A baby born in Lahore is about three times as likely to die before her first birthday as one born across the border in Amritsar. The gap is not destiny. It is a choice about where the money goes.
Some statistics are dry. The infant mortality rate is not. It counts the babies who are born alive and die before their first birthday, for every 1,000 born. No other single number says so much about a society whether its mothers eat enough, whether a midwife is there at the birth, whether the nearest clinic has a nurse and a working incubator, whether clean water runs from the tap.
By that measure, Pakistan is failing its newest citizens, and Punjab, the country’s largest and richest province, is not doing much better than the national average.
Pakistan’s infant mortality rate is about 48 deaths per 1,000 live births, according to the latest UNICEF and UN inter-agency estimates. Roughly 36 of those deaths happen in the first four weeks of life, from premature birth, complications during delivery and infections that a clean birth and basic newborn care could prevent.
India, whose own record was long dismal, now stands at 24, according to its Sample Registration System for 2024. That is half Pakistan’s rate. The United States, by comparison, recorded about 5.5 infant deaths per 1,000 births in 2024, according to provisional federal data (the CDC’s final 2024 report has since been published), a rate many Americans regard as a national embarrassment because it trails much of Western Europe and East Asia.
Put simply, a Pakistani baby is about twice as likely as an Indian baby, and nearly nine times as likely as an American baby, to die before turning one.
Pakistan and India – The Two Punjabs
The comparison that should trouble Lahore most is closer to home. The two Punjabs share a language, a cuisine, a climate, a farming economy and, until 1947, a government. Lahore and Amritsar are barely 50 kilometres apart.
Pakistani Punjab’s infant mortality rate is 49 per 1,000, according to the provincial Multiple Indicator Cluster Survey for 2023-24, slightly above the national figure. Its under-five mortality rate is 55, rising to 59 in rural areas against 45 in cities. Neonatal deaths alone account for 33 of every 49 infant deaths.
Indian Punjab’s infant mortality rate is 16, according to India’s 2024 Sample Registration System, a third below India’s own national average. Kerala, India’s best performer, is down to eight.
A caveat matters here. The two countries measure differently: Pakistan’s provincial figure comes from a household survey that asks mothers about births over the previous five years, while India’s comes from a large sample registration system that records births and deaths as they happen. The figures are not precise enough to compare decimal by decimal. But no difference in method can explain a gap of three to one.
Progress, but too slow
It is only fair to say that Pakistani Punjab has made real progress. In 2007-08, according to successive surveys, 77 of every 1,000 babies died before their first birthday and 93 before their fifth. Today those figures are 49 and 55. Behind those numbers are tens of thousands of children alive who would not have been a generation ago, thanks in part to Lady Health Workers, immunisation campaigns and better roads to district hospitals.
But the pace has slowed. Infant mortality fell by 15 points between 2007 and 2011, and by just four points between 2018 and 2024. At that rate, the province will not come close to the global goal of reducing under-five deaths to 25 per 1,000 by 2030. Indian Punjab’s infant mortality rate alone is already well below that mark.
Why the gap persists
There is no mystery about what kills Pakistani babies. Most deaths happen in the first month and are tied to the mother’s health and the conditions of the birth: low birth weight from maternal malnutrition, births at home or in poorly equipped facilities without a skilled attendant, birth asphyxia, sepsis and neonatal infections, and short gaps between pregnancies. After the first month, diarrhoea and pneumonia, both linked to dirty water, poor sanitation and malnutrition, take over.
Each has a known and affordable remedy: antenatal check-ups, iron and folic acid for mothers, a trained midwife at every birth, clean cord care, early breastfeeding, kangaroo care for small babies, oral rehydration salts, zinc and vaccines. What has been lacking is not knowledge but consistent, well-funded primary care that reaches the village and the urban slum, not only the teaching hospital in Lahore.
Indian Punjab is far from perfect, but it has invested steadily in institutional deliveries, cash incentives for mothers to give birth in health facilities, and community health workers tied to each village. Higher female literacy and smaller families have helped. Those are lessons, not reasons for envy.
What Punjab can do
The Punjab government has shown it can move quickly when it chooses to. It has spent heavily on free treatment, with the bill doubling to Rs36.5 billion in four months, and it ordered new neonatal care rules for all public hospitals after a fire at Islamabad’s PIMS hospital killed 14 newborns. Its polio campaigns show the reach of a determined health machine. The same energy now needs to go into the first month of life.
Three priorities stand out. First, make every rural basic health unit capable of a safe delivery, 24 hours a day, with a trained midwife, a newborn corner and a referral ambulance. Second, put maternal nutrition at the centre of the province’s response to rising food insecurity, because underweight mothers give birth to underweight babies. Third, publish infant and neonatal deaths by district every year, so that voters can see which districts are failing and hold their representatives to account.
A province that wants to be judged by its metro buses, laptops and motorways should also be judged by how many of its babies live to see their first birthday. On that test, Lahore is still losing to Amritsar by a wide margin.
The good news is that this is one race Pakistan can win quickly. Infant deaths respond faster to good policy than almost any other social indicator. If Punjab gets its mothers and midwives right, the numbers will follow within a few years, and thousands of families will be spared the grief that the statistics so coldly record.
The views expressed are writer’s own.
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