Developmental Disparities and Associated Factors Among Children Aged 36–59 Months in Four Pakistani Provinces

Background/Objectives: Early childhood developmental attainment varies across Pakistan, but provincial averages may obscure differences across developmental domains and socioeconomic groups. We examined developmental attainment and associated factors among children aged 36–59 months in four Pakistani provinces. Methods: We analyzed four provincially representative UNICEF-supported Multiple Indicator Cluster Surveys (MICS) conducted between 2017 and 2020. Development was assessed using the original Early Childhood Development Index (ECDI). Survey-design-based analyses estimated overall and domain-specific prevalence, adjusted prevalence ratios (aPRs), and wealth-related inequalities. Province-specific associations were summarized using random-effects meta-analysis. Results: Among 46,067 children, 59.4% met the overall ECDI criteria in Punjab, 54.6% in Khyber Pakhtunkhwa, 47.5% in Sindh, and 39.1% in Balochistan. This ordering persisted after age–sex standardization. Literacy–numeracy was the least frequently attained domain, ranging from 14.6% to 27.2%, whereas physical-domain attainment exceeded 90% in all four provinces. Early childhood education (ECE) attendance was associated with higher overall ECDI attainment (pooled aPR 1.29, 95% CI 1.22–1.37). Stunting and functional difficulty were associated with lower overall attainment, while associations with adult stimulation varied across provinces. Richest–poorest differences in overall ECDI prevalence ranged from 18.8 to 35.6 percentage points. Conclusions: Among children aged 36–59 months in four Pakistani provinces, developmental attainment differed substantially between provinces and across developmental domains, and these differences persisted after age–sex standardization. Socioeconomic inequalities were evident in every province. ECE attendance was associated with higher developmental attainment, but this association should be interpreted cautiously because the surveys were cross-sectional and may be affected by residual confounding and selection into ECE.