Editorial: Kerala’s lessons on reducing IMR

It indeed was an important achievement, and the Kerala government rightly went to town to brag about the State achieving an all-time low infant mortality rate of 5 per 1000 live births – said to be lower than that of the US at 5.6. State Health Minister Veena George highlighted the fact that there was not much difference between urban and rural areas, which is often the case due to skewed concentration of healthcare facilities in urban areas.

Kerala got several things right, which made it possible. As an important indicator, a low IMR reflects higher literacy, empowerment, and awareness about maternal health among women, and an accessible, affordable, and high-quality healthcare system across the State. Over the years, Kerala has put in considerable effort on literacy and access to healthcare. At a micro level, it conducted extensive audits to chalk out an evidence-based strategy to improve antenatal and neonatal care. Establishment of Newborn Care Corners (NBCCs), Newborn Stabilisation Units (NBSUs), and Special Newborn Care Units (SNCUs) yielded significant results in terms of survival rates. Secondly, training and capacity building of doctors, nurses, and paramedical staff ensured that expertise was available even in non-urban areas.

The findings of the Sample Registration System (SRS), which is a large-scale demographic survey for providing reliable annual estimates of infant mortality rate, birth rate, death rate, and other fertility and mortality indicators at the national and sub-national levels, has been encouraging across the country. The IMR declined by about 7 per cent since 2018. Previous governments brought it down to 39 by 2014 from 80 in 1991. It is not surprising that southern states, besides Delhi, Jammu & Kashmir and Maharashtra, have performed better, while some large states like Chhattisgarh, Uttar Pradesh, Madhya Pradesh, Assam, Odisha, Jharkhand, and Rajasthan had IMR higher than the national average. In contrast, smaller states and union territories have recorded impressive results.

The recently published United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) Report 2024 revealed that India has been performing better in reducing child mortality rates, which, besides IMR, includes under-5 IMR and neonatal mortality rates.

Though governments have been investing in rural and urban healthcare systems so that women can get free institutional delivery, natural or through caesarean sections, besides providing enabling and supportive services such as nutrition support, medication, diagnostics, and transport, the results have not been commensurate due to a number of reasons. As mentioned earlier, since IMR is interlinked with overall socio-economic indicators, states lagging behind in all-round development tend to underperform. Unless the inequalities are addressed, healthcare indicators will not improve.

Another area that needs to be addressed is women’s literacy, awareness, and empowerment so that they are able to seek and access maternal services.

For a targeted intervention in states with high IMR, the government needs to initiate large-scale surveys and generate relevant data about regions that require extra focus. The government’s digital data initiatives should extend to healthcare so that real-time surveillance and monitoring of new mothers and infants help in timely interventions. Using the data, focused, extensive, and sustained behaviour change campaigns need to be undertaken so that home delivery is discouraged and persuade them to adopt healthy practices. In rural areas, home delivery is considered risky and hazardous, especially making the mother and infant vulnerable to life-threatening medical complications. A holistic approach can help these states to accelerate socio-economic change to catch up with other states with better indicators.