National Family Health Survey 1998-1999

The second National Family Health Survey (NFHS-2), conducted in 1998-99, provides information on fertility, mortality, family planning, and important aspects of nutrition, health, and health care. The International Institute for Population Sciences (IIPS) coordinated the survey, which collected information from a nationally representative sample of more than 90,000 ever-married women age 15-49. The NFHS-2 sample covers 99 percent of India's population living in all 26 states. This report is based on the survey data for 25 of the 26 states, however, since data collection in Tripura was delayed due to local problems in the state.

IIPS also coordinated the first National Family Health Survey (NFHS-1) in 1992-93. Most of the types of information collected in NFHS-2 were also collected in the earlier survey, making it possible to identify trends over the intervening period of six and one-half years. In addition, the NFHS-2 questionnaire covered a number of new or expanded topics with important policy implications, such as reproductive health, women's autonomy, domestic violence, women's nutrition, anaemia, and salt iodization.

The NFHS-2 survey was carried out in two phases. Ten states were surveyed in the first phase which began in November 1998 and the remaining states (except Tripura) were surveyed in the second phase which began in March 1999. The field staff collected information from 91,196 households in these 25 states and interviewed 89,199 eligible women in these households. In addition, the survey collected information on 32,393 children born in the three years preceding the survey. One health investigator on each survey team measured the height and weight of eligible women and children and took blood samples to assess the prevalence of anaemia.

SUMMARY OF FINDINGS

POPULATION CHARACTERISTICS

Three-quarters (73 percent) of the population lives in rural areas. The age distribution is typical of populations that have recently experienced a fertility decline, with relatively low proportions in the younger and older age groups. Thirty-six percent of the population is below age 15, and 5 percent is age 65 and above. The sex ratio is 957 females for every 1,000 males in rural areas but only 928 females for every 1,000 males in urban areas, suggesting that more men than women have migrated to urban areas.

The survey provides a variety of demographic and socioeconomic background information. In the country as a whole, 82 percent of household heads are Hindu, 12 percent are Muslim, 3 percent are Christian, and 2 percent are Sikh. Muslims live disproportionately in urban areas, where they comprise 15 percent of household heads. Nineteen percent of household heads belong to scheduled castes, 9 percent belong to scheduled tribes, and 32 percent belong to other backward classes (OBCs). Two-fifths of household heads do not belong to any of these groups.

Questions about housing conditions and the standard of living of households indicate some improvements since the time of NFHS-1. Sixty percent of households in India now have electricity and 39 percent have piped drinking water compared with 51 percent and 33 percent, respectively, at the time of NFHS-1. Sixty-four percent of households have no toilet facility compared with 70 percent at the time of NFHS-1.

About three-fourths (75 percent) of males and half (51 percent) of females age six and above are literate, an increase of 6-8 percentage points from literacy rates at the time of NFHS-1. The percentage of illiterate males varies from 6-7 percent in Mizoram and Kerala to 37 percent in Bihar and the percentage of illiterate females varies from 11 percent in Mizoram and 15 percent in Kerala to 65 percent in Bihar. Seventy-nine percent of children age 6-14 are attending school, up from 68 percent in NFHS-1. The proportion of children attending school has increased for all ages, particularly for girls, but girls continue to lag behind boys in school attendance. Moreover, the disparity in school attendance by sex grows with increasing age of children. At age 6-10, 85 percent of boys attend school compared with 78 percent of girls. By age 15-17, 58 percent of boys attend school compared with 40 percent of girls. The percentage of girls 6-17 attending school varies from 51 percent in Bihar and 56 percent in Rajasthan to over 90 percent in Himachal Pradesh and Kerala.

Women in India tend to marry at an early age. Thirty-four percent of women age 15-19 are already married including 4 percent who are married but gauna has yet to be performed. These proportions are even higher in the rural areas. Older women are more likely than younger women to have married at an early age: 39 percent of women currently age 45-49 married before age 15 compared with 14 percent of women currently age 15-19. Although this indicates that the proportion of women who marry young is declining rapidly, half the women even in the age group 20-24 have married before reaching the legal minimum age of 18 years. On average, women are five years younger than the men they marry. The median age at marriage varies from about 15 years in Madhya Pradesh, Bihar, Uttar Pradesh, Rajasthan, and Andhra Pradesh to 23 years in Goa.

As part of an increasing emphasis on gender issues, NFHS-2 asked women about their participation in household decisionmaking. In India, 91 percent of women are involved in decision-making on at least one of four selected topics. A much lower proportion (52 percent), however, are involved in making decisions about their own health care. There are large variations among states in India with regard to women's involvement in household decisionmaking. More than three out of four women are involved in decisions about their own health care in Himachal Pradesh, Meghalaya, and Punjab compared with about two out of five or less in Madhya Pradesh, Orissa, and Rajasthan. Thirty-nine percent of women do work other than housework, and more than two-thirds of these women work for cash. Only 41 percent of women who earn cash can decide independently how to spend the money that they earn. Forty-three percent of working women report that their earnings constitute at least half of total family earnings, including 18 percent who report that the family is entirely dependent on their earnings. Women's work-participation rates vary from 9 percent in Punjab and 13 percent in Haryana to 60-70 percent in Manipur, Nagaland, and Arunachal Pradesh.

FERTILITY AND FAMILY PLANNING

Fertility continues to decline in India. At current fertility levels, women will have an average of 2.9 children each throughout their childbearing years. The total fertility rate (TFR) is down from 3.4 children per woman at the time of NFHS-1, but is still well above the replacement level of just over two children per woman. There are large variations in fertility among the states in India. Goa and Kerala have attained below replacement level fertility and Karnataka, Himachal Pradesh, Tamil Nadu, and Punjab are at or close to replacement level fertility. By contrast, fertility is 3.3 or more children per woman in Meghalaya, Uttar Pradesh, Rajasthan, Nagaland, Bihar, and Madhya Pradesh. More than one-third to less than half of all births in these latter states are fourth or higher-order births compared with 7-9 percent of births in Kerala, Goa, and Tamil Nadu.

