India - Demographic and Health Survey - 2000

Publication date: 2000

����� ���� �� �� � �� �� � � � � ���� ����G46������������ ���������G46�� �� � � �� � � ��G46 � � ��� �� � � ��� �� � � � � � ��� G46 � � � � �� ���� � ������� � � ��� ��� ���� � ���������� ������������ ��������� World Summit for Children Indicators: India, 1998–99 BASIC INDICATORS Childhood mortality Childhood malnutrition Clean water supply Sanitary excreta disposal Basic education Children in especially difficult situations Infant mortality rate Under-five mortality rate Percent stunted (children 0–35 months) Percent wasted (children 0–35 months) Percent underweight (children 0–35 months) Percent of households within 15 minutes of a safe water supply1 Percent of households with flush toilets Percent of women age 15–49 with completed primary education Percent of men age 15–49 with completed primary education Percent of girls age 6–12 attending school Percent of boys age 6–12 attending school Percent of women age 15–49 who are literate Percent of children age 0–14 who live in single adult households 68 per 1,000 95 per 1,000 45.5 15.5 47.0 62.3 24.0 44.4 68.9 76.5 84.7 50.8 2.3 SUPPORTING INDICATORS Birth spacing Safe motherhood Family planning Percent of births within 24 months of a previous birth Percent of births with medical antenatal care Percent of births with antenatal care in first trimester Percent of births with medical assistance at delivery Percent of births in a medical facility Percent of births at high risk Contraceptive prevalence rate (any method, currently married women) Percent of currently married women with an unmet need for family planning Percent of currently married women with an unmet need for family planning to avoid a high-risk birth 28.3 65.2 33.0 42.3 33.6 50.7 48.2 15.8 11.2 Maternal nutrition Low birth weight Breastfeeding Iodized salt intake Percent of mothers with low BMI Percent of births with low birth weight (of those reporting a numeric weight) Percent of children under 4 months who are exclusively breastfed Percent of households that use iodized salt 35.8 22.7 55.2 49.3 Vaccinations Diarrhoea control Acute respiratory infection Percent of children whose mothers received tetanus toxoid vaccinations during pregnancy Percent of children 12–23 months with measles vaccination Percent of children 12–23 months fully vaccinated Percent of children with diarrhoea in the preceding 2 weeks who received ORS, sugar-salt-water solution, or gruel Percent of children with acute respiratory infection in the preceding 2 weeks seen by medical personnel 75.0 50.7 42.0 35.5 64.0 1Water from pipes, handpump, covered well, or tanker truck NATIONAL FAMILY HEALTH SURVEY (NFHS-2) 1998–99 INDIA International Institute for Population Sciences Mumbai, India ORC MACRO Calverton, Maryland, USA October 2000 Suggested citation: International Institute for Population Sciences (IIPS) and ORC Macro. 2000. National Family Health Survey (NFHS-2), 1998–99: India. Mumbai: IIPS. For additional information about the National Family Health Survey (NFHS-2) please contact: International Institute for Population Sciences Govandi Station Road, Deonar, Mumbai-400 088 Telephone: 5564883, 5563254, 5563255, 5563256 Fax: 5563257 E-mail: iipsnfhs@vsnl.com Website: http://www.nfhsindia.org CONTRIBUTORS T. K. Roy Fred Arnold Sumati Kulkarni Sunita Kishor Kamla Gupta Vinod Mishra Parveen Nangia Robert D. Retherford Arvind Pandey Sushil Kumar CONTENTS Page Tables . v Figures. xi Preface.xiii Acknowledgements . xv Fact Sheet .xviii Summary of Findings . xix CHAPTER 1 INTRODUCTION 1.1 Background of the Survey. 1 1.2 Basic Demographic Features. 1 1.3 Economic Development .2 1.4 Performance of Social Sectors and Demographic Change.3 1.5 Population Policies and Programmes. 4 1.6 Questionnaires. 6 1.7 Sample Design and Implementation . 8 Sample Size and Reporting Domains. 8 Sample Design. 8 Sample Selection in Rural Areas. 9 Sample Selection in Urban Areas. 10 Sample Weights. 10 Sample Implementation. 11 1.8 Recruitment, Training, and Fieldwork . 11 1.9 Data Processing . 14 CHAPTER 2 BACKGROUND CHARACTERISTICS OF HOUSEHOLDS 2.1 Age-Sex Distribution of the Household Population. 15 2.2 Marital Status . 18 2.3 Household Composition. 22 2.4 Educational Attainment. 25 2.5 Housing Characteristics. 35 2.6 Lifestyle Indicators. 41 2.7 Availability of Facilities and Services to the Rural Population . 46 CHAPTER 3 BACKGROUND CHARACTERISTICS OF RESPONDENTS 3.1 Background Characteristics. 49 3.2 Educational Level. 52 3.3 Age at First Marriage . 54 3.4 Exposure to Mass Media . 57 3.5 Women’s Employment. 61 3.6 Women’s Autonomy . 64 3.7 Women’s Educational Aspirations for Their Children . 69 3.8 Domestic Violence: Attitudes and Experience. 71 ii Page CHAPTER 4 FERTILITY AND FERTILITY PREFERENCES 4.1 Age at First Cohabitation . 81 4.2 Fertility Levels . 83 4.3 Fertility Differentials and Trends. 90 4.4 Pregnancy Outcomes. 95 4.5 Children Ever Born and Living. 96 4.6 Birth Order . 98 4.7 Birth Intervals. 98 4.8 Age at First and Last Birth . 103 4.9 Postpartum Amenorrhoea, Abstinence, Insusceptibility, and Menopause. 107 4.10 Desire for More Children . 111 4.11 Ideal Number of Children . 115 4.12 Sex Preference for Children . 119 4.13 Fertility Planning. 122 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Family Planning Methods. 127 Interstate Variations in Knowledge. 129 5.2 Contraceptive Use . 129 Ever Use of Family Planning Methods . 129 Current Use of Family Planning Methods. 131 Socioeconomic Differentials in Current Use of Family Planning Methods. 134 Interstate Variations in Current Use of Family Planning Methods. 139 Number of Living Children at First Use of Contraception . 144 Problems with Current Method. 144 5.3 Sterilization . 146 Timing of Sterilization . 146 Interstate Variations in Timing of Sterilization. 148 Methods Used before Sterilization. 149 5.4 Sources of Contraceptive Methods . 149 Interstate Variations in the Role of the Public Sector . 154 5.5 Reasons for Discontinuation/Non-Use of Contraception. 158 5.6 Future Intentions Regarding Contraceptive Use . 158 Interstate Variations in the Intentions to Use Contraception in the Future . 161 Reasons for Not Intending to Use Contraception. 162 Preferred Future Method of Contraception . 163 5.7 Exposure to Family Planning Messages. 165 5.8 Discussion of Family Planning . 167 Interstate Variations in Exposure to Family Planning Messages and Discussions about Family Planning . 167 5.9 Need for Family Planning . 169 Interstate Variations in Unmet Need. 173 iii Page CHAPTER 6 MORTALITY, MORBIDITY, AND IMMUNIZATION 6.1 Crude Death Rates and Age-Specific Death Rates . 178 6.2 Infant and Child Mortality. 181 Assessment of Data Quality . 181 Levels, Trends, and Differentials in Infant and Child Mortality. 183 Socioeconomic Differentials in Infant and Child Mortality. 185 Demographic Differentials in Infant and Child Mortality . 188 6.3 Maternal Mortality . 195 6.4 Morbidity. 196 Asthma . 198 Tuberculosis . 198 Jaundice. 198 Malaria . 199 Comparisons by State. 199 6.5 Child Immunization . 202 6.6 Vitamin A Supplementation. 213 6.7 Child Morbidity and Treatment. 216 Acute Respiratory Infection . 216 Fever. 218 Diarrhoea. 220 6.8 HIV/AIDS . 230 Knowledge of AIDS. 230 Source of Knowledge about AIDS. 233 Knowledge of Ways to Avoid AIDS. 235 CHAPTER 7 NUTRITION AND THE PREVALENCE OF ANAEMIA 7.1 Women’s Food Consumption . 241 7.2 Nutritional Status of Women . 243 7.3 Anaemia Among Women. 247 7.4 Infant Feeding Practices . 251 7.5 Nutritional Status of Children . 263 7.6 Anaemia Among Children . 271 7.7 Iodization of Salt . 274 CHAPTER 8 MATERNAL AND REPRODUCTIVE HEALTH 8.1 Antenatal Problems and Care. 280 Problems During Pregnancy. 281 Antenatal Check-Ups . 281 Reasons for Not Receiving Antenatal Check-Ups . 285 Number and Timing of Antenatal Check-Ups . 285 Components of Antenatal Check-Ups. 287 Tetanus Toxoid Vaccination . 289 Iron and Folic Acid Supplementation . 291 Antenatal Care Indicators by State. 292 iv Page 8.2 Delivery Care . 294 Place of Delivery. 294 Assistance During Delivery . 297 Delivery Characteristics . 299 8.3 Postnatal Care. 300 Postpartum Complications . 303 8.4 Summary of Maternal Care Indicators by State . 304 8.5 Reproductive Health Problems. 307 Reproductive Health Problems by State. 311 CHAPTER 9 QUALITY OF CARE 9.1 Source of Health Care for Households. 315 9.2 Contacts at Home with Health and Family Planning Workers . 316 9.3 Quality of Home Visits . 317 9.4 Matters Discussed during Home Visits or Visits to Health Facilities. 320 9.5 Quality of Services Received at the Most Recent Visit to a Health Facility . 322 9.6 Family Planning Information and Advice Received . 325 9.7 Person Motivating Users of a Modern Contraceptive Method . 326 9.8 Quality of Care of Family Planning Services. 327 REFERENCES . 333 APPENDICES Appendix A Organizations Involved in NFHS-2 Fieldwork . 341 Appendix B Sample Characteristics for States . 343 Appendix C Estimates of Sampling Errors . 347 Appendix D Data Quality Tables . 357 Appendix E NFHS-2 Survey Staff . 365 Appendix F Survey Instruments. 369 NFHS-2 FACT SHEET - STATES . 439 TABLES Page Table 1.1 Number of households and women interviewed by state. 12 Table 2.1 Household population by age and sex. 16 Table 2.2 Population by age and sex from the SRS and NFHS-2. 17 Table 2.3 Marital status of the household population . 19 Table 2.4 Singulate mean age at marriage by state . 21 Table 2.5 Household characteristics. 23 Table 2.6 Religion and caste/tribe of household head by state . 24 Table 2.7 Educational level of the household population . 26 Table 2.8 Educational level of the household population by state. 30 Table 2.9 School attendance by state . 33 Table 2.10 Reasons for children not attending school . 35 Table 2.11 Housing characteristics . 36 Table 2.12 Housing characteristics by state . 38 Table 2.13 Household ownership of agricultural land, house, and livestock. 39 Table 2.14 Household ownership of durable goods and standard of living. 40 Table 2.15 Lifestyle indicators. 42 Table 2.16 Lifestyle indicators by state . 44 Table 2.17 Distance from the nearest health facility. 46 Table 2.18 Availability of facilities and services. 47 Table 3.1 Background characteristics of respondents. 50 Table 3.2 Respondent’s level of education by background characteristics. 53 Table 3.3 Respondent’s level of education by state . 55 Table 3.4 Age at first marriage. 56 Table 3.5 Age at first marriage by state . 57 Table 3.6 Exposure to mass media. 58 Table 3.7 Exposure to mass media by state . 60 Table 3.8 Employment . 63 Table 3.9 Work status of respondents by state. 65 Table 3.10 Household decisionmaking . 66 Table 3.11 Women’s autonomy . 67 Table 3.12 Women’s autonomy by state. 70 vi Page Table 3.13 Perceived educational needs of girls and boys. 72 Table 3.14 Reasons given for justifying a husband beating his wife. 73 Table 3.15 Women’s experience with beatings or physical mistreatment. 76 Table 3.16 Women’s experience with beatings or physical mistreatment by state. 79 Table 4.1 Age at first cohabitation with husband. 82 Table 4.2 Current fertility. 84 Table 4.3 Fertility by state. 87 Table 4.4 Fertility by background characteristics . 91 Table 4.5 Fertility trends . 93 Table 4.6 Fertility by marital duration . 94 Table 4.7 Outcome of pregnancy by state. 95 Table 4.8 Children ever born and living . 97 Table 4.9 Birth order . 99 Table 4.10 Birth order by state. 100 Table 4.11 Birth interval . 101 Table 4.12 Birth interval by state . 103 Table 4.13 Median age at first birth . 104 Table 4.14 Age at last birth . 105 Table 4.15 Median age at first and last birth by state . 106 Table 4.16 Postpartum amenorrhoea, abstinence, and insusceptibility. 108 Table 4.17 Menopause by state . 109 Table 4.18 Fertility preferences . 110 Table 4.19 Fertility preferences by state . 113 Table 4.20 Desire to have no more children by background characteristics. 114 Table 4.21 Ideal and actual number of children. 116 Table 4.22 Ideal number of children by background characteristics . 118 Table 4.23 Ideal number of children by state. 119 Table 4.24 Indicators of sex preference . 120 Table 4.25 Indicators of sex preference by state . 122 Table 4.26 Fertility planning. 124 Table 4.27 Wanted fertility rates. 125 Table 4.28 Wanted fertility rates by state . 126 vii Page Table 5.1 Knowledge of contraceptive methods. 128 Table 5.2 Knowledge of contraceptive methods by state. 130 Table 5.3 Ever use of contraception. 131 Table 5.4 Current use of contraception . 132 Table 5.5 Current use by background characteristics . 136 Table 5.6 Current use by religion and education . 139 Table 5.7 Current use by state. 140 Table 5.8 Number of living children at first use . 145 Table 5.9 Problems with current method . 146 Table 5.10 Timing of sterilization. 147 Table 5.11 Timing of sterilization by state . 148 Table 5.12 Methods used before sterilization by state . 150 Table 5.13 Source of modern contraceptive methods . 151 Table 5.14 Public sector as source of modern contraceptives by state . 155 Table 5.15 Reasons for discontinuation/non-use . 159 Table 5.16 Future use of contraception. 160 Table 5.17 Future use of contraception by state. 161 Table 5.18 Reasons for not intending to use contraception . 162 Table 5.19 Preferred method. 164 Table 5.20 Exposure to family planning messages . 166 Table 5.21 Discussion of family planning . 168 Table 5.22 Exposure to messages and discussion of family planning by state . 169 Table 5.23 Need for family planning services . 171 Table 5.24 Need for family planning services by state . 174 Table 6.1 Age-specific death rates and crude death rates . 179 Table 6.2 Crude death rates by state . 180 Table 6.3 Infant and child mortality. 184 Table 6.4 Infant and child mortality by background characteristics . 186 Table 6.5 Infant and child mortality by demographic characteristics . 189 Table 6.6 Infant and child mortality by state . 194 Table 6.7 Morbidity. 197 Table 6.8 Morbidity by state . 200 viii Page Table 6.9 Childhood vaccinations by source of information . 204 Table 6.10 Childhood vaccinations by background characteristics . 207 Table 6.11 Childhood vaccinations by state. 209 Table 6.12 Childhood vaccinations received by 12 months of age. 211 Table 6.13 Source of childhood vaccinations . 212 Table 6.14 Vitamin A supplementation for children. 214 Table 6.15 Vitamin A supplementation for children by state . 215 Table 6.16 Prevalence of acute respiratory infection, fever, and diarrhoea. 217 Table 6.17 Prevalence of acute respiratory infection, fever, and diarrhoea by state. 219 Table 6.18 Knowledge of diarrhoea care . 222 Table 6.19 Knowledge of diarrhoea care by state . 223 Table 6.20 Treatment of diarrhoea. 225 Table 6.21 Treatment of diarrhoea by state. 227 Table 6.22 Source of ORS packets. 228 Table 6.23 Feeding practices during diarrhoea by state. 229 Table 6.24 Source of knowledge about AIDS. 231 Table 6.25 Source of knowledge about AIDS by state . 234 Table 6.26 Knowledge about avoidance of AIDS. 236 Table 6.27 Knowledge about avoidance of AIDS by state . 239 Table 7.1 Women’s food consumption . 242 Table 7.2 Women’s food consumption by background characteristics . 242 Table 7.3 Women’s food consumption by state. 244 Table 7.4 Nutritional status of women . 245 Table 7.5 Nutritional status of women by state. 246 Table 7.6 Anaemia among women. 249 Table 7.7 Anaemia among women by state . 252 Table 7.8 Initiation of breastfeeding . 254 Table 7.9 Initiation of breastfeeding by state. 255 Table 7.10 Breastfeeding status by child’s age . 256 Table 7.11 Type of food received by children . 258 Table 7.12 Median duration of breastfeeding . 262 Table 7.13 Median duration of breastfeeding by state . 264 ix Page Table 7.14 Recommended feeding indicators by state. 265 Table 7.15 Nutritional status of children by demographic characteristics. 266 Table 7.16 Nutritional status of children by background characteristics. 269 Table 7.17 Nutritional status of children by state . 270 Table 7.18 Anaemia among children . 272 Table 7.19 Aneamia among children by state . 273 Table 7.20 Iodization of salt. 276 Table 7.21 Iodization of salt by state . 277 Table 8.1 Health problems during pregnancy . 281 Table 8.2 Antenatal check-ups . 283 Table 8.3 Reason for not receiving an antenatal check-up . 285 Table 8.4 Number and timing of antenatal check-ups and stage of pregnancy. 286 Table 8.5 Components of antenatal check-ups. 288 Table 8.6 Tetanus toxoid vaccination and iron and folic acid tablets or syrup. 290 Table 8.7 Antenatal care indicators by state . 293 Table 8.8 Place of delivery. 295 Table 8.9 Assistance during delivery . 298 Table 8.10 Characteristics of births. 300 Table 8.11 Postpartum check-ups . 301 Table 8.12 Symptoms of postpartum complications. 304 Table 8.13 Maternal care indicators by state. 305 Table 8.14 Symptoms of reproductive health problems . 309 Table 8.15 Treatment of reproductive health problems . 312 Table 8.16 Symptoms of reproductive tract infections by state. 313 Table 9.1 Source of health care. 316 Table 9.2 Home visits by a health or family planning worker. 318 Table 9.3 Quality of home visits . 319 Table 9.4 Matters discussed during contacts with a health or family planning worker. 321 Table 9.5 Quality of care indicators for home visits by state. 322 Table 9.6 Quality of care during most recent visit to a health facility. 323 Table 9.7 Quality of care indicators for facility visits by state . 324 x Page Table 9.8 Family planning discussions with a health or family planning worker . 326 Table 9.9 Availability of regular supply of condoms/pills. 326 Table 9.10 Motivation to use family planning . 327 Table 9.11 Discussions about alternative methods of family planning. 328 Table 9.12 Information on side effects and follow-up for current method . 329 Table 9.13 Quality of care indicators for contraceptive users by state . 330 Appendix B Table B.1 Sample characteristics . 344 Appendix C Table C.1 List of selected variables for sampling errors, India, 1998–99 . 349 Table C.2 Sampling errors, India, 1998–99 . 350 Appendix D Table D.1 Household age distribution. 358 Table D.2 Age distribution of eligible and interviewed women . 359 Table D.3 Completeness of reporting . 359 Table D.4 Births by calendar year. 361 Table D.5 Reporting of age at death in days . 362 Table D.6 Reporting of age at death in months. 363 FIGURES Page Figure 2.1 Population Pyramid. 16 Figure 2.2 Percentage Literate by Age and Sex . 29 Figure 2.3 Percentage of Women Age 6+ Who Are Illiterate by State. 32 Figure 2.4 School Attendance by Age, Sex, and Residence . 34 Figure 3.1 Employment Status of Women by Residence. 52 Figure 3.2 Percentage of Women Not Regularly Exposed to Any Mass Media by State. 61 Figure 3.3 Percentage of Women Participating in Decisions About Their Own Health Care by State. 71 Figure 3.4 Percentage Who Agree With At Least One Reason Justifying a Husband Beating His Wife. 75 Figure 4.1 Age-Specific Fertility Rates by Residence . 84 Figure 4.2 Age-Specific Fertility Rates, NFHS-1, NFHS-2, and SRS . 85 Figure 4.3 Total Fertility Rate by State. 90 Figure 4.4 Total Fertility Rate by Selected Background Characteristics. 92 Figure 4.5 Fertility Preferences Among Currently Married Women . 112 Figure 5.1 Current Use of Contraceptive Methods . 133 Figure 5.2 Current Use of Family Planning by Residence, NFHS-1 and NFHS-2. 134 Figure 5.3 Current Use of Family Planning by State . 143 Figure 5.4 Sources of Family Planning Among Current Users of Modern Contraceptive Methods . 154 Figure 5.5 Unmet Need for Family Planning by State. 175 Figure 6.1 Infant Mortality Rates for Five-Year Periods by Residence. 184 Figure 6.2 Infant Mortality Rates by Selected Background Characteristics . 188 Figure 6.3 Infant Mortality Rates by Selected Demographic Characteristics. 192 Figure 6.4 Infant Mortality Rates by State. 195 Figure 6.5 Percentage of Children Age 12–23 Months Who Have Received Specific Vaccinations, NFHS-1 and NFHS-2. 205 Figure 6.6 Percentage of Children Age 12–23 Months Who Have Received All Vaccinations. 208 xii Page Figure 6.7 Percentage of Children Age 12–23 Months Who Have Received All Vaccinations by State. 210 Figure 6.8 Source of Childhood Vaccinations by Residence. 213 Figure 6.9 Percentage Who Have Heard About AIDS by State. 235 Figure 7.1 Anaemia Among Women . 250 Figure 7.2 Percentage of Breastfeeding Children Given Milk, Other Liquid, or Solid/Mushy Food the Day or Night Before the Interview. 261 Figure 7.3 Percentage of Children Under Age 3 Who Are Underweight, NFHS-1 and NFHS-2. 267 Figure 7.4 Percentage of Children Under Age 3 Who Are Stunted by Mother’s Education and SLI. 268 Figure 7.5 Anaemia Among Children . 271 Figure 7.6 Anaemia Among Children by State . 274 Figure 8.1 Problems During Pregnancy . 282 Figure 8.2 Source of Antenatal Check-Ups During Pregnancy . 284 Figure 8.3 Number and Timing of Antenatal Check-Ups. 287 Figure 8.4 Place of Delivery and Assistance During Delivery . 296 Figure 8.5 Percentage of Deliveries Assisted by a Health Professonal by State . 306 Figure 8.6 Reproductive Health Problems Among Currently Married Women Age 15–49 . 311 Figure 9.1 Motivator for Current Users of Modern Contraceptive Methods . 