Reasons of Infant Mortality (Except Neonates) in Patients Admitted in Tertiary Care Hospital, Bhavnagar: A Cross-Sectional Study.

Infant mortality, defined as death before completion of the first year of life, is an important indicator of population health and reflects socioeconomic, nutritional, environmental, and healthcare conditions [1]. The Infant Mortality Rate (IMR), expressed as the number of infant deaths per 1,000 live births, is widely used to assess child survival and the effectiveness of maternal and child health services [1]. Infant survival is influenced by factors operating from pregnancy through early childhood, including access to healthcare, maternal education, nutrition, and living conditions. [1-3]

India has achieved considerable reductions in child mortality over recent decades; however, substantial disparities persist across socioeconomic and geographical groups [4]. UNICEF reported approximately 468,000 neonatal deaths in India in 2020, emphasizing the continuing need for effective interventions during the antenatal, intrapartum, neonatal, and early infancy periods [5]. Prematurity, low birth weight, birth asphyxia, neonatal infections, congenital anomalies, respiratory infections, and diarrhoeal diseases are important contributors to infant mortality [5,6]. These outcomes are further influenced by maternal age, birth order, socioeconomic status, maternal education, nutrition, immunization, and access to healthcare [6,7].

Hospital-based studies provide an opportunity to evaluate clinical and social factors associated with infant mortality through systematic review of medical records. [8-10] Tertiary-care hospitals, which serve diverse urban and rural populations, are particularly useful for identifying potentially modifiable determinants and guiding targeted interventions. [8-10]

Sir Takhtsinhji General Hospital, Bhavnagar, is a government tertiary-care teaching hospital and major paediatric referral centre serving urban and rural populations. Its Departmental Monthly Death Review Committee provides a systematic mechanism for reviewing paediatric deaths and identifying contributing factors. Therefore, the present study was undertaken to assess the nutritional status, socioeconomic characteristics, immunization status, and parental educational status among infants who died during hospitalization, along with selected demographic and clinical factors, to identify potentially modifiable determinants and inform strategies for reducing infant mortality in the region.

Study Design and setting

The present study was a hospital-based retrospective cross-sectional observational study conducted in the Department of Paediatrics, Sir Takhtsinhji General Hospital, Bhavnagar, Gujarat, a government tertiary-care teaching hospital affiliated with Government Medical College, Bhavnagar.  A retrospective design was adopted as the study utilized existing hospital records and documentation from the Departmental Monthly Death Review Committee. The cross-sectional approach was appropriate for assessing the distribution of study variables among infant deaths during the defined study period, without any intervention. All patients had received standard medical care according to institutional protocols, and no additional diagnostic or therapeutic interventions were undertaken for the purpose of the study.

Study Duration

The study was conducted over a period of one year, followed by one month for data compilation, analysis, and interpretation.

Study Population

The study population comprised infants aged 29 days to less than 12 months who died during admission in the paediatric wards or PICU of Sir Takhtsinhji General Hospital during the study period. Eligible cases were reviewed and documented during the Departmental Monthly Death Review Committee meetings.

Sample Size

All eligible infant deaths occurring during the study period were included in the study. As a complete enumeration of eligible cases was undertaken, no formal sample size calculation was performed. A total of 64 infant death case records were included in the final analysis.

Inclusion Criteria

·         Infants aged 29 days to less than 12 months who died during hospitalization in the paediatric wards or PICU.

·         Infant deaths reviewed and documented by the Departmental Monthly Death Review Committee.

Exclusion Criteria

·         Neonates aged less than 28 completed days.

·         Infants brought dead to the hospital.

·         Cases with incomplete medical records or insufficient documentation to assess the study variables.

Data Collection

Prior approval was obtained from the Institutional Ethics Committee before commencement of data collection. Data were retrospectively collected using a structured, pre-approved data collection proforma. Information was obtained from inpatient case records, treatment charts, investigation reports, discharge summaries, death summaries, and records of the Departmental Monthly Death Review Committee.

