Child Survival and Early Lifetime Exposures to Ambient Fine Particulate Matter in India: A Retrospective Cohort Study

BACKGROUND: Ambient fine particulate matter [PM [Formula: see text] in aerodynamic diameter ([Formula: see text])] is a major health risk for children, particularly in South Asia, which currently experiences the highest [Formula: see text] levels globally. Nevertheless, there is comparatively little epidemiological evidence from this region to quantify the effects of [Formula: see text] on child survival. OBJECTIVES: We estimated the association between [Formula: see text] exposure and child survival in India. METHODS: We constructed a large, retrospective, and nationally representative cohort of children [Formula: see text] , born between 2009–2016, from the publicly available, cross-sectional 2015–2016 Demographic Health Surveys in India. In utero and post-delivery lifetime average ambient [Formula: see text] exposures were estimated with data from satellite remote sensing, meteorology, and land use information (model [Formula: see text] 0.82). We used Cox proportional hazards regression to estimate the association between both average in utero and post-delivery lifetime [Formula: see text] and all-cause child mortality, controlling for individual- and household-level covariates, seasonality, location, and meteorology. RESULTS: Over 7,447,724 child-months of follow-up, there were 11,559 deaths at [Formula: see text] reported by the children’s mothers. The mean concentrations of 9-month in utero and post-delivery lifetime average ambient [Formula: see text] exposure were [Formula: see text] (range: [Formula: see text]) and [Formula: see text] (range: [Formula: see text]), respectively. Estimated child mortality adjusted hazard ratios were 1.023 [95% confidence interval (CI): 1.008, 1.038] and 1.013 (95% CI: 1.001, 1.026) per [Formula: see text] increase of in utero and post-delivery lifetime [Formula: see text] , with both exposures in the model. DISCUSSION: This study adds to the growing body of evidence about the adverse health effects of [Formula: see text] by demonstrating the association between exposure, both in utero and post-delivery, on child survival at the national level in India. Strategies to reduce ambient air pollution levels, including steps to minimize in utero and early life exposures, are urgently needed in India and other countries where exposures are above recommended guideline values. https://doi.org/10.1289/EHP8910