The report of the National Family Health Survey 2019–21 (NFHS–5) was released in May 2022. Before 2015–16, the District Level Health Survey (DLHS) and Annual Health Survey (AHS) were conducted by the Ministry of Health and Family Welfare (MoHFW). Since then, the integrated NFHS replaced them. The NFHS has a periodicity of three years. The first four rounds of NFHS were conducted in 1992–93, 1998–99, 2005–06, and 2015–16, respectively.
The first phase data of NFHS-5 (conducted from June 2019 to January 2020 and covering 17 states and 5 union territories) was released on December 12, 2020. The survey was suspended in May 2019 due to the COVID-19 pandemic, so the second phase data (conducted from January 2020 to April 2021 and covering 11 states and 3 union territories) was released towards the end of 2021. The final report comprising data for all states and union territories could be released in 2022.
The main objective of NFHS is to provide reliable and comparable data regarding health and family welfare. It presents a wide range of indicators in the areas of population, adult health, nutrition, fertility, infant and child mortality, the practice of family planning, maternal and child health, domestic violence, etc. Information on several emerging issues is also provided by NFHS-5, including perinatal mortality, high-risk sexual behaviour, safe injections, tuberculosis, noncommunicable diseases, and the use of emergency contraception. The data provided by socio-economic and other background characteristics would be of great use in formulating policies and implementing programmes.
New Dimensions in NFHS-5
The dimensions of the NFHS-4 are considered in NFHS-5. Besides those, the NFHS-5 also considers some new dimensions, such as death registration, pre-school education, expanded domains of child immunization, components of micro-nutrients to children, menstrual hygiene, frequency of alcohol and tobacco use, additional components of non-communicable diseases, expanded age range for measuring hypertension and diabetes among all aged 15 years and above. The data will help to monitor and strengthen existing programmes and evolve new strategies for policy intervention. Information is also provided on important indicators that would help in keeping track of the progress of Sustainable Development Goals (SDGs) in the country.
Highlights of NFHS-5
(i) Socioeconomic Background of the Households and Respondents in the Survey
The NFHS-5 work was conducted in 6,36,699 sample households from 707 districts (as on March, 2017) of the country from 28 states and 8 union territories. It covered 7,24,115 women and 1,01,839 men to provide disaggregated estimates up to district level. (The eligible women were women of age 15–49 and the eligible men were men of age 15–54 who stayed in the household the night before the household interview.) Information on the living conditions of a representative sample of the population gives a context for interpreting demographic and health indicators.
Drinking water access Some 96 per cent of the households (99 per cent of urban households and 95 per cent of rural households) have access to an improved (protected from outside contamination and more likely to be safe for drinking) source of drinking water. In 71 per cent of cases where water is not available on the premises, women of 15 years and above are most likely to go to get drinking water.
Sanitation Improved toilet facilities, which are non-shared facilities, are used by 69 per cent of households in India which is about 20 per cent higher than in 2015–16. Households with access to a toilet facility form 83 per cent. There is still 19 per cent of households that do not use any toilet facility, a decrease from 39 per cent in 2015–16. However, hand-washing facility with soap and water has gone up from 60 per cent in NFHS-4 to 78 per cent in NFHS-5.
Use of clean fuel Between NFHS-4 and NFHS-5, households using clean cooking fuel has increased from 44 per cent to 59 per cent.
Electricity and pucca houses Some 97 per cent of households have electricity (99 per cent urban and 95 per cent rural). Some 60 per cent of households have pucca houses.
Household wealth Household wealth depends on the number and kinds of consumer goods owned and housing characteristics such as source of drinking water, toilet facilities, and flooring materials. A concentration of wealthy households is found in urban areas with 74 per cent of the urban population in the two highest wealth quintiles. Some 54 per cent of rural population falls in the two lowest wealth quintiles. The highest percentage of population in the highest wealth quintile is in Chandigarh (79 per cent), followed by Delhi (68 per cent), and Punjab (61 per cent). The highest percentage of population in the lowest wealth quintile are in Jharkhand (46 per cent), Bihar (43per cent) and Assam (38 per cent). Of the scheduled tribe households and scheduled caste households, 71 per cent and 49 per cent, respectively, are in the two lowest wealth quintiles. The percentage of households that have a bank account or a post office account is almost the same in urban and rural areas – 95 per cent and 96 per cent, respectively. Mobile phones are slightly more in urban than in rural populations. Rural households are more likely than urban households to own agricultural land or farm animals.
Household population For the purpose of the survey, a household consists of a person or group of related or unrelated persons who live together in the same dwelling unit, acknowledge one adult male or female as the head of the household, and share the same housekeeping arrangements, and are considered a single unit.
Children under age 15 represent 27 per cent of the household population (down from 29 per cent in NFHS-4) and persons of age 60 and above represent 12 per cent of the household population (a slight increase from 10 per cent in NFHS-4).
Size-wise, there was decrease in households from 4.6 persons in 2015–16 to 4.4 persons in 2019–21. The percentage of households with female heads showed a slight increase, from 15 per cent in 2015–16 to 18 per cent in 2019–21.
Birth registration The percentage of children under five years of age whose birth is registered with the civil authorities increased from 80 per cent in NFHS-4 to 89 per cent in NFHS-5. There is hardly any gender disparity in the registration of births. Birth registration of children in urban areas is more likely than that of children in rural areas. Birth registration is universal (100 per cent) in Lakshadweep and Goa. The states of Arunachal Pradesh, Manipur, Meghalaya, Uttar Pradesh, Bihar, Jharkhand, and Nagaland show a percentage of below 80 per cent, i.e., lower than the all-India average. However, Jharkhand, Bihar, Uttar Pradesh, and Nagaland show an increase in birth registrations by more than 60 percentage points between NFHS-4 and NFHS-5.
