Miles to go

The third National Family Health Survey has immense significance for policymaking in health, nutrition and gender issues.

FRONTLINE NOVEMBER 3, 2007

The report of the third National Family Health Survey (NFHS-3), released in the second week of October, has immense significance for policymakers in health, nutrition, education and gender issues. The NFHS-3 (2005-06) is significant in that it has gone beyond the parameters set by the two preceding surveys, in 1998-99 and 1992-93. And for the first time, the survey interviewed all women (ever-married and never-married) in the 15-49 age group and all men in the 15-54 age group. In earlier surveys, only ever-married women were chosen for individual interviews. The NFHS-3 sample covered 109,041 households, 124,385 women and 74,369 men in the 29 States. According to G.C. Chaturvedi, Director of the National Rural Health Mission (NRHM), the findings of the NFHS-3 are an important benchmark for the NRHM.

The NFHS-3 included testing of the adult population in a community-based survey, the first of its kind, to estimate HIV (human immunodeficiency virus) prevalence in the general population. Surprisingly, the figures dipped sharply, forcing the government to revise its national figures.

The NFHS-3 essentially throws light on the state of India’s health, behavioural attitudes, fertility and mortality. In another first, it provides information on perinatal mortality (stillbirths and early infant deaths), male involvement in the use of health and family welfare services, adolescent reproductive health, family life, education, high-risk sexual behaviour and awareness of tuberculosis.

The shocking parts of the report contain implications for the girl child. India continues to be in the stranglehold of a very strong son preference; the presence or absence of a male child in the family dictates family planning. “Many women prefer not to use contraception and to continue childbearing until they have at least one son,” says the report.

The survey drew out responses of women to domestic violence. More than one-third of the women in the 15-49 age group had undergone physical violence; and 9 per cent of the women in the same age group, some form of sexual violence. Only 6 per cent of women were subjected to domestic violence in Himachal Pradesh, but the figure was 40 per cent or more in Rajasthan and Madhya Pradesh and 56 per cent in Bihar.

As much as 37 per cent of ever-married women had experienced violence at the hands of their spouses and 16 per cent, emotional violence. The survey found that 1 per cent of the women had initiated violence against their husbands; evidently, that was in reaction to violence perpetrated on them earlier.

Slapping was the most common form of violence from husbands; 62 per cent of the women reported physical or sexual violence in the first two years of their marriage. Only one out of four abused women sought help to end the violence. A large majority of them chose to bear it in silence. Alarmingly, the report said that more than half the women in India believed that it was justifiable for a husband to beat his wife. The acceptance of wife-beating was found to be high in Manipur and low in Himachal Pradesh and Uttarakhand.

The good news in the survey is that women waited longer to marry and fertility was on the decline. As a telling example, a domestic worker based in Delhi said she was married off at 15 in her village in Allahabad, conceived at the age of 16 and bore seven children in 14 years. But she was determined that none of her daughters were going to be married before 22. She got her eldest daughter married at 24 and ensured that at least one of her daughters completed college. Such instances are common in urban centres, particularly the metros.

But the bad news is that more than half the women were getting married off before the minimum age of 18. Urban women waited two years longer than their rural counterparts for marriage; the median age at marriage among urban women aged between 20 and 29 was 18.8 years while that of rural women in the same age group was 16.4 years. This, in turn, had an impact on maternal mortality as well as infant and perinatal mortality.

The survey has other revealing facts. For instance, the fertility rate has come down from 2.9 per woman in the NFHS-2 to 2.7 per woman. However, this is seldom appreciated by policymakers, who often speak of a population boom in the country.

Recently, the Supreme Court suggested that women with more than two children should be excluded from the Janani Suraksha Yojana (JSY), or scheme for safe motherhood, which now covers all Below Poverty Line (BPL) mothers. Health Ministry sources told Frontline that they were yet to respond to the suggestion. Initially, the JSY was confined to families with only two children; but when sections among the Left and other health activists pointed out the inherent injustice in the scheme, it was made accessible to all BPL mothers.

Though the fertility rate has come down, replacement levels (two children for two parents) are yet to be reached. The NFHS-3 brings out the fact that the desire to stop childbearing has increased rapidly with the number of living children. Only 3 per cent of women with no living children said they did not want any more children, compared with 83 per cent of women with two children and 90 per cent of women with three children.

The desire to stop childbearing increased with education. The fertility rate decreased sharply by the household’s wealth index as well, from 3.9 children for women living in households in the lowest wealth quintile to 1.8 children for those living in households in the highest wealth quintile. Ninety per cent of women, the survey found, wanted to stop childbearing if both their children were sons, 87 per cent wanted to stop if they had one son and one daughter.

The proportion of women with two daughters and no sons and who wanted no additional children increased from 37 per cent in the NFHS-2 to 61 per cent in the NFHS-3. But this does not indicate that son preference has gone down or that the women themselves are in a position to decide the ideal family size or the number of sons or daughters they would like to have. The motivating reason for wanting a daughter is more religious – fulfilling of the obligation of kanyadaan (giving a daughter away in marriage), which is supposed to enable parents to acquire the highest level of merit or punya.

