NFHS Subject Reports

The NFHS Subject Reports are based on secondary analysis of data from the 1992-93 and 1998-99 National Family Health Surveys (NFHS) in India. The series is copublished by the International Institute for Population Sciences (IIPS) in Mumbai and the East-West Center.

The NFHS surveys collected information from nearly 90,000 Indian women on a range of demographic and health topics. Conducted under the auspices of the Indian Ministry of Health and Family Welfare, they provide national and state-level estimates of fertility, infant and child mortality, family planning practice, maternal and child health, and the utilization of services available to mothers and children. IIPS conducted the surveys in cooperation with consulting organizations and population research centres in India. The East-West Center and ORC Macro provided technical assistance, and the United States Agency for International Development (USAID) provided financial support.

Single copies of NFHS Subject Reports are available free by airmail and may be reproduced for educational use. Airmail postage charges for additional copies are $1.50 each within the United States and its territories and $4.00 each elsewhere. Send an e-mail message to Population and Health Studies at the East-West Center.

You are also welcome to download NFHS Subject Reports as fully formated Adobe Acrobat .pdf files including all text and graphics. Just click on any of the titles that are underlined. (You can download the Acrobat Reader free from the Internet.)

No. 21, Factors affecting sex-selective abortion in India and 17 major states by Robert D. Retherford and T. K. Roy. January 2003. 80 pp.

Birth histories collected during the first and second National Family Health Surveys (NFHS-1 and NFHS-2) show an unusually large proportion of male births in some population groups, which suggests that female fetuses are being aborted. Male births are particularly overrepresented in certain western and northern states, in families that already have daughters but no sons, and among women with a high level of education and media exposure. Analysis of women's ideal sex ratio (the ratio of ideal number of sons to ideal number of daughters) indicates that son preference is declining in almost all states and socioeconomic groups. Nevertheless, ideal sex ratios are still much higher than the biological norm, implying that considerable potential exists for further increases in levels of sex-selective abortion.

No. 20, Promoting institutional deliveries in rural India: The role of antenatal-care services by K.S. Sugathan, Vinod Mishra, and Robert D. Retherford. December 2001. 38 pp.

This report examines the role of existing antenatal-care services in promoting institutional delivery in rural areas. The analysis is based on NFHS-1 results from four Indian states—Andhra Pradesh, Gujarat, Bihar, and Rajastan. Mothers who receive antenatal check-ups are two to five times more likely to give birth in a medical institution than mothers who did not receive antenatal check-ups. Mother's age and education and child's birth order also have strong effects on the likelihood of institutional delivery, and household standard of living has a substantial effect in most cases. Contrary to expectation, access to health services does not generally have a statistically significant effect. These results suggest that it may be possible to increase institutional deliveries by promoting antenatal check-ups without having to build additional hospitals.

No. 19, An evaluation of recent estimates of fertility trends in India by Robert D. Retherford and Vinod Mishra. November 2001. 52 pp.

A comparative analysis of data from India's Sample Registration System (SRS) and from two recent National Family Health Surveys (NFHS-1 in 1992–93 and NFHS-2 in 1998–99) indicates major discrepancies in fertility estimates. For India as a whole, the true total fertility rate (TFR) for 1990–92 was probably around 3.92 children per woman. The true TFR for 1996–98 was probably between 3.39 and 3.55 children per woman. The analysis demonstrates that calculating TFR estimates for the three-year period immediately preceding a survey does not work well in India. In NFHS-1 and NFHS-2, widespread ignorance of children's ages resulted in substantial displacement of births to earlier years, producing an underestimation of the TFR for the most recent three-year period.

No. 18, Does community access affect the use of health and family welfare services in India, by N. P. Das, Vinod K. Mishra, and P. K. Saha. May 2001. 79 pp.

Focused on NFHS-1 results from India's four large northern states—Uttar Pradesh, Madhya Pradesh, Bihar, and Rajasthan—this analysis shows that variations in utilization of family planning and maternal and child health services are explained mainly by variations in household- and individual-level socioeconomic and demographic factors, not by variation in community access to services. Apparently family planning and maternal and child health services are available at a sufficient level in rural India so that further improvements in physical accessibility alone will not make a substantial difference in the propensity to use these services. Quality of services is likely also to be important, but NFHS-1 did not assess service quality.

No. 17, How much has fertility declined in Uttar Pradesh?, by Robert D. Retherford, Vinod K. Mishra, and G. Prakasam. May 2001. 40 pp.

