How Kerala’s infant mortality rate fell to remarkably low levels
Despite best efforts, Kerala was not able to further reduce IMR from 12-10 per 1,000 live births for many years. This was due to the persistently high neonatal mortality (death before 28 days of birth) rates. Focused initiatives helped reduce neonatal mortality and thus bring down IMR to seven per 1,000 in 2018, six in 2019, and five in 2023
Infant mortality rate or IMR is considered one of the most sensitive indicators of the total health of a population. So it is often used as an index to measure ups and downs in population health as well as to compare countries or regions with respect to their health status. Kerala has reported a lower infant mortality rate compared to the national average for a long time. The infant mortality rate in India is officially reported periodically through the sample registration system or SRS. The most recent report of the SRS, the reference year being 2023, published in September 2025 indicates that infant mortality rate in Kerala has touched a new low of five per 1,000 live births; Chhattisgarh, Madhya Pradesh and Uttar Pradesh have the highest infant mortality rate of 37, and India’s national average is 25. Infant mortality rate is usually reported as a rate, relating the number of deaths of infants under one year of age to the number of live births, usually expressed per 1,000.
This is quite remarkable even for a high-performing State in health such as Kerala. This level of infant mortality compares well with countries and regions that are much more advanced in terms of socio-economic development. To illustrate, the United States has reported an infant mortality rate of 5.6 for the same period. In many European countries it hovers between three and eight. Japan and Singapore have much lower rates at around two per 1,000 live births.
Reflection of very high level of health achievement
Kerala, which is a State in India, by no stretch of the imagination can be considered a developed country. The low infant mortality rate reflects a very high level of health achievement. Kerala shows consistency with a trend that has always shown health achievement beyond the national statistics, and high for its level of other development indicators such as income. It is perhaps not surprising that the State has achieved this distinction, since it has demonstrated a consistent trend of falling infant mortality rate for a long period.
Much of the fall in the infant mortality rate in Kerala — or anywhere, for that matter — has been attributed by researchers to the social determinants of health — rise in education, especially female education, better nutrition, especially for females during teenage years and pregnancy, later marriage and childbirth, contraception and the avoidance of frequent pregnancies, better access to health care etc. In Kerala we can see a consistent trend of falling birth rates, falling infant mortality rate, along with the rise in the proportion of institutional births, which has touched almost 100% in the State much earlier than the rest of India.
Infant mortality can be categorised into ‘neonatal mortality’, or death in the period immediately following birth (till 28 days), and ‘post-neonatal mortality’, death after the neonatal period, under one year. Post neonatal mortality is easier to prevent, since much of it occurs due to preventable causes such as infections and vaccine preventable diseases, besides accidents. Neonatal mortality, on the other hand, is mostly attributable to congenital malformations and genetic causes, much more difficult to prevent or treat. Therefore as the infant mortality rate comes down, the proportion of neonatal mortality in the total infant mortality can be expected to rise.
Around the 1990s there was a period when Kerala had a relatively low IMR around 10. In 2002, the infant mortality rate dropped to 10 but again started rising steadily to touch 15 in 2006, as per the sample registration system data. The rate kept hovering around 12 since 2009 and once again dropped to 10 in 2016 and 2017 and reached single digit for the first time in 2018 when the infant mortality rate dropped to seven and then to six in 2019.
A focussed approach
However, in spite of best efforts, it was not able to bring it down further. This was due to the persistently high neonatal mortality rates. There have been focused government initiatives to bring down the infant mortality rate for quite some time by bringing down neonatal mortality.
In 2012, concerned that the infant mortality rate was stagnant for a long time. Kerala commissioned studies to evaluate the causes of infant deaths. A study by the Indian Academy of Paediatrics in 2013, when the infant mortality rate was 12, found that 75% of the infant deaths in Kerala occurred in the neonatal period (0-28 days), of which 59% occurred during the first week. Prematurity accounted for 35% of deaths while congenital anomalies, especially congenital heart disease, accounted for 28% of the infant mortality rate.
In 2017, Kerala launched the Hridyam programme for the early detection and treatment of congenital heart anomalies in infants under the flagship Rashtriya Bal Swasthya Karyakram (RBSK). After the launch of the Hridyam programme, congenital heart disease-related deaths dropped by 41% in the first two years of the programme, while overall infant deaths dropped by 21%. Nearly, 8,500 infants have been treated under the programme till date.
According to a study, the number of heart operations managed through Hridyam rose from 208 to 624 and 1,227 in 2017, 2018, and 2019, respectively. “The overall- and CHD-related infant mortality in Kerala fell by 21.1% and 41.0%, respectively, over the same interval.”
In 2018, Kerala introduced a comprehensive newborn screening programme to universally screens newborns for visible birth defects, hearing, and congenital heart defects.
An increasingly challenging task
As the infant mortality rate goes down, it becomes more difficult to achieve lower levels, as preventable infant deaths become rarer. This is reflected in the curves comparing India with Kerala: India has the potential to come down much further, but bringing IMR down in Kerala is an increasingly challenging task. What is also remarkable is the very narrow gap between urban and rural IMR in the State; as per the latest sample registration system data for 2023, the infant mortality rate in both urban and rural areas in Kerala was five. This is as if the whole State functions as a unit, a reflection of the remarkable social equity characterising the State.
A caveat
When we compare the infant mortality rate in Kerala with that in a large country like the U.S., we may be falling into the error of comparing apples with oranges. For one thing, the number of births taking place in the U.S. per year is much larger compared to the number in Kerala: the latter is estimated at the current birth rates to be below 3,50,000 births per year, while in the U.S. it is estimated to be around 3.5-4.5 million per year. For another, infant mortality rate from the sample registration system (SRS) data is an estimate: it is a figure calculated from a carefully selected sample of the population, selected to be representative of the whole population. Thus, the Kerala infant mortality rate in the SRS estimates is calculated from 200-220 sampling units, which are villages or blocks of households. This sample size ensures that the margin of error is not too wide.
Any estimate has an error margin attached to it, which is expressed as a 95% confidence interval- or the range within which we can say with 95% confidence that the real number lies. The sample registration system reports the 95% CI around the Kerala estimate to be from two-eight. This means that though the most likely estimate is around five, it may be anything between two and eight. On the other hand, the figure from a country like the US is an absolute figure — it is calculated from a data base that links all births and deaths in the country. So there is no error margin around it: it is the absolute figure for the year.
What this means is that while our estimate of the Kerala IMR is five, it could be anything from two to eight; so it could be higher or lower than the U.S. figure. What is perhaps disappointing is that with a health system that covers all births in the private and public sectors, and modern data collecting methods, Kerala is not able to create a birth- and death-linked data-collecting system like the U.S.
