The recently released data of the fifth round of the National Family Health Survey (NFHS, 2019-20) offer little to feel optimistic about. The data unveiled several disturbing trends, ranging from increased levels of stunting (low height for age), wasting (weight for height) and severe wasting and underweight (weight for age) among children to heightened levels of anaemia among women and children in the States and Union Territories surveyed, with hardly any exception.
All these indicators point to the prevalence of malnutrition and undernutrition among children under five years of age. The survey also revealed very low levels of dietary intake among children under five years of age. The secular increase in the levels of anaemia as compared to 2015-16, when the previous survey was conducted, in women (pregnant and non-pregnant), children as well as men in most States and Union Territories was one of the most baffling sets of data to emerge. But overall, the data should not come as a surprise given that the Global Hunger Index (GHI) ranked India 94th out of 107 countries as recently as October 2020. GHI 2020, a peer-reviewed annual report, had described the hunger levels in India as “serious”. The GHI is based and calculated on four indicators: undernourishment, child wasting, child stunting and under-five child mortality. Among the 13 countries worse off than India were Rwanda, Nigeria, Afghanistan, Liberia, Mozambique, and Chad. Unlike India, most of these countries went through long periods of civil strife, which probably explains the hunger levels in them.
Phase One
The NFHS-5 data have been released only for 22 States and Union Territories where the survey could be completed. A covering note in the survey states that data for 14 States and Union Territories could not be compiled owing to disruption following the COVID-19 pandemic. Among the States that do not feature in the Phase One list are large and populous States such as Uttar Pradesh, Madhya Pradesh, Odisha, Rajasthan, and Chhattisgarh, whose development indicators have always lagged behind the rest of the country. The exception among the traditionally backward States is Bihar, which features in the Phase One survey. As was the case earlier, the International Institute of Population Sciences was designated the nodal agency for conducting the survey.
The data in Phase One are far from encouraging although they allow a lot of scope for reviewing policies that have led to the kind of figures thrown up by the survey. There are some new areas pertaining to women’s health that have been explored for the first time: for instance, the percentage of women undergoing screening for cervical, breast and oral cancer, which might lead the way to some policy prescriptions of a universal nature. There are also data on blood sugar and hypertension levels for men and women.
Also read: Findings of the Comprehensive National Nutrition Survey: Deprived Childhoods
The first phase covered six States in the Northeastern region; Goa, Gujarat and Maharashtra in the west; West Bengal in the east; Bihar and Himachal Pradesh in the north; Kerala, Karnataka, Andhra Pradesh and Telangana in the south, and the Union Territories of Andaman & Nicobar Islands, Lakshadweep, Daman & Diu, Dadra & Nagar Haveli, Jammu and Kashmir, and Ladakh.
In almost all the States and Union Territories surveyed, the indicators of child nutrition levels—anaemia among women and children—showed declines ranging from sharp to moderate. There is little doubt that the data for the rest of the States surveyed will show a different pattern after the survey results for them are made available.
An analysis of the current data showed that households had a greater dependence on the private sector for health care, especially maternal and child health care. Yet, the survey also revealed an increase in out-of-pocket (OOP) expenditure for child deliveries in the public health sector, which meant that people had to pay even at government public health facilities. Surprisingly, no information was collected on the OOP expenditure in the private sector as a whole and for deliveries specifically. This would have further helped in understanding the extent of dependence on and money spent for private sector health care. The data showed a whopping increase in the prevalence of Caesarean deliveries mostly in the private health sector during 2019-20. The percentage of Caesarean deliveries in the public health sector was higher but still much less when compared to the private health sector.
Rise in female sterilisations
Even though the number of children per woman (total fertility rate) showed a marked decline across all States almost uniformly, women continued to bear the brunt of family planning methods and that too irreversible methods such as sterilisation. Male sterilisation as a preferred choice of family planning was practically non-existent, while the use of condoms as a method of family planning was negligible. There were some notable exceptions in certain States where the pill as a method of contraception was preferred, even though the proportion of female sterilisations continued to dominate the family planning spectrum. Therefore, fundamentally very little has changed.
The gender differential, if anything, was stark in a context where the unmet need for contraception was almost fully borne by the woman. In Andhra Pradesh, for instance, female sterilisation levels went up from 68.3 per cent to 69.6 per cent whereas male sterilisation levels, which were already very low at 0.6 per cent, fell further to 0.4 per cent between NFHS-4 and NFHS-5. The average OOP expenditure on deliveries in a public health facility went up from Rs.2,322 to Rs.3,105.
