National Family Health Survey, India Database that strengthen India's demographic and health policies and programmes . . . .

RESEARCH

There have been series of research activities with National Family Health Survey-1 data since it was made public in 1993. Several research papers are published by distinguished reseachers all over the world in many reputed peer review journals. Apart from that there are series of research publications dedicated to NFHS results. The NFHS Bulletin series and NFHS Subject report series are two such series. NFHS Bulletins are typically summaries of bigger Subject reports and are not more than 4 pages lenght. Subject reports deal with the research topic in a more detailed way. We present below a complete list of NFHS Bulletins and Subject reports. Also included a few selected journal articles related to NFHS. Abstracts of the same are also provided for user's easy reference.

List of NFHS Bulletins
List of NFHS Subject Reports
List of Selected Journal Articles

All published NFHS Bulletins and Subject Reports are available at the East-West Center website (http://www2.ewc.hawaii.edu/pop/pop53000.htm) .

For dowloading pdf files of Bulletins with abstracts please visit: http://www2.ewc.hawaii.edu/pop/pop53001.htm

For dowloading pdf files of Subject Reports with abstracts please visit: http://www2.ewc.hawaii.edu/pop/pop53002.htm

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NFHS Subject Report No. 1 (1996). Unmet Need for Family Planning in Uttar Pradesh, by D. Radha Devi, S. R. Rastogi, and Robert D. Retherford.

NFHS Subject Report No. 2 (1996). Contraceptive Use in India, by B. M. Ramesh, S. C. Gulati, and Robert D. Retherford.

NFHS Subject Report No. 3 (1997). Effect of Son Preference on Fertility in India, by R. Mutharayappa, Minja Kim Choe, Fred Arnold, and T. K. Roy.

NFHS Subject Report No. 4 (1997). Comparison of Fertility Estimates from India’s Sample Registration System and National Family Health Survey, by R. L. Narasimhan, Robert D. Retherford, Vinod Mishra, Fred Arnold, and T. K. Roy.

NFHS Subject Report No. 5 (1997). Maternal Education and the Utilization of Maternal and Child Health Services in India, by Pavalavalli Govindasamy and B. M. Ramesh.

NFHS Subject Report No. 6 (1998). Wanted and Unwanted Fertility in Selected States of India, by Sumati Kulkarni and Minja Kim Choe.

NFHS Subject Report No. 7 (1998). Alternative Contraceptive Methods and Fertility Decline in India, by K. B. Pathak, Griffith Feeney, and Norman Y. Luther.

NFHS Subject Report No. 8 (1998). Mother’s Employment and Infant and Child Mortality in India, by Sunita Kishor and Sulabha Parasuraman.

NFHS Subject Report No. 9 (1998). Fertility in India, by M. M. Gandotra, Robert D. Retherford, Arvind Pandey, Norman Y. Luther, and Vinod K. Mishra.

NFHS Subject Report No. 10 (1998). Knowledge and Use of Oral Rehydration Therapy for Childhood Diarrhoea in India: Effects of Exposure to Mass Media, by K. V. Rao, Vinod K. Mishra, and Robert D. Retherford.

NFHS Subject Report No. 11 (1998). Infant and Child Mortality in India, by Arvind Pandey, Minja Kim Choe, Norman Y. Luther, Damodar Sahu, and Jagdish Chand.

NFHS Subject Report No. 12 (1999). Factors Affecting Source of Family Planning Services in India, by P. S. Nair, Griffith Feeney, Vinod K. Mishra, and Robert D. Retherford.

NFHS Subject Report No. 13 (1999). Reasons for Discontinuing and not Intending to Use Contraception in India, by Vinod K. Mishra, Robert D. Retherford, P. S. Nair, and Griffith Feeney.

NFHS Subject Report No. 14 (1999). Child Nutrition in India, by Vinod K. Mishra, Subrata Lahiri, and Norman Y. Luther.

NFHS Subject Report No. 15 (2000). Child Immunization in Madhya Pradesh, by Rakesh Munshi and Sang-Hyop Lee

NFHS Subject Report No. 16 (2000). Are the WHO Guidelines on Breastfeeding Appropriate for India? by Ravilla Anandaiah and Minja Kim Choe

NFHS Subject Report No. 17 (2001). How much has fertility declined in Uttar Pradesh? by Robert D. Retherford, Vinod K. Mishra, and G. Prakasam

NFHS Subject Report No. 18 (2001). Does community access affect the use of health and family welfare services in India? by N. P. Das, Vinod K. Mishra, and P. K. Sah

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List of Selected Journal Articles

Acharya, Rajib. 1998. Gender Disparity, Development, and Fertility Transition in India: An Inter-state Analysis. Journal of Social Sciences 2(4) : 253-263.

