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The Hindu
3 days ago
- Health
- The Hindu
India's pandemic toll remains elusive
The Civil Registration System (CRS) data has brought into sharp relief the magnitude of excess mortality that India witnessed during the COVID-19 pandemic years. Excess mortality refers to the difference between the total number of deaths during a pandemic or any other natural disaster compared to the number of deaths that would have been expected under normal conditions. According to the CRS, India recorded 76.4 lakh deaths in 2019. This figure rose to 81.11 lakh in 2020 and further surged to 1.02 crore in 2021 — an implicit acknowledgement of the fact that the true mortality impact of COVID-19 far exceeds the official toll of 5.33 lakh. Data from the Medical Certification of Cause of Death (MCCD) for 2021, released alongside the CRS and Sample Registration System reports, adds further weight to this claim. COVID-19 was identified as the second leading cause of death, with 5.74 lakh certified fatalities attributed to the virus — already exceeding the official figure. However, this estimate was drawn from less than a quarter (23.4%) of registered deaths in 2021. Taken together, the rise in all-cause mortality and the limited scope of medical certification offer a compelling case that India's true pandemic death toll may be far closer to the World Health Organization's estimate of 47 lakh deaths — a model that the Government of India had earlier rejected, citing concerns over its methodological robustness. A systemic deficiency CRS data/all-cause mortality data is indispensable, especially given the widespread undercounting of COVID-related deaths. This metric captures not only confirmed cases but also fatalities arising from misdiagnoses, misclassification, and pandemic-induced systemic disruptions. Nonetheless, the utility of the all-cause mortality data in gauging the true impact of COVID-19 is limited in the Indian setting, as the recording of deaths is far from universal. The National Family Health Survey-5 states that nearly 29% of deaths between 2016 and 2020 went unregistered. The omission of civil registration from the list of essential services during the 2020 lockdown further obscured the mortality landscape. As a consequence, even comprehensive datasets such as CRS may fall short in reflecting the full impact of the pandemic. Editorial | A belated admission: On the undercount of India's COVID-19 pandemic deaths Beyond numerical discrepancies lies a deeper issue — the structural inadequacy of death certification and classification. During the pandemic years, we visited crematoriums and burial grounds in a locality in Kerala. We observed a marked rise in the number of daily cremations compared to previous years — an increase that was evident not only in facilities designated for handling COVID-19 deaths, but also in those without such designation. This raises pertinent questions regarding the misclassification of COVID-19 deaths and under-ascertainment of causes. A significant driver of this opacity is the absence of medical certification. In 2020, 45% of deaths occurred without any form of medical attention — 10% points higher than in pre-pandemic years. Within our study cohort, only 22.8% of the deceased had any formal medical documentation indicating the cause of death. Nationally, only 23.4% of deaths are medically certified as per the recent MCCD data. This systemic deficiency compromises mortality surveillance as well as public health planning. Indirect deaths A further dimension of the pandemic's mortality burden relates to indirect deaths — a category of deaths that, while not directly caused by SARS-CoV-2 infection, can be reasonably attributed to the wider repercussions of the pandemic. These fatalities, often absent from COVID-19 official statistics, occurred due to systemic disruptions: delays in seeking care due to fear of infection, scarcity of hospital beds and essential medicines, post-infection complications, economic distress, and logistical barriers to healthcare access during prolonged lockdowns. During our field study, we found that a considerable share of deaths was indirectly linked to these cascading effects of the pandemic. Many people suffered physical and psychological deterioration post-infection, some experienced an exacerbation of chronic conditions, and others refrained from seeking timely medical attention. When extrapolated to the broader national context, particularly in regions where healthcare systems are fragile and supply chains were acutely disrupted, the implications would be sobering. To gauge the true mortality impact of the pandemic, it is insufficient therefore to rely solely on officially recorded COVID-19 deaths or all-cause mortality data. Also read | 'Excess deaths in 2020 and 2021 not equal to deaths by COVID-19, increase attributable to several reasons' Our study in Kerala found that 34% of deaths were indirectly attributable to the pandemic, and 9% may have been misclassified. If such patterns exist in a State with a relatively strong public health systems (although the death registration in the prescribed time was around 61% in 2021), the scale of undercounting could be even more pronounced in States such as Gujarat and Madhya Pradesh where discrepancies between excess deaths and official figures are significantly wider. These findings make a compelling case for a systematic inquiry into the full extent of mortality during the pandemic. Policymakers should consider conducting a large-scale study, which could be also accomplished by including questions on decedents in the next Census. More importantly, they must serve as a wake-up call to urgently reform India's mortality surveillance architecture. Shilka Abraham, Master of Public Health graduate, School of Health Systems Studies, Tata Institute of Social Sciences; Soumitra Ghosh, Associate Professor and Chairperson, Centre for Health Policy, Planning and Management, School of Health Systems Studies, Tata Institute of Social Sciences
