5	-1.8
Kerala	6.0	6.3	5.0	6.0	6.2	3.3	6.1	6.3	3.3
Madhya Pradesh*	11.8	9.0	-23.7	12.8	9.8	-23.4	7.7	6.6	-14.3
Maharashtra	7.4	6.7	-9.5	9.1	7.5	-17.6	5.3	5.6	5.7
Orissa	11.4	9.6	-15.8	12.0	10.0	-16.7	6.9	6.8	-1.4
Punjab	7.6	6.7	-11.8	8.3	7.1	-14.5	6.0	5.8	-3.3
Rajasthan	9.1	7.2	-20.9	9.7	7.5	-22.7	6.6	6.2	-6.1
Tamil Nadu	8.1	7.5	-7.4	9.1	8.3	-8.8	6.2	6.2	0.0
Uttar Pradesh*	11.0	8.8	-20.0	11.6	9.5	-18.1	8.0	6.3	-21.3
West Bengal	7.9	6.4	-19.0	8.5	6.5	-23.5	6.2	6.3	1.6

* Bihar includes Jharkahand, Madhya Pradesh includes Chhattisgarh and Uttar Pradesh includes Uttaranchal.

Table 5.3 given below presents the estimated crude death rate for India by residence separately for males and females. It is observed that, compared to males, death rate for females is lower in both rural and urban areas.

Table 5.3
Crude death rates by sex and residence, India, 2005
Residence	Total	Males	Females

Total	7.6	8.0	7.1
Rural	8.1	8.5	7.7
Urban	6.0	6.5	5.5

Crude death rates for males and females in the bigger states are shown below in Table 5.4. It is observed that male death rate exceeds female death rate in all bigger states.

Table 5.4
Crude death rates by sex, India and bigger states, 2005
India and bigger states	Total	Males	Females
India	7.6	8.0	7.1

Andhra Pradesh	7.3	7.7	6.9
Assam	8.7	9.3	7.9
Bihar	8.1	8.2	8.0
Chhattisgarh	8.1	8.6	7.6
Delhi	4.6	4.7	4.6
Gujarat	7.1	7.6	6.6
Haryana	6.7	7.0	6.3
Himachal Pradesh	6.9	7.6	6.1
Jammu & Kashmir	5.5	5.8	5.3
Jharkhand	7.9	7.9	7.8
Karnataka	7.1	7.6	6.6
Kerala	6.4	7.6	5.2
Madhya Pradesh	9.0	9.2	8.6
Maharashtra	6.7	7.4	5.9
Orissa	9.5	10.1	8.8
Punjab	6.7	7.2	6.1
Rajasthan	7.0	7.0	6.9
Tamil Nadu	7.4	8.0	6.7
Uttar Pradesh	8.7	8.8	8.6
West Bengal	6.4	7.0	5.7

Table 5.5 given below provides the per cent distribution of deaths by broad age groups for India and bigger states. At the national level 18.5 per cent of the deaths were infant deaths (0-1 year) whereas 42.8 per cent of the deaths occurred to persons aged 60 years and above. Toddlers (1-4 years) accounted for 5.4 per cent of the deaths. The percentage of infant deaths to total deaths varied from a low 3.4 per cent in Kerala to a high of 27.8 per cent in Rajasthan. Percentage contribution of deaths from person’s 60 years and above varied from 34.4 in Madhya Pradesh to 69.5 in Kerala. The percent distributions of deaths to total deaths by residence, sex and age-group at the national level and for the bigger states are given in (annexure-5).

Table 5.5

Per cent distribution of deaths by broad age groups, India and bigger states, 2005

India and bigger states	Broad age-groups
	<1	1-4	0-4	5-14	15-59	60+

India	18.5	5.4	23.8	4.1	29.3	42.8

Andhra Pradesh	14.8	2.3	17.2	2.6	35.9	44.4
Assam	19.6	4.8	24.4	4.8	35.6	35.2
Bihar	22.9	9.5	32.5	6.8	24.7	36.0
Chhattisgarh	21.3	8.3	29.6	4.7	27.7	38.0
Delhi	14.0	4.1	18.1	2.7	34.9	44.3

Gujarat	17.8	4.4	22.2	3.2	30.6	43.9
Haryana	21.7	4.0	25.8	2.8	26.7	44.7
Himachal Pradesh	15.5	2.8	18.3	1.1	28.3	52.3
Jammu & Kashmir	17.3	3.0	20.3	3.5	26.1	50.1
Jharkhand	17.1	7.8	25.0	7.3	31.5	36.2

Karnataka	14.5	1.9	16.3	1.9	34.5	47.3
Kerala	3.4	0.9	4.3	1.1	25.1	69.5
Madhya Pradesh	24.8	7.1	31.9	5.5	28.2	34.4
Maharashtra	10.1	2.3	12.4	2.5	32.8	52.3
Orissa	17.8	4.9	22.7	3.8	28.8	44.8

Punjab	12.0	2.8	14.8	1.9	28.6	54.6
Rajasthan	27.8	7.1	35.0	4.3	23.9	36.8
Tamil Nadu	8.3	1.2	9.5	1.8	33.4	55.2
Uttar Pradesh	25.6	8.4	34.0	5.5	25.1	35.3
West Bengal	11.4	3.1	14.5	3.5	31.8	50.2

Note: Total may not add upto 100 due to rounding.

The percent share of infant deaths to total deaths by residence is shown below in Table 5.6 for India and bigger states. At the national level, such share in the year 2005 was 18.5 per cent and varied from 20.1 per cent in rural areas to 12.6 per cent in urban areas. In rural areas, Kerala registered 3.6, the lowest per cent share of infant deaths as compared to 31.1 in Rajasthan. In urban areas the variation was from 2.7 per cent in Kerala to 20.9 per cent in Uttar Pradesh.