The variables assessed included demographic characteristics, clinical history, nutritional status, immunization status, socioeconomic status, parental education, relevant birth history, and cause of death. Data were collected by the principal investigator using paper-based case record forms and subsequently entered into a Microsoft Excel master database. The entries were reviewed for completeness and accuracy, and cross-verification was performed to minimize data-entry errors.

Variables Studied

The principal study variables included nutritional status, socioeconomic status, immunization status, gestational age at birth, birth order, and maternal age. Additional variables included sex of the infant, maternal and paternal educational status, weight-for-age percentile, past medical history, family history, and primary cause of death. The outcome measure was the distribution of infant deaths according to these characteristics.

Statistical Analysis:

Data were entered into Microsoft Excel and analysed using Microsoft Excel. Categorical variables were summarized using frequencies and percentages. The findings were presented in appropriate tables and figures for descriptive analysis.

Table 1. Demographic distribution and infant death parameters of the study

Table 1 summarizes the demographic and clinical characteristics of infant deaths. A slight male predominance was observed (57.8%). Undernutrition was common, with 39.06% of infants being underweight, 34.38% having severe acute malnutrition, and 73.44% having weight-for-age below the 3rd percentile. Most deaths occurred among preterm infants, particularly moderately preterm (29.69%) and early preterm (25%). Additionally, 75% of deaths occurred among infants from the lower socioeconomic class and 21.88% from the lower-middle class, indicating a substantial burden of mortality among socioeconomically disadvantaged and nutritionally vulnerable infants.

Table 2. Distribution of Infant death by various demographic and clinical parameters

Table 2 shows that 35.94% of mothers were illiterate, while paternal education was relatively higher, with 29.69% having secondary and 31.25% higher secondary education. Inadequate immunization was common, with 54.69% partially immunized and 18.75% unimmunized.

The highest proportion of deaths occurred among mothers aged 18–25 years (40.63%), while 48.44% occurred among third or higher-order births. Additionally, 82.81% of infants had a previous NICU admission and 60.94% had a history of prior illness, indicating a high-risk population requiring close follow-up and appropriate post-discharge care.

Table 3. Cause of death in Infant Mortality

Table 3 demonstrates that low birth weight and prematurity were the most frequently identified causes associated with infant mortality, accounting for 81.25% of deaths. Sepsis was reported in 68.75% of cases, followed by respiratory tract infections (51.56%).

Congenital anomalies contributed to 21.88% of deaths, while 6.25% were associated with diarrhoeal diseases. Birth asphyxia and difficult labour accounted for 1.56% of deaths, whereas 39.06% were attributed to other causes. Overall, the findings indicate that prematurity, low birth weight, sepsis, and respiratory tract infections constituted the predominant contributors to infant mortality in the study population.

Table 4. Association of Immunisation status with different clinical parameters

Table 4 demonstrates that RTI and sepsis were more frequently observed among unimmunized infants, occurring in 75.0% and 83.3%, respectively, compared with 35.3% and 58.8% among fully immunized infants. Full immunization was also more common among infants with both literate parents (33.3%) than among those with one illiterate (28.0%) or both illiterate parents (13.3%). These findings suggest an association between inadequate immunization, infectious morbidity, and lower parental educational status; however, causality cannot be established from this descriptive study.

Table 5. Relationship of various parameters with RTI and Sepsis among Infant mortality

Table 5 shows that sepsis and RTI were more frequent among infants of higher birth order, with sepsis occurring in 60.0% of first-born, 65.2% of second-born, and 74.2% of third or higher-order infants. Similarly, RTI was present in 40.0%, 43.5%, and 61.3%, respectively. Preterm infants also had higher proportions of sepsis (73.1%) and RTI (53.85%) compared with term infants (50.0% and 41.66%, respectively). These findings suggest greater infectious vulnerability among preterm and higher-order infants, although causal relationships cannot be established from the present study.