Time of India
30-07-2025
- Health
- Time of India
MP has highest infant mortality rate in India, govt admits in assembly
Bhopal: Madhya Pradesh has the highest infant mortality rate in the country, with 40 out of every 1,000 newborns dying in the state, the govt informed the assembly on Wednesday. The disclosure came in a written reply by Deputy CM and health minister Rajendra Shukla to a question raised by Congress MLA Jhuma Solanki. Citing the latest Sample Registration System (SRS) 2022 data, Shukla said the state's infant mortality rate (IMR) was not only higher than the national average but also the highest among all states. "Yes, the infant mortality rate in MP is higher compared to other states and the national average," he said. In her question, Solanki had sought comparative figures, reasons behind the high IMR, and details of govt schemes and expenditure aimed at tackling the crisis. On a question regarding what was the expenditure incurred in the previous fiscal year, the govt said it had spent Rs 110 crore under different schemes and activities to reduce the infant mortality rate. The primary causes of infant deaths in MP include premature birth, pneumonia, sepsis, low birth weight, birth asphyxia and diarrhea among other reasons, the minister said in his reply. The govt also listed the schemes, activities and budget allocation aimed to reduce infant mortality rate. It includes Anaemia Mukt Bharat, nutritional rehabilitation centre, total facility based newborn care, total child death review, total paediatric care, total Janani Shishu Suraksha Karyakram among several others.
Time of India
09-07-2025
- Health
- Time of India
Policy should focus on well-being than population control: Experts
1 2 Bhubaneswar: Ahead of World Population Day, experts said here on Wednesday that there is a pressing need to revise population control strategies according to demographic indices. The shift must be towards well-being and healthy ageing rather than population control, they observed. Binod Kumar Patro, professor of community medicine and family medicine at AIIMS Bhubaneswar, said India achieved the total fertility rate (TFR) targets by 2022. "India's TFR stands at 2.0, as per the 2022 Sample Registration System (SRS) report released in June this year. This means, on average, a woman in India is expected to give birth to two children during her reproductive years," he added. "While it is a remarkable achievement for India to have a fertility rate below the replacement level of 2.1, it masks significant differences across the states that demand state-specific policy approaches rather than blanket solutions," said Patro. A TFR of below 2.1 children per woman indicates that the population is declining. States like Bihar, Uttar Pradesh, and Madhya Pradesh have TFRs above the replacement level, whereas Sikkim has the lowest TFR of 1.1. by Taboola by Taboola Sponsored Links Sponsored Links Promoted Links Promoted Links You May Like One of the Most Successful Investors of All Time, Warren Buffett, Recommends: 5 Books for Turning... Blinkist: Warren Buffett's Reading List Click Here Undo Similarly, Tamil Nadu, West Bengal and Odisha have TFRs of 1.3, 1.4 and 1.7, respectively. "The one-size-fits-all approach to population policy has outlived its utility. While the country has successfully stabilised overall population growth, with an average TFR of 2.0, which is below the replacement level, the complex challenge now is to manage different demographic stages across various states. It requires tailored approaches that address each region's specific needs and challenges," said Patro. Amarendra Das, an associate professor of humanities and social sciences at NISER Bhubaneswar, said India will have to worry about decline in population by 2047. "We need to think about and prepare a policy to tackle the problem. TFR of 11 states, including Odisha, is decreasing, which means population growth is stabilising there," he added. He said a support system should be provided to couples to encourage having a second child. "A crèche system at different govt and private offices should be made mandatory. Govt support in terms of leaves and other assistance should be given to couples having a second child," he added. B M Otta, former professor of population studies at Fakir Mohan University, Balasore, said the govt should consider preparing tailor-made policies, keeping in mind the TFR rate of the states. "When policies were framed for population control, we were struggling to bring down the increasing population of the country. But now the situation is changing fast," he added.