Table 5.6

Percentage of infant deaths to total deaths by residence India and bigger states, 2005

India and bigger states	Total	Rural	Urban

India	18.5	20.1	12.6

Andhra Pradesh	14.8	16.0	11.1
Assam	19.6	20.5	10.6
Bihar	22.9	23.5	17.1
Chhattisgarh	21.3	22.6	14.9
Delhi	14.0	15.1	13.8

Gujarat	17.8	19.9	13.3
Haryana	21.7	23.7	16.3
Himachal Pradesh	15.5	16.1	8.1
Jammu & Kashmir	17.3	18.9	11.1
Jharkhand	17.1	18.2	10.8

Karnataka	14.5	15.2	12.5
Kerala	3.4	3.6	2.7
Madhya Pradesh	24.8	25.8	19.6
Maharashtra	10.1	10.9	8.7
Orissa	17.8	18.3	12.8

Punjab	12.0	12.6	10.7
Rajasthan	27.8	31.1	16.3
Tamil Nadu	8.3	8.0	8.8
Uttar Pradesh	25.6	26.4	20.9
West Bengal	11.4	13.5	6.0

Table 5.7 given below presents IMR by sex and residence for the year 2005 for India and bigger states. Infant Mortality Rate (IMR) is defined as the infant deaths (less than one year) per thousand live births. At the national level IMR was reported to be 58 and varied from 64 in rural areas to 40 in urban areas. Among the bigger states, it varied from 14 in Kerala to 76 in Madhya Pradesh. Female infants experienced a higher mortality than male infants in all states. Chart 20 provides the values of IMR by residence for India and bigger states. On account of limited deaths there can be some distortion in gender infant mortality rates.

Table 5.7

Infant mortality rates by sex and residence, India and bigger states, 2005

India and bigger states	Total			Rural			Urban
India and bigger states	Total	Males	Females	Total	Males	Females	Total	Males	Females

India	58	56	61	64	62	66	40	37	43

Andhra Pradesh	57	56	58	63	62	64	39	38	40
Assam	68	66	69	71	69	72	39	36	43
Bihar	61	60	62	62	61	63	47	45	50
Chhattisgarh	63	63	64	65	65	66	52	49	55
Delhi	35	33	37	44	50	36	33	30	37

Gujarat	54	52	55	63	61	64	37	36	38
Haryana	60	51	70	64	55	76	45	40	52
Himachal Pradesh	49	47	51	53	48	53	20	27	14
Jammu & Kashmir	50	47	55	53	49	58	39	36	43
Jharkhand	50	43	58	53	45	62	33	31	35

Karnataka	50	48	51	54	54	55	39	37	42
Kerala	14	14	15	15	15	16	12	11	14
Madhya Pradesh	76	72	79	80	77	84	54	52	56
Maharashtra	36	34	37	41	40	42	27	25	29
Orissa	75	74	77	78	77	79	55	50	61

Punjab	44	41	48	49	46	51	37	32	43
Rajasthan	68	64	72	75	71	79	43	37	49
Tamil Nadu	37	35	39	39	38	40	34	30	39
Uttar Pradesh	73	71	75	77	75	79	54	53	55
West Bengal	38	38	39	40	40	40	31	28	35

The percentage change in the average level of infant mortality between 1993-95 and 2003-05 is given below in Table 5.8. During this period IMR, at the national level, declined by 20.7 per cent. Among the bigger states the decline varied from 30.4 per cent in West Bengal to 10.7 per cent in Andhra Pradesh. In the rural areas decline in IMR varied from 33.5 per cent in Maharashtra to 6.5 per cent in Gujarat. The decline in IMR varied from 42.6 per cent in Assam to 6.1 per cent in Punjab in urban areas.

Table 5.8
Per cent change in average infant mortality rates between 1993-95 and 2003-2005 by residence, India and bigger states
India and Bigger states	Total			Rural			Urban
	1993-95	2003-05	% Change	1993-95	2003-05	% Change	1993-95	2003-05	% Change
	1993-95	2003-05	% Change	1993-95	2003-05	% Change	1993-95	2003-05	% Change
India	74.0	58.7	-20.7	80.7	64.7	-19.8	48.3	39.3	-18.6
Andhra Pradesh	65.3	58.3	-10.7	71.0	65.0	-8.5	47.0	37.0	-21.3
Assam	78.7	67.0	-14.9	80.0	70.0	-12.5	65.0	37.3	-42.6
Bihar*	70.0	57.1	-18.4	71.7	58.8	-18.0	53.0	41.7	-21.3
Gujarat	61.3	54.7	-10.8	67.7	63.3	-6.5	46.7	37.0	-20.8
Haryana	68.3	60.0	-12.2	70.0	63.7	-9.0	62.0	47.0	-24.2
Himachal Pradesh	61.7	49.7	-19.4	63.0	51.3	-18.6	39.3	23.0	-41.5
Karnataka	65.3	50.3	-23.0	73.7	56.3	-23.6	45.0	33.7	-25.1
Kerala	14.7	12.3	-16.3	15.7	13.3	-15.3	11.7	10.3	-12.0
Madhya Pradesh*	101.0	74.3	-26.4	107.3	79.0	-26.4	61.7	53.1	-13.9
Maharashtra	53.3	38.0	-28.7	65.7	43.7	-33.5	34.7	28.7	-17.3
Orissa	105.3	78.3	-25.6	110.0	81.3	-26.1	66.3	56.0	-15.5
Punjab	54.0	46.0	-14.8	59.0	50.7	-14.1	38.0	35.7	-6.1
Rajasthan	84.0	70.0	-16.7	88.3	75.7	-14.3	59.3	46.0	-22.4
Tamil Nadu	56.3	40.3	-28.4	63.7	44.0	-30.9	41.7	33.3	-20.1
Uttar Pradesh*	89.3	71.8	-19.6	92.7	76.4	-17.6	66.0	49.7	-24.7
West Bengal	59.3	41.3	-30.4	63.0	43.3	-31.3	43.3	32.3	-25.4
* Bihar includes Jharkahand, Madhya Pradesh includes Chhattisgarh and Uttar Pradesh includes Uttaranchal.

Table 5.9 given below presents the neo-natal (less than 29 days) mortality rate and the percentage of neo‑natal deaths to infant deaths for the year 2005 both at the national and state levels. At the national level, the neo‑natal mortality rate was 37 and ranged from 23 in urban areas to 41 in rural areas. Among the bigger states neo‑natal mortality ranges from 53 in Orissa to 11 in Kerala. The percentage of neo‑natal deaths to total infant deaths was 62.9 per cent at the national level and varied from 58.2 per cent in urban areas to 63.7 per cent in rural areas. Among the bigger states West Bengal (76.8) registered the highest percentage of neo‑natal deaths to infant deaths and the lowest in Assam (49.2).

