Trends, patterns and predictive factors of infant and child mortality in well-performing and underperforming states of India: a secondary analysis using National Family Health Surveys

OBJECTIVES: This paper analyses the patterns and trends in the mortality rates of infants and children under the age of 5 in India (1992–2016) and quantifies the variation in performance between different geographical states through three rounds of nationally representative household surveys. DESIGN: Three rounds of cross-sectional survey data. SETTING: The study is conducted at the national level: India and its selected good-performing states, namely Haryana, Kerala, Maharashtra, Punjab and Tamil Nadu, and selected poor-performing states, namely Bihar, Chhattisgarh, Madhya Pradesh and Uttar Pradesh. PARTICIPANTS: Adopting a multistage, stratified random sampling, 601 509 households with 699 686 women aged 15–49 years in 2015–2016, 109 041 households with 124 385 women aged 15–49 years in 2005–2006, and 88 562 households with 89 777 ever married women in the age group 13–49 years in 1992–1993 were selected. RESULTS: Through the use of maps, this paper clearly shows that the overall trend in infant and child mortality is on a decline in India. Computation of relative change shows that majority of the states have witnessed over 50% reduction in both infant and under-5 mortality rates from National Family Health Survey (NFHS)-I to NFHS-4. However, the improvements are not evenly distributed, and there is huge variation in performance between states over time. Funnel plots show that the most populous states like Uttar Pradesh Bihar and Madhya Pradesh have underperformed consistently across the survey period from 1992 to 2016. Regression analysis comparing high-performing and low-performing states revealed that female infants and women with shorter birth intervals had greater risk of infant deaths in poor-performing states. CONCLUSION: Attempts to reduce infant and child mortality rates in India are heading in the right direction. Even so, there is huge variation in performance between states. This paper recommends a mix of strategies that reduce child and infant mortality among the high-impact states where the biggest improvements can be expected, including the need to address neonatal mortality.