The Hindu
07-07-2025
- Health
- The Hindu
Fostering a commitment to stop maternal deaths
In childbirth in India, why should 93 women lose their life while one lakh women have a safe delivery? For the time period 2019-21, the Maternal Mortality Ratio (MMR) estimate for India was 93, in other words, the proportion of maternal deaths per 1,00,000 live births, reported under the Sample Registration System (SRS). 'Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes'. But the MMR in India has declined over the years — it was 103 in 2017-19, then 97 in 2018-20 and now 93 in 2019-21. To understand the maternal mortality situation better, States have been categorised into three: 'Empowered Action Group' (EAG) States that comprise Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh, Uttarakhand and Assam; 'Southern' States which include Andhra Pradesh, Telangana, Karnataka, Kerala and Tamil Nadu; and 'Other' States that cover the remaining States/Union Territories. In the group of 'Southern' States, Kerala has the lowest MMR (20) and Karnataka the highest (63). The rest of the data is Andhra Pradesh (46) Telangana (45) and Tamil Nadu (49). In the EAG States, Assam has a very high MMR (167); the rest of the data is Jharkhand (51), and Madhya Pradesh (175). Bihar, Chhattisgarh, Odisha, Rajasthan, Uttar Pradesh and Uttarakhand are in the 100-151 range. In the category of 'Other' States. Maharashtra is 38 and Gujarat 53; the rest of the data is Punjab 98, Haryana 106 and West Bengal 109. We need to have a differential approach in strategy to reduce maternal deaths in the different clusters of States. In this, addressing three issues is fundamental. There are 'three delays' that lead to a mother dying, according to Deborah Maine of Columbia University — I had incorporated this in the training module on 'Safe Motherhood in India' in 1992. Key factors that endanger a life The first delay is in recognising impending danger and making a decision to rush and seek expert care. The husband and other family members often experience inertia, thinking that all deliveries are a natural process and so the mother-to-be can wait. Or they may not have enough money or other issues at the family level that prevent them from going to a hospital. If the educational level of family members and their financial position are weak, delaying decision making is detrimental. But empowered, neighbourhood mothers and women's self-help-groups have resulted in a remarkable change; no longer is a mother-to-be neglected by lethargic family members. Ever since Accredited Social Health Activists (ASHA) began networking with Auxiliary Nurse Midwives (ANM) since 2005 (when the National Rural Health Mission (NHRM) was launched), institutional over home deliveries have become the better option. The financial incentives for the mother and ASHA were the turning point. The second delay is in transportation. From remote rural hamlets and forest settlements or faraway islands it may take many hours, or an overnight journey for a mother-to-be to reach a health facility with a skilled birth attendant (midwife/staff nurse) or a doctor or an obstetrician. Many women die on the way. However, the 108 ambulance system and other Emergency transport mechanisms under the National Health Mission has made a difference. Other problems The third delay, an unpardonable one, is in initiating specialised care at the health facility. The excuses are plenty and difficult to justify — a delay in attending to a woman in the emergency room; a delay in reaching the obstetrician; a delay in getting a blood donor, in laboratory support, the operation theatre not being ready, an anaesthetist not being available is a list that can go on. The concept of the operationalisation of a 'minimum four FRUs [first referral units] per district of two million population, is crucial. The 'first level referral unit' with specialists such as an obstetrician, anaesthetist, paediatrician, blood bank and operation theatre was aimed at preventing maternal death at the doorstep of a hospital. Unfortunately, this has not worked out as expected since 1992. There are problems such as 66% vacancies of specialists in 5,491 community health centres out of which 2,856 are supposed to be FRUs in 714 districts. The lack of blood banks or blood storage units in these designated FRUs was another reason for many mothers not receiving adequate blood transfusion within two hours of the onset of massive