328 PREFACE The success of the first National Family Health Survey, conducted in 1992–93, in creating an important demographic and health database in India has paved the way for repeating the survey. The second National Family Health Survey (NFHS-2), undertaken in 1998–99, is designed to strengthen the database further and facilitate implementation and monitoring of population and health programmes in the country. As in the earlier survey, the principal objective of NFHS-2 is to provide state and national estimates of fertility, the practice of family planning, infant and child mortality, maternal and child health, and the utilization of health services provided to mothers and children. In addition, the survey provides indicators of the quality of health and family welfare services, women’s reproductive health problems, and domestic violence, and includes information on the status of women, education, and the standard of living. Another feature of NFHS-2 is measurement of the nutritional status of women. Height and weight measurements, which were available only for young children in the earlier survey, were extended to cover all eligible women in NFHS-2. In addition, ever-married women and their children below age three had their blood tested for the level of haemoglobin, using the HemoCue instrument. Through these blood tests, for the first time the survey provides information on the prevalence of anaemia throughout India. In two metropolitan cities, Delhi and Mumbai, a further test was done for children below age three to measure the lead content in their blood. The survey also measured the extent to which households in India use cooking salt that has been fortified with iodine. The NFHS-2 survey was funded by the United States Agency for International Development (USAID) through ORC Macro, USA. UNICEF provided additional financial support for the nutritional components of the survey. The survey is the outcome of the collaborative efforts of many organizations. The International Institute for Population Sciences (IIPS) was designated as the nodal agency for this project by the Ministry of Health and Family Welfare, Government of India, New Delhi. Thirteen reputed field organizations (FOs) in India, including five Population Research Centres, were selected to carry out the houselisting operation and data collection for NFHS-2. ORC Macro, Calverton, Maryland, USA, and the East-West Center, Honolulu, Hawaii, USA, provided technical assistance for all survey operations. The NFHS-2 survey covered a representative sample of more than 90,000 eligible women age 15–49 from 26 states that comprise more than 99 percent of India’s population. The data collection was carried out in two phases, starting in November 1998 and March 1999. The survey provides state-level estimates of demographic and health parameters as well as data on various socioeconomic and programmatic factors that are critical for bringing about desired changes in India’s demographic and health situation. The survey provides urban and rural estimates for most states, regional estimates for four states (Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh), separate estimates for three metro cities (Calcutta, Chennai and Mumbai), and estimates for slum areas in Mumbai. The survey used uniform questionnaires, sample designs, and field procedures to facilitate comparability of the data and to achieve a high level of data quality. Preliminary reports with selected results were prepared earlier for each state and presented to policymakers and programme administrators responsible for improving health and family welfare programmes in xiv the states. The report presents survey findings from all Indian states except Tripura, where the fieldwork was delayed due to a local problem. The contents of this report are based on a standard tabulation plan developed at a workshop held in Kodaikanal during the period 15–17 January 1999. IIPS finalized the tabulation plan according to the recommendations of the NFHS-2 Technical Advisory Committee and produced the tables and figures for the final reports. This report has been written jointly by authors from IIPS, ORC Macro, and the East-West Center. We are happy to present the final NFHS-2 national report, through which the information collected in NFHS-2 is being made public. We hope that the report will provide helpful insights into the changes that are taking place in the country and will provide policymakers and programme managers with up-to-date estimates of indicators that can be used for effective management of health and family welfare programmes, with an emphasis on reproductive health dimensions. The report should also contribute to the knowledge of researchers and analysts in the fields of population, health, and nutrition. T.K. Roy Director International Institute for Population Sciences Mumbai ACKNOWLEDGEMENTS The second National Family Health Survey was successfully completed due to the efforts and involvement of numerous organizations and individuals at different stages of the survey. We would like to thank everyone who was involved in the survey and made it a success. First of all, we are grateful to the Ministry of Health and Family Welfare, Government of India, New Delhi, for its overall guidance and support during the project. Mr. Y.N. Chaturvedi and Mr. K.S. Sugathan, the then Secretary and Joint Secretary, respectively, at the Department of Family Welfare deserve special thanks. They initiated the project and designated the International Institute for Population Sciences (IIPS) as the nodal agency for the survey. They also formed the Steering Committee, the Administrative and Financial Management Committee, and the Technical Advisory Committee for the smooth and efficient functioning of the project. Special thanks are due to Mr. A.R. Nanda, the present Secretary of the Department of Family Welfare, who continued to take an active interest in the project and provided timely guidance and support. The contributions of Mr. Vijay Singh, Joint Secretary (FA), Ms. Meenakshi Dutta Ghosh, Joint Secretary (S), Mr. Gautam Basu, Joint Secretary (RCH), Mr. P.K. Saha, Chief Director (S), and Dr. K.V. Rao, Chief Director (S), are acknowledged with gratitude. We gratefully acknowledge the immense help received from the Office of the Registrar General, India, New Delhi (particularly Dr. M. Vijayanunni, the then Registrar General of India, Mr. J.K. Banthia, the present Registrar General of India, Mr. S.P. Sharma, Consultant, and Mr. S.K. Sinha, Deputy Registrar General, Vital Statistics) in implementing the sample design and making the latest SRS results available to cite in the reports. We thank all the expert participants in the series of workshops to finalize the questionnaire design, the sample design and tabulations plans for the survey. Special mention and thanks are due to Dr. Vijay Verma for his expert advice on the sample design and the calculation of sample weights. We are grateful to the Directorate of Census Operations, Directorate of Health Services, and Office of the Integrated Child Development Scheme, Maharashtra, for their support in conducting training of the houselisters and investigators. We acknowledge the support of the All India Institute of Medical Sciences, New Delhi, which extended its facilities for training of the health investigators. We are thankful to the Department of Health and Family Welfare of each state covered in NFHS-2 for helping the Field Organizations (FOs) by providing them with logistic assistance, whenever possible. Special thanks go to the local officials in all of the sample areas for facilitating the data collection. The United States Agency for International Development (USAID) provided generous funding for NFHS-2. USAID’s contribution to the project is sincerely acknowledged. Special thanks are due to Mr. William Goldman, the former Director of the Office of Population, Health and Nutrition (PHN), USAID, New Delhi, Ms. Sheena Chhabra, Team Leader, Policy, Research, Evaluation, and Marketing (PHN), and Dr. Victor K. Barbiero, current Director of PHN, for their initiative and involvement in the project. Many thanks are due to UNICEF for providing additional funding for the nutrition component of the project and the most modern medical equipment for carrying out the height-weight measurements and anaemia testing. Special thanks are due to xvi Dr. Sanjiv Kumar, Project Officer (Health), UNICEF, New Delhi, for his earnest cooperation in this respect. We gratefully acknowledge the help and cooperation given by Dr. Rameshwar Sharma, the then Director, and Dr. Shiv Chandra Mathur, Professor, State Institute of Health and Family Welfare (SIHFW), Jaipur, during the national pretest of the NFHS-2 questionnaires in Rajasthan. Thanks are due to all the members of the Steering Committee, Administrative and Financial Management Committee, and Technical Advisory Committee for participating in various meetings and providing valuable guidance for successful execution of the project. Dr. K.B. Pathak was the Director of IIPS during the development of the project and throughout the first phase of data collection. His immense interest and great assistance to NFHS-2 are gratefully acknowledged. We appreciate and acknowledge the untiring efforts, interest, and initiative taken by Dr. Fred Arnold, Dr. Sunita Kishor, Mr. Sushil Kumar, and Mr. Zaheer Ahmad Khan from ORC Macro, and Dr. Robert D. Retherford and Dr. Vinod Mishra from the East-West Center. It is only due to their hard work that NFHS-2 could be completed successfully. Thanks go to Dr. Umesh Kapil, Additional Professor, Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi, for organizing, in collaboration with IIPS, the training programme for the health component of the survey, and to Dr. Almaz Sharman of ORC Macro for assisting with the training programme. Dr. Rachel Kaufmann and her colleagues from the Centers for Disease Control and Prevention, Atlanta, also deserve special thanks for providing special training to the health investigators for analyzing lead levels in the blood of young children in Delhi and Mumbai. ORC Macro made available the ISSA (Integrated System for Survey Analysis) computer package for data entry and tabulation. Special thanks go to Mr. Martin Wulfe and Mr. Hendrik J. Raggers for their immense help in the data processing operation, data analysis, and preparation of the tables for NFHS-2 reports and to Dr. Rajib Acharya for his assistance at every stage of the data processing operation and report writing and his maintenance of the NFHS website. Special thanks go to Mr. Somnath W. Choughule, Data Entry Operator, for designing the NFHS website. We gratefully acknowledge the valuable contribution of IIPS Senior Research Officers Dr. Rajeshri Chitanand, Dr. Damodar Sahu, and Dr. Yonah Bhutia, and Research Officers Mr. M.N. Murthy, Ms. Y. Vaidehi, Ms. Pavani Upadrashta, Dr. Madhumita Das, and Mr. Nizamuddin Khan. We also thank the other Research Officers and the health coordinators listed in Appendix E for their valuable assistance during the fieldwork. Thanks are also due to the other supporting staff of the project, particularly Mr. R.S. Hegde, Sr. Accountant, Mr. Dandapani Lokanathan, Sr. Secretarial Assistant, Mr. Sadashiv Jathade, Jr. Secretarial Assistant, and Office Assistants Mr. Parasnath Verma and Mr. Pramod T. Sawant, as well as the Administrative, Accounts, and Library staff of IIPS, for their continuous cooperation during the entire project period. The difficult task of data collection, office editing and data entry for NFHS-2 was successfully carried out by several field organizations. Our heartfelt thanks are due to the directors and staff of all 13 FOs: ACNielsen, New Delhi; Centre for Operations Research and Training, Vadodara; Centre for Population and Development Studies, Hyderabad; Economic Information Technology, Calcutta; Indian Institute of Health and Family Welfare, Hyderabad; Operations Research Group, New Delhi; PRC, Centre for Research in Rural and Industrial Development, Chandigarh; PRC, Institute of Economic Growth, New Delhi; PRC, Institute of Rural Health and xvii Family Welfare Trust, Gandhigram; PRC, Institute of Social and Economic Change, Bangalore; PRC, J.S.S. Institute of Economic Research, Dharwad; PRC, M.S. University of Baroda, Vadodara; and Taylor Nelson Sofres MODE, New Delhi. This acknowledgement cannot be concluded without expressing appreciation for the hard work put in by the interviewers, health investigators, supervisors and field editors in collecting data for NFHS-2. Last but not the least, credit goes to all the eligible women and the household respondents who spent their time and responded to the rather lengthy questionnaires with tremendous patience and without any expectation from NFHS-2. T.K. Roy Sumati Kulkarni Arvind Pandey Kamla Gupta Parveen Nangia NFHS-2 Coordinators, IIPS FACT SHEET - INDIA NATIONAL FAMILY HEALTH SURVEY, 1998–99 Sample Size Households . 91,196 Ever-married women age 15–49. 89,199 Characteristics of Households Percent with electricity . 60.1 Percent within 15 minutes of safe water supply1 . 62.3 Percent with flush toilet. 24.0 Percent with no toilet facility. 64.0 Percent using govt. health facilities for sickness . 28.7 Percent using iodized salt (at least 15 ppm). 49.3 Characteristics of Women2 Percent urban. 26.2 Percent illiterate. 58.2 Percent completed high school and above . 14.3 Percent Hindu . 81.7 Percent Muslim. 12.5 Percent Christian . 2.5 Percent regularly exposed to mass media . 59.7 Percent working in the past 12 months . 39.2 Status of Women2 Percent involved in decisions about own health . 51.6 Percent with control over some money. 59.6 Marriage Percent never married among women age 15–19 . 66.4 Median age at marriage among women age 20–49. 16.7 Fertility and Fertility Preferences Total fertility rate (for the past 3 years) . 2.85 Mean number of children ever born to women 40–49. 4.45 Median age at first birth among women age 20–49. 19.6 Percent of births3 of order 3 and above . 45.2 Mean ideal number of children4. 2.7 Percent of women with 2 living children wanting another child . 23.0 Current Contraceptive Use5 Any method . 48.2 Any modern method . 42.8 Pill . 2.1 IUD. 1.6 Condom . 3.1 Female sterilization . 34.2 Male sterilization . 1.9 Any traditional method. 5.0 Rhythm/safe period . 3.0 Withdrawal . 2.0 Other traditional or modern method . 0.4 Unmet Need for Family Planning5 Percent with unmet need for family planning. 15.8 Percent with unmet need for spacing. 8.3 1Water from pipes, handpump, covered well or tanker truck 2Ever-married women age 15–49 3For births in the past 3 years 4Excluding women giving non-numeric responses 5Among currently married women age 15–49 Quality of Family Planning Services6 Percent told about side effects of method. 21.7 Percent who received follow-up services . 69.1 Childhood Mortality Infant mortality rate7 . 67.6 Under-five mortality rate7. 94.9 Safe Motherhood and Women’s Reproductive Health Maternal mortality ratio. 540 Percent of births8 within 24 months of previous birth . 28.3 Percent of births3 whose mothers received: Antenatal check-up from a health professional . 65.1 Antenatal check-up in first trimester . 33.0 Two or more tetanus toxoid injections . 66.8 Iron and folic acid tablets or syrup . 57.6 Percent of births3 whose mothers were assisted at delivery by a: Doctor . 30.3 Nurse/midwife. 11.4 Traditional birth attendant . 35.0 Percent5 reporting at least one reproductive health problem. 39.2 Awareness of AIDS Percent of women who have heard of AIDS . 40.3 Child Health Percent of children age 0–3 months exclusively breastfed . 55.2 Median duration of breastfeeding (months) . 25.4 Percent of children9 who received vaccinations: BCG . 71.6 DPT (3 doses) . 55.1 Polio (3 doses) . 62.8 Measles. 50.7 All vaccinations. 42.0 Percent of children10 with diarrhoea in the past 2 weeks who received oral rehydration salts (ORS). 26.8 Percent of children10 with acute respiratory infection in the past 2 weeks taken to a health facility or provider. 64.0 Nutrition Percent of women with anaemia11 . 51.8 Percent of women with moderate/severe anaemia11 . 16.7 Percent of children age 6–35 months with anaemia11. 74.3 Percent of children age 6–35 months with moderate/ severe anaemia11. 51.3 Percent of children chronically undernourished (stunted)12. 45.5 Percent of children acutely undernourished (wasted)12 . 15.5 Percent of children underweight12 . 47.0 6For current users of modern methods 7For the 5 years preceding the survey (1994–98) 8For births in the past 5 years (excluding first births) 9Children age 12–23 months 10Children under 3 years 11Anaemia–haemoglobin level < 11.0 grams/decilitre (g/dl) for children and pregnant women and < 12.0 g/dl for nonpregnant women. Moderate/severe anaemia –haemoglobin level < 10.0 g/dl. 12Stunting assessed by height-for-age, wasting assessed by weight-for-height, underweight assessed by weight-for-age SUMMARY OF FINDINGS The second National Family Health Survey (NFHS-2), conducted in 1998–99, provides information on fertility, mortality, family planning, and important aspects of nutrition, health, and health care. The International Institute for Population Sciences (IIPS) coordinated the survey, which collected information from a nationally representative sample of more than 90,000 ever-married women age 15–49. The NFHS-2 sample covers 99 percent of India’s population living in all 26 states. This report is based on the survey data for 25 of the 26 states, however, since data collection in Tripura was delayed due to local problems in the state. IIPS also coordinated the first National Family Health Survey (NFHS-1) in 1992–93. Most of the types of information collected in NFHS-2 were also collected in the earlier survey, making it possible to identify trends over the intervening period of six and one-half years. In addition, the NFHS-2 questionnaire covered a number of new or expanded topics with important policy implications, such as reproductive health, women’s autonomy, domestic violence, women’s nutrition, anaemia, and salt iodization. The NFHS-2 survey was carried out in two phases. Ten states were surveyed in the first phase which began in November 1998 and the remaining states (except Tripura) were surveyed in the second phase which began in March 1999. The field staff collected information from 91,196 households in these 25 states and interviewed 89,199 eligible women in these households. In addition, the survey collected information on 32,393 children born in the three years preceding the survey. One health investigator on each survey team measured the height and weight of eligible women and children and took blood samples to assess the prevalence of anaemia. Background Characteristics of the Survey Population Three-quarters (73 percent) of the population lives in rural areas. The age distribution is typical of populations that have recently experienced a fertility decline, with relatively low proportions in the younger and older age groups. Thirty-six percent of the population is below age 15, and 5 percent is age 65 and above. The sex ratio is 957 females for every 1,000 males in rural areas but only 928 females for every 1,000 males in urban areas, suggesting that more men than women have migrated to urban areas. The survey provides a variety of demographic and socioeconomic background information. In the country as a whole, 82 percent of household heads are Hindu, 12 percent are Muslim, 3 percent are Christian, and 2 percent are Sikh. Muslims live disproportionately in urban areas, where they comprise 15 percent of household heads. Nineteen percent of household heads belong to scheduled castes, 9 percent belong to scheduled tribes, and 32 percent belong to other backward classes (OBCs). Two-fifths of household heads do not belong to any of these groups. Questions about housing conditions and the standard of living of households indicate some improvements since the time of NFHS-1. Sixty percent of households in India now have electricity and 39 percent have piped drinking water compared with 51 percent and 33 percent, respectively, at the time of NFHS-1. Sixty-four percent of households have no toilet facility compared with 70 percent at the time of NFHS-1. xx About three-fourths (75 percent) of males and half (51 percent) of females age six and above are literate, an increase of 6–8 percentage points from literacy rates at the time of NFHS-1. The percentage of illiterate males varies from 6–7 percent in Mizoram and Kerala to 37 percent in Bihar and the percentage of illiterate females varies from 11 percent in Mizoram and 15 percent in Kerala to 65 percent in Bihar. Seventy-nine percent of children age 6–14 are attending school, up from 68 percent in NFHS-1. The proportion of children attending school has increased for all ages, particularly for girls, but girls continue to lag behind boys in school attendance. Moreover, the disparity in school attendance by sex grows with increasing age of children. At age 6–10, 85 percent of boys attend school compared with 78 percent of girls. By age 15–17, 58 percent of boys attend school compared with 40 percent of girls. The percentage of girls 6–17 attending school varies from 51 percent in Bihar and 56 percent in Rajasthan to over 90 percent in Himachal Pradesh and Kerala. Women in India tend to marry at an early age. Thirty-four percent of women age 15–19 are already married including 4 percent who are married but gauna has yet to be performed. These proportions are even higher in the rural areas. Older women are more likely than younger women to have married at an early age: 39 percent of women currently age 45–49 married before age 15 compared with 14 percent of women currently age 15–19. Although this indicates that the proportion of women who marry young is declining rapidly, half the women even in the age group 20–24 have married before reaching the legal minimum age of 18 years. On average, women are five years younger than the men they marry. The median age at marriage varies from about 15 years in Madhya Pradesh, Bihar, Uttar Pradesh, Rajasthan, and Andhra Pradesh to 23 years in Goa. As part of an increasing emphasis on gender issues, NFHS-2 asked women about their participation in household decisionmaking. In India, 91 percent of women are involved in decision-making on at least one of four selected topics. A much lower proportion (52 percent), however, are involved in making decisions about their own health care. There are large variations among states in India with regard to women’s involvement in household decisionmaking. More than three out of four women are involved in decisions about their own health care in Himachal Pradesh, Meghalaya, and Punjab compared with about two out of five or less in Madhya Pradesh, Orissa, and Rajasthan. Thirty-nine percent of women do work other than housework, and more than two-thirds of these women work for cash. Only 41 percent of women who earn cash can decide independently how to spend the money that they earn. Forty-three percent of working women report that their earnings constitute at least half of total family earnings, including 18 percent who report that the family is entirely dependent on their earnings. Women’s work-participation rates vary from 9 percent in Punjab and 13 percent in Haryana to 60–70 percent in Manipur, Nagaland, and Arunachal Pradesh. Fertility and Family Planning Fertility continues to decline in India. At current fertility levels, women will have an average of 2.9 children each throughout their childbearing years. The total fertility rate (TFR) is down from 3.4 children per woman at the time of NFHS-1, but is still well above the replacement level of just over two children per woman. There are large variations in fertility among the states in India. Goa and Kerala have attained below replacement level fertility and Karnataka, Himachal Pradesh, Tamil Nadu, and Punjab are at or close to replacement level fertility. By contrast, fertility is 3.3 or more children per woman in Meghalaya, Uttar Pradesh, Rajasthan, Nagaland, xxi Bihar, and Madhya Pradesh. More than one-third to less than half of all births in these latter states are fourth or higher-order births compared with 7–9 percent of births in Kerala, Goa, and Tamil Nadu. Efforts to encourage the trend towards lower fertility might usefully focus on groups within the population that have higher fertility than average. In India, rural women and women from scheduled tribes and scheduled castes have somewhat higher fertility than other women, but fertility is particularly high for illiterate women, poor women, and Muslim women. Another striking feature is the high level of childbearing among young women. More than half of women age 20–49 had their first birth before reaching age 20, and women age 15–19 account for almost one-fifth of total fertility. Studies in India and elsewhere have shown that health and mortality risks increase when women give birth at such young agesboth for the women themselves and for their children. Family planning programmes focusing on women in this age group could make a significant impact on maternal and child health and help to reduce fertility. The appropriate design of family planning programmes depends, to a large extent, on women’s fertility preferences. Women may have large families because they want many children, or they may prefer small families but, for a variety of reasons, may have more children than they actually want. For 9 percent of births over the three years preceding the survey and current pregnancies, mothers report that they did not want the pregnancy at all, and for another 12 percent, mothers say that they would have preferred to delay the pregnancy. When asked about their preferred family size, 41 percent of women who already have three children and 24 percent of women with four or more children respond that they consider the two-child family ideal. This gap between women’s actual fertility experience and what they want or would consider ideal suggests a need for expanded or improved family welfare services to help women achieve their fertility goals. On average, a woman in India considers less than 3 children (2.7) ideal, but in Bihar, Uttar Pradesh, and several of the northeastern states, women’s ideal number of children is 3.1 or above. In the country as a whole, 85 percent of women want at least one son and 80 percent want at least one daughter. A preference for sons is indicated by the fact that one-third want more sons than daughters but only a negligible proportion want more daughters than sons. If many women in India are not using family planning, it is not due to lack of knowledge. Knowledge of contraception is nearly universal: 99 percent of currently married women know at least one modern family planning method. Women are most familiar with female sterilization (98 percent), followed by male sterilization (89 percent), the pill (80 percent), the condom (71 percent), and the IUD (71 percent). Knowledge of modern spacing methods has increased by 10–13 percentage points since the time of NFHS-1, although use rates for these methods remain extremely low. Forty-eight percent of currently married women are using some method of contraception, up from 41 percent at the time of NFHS-1. Contraceptive prevalence is considerably higher in urban areas (58 percent) than in rural areas (45 percent). Female sterilization is by far the most popular method: 34 percent of currently married women are sterilized, a substantial increase from 27 percent at the time of NFHS-1. By contrast, only 2 percent of women report that their husbands are sterilized, a decrease from 4 percent in NFHS-1. Overall, sterilization accounts for 75 percent of total contraceptive use. Only 18 percent of sterilized couples have ever used any xxii method other than sterilization. Current-use rates for the pill, IUD, and condom remain very low, each at about 2–3 percent. Contraceptive prevalence varies widely among socioeconomic groups. Muslim women, scheduled-tribe women, and women belonging to