Mortality among Children Aged 1–59 Months in India: Evidence from a Systematic Review and Meta-Analysis (2009–2024)

BACKGROUND: Mortality among Indian children aged 1–59 months remains a concern, yet evidence arises from hospital and community settings that reflect different populations and metrics. A setting-specific synthesis is needed to clarify mortality trends, causes, and associated factors. METHODS: We reviewed observational studies (2009–2024) on deaths, causes, or risk factors among children aged 1–59 months. Two reviewers independently extracted data. Hospital and community studies were analyzed separately, using setting-specific mortality definitions. Random-effects GLM models pooled mortality and risk factors. Cause-of-death distributions and trends were synthesized only for hospital studies due to limited community data. FINDINGS: Sixty-seven studies were included: 50 hospital-based, 11 community-based, and six case-control. The pooled in-hospital mortality was 8.1%, with substantial heterogeneity (0.1%-65%); largely reflecting cohorts restricted to critically ill children. Pneumonia (38%), congenital anomalies (32%) and central nervous system infections (23%), accounted for most clinically ascertained deaths. Deaths declined over time (2.4%) particularly during the pre-COVID period; while post-COVID trends were imprecise; a regional decline (3%) was detected only in northern India. Community mortality was highly heterogeneous, with a pooled estimate of 3.3% and data were insufficient for trend analysis. Female sex and lack of immunization were significantly associated with in hospital mortality, while no significant risk factors were identified in community analyses. CONCLUSION: India achieved meaningful reductions in child mortality, although recent trends remain uncertain following the COVID-19 period. Persistent heterogeneity across settings and sex differences in hospital-based mortality underscore the need for strengthened community surveillance and standardized reporting to sustain and accelerate national gains.