bleeding after delivery, leading to fatalities. The biggest killer is bleeding after delivery. This could be due to inadequate and timely contraction of an overstretched uterus with a baby of three-kilogram weight floating in amniotic fluids. When the placenta is separated after delivery, the raw opened surfaces of the uterine wall will bleed profusely unless it immediately contracts. From a total reserve of five litres of blood, more than half is lost in such a short duration, resulting in the mother going into shock and death. If there is underlying anaemia, which has not been treated with iron folic acid supplements in pregnancy, it will also result in tragedy. Thus, there is a need for immediate blood transfusion and emergency surgical care. The next emergency is obstructed labour where the contracted bony pelvis of an already stunted young mother (who is also malnourished and has low body mass index) does not allow the normally grown baby to emerge. Prolonged labour can lead to foetal distress and a lethal rupture of the uterus. This can be avoided by a Caesarean section. Thus, there is a need for a well-equipped operation theatre and obstetrician/ surgeon and an anaesthetist on call. The third medical cause is hypertensive disorders of pregnancy that are not recognised and treated on time. They can result in a dire emergency with convulsions and coma and very little time to medically control high blood pressure. There are some home deliveries by untrained birth attendants which lead to trauma and puerperal infection, resulting in sepsis and death. Antibiotics could have saved their lives, but the patient is admitted to hospital late. A failure of contraceptive devices, resulting in unwanted pregnancies and crude abortion techniques by quacks, also leads to sepsis and death. In EAG States, associated illnesses such as malaria, chronic urinary tract infections and tuberculosis are also high risk factors. The focus areas for States The prescription for averting maternal deaths is early registration and routine antenatal care and ensuring institutional delivery. Many of these systemic deficiencies will be highlighted in the mandatory reporting and audit of all maternal deaths under the NHM. While the EAG States have to focus on the implementation of basic tasks, the southern States group and probably Jharkhand, Maharashtra and Gujarat need to fine tune the quality of their emergency and basic obstetric care. The Kerala model of a Confidential Review of Maternal deaths, initiated by Dr. V.P. Paily, has some analytical leads on how Kerala can further reduce its already low MMR of 20. It is a model other southern States can emulate. The use of uterine artery clamps on the lower segment, application of suction canula to overcome atonicity of the uterus, and a sharp lookout for and energetic management of amniotic fluid embolism, diffused intravascular coagulation, hepatic failure secondary to fatty liver cirrhosis are strategies taught to obstetricians, which even developed countries have yet to practise routinely. They even address antenatal depression and post-partum psychosis as there were a few cases of pregnant mothers ending their life. Finally, if there is a commitment and a will to stop preventable maternal deaths there is no limit to the varieties of proactive interventions. Dr. K.R. Antony is a Public Health Consultant in Kochi, Kerala, and drafted the first Safe Motherhood module for the Ministry of Health on behalf of UNICEF. The writer acknowledges inputs on the Confidential Review of Maternal Deaths in Kerala from Dr. Smithy Sanel, a Spokesperson of the Kerala Federation of Obstetrics and Gynaecology
Time of India
03-07-2025
- Health
- Time of India
Suicide is killing young Indians more than cancer, diabetes, or heart disease
Suicide is killing young Indians more than cancer, diabetes, or heart disease Bansri Shah Jul 3, 2025, 23:32 IST IST One in six deaths among India's young is by suicide — a rate that hasn't budged in two decades. Are we underestimating the scale of this tragedy? A recent study shows that of all the deaths in the age group 15 to 29 in India, one in six is due to suicide. The number, alarmingly high for a country with a very large young population, has remained stubbornly consistent over the past two decades. This figure, drawn from the Sample Registration System (SRS) Cause of Death Report for 2020–2022, offers grim proof that India's youth are in crisis.
