CHRISMED Journal of Health and Research

: 2020  |  Volume : 7  |  Issue : 1  |  Page : 12--15

Sociodemographic correlates of infant mortality in India: A review of national family health survey data

Ratan Gupta, Manas Pratim Roy 
 Department of Pediatrics, Safdarjung Hospital, New Delhi, India

Correspondence Address:
Manas Pratim Roy
Department of Pediatrics, Safdarjung Hospital, New Delhi - 110 029


Introduction: Infant mortality rate (IMR) is interplay of several sociodemographic factors. There are several scopes for policymakers to bring IMR down by improving those factors. An ecological analysis was performed, with the aim to identify such factors. Methods: Data were taken from nationally-representative National Family Health Survey 4 (2015–2016). Correlation was used for the analysis. States were compared individually and in groups. Results: Female literacy (r = −0.639), improved sanitation (r = −0.604), and clean fuel (r = −0.463) were significantly related to IMR. States belonging to the Empowered Action Group performed poorly in terms of infant death and basic amenities provided to the citizens. Conclusion: Efforts should be made to improve household environments to reduce infant deaths in future.

How to cite this article:
Gupta R, Roy MP. Sociodemographic correlates of infant mortality in India: A review of national family health survey data.CHRISMED J Health Res 2020;7:12-15

How to cite this URL:
Gupta R, Roy MP. Sociodemographic correlates of infant mortality in India: A review of national family health survey data. CHRISMED J Health Res [serial online] 2020 [cited 2020 Jul 8 ];7:12-15
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Infant mortality rate (IMR) is not only a health-related indicator but also recognized widely as a social indicator. From the perspective of a developing country, it remains as a priority in public health issues. Hence, even beyond the success registered under the Millennium Development Goal-4 by many countries, it keeps its relevance intact. As part of the Physical Quality of Life Index, IMR continues to reflect the health of a nation.

Worldwide, 4.1 million infant deaths occurred in 2017. In terms of global IMR, there is a reduction from 65/1000 live births in 1990 to 29/1000 live births in 2017.[1] Most of these deaths are preventable or treatable.[2] The global leaders, therefore, put it in the Sustainable Development Goal within the scope of target 3.2.

Although India has registered gradual reduction in infant mortality over the past one decade, as evident from National Family Health Survey (NFHS) report (57/1000 live births in 2005–2006 and 41/1000 live births in 2015–2016), the achievement has been patchy, with few pockets still registering high mortality rate.[3] This demands for the identification of vulnerable geographical areas and explore the socioeconomic determinants for developing strategies to improve IMR in those areas, apart from ensuring community- and facility-based healthcare for the infants.

Earlier, several studies tried to find out the factors responsible for high mortality among infants in certain parts of India.[4],[5] Socio-economic factors such as female literacy and sanitation were stressed on to impact the extent of IMR. Studies from other countries also support the role of household environment for the same.[6],[7]

In this perspective, state-wise data were analyzed for identifying factors linked to infant mortality.


Data were retrieved from the latest NFHS 4, conducted in 2015–2016.[3] Along with IMR, seven other variables were considered. Other variables were female literacy, provision for improved drinking water and improved source of sanitation, use of clean fuel for cooking, children vaccinated with measles, the prevalence of diarrhea in the past 2 weeks preceding survey, and children exclusively breastfed. Improved drinking water source indicates piped water into dwelling/yard/plot, public tap/standpipe, tubewell or borehole, protected dug well-protected spring, rainwater, and community reverse osmosis plant. By improved sanitation, the following were considered-flush to piped sewer system, flush to septic tank, flush to pit latrine, ventilated improved pit/biogas latrine, pit latrine with slab, twin pit/composting toilet, which is not shared with any other household. Clean fuel includes electricity, liquefied petroleum gas/natural gas, and biogas. Measles vaccination was assessed in children between the ages of 12–23 months. Children under 6 months of age were assessed for exclusive breastfeeding (EBF).

Initially, States/Union Territories (UT) were divided into three groups. Empowered Action Group (EAG) states, as defined by the Government, include Bihar, Chhattisgarh, Rajasthan, Uttar Pradesh, Uttarakhand, Odisha, Jharkhand, and Madhya Pradesh. Eight states of North East (NE) India were clubbed together. Rest states/UTs were kept in another group. Descriptive statistics were calculated for each of the variables. Using bar diagram, group averages were compared. The Pearson correlation coefficient was calculated between IMR and other variables. Special consideration was given to the EAG and NE states.

P < 0.05 was considered statistically significant. PASW for Windows software (version 19.0; SPSS Inc., Chicago, USA) was used.