poor households are less likely (37–40 percent) than most other women to use contraception at all. The three modern spacing methods—pills, IUDs, and condoms—are used more by Sikh women, more educated women, women from households with a high standard of living, Jain women, and urban women (13–23 percent) than other women. Contraceptive prevalence varies by state from 20 percent in Meghalaya, 25 percent in Bihar, and 28 percent in Uttar Pradesh to 67–68 percent in Punjab and Himachal Pradesh. Other states where contraceptive prevalence is at or below the national average of 48 percent are Rajasthan, Madhya Pradesh, Orissa, Goa, and all northeastern states except Mizoram and Sikkim. Modern temporary methods are most prevalent in Delhi, Punjab, and Sikkim (17–28 percent) and are also relatively common (9–14 percent) in West Bengal, Haryana, Jammu and Kashmir, and other northeastern states. Traditional methods are used most widely in West Bengal, followed by Assam, Manipur, Punjab, and Sikkim. Sterilization dominates the contraceptive method-mix in most states, but especially so in Maharashtra, Madhya Pradesh, Bihar, Rajasthan, and all the southern states. Given the near-exclusive emphasis on sterilization in the contraceptive method-mix, women tend to adopt family planning only after they have achieved their desired family size. As a result, contraceptive use can be expected to rise steadily with age and with number of living children. In India, contraceptive use does indeed go up with age, peaking at 67 percent for women age 35–39. Use also goes up with the number of children, peaking at 68 percent for women with three living children. Son preference appears to have a strong effect on contraceptive use, especially the adoption of sterilization. Among women with two or more living children, only 23–30 percent of women with only daughters have been sterilized compared with 41–67 percent of women with at least one son. Eight percent of currently married women are not using contraception but say that they want to wait at least two years before having another child. Another 8 percent are not using contraception although they do not want any more children. These women are described as having an ‘unmet need’ for family planning. Unmet need is highest (27 percent) for young women below age 20, who are particularly interested in spacing their births. Unmet need in different states varies from 7–9 percent of currently married women in Punjab, Haryana, Andhra Pradesh, Gujarat, and Himachal Pradesh to 25–36 percent in Meghalaya, Nagaland, Arunachal Pradesh, Uttar Pradesh, and Bihar. These results underscore the need for strategies that provide spacing as well as terminal methods in order to meet the changing needs of women over their lifecycle. For many years, the Government of India has been using electronic and other mass media to promote family planning. Among the different types of media, television has the broadest reach across almost all categories of women, including illiterate women and women living in rural areas. Overall, 46 percent of ever-married women watch television at least once a week. Despite the fact that 40 percent of women are not regularly exposed to television, radio, and other types of media, however, 60 percent of women saw or heard a family planning message in the media during the few months before the survey. Women are more likely to have seen or heard a family planning message on television than through any other form of media. Exposure xxiii to family planning messages is relatively low among poor, scheduled-tribe, illiterate, and rural women. Nonetheless, family planning messages are reaching about two out of five or more socioeconomically disadvantaged women. Exposure to family planning messages is particularly limited in Rajasthan, Bihar, Uttar Pradesh, and Madhya Pradesh, where less than half the women were exposed to a family planning message in the past few months. More than three-fourths (76 percent) of current users of modern contraceptives obtained their method from a government hospital or other source in the public sector. Only 17 percent obtained their method from the private medical sector. The private medical sector along with shops is the major source of pills and condoms, however. Overall, the public medical sector plays a larger role in rural areas than in urban areas, and at least two-thirds of modern contraceptive users obtain their method from a public-sector source in every state except Meghalaya, Delhi, Nagaland, Assam, and Punjab. An important indicator of the quality of family planning services is the information that women receive when they obtain contraception and the extent to which they receive follow-up services after accepting contraception. In India, only 15 percent of users of modern contraceptives who were motivated by someone to use their method were told about any other method. Only 22 percent were told about possible side effects of their current method by a health or family planning worker at the time of adopting the method. Sixty-nine percent of contraceptive users, however, received follow-up services. From the information provided in NFHS-2, a picture emerges of women marrying early, having their first child soon after marriage, having a second and possibly a third child in close succession, and then being sterilizedall by the time they reach their mid-20s. The median age for female sterilization has been declining in recent years and is now 26 years, one year earlier than at the time of NFHS-1. Very few women use modern spacing methods that could help them delay their first births and increase intervals between pregnancies. Infant and Child Mortality NFHS-2 provides estimates of infant and child mortality and examines factors associated with the survival of young children. During the five years preceding the survey, the infant mortality rate was 68 deaths at age 0–11 months per 1,000 live births, substantially lower than 79 per 1,000 in the five years preceding the NFHS-1 survey. The child mortality rate, 29 deaths at age 1–4 years per 1,000 children reaching age one, also declined from the corresponding rate of 33 per 1,000 in NFHS-1. Ninety-five children out of 1,000 born do not live to age five years. Expressed differently, 1 in 15 children die in the first year of life, and 1 in 11 die before reaching age five. Child-survival programmes might usefully focus on specific groups of children with particularly high infant and child mortality rates, such as children who live in rural areas, children whose mothers are illiterate, children belonging to scheduled castes or scheduled tribes, and children from poor households. Infant mortality rates are more than two and one-half times as high for women who did not receive any of the recommended types of maternity related medical care than for mothers who did receive all recommended types of care. Along with various socioeconomic groups, efforts to promote child survival need to concentrate on very young mothers and mothers whose children are closely spaced. Infant mortality is almost 50 percent higher among children born to mothers under age 20 than among xxiv children born to mothers age 20–29 (93 deaths, compared with 63, per 1,000 live births). Infant mortality is nearly three times as high among children born less than 24 months after a previous birth as among children born after a gap of 48 months or more (110 deaths, compared with 39, per 1,000 live births). Clearly, efforts to expand the use of temporary contraceptive methods for delaying and spacing births would help reduce infant mortality as well as fertility. There are large variations in infant mortality among states. Infant mortality ranges from a high of 80–89 deaths per 1,000 live births in Meghalaya, Uttar Pradesh, Madhya Pradesh, Orissa, and Rajasthan to a low of 16 per 1,000 live births in Kerala and 34–37 per 1,000 live births in Himachal Pradesh, Goa, Mizoram, and Manipur. Health, Health Care, and Nutrition Promotion of maternal and child health has been one of the most important components of the Family Welfare Programme of the Government of India. One goal is for each pregnant woman to receive at least three antenatal check-ups plus two tetanus toxoid injections and a full course of iron and folic acid supplementation. In India, mothers of 65 percent of the children born in the three years preceding NFHS-2 received at least one antenatal check-up and 44 percent received at least three check-ups. For 67 percent of these births, mothers received the recommended number of tetanus toxoid vaccinations during pregnancy, up from 54 percent in NFHS-1. For 58 percent, mothers received iron and folic acid supplementation during pregnancy. Women in disadvantaged socioeconomic groups are less likely than other women to be covered by each of these interventions. Coverage is also low for women who already have four or more children. States that perform well below the national average with regard to the provision of recommended components of antenatal care include Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh, and several of the northeastern states. Kerala, Goa, and Tamil Nadu, by contrast, have achieved relative success with regard to antenatal care. In these states, mothers of over 90 percent of births receive at least three antenatal check-ups, at least 86 percent receive two or more tetanus toxoid injections, and at least 93 percent receive iron and folic acid tablets. Even in these states, however, a substantial proportion of women do not receive all of the recommended components of antenatal care. The Family Welfare Programme encourages women to deliver in a medical facility or if at home, with assistance from a trained health professional and to receive at least three check-ups after delivery. During the three years preceding NFHS-2, only one-third of births in India took place in a medical facility, up from one-fourth at the time of NFHS-1. Among births at home, over 50 percent were assisted by a traditional birth attendant, and only 13 percent were assisted by a health professional. Only 17 percent of births outside a medical facility were followed by a postpartum check-up within two months of delivery. While over 84 percent of deliveries were assisted by a health professional in Kerala, Goa, and Tamil Nadu, less than one-fourth were assisted by a health professional in Meghalaya, Assam, Uttar Pradesh, and Bihar. The proportion of noninstitutional deliveries with a postpartum check-up within two months ranges from a high of only 53 percent in Tamil Nadu to below 10 percent in Nagaland, Rajasthan, and Uttar Pradesh. Overall, these results show that maternal health services in India are reaching many more women during pregnancy than during delivery or after childbirth. They also point to the important role of traditional birth attendants for the substantial proportion of births that occur at home. xxv The Government of India recommends that breastfeeding should begin immediately after childbirth and that infants should be exclusively breastfed for the first four months of life. Although breastfeeding is nearly universal in India, very few children begin breastfeeding immediately after birthonly 16 percent in the first hour and 37 percent in the first day. Fifty-five percent of children under four months of age are exclusively breastfed. The median duration of breastfeeding is 25 months, or slightly over two years, and the median duration of exclusive breastfeeding is two months. At age 6–9 months, all children should be receiving solid or mushy food in addition to breast milk to provide sufficient nutrients for optimal growth. However, only 34 percent of children age 6–9 months receive the recommended combination of breast milk and solid or mushy food. The proportion of children age 6–9 months who receive solid or mushy food is even lower than the national average in six states, including Bihar, Uttar Pradesh, and Rajasthan, where this proportion is only 15–18 percent. NFHS-2 uses three internationally recognized standards to assess children’s nutritional statusweight-for-age, height-for-age, and weight-for-height. Children who are more than two standard deviations below the median of an international reference population are considered underweight (measured in terms of weight-for-age), stunted (height-for-age), or wasted (weight- for-height). Stunting is a sign of chronic, long-term undernutrition, wasting is a sign of acute, short-term undernutrition, and underweight is a composite measure that takes into account both chronic and acute undernutrition. Based on international standards, 47 percent of children under age three years in India are underweight, down slightly from 52 percent at the time of NFHS-1. Forty-six percent of children are stunted and 16 percent are wasted. Undernutrition is much higher in rural areas than in urban areas, and is particularly high among children from disadvantaged socioeconomic groups. Nearly three-quarters (74 percent) of children age 6–35 months are anaemic, with very little variation in anaemia rates for children in most subgroups of the population. Christian children, children whose mothers have completed at least high school, children from households with a relatively high standard of living, and children whose mothers are not anaemic, have anaemia rates that are substantially below the national average. Even among these groups, however, at least 61 percent of children are anaemic. The prevalence of anaemia among children age 6–35 months varies from 44 percent in Kerala and Nagaland to 80–84 percent in Haryana, Rajasthan, Bihar, and Punjab. Child immunization is an important component of child-survival programmes in India, with efforts focussing on six serious but preventable diseasestuberculosis, diphtheria, pertussis, tetanus, polio, and measles. The objective of the Universal Immunization Programme (UIP), launched in 1985–86, was to extend immunization coverage against these diseases to at least 85 percent of infants by 1990. In India, 42 percent of children age 12–23 months have received all the recommended vaccinations, 44 percent have received some but not all, and 14 percent have received none of the recommended vaccinations. Immunization coverage, although far from complete, has improved substantially since NFHS-1, when only 36 percent of children were fully vaccinated and 30 percent had not been vaccinated at all. Coverage of individual vaccines has also increased considerably, and is much higher than would appear from information on full coverage alone. According to NFHS-2, 72 percent of children age 12–23 months have been vaccinated against tuberculosis, 63 percent have received three doses of the polio vaccine, 55 percent have received three doses of the DPT xxvi vaccine, and 51 percent have been vaccinated against measles. The largest increases in vaccination coverage between NFHS-1 and NFHS-2 are for the first two doses of polio vaccine, undoubtedly because of the introduction of the Pulse Polio Immunization Campaign in 1995. Dropout rates for the series of DPT and polio vaccinations continue to be a problem, however. Eighty-four percent of children received the first polio vaccination, but only 63 percent received all three doses; 71 percent received the first DPT vaccination, but only 55 percent received all three doses. It is also recommended that children under age five years should receive oral doses of vitamin A every six months starting at age nine months. However, only 30 percent of children age 12–35 months have received any vitamin A supplementation and only 17 percent received a dose of vitamin A in the six months preceding the survey. NFHS-2 collected information on the prevalence and treatment of three health problems that cause considerable mortality in young childrenfever, acute respiratory infection (ARI), and diarrhoea. In India 30 percent of children under age three had fever during the two weeks preceding the survey, 19 percent had symptoms of ARI, and 19 percent had diarrhoea. About two-thirds of the children who had symptoms of ARI or diarrhoea were taken to a health facility or health-care provider. Knowledge of the appropriate treatment of diarrhoea remains low. Only 62 percent of mothers of children age less than 3 years know about oral rehydration salt (ORS) packets and 34 percent of mothers incorrectly believe that children should be given less to drink than usual when sick with diarrhoea. Forty-eight percent of children with diarrhoea received some form of oral rehydration therapy (ORT), including 27 percent who received ORS. The percentage of children with diarrhoea who received ORS has increased substantially since NFHS-1, when it was only 18 percent, suggesting some improvement in the management of childhood diarrhoea. Among children sick with diarrhoea in the two weeks prior to the survey, the proportion who were given some form of ORT varies from 90 percent in Kerala, 76 percent in Goa, and 73 percent in West Bengal to 34 percent in Rajasthan and 36 percent in Uttar Pradesh. The proportion given ORS varies from 56 percent in Goa and 51 percent in Manipur to only 15–16 percent in Bihar and Uttar Pradesh. Based on a weight-for-height index (the body mass index), more than one-third (36 percent) of women in India are undernourished. Nutritional deficiency is particularly acute for women in rural areas, younger women, women in disadvantaged socioeconomic groups, and women who work for someone else. Women who are undernourished themselves are also much more likely than other women to have children who are undernourished. The proportion of women undernourished is highest in Orissa (48 percent) and West Bengal (44 percent) and lowest in Arunachal Pradesh (11 percent), Sikkim (11 percent), and Delhi (12 percent). Obesity is a substantial problem among several groups of women in India, particularly urban women, well-educated women, and women from households with a high standard of living. Approximately one-quarter of these women have a body mass index of 25 or more, compared with 11 percent of all women in India. Obesity is particularly prevalent in Delhi and Punjab. Overall, 52 percent of women in India have some degree of anaemia and 40 percent or more of women in every population subgroup are anaemic. The prevalence of anaemia is particularly high for scheduled-tribe women and poor women. Pregnant women are much more likely than nonpregnant women to be moderately to severely anaemic. The prevalence of anaemia is lowest in Kerala, Manipur, Goa, and Nagaland, where 23–38 percent of women are anaemic, and highest in Assam, Bihar, Meghalaya, Orissa, West Bengal, Arunachal Pradesh, and Sikkim, where 61–70 percent are anaemic. xxvii Less than half of the households use cooking salt that is iodized at the recommended level of 15 parts per million, suggesting that iodine deficiency disorders are likely to be a serious problem. Rural households and households with a low standard of living are much less likely than other households to be using adequately iodized cooking salt. While 88–91 percent of households in Himachal Pradesh, Mizoram, Delhi, and Manipur consume adequately iodized salt, only 21 percent of households in Tamil Nadu and 27 percent in Andhra Pradesh do so. About two-fifths (39 percent) of currently married women in India report some type of reproductive-health problem, including abnormal vaginal discharge, symptoms of a urinary tract infection, and pain or bleeding associated with intercourse. Among these women, 66 percent have not sought any advice or treatment. These results suggest a need to expand reproductive- health services and IEC programmes that encourage women to discuss their problems with a health-care provider. The percentage of currently married women reporting at least one reproductive-health problem varies among states from 19 percent in Karnataka to above 60 percent in Meghalaya and Jammu and Kashmir. In recent years, there has been growing concern about domestic violence in India. NFHS-2 found that there is widespread acceptance among ever-married women that the beating of wives by husbands is justified under some circumstances. More than half (56 percent) the women accept at least one of six reasons as justification for a husband beating his wife. Domestic violence is also fairly common. At least one in five women have experienced beatings or physical mistreatment since age 15 and at least one in nine experienced such violence in the 12 months preceding the survey. Most of these women have been beaten or physically mistreated by their husbands. Domestic violence against women is especially prevalent (27–29 percent) among women working for cash, poor women, scheduled-caste women, and widowed, divorced, or deserted women. Overall, only 13 percent of women received a home visit from a health or family planning worker during the 12 months preceding the survey. Women who received visits were visited three times, on average, in the year preceding the survey. A large majority of women who received a home visit expressed satisfaction with the amount of time that the worker spent with them and with the way the worker talked to them. Home visits are much more common in the southern states, western states, Mizoram, and West Bengal, where 17–33 percent of ever-married women received a home visit from a health and family planning worker, than in all other states. The survey collected information on the prevalence of tuberculosis, asthma, malaria, and jaundice among all household members. Disease prevalence based on reports from household heads must be interpreted with caution, however. The survey found that less than 1 percent of the population suffers from tuberculosis, 2 percent suffers from asthma, 4 percent suffered from malaria during the three months preceding the survey, and 1 percent suffered from jaundice during the 12 months preceding the survey. Prevalence of all four conditions is higher in rural areas than in urban areas and among men than among women. Most households in India (65 percent) go to private hospitals/clinics or doctors for treatment when a family member is ill. Only 29 percent normally use the public medical sector. Even among poor households, only 34 percent normally use the public medical sector when members become ill. Most respondents are generally satisfied with the health care they receive. xxviii Ratings on quality of services are, however, lower for public-sector facilities both in rural and urban areas than for private sector/NGO/trust facilities. NFHS-2 also collected information on selected lifestyle indicators for household members. According to household respondents, 29 percent of men and 3 percent of women smoke, 17 percent of men and 2 percent of women drink alcohol, and 28 percent of men and 12 percent of women chew paan masala or tobacco. Although the spread of HIV/AIDS is a major concern in India, 60 percent of women in India have not heard of AIDS. Awareness of AIDS is particularly low among women who are not regularly exposed to media, scheduled-tribe women, illiterate women, women living in households with a low standard of living, and rural women. Among women who have heard of AIDS, 79 percent learned about the disease from television and 42 percent from radio, suggesting that the government’s efforts to promote AIDS awareness through the electronic mass media have achieved some success. Among women who have heard of AIDS, however, one-third do not know of any way to avoid infection. Survey results suggest that health personnel could play a much larger role in promoting AIDS awareness. In India, only 4 percent of women who know about AIDS learned about the disease from a health worker. Only 12 percent of women have heard of AIDS in Bihar and 20–23 percent in Uttar Pradesh, Rajasthan, and Madhya Pradesh, compared with 87 percent or more in Mizoram, Manipur, Tamil Nadu, and Kerala. Among women who have heard of AIDS, at least one-fourth do not know of any way to avoid it in all states except Mizoram, Tamil Nadu, Orissa, and Delhi. These results suggest the need for effective IEC strategies throughout India. CHAPTER 1 INTRODUCTION 1.1 Background of the Survey India’s first National Family Health Survey (NFHS-1) was conducted in 1992–93. The Ministry of Health and Family Welfare (MOHFW) subsequently designated the International Institute for Population Sciences (IIPS), Mumbai, as the nodal agency to initiate a second survey (NFHS-2), which was conducted in 1998–99. An important objective of NFHS-2 is to provide state-level and national-level information on fertility, family planning, infant and child mortality, reproductive health, child health, nutrition of women and children, and the quality of health and family welfare services. Another important objective is to examine this information in the context of related socioeconomic and cultural factors. The survey is also intended to provide estimates at the regional level for four states (Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh) and estimates for three metro cities (Calcutta, Chennai, and Mumbai), as well as slum areas in Mumbai. This information will assist policymakers and programme administrators in planning and implementing strategies for improving population, health, and nutrition programmes. The NFHS-2 sample covers more than 99 percent of India’s population living in all 26 states. It does not cover the union territories. NFHS-2 is a household survey with an overall target sample size of approximately 90,000 ever-married women in the age group 15–49. This report presents findings based on the analysis of all the states in India except Tripura, where the fieldwork was delayed. NFHS-2 was conducted with financial support from the United States Agency for International Development (USAID), with additional funding from UNICEF. Technical assistance was provided by ORC Macro, Calverton, Maryland, USA, and the East-West Center, Honolulu, Hawaii, USA. Thirteen field organizations were selected to collect the data. Eight of the field organizations are private sector organizations and five are Population Research Centres (PRCs) established by the Government of India in various states. Each field organization had responsibility for collecting the data in one or more states. A complete list of these field organizations is given in Appendix A. 1.2 Basic Demographic Features of India India crossed the one billion population mark in May 2000. According to the Census of India, India had a population of 548 million in 1971, 683 million in 1981, and 846 million in 1991. The exponential growth rate was virtually constant between 1961–71 and 1971–81 (2.22 and 2.20 percent, respectively), but it declined to 2.14 in 1981–91. The sex ratio of the Indian population has been unfavourable to females since the beginning of this century and has declined in every decade except 1971–81. The sex ratios were 930, 934, and 927 females per 1,000 males in 1971, 1981, and 1991, respectively. Population density increased from 177 persons per km2 in 1971 to 216 in 1981 and 267 in 1991, indicating increasing population pressure on the land. As per the 1991 Census, 37 percent of the population is in the childhood ages (0–14 years), 7 percent is in the age group 60 and over, and 55 percent is in the working-age group 15–59, which indicates a 2 high dependency burden. The process of urbanization has been rather slow in India. The percentage of the total population living in urban areas increased from 20 percent in 1971 to 23 percent in 1981 and 26 percent in 1991. During the decade 1981–91 the growth rate of the rural population was 2.00 percent per annum, while that of the urban population was 3.65 percent per annum. One-fifth of India’s population lives in Class I cities and Class II towns that have populations of 50,000 and above. One-fourth of India’s population lives in villages that have fewer than 1,000 residents. As per the 1991 Census, 16 percent of India’s population belongs to scheduled castes and 8 percent belongs to scheduled tribes1 (Central Statistical Organisation, 1999; Ministry of Health and Family Welfare, 1998a). 