Death registration Death registration data takes into account deaths of household members that occurred during the three years preceding the survey and are registered with the civil authorities. Overall, 70.8 per cent of deaths were registered. Death registration is higher in urban areas than in rural areas and among males than females. Death registration increases with wealth: the highest percentage of registration is in the highest wealth quintile and the lowest percentage is in the lowest wealth quintile. Goa shows 100 per cent death registration; Kerala and Chandigarh come next with more than 97 per cent and 95 per cent, respectively. Death registration is lowest in Bihar. Just above come Arunachal Pradesh and Nagaland.
Children living/not living with parents Among children under age 18, 5 per cent are orphans (one or both parents are dead) and 3 per cent are not living with a biological parent (percentage unchanged from NFHS-4).
Pre-school and school attendance Of the boys and girls age 2–4 years, 40 per cent attend preschool. Eighty-seven per cent of children age 6–17, 87 percent attend school (almost same percentage for males and females). The gross attendance ratio (GAR) is 92 per cent at the primary school level and 82 per cent at the secondary school level.
The net attendance ratio (NAR) falls from 83 per cent in primary school to 71 per cent in middle, secondary, and higher secondary school. The most common reason given for not attending school was that the child is not interested in studies.
The GARs increase with household wealth at the secondary school level. Though there is not much difference by caste/tribe in the NAR and GAR at the primary school level, at the secondary school level, children belonging to scheduled tribes have the lowest NARs and GARs.
Disability Of the de jure household population, just 1 per cent have any disability. The most prominent type of disability is locomotor. The likelihood for men to have any disability is slightly more than for women.
Tobacco and alcohol use Use of tobacco products is common among 38 per cent of men and 9 per cent of women age 15 and over. Only 1 per cent of women and 19 per cent of men age 15 and over drink alcohol.
Literacy and education Of the men, 84 per cent are literate and of the women 72 per cent are literate. Literacy is lowest among men and women in rural areas. Since 2015–16, there has been a considerable increase in the percentage of women and men aged 15–49 attending school and completing higher levels of education. Also, the gap between women and men has narrowed in the period under consideration. Some 50 per cent of the men and some 41 per cent of the women have 10 or more years of schooling.
Exposure to mass media The most common form of media to which men as well as women are exposed to is the television, followed by newspapers or magazines. A considerable proportion of the persons (32 per cent of the men and 41 per cent of the women) do not regularly access any of the media (newspapers and magazines, television, radio, or cinema).
Employment and occupation Women are three times less likely to be currently employed compared to men: 25 per cent of women age 15–49 are currently employed, compared with 75 per cent of men in the same age group. Bihar had the lowest percentage of women in employment. The employment level is much higher among less educated persons—highest among those with less than 5 years of schooling and those with no schooling at all. Agricultural sector was the occupation of 32 per cent men and 46 per cent women. Only 11 per cent of women and 9 per cent of men work in the service sector.
Internet usage One-third of women and slightly over half the men age 15–49 have ever used the internet. In urban areas, more than 50 per cent of women surveyed have used the internet.
(ii) Fertility
The age at which a woman begins childbearing, how long the intervals between births, and her fertility are factors that influence the number of children she bears. These factors, thus, influence population growth of a country.
Fertility rate The total fertility rate (TFR) at the national level is 1.99 children per woman, showing a decline from 2.2 in NFHS-4, i.e., the TFR is slightly lower than the replacement level of fertility of 2.1 children per woman. The lowest TFR is in Sikkim (1.05). Thirty-one states and union territories (all the states in the south region, the west region, and the north region) have fertility below the replacement level of 2.1. The five states above replacement level of fertility are: Bihar (2.98), Meghalaya (2.91), Uttar Pradesh (2.35), Jharkhand (2.26), and Manipur (2.17). The TFR among women in rural areas has declined from 3.7 children in 1992–93 to 2.1 children in 2019–21. Among women in urban areas the decline was from 2.7 children in 1992–93 to 1.6 children in 2019–21. The fertility rate in all places peaks at age 20–24, after which it declines steadily; this is true for all NFHS surveys.
Birth order In the three years preceding the survey, taking birth order (an individual’s rank by age among siblings), 40 per cent were of birth order one, 34 per cent were second-order births, 15 per cent were third-order births, and the rest were of birth order four or higher. Thirty-two per cent of births to women with no schooling were of birth order four or higher, compared with 2 per cent of births to women with 12 or more years of schooling.
Birth intervals Birth intervals of less than 24 months are associated with greater health risks for mothers as well as the new-borns. As per NFHS-5, the median birth interval in India is 32.7 months. Longer birth intervals were observed in women of wealthier households and of older age. The median birth interval increases if the preceding birth is living.
Age at first birth While the median age at first birth among women age 25–49 (sample) in India is 21.2 years, women with schooling of 12 years, those in the urban areas, and those in the higher levels of wealth show a higher median age at first birth.
Menstrual hygiene It is important for women’s health that they use a hygienic method of menstrual protection. NFHS-5 surveyed women age 15–24 on the matter. A hygienic method is used by 78 per cent of women in this age group. Women with 12 or more years of schooling compared to those with no schooling, those in the highest wealth quintile compared to those below, and those in urban areas compared to those in rural areas are more likely to be using a hygienic method. Most women take a bath during the menstrual period.
