National Family Health Survey 5
The first phase of the fifth round of the National Family Health Survey (NFHS-5) was conducted in 2019-20 and its findings were released in December 2020. The NFHS provides estimates on key indicators related to population, family planning, child and maternal health, nutrition, adult health, and domestic violence, among others. The fourth round of NFHS was conducted five years ago in 2015-16. In the first phase of the fifth round, the findings for 22 states and union territories (17 states and 5 union territories) have been presented. A total of 2,81,429 households, 3,07,422 women, and 43,945 men were surveyed across the 17 states. In this note, we look at the findings for the 17 states on indicators related to: (i) population, (ii) health and nutrition, (iii) access to infrastructure, and (iv) gender.
In this section, we look at certain indicators related to population: (i) use of family planning methods (includes female or male sterilisation, and use of contraceptives), (ii) Total Fertility Rate (TFR), and (iii) sex ratio at birth. TFR is the average number of children born to a woman in her life time. Governments set targets for TFR for the purpose of population control. TFR of 2.1 is considered as the replacement level fertility rate at which population stability is achieved (i.e., population replaces itself). The National Population Policy, 2000 had sought to achieve replacement level fertility by the year 2010.
Use of family planning methods increased; most states reduce their fertility rate, below the target of 2.1
- All states (except Mizoram) have seen an increase in the use of family planning methods. Goa (42%-point) and Bihar (32%-point) have seen the highest increase in the use of family planning methods.
Figure 1: Use of Family Planning methods (in %)
Note: AP = Andhra Pradesh, AS = Assam, BR = Bihar, GA = Goa, GJ = Gujarat, HP = Himachal Pradesh, KA = Karnataka, KL = Kerala, MH = Maharashtra, MG = Meghalaya, MZ = Mizoram, NL = Nagaland, SK = Sikkim, TS = Telangana, TR = Tripura, WB = West Bengal.
- Consequently, most states have seen a decrease in the total fertility rate (TFR). Bihar’s TFR has declined from 3.4 (in NFHS-4) to 3. All other medium and large states in the survey (i.e., population above 1 crore) have a TFR below the replacement level rate of 2.1.
Figure 2: Total Fertility Rate across states
Sex ratio at birth has declined in a few states
- Sex ratio at birth for children born in the last five years is below 950 for seven (of the 17) states. Sex ratio at birth is the number of female children born per 1,000 male children born. In three states, the ratio is below 900 (Goa: 838, Himachal Pradesh: 875, and Telangana: 894).
- The ratio has declined in seven states. The most notable decline was in Goa (from 966 to 838), and Kerala (from 1,047 to 951). Only Tripura has a sex ratio at birth above 1,000 (i.e., more females born than males).
Figure: 3: Sex ratio at birth for children born in the last five years
In this section, we look at certain health related indicators: (i) proportion of institutional births across states, (ii) the average out of pocket expenditure for deliveries at public health facilities, (iii) infant mortality rate (IMR), and (iv) nutrition levels for children and adults. IMR is the number of infants who die before reaching the age of one year, per 1,000 live births. Institutional deliveries are helpful in reducing infant mortality rates.
Institutional births have increased; out of pocket expenditure on deliveries increased in some states
- In 7 states, more than 90% of the births in the last five years were institutional births. In Kerala, nearly 100% of the births were institutional births. Only 46% of the births in Nagaland were institutional births.
- The average out of pocket expenditure on a delivery in a public health facility increased in 8 of the 17 states. Note that in West Bengal, the average expenditure on deliveries declined by Rs 5,236 per delivery (66% of the cost in 2015-16), and the proportion of institutional births increased from 75% to 92%.
Figure 4: Institutional births (in %) and out of pocket expenditure on a delivery in public health facilities
Infant Mortality Rate has declined across states; however, malnourishment among children is increasing
- IMR has marginally declined in nearly all states. Assam has seen one of the largest drops in IMR, from 48 deaths (per 1,000 live births) to 32 deaths. IMR remains high in Bihar (47 deaths per 1,000 live births).
