Kerala reports the lowest first-order birth rate in South India at 48.4%, while leading in third-order births (11.5%) and recording 3.4% of total births as fourth-order deliveries
Published May 22, 2025 | 7:00 AM ⚊ Updated May 22, 2025 | 7:00 AM
Synopsis: Kerala, long admired for its human development metrics, is now facing a sharp demographic shift as birth rates plunge. Deliveries have dropped nearly 32% over a decade—from 4.7 lakh in 2015–16 to a projected 3.2 lakh in 2024–25. Recent years show an accelerating decline, signaling a deeper transition that could significantly impact the state’s economy and healthcare system
Kerala, often cited as a model for human development indicators in India, is now witnessing a sharp and sustained decline in the number of births. Data from the Directorate of Public Health shows that the total number of deliveries in the state has dropped by nearly 32 percent over the last ten years.
In 2015–16, Kerala recorded around 4.7 lakh deliveries. By 2024–25, that number is projected to fall to just over 3.2 lakh, marking a decline of more than 1.5 lakh births. The fall has not been linear. While there were minor upticks in some years, the broader trend has been downward—and in the last few years, the pace of decline has accelerated.
For instance, between 2023–24 and 2024–25, the state witnessed a steep 13.46 percent drop in total deliveries—the largest single-year decline in the decade. The previous year, 2022–23 to 2023–24, had already seen a 10.89 percent fall.
In the initial years, Kerala recorded relatively stable birth numbers, with around 4.7 lakh deliveries in 2015–16. There were brief periods of increase in 2017–18 and 2018–19, when total deliveries rose by 1.39 percent and 6.99 percent, respectively—likely reflecting residual effects of earlier birth trends. However, during the Covid-19 pandemic, especially in 2020–21, the state saw a sharp decline of 8.8 percent, followed by only a slight recovery in 2021–22, before the downward trend resumed more steeply in the following years.
These back-to-back drops suggest that Kerala may be entering a new phase in its demographic trajectory, one that could have long-term implications for its economy and healthcare system.
The recent Sample Registration Survey (SRS) data reveals a significant demographic trend in Kerala. The state continues to have the lowest birth rate in India, with a Crude Birth Rate (CBR) of just 12.9 in 2021.
This figure is substantially lower than the national average, positioning Kerala alongside regions in developed nations with similarly low birth rates. Between 2009–11 and 2019–21, Kerala’s CBR declined by 11.4 percent. Interestingly, the urban and rural CBRs are now nearly identical, with urban areas (13.0) slightly surpassing rural areas (12.8), indicating near parity between the two.
In terms of education, Kerala stands out with 99.6 percent literacy among women aged 15–49, with 28.2 percent having completed Class XII and 25.4 percent holding a graduate degree or higher—making it the highest in India. While this pattern is most pronounced in southern states, some northern states also exhibit similar trends. For instance, in Delhi, 19.3 percent of women aged 15–49 are graduates, placing it second only to Kerala.
Kerala’s Total Fertility Rate (TFR), which was 1.8 in the NFHS-5 report, is now recorded at 1.5 by SRS 2021, mirroring trends seen in Tamil Nadu.
Despite its low fertility rate, Kerala displays a strong preference for having a second child. The state has the highest share of second-order births among all major states and Union Territories in India, with 36.6 percent of current live births falling into this category.
Furthermore, Kerala now records the lowest proportion of first-order births among South Indian states, at just 48.4 percent, significantly below the national average. In contrast, it stands out in South India for having the highest proportion of third-order births at 11.5 percent—more than double the rates in other southern states. Additionally, 4th-order births account for 3.4 percent of the total in Kerala.
Across hospitals in Kerala, doctors have been noticing a dramatic fall in delivery rates over the last several years—something that’s no longer anecdotal but consistent and widespread.
Dr Sareena Gilvaz, a senior gynaecologist and former president of the Kerala Federation of Obstetrics and Gynaecology (KFOG), said the change has been stark. “Back in 2015 or 2016, our hospital used to record about 315 to 320 deliveries a month. Today, we are down to 120. That’s a tremendous decline.”
She told South First that while the trend had been gradually appearing over the past couple of years, the real dip has come recently. “There was a sharp drop from 2024. I started seeing this in our institution and raised it during our meetings. The officers agreed—the rates were clearly falling. Even during a National Medical Commission inspection, I told them this is not just about our hospital. It’s happening across Kerala. The drastic decline truly started from 2023, but 2024 marked the steepest fall.”
Dr Alsiha Shafjeer, a senior consultant in high-risk obstetrics at the Centre for Research in Assisted Reproduction and Fetal Therapy (CRAFT) Hospital & Research Centre in Thrissur, noted a similar pattern in her private practice. “In 2015, we would see about 100 deliveries a month. Now, it has come down by almost 25 to 30 percent.”