Teenage childbearing According to NFHS-5, 7 per cent of women in the age group 15-19 have begun childbearing; 5 per cent of women have had a live birth and 2 per cent of women are pregnant with their first child. More than 50 per cent of currently married women in the age group 15-19 have already begun childbearing. However, a decline is observed in the level of teenage childbearing from 8 per cent in 2015-16 to 7 per cent in 2019-21. In rural areas, teenage pregnancy is higher than the average. The level of teenage childbearing decreases with an increasing level of schooling and level of wealth. Higher levels of teenage pregnancies are found in Tripura (22 per cent), West Bengal (16 per cent), Andhra Pradesh (13 per cent), Assam (12 per cent), Bihar (11 per cent), and Jharkhand (10 per cent). Among states, it is lowest in Kerala and Goa. Overall, it is least in Chandigarh.
Desire for another child Some 23 per cent women and some 26 per cent of men of age 15–49, currently married, want to have another child. The percentage of currently married women age 15–49 who want no more children (including women who were sterilised) is slightly higher at 70 per cent in 2019–21 compared to 68 per cent in 2015–16. The proportion of women who want no more children increases with age. Of those married persons who have two living daughters and no son, 65 per cent of women and 66 per cent of men want no children, while some 90 per cent of those with two sons and no daughters want no more children. This indicates that preference for a son continues to be an important factor in overall fertility preferences in India.
Ideal number of children in family Both men and women in the age group 15–49, if given a chance to choose their family size, would choose to have an average of 2.1 children. This is just a marginal decline from 2.2 in 2015–16. Bihar, Mizoram, Arunachal Pradesh, Jharkhand, Manipur, and Uttar Pradesh have the highest proportion of women who want more sons than daughters in their ideal family size, while Chandigarh, Goa, Andhra Pradesh, and Puducherry have the lowest proportion of such women.
Wanted fertility rates Wanted fertility rate indicates the level of fertility that would result if all unwanted births were prevented. The total wanted fertility rate in India is 1.6 children per woman, compared with the actual TFR of 1.99. Only Meghalaya and Bihar have a wanted fertility rate above the replacement level of fertility. With schooling and wealth, there is a decline in wanted fertility rates.
Factors determining fertility As marriage and sexual activity help to determine women’s exposure to the risk of pregnancy, they are important determinants of fertility levels. Furthermore, the timing and circumstances of marriage and sexual activity are also of importance.
Marital status In India, marriage is almost universal. By the age 45-49, Only 1 per cent of women and 3 per cent of men have never been married by the age of 45-49. In the age group 15-49, 72 per cent of women (a decline from 73 per cent in 2015–16) and 60 per cent of men (same as in 2015–16) are currently married; 0.3 per cent of men and women are divorced; and 11 per cent women and 1.3 per cent of men are widowed.
Marriage age Men, compared to women, tend to marry later. However, over time, early marriage has been declining.
The median age at first marriage has increased slightly: for women (age 20-49), it has increased from 19.0 years in 2015-16 to 19.2 years in 2019-21, while that for men (25-49) has increased to 24.9 years from 24.5 years.
The figures for those marrying before the legal age are: 25 per cent of women age 18–29 and 15 per cent of men age 21–29. In the age group 20–24, marriage for women before the legal age of 18 is 23 per cent whereas for women in the age group 45–49 it is 47 per cent. For men, marriage before the legal age of 21 years was 18 per cent for men age 25–29 compared to 27 per cent for men age 45–49, down from 26.8 per cent reported in NFHS-4.
States with around 40 per cent of women marrying before reaching the legal minimum age at marriage are: West Bengal, Bihar, and Tripura. Nearly one-third women marry before reaching the legal minimum age at marriage in Jharkhand and Andhra Pradesh. About 20–25 per cent of men age 21–29 in Bihar, Gujarat, Rajasthan, Madhya Pradesh, Jharkhand, Arunachal Pradesh, and West Bengal marry before the age of 21 years. The percentage of women marrying before reaching 18 years is lowest in Lakshadweep, Jammu and Kashmir, Ladakh, Himachal Pradesh, Goa, Nagaland, Kerala, and Puducherry. The lowest proportions (less than 1 to 4 per cent) of men marrying below the legal age at marriage are in Lakshadweep, Chandigarh, Kerala, Puducherry, and Tamil Nadu. Tripura has seen the largest increase in marriages under the legal age of 18 years for women (up from 33.1 per cent in NHFS-4) to 40.1 per cent; for men the increase was from 16.2 per cent to 20.4 per cent. The biggest improvements in legal marriage have been seen in Chhattisgarh, Haryana, Madhya Pradesh, and Rajasthan.
Age at first sexual intercourse The median age at first sexual intercourse for women age 25–49 is 18.9 years. In age group 25–49, 10 per cent of women had sex before age 15, and 39 per cent before age 18. For men in age 25–49, the median age of first sexual intercourse is 24.8 years; 1 per cent had sexual intercourse before age 15, and 6 per cent had sexual intercourse before age 18. Urban women age 25–49 begin having sex later than rural women. With schooling, the median age at first intercourse increases for both women and men.
