**Background:** Child mortality remains a critical public health challenge in developing countries, with Pakistan ranking among the highest globally. The United Nations Children's Fund (UNICEF) defines child mortality rate as the likelihood of a child dying between birth to 5 years of age per 1000 live births. Infant mortality rate (IMR) refers to deaths before 12 months of age per 1000 live births. As of 2020, Pakistan's under-5 child mortality rate was 65.2/1000, substantially exceeding the global rate of 37/1000. The IMR was 56.9/1000 in 2022, compared to the global IMR of 26.7/1000. For context, developed countries report far lower rates: USA (5.5/1000), Australia (2.8/1000), and Japan (1.6/1000). This narrative review aims to evaluate the factors contributing to high child and infant mortality in Pakistan and provide actionable recommendations.
**Methods:** The authors conducted a literature search using PubMed and Google Scholar with search terms including "Child mortality," "Infant mortality," "SIDS," "COVID-19," and "Pakistan." External sources such as UNICEF, CDC, WHO, JPMA, and UNESCO were also utilized. Inclusion criteria comprised original studies, systematic reviews, case studies, and reports from various organizations published in English. Exclusion criteria included abstract-only articles, editorials, and non-English publications. Data were cross-checked by researchers to avoid discrepancies.
**Key Results:** The review identifies multiple major determinants of child mortality in Pakistan. Neonatal death (death within 28 days of birth) is driven by premature birth (before 37 weeks), low birth weight (under 5 pounds 8 ounces), and complications including Respiratory Distress Syndrome (RDS), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), and sepsis. Harmful traditional practices such as applying substances (surma, cow dung, ghee, ash) to the umbilical cord exacerbate infection risk. Birth defects account for a significant burden, with low- and middle-income countries accounting for approximately 94% of severe birth defects. Vaccination coverage is critically low—only 58% of at-risk children are vaccinated in Pakistan, despite the Expanded Program on Immunization (EPI) being introduced in 1978. Vaccine hesitancy persists due to misconceptions, traditional beliefs, and violence against vaccine providers. Unsafe delivery practices are widespread: nearly half of all births are home deliveries, and 72% of those are attended by untrained midwives or relatives. Poor breastfeeding practices are linked to approximately 1.4 million child deaths and 44 million disability-adjusted life years globally. A cross-sectional study using Pakistan Demographic and Health Survey 2017-2018 data found that breastfeeding was associated with a 98% lower risk of neonatal mortality, 96% lower risk of infant mortality, and 94% lower risk of under-5 mortality. Pakistan had the highest stillbirth rate among 186 countries by the end of 2015. Sudden Infant Death Syndrome (SIDS) risk factors include prone positioning, alcohol consumption, prematurity, bed-sharing, maternal age below 20 years, and smoking more than 10 cigarettes per day during pregnancy. Socioeconomic determinants include low female education, low household wealth, and poor sanitation—80% of rural houses had no pipe-borne water, and 72% of those households had children suffering from diarrhea. The healthcare system is severely under-resourced: as of 2017, there were only 731 maternal and child health units, approximately 1201 hospitals, 683 basic health units, and a total bed capacity of slightly above 123,000. In 2019, there were only 0.5 midwives and nurses per 1000 individuals and 1.1 physicians per 1000 individuals. The COVID-19 pandemic further exacerbated the situation, with a 23% reduction in PICU admissions in 2020 compared to 2018, and a 44% reduction compared to 2019. Poor record-keeping and inadequate surveillance infrastructure have led to undocumented deaths and underestimation of official statistics.
**Clinical Implications:** The review presents several evidence-based recommendations. To address low vaccination rates, the authors propose that PEMRA regulate media to curb misinformation, hospitals incentivize vaccination, private schools mandate vaccination for admission (modeled after Italy's 2019 laws), and religious leaders and influencers promote vaccination on social media. For breastfeeding promotion, hospitals should educate staff, promote colostrum feeding, teach effective techniques like the cross-cradle position, and governments should mandate paid maternity leave and private breastfeeding rooms. To improve female education, the review recommends Take Home Rations (THR) programs conditional on school attendance and immunization, establishing girls-only schools, hiring more female teachers, and using online platforms (Zoom, Google Classroom) for remote education. Healthcare system strengthening requires increased funding for beds, PICUs, thermal units, and opening additional medical colleges. Water sanitation infrastructure investment is critical, as diarrhea causes 53,000 child deaths annually in Pakistan. The government should regulate essential goods pricing and expand programs like the Ehsas program launched in 2020. Telemedicine is recommended for a country where 63% of the population resides in rural areas, to reduce commuting costs, enable remote physician counseling of midwives during home births, and provide home-based fetal monitoring and medication reminders.