New Delhi, India. The much-awaited final report of the 2005-06 National Family Health Survey (NFHS-3) was released on Thursday, October 11th, by the Ministry of Health and Family Welfare at an official ceremony at the Ashok Hotel, New Delhi. The report offers the first-ever comprehensive picture of the health and well-being of India’s men, women, and children.
At a ceremony in New Delhi, Mission Director of the National Rural Health Mission (NRHM), Shri G.C. Chaturvedi, said findings from NFHS-3 have added substantially to the knowledge base about the health and family welfare situation of the country and will be a valuable source of information for making further improvements in health and family welfare policies and programmes.
The new report paints a mixed picture of India’s overall health. On the one hand, women are having fewer children and infant mortality has dropped in the seven-year period since the last NFHS survey in 1998-99. On the other hand, anaemia and malnutrition are still widespread among children and adults. And, in an unusual juxtaposition, more adults, especially urban women, are overweight or obese than seven years ago.
For the first time, the survey measured HIV prevalence at the national level and for selected states (Andhra Pradesh, Karnataka, Maharashtra, Manipur, Tamil Nadu, and Uttar Pradesh). The NFHS-3 survey found an HIV prevalence rate of 0.28 percent for the population age 15-49. The important new information about HIV prevalence from NFHS-3 has spurred the Government of India and international agencies to greatly reduce the official estimate of Indians living with HIV from more than 5 million persons to 2.47 million. This change has had a major impact on the global estimate of persons living with HIV.
NFHS-3, the third in the NFHS series of surveys, provides information on population, health and nutrition in India and each of its 29 states. Unlike the earlier surveys in which only ever-married women age 15-49 were eligible for individual interviews, NFHS-3 interviewed all women age 15-49 and all men age 15-54. The survey is based on a sample of households which is representative at the national and state levels. NFHS-3 conducted interviews with almost 199,000 women age 15-49 and men age 15-54 throughout India.1 NFHS-3 also tested more than 100,000 women and men for HIV and 214,000 adults and young children for anaemia.
NFHS-3 provides trend data on key indicators and includes information on several new topics, such as HIV/AIDS-related attitudes and behaviour, male involvement in family welfare and attitudes about family life education for children in school.
More key findings from the final report are highlighted below.
Family Planning Use Up, Fertility Down
Smaller families are slowly becoming the norm in India. Fertility has continued to decline since NFHS-2, dropping to an average of 2.7 children per woman from 2.9 children per woman. Ten states, mostly in Southern India, have reached replacement level or below replacement level fertility. While son preference remains a barrier to more rapid decline in fertility, an increasing number of women who have only daughters say that they want no more children. In NFHS-3, 62% of women with two daughters and no sons say they want no more children, compared with 47% in NFHS-2.
Declining fertility in large part is due to women’s increased use of contraception. For the first time ever, more than half of currently married women in India are using contraception, and their use of modern contraceptive methods increased from 43% to 49% between NFHS-2 and NFHS-3. A rise in the average age at marriage is also contributing to the drop in fertility. Forty-seven percent of women ages 20-24 were married before the legal age of marriage of 18 years, compared with 50% seven years earlier. This shift in age at marriage also influences the median age at first birth, which increased by six months to 19.8 years for women age 25-49.
Half of Women Lack Proper Care during Pregnancy and Delivery
More than three-quarters of pregnant women in India receive at least some antenatal care (ANC), but only half of women have at least three ANC visits with a health provider during their pregnancy, as recommended. The disparity between urban and rural women is especially pronounced, with 75% or urban women having ANC at least three times, compared with 44% of rural women. Three-quarters of urban women but only 38% of rural women received assistance at delivery from a skilled provider.
The above findings are based on births in the last 5 years, but comparisons of trends over time have to be restricted to births in the last 3 years since NFHS-2 included only that age group. Births assisted by a health professional increased from 42% in NFHS-2 to 49% in NFHS-3. Institutional births increased from 34% to 41%, but most women still deliver their children at home.
It is recommended that women receive postnatal care within two days of delivery, but only about one-third of women received care during that critical period.
Infant Mortality Drops, but Full Immunization Coverage Shows Little Progress
Infant mortality continues to decline, dropping from 68 to 57 per thousand births. There were particularly notable drops in the infant mortality rate in Bihar, Goa, Haryana, Jammu and Kashmir, Meghalaya, Orissa, Punjab, Rajasthan, Tamil Nadu, and Uttar Pradesh. The situation regarding child immunization rates, however, is not as clear cut. By the time they are one year old, children are supposed to receive a BCG vaccination against tuberculosis, a measles vaccination, and three doses each of polio and DPT vaccine. Overall, there was only a small improvement in full vaccination coverage, with 44% of children ages 12-23 months receiving all recommended vaccinations, up from 42% seven years earlier. Substantial improvements in coverage have been made in all vaccinations except DPT, which did not change at all between NFHS?2 and NFHS-3. Gains are particularly evident for polio vaccination coverage, but nearly one-quarter of children age 12-23 months have still not received three doses of polio vaccine, as recommended.
Progress in vaccination coverage varies markedly among the states. In 11 states, there has been a substantial deterioration in full immunization coverage in the last seven years, due to a decline in vaccination coverage for both DPT and polio. Particularly large decreases in vaccination coverage were seen in Maharashtra, Mizoram, Andhra Pradesh, and Punjab. On the other hand, there was major improvement in full immunization coverage in Bihar, Chhattisgarh, Jharkhand, Sikkim, and West Bengal. Other states with marked improvements in full immunization coverage were Assam, Haryana, Jammu and Kashmir, Madhya Pradesh, Meghalaya, and Uttaranchal.