(iii) Family Planning
Contraceptive knowledge and use More than 99 per cent of currently married women and men in the age group 15–49 are aware of at least one method of contraception. Overall contraceptive prevalence rate (CPR) has increased from 54 per cent to 67 per cent. (CPR is the percentage of women who use any contraceptive method.) Female sterilization remains the most popular modern contraceptive method (38 per cent). Contraceptive use among married women rises with an increasing number of living children, employment, and wealth. Use of modern methods of contraceptives has also increased in almost all states and union territories, but there is a large variation.
Among the states, the use of contraceptive methods is the lowest in Meghalaya, Mizoram, and Bihar, and highest in West Bengal, Odisha, and Himachal Pradesh. Contraceptive methods are used by relatively few married women in most of the smaller states in the northeast region. Among the union territories, the use of contraceptive methods is the lowest in Ladakh and the highest in Chandigarh. Almost 68 per cent of those who used modern methods obtained their method from the public health sector (more in rural than in urban areas), others obtaining it from the private sector, including relatives and friends. Contraceptive use increases in communities and regions where socioeconomic progress is greater.
Some 62 per cent of women currently using selected modern contraceptives made informed choices, i.e., with awareness of side effects and other available contraceptive methods.
More than one-third of men believe that contraception is not something for men to bother about but something women have to take care of. Some 20 per cent of men believe that a woman who adopts contraceptive methods could become promiscuous.
Demand for family planning More than 75 per cent of currently married women age 15–49 have a demand for family planning, showing an increase from 66 per cent in 2015-16; 14 per cent have a demand for spacing births; and 63 per cent have a demand for limiting births. Unmet needs of family planning have seen a decline from13 per cent to 9 per cent. (By unmet needs of family planning is meant the proportion of women who want to postpone their next birth for 2 or more years or stop childbearing altogether, but are not using a contraceptive method, or have a mistimed or unwanted current pregnancy.) The unmet need for spacing has come down to less than 10 per cent.
Abortions Some 48 per cent of women who had abortions gave the main reason as an unplanned pregnancy, followed by health not permitting continuing the pregnancy.
(iv) Infant and Child Mortality
The under-five mortality rate was 42 deaths per 1,000 live births in the five years before the 2019–21 survey, showing a decline from 50 deaths per 1,000 live births in the five years before the 2015–16 survey. The infant mortality rate (probability of dying between birth and the first birthday) was 35 deaths per 1,000 live births showing a decline from 41 deaths per 1,000 live births during the same period. (Child mortality is the probability of dying between the first and fifth birthday.) The neonatal mortality rate (probability of dying within the first month of life) was 25 deaths per 1,000 live births.
The under-five mortality rate and infant mortality rate are highest in Uttar Pradesh, followed by Bihar, and are lowest in Puducherry, followed by Kerala. The under-five mortality rate and infant mortality rate are much higher in rural areas than in urban areas.
The findings show that boys are slightly more likely to die before their fifth birthday than girls. This gap is greatest in the neonatal period. Higher under-five mortality is associated with shorter birth intervals. Mother’s age is also a factor in children dying before the age of five —greater in age less than 20 and in age 40-49.
Perinatal mortality and high-risk pregnancy The perinatal mortality rate, calculated as the number of perinatal deaths per 1,000 pregnancies of seven or more months’ duration, was 32 deaths per 1,000 pregnancies. (Perinatal deaths comprise stillbirths or pregnancy loss that occurs after seven months of gestation and early neonatal deaths, i.e., deaths of live births within the first seven days of life.)
In the five years preceding the survey, 29 per cent of births were in an avoidable risk category. Births in the high risk category are twice as likely to die as births not in any high-risk category. (A birth is considered high risk if mother’s age is less than 18 years; if mother’s age is more than 34 years; if previous birth interval is less than two years; and birth order is more than three.)
(v) Maternal Health
Antenatal care Health risks faced by mothers and babies can be reduced by antenatal care (ANC) as pregnancies can be monitored and screened for complications. Women in age group15–49 who received ANC rose to 94 per cent in NFHS-5 from 84 per cent in NFHS-4. The majority (85 per cent) received ANC from a skilled provider in NFHS-5. While the use of a skilled provider for ANC is high in Goa, Kerala, and Lakshadweep, it is low in Bihar and Nagaland. The proportion of women who received ANC in the first trimester increased to 70 per cent from 59 per cent in NFHS-4.
Some 59 per cent of women had at least four ANC visits during their last pregnancy, as recommended by WHO. This was an increase from 51 per cent in NFHS-4. The proportion of women who had at least four ANC visits during their last pregnancy was highest in Goa, Lakshadweep, and Tamil Nadu, while it was lowest in Nagaland and Bihar, but the rate is increasing even in those states where ANC visits are low. No ANC visits were availed by 6 per cent of pregnant women.
Delivery Risk of complications and infections during labour and delivery is reduced through institutional delivery, i.e., in a health facility with skilled medical attention. Institutional deliveries increased to 89 per cent in 2019–21 from 79 per cent in 2015–16. It was just 39 per cent in 2005–06. In Puducherry, Goa, Kerala, Lakshadweep, and Tamil Nadu almost 100 per cent of births took place in a health facility. Institutional deliveries to the extent of 95 or more took place in 16 states and union territories. In Nagaland only 46 per cent of births and in Meghalaya only 58 per cent of births took place in health facilities. However, institutional births increased in several states and union territories: by a maximum of 27 percentage points in Arunachal Pradesh, and by over 10 percentage points in Assam, Bihar, Meghalaya, Chhattisgarh, Nagaland, Manipur, Uttar Pradesh, and West Bengal.
