NFHS 2019-21 - Some key lessons

The NFHS 2019-20 has given a good insight into the direction of Indian society. A detailed update.

NFHS 2019-21 - Some key lessons

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• The story: The latest NFHS 2019-21 (National Family Health Survey) has found important statistical indicators of the direction Indian society is moving in.
• India's fertility rate: The country hit a positive demographic milestone as its total fertility rate slipped below the replacement level for the first time. The replacement mark—2.1 children per woman—is the fertility rate that keeps a population stable over time by balancing births with deaths. The data for 14 states and Union territories, pertaining to surveys held in 2019-21, was released on Wednesday. These states include key ones such as Uttar Pradesh, Punjab, Odisha, Madhya Pradesh and Rajasthan. The data for 22 states had already been released last year. The new findings complete the all-India picture on issues such as population, health, and nutrition.

1. Replacement-level fertility - The total fertility rate (TFR) has declined considerably in the last 15 years across urban and rural India. Each woman was likely to bear 2.7 children on average in her lifetime in the 2005-06 survey, but this was 2.0 in the 2019-21 survey. A replacement-level fertility rate (2.1) is considered essential to keep population growth in check, and has been linked to better education of women, less unmet need for family planning and reduced child mortality.
2. The urban-rural gap has also narrowed. The TFR was 1.6 for urban areas and 2.1 for rural areas in the latest survey. Just five states had a TFR exceeding the replacement level: Bihar (3.0), Meghalaya (2.9), Uttar Pradesh (2.4), Jharkhand (2.3) and Manipur (2.2).
3. Nagaland, Jammu and Kashmir, Mizoram, Chhattisgarh, Rajasthan and Bihar have registered the maximum declines in TFR since 2015-16, while Meghalaya, Jharkhand, Nagaland and Bihar recorded the highest rural-urban gaps.

• Child marriage: This is a key determinant of high fertility, poor maternal and child health, and lower social status of women. The share of women aged 20-24 who married before turning 18 has declined from 27% to 23% in the last five years, the data shows. However, this means every fifth girl still gets married underage. Although the reduction was spread across rural and urban areas, wide disparities persist. While 15% of women aged 20-24 got married before turning 18 in urban areas, the share was 27% in rural areas. West Bengal and Bihar, with around 41% such women each, had the highest prevalence of girl child marriage, and this has remained unchanged since the last survey held in 2015-16. Surprisingly, while Bihar reported the highest fertility rate, the same in West Bengal was very low (1.6). The maximum reduction in the proportion of underage marriages was observed in Rajasthan, Madhya Pradesh, and Haryana.
• Anaemia is widespread: The prevalence of anaemia has risen across age groups, the survey found. As many as 57% women aged 15-49 were anaemic in 2019-21, compared to 53% in 2015-16, while the same for men rose from 22.7% to 25%. The most formidable increase—8.5 percentage points—was observed for children aged 6-59 months (67.1%). Among larger states, West Bengal (71%) and Kerala (36%) reported the highest and lowest prevalence, respectively, of anaemic women. Assam, Jammu and Kashmir, Chhattisgarh, Odisha, Tripura, Gujarat and Mizoram recorded a 10-20 percentage-point rise. Every third man was anaemic in West Bengal, Tripura, Jammu and Kashmir and Assam. Kerala (18%), along with Rajasthan (23%), Gujarat (27%), Chhattisgarh (27%) and Maharashtra (22%), reported a 4-6 percentage-point increase among male adults. Child anaemia rates worsened the most in Assam, Mizoram, Chhattisgarh, and Odisha. Gujarat (80%) and Madhya Pradesh (73%) had the highest prevalence, and Kerala the lowest (39%).
• High malnutrition: The share of under-five children who were stunted (too short for age), wasted (low weight for height), or underweight has declined. However, every third child still suffers from chronic undernourishment, and every fifth child is acutely malnourished. Meghalaya (46%) had the highest stunting prevalence, followed by Bihar, Uttar Pradesh and Jharkhand, all over 39%. Rajasthan, Madhya Pradesh, Jharkhand, Uttar Pradesh and Bihar recorded declines of 5-7 percentage points since 2015-16.

1. Despite having the second lowest prevalence of child stunting, Kerala registered a marginal increase in its share (3.5 percentage points). Acute malnutrition among under-five children increased significantly in Telangana, Bihar and northeastern states, whereas states such as Haryana, Jharkhand, Madhya Pradesh, Karnataka, Rajasthan, and Chhattisgarh saw noteworthy improvement.
2. Every fourth child in Bihar, Gujarat and Maharashtra, and every fifth child in Jharkhand, Assam, Telangana, West Bengal and Karnataka were found wasted. Bihar had the highest prevalence (41%) of underweight children, followed closely by Gujarat (40%).

• Improving amenities: Access to household amenities has improved. All states, except Manipur, Meghalaya, Assam and Jharkhand, had over 90% population with access to improved drinking water sources. Only Uttar Pradesh, Meghalaya, Assam, Jharkhand and Arunachal Pradesh had less than 95% population living in households with access to electricity.

1. Despite remarkable growth, only 70% of the population had access to improved sanitation facilities. Bihar, Jharkhand, Odisha, Madhya Pradesh, Uttar Pradesh and Chhattisgarh almost doubled the access since 2015-16, but most fell below the 75% mark.
2. Access to clean cooking fuel has improved from 45% to 60%. Telangana (92%) and Jharkhand (32%) reported the highest and lowest coverage among larger states.
3. The NFHS findings are a reminder of the urgent need to close gaps in girls’ education and address the pathetic nutritional status of women and children.

• Sex ratio: India’s overall sex ratio — women per thousand men — is now at a level seen in developed countries. For every 1,000 men, India has 1,020 women. In 2015-16, the sex ratio was just 991. But there is a cause for concern, too, since the sex ratio at birth continues to be lower than what is naturally expected. The fifth NFHS found that the sex ratio is better in rural areas compared to urban centres. 13 states and union territories still have more males than females. In a rural versus urban analysis, the sex ratio was found skewed in favour of males in rural areas of 14 states, while 22 states had a sex ratio favouring males in urban areas.

1. It has been observed that in backward states and districts, the female-male ratio is better as medical facilities are yet to become easily available. In districts where these are available, sex determination goes up and sex ratio declines.
2. The union territory of Dadra and Nagar Haveli and Daman and Diu had the worst urban sex ratio: 775 women per 1,000 men. And Delhi had the worst rural sex ratio (859) among all states.
3. So development may empower women but it brings down the number of girl children. This is the case in most of the northern states. Urban sex ratio for children is lower than rural for the same reason. Overall urban sex ratio is low also because of male selective migration from rural to urban areas.
4. Data also indicates that six states saw a decline in sex ratio compared to 2015-16. Experts say the decline in sex ratio at birth calls for an urgent need to strengthen pre-conception and prenatal diagnostic technique norms.
5. But the headline number does not present a complete picture. The sex ratio at birth for the country was still 929 females per males — an improvement from 919 in 2015-16, but still lower than the natural standard of 952 female births per 1,000 male births.
6. Analysis indicates that 19 states/UTs had a lower sex ratio than the natural standard, and the sex ratio at birth was more skewed in urban areas than rural centres. Twenty-nine states had a lower sex ratio at birth than the natural standard in urban areas as compared to 21 states that had worse than natural standards in rural areas.

• EXAM QUESTIONS: (1) If India's total fertility rate is now less than 2.0, which is lower than the replacement rate of 2.1, then how is the total population of India still growing? (2) Explain the top five major learnings from the NFHS 2019-20 survey.

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