Acharya, R. and S. Sureender. 1996. Interspouse Communication, Contraceptive Use and Family Size : Relationship Examined in Bihar and Tamil Nadu. Journal of Family Welfare 42(4) : 5-11.

Achyut, P., R. Acharya and S. Lahiri. 1997. Non-Biological Correlates of Early Neonatal Deaths : Evidences from five selected states of India. Demography India 26(2) : 241-260.

Arnold, Fred, Minja Kim Choe, and T. K. Roy. 1998. Son preference, the family-building process and child mortality in India. Population Studies 52: 301-315.

Balk, Deborah, and Subrata Lahiri. 1997. Awareness and knowledge of AIDS among Indian women: evidence from 13 states. Health Transition Review 7: 421-465.

Bhat, P.N. Mari and Francis Zavier. 1999. Finding of the National Family Health Survey: Regional Analysis. Economic and Political Weekly 34(42 & 43) : 3008 – 3032.

Begum, S., P. Arokiasamy, and Rajib Acharya. 1998. Factors Affecting Complications During Delivery- An Analysis of NFHS Data. Journal of Family Welfare 44(4) : 15-26.

Chatterjee, Uma, and Rajib Acharya. 2000. Seasonal Variation of Births in Rural West Bengal: Magnitude, Direction and Correlates. Journal of Biosocial Sciences 32:443-458.(forthcoming)

Clark, Shelley. 2000. Son Preference and Sex Composition of Children: Evidence from India. Demography 37(1) : 95-108.

Griffiths, Paula, L. and Bentley, Margaret, E. 2001. The Nutrition Transition is Underway in India. The Journal of Nutrition 131 : 2692-2700.

Jejeebhoy, Shireen J. 1999. Reproductive Health Information in India: What are the Gaps? Economic and Political Weekly 34(42 & 43) : 3075 – 3080.

Kanitkar, Tara. 1999. National Family Health Survey: Some Thoughts. Economic and Political Weekly 34(42 & 43) : 3081 – 3083.

Kulkarni, P.M. 1999. Gender Preference Contraceptive Prevalance: Evidence of Regional Variations. Economic and Political Weekly 34(42 & 43) : 3058 – 3062.

Mishra, Vinod K., Robert D. Retherford, and Kirk R. Smith. 1999. Biomass cooking fuels and prevalence of tuberculosis in India. International Journal of Infectious Diseases 3: 119-129.

Moulasha, K. and G Rama Rao. 1999. Religion-Specific Differentials in Fertility and Family Planning. Economic and Political Weekly 34(42 & 43) : 3047 – 3051.

Mulay, Sanjeevanee. 1999. Demographic Transition in Maharashtra, 1980-93. Economic and Political Weekly 34(42 & 43) : 3063 – 3074.

Roy, T.K., V. Jayachandran, and Sushanta K Banerjee. 1999. Economic Condition and Fertility: Is There a Relationship? Economic and Political Weekly 34(42 & 43) : 3041 – 3046.

Singh, Padam. 1999. National Family Health Survey, 1992-93: Post Survey Check. Economic and Political Weekly 34(42 & 43) : 3084 – 3088.

Srinivasan, K. and Sanjay Kumar. 1999. Economic and Caste Criteria in Definition of Backwardness. Economic and Political Weekly 34(42 & 43) : 3052 – 3057.

Visaria, Leela. 1999. Proximate Determinants of Fertility in India: An Exploration of NFHS Data. Economic and Political Weekly 34(42 & 43) : 3033 – 3040.

Visaria, Pravin and S Irudaya Rajan. 1999. National Family Health Survey: A Landmark in Indian Surveys. Economic and Political Weekly 34(42 & 43) : 3002 – 3007.