Initially, she and her colleagues thought it was an institutional problem. “We kept asking ourselves—maybe patients are going elsewhere? Maybe it’s our facilities? We even questioned whether not allowing husbands into the delivery suite was affecting patient choice. But when the official fertility rate reports came out, we breathed a sigh of relief. It wasn’t just us. The drop is across Kerala,” she told South First.
“Women in Kerala today are far more educated and literate than before, and that’s clearly influencing their reproductive choices,” said Dr Alisha. “Having children is no longer the first priority. Many want to build a career, earn their own money, and establish their independence before starting a family.”
She added, “The rising cost of living—education, healthcare, just raising a child—is a big factor too. And let’s not forget that many women are going abroad, either for work or higher studies. They delay childbirth and are well-informed, so they use contraception. Often, they end up having only one child. Also, in many cases, husbands and wives live apart due to jobs. He might be working in the Gulf, and she’s in Kerala. So even when they meet, it might not align with her ovulation cycle.”
Dr. Gilvaz, who is also a professor at Jubilee Mission Medical College, echoed similar concerns. “The fall in fertility rate is actually quite alarming. It’s something we should be seriously thinking about,” she said. “Family planning, now referred to as family welfare, is very strictly followed in Kerala—more so than in other states. People here strongly believe in small families and follow that philosophy with great discipline.”
She went on to explain how literacy, especially among women, plays a central role. “In medical college, over 60 to 70 percent of the students in our classes are girls. They’re more driven than the boys, aiming for postgraduate degrees, and many go abroad—to the UK, the US—for better opportunities. They delay marriage, settle down only after securing good jobs, and only then start thinking about having a family. These are the trends we’re witnessing more and more now.”
“Deciding whether to have another child is increasingly driven by economic factors,” said Dr R V Asokan, former president of the Indian Medical Association. “The COVID-19 pandemic hit hard, and the economy has never truly recovered at the individual level. That’s a crucial issue affecting family planning decisions today,” he told South First.
Dr Gilvaz, shared her personal encounters that reflect this shift. “What really shocked me was when I asked a few young people why they think the fertility rate has declined so sharply in Kerala. Almost all of them said the same thing—raising a child has become too expensive,” she said. “They told me, ‘Even one child is costly. Two is much harder to manage. So we’d rather wait till we are financially secure, and even then, one is more than enough.’ That sentiment was echoed by several young people I spoke to.”
She added, “It’s not just about preferring a small family anymore—some couples don’t want children at all. That’s the new trend. They say they’re comfortable, have everything they need by their early thirties, and don’t want to take on the responsibility of raising a child, especially in a nuclear family setup where there’s little support. Earlier, joint families would pitch in, but now they feel it’s just too much to handle. So this isn’t about small family norms anymore. It’s about no-family norms. For those who do want children, it’s usually just one. The idea of having five or six children, like in the older days, is completely out of the picture now.”
“Population ageing is a significant concern,” said Asokan. “We are painfully aware that Kerala’s population is steadily getting older. At the IMA, we’ve started initiatives focused on elderly care, but the big question is—are we really prepared for this demographic shift? We still don’t know.”
He added, “In the next decade, Kerala might be in a situation similar to what China is facing today. And if this trend continues, 20 years from now we could be staring at something like Japan’s ageing crisis. Whether it’s a positive or negative social shift, it often starts in Kerala—just like how the early impact of COVID-19 unfolded here.”
Dr Gilvaz, echoed the concern. “This ageing population is definitely a cause for worry. Is the state ready for it? Honestly, I don’t think so,” she said.
“What I do see now, compared to when I was younger, is that more and more old age homes are coming up. In a way, that shows some level of preparation. Many elderly people are now choosing—or are forced—to move into old age homes because their children are abroad. They’re alone in big houses, which they eventually sell and move into smaller flats or care homes.”
She continued, “It’s going to be a massive societal change. And we can’t simply reverse the decades of family planning efforts. In fact, I rarely see anyone coming to me asking for a reversal of sterilisation anymore. People are content with one child. I advise them to use temporary contraception methods instead of going for permanent sterilisation, just in case they change their minds later. But most say, ‘One is enough for us.’”
Dr Gilvaz also pointed out a related trend: “Infertility clinics and IVF centres are booming. That’s because many women now delay starting a family until their 40s—something we rarely saw earlier. Natural conception rates are falling, while assisted reproduction is on the rise.”
Dr Alisha said that “We’re seeing a mushrooming of old age homes, even luxury ones, especially because many elderly people have children living in the US or UK. They can afford to send money, but not time,” she said. “Staff nurses working in old age homes are also in high demand now. This is the reality—and like Japan, we will face the consequences of this demographic shift in the coming years.”
(Edited by Ananya Rao)