Table 5.9

Neo-natal mortality rates and percentage share of neo-natal deaths to infant deaths by residence, India and bigger states, 2005

India and Bigger states	Neo-natal mortality rate			Percentage of Neo-natal death to infant deaths
	Total	Rural	Urban	Total	Rural	Urban

India	37	41	23	62.9	63.7	58.2

Andhra Pradesh	35	43	11	61.1	68.0	28.7
Assam	33	35	18	49.2	49.4	45.5
Bihar	32	34	18	53.1	54.2	37.5
Chhattisgarh	45	46	36	70.3	70.5	68.5
Delhi	20	17	21	57.5	38.0	62.0

Gujarat	36	40	27	66.3	63.9	74.1
Haryana	35	38	27	58.7	58.3	60.3
Himachal Pradesh	33	35	14	62.4	62.9	50.0
Jammu & Kashmir	36	37	31	71.6	70.4	80.3
Jharkhand	28	30	16	56.2	57.0	48.3

Karnataka	28	34	15	56.9	62.8	38.1
Kerala	11	11	10	75.9	74.3	81.9
Madhya Pradesh	51	54	36	67.0	67.1	66.8
Maharashtra	25	30	19	70.8	71.9	68.3
Orissa	53	56	32	70.6	71.6	58.7

Punjab	30	33	23	67.3	68.9	63.5
Rajasthan	43	47	25	63.0	63.7	58.8
Tamil Nadu	26	31	19	70.9	80.7	54.9
Uttar Pradesh	45	48	33	61.6	61.7	61.4
West Bengal	30	32	20	76.8	79.1	64.0

Early neo-natal mortality rate viz. number of infant deaths less than seven days of life per thousand live births forms an important component of infant mortality rate and more specifically of the neo-natal mortality rate. Table 5.10 given below presents the early neo-natal mortality rate along with the percentage of early neo-natal deaths to the total infant deaths. At the national level the early neo-natal mortality rate for the year 2005 has been estimated at 28 and ranges from 31 in rural areas to 16 in urban areas. Among the bigger states Kerala (9) and Orissa (41) were the two extremes. The percentage of early neo-natal deaths to the total infant deaths during the year 2005, at the national level, has been 47.6 and it varied from 49.0 in rural area to 39.6 in urban areas. In most of the states rural proportion is relatively higher than the urban proportion. Among the bigger states the percentage for total, varied from 34.7 in Himachal Pradesh to 60.5 in Kerala.

Table 5.10

Early neo-natal mortality rates and percentage share of early neo-natal deaths to infant deaths by residence, India and bigger states, 2005

India and Bigger states	Early neo-natal mortality rate			Percentage of Early neo-natal deaths to infant deaths
	Total	Rural	Urban	Total	Rural	Urban

India	28	31	16	47.6	49.0	39.6

Andhra Pradesh	26	32	8	46.1	51.3	21.5
Assam	25	27	10	37.5	38.2	25.7
Bihar	28	29	13	45.7	46.9	27.8
Chhattisgarh	36	38	25	57.1	58.2	48.7
Delhi	16	10	17	45.0	22.8	50.1

Gujarat	28	31	21	51.4	49.4	57.8
Haryana	24	28	11	39.9	43.5	25.1
Himachal Pradesh	19	19	11	34.7	34.5	39.9
Jammu & Kashmir	29	31	18	57.4	58.8	47.4
Jharkhand	22	24	12	44.6	45.5	36.1

Karnataka	23	27	13	46.1	50.3	32.7
Kerala	9	8	10	60.5	55.1	81.9
Madhya Pradesh	38	40	28	49.8	49.5	51.9
Maharashtra	20	23	15	55.2	54.9	55.9
Orissa	41	44	15	54.7	57.0	27.6

Punjab	18	24	8	41.3	49.4	22.2
Rajasthan	33	38	16	49.1	50.8	37.3
Tamil Nadu	19	23	13	51.3	59.8	37.5
Uttar Pradesh	32	35	18	43.8	45.1	34.1
West Bengal	23	25	14	59.7	62.1	46.0

Table 5.11 given below presents the peri‑natal mortality rate and still birth rate for the year 2005, by residence, for India and bigger states. Peri-natal mortality rate (PMR) is defined as the number of still births together with infant deaths of less than 7 days per one thousand live births (LB) and still births (SB) during the year. The still birth rate (SBR) is estimated as the ratio of the number of still births per one thousand live births (LB) and still births (SB) during the year. At the national level peri‑natal mortality rate has been estimated to be 37 and ranged from 40 in rural areas to 24 in urban areas. Among the bigger states, Orissa (54) and Kerala(17) formed the two extremes. The estimate of still birth rate for the year 2005, at the national level is 9. Among the bigger states the highest level of still birth rate has been estimated for Himachal (19) and the lowest for Bihar (2). Still births are extremely difficult to capture and there is room for considerable improvement in netting the event.

	Table 5.11

	Peri-natal mortality rates and still birth rates by residence, India and bigger states, 2005

	India and	Peri-natal mortality rate					Still birth rate
	Bigger states	Total	Rural		Urban		Total			Rural		Urban

India		37		40		24		9	9		8

Andhra Pradesh		37		44		15		11	12		7
Assam		34		35		19		9	9		9
Bihar		30		31		14		2	2		1
Chhattisgarh		53		55		44		18	17		19
Delhi		25		27		25		10	17		9

Gujarat		36		39		29		8	8		8
Haryana		30		33		22		7	5		11
Himachal Pradesh		38		39		23		19	20		11
Jammu & Kashmir		36		39		23		7	8		4
Jharkhand		22		24		12		*	*		*

Karnataka		36		43		18		13	16		6
Kerala		17		18		14		9	10		4
Madhya Pradesh		45		46		43		8	7		15
Maharashtra		31		35		26		12	13		11
Orissa		54		57		34		14	13		20

Punjab		32		39		20		14	15		12
Rajasthan		44		49		27		11	11		11
Tamil Nadu		30		38		19		11	15		6
Uttar Pradesh		41		45		23		10	11		5
West Bengal		31		34		21		9	9		7

*: No estimate can be made on sample values.