Figure 5: Infant Mortality Rate across states
- However, nutritional status of children below 5 years of age is worsening. Stunting or chronic malnutrition (i.e., low height with respect to age) has increased in 11 of the 17 states. Proportion of severely wasted children has increased in 13 of the 17 states. Wasting or acute malnutrition refers to low weight with respect to height. Children who are stunted or wasted are more vulnerable to diseases and illness.
- The proportion of children who are underweight (low weight with respect to age) has increased in 11 of the 17 states. In Bihar and Gujarat, 40% or more of the children under the age of five years are underweight.
Figure 6: Proportion of children below five years who are stunted (low height for age)
Figure 7: Proportion of children below five years who are severely wasted (low weight for height)
Obesity is rising for both men and women across all states
- The proportion of women and men, between the age of 15-49 years, who are overweight or obese have increased across nearly all states (except Gujarat and Maharashtra). Overweight or obesity is measured through the Body Mass Index of persons.
- In Andhra Pradesh, Goa, Karnataka, Telangana, Kerala and Himachal Pradesh, nearly one-third of men and women (between 15-49 years of age) are overweight or obese.
Figure 8: Obesity amongst adults between 15-49 years of age (in %)
In this section, we look at certain indicators related to access to infrastructure for households. These include access to electricity, improved source of drinking water, improved sanitation facility (includes flush system, ventilated pit or composting toilet), and clean fuel for cooking (LPG / natural gas or biogas). Further, we look at certain indicators related to access to infrastructure among women: use of mobile phones, internet usage, use of a savings account, and ownership of land or house.
Access to electricity, improved source of drinking water and sanitation facility has increased
- The proportion of households with electricity and improved drinking water source has increased across all states. Households with an improved sanitation facility has also increased across all states. 99% households in Kerala have an improved sanitation facility, while only 49% households have it in Bihar.
- Similarly, the proportion of households using clean fuel for cooking has also increased across nearly all states. Telangana has seen a nearly 25%-point increase in access to improved sanitation facility and clean cooking fuel as compared to NFHS-4.
Figure 9: Proportion of households with an improved sanitation facility
More women using mobile phones across all states; however, many of them do not have access to internet
- The proportion of women who have a mobile phone has increased across all states. However, only about 50% women own and use a mobile phone in Andhra Pradesh, Bihar, Gujarat, and West Bengal.
Figure 10: Proportion of women who own a mobile phone that they use themselves
- The Survey also measured the proportion of men and women (15-49 years of age) who have ever used the internet. Across all states, the proportion of men who have used the internet was higher than women, with the difference being higher than 25%-point in states such as Telangana, Gujarat, and Andhra Pradesh. In Andhra Pradesh, Bihar, and Tripura, less than 25% women have used internet.
Figure 11: Men and women who have used internet (in %)
More women using bank accounts; ownership of house/ land amongst women declines in several states
- The proportion of women who have a savings or bank account has increased across all the 17 states. Bihar (51%-point) and Manipur (39%-point) have seen the highest increase in this regard. Across all 17 states, close to 80% women now have a savings or bank account, except in Gujarat (70%) and Nagaland (64%).
Figure 12: Proportion of women with savings or bank account
- However, the proportion of women who own a house or land (including joint ownership) has declined in 9 of the 17 states. Tripura, Maharashtra and Assam have seen a large decline in women owning house/ land.
Figure 13: Proportion of women owning a house or land
In this section, we look at indicators on: (i) use of hygienic methods of protection during menstrual period among women between 15-24 years of age, and (ii) spousal violence among married women.
Use of hygienic methods of protection during menstrual period has increased across states
- The Survey measured the proportion of women (15-24 years) who are using hygienic methods of protection during their menstrual period. This has increased across almost all states. The largest increase was seen in Bihar and West Bengal (28%-point). However, it still remains low in Bihar (59%), Assam and Gujarat (66%).
Figure 14: Proportion of women using hygienic methods of protection during menstrual period
Gender based violence still remains high, has increased in some states
- The proportion of married women (between 18-49 years of age) who have ever faced spousal violence has increased in 5 states. In Karnataka, it has doubled, from 21% to 44%. More than a third of the married women face spousal violence in Karnataka (44%), Bihar (40%), Manipur (40%), and Telangana (37%).
Figure 15: Proportion of women who have ever faced spousal violence
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