1.3 Economic Development India’s gross national product in the year 1999–2000 was Rs. 17.5 trillion at current prices. India’s national income (NNP at factor cost) was five times as high in 1992–93 (Rs. 2.0 trillion) as in 1950–51 (Rs. 0.4 trillion) at constant (1980–81) prices. From 1993–94 to 1998–99, the NNP increased by an additional 38 percent, reaching Rs. 9.5 trillion at 1993–94 prices. Between 1950–51 and 1992–93, however, per capita income only doubled and it increased further by only 27 percent between 1993–94 and 1998–99. In 1998–99, India’s per capita income was Rs. 14,682 at current prices. The growth rate of national income at constant prices increased from 3.6 percent per annum during the first plan (1951–56) to 6.6 percent per annum during the eighth plan (1992–97). The corresponding increase in the growth rate of per capita income was from 1.8 percent to 4.6 percent per annum (Ministry of Finance, 2000). Between 1950–51 and 1998–99, gross domestic savings and gross domestic capital formation as a percentage of the gross domestic product (GDP) increased from around 10 percent to 22 percent. Agricultural production increased nearly fourfold from 1950–51 to 1998–99. The century ended with the country’s output of food grains crossing 200 million tonnes, a fourfold increase since 1950–51, mainly due to the success of the green revolution since the 1970s. Although the area under cultivation with food grains has remained virtually constant since 1970–71, the yield has increased by 65 percent. India had to import food grains for some time after independence, but now it has emerged as a marginal exporter of food grains (Ministry of Finance, 2000). Agriculture contributes nearly one-fourth of the GDP (Reserve Bank of India, 1999) and provides a livelihood to about two-thirds of all workers in the country (Central Statistical Organisation, 1999). Although the percentage of land cultivated with food crops that is irrigated increased from 24 percent in 1970–71 to 41 percent in 1996–97, the performance of Indian agriculture still largely depends on monsoon rains. In spite of a fourfold increase in food production since the early fifties, daily per capita net availability of cereals and pulses has increased by only 18 percent, from 395 grams to 467 grams per day (Ministry of Finance, 2000). At the time of independence, India had a weak industrial base. Since 1948, within the framework of planned development of the economy, India has adopted the concept of a mixed economy for overall industrial development. The industrial policy resolution of 1948 demarcated the scope for development of industries in the private sector and also provided for reservation of some areas for exclusive development in the public sector. In subsequent industrial policy statements, the government adopted a variety of measures to modify licensing policies and 1Scheduled castes and scheduled tribes are castes and tribes that the Government of India officially recognizes as socially and economically backward and in need of special protection from injustice and exploitation. 3 regulate the private sector. Since 1980, however, the government has taken several steps towards liberalization of industrial policy (Singh, 1986). With the introduction of the New Industrial Policy, 1991, a substantial programme of structural reforms for liberalization and globalization has been undertaken to accelerate the process of making Indian industry internationally competitive. The industrial production index was more than 18 times as high in 1999–2000 (148) as it was in 1950–51 (8). Production of finished steel has increased from 1 million tonnes to 24 million tonnes, and production of coal from 32 million tonnes to 316 million tonnes. The generation of electricity has increased from 5 billion kwh to 448 billion kwh. The Indian economy is expected to grow by 5 percent in 1999–2000 and, as a result of industrial recovery, the growth of GDP from manufacturing will almost double to 7.0 percent in 1999–2000 from 3.6 percent in 1998–99. From 1950–51 to 1998–99, exports increased from US $1.3 billion to US $33.7 billion, while imports increased from US $1.3 billion to US $41.9 billion (Ministry of Finance, 2000). India’s achievements in the field of information technology have been internationally recognized. Software exports continued to show vigorous growth of over 50 percent from April to September 1999. 1.4 Performance of Social Sectors and Demographic Change The approach to the Ninth Five-Year Plan adopted by the National Development Council has accorded priority to social sector development. The goal is growth with social justice and equity. As per the latest Human Development Report (United Nations Development Program, 2000), India’s rank among countries in terms of GDP per capita is 121, while in terms of the human development index India ranks somewhat lower (128). In contrast, China’s rank in terms of the human development index (99) is not only much above India’s rank, but China ranks slightly higher than India in terms of GDP per capita (106). Some indicators of the performance of social sectors in India underscore the need for giving high priority to key sectors like education, health, and poverty eradication; these areas are also crucial for accelerating the demographic transition in India. As per the estimates of the Planning Commission, the percentage of the population living below the poverty line declined from 55 percent in 1973–74 to 36 percent in 1993–94 (Central Statistical Organisation, 1999). The literacy rate in India increased from 18 percent in 1951 to 52 percent in 1991. The literacy rate for adults in India (62 percent) is much lower than the rate in China (83 percent); in the Philippines and Thailand, the adult literacy rate is as high as 95 percent. In India, gross enrolment as a percentage of the total population for the age group 6–11 years increased from 43 percent in 1950–51 to 90 percent in 1997–98, while for ages 11–14 the corresponding increase was from 13 percent to 59 percent (Central Statistical Organisation, 1999). During the half century since India adopted the family planning programme as its official programme, India has seen the following improvements in its demographic situation (Ministry of Health and Family Welfare, 2000): • A reduction of the crude birth rate from 40.8 births per 1,000 population in 1951 to 26.4 in 1998 4 • A halving of the infant mortality rate from 146 per 1,000 live births in 1951 to 72 per 1,000 live births in 1998 • A quadrupling of the couple protection rate from 10 percent in 1971 to 44 percent in 1999 • A reduction of the crude death rate from 25 deaths per 1,000 population in 1951 to 9 in 1998 • The addition of 25 years to life expectancy from 37 years to 62 years • A reduction in the total fertility rate from 6.0 in 1951 to 3.3 in 1997 However, achievements in these areas have been less evident in India than in most other countries in Asia. India’s maternal mortality ratio (estimated at 408 maternal deaths per 100,000 live births in 1997) is several times as high as the MMR of 115 in China or 30 in Sri Lanka (Ministry of Health and Family Welfare, 2000). India’s infant mortality rate is much higher than that of China (31), Indonesia (46), and Thailand (22). Life expectancy at birth in India (62 years) is much lower than that of China, the Republic of Korea, and Malaysia (all above 70 years). India’s total fertility rate (3.3) is much higher than that of countries like China (1.8), Sri Lanka (2.1), and Thailand (1.9). Although India’s crude death rate is fairly low (9), it is still somewhat higher than the crude death rate in countries like China, Vietnam, and Sri Lanka (6). Similarly, India’ s crude birth rate is much higher than the birth rate of China (15), Thailand (16), and Sri Lanka (18) (Population Reference Bureau, 2000). India’s population, which already exceeds one billion, is expected to reach 1.26 billion by March 2016 (Ministry of Health and Family Welfare, 2000). With the objective of stabilizing the population at a level consistent with the requirements of the national economy for improving the quality of life, several measures have been adopted recently to make the family welfare programme more broad based. These measures are summarized in the next section. 1.5 Population Policies and Programmes The Family Welfare Programme in India has undergone important changes in recent years, particularly during the last five or six years. The government has dispensed with its procedure, initiated during the Fourth Five-Year Plan, of monitoring the family welfare programme on the basis of method-specific family planning targets to achieve a couple protection rate (CPR) of 60 percent. Experience has shown that the emphasis on achieving method-specific targets, particularly sterilization targets, has created a situation in which targets for numbers of acceptors gained precedence over everything else and the programme was not driven by demand. This led to the acceptance of sterilization by older and higher-parity couples at the expense of the promotion of spacing between children among younger couples. The target approach, along with incentive schemes to encourage better performance, led to unhealthy competition among states and among personnel at different levels within states. This emphasis had an adverse impact on the quality of services and care provided by the programme. Adequate emphasis was not placed on informed choice, counselling, and follow-up services to clients. The scope of the services provided by the progamme has increased consistently over the years. At the time of initiation of the programme in 1952, it was primarily a clinic-based family planning programme. After the adoption of the extension approach in 1963 and subsequent 5 integration with the maternal and child health (MCH) programme, the activities of the programme broadened significantly. In addition to family planning, the programme was supposed to provide a variety of services to mothers and children, including antenatal, delivery, and postnatal care, immunization of children against various vaccine-preventable diseases, and counselling on maternal and child health problems and nutrition. In 1992, the Child Survival and Safe Motherhood (CSSM) Programme was launched as part of the Family Welfare Programme. This was done with the intention of having an integrated package of interventions for the betterment of the health status of mothers and children. Under this programme, treatment of diarrhoea and acute respiratory infections, essential newborn care, and strengthening of emergency obstetric care services were the additional areas emphasized. In 1993, the Government of India constituted a committee under the chairmanship of Dr. M.S. Swaminathan to draft a new National Population Policy. The committee submitted its report in May 1994. The report consisted of a number of important recommendations, one of which was to abolish the target-oriented approach. After the International Conference on Population and Development (ICPD) in 1994 in Cairo, the programme was gradually reoriented towards the holistic approach of the Reproductive and Child Health (RCH) Programme. In addition to the activities covered under the CSSM Programme, the RCH Programme includes components relating to sexually transmitted diseases (STD) and reproductive tract infections (RTI). The family welfare programme’s target-free approach (TFA) was implemented throughout the country in 1996. This was done after some initial experiments to gauge the impact of making the programme target free in a few selected districts. The essence of the TFA was to modify the system of monitoring the programme and to make it a demand-driven system in which a worker would assess the needs of the community at the beginning of each year. Such an assessment would form the basis for planning and monitoring the programme during the year. Workers are supposed to assess the needs of the community on the basis of consultations with families in the area, Mahila Swasthya Sangh, anganwadis, and panchayats (Ministry of Health and Family Welfare, 1998b). To remove any misconceptions about the TFA, it was subsequently renamed the community needs assessment (CNA) approach. The recent National Population Policy (NPP), released in February 2000, paid special attention to the health and education of women and children to achieve population stabilization for the country by 2045. This suggests a paradigm shift to reproductive and child health with utmost concern towards improving the quality of care. The policy document begins with the statement that ‘the overriding objective of economic and social development is to improve the quality of lives that people lead, to enhance their well-being, and to provide them with opportunities and choices to become productive assets in society’ (Ministry of Health and Family Welfare, 2000). For the first time, the policy prepones to 2010 the time period for attaining the goal of replacement level fertility (that is, a net reproduction rate of 1.0). The NPP has elaborated 12 strategies to achieve its socio-demographic goals. The strategies can have far-reaching implications, including reductions in the high level of unwanted as well as wanted fertility. Unwanted fertility is high due to high levels of unmet need for family planning as first revealed by the 1992–93 National Family Health Survey (International Institute for Population Sciences, 1995). Wanted fertility is expected to decline with the control of infant and child mortality. 6 To achieve its objectives, the NPP reaffirms continuation of the TFA and emphasizes informed contraceptive choice and the availability of good quality services. The policy proposes decentralized planning and programme implementation. Towards the goal of lowering fertility, a number of strategies were suggested to improve RCH services, including an emphasis on education, women’s empowerment, and the involvement of men in the programme. The policy envisages free and compulsory school education up to age 14, a reduction in the infant mortality rate to less than 30 infant deaths per 1,000 live births, and a reduction in the maternal mortality ratio to less than 100 maternal deaths per 100,000 live births. The policy also aims to achieve universal immunization of children, delivery assistance by trained personnel for all births, and 100 percent registration of births, deaths, marriages, and pregnancies. Another important emphasis of the policy is the need for promoting delayed marriages for girls, the provision of wider choice and universal access to family planning information and services, and the prevention of major infectious diseases, including RTIs and AIDS. All these goals are to be achieved by 2010 to realize replacement level fertility by that year with an estimated population of 1.11 billion and population stabilization by 2045. 1.6 Questionnaires NFHS-2 collected information on a variety of indicators that will assist policymakers and programme managers to formulate and implement strategies to reach the goals set in the National Population Policy. NFHS-2 used three types of questionnaires: the Household Questionnaire, the Woman’s Questionnaire, and the Village Questionnaire. The overall content and format of the questionnaires were determined through a series of workshops held at IIPS in Mumbai in 1997 and 1998. The workshops were attended by representatives of a wide range of organizations in the population and health fields, as well as experts working on gender issues. The questionnaires for each state were bilingual, with questions in both the language of the state and English. The Household Questionnaire listed all usual residents in each sample household plus any visitors who stayed in the household the night before the interview. For each listed person, the survey collected basic information on age, sex, marital status, relationship to the head of the household, education, and occupation. The Household Questionnaire also collected information on the prevalence of asthma, tuberculosis, malaria, and jaundice, as well as three risk behaviours—chewing paan masala or tobacco, drinking alcohol, and smoking. Information was also collected on the usual place where household members go for treatment when they get sick, the main source of drinking water, type of toilet facility, source of lighting, type of cooking fuel, religion of the household head, caste/tribe of the household head, ownership of a house, ownership of agricultural land, ownership of livestock, and ownership of other selected items. In addition, a test was conducted to assess whether the household uses cooking salt that has been fortified with iodine. Finally, the Household Questionnaire asked about deaths occurring to household members in the two years before the survey, with particular attention to maternal mortality. The information on the age, sex, and marital status of household members was used to identify eligible respondents for the Woman’s Questionnaire. 7 The Woman’s Questionnaire collected information from all ever-married women age 15–49 who were usual residents of the sample household or visitors who stayed in the sample household the night before the interview. The questionnaire covered the following topics: Background characteristics: Questions on age, marital status, education, employment status, and place of residence provide information on characteristics likely to influence demographic and health behaviour. Questions are also asked about a woman’s husband, gender roles, and the treatment of women in the household. Reproductive behaviour and intentions: Questions cover dates and survival status of all births, current pregnancy status, and future childbearing intentions of each woman. Quality of care: Questions assess the quality of family planning and health services. Knowledge and use of contraception: Questions cover knowledge and use of specific family planning methods. For women not using family planning, questions are included about reasons for nonuse and intentions about future use. Sources of family planning: Questions determine where a user obtained her family planning method. Antenatal, delivery, and postpartum care: The questionnaire collects information on whether women received antenatal and postpartum care, who attended the delivery, and the nature of complications during pregnancy for recent births. Breastfeeding and health: Questions cover feeding practices, the length of breastfeeding, immunization coverage, and recent occurrences of diarrhoea, fever, and cough for young children. Reproductive health: Questions assess various aspects of women’s reproductive health and the type of care sought for health problems. Status of Women: The questionnaire asks about women’s autonomy and violence against women. Knowledge of AIDS: Questions assess women’s knowledge of AIDS and the sources of their knowledge, as well as knowledge about ways to avoid getting AIDS. In addition, the health investigator on each survey team measured the height and weight of each woman and each of her children born since January 1995 (in states where fieldwork started in 1998) or January 1996 (in states where fieldwork started in 1999) [see Table 1.1 for the month and year of fieldwork in each state]. This height and weight information is useful for assessing levels of nutrition prevailing in the population. The health investigators also took blood samples from each woman and each of her children born since January 1995/1996 to assess haemoglobin levels. This information is useful for assessing prevalence rates of anaemia among women and children. Haemoglobin levels were measured in the field at the end of each interview using portable equipment (the HemoCue) that provides test results in less than one minute. Severely anaemic women and children were referred to local medical authorities for treatment. In 8 Delhi and Mumbai, the blood samples of young children were also used to test levels of lead using the portable LeadCare instrument. For each village selected in the NFHS-2 sample, the Village Questionnaire collected information on the availability of various facilities in the village (especially health and education facilities) and amenities such as electricity and telephone connections. Respondents to the Village Questionnaire were also asked about development and welfare programmes operating in the village. The village survey included a short, open-ended questionnaire that was administered to the village head, with questions on major problems in the village and actions that could be taken to alleviate the problems. 