Per cent share of deaths to children below age five to total deaths by residence for India and bigger states is shown below in Table 5.12. At the national level such percentage was 23.8 and it varied from 26.1 in rural areas to 15.6 in urban areas. Among the bigger states, the variation was from 4.3 in Kerala to 35.0 in Rajasthan. In rural areas such variation was from 4.8 in Kerala to 39.4 in Rajasthan and in urban areas, it was 3.0 in Kerala to 28.2 in Uttar Pradesh.

	Table 5.12
	Percentage of deaths in the age group 0-4 years to total deaths by residence, India and bigger states, 2005
	India and bigger states	Total		Rural		Urban

India			23.8	26.1	15.6

Andhra Pradesh			17.2	18.5	12.9
Assam			24.4	25.6	12.7
Bihar			32.5	33.0	26.7
Chhattisgarh			29.6	31.8	18.3
Delhi			18.1	26.6	16.3

Gujarat			22.2	26.1	13.9
Haryana			25.8	27.6	20.7
Himachal Pradesh			18.3	19.0	8.9
Jammu & Kashmir			20.3	22.3	12.3
Jharkhand			25.0	26.6	15.4

Karnataka			16.3	17.4	13.4
Kerala			4.3	4.8	3.0
Madhya Pradesh			31.9	33.4	24.3
Maharashtra			12.4	13.5	10.5
Orissa			22.7	23.4	16.1

Punjab			14.8	15.6	13.4
Rajasthan			35.0	39.4	19.2
Tamil Nadu			9.5	9.5	9.5
Uttar Pradesh			34.0	35.1	28.2
West Bengal			14.5	17.5	7.0

The death rates for children below age 5 by residence are given below in Table 5.13 separately for males and females. At the national level, child mortality rate was estimated at 17.3 and it varied from 19.5 in rural areas to 10.3 in urban areas. Among the bigger states child death rate varied from 3.4 in Kerala to 24.7 in Uttar Pradesh. Except for the states of Assam and Kerala, female children have higher death rates than male children in the remaining states.

	Table 5.13
	Estimated death rates for children aged 0-4 years by sex and residence India and bigger states, 2005
	India and bigger states	Total			Rural			Urban
	India and bigger states	Total	Male	Female	Total	Male	Female	Total	Male	Female

India		17.3	16.4	18.2	19.5	18.6	20.4	10.3	9.5	11.1

Andhra Pradesh		14.8	14.4	15.2	17.3	16.7	17.9	8.8	9.1	8.6
Assam		19.7	20.4	19.0	21.1	21.9	20.2	8.7	7.9	9.6
Bihar		20.1	19.1	21.1	20.6	19.7	21.5	15.3	13.7	17.1
Chhattisgarh		20.2	18.6	22.1	21.6	19.6	23.9	13.0	13.4	12.5
Delhi		8.3	7.7	8.9	12.8	14.5	10.8	7.4	6.4	8.6

Gujarat		16.0	15.3	16.8	20.3	19.7	20.9	8.6	8.0	9.3
Haryana		17.8	14.6	21.7	19.7	16.1	24.3	13.0	10.8	15.5
Himachal Pradesh		13.5	9.4	18.0	14.2	9.6	19.1	5.8	7.9	3.3
Jammu & Kashmir		12.0	11.5	12.5	12.7	12.3	13.2	8.4	7.5	9.5
Jharkhand		16.1	14.1	18.3	17.5	15.1	20.3	8.8	9.0	8.5
Karnataka		13.1	12.5	13.7	15.6	14.7	16.6	8.5	8.5	8.4
Kerala		3.4	3.5	3.3	3.7	3.9	3.6	2.5	2.4	2.6
Madhya Pradesh		24.6	23.9	25.4	27.3	26.6	28.0	14.3	13.4	15.2
Maharashtra		8.6	8.6	8.6	9.8	10.1	9.5	6.7	6.2	7.2
Orissa		21.4	21.3	21.6	22.6	22.6	22.5	13.2	11.9	14.6

Punjab		11.3	10.1	12.8	12.8	11.8	14.1	8.9	7.2	10.8
Rajasthan		20.3	18.5	22.4	23.1	21.1	25.4	10.8	9.3	12.4
Tamil Nadu		9.0	8.9	9.2	9.8	9.9	9.7	8.0	7.5	8.4
Uttar Pradesh		24.7	23.2	26.3	26.0	24.4	27.7	18.2	17.0	19.5
West Bengal		10.0	9.9	10.1	11.0	11.2	10.8	6.2	5.1	7.4

Death rates for children in the age group 5‑14 are given below in Table 5.14. As revealed by the data, at the national level, the death rate in this age group was estimated to be 1.3. Rural-urban differentials exist with the urban areas registering in general significantly lower death rates as compared to that in rural areas. Among the bigger states the lowest death rate in this age group is registered in Kerala and Himachal Pradesh (0.4) and the highest in Jharkhand (2.2).

	Table 5.14
	Death rates for children age 5-14 years by sex and residence India and bigger states, 2005
	India and bigger states		Total						Rural					Urban
			Total		Male		Female		Total		Male		Female	Total	Male	Female

India		1.3		1.3		1.4		1.5		1.5		1.6		0.8	0.8	0.8

Andhra Pradesh		0.9		0.8		1.1			1.1	0.9		1.3		0.5	0.5	0.5
Assam		1.7		1.9		1.6			1.8	1.9		1.7		1.0	1.4	0.6
Bihar		2.0		1.8		2.2			2.1	1.8		2.3		1.2	1.5	0.9
Chhattisgarh		1.6		2.1		1.1			1.8	2.4		1.2		0.7	0.8	0.6
Delhi		0.6		0.7		0.4			1.1	1.0		1.2		0.5	0.6	0.3

