NFHS 2019-21: Anemia rising across all age-groups, fertility rate falls below replacement rate for first time

Growing cases of anemia across all age-groups, fertility rate falling below replacement rate, women outnumbering men and a continued challenge on child and maternal health are some of the key findings of the National Family Health Survey (NFHS) 2019-21.

NFHS is the most comprehensive survey on socio-economic and health indicators in the country and has highlighted some key demographic trends in its fifth edition, with the biggest being the distressing health epidemic -- rising cases of anemia across all age groups.

Seven out of 10 children under the age of 5 years in India (67 percent) suffer from some form of anemia, a number that has grown from 59 percent in 2015-16.

57 percent of all women in the age group of 15-49 years are anemic and 25 percent of men in the age group are iron deficient -- both categories have seen an increase since the last NFHS survey 2015-16.

India carries the highest burden of the disease world over, especially in pregnant and lactating mothers. Here too, the family health survey 2019-21 points to worsening statistics. Poor dietary habits, preference for boys, repeated pregnancies & lactation leading to increased iron requirements have been key reasons for women bearing the brunt of anemia.

The data is worrisome more so because the increase in anemia burden is despite the country running an anemia control program for 50 years.

An increase in iron deficiency in adolescents (15-19 years) is recorded in NFHS 2019-21. A sharper rise was observed in girls. Rising urbanization with changes in dietary habits towards junk food is leading to faster increase in anemia in urban areas as compared to rural, according to the survey.

Assam is among the worst performing states, with a sharp increase in anemic cases, especially in children -- 68.4 percent reporting anemia in NFHS-5, up from 35.7 percent in NFHS-4.

Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh have all shown an increase in anemia cases between 2015-2016 and 2019-21. Rajasthan has seen a 9-12 percent increase in anemia cases.

Chhattisgarh saw a 26 percent increase in anemia in children and a 10-15 percent increase in women. Maharashtra reported 4-15 percent increase across age groups and Gujarat recorded a 17 percent rise in anemia cases in children.

Malnutrition is still a burden with the NFHS-5 recording just a marginal improvement in the last six years. 35.5 percent children under 5 years are still stunted and 32 percent still underweight, indicating programs focused on addressing nutritional requirements for mother and child are not adequate.

The slow pace of improvement is despite government schemes such as Integrated Child Development Services (ICDS) and now the National Nutrition Mission that seek to address the nutritional needs at the time of childbirth and infancy.

There has been no improvement in children who are severely underweight as per their height. There is, in fact, a marked increase in children who are overweight, according to the survey.

While there is a marked increase in institutional deliveries, the share of cesarean section deliveries in private hospitals has risen with nearly half of all deliveries performed being cesarean.

There has been an improvement in child health metrics with the under 5 mortality falling to ~42 (per 1000 live births) against ~50 in 2015-16 and infant mortality rate at 35 (per 1000 live births) against ~41 in 2015-16. However, it is still very high. The pace of improvement is slower than the earlier periods.

Availability of basic amenities such as clean fuel for cooking, electricity, clean drinking water and better sanitation has improved since the last survey and can improve health outcomes. However, the degree of improvement might be less and the poor nutrition and child health metrics may take away from the sheen of the government claims.

According to the NFHS 2019-21 survey, women outnumber men with a sex ratio of 1020 females per 1000 males from 991 in 2015-16 survey. The sex ration when seen for the last 5 years is sobering at 929 females per 1000 males.

Total fertility rate, which means average number of children born per woman, has fallen to 2 in 2019-21 from 2.2 in 2015-16. This is below the replacement level of TFR (2.1), at which the population exactly replaces itself from one generation to the next.

A fertility rate below the replacement rate of fertility will lead to the population starting to decline.

TFR for urban areas stands at 1.6 and for rural areas at 2, according to the survey.

Population Foundation of India calls this a significant feat for the country’s family-planning programme, which does not include coercive policies. "These findings bust the population-explosion myth and show that India must steer away from coercive measures of population control," it said.

The survey also highlights increase in the use of family planning methods. The total unmet need for family planning has come down to 9.4 percent in 2019-21 against 12.9 percent in 2015-16. Use of modern contraceptive method has increased to 56.5 percent in 2019-21 against 47.8 percent in 2015-16. However, the onus of family planning still lies with women as the survey points to an increase in use of female sterilization methods to 38 percent against 36 percent in 2015-16.

NFHS 2019-21 in its fifth edition has recorded that more women are now taking crucial decisions in their households, have a personal mobile phone and a bank account that they use and there is also an increase in land and property ownership of women.