As to why women stayed away from institutional delivery, the reasons included not feeling the necessity of it, the husband or family not allowing it, the distance from a health facility being too great or there being no transportation, and it being too costly.
In the five years before the 2019–21 survey, skilled assistance during deliveries in India increased with the proportion of births assisted by a skilled provider increasing from 81 per cent in 2015–16 to 89 per cent in 2019–21, i.e., almost 9 in 10 live births were delivered by a skilled provider.
According to NFHS-5, 22 per cent of live births in the five years before the survey were through caesarean section. This was an increase from 17 per cent in 2015–16. While 9 per cent of the C-sections were decided on after the onset of labour pains, 12 per cent were decided on before the onset of labour pains. A strong positive relationship is found between wealth quintiles and C-section delivery. C-sections should be undertaken only when medically necessary, says WHO.
Postnatal checks According to the recommendations of the Ministry of Health and Family Welfare (MoHFW), all women who deliver in a health facility receive a postnatal health check within the first 24 hours after delivery while women giving birth outside of a health facility should be referred to a health facility for a postnatal check within 12 hours of giving birth. As per NFHS-5, among women age 15–49 giving birth in the five years before the survey, 61 per cent had a postnatal check during the first two days after birth, but 16 per cent of mothers did not receive any postnatal check. Of the new-borns, 82 per cent had a postnatal check within 2 days of birth.
(vi) Child Health
Birth weight A weight of less than 2.5 kg at birth means children could have a higher-than-average risk of early childhood death. As per NFHS-5, 18 per cent of those whose birth weights were available had a birth weight of less than 2.5 kg. Low birth weight decreases with an increase in the mother’s schooling and household wealth status.
Vaccination/Immunisation Some 77 per cent children in the age group 12-23 months were immunised having received all the basic vaccinations (one dose of BCG vaccine, three doses of DPT vaccine, three doses of polio vaccine, and one dose of measles vaccine), compared with 62 per cent in NFHS-4. The coverage is highest in Dadra and Nagar Haveli and Daman and Diu (95 per cent), Odisha (91 per cent), Tamil Nadu (89 per cent), and Himachal Pradesh (89 per cent) and lowest in Nagaland (58 per cent), Meghalaya (64 per cent), and Arunachal Pradesh (65 per cent).
Anganwadi services Anganwadi centres (AWCs) provide health, nutrition, and education services for children from birth to six years of age, as well as nutritional and health services for pregnant and breastfeeding mothers. Of children under age six years, 68 per cent receive one or more services from an AWC. Rural children are more likely to avail of any service from an AWC.
(vii) Nutrition and Anaemia
Child malnutrition Though the prevalence of the signs of malnutrition in children under five years of age has decreased since 2015–16, the decrease has been slight. Stunting (low height for age) declined from 38 per cent in 2015–16 to 36 per cent in 2019–21. Stunting is higher among children in rural areas (37 per cent) than urban areas (30 per cent) in 2019–21. It is the highest in Meghalaya (47 per cent), followed by Bihar (43 per cent), Uttar Pradesh, and Jharkhand. It is lowest in Puducherry (20 per cent). The greatest decrease in stunting was observed in Haryana, Uttarakhand, Rajasthan, Uttar Pradesh, and Sikkim (7 percentage points each), followed by Jharkhand, Madhya Pradesh, Manipur, Chandigarh, and Bihar. Over the same time period, the prevalence of wasting (low weight for height) has declined from 21 per cent to 19 per cent, and the percentage of underweight (low weight for age) children declined from 36 to 32. There is not much difference in the prevalence of undernutrition between girls and boys, although girls are slightly less well-nourished than boys on all three measures.
Anaemia in children Due to anaemia (haemoglobin level below 11.0 g/dl), children could suffer from stunted growth, impaired cognitive development, and greater chance of morbidity from infectious diseases. In NFHS-5, haemoglobin testing was performed on children age 6–59 months. Of the children tested, 67 per cent had some degree of anaemia: 29 per cent had mild anaemia (haemoglobin level 10–10.9 g/dl), 36 per cent had moderate anaemia (7–9.9 g/dl), and 2 per cent had severe anaemia (below 7 g/dl). What is disturbing is that between 2015–16 and 2019–21, the prevalence of anaemia among children increased from 59 per cent and continued to be higher among rural children. The prevalence of anaemia among children is highest among children in Ladakh (94 per cent), Gujarat (80 per cent), followed by Dadra and Nagar Haveli and Daman and Diu (76 per cent), Madhya Pradesh and Jammu & Kashmir (73 per cent), Rajasthan (72 per cent), and Punjab (71 per cent). The lowest prevalence of anaemia among children is in Kerala (39 per cent), Andaman and Nicobar Islands (40 per cent), and Nagaland and Manipur (43 per cent each).
Use of iodised salt Among the households tested, 94 per cent used iodised salt, similar to NFHS-4, when 93 per cent of households were using iodised salt. The use of iodised salt is lowest in Andhra Pradesh (83 per cent) and Dadra and Nagar Haveli and Daman and Diu (89 per cent).
Micronutrients Deficiency of micronutrients in diet is a major contributor to childhood morbidity and mortality. Breastfeeding children benefit from micronutrient supplements given to the mother. Information on food consumption among children below two years is useful in assessing the extent to which children are consuming foods rich in two key micronutrients-vitamin A and iron-in their daily diet. The intake of both vitamin A-rich and iron-rich foods increases as children are weaned.
Nutritional status of adults NFHS-5 collected data on the height and weight of women age 15–49 years and men age 15–54 years for calculating several measures of nutritional status. [Body mass index or (BMI) is kg/m2.]