Based on an analysis of fertility estimates from NFHS-1, NFHS-2, and India’s Sample Registration System (SRS), this report attempts to provide accurate estimates of fertility levels and trends in the state of Uttar Pradesh. The primary measure of fertility used in this analysis is the total fertility rate (TFR), which indicates the average number of children a woman would bear throughout her life at current age-specific fertility rates. Correction for displacement and omission of births in NFHS-1 and NFHS-2 and underregistration of births in the SRS yields a ‘best estimate’ that the TFR in Uttar Pradesh fell from 5.55 in 1991 (the midpoint of the three-year period before NFHS-1) to 5.19 in 1997 (the midpoint of the three-year period before NFHS-2), a decline of about 0.4 child during the six years between the two surveys.

No. 16, Are the WHO Guidelines on Breastfeeding Appropriate for India?, by Ravilla Anandaiah and Minja Kim Choe. May 2000. 24 pp.

The World Health Organization (WHO) recommends that children in developing countries should be exclusively breastfed up to 4–6 months of age. According to NFHS-1 results, both exclusive and nonexclusive (with supplements) breastfeeding lower mortality during early infancy. A surprising finding is that breastfeeding with supplements is more beneficial than exclusive breastfeeding, even for children at very young ages (less that four months). The reason appears to be that mothers who are poorly nourished and in poor health themselves may not provide adequate breast milk for their growing infants.

No. 15, Child immunization in Madhya Pradesh by Rakesh Munshi and Sang-Hyop Lee. February 2000. 20 pp.

NFHS-1 results indicate that the Government of India’s Universal Immunization Programme (UIP) has met with limited success in Madhya Pradesh. Only 29 percent of children age 12–23 months are fully immunized. Among the six diseases covered by the UIP, immunization rates are lowest for measles. Full immunization coverage reduces child mortality substantially.

No. 14, Child nutrition in India by Vinod K. Mishra, Subrata Lahiri, and Norman Y. Luther. June 1999. 39 pp.

More than half of all children under age four In India suffer chronic malnutrition, as indicate by height-for-age and weight-for-age measurements. Nearly one in five suffers acute malnutrition, as measured by weight-for-height. Child malnutrition is considerably higher in rural areas than in urban areas and varies widely by state. Children with two or more older siblings are more likely than other children to be malnourished. Children whose mothers are more educated and children who live in households with a relatively high standard of living tend to be better nourished than other children.

No. 13, Reasons for discontinuing and not intending to use contraception in India by Vinod K. Mishra, Robert D. Retherford, P. S. Nair, and Griffith Feeney. June 1999. 36 pp.

Among currently married women age 13-49 who discontinued using contraception, 38 percent did so because of a method-related problem or method failure. The proportion who discontinued for these reasons varies widely by state but not by socioeconomic group. Fifteen percent of women who do not use contraception and who do not intend to use contraception in the future report method-related problems as their main reason for not intending to use contraception, while 9 percent mention opposition to family planning. The proportion reporting method-related problems or opposition to family planning is particularly high among women in the prime reproductive ages and women not regularly exposed to electronic mass media. The proportion reporting opposition to family planning is particularly high among Muslim women.

No. 12, Factors affecting source of family planning services in India by P. S. Nair, Griffith Feeney, Vinod K. Mishra, and Robert D. Retherford. June 1999. 38 pp.

About four-fifths of all couples who use modern family planning methods in India obtain contraception from government sources. The proportion of couples using private-sector sources appears to be increasing, although levels vary considerably by socioeconomic status and by state. Women who live in urban areas and who have relatively high levels of education are more likely than other women to use private-sector sources of family planning. Contrary to expectations, there is little relationship between the proportion of women using private-sector family planning services in a state and state-level fertility rates.

No. 11, Infant and child mortality in India by Arvind Pandey, Minja Kim Choe, Norman Y. Luther, Damodar Sahu, and Jagdish Chand. December 1998. 99 pp.

Between 1981 and 1990, infant mortality declined 23 percent in India and child mortality declined 34 percent, but mortality rates are still high. Sex differentials in infant and child mortality reflect strong son preference in many states. Among socioeconomic background characteristics, mother's literacy, access to a flush or pit toilet, membership in a scheduled caste or tribe, and household economic level have substantial effects on infant and child mortality. Demographic characteristics, including birth order, mother's age at childbirth, length of previous and subsequent birth intervals, and mortality of an older sibling, all have substantial effects. Mother's tetanus immunization during pregnancy is strongly associated with reduced neonatal mortality. These results suggest that minimizing the number of births to very young mothers, encouraging mothers to space births by at least 24 months, and avoiding high-order births will all substantially enhance the survival chances of children in India. Family health programs should also emphasize tetanus immunization for all pregnant mothers.

No. 10, Knowledge and use of oral rehydration therapy for childhood diarrhoea in India: Effects of exposure to mass media by K. V. Rao, Vinod K. Mishra, and Robert D. Retherford. November 1998. 55 pp.