Diarrhoea continues to be a major health problem for many children. Although knowledge about Oral Rehydration Salts (ORS) for the treatment of diarrhoea is widespread among mothers, only 26% of children under 3 years who had diarrhoea received a solution made from ORS packets, virtually unchanged from 27% in NFHS-2. Further, only 58% of children with diarrhoea were taken to a health facility, down from 65% seven years earlier.
Domestic Violence Widespread
A substantial proportion of married women report that they have experienced physical or sexual violence at some time in their lives. Overall, 40% of ever-married women have experienced violence, with large variations among the states. The experience of spousal violence ranges from a low of 6% in Himachal Pradesh to a high of 59% in Bihar. Married women with no education were much more likely (at 46%) than other women to have suffered spousal violence. However, spousal violence also extends to women who have 12 or more years of education, with 12% reporting violence.
Malnutrition Persists; Anaemia Widespread
Malnutrition continues to be a significant problem for children and adults in India. While there have been some improvements in the nutritional status of young children in several states, nutritional deficiencies are still widespread. Most striking has been the increase in wasting, or weight for height, among children under age 3 years. NFHS-3 found that 23% of children were wasted, up from 20% seven years earlier. At the same time, there has been very little change in the percentage of children who are underweight (43% in NFHS-2 and 40% in NFHS-3).
NFHS-3 also found a remarkably high prevalence of anaemia – 70% – in children age 6-59 months. The prevalence of anaemia is even worse than it was in NFHS-2. Anaemia in India is primarily linked to poor nutrition.
Women and men suffer a dual burden of overnutrition and undernutrition. More than one?third of women are too thin, while 13% are overweight or obese. In all, nearly half of married women are either underweight or overweight. One-third of men are too thin, and 9% are overweight or obese. Overweight and obesity are even more common in the cities, among highly educated adults, and among adults from the wealthiest households. The states with the largest percentage of overweight women and men are Punjab, Kerala, and Delhi.
Anaemia is also disturbingly common among adults, and its prevalence has actually increased over the past seven years. More than half of women in India (55%) are anaemic, and anaemia among women has increased slightly in the past seven years. Anaemia also increased for pregnant women during that period. Even though men are much less likely than women to be anaemic, anaemia levels in men are still unacceptably high (24%).
Most Adults Support Family Life Education
Virtually all Indian adults agree that children should be taught moral values in school, and most adults think that children should learn about the changes that occur in their bodies during puberty. Men and women differ somewhat on whether children should be taught in school about contraception. About half of women and two-thirds of men think that girls should learn about contraception in school. Both women and men are slightly less likely to say that contraception should be part of boys’ school education.
Most men and women believe that information on HIV/AIDS should also be part of the school curriculum. About 80 percent of men think boys and girls should learn about HIV/AIDS, compared with 63 percent of women. More than 60 percent of men say that both boys and girls should be taught about sex and sexual behaviour in school, but slightly less than half of women feel that this is an appropriate topic to be taught to girls or boys in school.
Almost two-thirds of Married Women Don’t Know That Condoms Prevent HIV
Given the large number of people living with HIV in India, new findings from NFHS-3 on the extent and sex differentials in knowledge of HIV/AIDS are of concern. Only 84% of men and 61% of women have ever heard of AIDS. Further, only 70% of men and 36% of women know that HIV/AIDS can be prevented by using condoms. The results underscore the pressing need to educate women and men about the virus, how it is transmitted, and how it can be prevented. Increasing HIV/AIDS education will be a critical step to curbing the number of new HIV cases in India.
New scientific evidence from NFHS-3 has provided crucial information for understanding India’s HIV epidemic. The survey found an HIV prevalence rate of 0.28 percent for the population age 15-49. Prevalence is more than 60 percent higher among men than women, at 0.36 percent and 0.22 percent, respectively. NFHS-3 found HIV prevalence to be particularly high in Manipur (1.1%) and Andhra Pradesh (1.0%).
The 2005-06 National Family Health Survey (NFHS-3) is the third in a series of national surveys; earlier NFHS surveys were carried out in 1992-93 (NFHS-1) and 1998-99 (NFHS-2). All three surveys were conducted under the stewardship of the Ministry of Health and Family Welfare, Government of India, with the International Institute for Population Sciences, Mumbai, serving as the nodal agency. Macro International, Calverton, Maryland, USA, provided technical assistance for all three NFHS surveys. NFHS-3 funding was provided by the United States Agency for International Development (USAID), the Department for International Development (DFID), the Bill and Melinda Gates Foundation, UNICEF, the United Nations Population Fund (UNFPA), and the Government of India. Assistance for the HIV component of the NFHS-3 survey was provided by the National AIDS Control Organization and the National AIDS Research Institute. In NFHS-3, 18 research organizations conducted interviews with almost 199,000 women age 15-49 and men age 15-54 throughout India. NFHS-3 also tested more than 100,000 women and men for HIV and 214,000 adults and young children for anaemia. Fieldwork for NFHS-3 was conducted in two phases from November 2005 to August 2006.
For more information on the NFHS-3, please visit: http://nfhsindia.org/nfhs3.html
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1 The results in the briefing sheets are given for women and men age 15-49 to allow comparisons by sex.