At the national level, the prevalence of overweight (25-29.9 BMI) or obesity (> 30 BMI) increased for women to 24 per cent from 21 per cent in NFHS-4, and for men it creased to 23 per cent from 19 per cent in NFHS-4. The percentage of thin (< 25 BMI) women declined to 19 per cent from 23 per cent in NFHS-4. The highest proportion of overweight women was found in Puducherry (46 per cent), Chandigarh, Delhi, Tamil Nadu, Punjab, Kerala, and Andaman and Nicobar Islands. The highest proportion of thin women was in Jharkhand and Bihar (26 per cent each), followed by Gujarat and Dadra and Nagar Haveli and Daman and Diu. Overall, an increase in the mean BMI was found, up from 21.9 in 2015–16 to 22.4 in 2019–21.
In the case of men, 16 per cent were thin, 23 per cent were overweight or obese, and 61 per cent have a BMI in the normal (18.5-24.9 BMI) range. The mean BMI for men was the same as that of women. The proportion of thin men is highest in Bihar (22 per cent), followed by Madhya Pradesh, and Gujarat. The highest proportion of overweight or obese men is observed in Andaman and Nicobar Island, followed by Puducherry and Lakshadweep.
In NFHS-5, for the first time the waist circumference and hip circumference of women and men age 15-49 years were measured to calculate the waist-to-hip ratio (WHR). This ratio helps to predict abdominal obesity which is associated with an increased risk of type 2 diabetes, myocardial infarction, stroke, and premature death. Some 57 per cent of women and 48 per cent of men have a WHR that puts them at an increased risk of metabolic complications. The proportion of women with an increased risk WHR is highest (88 per cent) in Jammu and Kashmir, and lowest (40 per cent) in Madhya Pradesh. For men it is highest (67 per cent) in Chandigarh and lowest (25 per cent) in Meghalaya.
Anaemia in adults Of the women in the age group 15–49, 57 per cent were anaemic, showing an increase from 53 per cent NFHS-4. For men aged 15–49, 25 per cent were anaemic, an increase from 23 per cent in NFHS-4. While 26 per cent of women were mildly anaemic, 29 per cent were moderately anaemic, and 3 per cent were severely anaemic. Of the anaemic men, 20 per cent were mildly anaemic, 5 per cent were moderately anaemic, and 0.4 per cent were severely anaemic. The highest prevalence of anaemia among women (60 per cent or more) was found in Chhattisgarh, Bihar, Odisha, Gujarat, Jharkhand, Assam, Tripura, and West Bengal, and the prevalence is less than 30 per cent in Lakshadweep, Nagaland, and Manipur. Among the union territories, Ladakh (93 per cent) shows the highest prevalence. Anaemia prevalence in men is highest in Ladakh, West Bengal, Jammu and Kashmir, and Assam; it is lowest in Lakshadweep and Manipur.
Food consumption There has been no major change in the pattern of daily food consumption; however, there has been a reduction in the daily consumption of fried food and aerated drinks among both women and men. Overall, 29 per cent of women and 17 per cent of men are vegetarians.
(viii) Health and Morbidity
From the data available for NFHS-5, 222 persons per 100,000 were estimated to have medically treated tuberculosis. This was a decrease from 305 persons per 100,000 in NFHS-4. The prevalence is higher among men (283 per 100,000) than among women (162 per 100,000). However, the prevalence decreased with reference to NFHS-4 for men (from 389 persons per 100,000) as well as for women (from 220 persons per 100,000). Cooking fuel has an impact on prevalence of tuberculosis, with the higher prevalence among those who use wood and straw, etc., for fuel. The number of persons suffering from medically treated tuberculosis ranges from a low of 24 persons per 100,000 in Chandigarh to a high of 634 persons per 100,000 in Sikkim. Meghalaya, Mizoram, and Nagaland are high-prevalence states.
Non-communicable diseases (NCDs) account for 65 per cent of all deaths in India. The major metabolic risk factors for NCDs are obesity, raised blood pressure, raised blood glucose, and raised total cholesterol levels in the blood. The prevalence of diabetes is 2 per cent among both men and women age 15–49 years. The figure is unchanged from NFHS-4. The prevalence of asthma is 2 per cent among women and 1 per cent among men age 15–49 years, the same as in NFHS-4. Goitre or any other thyroid disorder is more prevalent among women (3 per cent) than men (0.5 per cent). There is an increase in the case of women from 2 per cent in NFHS-4, while there is no change for men. In the case of heart disease, it affects 1 per cent of both women and men; as for cancer, less than 1 per cent suffer from it. Hypertension prevails in 21 per cent of women and 24 per cent of men age 15 and over. The prevalence of hypertension is higher among men age 15 and over than among women age 15 and over. The prevalence of hypertension among men and women is highest in Sikkim.
As for tobacco consumption, which is associated with a wide range of diseases, 39 per cent of men and 4 per cent of women age 15–49 use some form of tobacco. The most common form of tobacco consumption among men is chewing paan masala or gutkha, followed by smoking cigarettes, using khaini, and smoking bidis. Among women, the most common form of tobacco used is chewing paan masala or gutkha, chewing paan with tobacco, and using khaini.
Alcohol consumption is found among 22 per cent of men (a decline from 29 per cent in NFHS-4) and 1 per cent of women (unchanged from NFHS-4). The percentage of women age 15–49 who drink alcohol is highest in Arunachal Pradesh and Sikkim, while among men it is highest in Goa, Arunachal Pradesh, and Telangana, in that order. It is lowest in Lakshadweep.
