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How does birth order influence full immunization coverage among children aged 12-23 months in India? evidence from

Tanmoy Ghosh1, Puja Das1, Apurba Sarkar2

  • 1Department of Geography, University of Gour Banga, Malda, West Bengal, India.

Plos One
|February 4, 2026
PubMed

Insights

Child immunization coverage in India declines with higher birth orders. First and secondborns have better full immunization rates, while laterborns face significant disparities, requiring targeted public health interventions.

Area of Science:

  • Public Health
  • Demography
  • Epidemiology

Background:

  • Despite free vaccination programs in India, immunization coverage disparities persist among young children.
  • Increasing birth order is identified as a significant factor influencing immunization status in children aged 12-23 months.

Purpose of the Study:

  • To investigate the association between birth order and the likelihood of complete immunization in children aged 12-23 months in India.
  • To identify socio-demographic factors associated with immunization disparities.

Main Methods:

  • Utilized data from the National Family Health Survey (NFHS) 5 (2019-21) with a nationally representative sample of 43,436 children.
  • Employed bivariate Local Indicators of Spatial Autocorrelation (LISA) and multilevel logistic regression models.
  • Assessed spatial and statistical patterns of immunization coverage based on birth order and covariates.

Main Results:

  • Spatial analysis revealed a positive association between first and second birth orders and full immunization.
  • The odds of full immunization significantly decreased with increasing birth order (2nd: OR 0.91 to 6+: OR 0.41).
  • Lower immunization likelihood was also observed for female children, Muslim families, and those in northeastern India.

Conclusions:

  • Birth order is a critical determinant of child immunization coverage in India, with laterborns facing substantial disadvantages.
  • Targeted public health interventions are urgently needed to address familial and structural barriers, particularly for mothers with multiple children.
  • Ensuring equitable immunization access for all children, irrespective of birth position, is essential for achieving universal health goals.

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