Gujarat		1.1		1.2		1.0			1.3	1.5		1.1		0.7	0.6	0.8
Haryana		0.8		0.7		0.9			0.9	0.8		1.0		0.6	0.7	0.6
Himachal Pradesh		0.4		0.1		0.6			0.2	0.0		0.5		1.7	1.1	2.3
Jammu & Kashmir		0.9		0.8		0.9			0.9	0.9		0.8		0.9	0.6	1.2
Jharkhand		2.2		2.4		1.9			2.4	2.6		2.1		1.2	1.4	1.0

Karnataka		0.7		0.7		0.6			0.6	0.8		0.4		0.7	0.4	1.0
Kerala		0.4		0.3		0.5			0.5	0.5		0.5		0.2	0.0	0.4
Madhya Pradesh		2.0		1.9		2.0			2.3	2.2		2.3		0.8	0.7	0.9
Maharashtra		0.8		0.8		0.9			0.9	0.9		0.9		0.6	0.6	0.7
Orissa		1.6		1.5		1.8			1.7	1.6		1.8		1.0	0.9	1.2

Punjab		0.6		0.8		0.5			0.6	0.8		0.4		0.7	0.7	0.7
Rajasthan		1.1		1.0		1.2			1.3	1.2		1.4		0.5	0.3	0.7
Tamil Nadu		0.8		1.0		0.5			0.9	1.1		0.7		0.6	0.9	0.3
Uttar Pradesh		1.7		1.5		2.0			1.8	1.6		2.1		1.3	1.3	1.4
West Bengal		1.1		1.1		1.1			1.2	1.2		1.2		0.5	0.5	0.4

Death rates in the age group 15‑59, by sex and residence, are given below in Table 5.15. At the national level, death rates in this age group is estimated to be 3.7 and it varies from 4.0 in rural areas to 3.2 in urban areas. In both rural and urban areas, females death rate are lower than that of males except for Chhattisgarh in rural area.

	Table 5.15
	Death rates for persons age 15-59 years by sex and residence India and bigger states, 2005
	India and bigger states		Total						Rural						Urban
			Total		Male		Female		Total		Male		Female		Total		Male		Female

India		3.7		4.3		3.1		4.0		4.4		3.5		3.2		3.9		2.4

Andhra Pradesh		4.1		4.9		3.4		4.3		5.2		3.4		3.7		4.3		3.1
Assam		5.2		5.8		4.5		5.5		6.2		4.8		3.4		4.0		2.7
Bihar		3.8		3.9		3.7		3.8		4.0		3.7		3.5		3.6		3.4
Chhattisgarh		3.9		4.0		3.8		3.9		3.8		4.0		3.9		4.8		2.8
Delhi		2.6		2.7		2.3		1.6		1.9		1.2		2.7		2.9		2.5

Gujarat		3.5		4.4		2.6		3.8		4.8		2.8		3.1		3.9		2.2
Haryana		3.0		3.5		2.3		3.1		3.6		2.4		2.7		3.3		2.0
Himachal Pradesh		3.2		4.2		2.2		3.2		4.3		2.2		2.9		4.0		1.8
Jammu & Kashmir		2.4		2.6		2.1		2.4		2.5		2.3		2.2		2.8		1.6
Jharkhand		4.4		4.6		4.2		4.7		4.7		4.7		3.5		4.4		2.5

Karnataka		3.9		4.6		3.0		4.4		5.1		3.6		2.9		3.8		2.0
Kerala		2.5		3.8		1.3		2.5		3.8		1.4		2.3		3.7		1.1
Madhya Pradesh		4.4		4.9		4.0		4.8		5.2		4.5		3.2		4.0		2.4
Maharashtra		3.6		4.5		2.6		3.9		4.7		3.0		3.2		4.3		2.0
Orissa		4.5		5.4		3.7		4.6		5.4		3.8		4.1		4.9		3.3

Punjab		3.1		3.5		2.6		3.5		4.1		2.9		2.4		2.7		2.1
Rajasthan		3.0		3.5		2.5		2.8		3.1		2.5		3.5		4.5		2.5
Tamil Nadu		3.7		4.5		3.0		4.2		4.8		3.7		3.1		4.0		2.1
Uttar Pradesh		4.0		4.2		3.9		4.3		4.3		4.2		3.1		3.5		2.6
West Bengal		3.2		3.7		2.7		3.2		3.6		2.8		3.2		4.0		2.5

Death rates for persons aged 60 years and above by sex and residence are given below in Table 5.16. At the national level, males had higher mortality than females in both rural and urban areas. The death rate for this age group, among the bigger states varies from 38.8 in Himachal Pradesh to 53.8 in Assam.

Table 5.16
Death rates for persons age 60 years and above by
sex and residence, India and bigger states, 2005
India and bigger states	Total			Rural			Urban
India and bigger states	Total	Male	Female	Total	Male	Female	Total	Male	Female

Table 3.2: Distribution of Medically Certified Deaths by Cause (ICD 10)