Table 6. Distribution of Nutritional Status Across Socioeconomic Classes

Table 6 shows a high prevalence of malnutrition among the 64 infant deaths, with 56 (87.5%) classified as malnourished and only 8 (12.5%) having normal nutritional status. Malnutrition was particularly common among infants from the lower (89.6%) and lower-middle (85.7%) socioeconomic classes, compared with 50.0% in the middle class. No infants belonged to the upper or upper-middle classes. These findings indicate a substantial burden of malnutrition among deceased infants, particularly those from lower socioeconomic groups.

The present hospital-based retrospective cross-sectional study evaluated 64 infant deaths at Sir Takhtsinhji General Hospital, Bhavnagar, with respect to demographic, nutritional, socioeconomic, immunization, and clinical factors. A slight male predominance was observed (57.8%).

Undernutrition was highly prevalent, with 39.06% of infants being underweight, 34.38% having severe acute malnutrition, and 73.44% having weight-for-age below the 3rd percentile. Only 12.5% were adequately nourished. These findings highlight the important association between nutritional vulnerability and infant mortality. Black RE et al. estimated that undernutrition contributes to approximately 45% of under-five deaths globally [11], while Olofin I et al. reported nearly a nine-fold higher mortality risk among severely underweight children [12]. The bidirectional interaction between malnutrition and infection may further increase mortality risk [13].

A marked socioeconomic disparity was observed, with 75% of deaths occurring in the lower socioeconomic class and 21.88% in the lower-middle class. Additionally, 89.6% of infants from the lower socioeconomic class were malnourished compared with 50% from the middle class. These findings are consistent with studies demonstrating higher child mortality among economically disadvantaged populations [14,15].

Prematurity and low birth weight were prominent, with 81.25% of deaths occurring among preterm infants. Sepsis and RTI were also more frequent among preterm infants than term infants. The major contributing causes of death were low birth weight and prematurity (81.25%), sepsis (68.75%), and RTI (51.56%), followed by congenital anomalies (21.88%) and diarrhoeal diseases (6.25%). As multiple contributing causes could be present in an individual infant, these findings indicate a multifactorial pattern of mortality. The substantial burden of infection among preterm infants is consistent with their increased biological vulnerability and the recognized burden of respiratory infections in low- and middle-income countries [13,16].

Immunization coverage was inadequate, with only 26.56% of infants fully immunized, while 54.69% were partially immunized and 18.75% unimmunized. RTI and sepsis were proportionately higher among unimmunized infants (75% and 83.3%, respectively) than among fully immunized infants (35.3% and 58.8%). Although causality cannot be established, these findings highlight the importance of complete immunization in reducing infectious morbidity [17-19].

Parental education showed a positive association with immunization. Full immunization increased from 13.3% among infants with both parents illiterate to 33.3% when both parents were literate. Maternal illiteracy was observed in 35.94% of cases. Previous studies have similarly demonstrated the importance of maternal and paternal education in immunization uptake and child health outcomes [20,21].

Deaths were more frequent among mothers aged 18–25 years (40.63%) and among third or higher-order births (48.44%). Sepsis and RTI were also more common among higher-order births. These findings may reflect the influence of maternal age, birth spacing, maternal nutritional reserves, and distribution of household resources, although causal relationships cannot be established from the present study [22].

A history of NICU admission was present in 82.81%, while 60.94% had previous illness and 34.38% had previous hospitalization, indicating that many deceased infants were already at high risk. Previous studies have emphasized the vulnerability of low-birth-weight and NICU survivors to subsequent infections and readmission, highlighting the need for structured post-discharge follow-up [23,24].

Overall, infant mortality in this setting was characterized by the interplay of prematurity, undernutrition, socioeconomic disadvantage, incomplete immunization, and recurrent illness. Strengthening antenatal care, nutritional screening, immunization services, parental health education, and structured follow-up of high-risk infants may contribute to reducing preventable infant deaths [25].

Infant mortality in this study was predominantly associated with prematurity, low birth weight, malnutrition, infections, socioeconomic disadvantage, and inadequate immunization. Strengthening antenatal care, nutrition, immunization, hygiene & sanitation, parental education, and post-discharge follow-up of high-risk infants will definitely help reduce preventable infant deaths.