1.7 Sample Design and Implementation Sample Size and Reporting Domains The sample size for each state was specified in terms of a target number of completed interviews with eligible women. The target sample size was set considering the size of the state, the resources available for the survey, and the aggregate level (urban/rural, region, metropolitan cities) at which separate estimates were needed. The initial target sample size was 4,000 completed interviews with eligible women in states with a 1991 population of more than 25 million, 3,000 completed interviews with eligible women in states with a 1991 population between 2 and 25 million, and 1,500 completed interviews with eligible women in states with a population of less than 2 million. However, there are some exceptions. For Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan, the samples were designed to provide estimates for major regions of the states. The target sample size was set at 10,000 completed interviews with eligible women in Uttar Pradesh and 7,000 completed interviews with eligible women in Madhya Pradesh, Bihar, and Rajasthan. For Maharashtra, West Bengal, and Tamil Nadu, the initial target samples were increased to allow separate estimates to be made for the metropolitan cities of Mumbai, Calcutta, and Chennai. The target sample size was 5,500 in Maharashtra, 4,750 in West Bengal, and 4,750 in Tamil Nadu. For Mumbai, the target sample was large enough to allow separate estimates for its slum and non-slum populations. The urban and rural samples within each state were drawn separately and, to the extent possible, the sample within each state was allocated proportionally to the size of the state’s urban and rural populations. In states where the proportion of urban population was not sufficiently large to provide a sample of at least 1,000 completed interviews with eligible women, the urban areas were appropriately oversampled (except in Goa, Sikkim, and the six small northeastern states where the target sample size was only 1,500 eligible women each). The state samples are not large enough to provide reliable estimates for individual districts in any state. Sample Design A uniform sample design was adopted in all the states (see Table B.1 in Appendix B for a summary of the sample characteristics). In each state, the rural sample was selected in two stages: the selection of Primary Sampling Units (PSUs), which are villages, with probability proportional to population size (PPS) at the first stage, followed by the random selection of 9 households within each PSU in the second stage. In urban areas, a three-stage procedure was followed. In the first stage, wards were selected with PPS sampling. In the next stage, one census enumeration block (CEB) was randomly selected from each sample ward (except in Jammu and Kashmir, where two CEBs were randomly selected from each sample ward). In the final stage, households were randomly selected within each sample CEB. Sample Selection in Rural Areas In rural areas, the 1991 Census list of villages served as the sampling frame. The list was stratified by a number of variables. Except in Delhi, the first level of stratification was geographic, with districts being subdivided into contiguous regions. Within each of these regions, villages were further stratified using selected variables from the following list: subregions, village size, percentage of males working in the nonagricultural sector, percentage of the population belonging to scheduled castes or scheduled tribes, and female literacy. However, not all variables were used in every state. Each state was examined individually and a subset of variables was selected for stratification with the aim of creating not more than 6 strata for small states, not more than 12 strata for medium size states, and not more than 15 strata for large states. Female literacy was used for implicit stratification (i.e., the villages were ordered prior to selection according to the proportion of females who were literate) in every state except Kerala and Orissa, where female literacy was an explicit stratification variable. From the list of villages arranged in this way, villages were selected systematically with probability proportional to the 1991 Census population of the village. Small villages with 5–49 households were linked with an adjoining village to form PSUs with a minimum of 50 households. Villages with fewer than five households were excluded from the sampling frame. In every state, a mapping and household listing operation was carried out in each sample area. The listing provided the necessary frame for selecting households at the second stage. The household listing operation involved preparing up-to-date notional and layout sketch maps of each selected PSU, assigning numbers to structures, recording addresses of these structures, identifying residential structures, and listing the names of heads of all the households in residential structures in the selected PSUs. Large sample villages (with more than a specified number of households, usually 500) were segmented, and two segments were selected randomly using the PPS method. Household listing in the segmented PSUs was carried out only in the selected segments. Each household listing team comprised one lister and one mapper. Senior field staff of the concerned field organization supervised the listing operation. The households to be interviewed were selected with equal probability from the household list in each area using systematic sampling. The interval applied for the selection was determined to obtain a self-weighting sample of households. On average, 30 households were initially targeted for selection in each selected enumeration area. To avoid extreme variations in the workload, minimum and maximum limits were put on the number of households that could be selected from any area, at 15 and 60, respectively. Each survey team supervisor was provided with the original household listing, layout sketch map, and the list of selected households for each PSU. All the households which were selected were contacted during the main survey, and no replacement was made if a selected household was absent during data collection. However, if a PSU was inaccessible, a replacement PSU with similar characteristics was selected by IIPS and provided to the field organization. 10 Sample Selection in Urban Areas The procedure adopted for the first stage of the sample design in urban areas was similar to the one followed in rural areas. The 1991 Census list of wards was arranged according to districts and within districts by the level of female literacy, and a sample of wards was selected systematically with probability proportional to size. Next, one census enumeration block, consisting of approximately 150–200 households, was selected from each selected ward using the PPS method. In Jammu and Kashmir, two census enumeration blocks were selected in each selected ward. As in rural areas, a household listing operation was carried out in each selected census enumeration block, which provided the necessary frame for selecting households in the third stage of sample selection. On average, 30 households per block were targeted for selection (except in Jammu and Kashmir and in Mumbai, where the target was 20 households per block). Sample Weights2 At the national level, the overall sample weight for each household or woman is the product of the design weight for each state (after adjustment for nonresponse) and the state weight. The national weights are defined below: Let Wsij = weight for the j th household (or woman) in the ith PSU in state s Wasij = weight for the j th household (or woman) in the ith PSU in state s for the national estimate where Ps = projected population of state s After adjustment for nonresponse, the weights are normalized so that the total number of weighted cases is equal to the total number of unweighted cases. The final normalized weight for a household (or eligible woman) for the national estimate is: Wbsij = normalized weight for the j th household (or woman) in the ith PSU in state s for the national estimate 2The population covered in NFHS-2 differs slightly from that in NFHS-1. NFHS-1 did not include Sikkim and the Kashmir region of Jammu and Kashmir. NFHS-2 covered all the 26 states, but the survey work in Tripura was delayed considerably due to some local problems. Therefore, estimates for Tripura are not included in the national estimates. However, the population of the regions not common in the two surveys is small and should have only a negligible impact on the comparability of the national estimates from the two surveys. sij ij sij s W W P *∑= W W P P n sij ij sij si **∑ ∑ = 11 where P = projected population of the 25 states3 ni = sample size in the i th state For the tabulations on anaemia and height/weight of women and children, two separate sets of weights were calculated using a similar procedure. In this case, however, the response rates for anaemia (for both women and children) are based on the percentage of eligible women whose haemoglobin level was measured and the response rates for height/weight (for both women and children) are based on the percentage of eligible women who were weighed or measured. Sample Implementation In order to achieve better coordination and supervision, the NFHS-2 survey operation was carried out in two phases. The first phase included the states of Andhra Pradesh, Bihar, Gujarat, Haryana, Madhya Pradesh, Punjab, Rajasthan, Sikkim, Uttar Pradesh, and West Bengal. The second phase states were Arunachal Pradesh, Assam, Delhi, Goa, Himachal Pradesh, Jammu and Kashmir, Karnataka, Kerala, Maharashtra, Manipur, Meghalaya, Mizoram, Nagaland, Orissa, and Tamil Nadu. Tripura fieldwork was delayed due to local problems. Table 1.1 shows the period of fieldwork, number of households and eligible women interviewed (excluding Tripura), and the household and women’s response rates. A total of 91,196 households were interviewed, two-thirds of which were rural. The overall household response rate—the number of households interviewed per 100 occupied households—was 98 percent. The household response rate was more than 94 percent in every state except Meghalaya and Delhi where it was 89 percent and 91 percent, respectively. The household response rate was almost 100 percent in Tamil Nadu. In the interviewed households, interviews were completed with 89,199 eligible women who stayed in the household the night before the household interview. The individual response rate—the number of completed interviews per 100 identified eligible women in the households with completed interviews—was 96 percent for the country as a whole. The variation in the women’s response rate by state was similar to that observed for the household response rate. 1.8 Recruitment, Training, and Fieldwork In order to maintain uniform survey procedures across the states, four manuals dealing with different aspects of the survey were prepared. The Interviewer’s Manual consists of instructions to the interviewers regarding interviewing techniques, field procedures, and the method of asking questions and recording answers. The Manual for Field Editors and Supervisors contains a detailed description of the role of field editors and supervisors in the survey. A list of checks to be made by the field editor in the filled-in questionnaires is also provided in this manual. The Household Listing Manual, designed for household listing teams, contains procedures to be adopted for household listing. Guidelines for the training of the field staff are described in the manual entitled Training Guidelines. 3All states except Tripura 12 Representatives of each field organization were trained in Training of Trainers Workshops organized by IIPS at the beginning of each phase of data collection. The purpose of these workshops was to ensure uniformity in data collection procedures in different states. The workshops covered the objectives of NFHS-2, different aspects of the survey, roles of various organizations participating in the survey, details of each of the three questionnaires used in the survey, methods of data collection and field supervision, and guidelines for the training of the field staff. Persons who were trained in each workshop subsequently trained the field staff in each state according to the standard procedures discussed in the Training of Trainers Workshops. Table 1.1 Number of households and women interviewed by state Month and year of fieldwork and number of households and women interviewed by residence and state (based on the unweighted sample), India, 1998–99 Month and year of fieldwork Number of households interviewed Number of women interviewed State From To Urban Rural Total Urban Rural Total Household response rate Women’s response rate India North Delhi Haryana Himachal Pradesh Jammu & Kashmir Punjab Rajasthan Central Madhya Pradesh Uttar Pradesh East Bihar Orissa West Bengal Northeast Arunachal Pradesh Assam Manipur Meghalaya Mizoram Nagaland Sikkim West Goa Gujarat Maharashtra South Andhra Pradesh Karnataka Kerala Tamil Nadu 11/98 12/99 30,435 60,761 91,196 27,862 61,337 89,199 97.5 95.5 3/99 4/99 2,564 199 2,763 2,287 190 2,477 91.3 90.8 11/98 5/99 891 1,950 2,841 826 2,082 2,908 98.5 97.6 4/99 8/99 1,086 2,357 3,443 835 2,177 3,012 99.3 96.5 4/99 9/99 887 1,899 2,786 797 1,947 2,744 97.0 93.4 11/98 5/99 1,066 1,901 2,967 993 1,803 2,796 98.5 97.3 11/98 2/99 1,546 4,765 6,311 1,592 5,221 6,813 95.9 92.8 11/98 4/99 1,799 4,950 6,749 1,829 5,112 6,941 97.5 97.5 12/98 3/99 1,835 6,847 8,682 1,813 7,479 9,292 96.7 93.0 12/98 4/99 701 5,644 6,345 687 6,337 7,024 98.8 96.2 3/99 6/99 932 3,757 4,689 868 3,557 4,425 99.2 98.4 12/98 4/99 2,335 2,390 4,725 1,947 2,461 4,408 96.6 96.6 5/99 8/99 174 1,245 1,419 145 972 1,117 94.4 91.6 3/99 6/99 838 2,283 3,121 808 2,633 3,441 98.1 96.1 7/99 10/99 536 1,153 1,689 479 956 1,435 99.6 96.8 5/99 12/99 256 984 1,240 193 752 945 89.0 90.5 6/99 8/99 781 592 1,373 597 451 1,048 97.6 94.3 5/99 12/99 237 896 1,133 167 651 818 98.4 98.0 12/98 3/99 164 1,135 1,299 129 978 1,107 96.2 94.3 3/99 6/99 623 976 1,599 491 755 1,246 98.6 95.0 11/98 3/99 1,709 2,223 3,932 1,657 2,188 3,845 98.4 96.6 3/99 6/99 3,662 2,168 5,830 3,191 2,200 5,391 97.6 94.1 11/98 3/99 1,018 2,854 3,872 1,068 2,964 4,032 99.4 98.2 3/99 9/99 1,552 2,721 4,273 1,504 2,870 4,374 97.1 94.7 3/99 7/99 855 1,979 2,834 846 2,038 2,884 98.0 92.9 3/99 6/99 2,388 2,893 5,281 2,113 2,563 4,676 99.8 99.7 Note: This table is based on the unweighted sample; all other tables are based on the weighted sample unless otherwise specified. This table shows the number of households and de facto women with completed interviews. The household response rate is defined as the number of households interviewed per 100 occupied households. The women’s response rate is defined as the number of eligible women interviewed per 100 eligible women identified in the selected households. Information on Tripura is not included in this report because the fieldwork was not completed at the time this report was prepared. 13 The fieldwork in each state was carried out by a number of interviewing teams, each team consisting of one field supervisor, one female field editor, four female interviewers, and one health investigator. The number of interviewing teams in each state varied according to the sample size. In each state, interviewers were hired specifically for NFHS-2, taking into consideration their educational background, experience, and other relevant qualifications. All interviewers were female, a stipulation that was necessary to ensure that women who were survey respondents would feel comfortable talking about topics that they may find somewhat sensitive. Training of the field staff lasted for a minimum of three weeks in each state. The training course consisted of instruction in interviewing techniques and survey field procedures, a detailed review of each item in the questionnaires, instruction and practice in weighing and measuring children, mock interviews between participants in the classroom, and practice interviews in the field. In addition, at least two special lectures were arranged in each state: one on the topic of family planning at the beginning of training on the section on contraception in the Woman’s Questionnaire, and one on maternal and child health practices, including immunizations, at the beginning of training on the section on the health of children. In addition to the main training, two days’ training was arranged for field editors and supervisors, which focused on the organization of fieldwork as well as methods of detecting errors in field procedures and in the filled-in questionnaires. Health investigators attached to interviewing teams were given additional specialized training on measuring height and weight and testing for anaemia in a centralized training programme conducted by IIPS in collaboration with the All India Institute of Medical Sciences (AIIMS), New Delhi. This specialized training included classroom training and extensive field practice in schools, anganwadis, and communities. Assignment of Primary Sampling Units (PSUs) to the teams and various logistical decisions were made by the survey coordinators from each field organization. Each interviewer was instructed not to conduct more than three individual interviews a day and was required to make a minimum of three callbacks if no suitable informant was available for the household interview or if the eligible woman identified in the selected household was not present at the time of the household interview. The main duty of the field editor was to examine the completed questionnaires in the field for completeness, consistency, and legibility of the information collected, and to ensure that all necessary corrections were made. Special attention was paid to missing information, skip instructions, filter questions, age information, and completeness of the birth history and the health section. If major problems were detected, such as discrepancies between the birth history and the health section, the interviewers were required to revisit the respondent to correct the errors. An additional duty of the field editor was to observe ongoing interviews and verify the accuracy of the method of asking questions, recording answers, and following skip instructions. The field supervisor was responsible for the overall operation of the field team and collection of information on villages using the Village Questionnaire. In addition, the field supervisor conducted spot-checks to verify the accuracy of information collected on the eligibility of respondents. IIPS also appointed one or more research officers in each state to help with monitoring throughout the training and fieldwork period in order to ensure that correct survey procedures were followed and data quality was maintained. Survey directors and other senior staff from the field organizations, project coordinators, other faculty members from IIPS, 14 senior research officers, and staff members from ORC Macro and the East-West Center also visited the field sites to monitor the data collection operation. Medical health coordinators appointed by IIPS monitored the nutritional component of the survey. Field data were quickly entered into microcomputers, and field-check tables were produced to identify certain types of errors that might have occurred in eliciting information and filling out questionnaires. Information from the field-check tables was fed back to the interviewing teams and their supervisors so that their performance could be improved. 1.9 Data Processing All completed questionnaires were sent to the office of the concerned field organization (FO) for editing and data processing (including office editing, coding, data entry, and machine editing). Although field editors examined every completed questionnaire in the field, the questionnaires were re-edited at the FO headquarters by specially trained office editors. The office editors checked all skip sequences, response codes that were circled, and information recorded in filter questions. Special attention was paid to the consistency of responses to age questions and the accurate completion of the birth history. In the second stage of office editing, appropriate codes were assigned for open-ended responses on occupation and cause of death, and commonly mentioned “other” responses were added to the coding scheme. For each state, the data were processed with microcomputers using the data entry and editing software known as the Integrated System for Survey Analysis (ISSA). The data were entered directly from the precoded questionnaires, usually starting within one week of the receipt of the first set of completed questionnaires. Data entry and editing operations were usually completed a few days after the end of fieldwork in each state. Computer-based checks were used to clean the data and remove inconsistencies. Age imputation was also completed at this stage. Age variables such as the woman’s current age and the year and month of birth of all of her children were imputed for those cases in which information was missing or incorrect entries were detected. Preliminary reports with selected results were prepared for each state within a few months of data collection and presented to policymakers and programme administrators responsible for improving health and family welfare programmes. Detailed NFHS-2 state reports are being prepared by IIPS, in collaboration with the Population Research Centres, other local organizations, ORC Macro, and the East-West Center. The state reports contain detailed information on such topics as the state’s survey design and implementation, household and respondent background characteristics, fertility and fertility preferences, family planning, mortality, morbidity, child immunization, lifestyle indicators, domestic violence, knowledge of HIV/AIDS, nutritional status of women and children, infant feeding practices, anaemia among women and children, maternal care and reproductive health, and the quality of care of health and family welfare services. CHAPTER 2 BACKGROUND CHARACTERISTICS OF HOUSEHOLDS This chapter presents a profile of the demographic and socioeconomic characteristics of NFHS-2 households and describes facilities and services that are available in villages in India. The chapter also includes some comparisons of NFHS-2 results with results from NFHS-1, the Census of India, and the Sample Registration System (SRS). 