Knowledge of contraception was found to be almost universal, but more women and men knew about female sterilisation than male sterilisation though the latter is considered to be safer among the terminal methods of contraception. Ninety-three per cent of the men knew about condoms as opposed to 74 per cent of women.

Significantly, even the choice of contraception was influenced by son preference. At 67 per cent, the adoption rate of female sterilisation was the highest among women with two sons. Also, women who had more sons were found to be more likely to be persuaded to go in for contraception. Wealth also influenced contraceptive prevalence; it was almost 68 per cent among women in the highest wealth quintile and 42 per cent in the lowest wealth quintile.

For health activists and women’s organisations who have been crying hoarse regarding informed choices, the survey has dismal news. Only one-third of the women contraceptive users said they were aware of the side effects while only one quarter were informed about what to do in case of any side effects. It was only in Tamil Nadu and Delhi that more than half the women knew what to do in case of side effects.

The survey has also confirmed the worst suspicions of health activists regarding the safety of injectable contraceptives. The NFHS-3 found that among the spacing methods, the discontinuation rates were the highest for injectables (53 per cent), followed by pills and male condoms. For pills, intrauterine devices (IUDs) and injectables, the most common reason for discontinuation were concerns about side effects or health problems.

Another important aspect of the survey relates to child sex ratio, which has dipped since Census 2001. Though the NFHS does not do a head count unlike the Registrar General’s office, its findings regarding the child sex ratio from the sample population are not likely to be very different from the child sex ratio figures that will emerge in the Census 2011.

In the NFHS-3, the sex ratio of the population in the 0-6 age group is 918 girls for every 1,000 boys; this was 927 girls per 1,000 boys according to Census 2001. The under-seven sex ratio in urban areas is the same as in Census 2001, but a decline was seen in rural areas.

On nutritional, maternal and child health indicators, there has not been much improvement. Perinatal mortality, which was explored for the first time, turned out to be rather high at 49 deaths for every 1,000 pregnancies. Such mortality was very high for young mothers and in first pregnancies. It is highest for the rural poor uneducated mother.

While the infant mortality rate (IMR) has gone down from 68 deaths to 57 per 1,000 live births, it is still very high. It is estimated that one in 18 children dies within the first year of birth and more than one in 13 dies before the age of five.

Children of the Scheduled Castes and the Scheduled Tribes are at a greater risk. Even here, there is a gender bias: 79 girls under five die before the fifth birthday compared with 70 boys per 1,000 births. Uttar Pradesh has the highest IMR in the country while Kerala and Goa fall in the category of States with the lowest IMR.

As for maternal health, only 44 per cent of women started antenatal care in the first trimester of pregnancy. The percentage of women getting more than three antenatal visits by the auxiliary nurse midwife (ANM) ranged from 17 per cent in Bihar and Uttar Pradesh to 90 per cent in Kerala, Goa and Tamil Nadu.

The quality of antenatal care is also a major issue. The iron and folic acid coverage for expectant mothers was lower than the national average in Nagaland, Bihar, Arunachal Pradesh, Jharkhand, Uttar Pradesh and Meghalaya. The percentage of women who received two or more tetanus toxoid injections ranged from 40 per cent in these States to 90 per cent or higher in Delhi, West Bengal and Tamil Nadu.

“The thrust of the NRHM is on the mother and child. The southern States are almost on the threshold of replacement level fertility while the northern States have still a long way to go. Our attempt is to get the IMR levels to 30 per 1,000 live births. There is a lot of demand for institutional deliveries but the supply side is weak,” said Chaturvedi. Of the 22,000 sub-centres in Uttar Pradesh, he said, only 7,000 had buildings.

Manpower is another concern. Between 1947 and 1997, there were only 47,000 doctors in Uttar Pradesh, in the private and public sectors taken together. The number of nurses was 30,000 less than what was recommended by the Bhore Committee. Chaturvedi felt that more than money, the motivating factor for the efficient functioning of the accredited social health activist (ASHA) was “recognition”. On the other hand, health activists argue that accredited social health activists need to be given a decent remuneration as most of them hail from poor families, and that there is need for more than just social appreciation.

The findings of the NFHS-3 underscore the need for more convergence among Ministries as it cannot be left to the Health Ministry alone to deal with what is primarily an economic issue. The survey brings out clearly which section of the population is desperately in need of health care. Health issues are not maternal health issues alone. The most commonly reported problem faced by women in terms of accessing health care was the distance to the health facility; 44 per cent of the Scheduled Tribe women reported “distance” to be a major problem.

The percentage of women who have at least one big problem in gaining access to health care declined rapidly with increasing wealth. On the other hand, the dependence on the private health sector continues to be quite high. According to the survey: “The private medical sector remains the primary source of health care for the majority of households in both urban areas (70 per cent) and rural areas (63 per cent) … overall, the private medical sector dominates health care delivery in the country and the use of private doctors and private clinics is the primary source of health care among the rich and poor alike.”

If the “Health for All” declaration, to which India was a signatory nearly 30 years ago at Alma Ata, must have any meaning, it cannot be with the majority of the population depending on the private sector, where health care is affordable to only a few. It cannot also be realisable in a situation of a declining child sex ratio, high IMR and rampant son preference.