Comparing data of the NFHS 5 survey with the previous years 2015-16 and 2019-20, Alok Vajpeyi, head, knowledge management, Population Foundation of India highlights some silver linings but also flags some areas of concern like the fact that a disproportionate burden for use of modern methods of contraception continues to fall on Indian women. He therefore urges that we continue to plug implementation gaps in the country’s family planning programme
Even as the country goes through a period of uncertainty precipitated by the COVID-19 pandemic, the recently released survey data from National Family Health Survey – NFHS 5 (2019-20) for 17 states and five union territories (UTs) offers a silver lining.
Two main themes emerge from the data – first, the state governments have improved the implementation of public health programmes; and second, people have demonstrated better health seeking behaviour, which is reflected by improvements in several indicators, such as use of modern contraceptives, ante-natal care visits and institutional deliveries.
The NFHS 5 data makes it abundantly clear that India is on course to achieving population stabilisation. Of the 17 states and five UTs where data is available. Only Bihar, Manipur and Meghalaya are yet to achieve a Total Fertility Rate (TFR) of 2.1 or less, implying that most states have attained the replacement level of fertility, which is defined as the rate at which the population replaces itself from one generation to the next.
Notably, Bihar has reduced its TFR from 3.4 in 2015-16 to 3.0 in 2019-20. All five UTs report TFR below the replacement level for 2019-20. According to NFHS 4, India had achieved a TFR of 2.2 in 2015-16, which is close to replacement level fertility. Given the trends seen in the Phase 1 of NFHS 5, it is expected that data from the remaining states and UTs will show that India will have achieved replacement level fertility overall. The NFHS data on family planning and fertility should now lay to rest any debate on implementing coercive family planning policies in the country.
In addition to a positive shift in the fertility rate, of 17 states surveyed, 16 states have demonstrated increased use of modern contraceptives. The highest increase in the use of modern contraceptives has been observed in Goa (by 35.3 per cent), followed by Nagaland (24 per cent) and Bihar (about 21 per cent). All surveyed UTs and states, except Andhra Pradesh and Meghalaya, have shown a decline in unmet need for family planning between 2015-16 and 2019-20; unmet need for family planning is defined as women who want to stop or delay childbearing but are not using any method of contraception. The increase in modern contraceptive use and reduction in unmet need for family planning provides possible explanations for fertility reduction in most states.
The states and UTs covered in Phase 1 of NFHS 5 have also shown improvement in infant and child mortality, use of ante-natal services, institutional deliveries and menstrual hygiene. Infant mortality and under-five mortality rates have shown improvement in most of the states over the past five years. All states, except Kerala and Sikkim which already had very high levels of institutional delivery at 99.8 per cent and 94.7 per cent respectively, have shown an increase in the proportion of women delivering in facilities. Bihar and Manipur have reported about a 10 per cent increase between two surveys in the number of women who have received at least four ante-natal check-ups visits. An increase in use of menstrual hygiene products among women age 15-24 years has been reported in all states, except Mizoram. A significant increase in the use of menstrual hygiene products are reported by West Bengal (83 per cent in 2019-20 from 54.9 per cent in 2015-16), Bihar (58.8 per cent in 2019-20 from 31 per cent in 2015-16) and Tripura (68.8 per cent in 2019-20 from 43.5 per cent in 2015-16).
With regard to indicators related to women empowerment, all states reported that more than 80 per cent women have participated in three key household decisions, including participation in making decisions about their own health care, major household purchases, and visits to their own family or relatives alone or jointly with their husband. Similarly, all states reported an increase in per cent age of women having a mobile phone that they themselves use, although there is still a considerable gap in mobile ownership between men and women. However, an increase in violence against women, child marriage and teenage pregnancy in some states are areas of worry.
Areas of concern
Moving forward, there are areas of concern that need attention. For instance, a disproportionate burden for use of modern methods of contraception continues to fall on Indian women. Of all modern methods, female sterilisation is the most used method (75.3 per cent) followed by Condoms (11.7 per cent) and Pills (8.6 per cent). NFHS-5 data shows that female sterilisation accounts for almost all modern contraceptives in Andhra Pradesh (98 per cent) and Telangana (93 per cent), while it is primary method used in Kerala (88 per cent), Karnataka (84 per cent), Bihar (78 per cent) and Maharashtra (77 per cent). While male sterilisation as a contraceptive method is a far simpler procedure than female sterilisation, the share of male sterilisation accounts for less than 1 per cent (0.6 per cent). Low acceptance of vasectomy and condoms reflect limited male engagement in family planning.
So even as we celebrate India’s progress towards achieving population stabilisation, we must continue to plug implementation gaps in the country’s family planning programme. India must remain focused on delivering high quality family planning services to those who need it, especially in high fertility states and districts. This would include expanding the basket of contraceptive choices, especially Long Acting Reversible Contraceptives (LARC), which are critical in view of our large population of adolescent s and youth. Moreover, promoting self-care and male engagement in family planning through social and behaviour change communication strategies and improved quality of care are much needed and even more relevant today.
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