Also read: Skewed progress
The State reported a high percentage of institutional births, with 42.4 per cent accounting for Caesarean births as compared to 40.1 per cent in NFHS-4. In private health facilities, Caesarean births accounted for 63 per cent of all deliveries, while the corresponding figure for public health facilities was 26.6 per cent. While the percentage of Caesarean deliveries went up in both public and private health facilities, it was clearly the predominant form of delivery in the private health sector, with exception of perhaps Kerala, where it was under 40 per cent in both public and private health facilities.
State of women
A general correlation was observed between levels of literacy of women and ownership of assets. The number of women having a separate bank account and managing those accounts and having their own mobile phones had increased substantively, though not uniformly to the same extent in the States surveyed. The progressive indicators for women included a greater role in three kinds of decision-making in the household, increase in joint ownership of assets such as houses, engagement in a job that paid them cash for the last 12 months and use of the Internet. On the flip side, the worsening of indicators such as anaemia among all women—married, unmarried, pregnant, or non-pregnant—spousal violence and sexual violence against women under the age of 18 was a matter of serious concern.
Of similar and equal concern was the drop in the proportion of children who were breastfed in the first hour after birth. In fact, in none of the States surveyed were more than 50 per cent of newborns fed within the first one hour after birth. This was important as the first breast milk (colostrum) has immunological benefits and protection against infection and disease and not feeding the child could have serious implications for it.
In Andhra Pradesh, for instance, 52 per cent of children under three years were breastfed within one hour of being born while 68 per cent under six months were exclusively breastfed. Breastfeeding rates were found to be higher in rural areas across all States.
There was not much difference in the incidence of child stunting in Andhra Pradesh between the two surveys (31.2 per cent), even though the overall figure was rather alarmingly high. The rates of wasting of children under five years had declined marginally. Some 29.6 children under the age of five were underweight. Among children in the 6-59 months age cohort, 63.2 per cent were anaemic while 58.8 per cent of women in the age cohort of 15-49 years were anaemic; the corresponding figure for men was 16.2 per cent.
Also read: Health Survey: Taking stock
Both men and women reported blood sugar problems, with 10-11 per cent among both reporting very high levels; 25 per cent of women and 29 per cent of men reported high blood pressure for which they were taking medicines. There was greater awareness among younger women regarding menstrual hygiene across all States.
Overall, very few women seemed to have been screened for cervical, breast or oral cancer. The general trend was that less than one per cent of women had got themselves screened, although in some States such as Andhra Pradesh, the figure was slightly higher: 4.7 per cent of women had screened themselves for cervical cancer, 0.8 per cent for breast cancer and 7.3 per cent for oral cancer.
A rural urban breakdown would have thrown more light on the issue, although it could be safely assumed that more urban than rural women were likely to have got themselves screened for cancer.
Domestic violence
Over the past few years, NFHS data has been bringing out data on domestic violence which has disabused the canard that domestic violence was faked by women in order to register false complaints against their in-laws. Not only was such violence a reality but the number of occurrences had gone up as data from some States showed. The section on gender violence includes three categories of violence: spousal violence, physical violence during pregnancy and any kind of sexual violence experienced by young women until the age of 18.
In Andhra Pradesh, spousal violence was reported for around 30 per cent of the women in compared with 43.4 per cent in the previous survey; 3.8 per cent of the women reported violence during pregnancy and 3.7 per cent complained of sexual violence they had experience before they attained the age of 18.
In fact, women from all States surveyed reported spousal violence and the other two categories as well, in differing degrees. In Assam, 32 per cent of the women reported spousal violence, up from 24.5 per cent, while 8 per cent of young women in the age cohort of 18-29 reported having experienced sexual violence by the age of 18, up from 5.8 per cent.
In Bihar, 40 per cent of the women reported spousal violence; it was 14 per cent in Gujarat; 9.6 per cent in Jammu & Kashmir; 9.9 per cent in Kerala; 18.1 per cent in Ladakh; 25.2 per cent in Maharashtra; 16 per cent in Meghalaya, 39.6 per cent in Manipur; 36.9 per cent in Telangana; 27 per cent in West Bengal and 20.7 per cent in Tripura.
Marriage before 18
Despite the legal age of marriage for women being set at 18 years, it was found that in almost all the States surveyed, women continued to get married before they turned 18. A correlation might exist between early marriages, literacy rates for women and the number of years of schooling completed by girls.