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ABSTRACTS OF NFHS BULLETINS, NFHS SUBJECT REPORTS,; AND SELECTED JOURNAL ARTICLES; (Based on data from India’s first National Family Health Survey, 1992-93)
[Abstarcts are generally "author-provided" whenever one available, except for NFHS Bulletin and Subject reports]

NFHS Bulletin No. 1 (1995). Eight Million Women Have Unmet Need for Family Planning in Uttar Pradesh, by D. Radha Devi, S. R. Rastogi, and Robert D. Retherford.

NFHS Subject Report No. 1 (1996). Unmet Need for Family Planning in Uttar Pradesh, by D. Radha Devi, S. R. Rastogi, and Robert D. Retherford.

The main findings from these two studies are that, in Uttar Pradesh, 89 percent of contraceptive need for spacing is unmet, and 43 percent of contraceptive need for limiting is unmet. The main policy implication is that family planning services, especially the provision of temporary methods, need to be expanded and improved. The research findings strongly suggest that improved services could result in substantial increases in the use of contraception for both limiting and spacing. Because many women prefer to use temporary methods rather than sterilization to limit their family size, intensified promotion of temporary methods would reduce not only unmet need for spacing but also unmet need for limiting.

NFHS Bulletin No. 2 (1995). Women in 13 States Have Little Knowledge of AIDS, by Subrata Lahiri, Deborah Balk, and K. B. Pathak.

Balk, Deborah, and Subrata Lahiri. 1997. Awareness and knowledge of AIDS among Indian women: evidence from 13 states. Health Transition Review 7: 421-465.

These two studies looked at the 13 states for which supplementary questions on knowledge of HIV/AIDS were included in NFHS-1. In the 13 states considered as a whole, only 17 percent of ever-married women of reproductive age had ever heard of AIDS. This percentage varied from 8 percent in Assam to 85 percent in Mizoram. By residence, it varied from 8 percent in rural areas to 33 percent in urban areas. By education, it varied from 2 percent among illiterate women to 71 percent among women with at least a high school education. By media exposure, it varied from 2 percent among women with no media exposure to 34 percent among those who regularly watch television. Even among those who had heard of AIDS, only about one-fourth had a solid understanding of how the disease is transmitted. Despite low levels of awareness and knowledge, the findings indicate a strong positive correlation between knowledge of AIDS and condom use.

The main policy implications are that the government needs to mount a major public education campaign about HIV/AIDS and to intensively promote condom use among high-risk subgroups. The mass media need to become much more effective communicators about AIDS. The finding that teachers are rarely a source of HIV/AIDS information suggests that a comprehensive HIV/AIDS-awareness program should include an expanded role for schools. Most important, effective ways to convey HIV/AIDS information to the rural majority and the illiterate must be developed — for example, through new uses of film, health workers, and community meetings.

NFHS Bulletin No. 3 (1996). Fertility and Contraceptive Use in Tamil Nadu, Andhra Pradesh, and Uttar Pradesh, by Robert D. Retherford and B. M. Ramesh.

A multiple regression analysis of data for 17 states, with states as the units of analysis, shows that the most powerful predictors of contraceptive prevalence and total fertility are the percentage of women who receive antenatal care and the percentage of girls age 6-14 who are attending school. The importance of antenatal care appears to reflect the dual role of auxiliary nurse-midwives in delivering both antenatal care and family planning services. The results suggest that antenatal care services are an important means of reaching women with contraceptive services. A policy implication is that the government should continue to improve its maternal and child health services, which can be expected not only to improve maternal and child health but also to increase contraceptive use and lower fertility. Another policy implication is that the government should step up its efforts to achieve universal primary and secondary education, especially of girls. Progress toward the goal of universal primary and secondary education can be expected to have many social and economic benefits, including increased contraceptive use and lower fertility.

The three-state comparison is interesting because Uttar Pradesh has very low contraceptive prevalence and very high fertility, while Tamil Nadu and Andhra Pradesh have much higher contraceptive prevalence and much lower fertility. Yet the three states differ little in many socioeconomic indices, including the percentages of households that live below the poverty line, that obtain drinking water from a pump or pipe, that have a toilet facility, that use wood as a cooking fuel, that own various consumer goods, or that have pucca houses. On the other hand, the percentage of pregnant women receiving antenatal care is much higher in Andhra Pradesh and Tamil Nadu than in Uttar Pradesh, as is also the percentage living in households with electricity and the percentage who are regularly exposed to the electronic mass media. Electrification and media exposure are linked of course, because the main sources of media exposure — televisions and radios — are usually powered by electricity. A policy implication is that high quality health and family planning services, combined with electrification of households and improved accessibility to the electronic mass media, can increase contraceptive use and lower fertility substantially, even in the absence of major progress in many other aspects of economic and social development. In the long run, development is still the best contraceptive, but in the short run, great progress can be made by improving basic health and family welfare services and communication infrastructure and by using that communication infrastructure to promote family planning.