Despite the Indian Government's vigorous Oral Rehydration Therapy (ORT) Programme, conducted for more than a decade, very few children who fall ill with diarrhoea are treated with ORT or increased fluids. Many of the children who receive treatment from a health facility or provider are given unnecessary, and sometimes harmful, antibiotics and other antidiarrhoeal drugs, but not ORT. These findings indicate a lack of awareness of proper treatment of diarrhoea not only among mothers but also among health-care providers. The analysis shows clearly, however, that mother's exposure to radio, television, and cinema increases awareness and use of ORT.

No. 9, Fertility in India by M. M. Gandotra, Robert D. Retherford, Arvind Pandey, Norman Y. Luther, and Vinod K. Mishra. May 1998. 70 pp.

An analysis of fertility differentials by socioeconomic and demographic characteristics reveals a wide diversity in the total fertility rate among Indian states. Total fertility tends to be high among women who live in rural areas, have little education, are Muslim, or belong to scheduled castes or tribes. Parity progression ratios tend to be high among women who have experienced one or more child deaths. They are low among women with one or more living sons and among women who are regularly exposed to the electronic mass media.

No. 8, Mother’s employment and infant and child mortality in India by Sunita Kishor and Sulabha Parasuraman. April 1998. 40 pp. (A joint publication of the International Institute for Population Sciences and Macro International Inc.)

A multivariate analysis of births during the four years before the NFHS shows that mortality rates are higher for children age 12-47 months if their mothers are employed. Mortality is higher for children age 0-11 months if their mothers are employed at home or outside the home for cash. Mother’s employment has a greater adverse effect on the mortality of sons than of daughters.

No. 7, Alternative contraceptive methods and fertility decline in India by K. B. Pathak, Griffith Feeney, and Norman Y. Luther. March 1998. 28 pp.

The Indian family welfare program has been dominated for decades by a reliance on female sterilization. NFHS results, however, show that Indian women tend to undergo sterilization only after giving birth to many children. This finding implies that further reliance on sterilization is not likely to reduce total fertility much below the current level of 3.4 children per woman. Efforts to continue India's fertility decline need to place more emphasis on temporary contraceptive methods.

No. 6, Wanted and unwanted fertility in selected states of India by Sumati Kulkarni and Minja Kim Choe. February 1998. 32 pp. (Out of print)

This report proposes new measures of wanted and unwanted fertility based on actual and wanted parity progression ratios and applies these procedures to NFHS data for eight states in India. In four large states with high fertility, levels of wanted fertility are high, at three or more children per married woman, and the proportion unwanted ranges from 20 to 28 percent of total marital fertility. In three states with moderate fertility, the proportion unwanted ranges from 31 to 34 percent. In Kerala, wanted fertility is already at replacement level, and there is very little unwanted fertility. Multivariate analysis indicates that education, religion, exposure to family planning messages on radio or television, experience of child loss, and son preference are important determinants of contraceptive use among women who want no more children.

No. 5, Maternal education and the utilization of maternal and child health services in India by Pavalavalli Govindasamy and B. M. Ramesh. December 1997. 28 pp. (A joint publication of the International Institute for Population Sciences, Mumbai, India, and Macro International Inc., Calverton, Maryland) (Out of print)

Using NFHS data for selected states in northern and southern India, the authors show that mother's schooling results in improved child survival because educated mothers use health services that effectively prevent fatal childhood diseases to a greater extent than do mothers with little or no education. Regression analysis indicates that the benefits of mother's education persist even when other socioeconomic factors are taken into account.

No. 4, Comparison of fertility estimates from India’s Sample Registration System and National Family Health Survey by R. L. Narasimhan, Robert D. Retherford, Vinod Mishra, Fred Arnold, and T. K. Roy. September 1997. 35 pp.

A comparison of trends for 1978-92 shows that fertility has fallen faster than indicated by the National Registration System (SRS) but more slowly than indicated by the NFHS. The true level of fertility during 1988-92 was probably somewhat higher than indicated by either source.

No. 3. Son preference and its effect on fertility in India by Rangamuthia Mutharayappa, Minja Kim Choe, Fred Arnold, and T. K. Roy. March 1997. 36 pp.

The effect of son preference on fertility varies substantially by region and state.

No. 2. Contraceptive use in India, 1992-93 by B. M. Ramesh, S. C. Gulati, and Robert D. Retherford. October 1996. xvi, 108 pp. (Out of print)

Knowledge of contraception is almost universal among currently married women, but only 42 percent actually use family planning.

No. 1. Unmet need for family planning in Uttar Pradesh by D. Radha Devi, S. R. Rastogi, and Robert D. Retherford. April 1996. 28 pp. (Out of print)

In Uttar Pradesh, 30 percent of currently married women of reproductive age have an unmet need for family planning. The percentage of total need that is unmet is especially high among women who are Muslim, who live in rural areas, who are illiterate, whose husbands are illiterate, who belong to scheduled tribes, and who are not exposed to media messages on family planning.