State-wise statistical analysis of infant, child and under-five mortality in India: Evidence from NFHS-5

Introduction

Child mortality remains one of the most important indicators of population health and socioeconomic development. The survival of children during the first five years of life reflects the combined influence of maternal health, nutritional status, healthcare services, education, sanitation, environmental conditions, and household living standards. Although remarkable progress has been achieved in reducing child deaths worldwide, preventable mortality among infants and young children continues to be a major public health concern, particularly in developing countries. Therefore, improving child survival has become a global priority under the Sustainable Development Goals (SDGs), which emphasize reducing preventable deaths and ensuring healthy lives for all children. [1][2][3] Infant Mortality Rate (IMR), Child Mortality Rate (CMR), and Under-Five Mortality Rate (U5MR) are widely used demographic indicators for assessing child health and monitoring the performance of healthcare systems. IMR measures the number of deaths among infants before reaching one year of age per 1, 000 live births, while CMR represents the probability of dying between one and five years of age. U5MR measures the overall probability of dying before completing five years of age and is internationally recognized as one of the most comprehensive indicators of child survival.

Together, these indicators provide valuable information on the health status of a population and help evaluate the effectiveness of maternal and child health programmes. [2,4,5] India has made substantial progress in reducing child mortality over the past three decades through improvements in maternal and child healthcare services, expansion of immunization programmes, increased institutional deliveries, better nutritional interventions, and implementation of various national health initiatives. Data from successive rounds of the National Family Health Survey (NFHS) and the Sample Registration System (SRS) indicate a continuous decline in child mortality. However, this progress has not been uniform across the country. Significant differences persist among states because of variations in socio-economic development, maternal education, healthcare infrastructure, utilization of health services, and environmental conditions. As a result, national estimates often mask considerable regional disparities in child survival. [6][7][8] Several studies have investigated child mortality in India by examining mortality trends, socio-economic differentials, and associated risk factors. Most previous research has focused either on infant mortality or under-five mortality and has primarily emphasized the identification of determinants using demographic or regression-based approaches. While these studies have improved the understanding of child mortality, relatively limited attention has been given to a comprehensive state-wise assessment of IMR, CMR, and U5MR using recent nationally representative data. Such an analysis is important for understanding regional variations and identifying states that require greater policy attention and public health interventions. [4,6,9] The present study addresses this gap by examining the statewise distribution of Infant Mortality Rate, Child Mortality Rate, and Under-Five Mortality Rate in India using data from the National Family Health Survey-5 (2019-21). The study compares mortality patterns according to selected socioeconomic, demographic, and maternal healthcare characteristics and presents their geographical distribution across Indian states. The findings are expected to provide updated evidence on regional disparities in child mortality and support the formulation of targeted strategies for improving child survival.

Objectives

The objectives of the present study are: 1. To examine the state-wise distribution of Infant Mortality Rate (IMR), Child Mortality Rate (CMR), and Under-Five Mortality Rate (U5MR) in India using NFHS-5 data. 2. To compare mortality patterns according to selected socio-economic, demographic, and maternal healthcare characteristics across Indian states. 3. To examine the geographical distribution of child mortality indicators and identify regional variations in mortality across India.

Materials and Methods

Data Source

The study was based on data from the fifth round of the National Family Health Survey (NFHS-

Mortality Indicators and Study Variables

The study examined three standard child mortality indicators: Infant Mortality Rate (IMR), Child Mortality Rate (CMR), and Under-Five Mortality Rate (U5MR). IMR represents the number of deaths before one year of age per 1, 000 live births, CMR denotes the probability of dying between one and five years of age, and U5MR represents the probability of dying before reaching five years of age. These indicators were analysed according to selected background characteristics, including place of residence, religion, caste, maternal education, household wealth index, maternal age at birth, birth order, sex of the child, antenatal care visits, and place of delivery. [3]

Statistical Analysis

State-wise estimates of IMR, CMR, and U5MR were obtained from the NFHS-5 birth history data using standard direct estimation procedures. Mortality patterns were compared across Indian states according to the selected socio-economic, demographic, and maternal healthcare characteristics. The results are presented using tables and thematic maps to illustrate the geographical distribution and regional variation in child mortality. Statistical analyses were performed using Stata version 14.1.

Ethical Considerations

The study used anonymized secondary data obtained from the Demographic and Health Surveys (DHS) programme with prior permission. Since the dataset contains no personally identifiable information, no additional ethical approval was required for the present analysis. The original NFHS-5 survey received ethical clearance from the appropriate national ethics committees, and informed consent was obtained from all participants before data collection. [10] 3. Results