S.No	Cause of Death	1998				1999				2000
S.No	Cause of Death	Male	Female	Total	%age	Male	Female	Total	%age	Male	Female	Total	%age
1	Infectious and Parasitic Diseases (A00-B99)	53594	28314	81908	16.43	46916	24800	71716	14.68	52674	27609	80283	15.72
2	Neoplasms (C00-C14)	9373	6415	15788	3.17	10232	7226	17458	3.57	10655	7766	18421	3.61
3	Diseases of the Blood and blood forming organs and certain disorders involving the immune mechanism (D50-D89)	5776	5355	11131	2.23	4177	3690	7867	1.61	4106	4071	8177	1.60
4	Endocrine, Nutritional and Metabolic Diseases (E00-E99)	7593	5138	12731	2.55	8675	5709	14384	2.94	9937	6747	16684	3.27
5	Mental and Behavioural disorders (F01-F99)	477	98	575	0.12	466	114	580	0.12	437	103	540	0.11
6	Diseases of the Nervous System (G00-G98)	8945	5888	14833	2.98	8972	5516	14488	2.97	9886	5968	15854	3.11
7	Disease of the eye and adnexa (H00-H59)	86	48	134	0.03	78	35	113	0.02	32	11	43	0.01
8	Disease of ear and mastoid process (H60-H95)	52	26	78	0.02	26	16	42	0.01	33	11	44	0.01
9	Diseases of the circulatory system (I00-I99)	80112	45307	125419	25.15	75139	41042	116181	23.78	79947	44323	124270	24.34
10	Diseases of the Respiratory System (J00-J98)	23375	13260	36635	7.35	23993	13541	37534	7.68	23079	12849	35928	7.04
11	Diseases of the Digestive System (K00-K92)	17214	6214	23428	4.70	15511	5085	20596	4.22	17650	5660	23310	4.57
12	Diseases of the skin and subcutaneous tissue (L00-L98)	455	231	686	0.14	487	229	716	0.15	421	240	661	0.13
13	Diseases of the Muscular Skeletal system connective tissue (M00-M99)	161	135	296	0.06	170	144	314	0.06	158	119	277	0.05
14	Diseases of the Genitourinary System (N00-N99)	5123	3052	8175	1.64	5167	2902	8069	1.65	6283	3569	9852	1.93
15	Pregnancy, Childbirth and Puerperium (O00-O99)	N.A	3194	3194	0.64	N.A	4169	4169	0.85	N.A	3982	3982	0.78
16	Certain conditions originating in the prenatal period (P00-P96)	24100	15228	39328	7.89	22437	14217	36654	7.50	24328	15456	39784	7.79
17	Congenital Malformations, Deformations & Chromosomal abnormalities (Q00-Q99)	1348	849	2197	0.44	1699	1191	2890	0.59	1471	876	2347	0.46
18	Symptoms, Signs and abnormal clinical & Laboratory finding not elsewhere classified (R00-R99)	37515	23958	61473	12.33	43316	27992	71308	14.59	43715	28831	72546	14.21
19	Injury, poisoning and certain other consequences of external causes (S00-T98)	36725	23852	60577	12.15	37705	25835	63540	13.00	34307	23270	57577	11.28
	Total	312024	186562	498586	100.00	305166	183453	488619	100.00	319119	191461	510580	100.00

Age in Years	Medically Certified Deaths
	Male		Female		Combined
	Number	%age	Number	%age	Number	%age
Less than 1	37360	11.71	24138	12.61	61498	12.04
1-4	6859	2.15	5366	2.80	12225	2.39
5-14	8256	2.59	6556	3.42	14812	2.90
15-24	16696	5.23	17574	9.18	34270	6.71
25-34	27971	8.77	19683	10.28	47654	9.33
35-44	37773	11.84	16877	8.81	54650	10.70
45-54	44146	13.83	18495	9.66	62641	12.27
55-64	47613	14.92	23213	12.12	70826	13.87
65-69	27561	8.64	15363	8.02	42924	8.41
Above 70	54492	17.08	38914	20.32	93406	18.29
Not Specified	10392	3.26	5282	2.76	15674	3.07
Total	319119	100.00	191461	100.00	510580	100.00

S.No.	Cause of Death & ICD 10	Below 1 year	1-4 years	5-14 years	15-54 years	55 and above	NS	Total
1	Infectious and Parasitic Diseases (A00-B99)	3468	1976	2032	26308	17134	1756	52674
2	Neoplasms (C00-C14)	103	142	271	3975	5872	292	10655
3	Diseases of the Blood and blood forming organs and certain disorders involving the immune mechanism (D50-D89)	259	273	336	1642	1351	245	4106
4	Endocrine, Nutritional and Metabolic Diseases (E00-E99)	238	142	83	2826	6398	250	9937
5	Mental and Behavioural disorders (F01-F99)	5	3	10	292	118	9	437
6	Diseases of the Nervous System (G00-G98)	1078	851	924	3859	2724	450	9886
7	Disease of the eye and adnexa (H00-H59)	2	3	2	18	6	1	32
8	Disease of ear and mastoid process (H60-H95)	1	3	5	11	12	1	33
9	Diseases of the circulatory system (I00-I99)	840	337	658	26654	48901	2557	79947
10	Diseases of the Respiratory System (J00-J98)	2904	1155	693	6866	10556	905	23079
11	Diseases of the Digestive System (K00-K92)	295	265	377	10063	5978	672	17650
12	Diseases of the skin and subcutaneous tissue (L00-L98)	11	6	6	187	189	22	421
13	Diseases of the Muscular Skeletal system connective tissue (M00-M99)	4	1	8	68	71	6	158
14	Diseases of the Genitourinary System (N00-N99)	200	82	157	2503	3034	307	6283
15	Pregnancy, Childbirth and Puerperium (O00-O99)	0	0	0	0	0	0	0
16	Certain conditions originating in the prenatal period (P00-P96)	24328	0	0	0	0	0	24328
17	Congenital Malformations, Deformations & Chromosomal abnormalities (Q00-Q99)	986	122	85	128	63	87	1471
18	Symptoms, Signs and abnormal clinical & Laboratory finding not elsewhere classified (R00-R99)	2258	851	1070	16585	21755	1196	43715
19	Injury, poisoning and certain other consequences of external causes (S00-T98)	380	647	1539	24601	5504	1636	34307
	Total	37360	6859	8256	126586	129666	10392	319119

S.No.	Cause of Death & ICD 10	Below 1 year	1-4 years	5-14 years	15-54 years	55 and above	NS	Total
1	Infectious and Parasitic Diseases (A00-B99)	2157	1558	1767	12886	8426	815	27609
2	Neoplasms (C00-C14)	87	66	137	3570	3732	174	7766
3	Diseases of the Blood and blood forming organs and certain disorders involving the immune mechanism (D50-D89)	179	245	313	1891	1229	214	4071
4	Endocrine, Nutritional and Metabolic Diseases (E00-E99)	235	143	95	1617	4515	142	6747
5	Mental and Behavioural disorders (F01-F99)	3	2	1	54	43	0	103
6	Diseases of the Nervous System (G00-G98)	676	651	669	2209	1500	263	5968
7	Disease of the eye and adnexa (H00-H59)	1	1	3	6	0	0	11
8	Disease of ear and mastoid process (H60-H95)	0	1	2	5	3	0	11
9	Diseases of the circulatory system (I00-I99)	519	228	474	12425	29448	1229	44323
10	Diseases of the Respiratory System (J00-J98)	2086	1028	561	3240	5567	367	12849
11	Diseases of the Digestive System (K00-K92)	167	140	283	2733	2134	203	5660
12	Diseases of the skin and subcutaneous tissue (L00-L98)	14	6	6	117	92	5	240
13	Diseases of the Muscular Skeletal system connective tissue (M00-M99)	5	1	2	62	44	5	119
14	Diseases of the Genitourinary System (N00-N99)	104	58	107	1511	1659	130	3569
15	Pregnancy, Childbirth and Puerperium (O00-O99)	0	0	3	3891	0	88	3982
16	Certain conditions originating in the prenatal period (P00-P96)	15456	0	0	0	0	0	15456
17	Congenital Malformations, Deformations & Chromosomal abnormalities (Q00-Q99)	552	81	31	134	29	49	876
18	Symptoms, Signs and abnormal clinical & Laboratory finding not elsewhere classified (R00-R99)	1655	664	879	8579	16504	550	28831
19	Injury, poisoning and certain other consequences of external causes (S00-T98)	242	493	1223	17699	2565	1048	23270
	Total	24138	5366	6556	72629	77490	5282	191461