2.1 Age-Sex Distribution of the Household Population The NFHS-2 household population can be tabulated in two ways: de facto (the place each person stayed the night before the survey interview) or de jure (the place of usual residence). The de facto and de jure populations in India may differ because of temporary population movements within or between states. Table 2.1 shows the de facto population in the NFHS-2 household sample for India, classified by age, residence, and sex. The total de facto sample population is 486,011. The sample is 27 percent urban and 73 percent rural. The age distribution of the population in India is typical of populations in which fertility has fallen recently, with relatively low proportions of the population in the younger and older age groups (Figure 2.1). Thirty-six percent are below 15 years of age and 5 percent are age 65 or older. The proportion below age 15 is slightly higher in rural areas (38 percent) than in urban areas (32 percent). The single-year age distributions by sex in the de facto population (see Appendix Table D.1) indicate that there is some misreporting of ages, including considerable preference for ages ending in particular digits, especially 0, 2, and 5. One of the most commonly used measures of digit preference in age reporting is Myers’ Index (United Nations, 1955). This index provides an overall summary of preferences for, or avoidance of, each of the 10 digits, from 0 to 9. Values of Myers’ Index computed for the age range 10–69 in the household sample population in India are 23 for males and 18 for females. The index is often used as one indicator of survey quality. The lower estimate for females is probably due to the emphasis during the interviewer training on obtaining accurate age information for women to correctly determine the eligibility of women for the individual interview. The values of Myers’ Index from NFHS-2 are almost the same as from NFHS-1 (revised from the published NFHS-1 estimates). This indicates that age reporting on the household questionnaire is of the same quality in NFHS-2 and NFHS-1. Table 2.2 compares the age distributions by sex from the NFHS-2 de jure sample with the age distributions by sex from the Sample Registration System for 1997. The SRS baseline survey, which is de jure, counts all usual residents in a sample area (Office of the Registrar General, 1999a). The NFHS-2 and SRS age distributions are similar for broad age groups, despite the misreporting of age that is evident in the NFHS-2 single-year age data. 16 Table 2.1 Household population by age and sex Percent distribution of the household population by age, according to residence and sex, India, 1998–99 Urban Rural Total Age Male Female Total Male Female Total Male Female Total < 1 1–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80+ Total percent Number of persons Sex ratio1 2.0 1.9 1.9 2.6 2.4 2.5 2.4 2.3 2.3 7.7 7.8 7.8 9.7 9.5 9.6 9.2 9.0 9.1 10.7 10.6 10.6 13.8 13.0 13.4 13.0 12.4 12.7 11.5 11.1 11.3 12.5 11.9 12.2 12.2 11.7 12.0 11.1 10.8 11.0 10.0 10.3 10.1 10.3 10.4 10.4 9.8 10.3 10.0 7.8 9.2 8.5 8.4 9.5 8.9 8.7 9.1 8.9 7.4 8.6 8.0 7.7 8.7 8.2 7.2 7.5 7.3 6.4 6.9 6.6 6.6 7.0 6.8 7.0 7.2 7.1 6.4 6.0 6.2 6.5 6.3 6.4 5.7 5.3 5.5 4.8 4.4 4.6 5.1 4.7 4.9 5.1 4.6 4.8 4.2 3.9 4.1 4.4 4.1 4.3 3.6 3.4 3.5 3.3 2.9 3.1 3.4 3.0 3.2 2.8 3.1 3.0 2.6 3.2 2.9 2.6 3.2 2.9 2.6 2.6 2.6 3.0 3.1 3.1 2.9 3.0 2.9 1.8 2.0 1.9 2.1 2.0 2.0 2.0 2.0 2.0 1.4 1.4 1.4 1.8 1.4 1.6 1.7 1.4 1.6 0.7 0.6 0.7 0.7 0.6 0.6 0.7 0.6 0.6 0.6 0.8 0.7 0.9 0.8 0.8 0.8 0.8 0.8 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 66,790 62,520 129,310 181,223 175,477 356,700 248,014 237,997 486,011 NA NA 936 NA NA 968 NA NA 960 Note: Table is based on the de facto population, i.e., persons who stayed in the household the night before the interview (including both usual residents and visitors). NA: Not applicable 1Females per 1,000 males Figure 2.1 Population Pyramid 8 6 4 2 0 2 4 6 8 0–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80+ Age Percent FemaleMale NFHS-2, India, 1998–99 17 Table 2.2 Population by age and sex from the SRS and NFHS-2 Percent distribution of population by age and sex from the SRS and NFHS-2, India, 1997–99 SRS (1997) NFHS-2 (1998–99) Age Male Female Male Female Sex ratio1 URBAN 0–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70+ Total Median age 9.9 9.8 10.7 10.6 11.2 11.2 10.1 10.0 10.0 10.5 9.3 9.4 8.3 8.6 7.3 6.9 6.2 5.9 4.9 4.4 3.8 3.7 2.7 2.7 2.3 2.5 1.5 1.7 1.9 2.1 100.0 100.0 U U 9.4 9.5 931 10.6 10.5 920 11.5 11.2 902 11.1 10.7 893 9.8 10.2 958 8.6 9.0 966 7.2 7.5 968 7.1 7.3 951 5.8 5.3 857 5.1 4.7 856 3.6 3.4 869 2.8 3.2 1,055 2.6 2.6 950 1.8 2.0 1,010 2.7 2.9 972 100.0 100.0 928 23.6 23.8 NA RURAL 0–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70+ Total Median age 11.8 11.5 13.5 13.2 12.4 11.9 10.1 9.3 8.9 9.0 8.1 8.4 7.0 7.6 6.3 6.0 5.1 5.3 4.2 4.0 3.6 3.7 2.6 2.8 2.6 2.9 1.7 1.9 2.2 2.6 100.0 100.0 U U 11.9 11.7 948 13.6 13.0 915 12.3 12.0 929 10.2 10.1 953 8.0 9.0 1,075 7.5 8.6 1,096 6.5 6.9 1,022 6.5 6.0 891 4.9 4.5 890 4.2 4.0 891 3.3 2.9 850 2.6 3.3 1,221 3.0 3.2 996 2.1 2.0 928 3.4 2.7 755 100.0 100.0 957 20.8 21.2 NA 18 Tables 2.1 and 2.2 also present sex ratios (females per 1,000 males) in India from NFHS-2. The sex ratio for the de facto population (960) in Table 2.1 is slightly higher than the sex ratio of the de jure population (949) in Table 2.2. The sex ratio for the de facto sample is 936 in urban areas and 968 in rural areas, suggesting that rural-urban migration has been dominated by males in India. 2.2 Marital Status NFHS-2 includes information on the marital status of all household members age six and above. Table 2.3 shows the marital status distribution of the de facto household population, classified by age, residence, and sex. Among females age six and above, 53 percent are currently married and 36 percent have never been married. The proportion never married is higher for males (48 percent) than for females (36 percent) and slightly higher in urban areas (49 percent for males and 38 percent for females) than in rural areas (47 percent for males and 35 percent for females). The proportion divorced, separated, or deserted is small and widowhood is quite limited until the older ages. Forty-three percent of women age 50 or older are widowed, but only 12 percent of men in that age group are widowed. Table 2.2 Population by age and sex from the SRS and NFHS-2 (contd.) Percent distribution of population by age and sex from the SRS and NFHS-2, India, 1997–99 SRS (1997) NFHS-2 (1998–99) Age Male Female Male Female Sex ratio1 TOTAL 0–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70+ Total Median age 11.4 11.1 12.8 12.6 12.1 11.7 10.1 9.5 9.2 9.4 8.3 8.6 7.3 7.8 6.5 6.2 5.4 5.4 4.3 4.1 3.6 3.7 2.6 2.8 2.5 2.8 1.7 1.9 2.2 2.5 100.0 100.0 U U 11.2 11.1 944 12.8 12.4 916 12.1 11.8 922 10.4 10.3 936 8.5 9.3 1,039 7.8 8.7 1,057 6.7 7.1 1,007 6.6 6.4 908 5.1 4.7 880 4.5 4.2 880 3.4 3.1 855 2.6 3.3 1,173 2.9 3.0 985 2.0 2.0 948 3.3 2.8 803 100.0 100.0 949 21.8 22.1 NA Note: Table is based on the de jure population, i.e., usual residents. NA: Not applicable U: Not available 1Females per 1,000 males Source for SRS: Office of the Registrar General, 1999a 19 Table 2.3 Marital status of the household population Percent distribution of the household population age 6 and above by marital status, according to age, residence, and sex, India, 1998–99 Marital status Age Never married Currently married Married, gauna not performed Widowed Divorced Separated Deserted Total percent URBAN Male 6–12 13–14 15–19 20–24 25–29 30–49 50+ Total 99.7 0.2 0.1 0.0 0.0 0.0 0.0 100.0 99.6 0.2 0.2 0.0 0.0 0.0 0.0 100.0 97.5 2.0 0.5 0.0 0.0 0.0 0.0 100.0 78.4 20.7 0.5 0.2 0.1 0.0 0.1 100.0 39.1 59.7 0.2 0.3 0.1 0.3 0.4 100.0 5.7 92.4 0.0 1.0 0.2 0.2 0.4 100.0 1.3 89.0 0.0 9.3 0.0 0.1 0.2 100.0 49.4 48.3 0.2 1.8 0.1 0.1 0.2 100.0 Female 6–12 13–14 15–19 20–24 25–29 30–49 50+ Total 99.6 0.2 0.2 0.0 0.0 0.0 0.0 100.0 99.0 0.6 0.5 0.0 0.0 0.0 0.0 100.0 82.2 16.4 1.2 0.1 0.1 0.1 0.1 100.0 36.3 61.8 0.4 0.3 0.5 0.2 0.5 100.0 9.8 87.4 0.0 1.1 0.5 0.3 0.7 100.0 2.3 88.9 0.1 6.8 0.5 0.5 0.9 100.0 1.0 52.8 0.0 45.2 0.2 0.4 0.4 100.0 38.2 51.3 0.3 9.2 0.3 0.3 0.5 100.0 RURAL Male 6–12 13–14 15–19 20–24 25–29 30–49 50+ Total 99.3 0.4 0.3 0.0 0.0 0.0 0.0 100.0 98.7 0.4 0.9 0.0 0.0 0.0 0.0 100.0 92.2 4.9 2.8 0.0 0.0 0.0 0.1 100.0 59.6 37.6 2.1 0.3 0.1 0.1 0.1 100.0 23.1 74.9 0.6 0.6 0.3 0.2 0.3 100.0 3.3 94.2 0.1 1.7 0.2 0.2 0.3 100.0 1.3 85.0 0.0 13.3 0.1 0.1 0.2 100.0 46.8 49.4 0.7 2.8 0.1 0.1 0.2 100.0 Female 6–12 13–14 15–19 20–24 25–29 30–49 50+ Total 98.8 0.4 0.8 0.0 0.0 0.0 0.0 100.0 95.0 1.6 3.4 0.0 0.0 0.0 0.0 100.0 60.4 34.4 4.5 0.1 0.2 0.1 0.2 100.0 15.1 81.7 0.9 0.8 0.6 0.3 0.6 100.0 3.9 92.7 0.1 1.7 0.5 0.4 0.6 100.0 1.0 90.0 0.0 6.9 0.6 0.5 1.0 100.0 0.5 55.7 0.0 42.8 0.2 0.3 0.4 100.0 35.1 53.9 1.0 9.0 0.3 0.3 0.5 100.0 20 Also of interest is the proportion of persons who marry young. At age 15–19, the proportions ever married are 3 percent for males and 18 percent for females in urban areas, 8 percent for males and 40 percent for females in rural areas, and 6 percent for males and 34 percent for females in the country as a whole. By age 25–29, almost all women (95 percent) have ever been married. Only 72 percent of males in this age group have ever been married (61 percent in urban areas and 77 percent in rural areas). Overall, the table shows that women in India marry at much younger ages than men, and that both men and women marry at younger ages in rural areas than in urban areas. Table 2.4 shows estimates of the singulate mean age at marriage (SMAM), which can be calculated from age-specific proportions single in a census or household survey. SMAM is calculated from the de jure population in NFHS-2 in order to arrive at estimates that are more comparable to those derived from the censuses, which are modified de jure counts. According to the SMAM measure, men in India tend to marry women who are five years younger than themselves. The census and NFHS-2 data indicate that the age at marriage has been rising for both men and women at approximately the same rate (about two and one-half years between 1971 and 1998–99). Marriage ages are higher in urban areas, with urban men and women marrying about two and one-half years later than their rural counterparts. The SMAM for Table 2.3 Marital status of the household population (contd.) Percent distribution of the household population age 6 and above by marital status, according to age, residence, and sex, India, 1998–99 Marital status Age Never married Currently married Married, gauna not performed Widowed Divorced Separated Deserted Total percent TOTAL Male 6–12 13–14 15–19 20–24 25–29 30–49 50+ Total 99.4 0.3 0.2 0.0 0.0 0.0 0.0 100.0 98.9 0.4 0.7 0.0 0.0 0.0 0.0 100.0 93.7 4.0 2.1 0.0 0.0 0.0 0.1 100.0 65.6 32.3 1.6 0.3 0.1 0.1 0.1 100.0 27.9 70.3 0.5 0.5 0.2 0.3 0.3 100.0 4.0 93.7 0.1 1.5 0.2 0.2 0.3 100.0 1.3 86.0 0.0 12.3 0.1 0.1 0.2 100.0 47.5 49.1 0.6 2.5 0.1 0.1 0.2 100.0 Female 6–12 13–14 15–19 20–24 25–29 30–49 50+ Total 99.0 0.3 0.6 0.0 0.0 0.0 0.0 100.0 96.1 1.3 2.6 0.0 0.0 0.0 0.0 100.0 66.4 29.5 3.6 0.1 0.2 0.1 0.2 100.0 21.2 76.0 0.8 0.6 0.6 0.3 0.6 100.0 5.5 91.3 0.1 1.5 0.5 0.4 0.7 100.0 1.4 89.7 0.1 6.9 0.6 0.5 1.0 100.0 0.6 55.0 0.0 43.4 0.2 0.3 0.4 100.0 35.9 53.2 0.8 9.0 0.3 0.3 0.5 100.0 Note: Table is based on the de facto population, i.e., persons who stayed in the household the night before the interview (including both usual residents and visitors). The marital status distribution for females by age cannot be directly compared with the published distribution for NFHS-1 because the ages in the current table are based entirely on the reports of the household respondents, whereas in NFHS-1 the ages of ever-married women age 13–49 were taken from the Woman’s Questionnaire. Table 2.4 Singulate mean age at marriage by state Singulate mean age at marriage from selected sources by sex and state, India, 1971–1998/99 NFHS-2 (1998–99) 1971 Census 1981 Census 1991 Census Urban Rural Total State Male Female Male Female Male Female Male Female Male Female Male Female India North Delhi Haryana Himachal Pradesh Jammu & Kashmir Punjab Rajasthan Central Madhya Pradesh Uttar Pradesh East Bihar Orissa West Bengal Northeast Arunachal Pradesh Assam Manipur Meghalaya Mizoram Nagaland Sikkim West Goa Gujarat Maharashtra South Andhra Pradesh Karnataka Kerala Tamil Nadu 22.6 17.2 23.5 18.4 24.0 19.3 24.0 20.0 24.3 20.5 24.2 20.6 20.9 17.7 25.2 17.9 22.8 18.8 23.5 17.7 24.2 19.2 24.5 20.3 U U U U U U 24.1 20.1 25.0 21.1 24.3 21.0 19.9 15.1 20.6 16.1 21.3 17.5 19.5 15.0 20.8 16.6 21.7 17.8 19.8 15.5 21.3 16.7 21.9 18.0 20.0 15.3 21.6 16.6 22.1 17.5 22.7 17.3 24.3 19.1 25.0 20.2 24.6 18.0 26.0 19.3 25.9 19.7 25.6 19.6 U U 25.1 20.1 25.8 18.7 U U U U 26.4 22.2 27.3 23.4 28.1 24.7 25.5 20.2 26.0 21.0 25.8 21.4 U U U U 26.7 22.4 27.8 24.0 29.0 24.8 28.9 24.9 U U U U 25.8 21.4 U U 28.5 23.0 29.4 24.2 22.4 18.5 23.3 19.6 23.4 19.9 23.8 17.6 24.4 18.8 24.8 19.7 22.8 16.3 23.1 17.3 23.5 18.3 25.2 17.9 26.0 19.3 26.2 20.1 27.0 21.3 27.5 22.1 27.7 22.2 26.1 19.6 26.1 20.3 26.4 20.9 26.5 21.5 24.2 19.0 24.9 19.7 26.0 22.1 24.1 19.9 25.8 21.9 25.2 21.4 24.3 19.2 24.6 19.8 27.2 23.7 26.6 21.9 26.7 22.1 29.1 24.5 26.5 21.9 27.1 22.5 26.4 23.2 25.5 21.6 25.7 22.1 24.1 19.9 21.6 17.8 22.3 18.3 26.0 20.9 22.4 18.2 23.5 18.9 26.2 21.5 22.4 18.3 23.3 19.0 26.3 20.9 23.5 18.5 23.8 18.8 27.7 22.8 26.4 21.0 26.6 21.2 29.0 22.4 25.2 18.7 26.2 19.6 23.9 21.9 25.3 21.6 25.1 21.6 29.3 23.6 27.7 21.5 27.8 21.7 28.7 25.9 28.6 25.0 28.6 25.4 27.8 25.0 26.7 22.2 27.0 23.0 27.5 24.7 26.3 23.2 27.0 24.1 28.4 23.4 27.3 22.9 27.6 23.0 24.7 23.0 26.5 21.7 26.2 21.9 30.3 25.2 30.1 24.4 30.2 24.8 25.0 21.1 23.8 19.6 24.4 20.2 26.0 21.3 24.6 18.6 25.3 19.8 25.8 20.3 23.1 17.6 23.9 18.3 27.8 21.5 26.1 19.4 26.7 20.1 28.9 22.7 27.6 21.2 27.9 21.5 27.1 21.7 26.4 20.4 26.6 20.9 Note: Table is based on the de jure population. U: Not available 22 females in India as estimated in NFHS-2 is 21.5 years in urban areas, 19.0 years in rural areas, and 19.7 years for the country as a whole. SMAM varies substantially across states. The female SMAM is lowest in Rajasthan and Andhra Pradesh (18.3 years) and highest in Manipur (25.4 years), followed by Goa (24.8 years). The mean age at marriage for females is also below the national average in the Central Region, and in Bihar and West Bengal. In addition to Goa, the SMAM is higher than 21 years in all of the northeastern states, most states in the North Region, Kerala and Orissa. Similar differences across the states are also found for the SMAM for males. 2.3 Household Composition Table 2.5 shows the percent distribution of households by various characteristics of the household head (sex, age, religion, and caste/tribe), as well as by household type and the number of usual household members. The table is based on the de jure population because household type and the number of usual household members pertain to the usual-resident population. The table shows that 89–90 percent of household heads are male, regardless of area of residence (rural or urban). More than two-thirds of household heads are 30–59 years of age and the median age of household heads is 45 years in both urban and rural areas. Eighty-two percent of household heads are Hindu, 12 percent are Muslim, 3 percent are Christian, 2 percent are Sikh, 1 percent are Buddhist or Neo-Buddhist, and less than 0.5 percent are Jain. The percent distribution of household heads by religion is almost identical in NFHS-2 and NFHS-1, and is very close to the religious distribution of the population enumerated in the 1991 Census. Muslims constitute 15 percent of urban households, but only 10 percent of rural households. Christians, Jains, and Buddhists are also more concentrated in urban areas than in rural areas. Nineteen percent of household heads belong to scheduled castes and 9 percent belong to scheduled tribes. Both of these groups, but especially scheduled tribes, constitute higher proportions of households in rural areas than in urban areas. Almost one-third of household heads belong to other backward classes (OBC)1. The largest proportion of household heads (39 percent) belong to the ‘other’ caste category. Fifty-seven percent of all households are nuclear family households (consisting of an unmarried adult living alone or a married person or couple and their unmarried children, if any). Mean household size (5.4 persons per household in India as a whole) is slightly higher in rural areas (5.5) than in urban areas (5.2). States differ substantially in terms of the distribution of household heads by religion and caste/tribe (Table 2.6). In 18 of the 25 states, a large majority of household heads are Hindu. More than half of household heads in Jammu and Kashmir, more than one-quarter in Assam and Kerala, and more than one-fifth in West Bengal are Muslim. Other states with at least 15 percent of Muslim household heads are Uttar Pradesh and Bihar and with at least 10 percent of Muslim household heads are Karnataka and Maharashtra. The largest percentages of households headed by Christians are in Mizoram (96 percent), Nagaland (82 percent), Meghalaya (73 percent), Manipur (37 percent), and Goa (33 percent). Sikhs are concentrated primarily in Punjab, where they constitute 54 percent of households. One-third of household heads in Sikkim are Buddist or Neo-Buddhist. Eleven percent of household heads in Arunchal Pradesh and 7 percent in Maharashtra are also Buddhist or Neo-Buddhist. The proportion of household heads who come from ‘other religions’ is 36 percent in Arunachal Pradesh (almost all of whom are from the Doni- polo religion) and 11 percent in Manipur (almost all of whom are from the Sanamahi religion). 1Other backward classes are castes and communities that have been designated by the Government of India as socially and educationally backward and in need of protection from social injustice. 23 Table 2.5 Household characteristics Percent distribution of households by selected characteristics of the household head, household type, and household size, according to residence, India, 1998–99 Characteristic Urban Rural Total Sex of household head Male Female Age of household head < 30 30–44 45–59 60+ Median age Religion of household head Hindu Muslim Christian Sikh Jain Buddhist/Neo-Buddhist Other No religion Missing Caste/tribe of household head Scheduled caste Scheduled tribe Other backward class Other Don’t know/missing Household type Nuclear household Non-nuclear household Number of usual members 1 2 3 4 5 6 7 8 9+ Mean household size Total percent Number of households 88.9 90.0 89.7 11.1 10.0 10.3 9.7 11.4 10.9 39.1 38.2 38.4 32.1 28.1 29.2 19.2 22.4 21.5 45.2 45.1 45.1 77.2 83.7 81.9 15.0 10.4 11.7 3.6 2.7 3.0 1.6 1.8 1.7 0.9 0.2 0.4 1.4 0.6 0.8 0.1 0.3 0.3 0.0 0.1 0.1 0.1 0.1 0.1 14.7 20.2 18.7 3.7 11.2 9.1 29.6 33.5 32.4 51.5 33.9 38.8 0.5 1.1 1.0 59.3 55.6 56.6 40.7 44.3 43.3 3.2 3.1 3.1 7.6 7.9 7.8 13.1 10.9 11.5 21.4 17.5 18.6 19.3 18.4 18.7 13.7 14.9 14.5 7.9 10.0 9.4 4.9 6.3 5.9 8.8 11.0 10.4 5.2 5.5 5.4 100.0 100.0 100.0 25,243 65,953 91,196 Note: Table is based on the de jure population. Table 2.6 Religion and caste/tribe of household head by state Percent distribution of households by religion and caste/tribe of the household head, according to state, India, 1998–99 Religion of household head Caste/tribe of household head State Hindu Muslim Christian Sikh Jain Buddhist/ Neo- Buddhist Other1 No religion Missing Total percent Sched- uled caste Sched- uled tribe Other back- ward class Other Missing Total percent India North Delhi Haryana Himachal Pradesh Jammu & Kashmir Punjab Rajasthan Central Madhya Pradesh Uttar Pradesh East Bihar Orissa West Bengal Northeast Arunachal Pradesh Assam Manipur Meghalaya Mizoram Nagaland Sikkim West Goa Gujarat Maharashtra South Andhra Pradesh Karnataka Kerala Tamil Nadu 81.9 11.7 3.0 1.7 0.4 0.8 0.3 0.1 0.1 100.0 84.3 8.3 1.2 4.6 0.8 0.1 0.2 0.1 0.3 100.0 88.5 4.1 0.1 7.1 0.1 0.0 0.0 0.0 0.1 100.0 93.1 3.1 0.1 1.3 0.1 2.3 0.0 0.0 0.1 100.0 45.2 52.8 0.3 1.6 0.0 0.0 0.0 0.0 0.0 100.0 41.9 2.1 2.0 53.9 0.0 0.0 0.0 0.0 0.1 100.0 88.6 9.1 0.1 1.0 1.2 0.0 0.1 0.0 0.0 100.0 92.2 5.0 1.4 0.2 1.0 0.2 0.0 0.0 0.0 100.0 82.6 16.3 0.1 0.7 0.0 0.0 0.0 0.0 0.2 100.0 83.2 14.8 1.1 0.0 0.0 0.0 0.9 0.0 0.0 100.0 96.5 1.6 1.9 0.0 0.0 0.0 0.0 0.0 0.0 100.0 75.8 21.8 0.3 0.1 0.0 0.4 1.3 0.1 0.2 100.0 37.5 1.3 13.0 0.1 0.0 11.0 35.8 1.1 0.2 100.0 66.9 29.4 2.4 0.0 0.0 0.2 0.3 0.1 0.7 100.0 49.5 3.0 36.8 0.0 0.0 0.1 10.6 0.1 0.0 100.0 9.6 3.4 73.1 0.0 0.0 0.0 2.1 11.6 0.2 100.0 2.5 0.4 95.6 0.1 0.0 1.2 0.1 0.0 0.2 100.0 10.3 6.3 81.8 0.0 0.0 0.1 0.3 0.4 0.9 100.0 59.9 1.3 5.3 0.0 0.0 32.9 0.3 0.0 0.3 100.0 63.0 3.8 32.9 0.0 0.2 0.0 0.0 0.1 0.0 100.0 89.8 8.1 0.7 0.2 1.2 0.0 0.1 0.0 0.0 100.0 79.7 9.8 1.3 0.2 1.4 7.1 0.5 0.1 0.0 100.0 87.8 6.1 6.0 0.0 0.0 0.0 0.0 0.1 0.0 100.0 85.4 10.6 3.2 0.0 0.7 0.0 0.0 0.0 0.0 100.0 55.0 25.6 19.3 0.1 0.1 0.0 0.0 0.0 0.0 100.0 89.1 5.3 5.3 0.0 0.1 0.0 0.1 0.0 0.1 100.0 18.7 9.1 32.4 38.8 1.0 100.0 17.7 0.9 14.9 66.4 0.1 100.0 21.3 0.1 21.4 57.2 0.0 100.0 22.4 0.6 17.3 59.7 0.0 100.0 14.8 2.5 11.3 71.5 0.0 100.0 29.8 0.1 16.8 53.4 0.0 100.0 18.6 12.0 23.2 46.1 0.1 100.0 16.1 23.7 39.8 20.2 0.0 100.0 20.2 2.2 26.2 46.2 5.1 100.0 20.8 9.9 49.9 19.3 0.0 100.0 21.6 21.7 29.6 27.0 0.0 100.0 22.8 7.2 4.5 65.1 0.5 100.0 13.7 68.0 12.4 5.9 0.0 100.0 9.9 21.3 12.5 54.0 2.4 100.0 5.0 38.0 4.5 52.2 0.3 100.0 2.1 89.5 1.2 7.1 0.2 100.0 0.4 98.4 0.2 1.1 0.0 100.0 5.7 83.5 3.4 6.8 0.6 100.0 7.1 27.9 33.3 31.5 0.2 100.0 6.2 0.3 6.4 86.8 0.2 100.0 14.7 19.7 23.6 42.0 0.0 100.0 13.4 10.2 22.6 53.3 0.5 100.0 20.1 5.0 43.5 31.1 0.2 100.0 16.7 5.6 40.3 36.3 1.0 100.0 9.3 1.1 40.5 49.2 0.0 100.0 23.5 0.9 73.4 2.2 0.0 100.0 1Includes 34.2 percent belonging to the Doni-polo religion in Arunachal Pradesh and 9.9 percent belonging to the Sanamahi religion in Manipur 25 Thirty percent of households in Punjab, and more than one-fifth in Tamil Nadu, Himachal Pradesh, Haryana, Uttar Pradesh, Andhra Pradesh, and the East Region, belong to scheduled castes. Between 10 and 20 percent of households belong to scheduled castes in Rajasthan, Delhi, Karnataka, Madhya Pradesh, Jammu and Kashmir, Gujarat, Arunachal Pradesh, and Maharashtra. Scheduled tribes are more concentrated in the northeastern states, particularly Mizoram (where 98 percent of household heads belong to scheduled tribes), Meghalaya (90 percent), Nagaland (84 percent), and Arunachal Pradesh (68 percent). Scheduled tribes constitute 38 percent of the household heads in Manipur, 28 percent in Sikkim, 24 percent in Madhya Pradesh, 22 percent in Orissa, and 21 percent in Assam. The percentage of scheduled tribes is negligible (3 percent or less) in the North Region (except for Rajasthan), and in Goa, Tamil Nadu, Kerala, and Uttar Pradesh. Other backward classes (OBCs) are particularly prominent in the South Region (where 40–73 percent of household heads belongs to OBCs), and in Bihar (50 percent), Madhya Pradesh (40 percent), and Sikkim (33 percent). The highest proportions of household heads who do not belong to scheduled castes, scheduled tribes, and OBCs are in Goa (87 percent), Jammu and Kashmir (72 percent), Delhi (66 percent), West Bengal (65 percent), and Himachal Pradesh (60 percent). 2.4 Educational Attainment The level of education of household members may affect reproductive behaviour, contraceptive use, the health of children, and proper hygienic practices. Table 2.7 shows the percent distribution of the de facto household population by literacy and educational level, according to age, residence, and sex. (This table and all subsequent tables and figures in this report are based on the de facto sample, unless otherwise specified.) Table 2.7 shows that in India 49 percent of females and 26 percent of males age six and above are illiterate. Comparable figures from NFHS-1 are 57 percent of females and 31 percent of males, indicating a substantial decline in illiteracy in only six and one-half years. Cohort differences in literacy also suggest that there has been considerable progress over time (Table 2.7 and Figure 2.2). For example, while only 21 percent of women age 50 and over are literate, the literacy rate doubles for those age 30–39, and steadily increases to 76 percent for women age 10–14. The literacy gap between males and females has narrowed over time, but even at age 10–14 there is still a gap of 11 percentage points (although the gap has decreased from 18 percentage points in NFHS-1). Changes over time in educational attainment can be seen by examining the differences in educational levels by age. For example, the proportion of males completing at least high school rises from 18 percent at age 50 and above to 40 percent at ages 20–29. For females, the proportion completing at least high school is almost negligible (only 4 percent) at age 50 and above but reaches a level of 23 percent at age 20–29. A higher percentage of males than of females have completed each level of schooling. The median number of years of schooling is 5.5 for males and 1.6 for females. The proportion illiterate is lowest at age 10–14 for both males and females and is highest at age 50 and above. 