Over 40 per cent of households have at least one usual member covered under health insurance or a health scheme (which is an increase from 29 per cent in NFHS-4). Only 30 per cent of women and 33 per cent of men age 15–49 are covered by health insurance or a health scheme. About 46 per cent of those with insurance are covered by a state health insurance scheme and about 16 per cent by Rashtriya Swasthya Bima Yojana. The highest proportion of households covered was in Rajasthan (88 per cent) and Andhra Pradesh (80 per cent); the lowest coverage (less than 15 per cent) was in the Andaman and Nicobar Islands, and Jammu and Kashmir.
The crude death rate (CDR) for India is 9 deaths per 1,000 population per year; it was10 per 1,000 for men and 8 per 1,000 for women. There is not much variation in CDRs across states, but they are highest in Odisha, Tamil Nadu, and Puducherry. The CDR is less than the national average in northeastern, western, and northern states. Age-specific death rates decrease from 15 deaths per 1,000 population age 0–4 to less than 1 death per 1,000 population age 10–14; thereafter, there is an increase to a high of 79 deaths per 1,000 population at age 70 and over. Regarding cause of death, the percentage of deaths due to non-medical reasons (accidents, violence, poisoning, homicides, or suicides) is higher among men (11 per cent) than women (6 per cent). The proportion of deaths due to non-medical reasons peaks at ages 15–29 for both men and women.
Sources of health care are in the public sector (50 per cent) and in the private sector (48 per cent). In the public sector, government and municipal hospitals are the most important source. Nearly 50 per cent of households in India do not generally go to the public sector healthcare sources. The percentage is highest in Bihar and Uttar Pradesh, and lowest (less than 5 per cent) in Ladakh, Lakshadweep, and the Andaman and Nicobar Islands. The reasons for not using government health facilities at the national level: the poor quality of care; the long waiting time at government facilities; and lack of government facility nearby. The problems faced by women in accessing medical care include lack of money, distance of facility, and absence of female healthcare provider.
(ix) HIV and Sexual Behaviour
The percentage of men and women in India who have heard of HIV and AIDS is 94 per cent and 87 per cent, respectively, while 71 per cent of men and 60 per cent of women know that both consistent condom use and sex with only one uninfected partner can prevent HIV/AIDS. Since NFHS-4, knowledge of HIV/AIDS has increased more among women than men. However, only 22 per cent of women and 31 per cent men age 15–49 in India have comprehensive knowledge of HIV/AIDS, the figure remaining unchanged since NFHS-4. Among youth (age 15–24), 29 per cent of men and 20 per cent of women have comprehensive knowledge of HIV. The figures show a slight decrease from NFHS-4. (Comprehensive knowledge includes knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chances of getting HIV/AIDS, and rejecting two common misconceptions about transmission or prevention of HIV/AIDS, namely, transmission through mosquito bites and through sharing food.) As for attitude towards persons with HIV/AIDS, overall, only 24 per cent of men and 23 per cent of women expressed accepting attitudes toward people living with HIV/AIDS.
Regarding sexually transmitted infections (STI), 12 per cent of women and 9 per cent of men age 15–49 who have ever had sex reported having an STI and/or symptoms of an STI in the 12 months preceding the survey.
Overall, the percentage of young people age 15–24 who have had sex before age 15 has decreased slightly between NFHS-4 and NFHS-5 for women (from 3 per cent to 2 per cent) and men (from 0.9 per cent to 0.5 per cent). Among women age 15–24, the likelihood of ever having had sex and having had sex before age 15 declines sharply with schooling; it also declines with increasing wealth. Only 7 per cent of never married men and 2 per cent of never married women age 15–24 reported premarital sex in the 12 months before the survey.
Of the young men age 15–24, 39 per cent fell in the category of higher-risk intercourse (sex with a non-marital, non-cohabitating partner); while 2 per cent of women age 15–24 fell into the same category.
(x) Empowerment of Women
Employment and decision on use of earnings Of currently married women age 15–49, 32 per cent are employed compared to 98 per cent of currently married men age 15–49. There is a marginal increase of 1 per cent in the case of women from NFHS-4. While 85 per cent of these women (an increase from 82 per cent in NFHS-4) make decisions alone or jointly with their husband on the use of their earnings are used, only 18 per cent of these make these decisions alone. Based on women’s responses, joint decision on use of men’s earnings has increased to 71 per cent from 64 per cent in NFHS-4.
Participation in household decision-making Participation in household decisions by women is based on their making decisions alone or jointly with their husband in all of these areas: (i) woman’s own health care, (ii) major household purchases, and (iii) visits to the woman’s family or relatives. It was found that 71 per cent of currently married women participate in making household decisions alone or jointly with their husband, while 11 per cent do not participate in any of the three decisions. Women’s participation in decision making has increased since NFHS-4. Women’s participation in all three decisions ranges from 48 percent in Ladakh to the high of 95 per cent in Nagaland. As for men, 57 per cent say that a wife should have an equal or greater say in decisions (a decrease from NFHS-4), and only 5 per cent say that she should not have an equal or greater say.
Access to a bank account and mobile phone The prevalence of women with a bank or savings account that they themselves use has increased to 79 per cent from 53 per cent in NFHS-4. However, only 51 per cent of women know about a microcredit programme (which is an increase from 41 per cent in NFHS-4), and only 11 per cent have ever taken a microcredit loan (up from 8 per cent in NFHS-4). Overall, 54 per cent of women themselves own and use a mobile phone. The percentage varies from 39 per cent in Madhya Pradesh to 91 per cent in Goa, followed closely by Sikkim and Kerala.