NFHS Subject Report No. 2 (1996). Contraceptive Use in India, by B. M. Ramesh, S. C. Gulati, and Robert D. Retherford.

Knowledge of contraception is almost universal among Indian women, but only 41 percent are actually using contraception, according to the NFHS. The mean number of children at first use of contraception is 2.8. Three-quarters of couples who use contraception rely on sterilization, mainly female sterilization. Among these couples, the median age of the wife when she or her husband was sterilized is 26.6 years. Seventy-nine percent of current users of modern contraceptive methods obtain contraception from government sources. Although only 6 percent of women currently using contraception are using modern temporary methods, nearly one-third of women who not currently using contraception but intend to do so in the future expressed a preference for such methods.

The effects of various predictor variables on contraceptive use are analyzed first without and then with statistical controls for women’s level of education and urban/rural residence. The analysis results in several major findings. Contraceptive use is higher in urban than in rural areas in part because urban women are more educated than rural women. Son preference has a strong effect on contraceptive use up to the point at which women have two living sons, but not beyond. Religion has a substantial effect on contraceptive use, even after residence and education are controlled. In almost all states, Muslims have lower use rates than Hindus.

Although there is considerable variability among states in the effect of caste and tribe on contraceptive use, there is a strong tendency for women from scheduled castes or scheduled tribes to have lower contraceptive use rates than other women. Exposure to the electronic mass media (radio, television, and cinema) has a large, positive effect on contraceptive use, which persists after residence and education are controlled. Utilization of health services for antenatal care or delivery tends to have a positive effect on contraceptive use, even after residence and education are controlled, but the magnitude of this effect varies considerably by state.

The study has a number of policy implications. The analysis of demand for temporary methods of contraception indicates that the government should make greater efforts to promote temporary methods of contraception, and should do so in part through private sector outlets. The finding that education is a key factor influencing contraceptive use indicates that the government should increase its efforts to achieve universal primary and secondary education in the country. The finding that son preference has a negative impact on contraceptive use indicates that the government should increase its efforts to promote values of gender equality and to increase the status of women in society. The finding that religion influences contraceptive use independently of residence and education suggests that the government should take steps to make family planning services more attractive and acceptable to Muslims. For example, Muslim women may be more receptive to temporary methods that can be obtained with less violation of privacy and modesty than is the case with sterilization. The finding that exposure to the electronic mass media has substantial effects on contraceptive use, even after controlling for residence and education, suggests that the government should intensify its efforts at rural electrification as well as its efforts to propagate family planning messages through these electronic media. This is especially important in rural areas where a large majority of women are illiterate.

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NFHS Bulletin No. 4 (1997). Is Son Preference Slowing Down India’s Transition to Low Fertility?, by R. Mutharayappa, Minja Kim Choe, Fred Arnold, and T. K. Roy.

NFHS Subject Report No. 3 (1997). Effect of Son Preference on Fertility in India, by R. Mutharayappa, Minja Kim Choe, Fred Arnold, and T. K. Roy.

The main finding of these studies is that India’s total fertility rate would fall by about 8 percent if gender preference were eliminated (because some couples with gender preferences would stop having children sooner). Most of this gender preference takes the form of son preference, which is strongest in the northern states of Himachal Pradesh, Punjab, and Haryana and in the western state of Maharashtra. Interestingly, the influence of son preference on fertility is stronger among literate women than among illiterate women. This may occur simply because literate women are more likely to use modern contraception to control their fertility, inasmuch as son preference can have no effect on fertility in the absence of conscious fertility control. Thus the findings should not be interpreted as indicating that son preference is stronger among literate women. Nevertheless, the findings do suggest that values relating to son preference are likely to change slowly. A policy implication is that the government can speed up the process by promoting the value of gender equality and by enhancing the status of women by increasing educational levels, media exposure, and opportunities to work outside the home for women.