S.No.	Cause of Death & ICD 10	Below 1 year	1-4 years	5-14 years	15-54 years	55 and above	NS	Total
1	Infectious and Parasitic Diseases (A00-B99)	5625	3534	3799	39194	25560	2571	80283
2	Neoplasms (C00-C14)	190	208	408	7545	9604	466	18421
3	Diseases of the Blood and blood forming organs and certain disorders involving the immune mechanism (D50-D89)	438	518	649	3533	2580	459	8177
4	Endocrine, Nutritional and Metabolic Diseases (E00-E99)	473	285	178	4443	10913	392	16684
5	Mental and Behavioural disorders (F01-F99)	8	5	11	346	161	9	540
6	Diseases of the Nervous System (G00-G98)	1754	1502	1593	6068	4224	713	15854
7	Disease of the eye and adnexa (H00-H59)	3	4	5	24	6	1	43
8	Disease of ear and mastoid process (H60-H95)	1	4	7	16	15	1	44
9	Diseases of the circulatory system (I00-I99)	1359	565	1132	39079	78349	3786	124270
10	Diseases of the Respiratory System (J00-J98)	4990	2183	1254	10106	16123	1272	35928
11	Diseases of the Digestive System (K00-K92)	462	405	660	12796	8112	875	23310
12	Diseases of the skin and subcutaneous tissue (L00-L98)	25	12	12	304	281	27	661
13	Diseases of the Muscular Skeletal system connective tissue (M00-M99)	9	2	10	130	115	11	277
14	Diseases of the Genitourinary System (N00-N99)	304	140	264	4014	4693	437	9852
15	Pregnancy, Childbirth and Puerperium (O00-O99)	0	0	3	3891	0	88	3982
16	Certain conditions originating in the prenatal period (P00-P96)	39784	0	0	0	0	0	39784
17	Congenital Malformations, Deformations & Chromosomal abnormalities (Q00-Q99)	1538	203	116	262	92	136	2347
18	Symptoms, Signs and abnormal clinical & Laboratory finding not elsewhere classified (R00-R99)	3913	1515	1949	25164	38259	1746	72546
19	Injury, poisoning and certain other consequences of external causes (S00-T98)	622	1140	2762	42300	8069	2684	57577
	Total	61498	12225	14812	199215	207156	15674	510580

Leading causes of death - all age groups in Andhra Pradesh, 1991
All		Females		Males
Cause	%	Cause	%	Cause	%
Ischemic heart disease	13.21	Ischemic heart disease	12.2	Ischaemic heart disease	14.08
Cerebrovascular disease	8.11	Cerebrovascular disease	8.33	Cerebrovascular disease	7.92
Lower respiratory infections	7.02	Diarrhoeal diseases	7.49	Tuberculosis	7.76
Diarrhoeal diseases	6.61	Lower respiratory infections	7.15	Lower respiratory infections	6.91
Tuberculosis	6.32	Low birth weight	5	Diarrhoeal diseases	5.86
Low birth weight	4.96	Tuberculosis	4.67	Chronic obstructive Pulmonary Disease	5.34
Chronic obstructive pulmonary disease	4.76	Chronic obstructive pulmonary disease	4.08	Low birth weight	4.93
Self-inflicted injury	3.54	Self-inflicted injury	3.76	Self-inflicted injury	3.34
Asthma	2.55	Stomach cancer	2.71	Asthma	3.14
Stomach cancer	2.28	Dementia and other degenerative CNS dis.	2.09	Road accidents	2.59
				Cirrhosis of the liver	2.19
Residual cause with % deaths higher than last cause included above:
Other unintentional injuries	3.94	Other unintentional injuries	4.09	Other unintentional injuries	3.81
Other cardiac diseases	2.32	Other cardiac diseases	2.58

	In the case of deaths occurred in the institutions, Head of the institution is responsible for submission of form no.4 to the Local Registrar.
	In the case of domiciliary death attended by any physician prior to death is responsible to submit form no.4A to the local registrar.
	It is the duty of the registrar to provide forms No 4 & 4A to the Institutions & Physicians in his jurisdiction.
	It is the duty of Registrar, to ask about form No.4 & 4A according to occurrence of death, while entering the death event.
	Civil Surgeon of District Hospital & District Health Officer Z.P. is responsible for review of quantity, quality & training of M.C.C.D. at district level.
	Deputy Director is responsible for compilation, coding & analysis of data received through MCCD according to ICD-10.

1.1	The Office Of the Registrar General, India initiated in the 1960s a Scheme called as " Model Registration System" (MRS). With a view that, there should be some centers, which are to be model in Registration of vital events. The scheme was introduced according to recommendations made in the ' Conference on improvement of Vital Statistics' held in 1961.
1.2	The Registrar General, India had launched the scheme in some States on pilot basis in 1965. Further the scheme has expanded in 10 states Andhra, Bihar, Asam, Gujrat, keral, Orisa, Punjab, Rajasthan, Tamilnadu, West Bengal, The states Maharashtra, Hariyana, Jammu & Kashmir, Karnataka, M.P., U.P. are covered under the scheme in 1967.
1.3	The scheme was renamed in 1982 as" Survey Of Causes Of Death Scheme (Rural)".
1.4	The implementation of the scheme has stopped by Registrar General, India in 1997 at central level & merged in the S.R.S. Scheme.
1.5	The progress & data received under the scheme was satisfactory in the Maharashtra State., & there was no financial burden, in view of this , State has decided to continue the Scheme in Maharashtra.