Among the three groups, EAG states registered the highest average IMR (47.8/1000 live births). NE states not only registered the lowest coverage of improved drinking water and measles vaccination but also had the lowest prevalence of diarrhea. EAG states recorded the lowest female literacy, use of clean fuel for cooking, and improved source of sanitation but the highest average practice of EBF [Figure 1].{Figure 1}

IMR was negatively and significantly correlated with female literacy (r = −0.639, P = 0.000), households with improved sanitation (r = −0.604, P = 0.000), and clean fuel (r = −0.463, P = 0.006). There was no significant relation between IMR and drinking water, measles vaccination, diarrhea, and EBF.

[Table 1] shows eight EAG states and their comparative performance. Highest IMR was in Uttar Pradesh (64/1000 live births). While Bihar registered the best coverage of improved drinking water, it had the lowest female literacy and households with clean fuel. In four indicators, of eight, Uttarakhand performed better than the rest of the states in this group.{Table 1}

Similarly, in NE India, Sikkim, and Mizoram registered the best performance in three indicators than other states [Table 2]. Highest IMR was found in Assam (48/1000 live births).{Table 2}


There are considerable variations among states, in terms of IMR and other socioeconomic indicators. Socio-economic inequalities are known factors for determining such variations. These could influence access and utilization of health services. If we add the availability of services to that, differences between states may well be subjected to complex interplay of several factors that were not taken into consideration. Still, we made a sincere effort in this article to identify the factors influencing IMR.

The effect of literacy on IMR has been highlighted earlier by Schultz.[8] Higher education level of the mother is a protective factor in infant mortality.[6],[9] Maternal literacy not only promotes healthy practices but also changes attitude, contributes to family wages and supports decision-making.[10],[11] Previous analysis of Indian data also suggests the same.[4],[5] As female literacy is low in EAG states than the rest of the country, child survival suffers. Perhaps, more important is the gender gap in literacy, as highlighted by Kumar et al., which hinders the utilization of health-care services.[12] Even from NFHS 4, UP recorded 21% points in that gap, whereas MP scored 22. Literacy removes cultural superstitions from healthcare and paves way for the timely management of childhood morbidities. In an ecological study like ours, we expected female literacy, rather than maternal literacy, would play as an important indicator for intervention for policymakers.

Better sanitation is known to determine child mortality.[13],[14] A study from Africa reported that 1% increase in access to better sanitation reduces infant mortality by 2/1000 live births.[9] A report from UNICEF suggested sanitation as one of the major cost-effective interventions for reducing deaths in under-five children.[15] Hygienic toilet, prevalent in high economic status, is associated with decrease in infant mortality.[6] The higher proportion of hygienic toilets in urban areas may be responsible for the difference with rural counterparts, in terms of infant deaths.[6] It has been claimed that the effect of sanitation could best be demonstrated in children taking food other than breast milk.[16] Total Sanitation Campaign and Swachh Bharat are two examples for promoting sanitation practices in our country. It is expected that in the near future we may reap the benefits of good works done under these two schemes.

Cooking inside the house with solid fuel has been reported to increase infant mortality from other studies[7],[14] Traditional engagement of women in cooking puts their infants at direct exposure to indoor air pollution. In fact, such exposure increases the risk of lower respiratory tract infection among children.[17] It may be mentioned that household air pollution was responsible for 5% disease burden in India in 2016.[18] The problem aggravates in the rural area.[19] Ujjwala scheme, an initiative by the Government of India, has boosted the effort to enrich households situated even in distant pockets with clean fuel. This, if nurtured carefully, may prove to be game-changer in reducing infant mortality in the coming years.

One study from Africa suggested a reduction in mortality of girl infants following measles vaccination.[20] However, the present study could not get any correlation between the two. Measles, a childhood killer, is important as it could prevent the infants by herd immunity, therefore making measles vaccination crucial for ensuring child survival. Similarly, no significant correlation was detected with diarrhea, a major killer of the children. Our study could not find any significant relation with the provision of safe drinking water and EBF.

EAG states form about half of the country's population. High IMR has conventionally been recorded in these states. On the other hand, NE states, because of hilly terrain and difficult communications, may find it difficult to establish easy access to care. Both of these groups of states should take special care for adopting a strategy for the reduction of infant mortality. However, all EAG states except Uttarakhand should devise plan for improving their dilapidated systems of sanitation. From NE, Assam, and Manipur should do the same. The same is true for the use of clean fuel. Rampant use of solid fuel could be thought of as one of the major contributors to infant mortality in EAG states and Assam, as indicated from another study conducted in Nepal.[17] Such identification is important to identify the causes of inequality, to improve country parameters and bring about sustainable change.

As home-based neonatal care complements Integrated Management of Neonatal and Childhood Illnesses to ensure a complete package of care to every child, we probably need more stress on sanitation practices by front line health workers. Improved sanitation could reduce economic loss due to the treatment of sanitation-related illnesses.[9] From this point of view, investment in education and sanitation should be implemented to yield high returns in terms of infant lives.

