Clustering of Under-Five Mortality in Empowered Action Group States of India: A Binomial Distribution Analysis Using National Family Health Survey Data

Background: Under-five mortality is a key indicator of child health in India, especially in the Empowered Action Group (EAG) states and Assam, as child deaths are disproportionately concentrated in certain families.Such clustering reflects deep-rooted inequalities in access to healthcare.Understanding death clustering is important because it helps identify vulnerable populations and design targeted interventions.Methods: This study used data from the National Family Health Survey (NFHS-4) to examine clustering of under-five child deaths among families in EAG states and Assam.Applying a binomial distribution model, the study assesses whether observed child deaths exceed expected levels under uniform mortality risk.Results: The study findings reveal that, among the 325,296 women included in the analysis, 254,083 (78.1%) had not experienced an under-five child death, whereas 71,213 (21.9%) had experienced at least one underfive child death.The socio-economically disadvantaged families showed a high concentration of multiple child deaths.Women with low levels of education, low wealth status, rural residence, higher parity, and births at older maternal ages showed higher clustering of child deaths.Uttar Pradesh and Madhya Pradesh reported the highest levels of multiple child deaths.Conclusion: The study highlights that reducing overall child mortality alone is not sufficient.Focused interventions that address poverty, maternal education, healthcare access, and support for vulnerable families are necessary to reduce death clustering, improve child survival, and achieve health equity and the Sustainable Development Goals.