26 Table 2.7 Educational level of the household population Percent distribution of the household population age 6 and above by literacy and level of education, and median number of completed years of schooling, according to age, residence, and sex, India,1998–99 Educational level1 Age Illiterate Literate, < primary school complete Primary school complete Middle school complete High school complete Higher secondary complete and above Missing Total percent Number of persons Median number of years of schooling URBAN Male 6–9 10–14 15–19 20–29 30–39 40–49 50+ Total 16.2 83.1 0.7 0.0 0.0 0.0 0.0 100.0 5,648 1.8 7.0 30.0 48.9 13.6 0.5 0.0 0.0 100.0 7,714 5.7 8.8 5.4 18.1 31.0 24.7 12.0 0.0 100.0 7,418 9.3 9.1 4.4 13.1 17.3 19.4 36.6 0.0 100.0 12,338 10.4 12.8 5.8 14.4 13.9 18.6 34.5 0.0 100.0 9,504 10.2 14.4 6.8 15.1 12.7 20.3 30.7 0.0 100.0 7,193 10.1 20.6 12.6 16.7 9.5 18.6 22.0 0.0 100.0 8,987 8.1 12.5 17.2 18.2 14.6 15.6 21.9 0.0 100.0 58,804 8.3 Female 6–9 10–14 15–19 20–29 30–39 40–49 50+ Total 19.7 79.5 0.8 0.0 0.0 0.0 0.0 100.0 5,293 1.9 9.6 28.4 46.2 15.2 0.6 0.0 0.0 100.0 6,926 5.7 13.4 5.3 17.3 26.0 24.1 13.9 0.0 100.0 6,770 9.3 21.6 4.7 14.1 13.3 15.4 30.9 0.0 100.0 12,107 9.4 32.5 5.6 16.0 11.5 14.3 20.1 0.0 100.0 9,153 7.3 36.7 7.7 17.0 9.5 14.6 14.4 0.0 100.0 6,178 5.7 55.9 10.8 14.4 6.3 6.9 5.6 0.1 100.0 8,721 0.0 27.8 16.4 17.9 12.0 11.5 14.3 0.0 100.0 55,156 5.8 Total 6–9 10–14 15–19 20–29 30–39 40–49 50+ Total 17.9 81.3 0.7 0.0 0.0 0.0 0.0 100.0 10,942 1.9 8.2 29.3 47.6 14.4 0.5 0.0 0.0 100.0 14,640 5.7 11.0 5.4 17.7 28.6 24.4 12.9 0.0 100.0 14,187 9.3 15.3 4.6 13.6 15.3 17.4 33.8 0.0 100.0 24,445 10.1 22.4 5.7 15.2 12.7 16.5 27.4 0.0 100.0 18,656 9.0 24.7 7.2 16.0 11.2 17.7 23.2 0.0 100.0 13,371 8.3 38.0 11.7 15.6 7.9 12.8 14.0 0.1 100.0 17,708 5.1 19.9 16.8 18.1 13.3 13.6 18.2 0.0 100.0 113,959 7.3 27 Table 2.7 Educational level of the household population (contd.) Percent distribution of the household population age 6 and above by literacy and level of education, and median number of completed years of schooling, according to age, residence, and sex, India,1998–99 Educational level1 Age Illiterate Literate, < primary school complete Primary school complete Middle school complete High school complete Higher secondary complete and above Missing Total percent Number of persons Median number of years of schooling RURAL Male 6–9 10–14 15–19 20–29 30–39 40–49 50+ Total 30.0 69.1 0.8 0.0 0.0 0.0 0.1 100.0 19,420 1.4 15.0 39.3 37.3 8.1 0.2 0.0 0.0 100.0 22,646 4.7 17.0 9.0 22.7 30.0 16.1 5.1 0.0 100.0 18,196 8.1 23.7 8.0 16.7 18.3 15.9 17.3 0.0 100.0 27,623 8.2 35.1 10.5 16.9 13.9 11.6 11.9 0.0 100.0 23,153 5.6 37.9 12.2 17.8 11.7 11.8 8.7 0.0 100.0 16,339 5.0 52.3 15.8 15.6 6.1 6.4 3.7 0.0 100.0 25,973 0.0 30.5 22.6 18.4 12.5 8.9 7.1 0.0 100.0 153,381 4.6 Female 6–9 10–14 15–19 20–29 30–39 40–49 50+ Total 36.4 63.1 0.4 0.0 0.0 0.0 0.1 100.0 17,951 1.2 28.6 32.8 31.5 7.0 0.3 0.0 0.0 100.0 20,958 4.1 38.7 8.2 18.6 19.8 11.0 3.7 0.0 100.0 17,992 5.5 55.2 6.8 13.9 9.8 7.7 6.5 0.0 100.0 31,136 0.0 68.4 7.2 12.4 5.3 4.2 2.5 0.0 100.0 22,533 0.0 74.3 7.9 10.2 3.5 2.8 1.3 0.0 100.0 14,662 0.0 87.1 6.0 4.8 1.0 0.7 0.3 0.1 100.0 24,452 0.0 56.3 17.4 13.2 6.7 4.0 2.4 0.0 100.0 149,714 0.0 Total 6–9 10–14 15–19 20–29 30–39 40–49 50+ Total 33.1 66.2 0.6 0.0 0.0 0.0 0.1 100.0 37,371 1.3 21.5 36.2 34.5 7.6 0.2 0.0 0.0 100.0 43,604 4.5 27.8 8.6 20.7 24.9 13.6 4.4 0.0 100.0 36,188 7.1 40.4 7.4 15.3 13.8 11.5 11.6 0.0 100.0 58,759 5.4 51.5 8.9 14.7 9.7 8.0 7.3 0.0 100.0 45,687 2.1 55.1 10.2 14.2 7.8 7.5 5.2 0.0 100.0 31,001 0.0 69.2 11.1 10.4 3.6 3.7 2.1 0.0 100.0 50,425 0.0 43.3 20.0 15.9 9.6 6.5 4.7 0.0 100.0 303,095 2.6 28 Table 2.7 Educational level of the household population (contd.) Percent distribution of the household population age 6 and above by literacy and level of education, and median number of completed years of schooling, according to age, residence, and sex, India,1998–99 Educational level1 Age Illiterate Literate, < primary school complete Primary school complete Middle school complete High school complete Higher secondary complete and above Missing Total percent Number of persons Median number of years of schooling TOTAL Male 6–9 10–14 15–19 20–29 30–39 40–49 50+ Total 26.9 72.3 0.8 0.0 0.0 0.0 0.1 100.0 25,068 1.5 13.0 37.0 40.3 9.5 0.3 0.0 0.0 100.0 30,359 5.0 14.7 8.0 21.4 30.3 18.6 7.1 0.0 100.0 25,614 8.5 19.2 6.9 15.6 18.0 17.0 23.3 0.0 100.0 39,961 9.0 28.6 9.1 16.2 13.9 13.7 18.5 0.0 100.0 32,657 7.3 30.8 10.5 17.0 12.0 14.4 15.4 0.0 100.0 23,532 6.2 44.1 15.0 15.9 7.0 9.5 8.4 0.0 100.0 34,960 3.5 25.5 21.1 18.4 13.0 10.7 11.2 0.0 100.0 212,185 5.5 Female 6–9 10–14 15–19 20–29 30–39 40–49 50+ Total 32.6 66.8 0.5 0.0 0.0 0.0 0.1 100.0 23,244 1.4 23.9 31.7 35.1 9.0 0.3 0.0 0.0 100.0 27,885 4.6 31.8 7.4 18.2 21.5 14.6 6.5 0.0 100.0 24,762 7.0 45.8 6.2 14.0 10.8 9.9 13.3 0.0 100.0 43,243 4.5 58.0 6.8 13.4 7.1 7.1 7.6 0.0 100.0 31,686 0.0 63.2 7.9 12.2 5.3 6.3 5.2 0.0 100.0 20,840 0.0 78.9 7.2 7.3 2.4 2.3 1.7 0.1 100.0 33,173 0.0 48.6 17.1 14.5 8.1 6.0 5.6 0.0 100.0 204,870 1.6 Total 6–9 10–14 15–19 20–29 30–39 40–49 50+ Total 29.6 69.6 0.7 0.0 0.0 0.0 0.1 100.0 48,312 1.5 18.2 34.4 37.8 9.3 0.3 0.0 0.0 100.0 58,244 4.8 23.1 7.7 19.8 26.0 16.6 6.8 0.0 100.0 50,376 7.9 33.0 6.5 14.8 14.3 13.3 18.1 0.0 100.0 83,204 7.2 43.1 8.0 14.8 10.6 10.4 13.1 0.0 100.0 64,343 4.8 46.0 9.3 14.7 8.8 10.6 10.6 0.0 100.0 44,372 3.9 61.1 11.2 11.7 4.7 6.0 5.2 0.0 100.0 68,133 0.0 36.9 19.2 16.5 10.6 8.4 8.4 0.0 100.0 417,055 4.0 Note: This table and all the subsequent tables (unless otherwise indicated) are based on the de facto population. Illiterate persons may have been to school, but they cannot read and write. Total includes persons with missing information on age, who are not shown separately. 1In this report, ‘primary school complete’ means 5–7 completed years of education, ‘middle school complete’ means 8–9 completed years of education, ‘high school complete’ means 10–11 completed years of education, and ‘higher secondary complete and above’ means 12 or more completed years of education. 29 Education levels are much higher in urban areas than in rural areas for both males and females. The proportion illiterate is twice as high for rural females (56 percent) as for urban females (28 percent), and is more than twice as high for rural males (31 percent) as for urban males (13 percent). There are large interstate variations in the level of female and male literacy and educational attainment (Table 2.8 and Figure 2.3). At least three-quarters of females age six and above are literate in Mizoram (89 percent), Kerala (85 percent), Delhi (78 percent), and Goa (75 percent). At the other extreme, less than half of females age six and over are literate in Bihar (35 percent), Rajasthan (37 percent), Uttar Pradesh (43 percent), Madhya Pradesh (45 percent), Jammu and Kashmir (45 percent), and Andhra Pradesh (46 percent). The percentage of females who have a high school level of education or above is highest in Delhi (33 percent, up from 29 percent in NFHS-1), followed by Kerala (31 percent, up from 19 percent in NFHS-1), Goa (28 percent, up from 23 percent in NFHS-1), and Punjab (23 percent, up from 15 percent in NFHS-1). Figure 2.2 Percentage Literate by Age and Sex 0 20 40 60 80 100 6–9 10–14 15–19 20–29 30–39 40–49 50+ Age P e rc e n t Male Female NFHS-2, India, 1998–99 30 The states with the highest literacy rates for males are the same states that have the highest literacy rates for females (Mizoram, Kerala, Delhi, and Goa). Literacy rates for males are lowest in Bihar (63 percent), Andhra Pradesh (67 percent), and Jammu and Kashmir (69 percent). In every state, the percentage of the population that is literate is higher for males than for females, and a higher percentage of males than females have completed at least high school. The literacy gap between males and females is highest in Rajasthan and Uttar Pradesh, and the differences are least pronounced in Mizoram, Meghalaya, and Kerala. Table 2.8 Educational level of the household population by state Percent distribution of the de facto household population age 6 and above by literacy and level of education, and median number of completed years of schooling, according to sex and state, India, 1998–99 Educational level State Illiterate Literate, < primary school complete Primary school complete Middle school complete High school complete Higher secondary complete and above Miss- ing Total percent Median number of years of schooling MALE India North Delhi Haryana Himachal Pradesh Jammu & Kashmir Punjab Rajasthan Central Madhya Pradesh Uttar Pradesh East Bihar Orissa West Bengal Northeast Arunachal Pradesh Assam Manipur Meghalaya Mizoram Nagaland Sikkim West Goa Gujarat Maharashtra South Andhra Pradesh Karnataka Kerala Tamil Nadu 25.5 21.1 18.4 13.0 10.7 11.2 0.0 100.0 5.5 8.5 15.4 15.9 14.6 16.9 28.7 0.0 100.0 9.3 21.2 19.6 17.8 13.1 16.0 12.3 0.0 100.0 6.2 14.6 17.8 21.0 14.8 19.7 12.1 0.0 100.0 7.5 31.2 15.0 14.9 18.1 11.6 9.1 0.0 100.0 5.7 22.1 18.0 17.3 12.9 17.4 12.3 0.0 100.0 6.4 28.2 22.0 18.4 13.2 9.3 8.9 0.0 100.0 5.0 27.9 24.0 20.4 11.4 5.6 10.7 0.0 100.0 4.8 28.2 22.0 15.9 13.8 8.9 11.2 0.1 100.0 5.0 36.8 19.7 14.2 9.7 10.4 9.2 0.0 100.0 3.6 24.0 24.8 20.8 13.2 8.5 8.6 0.0 100.0 5.1 24.0 29.0 16.7 12.5 7.6 10.2 0.0 100.0 4.7 27.0 26.6 16.5 13.2 7.4 9.2 0.1 100.0 4.4 25.4 27.2 15.7 15.8 6.9 8.9 0.1 100.0 4.7 20.3 15.0 14.7 20.5 12.3 17.3 0.0 100.0 8.0 28.3 35.1 14.0 11.2 5.5 5.8 0.1 100.0 3.2 6.4 31.9 24.4 19.7 7.6 9.9 0.1 100.0 6.4 19.4 27.6 20.3 15.3 8.7 8.5 0.1 100.0 5.4 20.7 32.0 20.2 11.2 7.2 8.6 0.1 100.0 4.7 11.3 19.3 17.4 15.8 17.7 18.5 0.1 100.0 8.3 23.3 18.3 20.3 13.4 12.2 12.4 0.0 100.0 6.3 17.3 21.6 19.0 16.0 12.8 13.3 0.0 100.0 7.1 33.1 18.1 19.8 8.9 10.5 9.6 0.0 100.0 4.9 25.7 17.6 19.6 10.9 12.8 13.4 0.0 100.0 6.0 7.2 18.4 23.4 17.4 21.2 12.4 0.0 100.0 8.1 20.3 15.2 24.2 16.4 12.8 11.0 0.0 100.0 6.4 31 The median years of schooling for males and females also vary substantially over the states. All states in the West Region, all states in the South Region except Andhra Pradesh, and all states in the North Region except Rajasthan have median years of schooling above the national average for males. In the Central and East Regions, all states are below the national average. Among the northeastern states, only Manipur and Mizoram have a median number of years of schooling higher than the national average. For females, the median number of years of schooling ranges from a high of 7–8 years in Kerala, Delhi, and Goa to a low of zero years in six states where the majority of women have never been to school. Table 2.8 Educational level of the household population by state (contd.) Percent distribution of the de facto household population age 6 and above by literacy and level of education, and median number of completed years of schooling, according to sex and state, India, 1998–99 Educational level State Illiterate Literate, < primary school complete Primary school complete Middle school complete High school complete Higher secondary complete and above Miss- ing Total percent Median number of years of schooling FEMALE India North Delhi Haryana Himachal Pradesh Jammu & Kashmir Punjab Rajasthan Central Madhya Pradesh Uttar Pradesh East Bihar Orissa West Bengal Northeast Arunachal Pradesh Assam Manipur Meghalaya Mizoram Nagaland Sikkim West Goa Gujarat Maharashtra South Andhra Pradesh Karnataka Kerala Tamil Nadu 48.6 17.1 14.5 8.1 6.0 5.6 0.0 100.0 1.6 21.7 15.3 17.6 12.3 12.4 20.6 0.0 100.0 7.0 42.7 17.4 16.5 8.4 7.8 7.2 0.0 100.0 2.4 31.3 16.0 21.7 12.1 11.8 7.1 0.0 100.0 5.2 55.3 12.1 11.6 10.8 5.6 4.7 0.0 100.0 0.0 35.1 14.7 17.3 9.5 13.3 10.1 0.0 100.0 5.0 62.9 15.7 9.9 5.3 3.2 2.9 0.0 100.0 0.0 55.5 18.7 12.7 5.6 2.7 4.8 0.0 100.0 0.0 57.3 16.2 11.4 6.3 3.6 5.1 0.1 100.0 0.0 65.2 14.5 9.3 4.8 4.1 2.0 0.0 100.0 0.0 48.7 20.4 15.8 7.8 4.1 3.2 0.0 100.0 1.2 42.6 26.4 13.9 8.4 4.1 4.6 0.0 100.0 2.1 43.0 22.0 14.5 11.3 5.2 4.0 0.1 100.0 2.1 40.9 24.0 12.5 13.7 4.9 3.8 0.2 100.0 2.5 41.3 13.1 11.6 15.5 7.4 11.0 0.0 100.0 4.3 33.2 35.9 13.0 9.4 4.6 3.9 0.1 100.0 2.3 10.6 36.3 21.7 17.9 7.5 6.0 0.1 100.0 5.5 31.7 26.3 19.1 13.2 5.4 4.3 0.0 100.0 3.7 35.6 26.4 18.0 10.3 5.2 4.5 0.0 100.0 3.3 25.2 17.6 15.8 13.5 13.6 14.2 0.1 100.0 6.7 46.4 13.7 16.5 8.4 7.0 8.1 0.0 100.0 3.2 38.6 18.1 17.8 10.8 7.9 6.9 0.0 100.0 4.1 54.0 15.2 16.3 5.4 5.5 3.6 0.0 100.0 0.0 44.5 15.1 16.6 7.9 8.9 7.0 0.0 100.0 3.2 14.9 16.9 21.4 16.0 18.5 12.3 0.0 100.0 7.6 41.7 12.6 19.4 12.5 7.2 6.5 0.1 100.0 4.5 32 Table 2.9 and Figure 2.4 show school attendance rates for the school-age household population by age, sex, and residence in different states. In the country as a whole, 79 percent of children age 6–14 are attending school, up from 68 percent in NFHS-1. The attendance rate drops off sharply to 49 percent at age 15–17. For the age group 6–17, the attendance rate is 78 percent for males, 66 percent for females, and 72 percent for India as a whole. In urban areas, attendance rates for males and females differ by less than 5 percentage points for every age group. In rural areas, however, attendance rates are considerably higher for males than for females at every age, and the gap widens with increasing age. For both males and females, school attendance rates are much higher in urban areas than in rural areas in every age group. School attendance at age 6–17 years is more than 90 percent in Himachal Pradesh and Kerala, and 85–90 percent in Goa, Delhi, Manipur, Mizoram, and Punjab. Overall, school attendance is lowest in Bihar (only 60 percent), and it is also 70 percent or lower in the Central Region, Rajasthan, Gujarat, and Andhra Pradesh. Generally, the lower the overall attendance rate, the higher the difference in children’s school attendance by residence and sex. Figure 2.3 Percentage of Women Age 6+ Who Are Illiterate by State 0 10 20 30 40 50 60 70 B ihar Ra jasthan Uttar P radesh M adhya P radesh Jam m u & K ashm ir A ndhra P radesh O rissa INDIA G ujara t K arnataka A runacha l P radesh Haryana W est B enga l Tam il N adu M anipur A ssam M aharashtra S ikk im P unjab M eghalaya Nagaland H im acha l P radesh G oa De lh i K era la M izoram P ercent NFHS-2, India, 1998–99 33 Fifty percent of school-age girls in Bihar are not attending school. School attendance for school-age girls is also low in Rajasthan (56 percent), Uttar Pradesh (61 percent), Andhra Pradesh (62 percent), and Madhya Pradesh and Gujarat (63 percent each). Among females age 6–14 years, less than three-quarters attend school in 5 states compared with 11 states in NFHS-1. Similarly, for males age 6–14 years, less than 75 percent attend school only in Bihar, whereas there were eight such states in NFHS-1 (data not shown). Table 2.9 School attendance by state Percentage of the household population age 6–17 years attending school by sex, residence, age, and state, India, 1998–99 Male Female Total State Urban Rural Total Urban Rural Total Urban Rural Total India Age 6–10 years 11–14 years 15–17 years 6–14 years 6–17 years North Delhi Haryana Himachal Pradesh Jammu & Kashmir Punjab Rajasthan Central Madhya Pradesh Uttar Pradesh East Bihar Orissa West Bengal Northeast Arunachal Pradesh Assam Manipur Meghalaya Mizoram Nagaland Sikkim West Goa Gujarat Maharashtra South Andhra Pradesh Karnataka Kerala Tamil Nadu 91.7 83.2 85.2 89.1 75.1 78.3 90.4 79.3 81.9 85.1 78.5 80.2 82.8 61.6 67.0 84.0 70.4 73.9 65.3 54.8 57.7 60.5 32.8 40.3 63.0 44.0 49.3 88.7 81.4 83.1 86.3 69.7 73.7 87.6 75.7 78.6 83.0 75.8 77.6 80.0 61.7 66.2 81.5 69.0 72.1 86.0 89.2 86.2 87.6 83.2 87.2 86.7 86.2 86.7 87.1 85.4 85.9 86.1 74.7 77.8 86.7 80.5 82.2 96.4 95.4 95.5 96.3 92.8 93.0 96.3 94.1 94.3 83.0 85.8 85.3 85.2 67.6 70.4 84.0 76.6 77.8 93.0 84.1 86.7 92.7 78.1 82.7 92.8 81.5 84.9 83.9 80.4 81.3 73.5 49.9 55.6 79.0 66.0 69.1 84.0 73.1 75.9 77.9 58.0 62.8 81.2 65.7 69.6 77.7 77.3 77.3 77.0 57.3 61.4 77.3 68.0 69.9 79.1 66.8 68.2 72.1 47.5 50.5 75.5 57.4 59.6 78.2 77.1 77.2 75.4 65.8 66.8 76.9 71.5 72.1 78.5 72.5 73.7 76.1 65.9 68.0 77.3 69.3 70.9 96.7 82.3 84.2 87.3 74.3 75.9 92.2 78.3 80.1 86.8 73.3 74.2 81.1 69.0 69.9 83.8 71.2 72.1 91.8 87.8 89.1 89.3 82.0 84.4 90.5 84.7 86.6 91.4 75.3 78.5 91.3 76.8 79.9 91.3 76.0 79.2 92.6 78.6 85.5 89.8 79.8 85.3 91.0 79.2 85.4 87.3 84.5 85.1 84.8 78.0 79.4 86.0 81.1 82.2 88.0 82.7 83.2 73.4 83.6 82.6 80.6 83.2 82.9 91.2 88.5 89.6 87.2 86.5 86.8 89.2 87.5 88.1 82.8 69.6 74.8 73.4 56.7 63.1 78.3 63.2 69.1 86.3 82.6 84.1 84.6 75.7 79.1 85.5 79.3 81.8 80.1 71.3 73.5 78.5 56.0 61.5 79.4 63.9 67.7 81.9 71.4 74.9 79.7 62.4 68.0 80.8 66.9 71.4 95.6 89.7 91.0 94.5 89.8 90.8 95.0 89.8 90.9 84.4 81.6 82.6 84.7 73.3 76.9 84.5 77.4 79.7 34 Table 2.10 shows reasons for children never attending school or not currently attending school. For both boys and girls, the cost of schooling is cited most often as the main reason for never attending school. This reason is mentioned in one-quarter of cases for both boys and girls. This reason is almost twice as likely to be mentioned for children never attending school as for children not currently attending school. The most mentioned reason for not currently attending school is that the child is not interested in studies, which was cited for 41 percent of boys and 26 percent of girls. A lack of interest in school is also frequently given as a reason for children (especially boys) never attending school. Not surprisingly, the need for children to work in the household is mentioned more for girls than for boys, and the need for children to work on the family farm, in the family business, or outside the home for payment is more frequently mentioned for boys than for girls. Education is not considered necessary for 13 percent of girls and 8 percent of boys who never attended school. The lack of accessibility of schools (‘school too far away’ or ‘transport not available’) is mentioned infrequently for both boys and girls. The pattern of the reasons for not attending school for boys and girls is similar in urban and rural areas with the exception that the cost of schooling is cited more often in urban areas and the distance from school and the need for work (in the household, on a family farm, or in a family business) are mentioned slightly less often in urban areas. Figure 2.4 School Attendance by Age, Sex, and Residence 75 83 79 62 85 92 89 83 0 10 20 30 40 50 60 70 80 90 100 AGE 6–10, URBAN Male Female AGE 6–10, RURAL Male Female AGE 11–14, URBAN Male Female AGE 11–14, RURAL Male Female Percent NFHS-2, India, 1998–99 35 2.5 Housing Characteristics Table 2.11 provides information on housing characteristics by residence. Overall, three in every five households in India have electricity (up from one in two households in NFHS-1). The proportion of households with electricity is 91 percent in urban areas and 48 percent in rural areas, an increase of 10 and 24 percent, respectively, over the NFHS-1 results. Table 2.10 Reasons for children not attending school Percent distribution of children age 6–17 years who never attended school by the main reason for never attending school and percent distribution of children age 6–17 years who have dropped out of school by the main reason for not currently attending school, according to residence and sex, India, 1998–99 Urban Rural Total Reason Male Female Male Female Male Female Main reason for never attending school1 School too far away Transport not available Education not considered necessary Required for household work Required for work on farm/family business Required for outside work for payment in cash or kind Costs too much No proper school facilities for girls Required for care of siblings Not interested in studies Other Don’t know Total percent Number of children 1.3 2.8 3.8 4.5 3.5 4.3 0.2 0.6 0.6 0.7 0.6 0.7 6.1 12.9 7.8 13.1 7.6 13.1 4.6 9.6 6.7 15.5 6.4 14.9 2.8 1.2 5.2 3.4 4.9 3.2 4.6 2.9 4.3 2.6 4.4 2.6 28.5 30.1 25.8 23.8 26.2 24.5 0.0 1.1 0.0 2.6 0.0 2.5 0.6 1.7 0.9 3.0 0.9 2.9 26.5 15.7 25.7 15.9 25.8 15.8 21.9 18.6 17.0 12.8 17.6 13.4 3.0 2.8 2.0 2.1 2.2 2.2 100.0 100.0 100.0 100.0 100.0 100.0 1,107 1,438 7,081 12,614 8,188 14,052 Main reason for not currently attending school2 School too far away Transport not available Further education not considered necessary Required for household work Required for work on farm/family business Required for outside work for payment in cash or kind Costs too much No proper school facilities for girls Required for care of siblings Not interested in studies Repeated failures Got married Other Don’t know Total percent Number of children 0.2 1.0 1.0 5.9 0.8 4.8 0.1 0.2 0.4 1.6 0.3 1.3 2.4 5.4 2.3 4.3 2.4 4.5 5.7 14.7 8.7 17.3 8.0 16.7 4.7 1.6 9.2 2.9 8.0 2.6 11.3 3.0 9.9 3.7 10.3 3.5 15.2 17.0 13.3 11.4 13.8 12.6 0.0 1.2 0.0 3.5 0.0 3.0 0.2 1.5 0.6 2.3 0.5 2.2 42.5 30.2 40.0 24.8 40.6 26.0 6.0 6.1 5.3 3.7 5.5 4.2 0.1 4.9 0.2 8.5 0.2 7.7 5.8 8.2 5.3 6.2 5.5 6.6 5.7 5.1 3.8 4.0 4.2 4.2 100.0 100.0 100.0 100.0 100.0 100.0 1,852 1,747 5,475 6,121 7,327 7,868 1For children who have never attended school 2For children who have dropped out of school 36 Table 2.11 Housing characteristics Percent distribution of households by housing characteristics, according to residence, India, 1998–99 Housing characteristic Urban Rural Total Electricity Yes No Total percent Source of drinking water Piped Hand pump Well water Surface water Other Total percent Time to get drinking water Percentage < 15 minutes Median time (minutes) Method of drinking water purification1 Strains water by cloth Uses alum Uses water filter Boils water Uses electronic purifier Uses other method Does not purify water Sanitation facility Flush toilet Pit toilet/latrine Other No facility Total percent Main type of fuel used for cooking Wood Crop residues Dung cakes Coal/coke/lignite/charcoal Kerosene Electricity Liquid petroleum gas Biogas Other Total percent Type of house Kachha Semi-pucca Pucca Missing Total percent Persons per room < 3 3–4 5–6 7+ Missing Total percent Mean number of persons per room Number of households 91.3 48.1 60.1 8.7 51.9 39.9 100.0 100.0 100.0 74.5 25.0 38.7 18.1 47.3 39.2 6.0 23.5 18.7 0.4 3.5 2.6 1.0 0.7 0.8 100.0 100.0 100.0 86.4 69.3 74.1 0.0 4.9 4.3 25.1 16.1 18.6 1.4 1.2 1.2 14.8 2.4 5.8 13.6 6.1 8.2 1.2 0.1 0.4 0.6 0.8 0.7 50.4 75.3 68.4 63.9 8.8 24.0 16.8 10.0 11.9 0.0 0.1 0.1 19.3 81.1 64.0 100.0 100.0 100.0 23.1 73.1 59.3 0.5 8.1 6.0 1.4 8.4 6.5 4.9 1.7 2.6 21.5 2.7 7.9 0.8 0.2 0.4 46.9 5.1 16.7 0.6 0.5 0.5 0.2 0.2 0.2 100.0 100.0 100.0 9.4 41.4 32.5 24.4 39.5 35.3 66.0 19.0 32.0 0.2 0.2 0.2 100.0 100.0 100.0 68.6 60.2 62.5 19.5 24.4 23.1 8.3 10.7 10.0 3.5 4.5 4.2 0.1 0.1 0.1 100.0 100.0 100.0 2.5 2.8 2.7 25,243 65,953 91,196 1Totals add to more than 100.0 because households may use more than one method of purification. 37 Water sources and sanitation facilities have an important influence on the health of household members, especially children. NFHS-1 and NFHS-2 included questions on sources of drinking water and types of sanitation facilities. NFHS-2 found that 39 percent of households in India use piped drinking water (up from 31 percent in NFHS-1), the same proportion drink water from hand pumps (also up from 31 percent in NFHS-1), 19 percent drink water from wells (down from 26 percent in NFHS-1), and 3 percent drink surface water (down from 11 percent in NFHS-1). As in the case of electricity, there are large urban-rural differences in sources of drinking water. Three-quarters of households in urban areas use piped drinking water compared with only one-quarter in rural areas. The median time to get drinking water is five minutes in rural areas, whereas in urban areas the majority of households do not have any travel time to their source of drinking water. Only one-third of households in India purify water by any method (half of households in urban areas and one-quarter of households in rural areas). The most popular methods of water purification are straining and boiling water. Water filters are used by 30 percent of urban households that purified their drinking water. Regarding sanitation facilities, only 24 percent of households have a flush toilet that uses either piped water or bucket water for flushing (up slightly from 22 percent in NFHS-1), 12 percent have a pit toilet or latrine, and 64 percent have no facility. Again there are large urban- rural differences: 64 percent of urban households have a flush toilet compared with only 9 percent of rural households. A large majority (81 percent) of rural households have no toilet facility at all. Several types of fuel are used for cooking in India, with wood as the most common type. Overall, 59 percent of households rely mainly on wood, 17 percent on liquid petroleum gas, 13 percent on either crop residues or dung cakes, 8 percent on kerosene, and the rest on other fuels. Sixty-eight percent of urban households rely mainly on liquid petroleum gas or kerosene, while 73 percent of rural households rely mainly on wood. Regarding type of house construction, one-third of households in India live in houses that are kachha (made from mud, thatch, or other low-quality materials), one-third live in semi-pucca houses (using partly low-quality and partly high-quality materials), and one-third live in pucca houses (made with high-quality materials throughout, including the roof, walls, and floor). By residence, 66 percent of households in urban areas live in pucca houses compared with 19 percent of households in rural areas. Crowded housing conditions may affect health as well as the quality of life. Thirty-seven percent of households live in houses with three or more persons per room. The mean number of persons per room is 2.5 in urban areas, 2.8 in rural areas, and 2.7 overall (only a slight decrease from 2.8 persons per room in NFHS-1). Table 2.12 presents an interstate comparison of housing characteristics. The percentage of households with electricity is lowest in Bihar (18 percent), Assam (26 percent), Orissa (34 percent), and West Bengal and Uttar Pradesh (37 percent each). At least 90 percent of households have electricity in Delhi (98 percent), Himachal Pradesh (97 percent), Punjab (96 percent), Goa (94 percent), and Jammu and Kashmir (90 percent). In addition, over three- quarters of households have electricity in Haryana, Gujarat, Mizoram, Sikkim, Tamil Nadu, and Manipur. More than 60 percent of households use piped water or water from a hand pump for drinking in every state except Kerala and a few states in the Northeast Region. In Manipur, 38 Meghalaya, and Nagaland, piped water or water from a hand pump is used for drinking by 41–49 percent of households, and less than 20 percent of households use these water sources in Kerala. The majority of households in Kerala obtain their drinking water from wells. Most of the states in India have inadequate toilet facilities. There are