Kerala’s maternal mortality ratio, currently the lowest in the country at 19 per one lakh live births, is now climbing steadily, much to the consternation of the Health Department. And the reasons for the increase may be beyond the control of officials.
Except during 2020-21, when Kerala lost many mothers to COVID, the State had consistently maintained a firm grip over maternal mortality. Ironically, the State’s MMR is showing a spike now, not because more mothers are dying in Kerala, but because there are fewer child births than ever in the State.
The State, which used to have an average of 5-5.5 lakh live births annually, has now hit an all-time low of 3,93,231 births, according to latest data of the State’s Department of Economics and Statistics. The full Vital Statistics Report (VSR, 2023) is expected to be published by the end of the month. The Health Department puts live births in the State between 3.4 lakh and 3.9 lakh currently.
And it is this dip in the denominator that is pushing the State’s MMR up and not necessarily an actual spike in maternal deaths.
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The decline in fertility levels and changing demographics, many fear, are having an irrevocable impact on the State’s social fabric, and have been at the heart of many policy-level discussions in Kerala, especially the past three years.
From an average of 5.5 lakh annual births since the 1980s, the graph went below the five-lakh mark for the first time in 2016, when 4,96,262 live births were recorded.
Since 2018, the figure has been plummeting steadily, never going above the five-lakh mark again. The last published VSR (2021) recorded the total number of live births in Kerala as 4,19,767.
According to the last Sample Registration System (SRS) special bulletin on Maternal Mortality in India (2018-20), brought out by the Registrar General of India, Kerala had an MMR of 19. However, while SRS depended on a sample survey to arrive at the figure, the State Health Department’s actual estimates of maternal deaths – Kerala has near 100% institutional deliveries – put the MMR at 29.
“As part of the Sustainable Development Goals, Kerala was targeting an MMR of 20 by 2030. However that looks quite unlikely now, given that birth rates are falling steeply. We reckon the State’s MMR in 2024-25 has already climbed to 32,” says V.P. Paily, a senior consultant in Obstetrics and Gynaecology.
“It would now be a herculean task to hold the MMR at 20. Because, while we have successfully addressed all major medical causes of maternal mortality, the issues that are impacting the State’s MMR now are not something essentially within our control. We are seeing the impact of demographic changes like low fertility rates, immigration and changing societal attitudes towards marriage and childbirth in Kerala much earlier than we thought we would,” says Dr. Paily.
“It has been three decades since the birth rate began falling in Kerala and the steep fall in the number of children born now is part of a larger trend. But the problem is that once the fertility rate comes down, the graph rarely goes up because demographic transition is hard to reverse,” says S. Irudaya Rajan, Chairman of the International Institute of Migration and Development (IIMAD).
Kerala led the demographic transition in the South, attaining the replacement level fertility rate of 2.1 in 1987-88. Replacement level fertility is the average number of children a woman needs to have to replace herself and her generation, so that the population is stable. The State’s total fertility rate (TFR) went below the replacement level in 1991 and remained stagnant at 1.8-1.7 for years, before touching 1.5 in 2020.
The current TFR of Kerala (2021 VSR) is 1.46. This means that a couple of reproductive age in Kerala mostly have only one child and sometimes none. It is possible that the TFR will drop to 1. 35 once the latest data on live births are accounted for.
“Already, the impact of migration, especially the fact that a chunk of those in the reproductive age group are going abroad for higher education or jobs and choosing to settle down there; and the economic impact of the loss of a young workforce and changing attitudes regarding marriage and fertility are hurting us. In the next 10 years, the proportion of elderly population in Kerala is expected to go above that of children and the magnitude of the issues related to the care and welfare of this population is likely to overwhelm us, even though we have been anticipating it,” Dr. Rajan said.
But the birth rate is expected to plummet further and the consequences would be starkly evident in the next two decades itself.
Not just declining birth rates, the State is also beginning to see the consequences of a higher age at marriage and delayed childbearing. The proportion of older mothers and the increase in pregnancy-related morbidities in this group and their reproductive health issues are emerging concerns, though the State is yet to adduce hard evidence to substantiate this.
“It has been over 35 years since we attained the replacement level fertility rate and the cohort of those women in the reproductive age of 15-49 years we had then has now been replaced by a new cohort. The fertility is low in this new cohort of women, either by will or by nature, so naturally the number of childbirths will go down. Many in this group choose not to get married or not to have children. And even the number of women in this cohort has begun to dwindle,” points out Sajini B. Nair, Social Scientist, Population Research Centre.
According to the last Census in 2011, the female population in the reproductive age group of 15-49 years in Kerala was 93,32,494 and the Registrar General of India’s projected figure for 2021 was 92,23,500
Meanwhile, the State had not published the VSR after 2021, claiming that there are reporting errors. There is also an ongoing debate whether Kerala is registering its births properly and on time and the actual data of child births in the State collected by various official agencies are not available in the public domain now.
“The demographic transition in the State has been so fast that no long-term projections are possible. We do not know how much abortions contribute to the declining number of live births because we have absolutely no data on this. It would also be interesting to study if our youngsters settling down abroad are choosing to have their children there for reasons of obtaining citizenship and how much this has contributed to the declining birth rate,” Dr. Sajini says.
Published – January 13, 2025 12:24 am IST