1.1	The Scheme was implemented in 600 H.Q. villages of P.H.C. in the State previously
1.2	The enforcement of the SCD scheme has been included in the Project Implementation Plan of Maharashtra Health System Development Project in 2003-04 & received the financial support.
1.3	The implementation of the Scheme has been shifted from P.H.C.H.Q. village to village level, without changing the nos. of villages.
1.4	The lists of classification of the diseases have been modified baseonICD-10. Now the frame of 109 diseases through 19 major groups have been made available to the M.O. P.H.C. to select the cause of death, based on "lay diagnosis reporting".

Table 4.1 Agencies for Registration of Births & Deaths in States/UTs
Chief Registrars
Department of Health:	Andhra Pradesh, Assam, Gujarat, Haryana, Himachal Pradesh, Jammu & Kashmir, Maharashtra, Manipur, Meghalaya, Orissa, Punjab, Sikkim, Tamil Nadu, Tripura, Uttar Pradesh,Uttrakhand, West Bengal, A&N Islands, Chandigarh and Lakshadweep- (17 States & 3 UTs)
Department of Economics & Statistics/Planning & Evaluation	Arunachal Pradesh, Bihar, Goa,Jharkhand Karnataka, Madhya Pradesh, Mizoram, Chhatisgarh ,Rajasthan, Nagaland, Daman & Diu and Delhi -(10 States & 2 UTs).
Others	Kerala (Director of Panchayats), Dadra & Nagar Haveli (Administration), Pondicherry (Local Administration Deptt.) -(1 State & 2 UTs)
Additional/Deputy Chief Registrars
Addl./Dy. Director Health	Andhra Pradesh, Haryana, Himachal Pradesh, Maharashtra, Meghalaya, Orissa, Tamil Nadu, Uttar Pradesh, Uttrakhand, West Bengal and Lakshadweep - (10 States & 1 UT).
Addl/Dy. Director Economics & Statistics/Planning & Evaluation	Bihar, Jammu & Kashmir, Goa, Gujarat, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Chhattisgarh, Manipur, Mizoram, Nagaland, Punjab, Rajasthan, Sikkim and Daman & Diu -(15 States & 1 UT)
Others	Assam (Rural Development), Kerala (Dy. Director, Panchayats), Delhi (Municipal Health Officer)-(2 State & 1 UT)
District Registrar
District Health/ Medical Officer	Andhra Pradesh, Gujarat, Haryana, Himachal Pradesh, Jammu & Kashmir, Maharashtra, Manipur, Meghalaya, Orissa, Punjab, Sikkim, A&N Islands, Lakshadweep and Chandigarh -(11 States & 3 UTs)
District Statistical Officer	Chhattisgarh, Nagaland, Madhya Pradesh, Rajasthan, Delhi (Asstt. Director) -(4 States & 1 UT)
Dy. Commissioner/Collector	Arunachal Pradesh, Assam, Bihar, Goa, Jharkhand, Karnataka, Mizoram, Tamil Nadu, Tripura, Uttar Pradesh, Uttarakhand, West Bengal and Daman & Diu -(12 States & 1 UT)
Others	Kerala (Asstt. Director, Panchayats) Dadra & Nagar Haveli (Mamlatdar-cum-Survey & Settlement Officer) and Pondicherry (Municipal Administration)
Registrars in Rural Areas
Panchayat Secretary (Local Self Government)	Bihar, Goa, Gujarat (Talati-cum-Mantri), Himachal Pradesh, Jharkhand, Kerala, Madhya Pradesh, Maharashtra, Punjab, Rajasthan (Partly), Tripura (partly), Uttar Pradesh, Uttrakhand, West Bengal, Dadra & Nagar Haveli.Daman & Diu, Pondicherry.
Station House Officer (Police)	Chhattisgarh, Jammu & Kashmir and Chandigarh.
Village/Revenue Officer	Andhra Pradesh, Arunachal Pradesh, Karnataka, Tamil Nadu
Tehsildar-Sub Divisional Officer/ Asstt. Commissioner	Tripura (Partly)
Primary Health Centre Incharge/Health Inspector/ Block Sanitary Inspector	Assam, Haryana, Manipur (Partly) Maghalaya, Orissa, Sikkim, A&N Islands , Delhi and Lakshadweep
Block Development Officer	Manipur (Partly)
Teacher of Government School	Mizoram, Nagaland, Rajasthan (Partly)

EXECUTIVE SUMMARY

Vital Statistics

Mortality

Other data

Causes of Death

A. Civil Registration System (CRS)

A.1 Current Status

A.2 DEFICIENCIES

A.3 RECOMMENDATIONS

cHAPTER - 3

MEDICAL CERTIFICATION of Cause of DEATHs

1. Introduction:

4. Statutory Frame-work

REGISTRATION OF BIRTHS AND DEATHS

CHAPTER - 4

STATUS OF MORTaLITY REPORTING IN INDIA

1. Introduction

5. Data on Morbidity and Mortality at Disaggregated Levels

6. Current Status

6.1 National Commission on Population Task Force on Monitoring

1. Child mortality up to the age of 2

2. Maternal Mortality Rate

3. Percentage of births, deaths and marriages registered

Table 4.1 Agencies for Registration of Births & Deaths in States/UTs

Chief Registrars

8. Level of public awareness and enforcement

9. Recommendations

Table 5.1

Table 5.2

Total

Rural

Urban

Table 5.3

Crude death rates by sex and residence, India, 2005

Table 5.4

Crude death rates by sex, India and bigger states, 2005

Table 5.5

Broad age-groups

Table 5.6

Percentage of infant deaths to total deaths by residence

Table 5.7

Table 5.8

Table 5.11

India and

Peri-natal mortality rate

Table 5.12

Total

Rural

Table 5.13

Table 5.14

Table 5.15