Exploring Under-Five Mortality Rates in India: Patterns and Causes

Few demographic numbers carry as much weight as the under-five mortality rate. It tells us, in a single figure, how a society treats its youngest citizens – how well it feeds them, vaccinates them, and stands by their mothers during pregnancy and childbirth. India’s story on this front is one of remarkable progress mixed with stubborn inequalities. Over three decades, the country has cut child deaths by more than half, yet it still accounts for a disproportionate share of the world’s under-five deaths. Understanding the patterns and causes behind these numbers is essential for anyone studying population dynamics, public health, or social policy.

Understanding the categories of child mortality 🔗

Before looking at trends, it helps to be clear about what is being measured. Demographers slice early childhood deaths into specific age brackets because the causes of death change dramatically with age. A baby who dies on day one rarely dies of the same condition as a toddler who dies at three.

Neonatal, infant, and under-five mortality defined 🔗

The Neonatal Mortality Rate (NMR) measures deaths within the first 28 days of life per 1,000 live births. This is the most fragile window – deaths here are typically linked to pregnancy, delivery, and the immediate newborn period. The Infant Mortality Rate (IMR) extends this to the full first year of life, capturing both newborn deaths and post-neonatal deaths from infections, malnutrition, and accidents. Finally, the Under-Five Mortality Rate (U5MR) includes everything from birth up to a child’s fifth birthday. As one analysis notes, U5MR is considered a decisive metric in assessing a nation’s healthcare and developmental progress because it provides valuable insights into the health and survival of its youngest population.

There’s also the Perinatal Mortality Rate, which combines stillbirths after 28 weeks of pregnancy with deaths in the first week after birth – useful for evaluating obstetric and immediate newborn care together.

Tracking the decline across NFHS surveys 🔗

The National Family Health Survey (NFHS) has been India’s most comprehensive source of demographic and health data since 1992-93. Each round paints a clearer picture of how child survival has improved.

From NFHS-1 to NFHS-5: the long arc 🔗

The improvement across five rounds of NFHS is undeniable. According to a district-level analysis, the under-five mortality rate has declined by a little more than half in 23 years, falling from 109 deaths per 1,000 live births around 1990 to 50 deaths per 1,000 live births by 2013. By the time NFHS-5 (2019-21) results came out, the picture was even better. The survey reported an Under-Five Mortality Rate of 42 per 1,000 live births, a Neonatal Mortality Rate of 25, and an Infant Mortality Rate of 35 – compared to 50, 30, and 41 respectively in NFHS-4.

In simple terms: a child born in India in the early 1990s was nearly three times more likely to die before age five than a child born around 2020.

Why neonatal mortality deserves special attention 🔗

Here’s the part that worries demographers. Even as overall child mortality has fallen, the share of deaths happening in the first month of life has actually grown. Newborn deaths now account for a major chunk of all under-five deaths. UNICEF observes that nearly 40 per cent of newborn deaths and half of maternal deaths happen on the day a child is born.

This pattern is sometimes called the “neonatalisation of child mortality.” Deaths from preventable infections like diarrhoea, measles, and pneumonia have responded well to vaccination drives, oral rehydration, and antibiotics. But deaths within the first 28 days are harder to prevent – they require quality antenatal care, skilled birth attendants, functional intensive care for newborns, and management of premature and low-birth-weight babies. These are health-system intensive interventions, and progress on them has been slower.

The Press Information Bureau reports that following a steady downward trend, IMR, U5MR and NMR have further declined as a result of countrywide efforts towards increasing health service coverage under the RMNCAH+N strategy. But the pace of neonatal decline still lags.

Leading causes of under-five deaths 🔗

To reduce mortality further, we need to know what children are dying of. The causes split neatly along age lines.

What kills newborns 🔗

In the first month, the dominant causes are biological and obstetric. UNICEF India lists the major causes of newborn deaths as prematurity and low birth weight (48 per cent), birth asphyxia and birth trauma (13 per cent), neonatal pneumonia (12 per cent) and non-communicable diseases (7 per cent), along with diarrhoea and pneumonia. Almost half of all neonatal deaths in India trace back to babies being born too small or too soon.