For instance, in Kerala, where 77 per cent of the women had 10 or more years of schooling and the women’s literacy rate was 98.3 per cent, the percentage of women who had married under the age of 18 was 6.3 per cent.
In Kerala, the neonatal mortality rate, infant mortality rate and under-five mortality rate all showed a secular decline from NFHS-4. Some 91.2 per cent of the children in the State received post-natal care within two days of delivery. The State, as always, reported a very high percentage of institutional deliveries (99.8 per cent), while 100 per cent of the respondents reported of skilled birth personnel attending to the births. Caesarean deliveries were more or less at similar levels in private and public health facilities, which indicated that there was not much of a difference in cost in both settings. There was not much of a change in female sterilisation levels from the last survey, although 82.2 per cent were told about the side effects of family planning methods. Kerala was also the only State where the average OOP expenditure for deliveries in the public health sector had gone down, from Rs.6,901 to Rs.6,710.
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In Himachal Pradesh too, where the literacy rate of women was 91.7 per cent and 65.9 per cent of the women had done 10 or more years of schooling, the percentage of women in the 20-24 age group who had married before the age of 18 was only 5.4 per cent. Some 93.9 per cent of the women participated in key household decisions.
In Assam, 31.8 per cent of the women had got married before the age of 18; in Andhra Pradesh it was 29.3 per cent; in Bihar 40.8 per cent; in Gujarat 21.8 per cent; and in Karnataka it was 21.3 per cent. In all of these States, fewer women had completed more than 10 years of schooling and women as a whole had lower to medium level literacy levels. In contrast, in the Union Territory of Jammu and Kashmir, only 4.5 per cent of the women were married off under the age of 18 years. Apart from Himachal Pradesh and Kerala, where high literacy rates for women prevailed, this was one territory that showed significant decline in the neonatal mortality, infant mortality and under-five mortality rates.
Rampant anaemia
Very high levels of anaemia were reported among women and children and in all the States surveyed, the levels had gone up compared to NFHS-4.
In Andhra Pradesh, 63.2 per cent of the children aged 6-59 months were anaemic; in Assam it was 68.4 per cent; in Bihar 69.4 per cent (up 5.9 percentage points); and in Gujarat it was 79.7 per cent, the highest among the States surveyed, up by 17.1 percentage points. In Himachal Pradesh it was 55.4 per cent, while in Jammu and Kashmir it was 72.7, a 20 percentage point increase since the last survey. The figure for Karnataka was 65.5 per cent (up from 60.9 per cent) and for Kerala it was 39.4 per cent (up from 35.7 per cent). Ladakh had the highest anaemia rate among Union Territories at 92.5 per cent.
Among other States, Maharashtra showed a rate of 68.9 per cent (up from 53.8 per cent), West Bengal 69 per cent (up by 15 percentage points); Tripura 64.3 per cent; Telangana 70 per cent (up by 10.7 percentage points); and Manipur 42.8 per cent (up by 20 percentage points). The incremental difference was the lowest in Kerala.
If anaemia, stunting, wasting, and underweight in children has gone up, it is possible that the government’s policies and the economic downturn in the past few years contributed to the worsening of these health indicators. Moreover, with the lockdown imposed owing to the pandemic and the loss of livelihood opportunities, the situation is expected to be even more dismal.
Also read: Feeding lessons to tackle malnutrition
The survey does point out to inadequate dietary intake among children in the 6-23 months age cohort. Only 5.9 per cent of such children received an adequate diet in Gujarat compared to 25 per cent in Kerala. The problem is that both children and women are food-deficient. Anaemia among women has also risen considerably. Strangely, the NFHS does not offer data on maternal mortality.
Given that even today a considerable number of young women get married before the age of 18, it is important to find solutions that would allow girls to study further. The idea that raising the legal age of marriage would delay the onset of the first child and give opportunities for women for education is a non-starter, even though policy makers seem to be seriously thinking on those lines.
The only way to delay marriage is by providing large-scale opportunities of free, quality and universal education for girl children. What is significant is that with the total fertility rate well under the figure of 2, no one is bothered now about a demographic explosion. If indeed the survey findings are meant to assist the attainment of the Sustainable Development Goals, more public investment in education and health is required.
Interestingly, the survey findings were released at a time when the government had been claiming that it had a surplus of food stocks, and hence it was difficult to procure more. This was in the context of the ongoing protest by farmers, who are demanding a legal guarantee for both a minimum support price and assured procurement.