Lack of data on health-seeking behavior and the availability of health services could be considered as one of the limitations of the present study. On the other hand, with handful of articles available on ecological analysis of IMR, the present article brings the focus of public health policy to education, sanitation, and clean fuel. One of the strengths of this study is representation from the entire country. Therefore, extrapolation of findings and subsequent decision taking by the policymakers would be easier.


Socio-economic status could well be an individual factor, but sanitation, drinking water, and clean fuel may have clustered effect. Hence, strategies are warranted targeting basic amenities of healthy living in identified clusters. As inequality might be related to factors beyond the scope of health services, we need multisectoral approach to bring down IMR.[6] A comprehensive strategy, implemented in collaboration with other ministries, might be able to spell success in a shorter duration.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Global Health Observatory Data. Infant Mortality. Available from: [Last accessed on 2019 Jan 02].
2United Nations Children's Fund. UN Inter-agency Group for Child Mortality Estimation. Levels and Trends in Child Mortality. New York: United Nations Children's Fund; 2018.
3International Institute for Population Sciences and ICF. National Family Health Survey (NFHS-4), 2015-16: India. Mumbai: International Institute for Population Sciences and ICF; 2017. Available from: [Last accessed on 2018 Jun 02].
4Saurabh S, Sarkar S, Pandey DK. Female literacy rate is a better predictor of birth rate and infant mortality rate in India. J Family Med Prim Care 2013;2:349-53.
5Ladusingh L, Gupta AK, Yadav A. Ecological context of infant mortality in high-focus states of India. Epidemiol Health 2016;38:e2016006.
6Hosseinpoor AR, Van Doorslaer E, Speybroeck N, Naghavi M, Mohammad K, Majdzadeh R, et al. Decomposing socioeconomic inequality in infant mortality in Iran. Int J Epidemiol 2006;35:1211-9.
7Khan MN, B Nurs CZ, Mofizul Islam M, Islam MR, Rahman MM. Household air pollution from cooking and risk of adverse health and birth outcomes in Bangladesh: A nationwide population-based study. Environ Health 2017;16:57.
8Schultz TP. Investments in the Schooling and Health of Women and Men: Quantities and Returns. Bellagio, Italy: Paper presented at the Conference on Women's Human Capital and Development; 1992. p. 18-22.
9Alemu AM. To what extent does access to improved sanitation explain the observed differences in infant mortality in Africa? Afr J Prim Health Care Fam Med 2017;9:e1-9.
10D'Souza S, Bhuiya A. Socioeconomic mortality differentials in a rural area of Bangladesh. Popul Dev Rev 1982;8:753-69.
11Streatfield K, Singarimbun M, Diamond I. Maternal education and child immunization. Demography 1990;27:447-55.
12Kumar C, Singh PK, Rai RK. Under-five mortality in high focus states in India: A district level geospatial analysis. PLoS One 2012;7:e37515.
13Trussell J, Hammerslough C. A hazard model analysis of the covariates of infant and child mortality in Sri Lanka. Demography 1983;20:1-26.
14Kusneniwar GN, Mishra AK, Balasubramanian K, Reddy PS. Determinants of infant mortality in a developing region in rural Andhra Pradesh. Natl J Integr Res Med 2013;4:20-6.
15Van Maanen P. Evidence base: Water, Sanitation and Hygiene Interventions. New York: United Nations Children's Fund; 2010.
16Spears D. Effects of Rural Sanitation on Infant Mortality and Human Capital: Evidence from India's Total Sanitation Campaign; 2012. Available from; [Last accessed on 2019 Jan 10].
17Bates MN, Chandyo RK, Valentiner-Branth P, Pokhrel AK, Mathisen M, Basnet S, et al. Acute lower respiratory infection in childhood and household fuel use in Bhaktapur, Nepal. Environ Health Perspect 2013;121:637-42.
18Indian Council of Medical Research, Public Health Foundation of India, Institute for Health Metrics and Evaluation. India: Health of the Nation's States – The India State-Level Disease Burden Initiative. New Delhi, India: Indian Council of Medical Research, Public Health Foundation of India, Institute for Health Metrics and Evaluation; 2017.
19Neogi SB, Pandey S, Sharma J, Chokshi M, Chauhan M, Zodpey S, et al. Association between household air pollution sand neonatal mortality: An analysis of Annual Health Survey results, India. WHO South East Asia J Public Health 2015;4:30-7.
20Byberg S, Østergaard MD, Rodrigues A, Martins C, Benn CS, Aaby P, et al. Analysis of risk factors for infant mortality in the 1992-3 and 2002-3 birth cohorts in rural Guinea-Bissau. PLoS One 2017;12:e0177984.