1.       Beck D, Ganges F, Goldman S, Long P. Care of the Newborn: Reference Manual. Washington, DC: Save the Children Federation; 2004.

2.       United Nations Inter-Agency Group for Child Mortality Estimation (UN IGME). Levels & Trends in Child Mortality: Report 2023. New York: UNICEF; 2024.

3.       World Health Organization. Sustainable Development Goal 3: Health. Geneva: WHO; 2023.

4.       Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, et al. Global, regional, and national causes of under-5 mortality in 2000–15: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet. 2016;388(10063):3027-35.

5.       Office of the Registrar General & Census Commissioner, India. SRS Bulletin 2023. New Delhi: Ministry of Home Affairs, Government of India; 2024.

6.       Office of the Registrar General & Census Commissioner, India. Sample Registration System Statistical Report 2020. New Delhi: Ministry of Home Affairs, Government of India; 2022.

7.       Guilmoto CZ, Saikia N, Tamura V, Bora JK. Excess under-5 female mortality across India: a spatial analysis using 2011 census data. Lancet Glob Health. 2018;6(6):e650-e658.

8.       Ministry of Health and Family Welfare. National Health Mission: Child Health Programmes. New Delhi: Government of India; 2023.

9.       International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), 2019-21: Gujarat. Mumbai: IIPS; 2021.

10.    International Institute for Population Sciences (IIPS). District Fact Sheet: Bhavnagar, Gujarat (NFHS-5). Mumbai: IIPS; 2021.

11.    Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427-51.

12.    Olofin I, McDonald CM, Ezzati M, Flaxman S, Black RE, Fawzi WW, et al. Associations of suboptimal growth with all-cause and cause-specific mortality in children under five years: a pooled analysis of ten prospective studies. PLoS One. 2013;8(5):e64636.

13.    Scrimshaw NS, Taylor CE, Gordon JE. Interactions of nutrition and infection. Monogr Ser World Health Organ. 1968;57:3-329.

14.    Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D, Claeson M, Habicht JP. Applying an equity lens to child health and mortality: more of the same is not enough. Lancet. 2003;362(9379):233-41.

15.    Pandey A, Kumar P. Socio-economic inequalities in neonatal and post-neonatal mortality: analysis of the National Family Health Survey (NFHS-4). Indian J Pediatr. 2019;86(4):345-52.

16.    Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ. 2008;86(5):408-16.

17.    Feikin DR, Flannery B, Hamel MJ, Stack M, Hansen PM. Vaccine-preventable diseases in children. In: Black RE, Laxminarayan R, Temmerman M, Walker N, editors. Reproductive, Maternal, Newborn, and Child Health: Disease Control Priorities. 3rd ed. Vol. 2. Washington DC: The World Bank; 2016.

18.    Bagchi S. "Missed opportunities" for immunization in children. Indian Pediatr. 2013;50(10):984.

19.    World Health Organization. Missed Opportunities for Vaccination (MOV) Strategy: A Guide for Health Workers. Geneva: WHO; 2019.

20.    Vikram K, Vanneman R, Desai S. Linkages between maternal education and childhood immunization in India. Soc Sci Med. 2012;75(2):331-9.

21.    Huq NL, Grepin K, Sikder SS. Paternal education and child mortality: a trend analysis of demographic and health surveys in Bangladesh. BMC Public Health. 2019;19(1):1598.

22.    Conde-Agudelo A, Belizán JM. Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study. BMJ. 2000;321(7271):1255-59

23.    Yasmin S, Osrin D, Paul E, Costello A. Neonatal mortality of low-birth-weight infants in Bangladesh. Bull World Health Organ. 2001;79(7):608-14.

24.    Mathias E, Gupta A, Seetharam S. "NICU graduates": the challenge of follow-up in low-resource settings. J Trop Pediatr. 2019;65(1):1-8.

25.    Mosley WH, Chen LC. An analytical framework for the study of child survival in developing countries. Popul Dev Rev. 1984;10(Suppl):25-4