Freedom of movement Freedom of movement is decided on the basis of being usually allowed to go alone to the market, to the health facility, and to places outside the village or community. Just 42 per cent of women are allowed to go alone to all three places (a small increase from 41 per cent in NFHS-4), and 5 per cent are not allowed to go alone to any of the three places. Freedom of movement of women varies from 82 per cent in Himachal Pradesh to only 2 per cent in Lakshadweep, 15 per cent in Kerala, and less than one-third in Goa, Odisha, Manipur, Nagaland, and Karnataka.
Attitude towards wife beating A norm that goes against gender equality and empowerment of women is the right of a husband to control his wife in various ways, including through violence. Strangely, 45 per cent of women and 44 per cent of men believe that a husband is justified in beating his wife in at least one of seven specified circumstances. However, for women, agreement with any of the seven reasons justifying wife beating has declined from 52 per cent in NFHS-4 even as it has increased for men from 42 per cent in NFHS-4. Women (32 per cent) and men (31 per cent) are both most likely to agree that a husband is justified in hitting or beating his wife if she shows disrespect for her in-laws. Both are least likely to agree that a husband is justified in beating his wife if she refuses to have sex with him. There is wide variation across states/union territories on this matter: for women agreement with at least one reason for wife beating ranges from a low 9 per cent in Dadra and Nagar Haveli and Daman and Diu, and 14 per cent each in Chandigarh, and the Andaman and Nicobar Islands, and 15 per cent in Himachal Pradesh to the rather high level of 78 per cent in Tamil Nadu and 84 per cent each in Andhra Pradesh and Telangana. For men, the corresponding range is from 9 per cent in Chandigarh to 82 per cent in Karnataka.
Asset ownership More men (60 per cent) than women (42 per cent) own a house alone or jointly with someone, and 42 per cent of men and 32 per cent of women own land alone or jointly with someone. House ownership as well as land ownership among women is higher in Ladakh and Arunachal Pradesh. In the South, women’s ownership of property is most common in Karnataka and Telangana.
(xi) Domestic Violence
Information was obtained from never-married women age 18-49 on their experience of violence committed by anyone and from ever-married women age 18-49 on their experience of violence committed by their current and former husbands and by others. Overall, domestic violence has come down marginally from 31.2 per cent to 29.3 per cent between NFHS-4 and NFHS-5.
It was found that 30 per cent of women have experienced physical violence since age 15, and 23 per cent have experienced physical violence in the 12 months preceding the survey. Among women who have ever been pregnant, 3 per cent have experienced physical violence during any pregnancy. Of the ever-married women, 30 per cent have experienced physical, sexual, or emotional spousal violence. The most common type of spousal violence is physical violence, followed by emotional violence. Ever-married women’s experience of spousal physical or sexual violence has declined to 29 per cent from 31 per cent in NFHS-4. The percentage of women subjected to violence is more in rural areas than in urban areas. Only 14 per cent of women subjected to physical or sexual violence by anyone have sought help to stop the violence. Women’s experience of physical violence increases with age, and decreases with schooling and wealth. Strangely, women who are employed are more likely to experience physical violence than women who are not employed. Alcoholism, lower level of schooling, and greater marital control behaviour increase the tendency towards spousal violence in men. Women’s experience of any spousal violence varies from 2 per cent in Lakshadweep, 10 per cent in Himachal Pradesh and Goa, and 11 per cent in Mizoram and Chandigarh to 40–41 per cent of women in Manipur, Tamil Nadu, and Telangana, and 48 per cent in Karnataka.
Of ever-married women, 4 per cent have initiated physical violence against their husband when he was not already physically hurting them. A woman who has experienced spousal violence is much more likely than a women who has not experienced spousal violence to have initiated violence against her husband.
Women who have experienced physical or sexual violence seek help mostly from the woman’s own family, followed by the husband’s family. Among institutional sources of help, the most common is police, followed by a religious leader. Few have ever sought help from a doctor or a lawyer.
Comments
The data from NFHS-5 shows that with development and progress in women’s education, almost all variables improve, whether it be TFR, marriage age, number of children desired, or nutrition.
It is heartening to note that the sex ratio has increased, and rural India is performing even better than urban India in this matter. The sex ratio at birth has similarly improved at the overall level, and, again, rural areas have outperformed the urban areas. This may seem surprising. There must be an analysis as to how this improvement in sex ratio has been achieved; is it because of the ban on determining the sex of the unborn child or is because of the work done by grassroot activists, both government and non-government?
At the time of survey, Ayushman Bharat AB-PMJAY and Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) had not been fully implemented, hence their coverage may not have been factored in data relating to health insurance/financing scheme and mothers who received 4 or more antenatal care check-ups.
Child malnutrition continues to be on the high side and has persisted for long, though an improvement is noticed. Government needs to take action and strengthen nutrition programmes even while encouraging the community to take steps in this direction. Two major public health concerns are obesity and tobacco use, both of which are known to be high risks for non-communicable diseases. The general health of women needs to be given attention, considering the levels of anaemia and hypertension and diabetes among women aged 15 and above. Government needs to expand the health infrastructure. The improvements made in the well being of women have to be consolidated and improved further. The survey points to the fact that with women’s development comes development in many other areas.
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