Efforts to encourage the trend towards lower fertility might usefully focus on groups within the population that have higher fertility than average. In India, rural women and women from scheduled tribes and scheduled castes have somewhat higher fertility than other women, but fertility is particularly high for illiterate women, poor women, and Muslim women. Another striking feature is the high level of childbearing among young women. More than half of women age 20-49 had their first birth before reaching age 20, and women age 15-19 account for almost one-fifth of total fertility. Studies in India and elsewhere have shown that health and mortality risks increase when women give birth at such young ages?both for the women themselves and for their children. Family planning programmes focusing on women in this age group could make a significant impact on maternal and child health and help to reduce fertility.

INFANT AND CHILD MORTALITY

NFHS-2 provides estimates of infant and child mortality and examines factors associated with the survival of young children. During the five years preceding the survey, the infant mortality rate was 68 deaths at age 0-11 months per 1,000 live births, substantially lower than 79 per 1,000 in the five years preceding the NFHS-1 survey. The child mortality rate, 29 deaths at age 1-4 years per 1,000 children reaching age one, also declined from the corresponding rate of 33 per 1,000 in NFHS-1. Ninety-five children out of 1,000 born do not live to age five years. Expressed differently, 1 in 15 children die in the first year of life, and 1 in 11 die before reaching age five. Child-survival programmes might usefully focus on specific groups of children with particularly high infant and child mortality rates, such as children who live in rural areas, children whose mothers are illiterate, children belonging to scheduled castes or scheduled tribes, and children from poor households. Infant mortality rates are more than two and one-half times as high for women who did not receive any of the recommended types of maternity related medical care than for mothers who did receive all recommended types of care.

HEALTH, HEALTH CARE, AND NUTRITION

Promotion of maternal and child health has been one of the most important components of the Family Welfare Programme of the Government of India. One goal is for each pregnant woman to receive at least three antenatal check-ups plus two tetanus toxoid injections and a full course of iron and folic acid supplementation. In India, mothers of 65 percent of the children born in the three years preceding NFHS-2 received at least one antenatal check-up and 44 percent received at least three check-ups. For 67 percent of these births, mothers received the recommended number of tetanus toxoid vaccinations during pregnancy, up from 54 percent in NFHS-1. For 58 percent, mothers received iron and folic acid supplementation during pregnancy. Women in disadvantaged socioeconomic groups are less likely than other women to be covered by each of these interventions. Coverage is also low for women who already have four or more children. States that perform well below the national average with regard to the provision of recommended components of antenatal care include Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh, and several of the northeastern states. Kerala, Goa, and Tamil Nadu, by contrast, have achieved relative success with regard to antenatal care. In these states, mothers of over 90 percent of births receive at least three antenatal check-ups, at least 86 percent receive two or more tetanus toxoid injections, and at least 93 percent receive iron and folic acid tablets. Even in these states, however, a substantial proportion of women do not receive all of the recommended components of antenatal care.

NFHS-2 collected information on the prevalence and treatment of three health problems that cause considerable mortality in young children?fever, acute respiratory infection (ARI), and diarrhoea. In India 30 percent of children under age three had fever during the two weeks preceding the survey, 19 percent had symptoms of ARI, and 19 percent had diarrhoea. About two-thirds of the children who had symptoms of ARI or diarrhoea were taken to a health facility or health-care provider. Knowledge of the appropriate treatment of diarrhoea remains low. Only 62 percent of mothers of children age less than 3 years know about oral rehydration salt (ORS) packets and 34 percent of mothers incorrectly believe that children should be given less to drink than usual when sick with diarrhoea. Forty-eight percent of children with diarrhoea received some form of oral rehydration therapy (ORT), including 27 percent who received ORS. The percentage of children with diarrhoea who received ORS has increased substantially since NFHS-1, when it was only 18 percent, suggesting some improvement in the management of childhood diarrhoea. Among children sick with diarrhoea in the two weeks prior to the survey, the proportion who were given some form of ORT varies from 90 percent in Kerala, 76 percent in Goa, and 73 percent in West Bengal to 34 percent in Rajasthan and 36 percent in Uttar Pradesh. The proportion given ORS varies from 56 percent in Goa and 51 percent in Manipur to only 15-16 percent in Bihar and Uttar Pradesh.

Although the spread of HIV/AIDS is a major concern in India, 60 percent of women in India have not heard of AIDS. Awareness of AIDS is particularly low among women who are not regularly exposed to media, scheduled-tribe women, illiterate women, women living in households with a low standard of living, and rural women. Among women who have heard of AIDS, 79 percent learned about the disease from television and 42 percent from radio, suggesting that the government's efforts to promote AIDS awareness through the electronic mass media have achieved some success. Among women who have heard of AIDS, however, one-third do not know of any way to avoid infection. Survey results suggest that health personnel could play a much larger role in promoting AIDS awareness. In India, only 4 percent of women who know about AIDS learned about the disease from a health worker. Only 12 percent of women have heard of AIDS in Bihar and 20-23 percent in Uttar Pradesh, Rajasthan, and Madhya Pradesh, compared with 87 percent or more in Mizoram, Manipur, Tamil Nadu, and Kerala. Among women who have heard of AIDS, at least one-fourth do not know of any way to avoid it in all states except Mizoram, Tamil Nadu, Orissa, and Delhi. These results suggest the need for effective IEC strategies throughout India.