Arnold, Fred, Minja Kim Choe, and T. K. Roy. 1998. Son preference, the family-building process and child mortality in India. Population Studies 52: 301-315.

The analysis shows that the sex composition of children in the family affects subsequent fertility behaviour in each of the eight states examined (same states as those analyzed in the above Bulletin issue). The fact that the effect of sex composition on fertility is highest in states with a moderate level of fertility suggests that the overall effect of sex composition on fertility may well increase in the short run as fertility continues to fall in the populous northern states where fertility is still high. This occurs because the emergence of conscious fertility control means that it is increasingly possible for son preference to affect fertility.

The effects of family composition on excess female child mortality are more complex. Female children with older sisters are often (but not always) subject to the highest risks of mortality.

The analysis indicates that, in the absence of sex preference, the national contraceptive prevalence rate would increase from its current level (at the time of the NFHS) of 40.6 percent to 45.5 percent. Although moderate, even an increase of this magnitude would be a boon to the family welfare programme. Similarly, the unusually high degree of excess female child mortality in almost all Indian states suggests that the strong preference for sons is substantially diminishing the chances of survival of girls between one and four years of age. For these reasons, a concerted effort to reduce son preference and increase the status of women is essential. Such efforts would be admirable in their own right, but their potential demographic benefits provide a further rationale for placing relevant policies and programmes at the top of the government’s agenda.

NFHS Bulletin No. 6 (1997). Measuring the Speed of India’s Fertility Decline, by R. L. Narasimhan, Robert D. Retherford, Vinod Mishra, Fred Arnold, and T. K. Roy.

A comparative analysis of fertility estimates from the SRS and the NFHS indicates that fertility since the late 1970s has fallen faster than indicated by the SRS (because of greater underregistration of births in earlier years) but more slowly than indicated by the NFHS (because of displacement of births in the NFHS birth histories). Current fertility is probably somewhat higher than indicated by either source.

The findings have implications for the population projections that provide important input for India’s development plans. In the future, fertility will probably fall somewhat faster than officially projected. (Note: We should be able to get a much more accurate estimate of how fast fertility has been declining, once we have the NFHS-2 survey data in hand. We can then prepare trend estimates based on NFHS-1 and NFHS-2.)

NFHS Bulletin No. 5 (1997). State-Level Variations in Wanted and Unwanted Fertility Provide a Guide for India’s Family Planning Programmes, by Sumati Kulkarni and Minja Kim Choe.

NFHS Subject Report No. 6 (1998). Wanted and Unwanted Fertility in Selected States of India, by Sumati Kulkarni and Minja Kim Choe.

In these studies, the authors propose new measures of wanted and unwanted fertility based on actual and wanted parity progression ratios and calculate these measures for eight states in India. In the four large states with high fertility (Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan), levels of wanted fertility are high, at three or more children per married woman, and the proportion unwanted ranges from 20 to 28 percent of total marital fertility. In the three states with moderate levels of fertility (Himachal Pradesh, Punjab, Maharashtra), the proportions of unwanted fertility are even higher, ranging from 31 to 34 percent. In Kerala, which is the state with the lowest fertility, wanted fertility is already at replacement level, and there is very little unwanted fertility. A multivariate analysis indicates that education, religion, exposure to family planning messages on radio or television, experience of child loss, and son preference are among the important determinants of contraceptive use among women who want no more children.

The main policy implication is that, by emphasizing formal and informal education for women, making more imaginative and culturally sensitive use of radio and television to promulgate the advantages of small families, striving to improve child survival rates, and projecting a more positive image of girls and women, the Indian family welfare programme can strengthen women’s motivation to use contraception for limiting their fertility to the level they desire. Improvements in women’s educational levels cannot be achieved in a short time, however. Therefore it is important to strengthen further the role of the electronic mass media in providing women with information on family planning and ways to improve their children’s survival.

NFHS Bulletin No. 7 (1997). Media Exposure Increases Contraceptive Use, by Robert D. Retherford and Vinod Mishra.

An analysis of NFHS data for 84,558 currently married women of reproductive age indicates that general exposure to radio, television, and cinema has a strong positive effect on both current contraceptive use and intended future use of contraception. One question of particular interest to policymakers, however, concerns whether specific exposure to family planning messages has an effect on contraceptive behavior beyond the general effect of media exposure. The analysis shows that recent exposure to family planning messages on radio or television has a significant positive effect on current and intended future use of contraception, even after controlling for the effects of general media exposure and a number of other variables.