only seven states where more than 70 percent of households have any type of toilet facility. In order of decreasing proportions, these states are Mizoram, Delhi, Manipur, Kerala, Nagaland, Arunachal Pradesh, and Sikkim. Less than 30 percent of households have a toilet or latrine facility in Central India and in Orissa, Bihar, Himachal Pradesh, Andhra Pradesh, and Rajasthan. In Delhi, only 4 percent of households use biomass fuel for cooking. In every other state except Goa, a majority of households use biomass fuel for cooking. Table 2.12 Housing characteristics by state Selected housing characteristics by state, India, 1998–99 Percentage of households: State With electricity With drinking water that is piped or from a hand pump With a toilet or latrine facility Using biomass fuel for cooking Living in a pucca house Mean number of persons per room India North Delhi Haryana Himachal Pradesh Jammu & Kashmir Punjab Rajasthan Central Madhya Pradesh Uttar Pradesh East Bihar Orissa West Bengal Northeast Arunachal Pradesh Assam Manipur Meghalaya Mizoram Nagaland Sikkim West Goa Gujarat Maharashtra South Andhra Pradesh Karnataka Kerala Tamil Nadu 60.1 77.9 35.9 71.7 32.0 2.7 97.7 98.7 94.4 3.6 88.2 2.2 89.1 88.0 39.0 66.9 46.7 2.4 97.2 77.4 26.7 64.0 28.7 1.8 90.1 70.6 51.0 65.8 36.1 2.2 95.5 98.9 51.4 60.6 52.1 2.1 64.4 69.8 27.8 81.0 41.4 3.0 68.1 63.5 22.2 79.3 19.2 2.9 36.6 85.6 26.5 82.8 24.8 3.1 18.2 75.4 16.8 85.9 15.5 2.9 33.8 65.3 13.5 86.8 14.8 2.4 36.7 89.3 44.8 65.7 32.8 2.7 68.9 80.7 73.0 80.8 14.2 2.2 26.4 60.1 63.0 87.1 10.9 2.1 75.3 48.9 92.0 69.2 7.1 2.1 41.2 42.1 52.0 83.5 14.5 2.0 84.1 63.2 97.7 57.4 16.2 2.6 56.3 40.5 74.3 86.1 18.1 1.6 80.7 84.6 72.7 63.2 50.6 2.0 93.5 61.8 58.9 41.4 51.0 1.6 84.3 84.5 44.9 54.5 45.2 2.7 82.1 81.9 45.9 51.9 28.3 3.0 74.4 78.5 27.3 74.1 39.9 2.9 80.9 87.0 38.6 67.8 41.2 2.5 71.8 19.9 85.2 81.7 79.8 1.3 78.8 85.0 34.0 66.5 27.6 2.2 39 The percentage of households living in pucca houses is quite low in most states. In Orissa, Bihar, Madhya Pradesh, and all the states in the Northeast Region except Sikkim, less than 20 percent of households live in pucca houses. Delhi (88 percent) and Kerala (80 percent) are the only states in which more than 60 percent of households live in houses classified as pucca. Households are least crowded in Kerala (1.3 persons per room), followed by Goa and Nagaland (where the average number of persons per room is 1.6). Households in Uttar Pradesh, Rajasthan, Maharashtra, Andhra Pradesh, Bihar, and Madhya Pradesh have an average of around 3 persons per room, which puts them in the most crowded category. Table 2.13 gives a number of measures related to the socioeconomic status of the household (ownership of land, a house, and livestock). Overall, half of households in India do not own any agricultural land. Thirty-nine percent of households in rural areas do not own agricultural land (up slightly from 36 percent in NFHS-1), compared with 80 percent of households in urban areas. In rural areas, among those who own land, 64 percent have at least some irrigated land. The proportion of households owning a house is 78 percent in urban areas, 95 percent in rural areas, and 90 percent overall. The proportion of households owning livestock is 14 percent in urban areas, 59 percent in rural areas, and 47 percent overall. The possession of durable goods is another indicator of a household’s socioeconomic level, although these goods may also have other benefits. For example, having access to a radio or television may expose household members to innovative ideas or important information about health and family welfare; a refrigerator prolongs the wholesomeness of food; and a means of transportation allows greater access to many services outside the local area. Table 2.14 shows that the majority of Indian households have a cot or a bed (81 percent) or a clock or watch (67 Table 2.13 Household ownership of agricultural land, house, and livestock Percent distribution of households owning agricultural land and percentage owning a house and livestock by residence, India, 1998–99 Asset Urban Rural Total No agricultural land Irrigated land only < 1 acre 1–5 acres 6+ acres Nonirrigated land only < 1 acre 1–5 acres 6+ acres Both irrigated and nonirrigated land < 1 acre 1–5 acres 6+ acres Missing Total percent Percentage owning a house Percentage owning livestock Number of households 80.0 38.6 50.1 1.6 9.4 7.2 5.4 16.1 13.2 2.2 4.2 3.6 1.5 5.1 4.1 4.2 13.2 10.7 1.4 3.6 3.0 0.2 0.8 0.6 0.9 5.0 3.9 1.1 3.4 2.8 1.4 0.6 0.8 100.0 100.0 100.0 78.2 94.8 90.2 13.7 59.3 46.7 25,243 65,953 91,196 40 percent). Other durable goods found in many households are bicycles (48 percent), mattresses (47 percent), chairs or electric fans (46 percent each), tables (40 percent), radios (38 percent), pressure cookers (30 percent), and black and white televisions (25 percent). A small proportion of households own sewing machines (18 percent), motorcycles, scooters, or mopeds (11 percent), refrigerators (11 percent), colour televisions (10 percent), water pumps (9 percent), telephones (7 percent), or cars (2 percent). Urban households are much more likely than rural households to own each of these durable goods. In rural areas, 9 percent of households own a bullock cart, 3 percent own a thresher, and 2 percent own a tractor. Six percent of households in India do not own any of the above durable goods. The majority of households (57 percent) use stainless steel kitchenware and two in every five households use aluminium kitchenware. Table 2.14 shows a summary household measure called the standard of living index (SLI), which is calculated by adding the following scores: Table 2.14 Household ownership of durable goods and standard of living Percentage of households owning selected durable goods and percent distribution of households by type of kitchenware and the standard of living index, according to residence, India, 1998–99 Asset Urban Rural Total Durable goods Mattress Pressure cooker Chair Cot/bed Table Clock/watch Electric fan Bicycle Radio/transistor Sewing machine Telephone Refrigerator Television (black and white) Television (colour) Moped/scooter/motorcycle Car Water pump Bullock cart Thresher Tractor None of the above Main type of kitchenware used Clay Aluminium Cast iron Brass/copper Stainless steel Total percent Standard of living index Low Medium High Missing Total percent Number of households 71.7 38.1 47.4 65.2 16.0 29.6 71.3 35.6 45.5 86.1 79.4 81.2 64.9 30.0 39.6 90.1 57.5 66.5 82.2 31.4 45.5 53.5 45.7 47.8 53.2 32.2 38.0 35.5 11.9 18.4 20.1 2.6 7.4 28.8 3.7 10.6 44.8 17.0 24.7 27.3 3.5 10.1 25.0 6.0 11.2 4.4 0.6 1.6 9.3 8.2 8.5 1.4 9.4 7.2 0.7 2.5 2.0 0.8 2.0 1.6 1.9 7.3 5.8 0.5 1.1 0.9 29.8 45.5 41.1 0.2 0.3 0.3 0.6 1.2 1.0 68.9 51.9 56.6 100.0 100.0 100.0 14.3 44.7 36.3 45.2 44.0 44.3 39.0 10.3 18.2 1.5 1.0 1.2 100.0 100.0 100.0 25,243 65,953 91,196 41 House type: 4 for pucca, 2 for semi-pucca, 0 for kachha; Toilet facility: 4 for own flush toilet, 2 for public or shared flush toilet or own pit toilet, 1 for shared or public pit toilet, 0 for no facility; Source of lighting: 2 for electricity, 1 for kerosene, gas, or oil, 0 for other source of lighting; Main fuel for cooking: 2 for electricity, liquid petroleum gas, or biogas, 1 for coal, charcoal, or kerosene, 0 for other fuel; Source of drinking water: 2 for pipe, hand pump, or well in residence/yard/plot, 1 for public tap, hand pump, or well, 0 for other water source; Separate room for cooking: 1 for yes, 0 for no; Ownership of house: 2 for yes, 0 for no; Ownership of agricultural land: 4 for 5 acres or more, 3 for 2.0–4.9 acres, 2 for less than 2 acres or acreage not known, 0 for no agricultural land; Ownership of irrigated land: 2 if household owns at least some irrigated land, 0 for no irrigated land; Ownership of livestock: 2 if owns livestock, 0 if does not own livestock; Ownership of durable goods: 4 each for a car or tractor, 3 each for a moped/scooter/motorcycle, telephone, refrigerator, or colour television, 2 each for a bicycle, electric fan, radio/transistor, sewing machine, black and white television, water pump, bullock cart, or thresher, 1 each for a mattress, pressure cooker, chair, cot/bed, table, or clock/watch. Index scores range from 0–14 for a low SLI to 15–24 for a medium SLI and 25–67 for a high SLI. By this measure, more than one-third (36 percent) of Indian households have a low standard of living, 44 percent have a medium standard of living, and 18 percent have a high standard of living. The proportion with a low standard of living is much higher in rural areas than in urban areas (45 and 14 percent, respectively), and the proportion with a high standard of living is much higher in urban areas than in rural areas (39 and 10 percent, respectively). The proportion with a medium standard of living is almost the same in urban and rural areas. 2.6 Lifestyle Indicators The NFHS-2 Household Questionnaire asked about certain aspects of the lifestyle of household members. Table 2.15 shows the percentages of men and women age 15 and above who chew paan masala or tobacco, drink alcohol, or smoke. These lifestyle indicators are of considerable interest because the use of paan masala, tobacco, and alcohol all have detrimental effects on health. 42 Table 2.15 Lifestyle indicators Percentage of usual household members age 15 and above who chew paan masala or tobacco, drink alcohol, currently smoke, or have ever smoked by selected background characteristics and sex, India, 1998–99 Background characteristic Chew paan masala or tobacco Drink alcohol Currently smoke Ever smoked1 Number of household members MALE Age 15–19 20–24 25–29 30–39 40–49 50–59 60+ Residence Urban Rural Education Illiterate Literate, < middle school complete Middle school complete High school complete and above Standard of living index Low Medium High Total 9.4 2.4 4.4 4.8 26,297 20.3 7.7 13.7 14.6 21,461 28.0 14.9 25.1 27.3 19,641 34.1 23.6 37.6 41.2 33,554 35.6 26.1 45.0 49.9 24,151 35.4 23.9 45.3 52.3 15,195 37.6 18.6 38.2 46.6 20,571 20.8 12.4 21.4 24.5 46,245 31.3 18.5 32.6 36.5 114,626 38.0 26.7 44.8 49.6 44,661 31.5 17.8 33.1 37.5 43,328 23.2 11.8 21.2 23.7 25,376 18.9 8.9 15.9 18.5 47,485 37.6 24.8 39.4 43.5 46,887 27.7 15.0 29.1 32.7 76,510 17.2 9.8 16.9 20.2 35,463 28.3 16.7 29.4 33.1 160,871 FEMALE Age 15–19 20–24 25–29 30–39 40–49 50–59 60+ Residence Urban Rural Education Illiterate Literate, < middle school complete Middle school complete High school complete and above Standard of living index Low Medium High Total 2.1 0.6 0.2 0.3 24,602 4.3 1.1 0.6 0.6 22,288 8.0 2.0 1.1 1.2 20,761 12.3 2.5 2.2 2.4 32,127 18.6 3.1 4.0 4.5 21,253 22.8 3.8 5.7 6.4 15,108 25.0 3.1 5.3 6.0 18,588 8.8 0.5 0.9 1.0 43,173 13.8 2.9 3.1 3.4 111,554 17.4 3.5 4.0 4.5 86,359 10.2 0.8 0.8 0.9 30,563 3.8 0.5 0.3 0.3 14,217 1.8 0.2 0.1 0.2 23,529 18.7 4.4 4.2 4.7 47,225 11.7 1.7 2.2 2.4 71,497 5.2 0.3 0.6 0.8 34,144 12.4 2.2 2.5 2.8 154,726 Total male and female 20.5 9.6 16.2 18.2 315,598 Note: Total includes 23 males and 58 females with missing information on education and 2,012 males and 1,861 females with missing information on the standard of living index, who are not shown separately. 1Includes household members who currently smoke 43 The respondent to the Household Questionnaire reports on these lifestyle indicators for all persons in the household, and therefore the results should be interpreted with caution because the household respondent may not be aware of use that takes place outside the household environs. In addition, to the extent that social stigma may be attached to the use of some of the substances, underreporting is likely. Twenty-one percent of persons age 15 and above are reported to chew paan masala or tobacco. This proportion rises from 9 percent of men and 2 percent of women at age 15–19 to 38 percent and 25 percent, respectively, at age 60 and above. Chewing of paan masala or tobacco for both men and women is about one and one-half times as common in rural areas as in urban areas. Chewing of paan masala or tobacco is inversely related with education. It is twice as high among illiterate men as among men who have completed at least high school. Chewing of paan masala or tobacco is rare among educated women, and it is much higher among men and women in households with a low standard of living than in households with a high standard of living. Seventeen percent of men, but only 2 percent of women, age 15 and above are reported to drink alcohol. The proportion of men who drink alcohol rises with age up to age 40–49. The proportion of men who drink is one and one-half times as high in rural areas as in urban areas. Illiterate men are three times as likely to drink alcohol as men who have completed at least high school. Drinking alcohol by household members is negatively related to the household’s standard of living. Only 3 percent of women are reported to have ever smoked and to currently smoke. Among men age 15 and above, 29 percent currently smoke. The proportion of men who smoke rises from 4 percent at age 15–19 to 45 percent at age 40–59 and then falls to 38 percent at age 60 and above. As for chewing paan masala or tobacco and drinking alcohol, the proportion of men who smoke is one and one-half times as high in rural areas as in urban areas. It is much higher among illiterate than literate men, and more than twice as high among men with a low standard of living as among men with a high standard of living. Eighty-nine percent of men who ever smoked were still smokers at the time of the survey. The pattern of differentials for ever- smokers closely resembles the pattern for current smokers. An interstate comparison of life style indicators is presented in Table 2.16. The percentage of men chewing paan masala or tobacco is quite low (7–10 percent) in Jammu and Kashmir, Goa, Himachal Pradesh, Haryana, Punjab, and Kerala. More than half of men in Mizoram, Arunachal Pradesh, and Bihar and 40–50 percent in Orissa, Assam, Nagaland, Madhya Pradesh, and Sikkim chew paan masala or tobacco. In the northeastern states, chewing paan masala or tobacco is also quite common among women, particularly in Mizoram where the proportion chewing paan masala or tobacco is the same for men and women. Outside of the Northeast Region, chewing paan masala or tobacco is most common for women in Orissa, Maharashtra, West Bengal, Karnataka, and Madhya Pradesh. 44 Alcohol consumption is highest in Arunachal Pradesh, where 65 percent of men and 49 percent of women drink alcohol. There are only two other states, Sikkim and Assam, where more than 10 percent of women drink alcohol. In addition to Arunachal Pradesh, more than one- quarter of men drink alcohol in Sikkim, Manipur, Goa, Punjab, Meghalaya, Nagaland, and Andhra Pradesh. The lowest prevalence of alcohol consumption is in Gujarat, where there is a state ban on alcohol. Table 2.16 Lifestyle indicators by state Percentage of usual household members age 15 and above who chew paan masala or tobacco, drink alcohol, currently smoke, or have ever smoked by sex and state, India, 1998–99 State Chew paan masala or tobacco Drink alcohol Currently smoke Ever smoked1 MALE India North Delhi Haryana Himachal Pradesh Jammu & Kashmir Punjab Rajasthan Central Madhya Pradesh Uttar Pradesh East Bihar Orissa West Bengal Northeast Arunachal Pradesh Assam Manipur Meghalaya Mizoram Nagaland Sikkim West Goa Gujarat Maharashtra South Andhra Pradesh Karnataka Kerala Tamil Nadu 28.3 16.7 29.4 33.1 13.1 17.9 24.0 26.4 8.0 20.7 40.6 42.4 7.9 24.2 38.8 42.3 7.2 10.0 44.5 49.0 9.3 28.3 13.9 15.8 19.1 10.7 37.9 41.0 40.6 20.6 29.5 35.1 36.3 11.6 34.0 37.2 51.7 22.4 26.3 32.0 49.5 19.2 25.4 29.4 23.3 11.0 39.6 43.1 52.0 64.5 25.1 34.3 48.2 24.9 31.7 34.9 34.4 30.5 35.2 39.2 16.7 28.1 55.2 57.6 60.3 16.8 59.4 67.1 45.3 26.8 38.2 49.5 39.6 31.9 19.5 29.0 7.7 28.7 17.8 23.5 24.6 6.6 25.5 29.1 34.7 12.1 13.4 15.5 10.8 26.1 35.7 39.0 13.9 16.4 26.0 29.6 9.5 14.5 28.3 35.0 13.0 20.5 27.0 29.8 45 More than half of men have ever smoked in Mizoram and Meghalaya, and 41–50 percent have ever smoked in Nagaland, Jammu and Kashmir, West Bengal, Haryana, Himachal Pradesh, and Rajasthan. Current smoking is also highest in these states. Less 20 percent of men smoke in Maharashtra, Punjab, Goa, and Sikkim. In most states, around 90 percent of men who ever smoked currently smoke. In Mizoram, where the proportion of women who chew paan masala or tobacco is the highest, the proportions of women who have ever smoked and who currently smoke are also the highest. In a large majority of states, less than 5 percent of women smoke or have ever smoked. Between 5 and 15 percent of women currently smoke in Manipur, Jammu and Kashmir, Sikkim, Meghalaya, Bihar, and Arunachal Pradesh. Table 2.16 Lifestyle indicators by state (contd.) Percentage of usual household members age 15 and above who chew paan masala or tobacco, drink alcohol, currently smoke, or have ever smoked by sex and state, India, 1998–99 State Chew paan masala or tobacco Drink alcohol Currently smoke Ever smoked1 FEMALE India North Delhi Haryana Himachal Pradesh Jammu & Kashmir Punjab Rajasthan Central Madhya Pradesh Uttar Pradesh East Bihar Orissa West Bengal Northeast Arunachal Pradesh Assam Manipur Meghalaya Mizoram Nagaland Sikkim West Goa Gujarat Maharashtra South Andhra Pradesh Karnataka Kerala Tamil Nadu 12.4 2.2 2.5 2.8 2.5 0.1 1.8 1.9 0.9 0.1 3.6 3.8 0.5 0.2 2.4 2.6 0.9 0.3 8.5 10.2 0.2 0.2 0.3 0.4 3.9 0.2 4.3 4.4 14.8 3.4 0.9 1.1 11.4 0.2 3.1 3.5 6.9 3.3 6.4 7.2 34.9 6.2 0.9 1.0 15.6 2.0 2.6 2.8 33.2 48.9 5.4 7.2 24.9 11.1 2.7 3.1 19.6 2.0 12.2 14.4 27.6 3.1 6.8 7.0 60.7 0.4 22.1 29.3 16.5 2.6 2.5 3.7 18.9 17.1 8.3 11.8 8.2 4.5 2.1 3.1 8.2 1.0 1.4 1.7 18.5 0.5 0.2 0.2 10.3 7.5 4.4 4.9 14.9 1.0 0.3 0.4 10.5 0.2 0.4 0.6 11.0 0.5 0.4 0.4 1Includes household members who currently smoke 46 2.7 Availability of Facilities and Services to the Rural Population The NFHS-2 Village Questionnaire collected information from the sarpanch, other village officials, or other knowledgeable persons in the village on facilities and services in the village that can affect health and family planning. One important set of questions was on the distance of the village from various types of health facilities, including Primary Health Centres (PHCs), sub- centres, hospitals, and dispensaries or clinics. Table 2.17 summarizes findings on distance from a health facility. The unit of analysis is ever-married women age 15–49 who reside in rural areas. Thirteen percent of rural women live in a village with a Primary Health Centre, 33 percent live in a village with a sub-centre, and 37 percent live in a village with either a PHC or a sub-centre. The proportions who live in a village with other health facilities are 10 percent for hospitals and 28 percent for dispensaries or clinics. Nearly half of women (47 percent) live in a village that has some kind of health facility. Median distances from particular health facilities are 4.9 km for a Primary Health Centre, 1.3 km for a sub-centre, 6.7 km for a hospital, and 2.4 km for a dispensary or a clinic. Fourteen percent of rural women need to travel at least five kilometres to reach the nearest health facility. Table 2.18 shows the proportion of residents (the de jure rural population) in rural India that live in villages which have various facilities and services. Eighty percent of rural residents live in villages that have a primary school, 45 percent live in villages with a middle school, and more than one-quarter (26 percent) live in villages that have a secondary school. Higher secondary schools are available in villages where 14 percent of the rural population live. Almost two-thirds of rural residents (64 percent) live in villages that have an anganwadi2 (a nursery school for children age 3–6 years) and nearly one-quarter (24 percent) live in villages with an adult education centre. Forty-two percent of rural residents live in villages that have a private doctor and 59 percent live in villages with a traditional birth attendant. 2Anganwadi workers provide integrated child development services and may also engage in the promotion of family planning among parents of preschool age children. Table 2.17 Distance from the nearest health facility Percent distribution of ever-married rural women age 15–49 by distance from the nearest health facility, India, 1998–99 Health facility Distance Primary Health Centre Sub- centre Either PHC or sub-centre Hospital1 Dispensary/ clinic Any health facility Within village < 5 km 5–9 km 10+ km Don’t know/missing Total percent Median distance 13.1 33.0 36.5 9.7 28.3 47.4 28.4 39.7 40.8 25.0 32.4 38.9 29.2 16.3 15.3 25.1 17.4 9.7 28.8 9.6 7.0 40.0 21.7 3.9 0.5 1.4 0.3 0.2 0.2 0.2 100.0 100.0 100.0 100.0 100.0 100.0 4.9 1.3 1.0 6.7 2.4 0.0 Note: The category ‘< 5 km’ excludes cases where the facility is within the village. When median distance is calculated, ‘within village’ cases and cases with a facility less than 1 km from the village are assigned a distance of zero. PHC: Primary Health Centre 1Includes community health centre, rural hospital, government hospital, and private hospital 47 Eighty-one percent of rural residents live in villages that are at least partly electrified. Although only 14 percent of rural residents live in villages with an STD booth (for telephoning within India), 61 percent live in villages that have at least one household with a private telephone. Almost one-fifth of rural Indians live in villages that have a community television set, and 28 percent of rural residents live in villages that have cable television service, providing further evidence that the exposure to electronic mass media is limited in rural India. Slightly more than one-third live in villages with a mahila mandal, a women’s community group. Other facilities and clubs that are available in villages where more than one-third of rural residents live are kirana shops (small grocery stores), fair price shops, paan shops, post offices, and youth clubs. The most widely available rural development programmes as reported by the respondents to the Village Questionnaire are the Indira Awas Yojana (IAY) and the Integrated Rural Development Programme (IRDP). Table 2.18 Availability of facilities and services Percentage of rural residents living in villages that have selected facilities and services, India, 1998–99 Facility/service Percentage of residents Facility/service Percentage of residents Primary school Middle school Secondary school Higher secondary school College Anganwadi Adult education centre Primary Health Centre Sub-centre Hospital1 Dispensary/clinic Private doctor Visiting doctor Village health guide Traditional birth attendant Mobile health unit Electricity Bank Post office Telegraph office STD (Subscriber Trunk Dialling) phone booth 79.7 44.6 26.3 14.0 2.8 63.8 24.2 12.9 32.3 9.6 28.3 41.9 31.4 33.0 58.9 12.1 81.3 20.7 43.2 10.9 13.7 At least one village household has a telephone Mill/small-scale industry Credit cooperative society Agricultural cooperative society Fishermen’s cooperative society Milk cooperative society Kirana/general market shop Weekly market Fair price shop Paan shop Pharmacy/medical shop Mahila mandal Youth club Community centre Community television set Cable connection Integrated Rural Development Programme (IRDP) National Rural Employment Programme (NREP) Training Rural Youth for Self-Employment (TRYSEM) Employment Guarantee Scheme (EGS) Development of Women and Children of Rural Areas (DWACRA) Indira Awas Yojana (IAY) Sanjay Gandhi Niradhar Yojana (SGNY) Total population 61.0 24.8 25.0 27.2 5.5 21.8 67.0 23.1 61.1 57.6 25.6 33.7 38.8 19.9 17.7 28.3 53.6 13.3 22.2 9.5 28.4 59.1 27.4 360,764 Note: Table is based on the de jure population. 1Includes community health centre, rural hospital, government hospital, and private hospital CHAPTER 3 BACKGROUND CHARACTERISTICS OF RESPONDENTS Women's demographic and health-seeking behaviour is associated with several characteristics including their age, marital status, religion, and caste. Modernizing influences such as education and exposure to mass media are also important catalysts for demographic and socioeconomic change. In addition, women’s status and autonomy are critical in promoting change in reproductive attitudes and behaviour, especially in patriarchal societies (Dyson and Moore, 1983; Das Gupta, 1987; Jeffery and Basu, 1996). The National Population Policy, 2000, of the Government of India identifies the low status of women in India, typified by factors such as discrimination against the girl child and female adolescents, early age at marriage, and high rates of

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