What kills children aged 1-59 months 🔗

Once a child survives the newborn period, the threats shift to the environment. A nationally representative mortality survey found that two causes accounted for 50 per cent of all deaths at 1-59 months: pneumonia and diarrhoeal diseases. These two conditions – both highly preventable with vaccines, hygiene, breastfeeding, and prompt treatment – have historically been the biggest killers of toddlers and preschoolers.

Research published on seasonal patterns shows that pneumonia mortality is highest in January, while diarrhoea deaths peak in both July and January – reflecting how climate, water quality, and viral transmission combine to shape child survival across the year.

Contributing factors: what drives the differences 🔗

National averages hide enormous variation. A child born in Kerala has dramatically better survival odds than one born in Madhya Pradesh or Bihar. Three factors stand out in explaining why some children live and others don’t.

Birth interval and birth order 🔗

Spacing between births matters enormously. When women give birth in quick succession – say, less than two years apart – both mother and baby face higher health risks. The mother’s body hasn’t fully recovered, breastfeeding for the older child gets disrupted, and resources within the household are spread thinner. Multivariate analysis of NFHS data shows that factors such as breastfeeding and birth interval greater than 24 months are important in under-five survival.

Birth order tells a related story. Higher birth orders are often linked to older mothers, larger families, and depleted maternal nutrition. An analysis of NFHS-4 data found that birth order greater than 6 was significantly associated with high under-five mortality at 11.0 per cent. The takeaway: family planning is not just a population-control measure – it is a child-survival measure.

Size at birth 🔗

A baby’s size at birth is one of the strongest predictors of survival. Low birth weight – defined as below 2,500 grams – is associated with higher risk of infection, hypothermia, feeding difficulties, and long-term developmental issues. As already noted, prematurity and low birth weight together account for nearly half of all neonatal deaths in the country. The roots of low birth weight lie even before pregnancy: in the mother’s own nutrition, her body mass index, her age at conception, and her exposure to anaemia and infections.

Maternal anaemia, in particular, remains stubbornly high in India and contributes directly to small, premature babies who struggle in their first weeks.

Maternal education 🔗

Few variables have as consistent and powerful an effect on child survival as how long the mother went to school. Educated mothers are more likely to seek antenatal care, deliver in a health facility, recognise danger signs in a sick child, follow immunisation schedules, and exclusively breastfeed. NFHS-4 analysis confirmed that mothers with no education and rural residence had higher under-five mortality (5.99 per cent and 4.93 per cent, respectively), while better-informed mothers had the lowest rates of child loss.

The effect operates through multiple channels: better economic opportunities, later age at marriage, greater autonomy in household decisions, and more accurate health knowledge. This is why investments in girls’ secondary education almost always show up later as gains in child survival.

Inequalities that persist 🔗

Even as national averages improve, gaps between groups remain wide. Children from Scheduled Tribes, from poorer wealth quintiles, and from rural areas continue to die at higher rates than their urban, wealthier counterparts. Geography matters too – states like Madhya Pradesh, Chhattisgarh, Uttar Pradesh, and Bihar consistently report higher U5MR than southern states. Gender adds another layer; UNICEF notes that under-5 mortality for girls in India remains 3.3 per cent higher than for boys, a reversal of the global pattern where boys typically die at higher rates.

India has committed to the Sustainable Development Goal target of reducing under-five mortality to at most 25 per 1,000 live births by 2030. Reaching this goal will require closing these state-wise and social gaps, not just lowering the national average.

What do you think? 🔗

Reflect on this: If maternal education and birth spacing have such powerful effects on child survival, why do you think public discussion of child mortality so often focuses on hospitals and vaccines rather than on schools and family planning? And which intervention – improving newborn care in the first 28 days or expanding girls’ secondary education – do you think would save more young lives in India over the next decade?

References

1. https://pmc.ncbi.nlm.nih.gov/articles/PMC11463881/
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3. https://pmc.ncbi.nlm.nih.gov/articles/PMC10657051/
4. https://www.unicef.org/india/what-we-do/health
5. https://www.pib.gov.in/PressReleasePage.aspx?PRID=1894904
6. https://pubmed.ncbi.nlm.nih.gov/21075444/
7. https://pmc.ncbi.nlm.nih.gov/articles/PMC6759316/
8. https://springerplus.springeropen.com/articles/10.1186/2193-1801-2-284
9. https://www.ceghonline.com/article/S2213-3984(21)00174-3/fulltext
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11. https://data.unicef.org/topic/child-survival/under-five-mortality/