State-wise Distribution of Mortality

The state-wise analysis revealed substantial variation in child mortality across India, indicating that the burden of mortality remains uneven despite considerable improvements in child survival over recent decades. 31.45). However, the differences were relatively small in a few states, indicating that the influence of place of residence is closely associated with the overall level of socio-economic development and accessibility of maternal and child healthcare services rather than urbanization alone. Maternal characteristics also showed a strong association with child mortality across the states. Birth order exhibited a consistent positive relationship with mortality, with higherorder births generally experiencing poorer survival than firstor second-order births. At the national level, IMR increased from 35.45 among first births to 50.56 among births of order four and above. This pattern was particularly evident in Kerala, where IMR increased from 6.15 for first births to 70.47 for fourth and higher-order births, although the latter estimate should be interpreted cautiously because of the relatively small number of higher-order births in the state. Similarly, high mortality among fourth and higher-order births was observed in Punjab (54.19), Odisha (50.42), Bihar (47.86) and Uttar Pradesh (62.12). These findings suggest that increasing birth order remains an important risk factor for child mortality, particularly in states where fertility levels continue to be relatively high. 12.77) and West Bengal (24.80 vs. 18.52). However, the magnitude of these differences was much smaller than those observed for socio-economic and maternal healthcare factors, indicating that biological sex alone explains only a limited proportion of the interstate variation in child mortality. Mortality patterns according to religion were less consistent across the country. While some states reported relatively higher mortality among Hindu children and others among Muslim or other religious groups, no uniform national trend was evident. The observed differences appeared to reflect regional socio-economic conditions and disparities in healthcare access rather than religious affiliation itself.

Overall, the state-wise analysis demonstrates that child mortality in India continues to exhibit substantial geographical and socio-economic inequalities. States characterized by lower maternal education, poorer household economic conditions, higher birth order, inadequate antenatal care, and a greater proportion of home deliveries consistently experienced higher mortality. In contrast, states with better maternal healthcare utilization and stronger socio-economic development generally recorded more favourable child survival outcomes. These findings highlight the need for state-specific public health strategies that strengthen maternal healthcare services while addressing the broader social and economic determinants of child health.

Spatial Distribution of Infant Mortality Rate across Indian States

Figure 1 illustrates the spatial distribution of the Infant Mortality Rate (IMR) across Indian states according to selected socio-economic, demographic, and maternal healthcare characteristics. Although the magnitude of IMR varied across background characteristics, the geographical pattern remained largely consistent. States located in the northern and central regions of India generally exhibited higher infant mortality, whereas southern states recorded comparatively lower mortality under most background characteristics.

The maps consistently identified Uttar Pradesh, Bihar, Madhya Pradesh, Rajasthan, Odisha, and Chhattisgarh as high-mortality states. These states remained in the higher mortality categories across several socio-economic and maternal health characteristics, indicating that infant mortality is concentrated in regions with relatively lower socioeconomic development and weaker maternal and child healthcare services. In contrast, Kerala, Tamil Nadu, Puducherry, Himachal Pradesh, and Goa consistently appeared in the lower mortality categories, reflecting better healthcare utilization and improved living conditions. Clear geographical disparities were observed according to maternal healthcare indicators. States with lower utilization of antenatal care and higher proportions of home deliveries generally showed higher IMR. Conversely, states with better antenatal care coverage and higher institutional delivery rates were predominantly classified into lower mortality categories. These patterns highlight the important contribution of maternal healthcare services to improved infant survival. The spatial distribution also demonstrated marked socioeconomic inequalities. Higher mortality among children born to mothers with no formal education, children from poor households, and those belonging to socially disadvantaged communities was concentrated primarily in the northern and central states. Southern and some western states showed comparatively lower mortality across these population groups, suggesting that improvements in education, household economic conditions, and healthcare accessibility contribute substantially to reducing infant mortality. Differences according to demographic characteristics, including maternal age, birth order, and sex of the child, showed relatively smaller geographical variation compared with socio-economic and healthcare characteristics. Nevertheless, higher-order births and births to younger or older mothers tended to be concentrated in states already experiencing higher levels of infant mortality, indicating that these factors may further increase the risk of infant deaths in vulnerable populations.

The spatial analysis demonstrates that infant mortality in India is not randomly distributed but exhibits clear regional clustering. States with persistent socio-economic disadvantage and limited access to quality maternal and child healthcare consistently experienced higher infant mortality, whereas states with better health infrastructure and socio-economic development recorded substantially lower mortality. These geographical disparities emphasize the need for regionspecific public health interventions and continued investment in maternal and child healthcare services to reduce interstate inequalities in infant survival. The findings revealed substantial interstate variation in child mortality across different socio-economic, demographic, and maternal healthcare characteristics. Although India has achieved considerable progress in reducing child mortality over recent decades, important disparities continue to exist across states and population groups, consistent with previous national and global evidence on child survival inequalities [11,12] . Higher mortality was consistently observed among children from poor households, mothers with no formal education, higher birth orders, inadequate antenatal care, and home deliveries. In contrast, lower mortality was generally associated with better maternal education, improved household economic status, adequate antenatal care, and institutional delivery. These findings reinforce existing evidence that social determinants and access to quality maternal healthcare remain fundamental drivers of child survival in low-and middle-income countries [13,14] . The spatial distribution of IMR further demonstrated clear regional disparities, with several northern and central states continuing to experience relatively higher infant mortality than many southern states. These geographical differences suggest that national averages may conceal substantial interstate inequalities and highlight the importance of statespecific planning and resource allocation to address local health challenges. Overall, the study emphasizes that further reductions in child mortality require integrated strategies that combine improvements in maternal and child healthcare with broader socio-economic development. Strengthening antenatal care services, promoting institutional deliveries, improving female education, reducing household poverty, and ensuring equitable access to quality healthcare should remain key priorities for achieving the Sustainable Development Goal (SDG) targets related to child survival and reducing avoidable mortality among children under five years of age [15] .

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