A policy implication is that the Indian government should continue to sponsor family planning messages on radio and television and perhaps even intensify these efforts. This would seem to be a cost-effective approach to reaching the millions of women who are exposed to electronic media and informing them about the use of contraception and the benefits of small family size. The government should also do what it can to increase general exposure to electronic mass media. This is more difficult because the main barrier to increased ownership of radios and televisions is inadequate incomes — a daunting challenge for government policies and programmes. Another constraint limiting exposure to electronic mass media in much of India is inadequate access to electrical power, particularly in rural areas. According to the NFHS, nearly half of all households in India do not have electricity. Acceleration of the pace of rural electrification and expansion of telecommunications networks could do much to increase media exposure, especially exposure to television.

NFHS Subject Report No. 5 (1997). Maternal Education and the Utilization of Maternal and Child Health Services in India, by Pavalavalli Govindasamy and B. M. Ramesh.

This study examines the relationship between maternal schooling and factors known to reduce risks of maternal and child mortality, namely health-care practices, for selected northern and southern states in India. It is hypothesized that the practices of educated women are quite different from those of uneducated women with regard to pregnancy, childbirth, immunization, and management of childhood diseases such as diarrhoea and acute respiratory infection (ARI). However, there exist a number of potentially confounding factors, including various aspects of socioeconomic status, that are associated with maternal education, so that it is necessary to statistically control for these other factors. The findings indicate that a higher level of maternal education results in improved child survival because health services that effectively prevent fatal childhood diseases are used to a greater extent by mothers with more education than by those with little or no education. These effects of maternal education persist when the other socioeconomic factors are statistically controlled.

From a programmatic point of view, the conclusions reached in this paper reinforce the call for continued investments in female education.

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NFHS Bulletin No. 8 (1997). Cooking Smoke Increases the Risk of Acute Respiratory Infection in Children, by Vinod Mishra and Robert D. Retherford.

In India, as in many other countries, acute respiratory infections are the leading cause of child death. The NFHS found that 1 in every 15 children under age three had suffered from ARI — defined as a cough accompanied by short, rapid breathing — during the two weeks before the survey. At the same time, about three-quarters of households in the survey reported using wood or animal dung as their main source of energy for cooking. The analysis in this bulletin shows that children under age three living in households that use wood or animal dung as their primary cooking fuel have an almost one-third higher risk of ARI than do children living in households using cleaner fuels, even after controlling for a number of other potentially confounding factors.

The results suggest that a great deal of childhood sickness and death could be prevented by reducing indoor air pollution from biomass fuels used for cooking. An obvious policy implication is that the Indian government should educate the public about the adverse effects of cooking smoke on child health and should do what it can to encourage a shift from biomass fuels to cleaner cooking fuels. Such a shift will probably occur slowly, however, because cleaner fuels are more expensive than biomass fuels, and many Indian households cannot afford to purchase them. Cleaner fuels are also simply not available in many areas. Given these constraints, the government should strengthen its efforts to make improved biomass-burning stoves more widely available — stoves that use fuel more efficiently, that produce less smoke than traditional models, and that are properly vented. These government efforts should give high priority to local needs and emphasize community participation in the design of the stoves. Community participation is important, because if the stoves are unsuitable for cooking local foods, the stoves are not likely to be adopted readily.NFHS Bulletin No. 9 (1998). Accelerating India’s Fertility Decline: The Role of Temporary Contraceptive Methods, by K. B. Pathak, Griffith Feeney, and Norman Y. Luther.

NFHS Subject Report No. 7 (1998). Alternative Contraceptive Methods and Fertility Decline in India, by K. B. Pathak, Griffith Feeney, and Norman Y. Luther.

Three-quarters of contraceptive users in India are sterilized, more than five times the level typical of developing countries. Because sterilization is irreversible, couples are unlikely to use this method unless they are certain they will not want more children in the future. Indian women who choose sterilization have already had an average of four children.

Non-users of contraception who say they do not want another child are identified as having an "unmet need" for family planning. The 1992-93 NFHS identified one-fifth of currently married Indian women as having an unmet need, either for limiting or for spacing births. If all those with an unmet need became users, use in India would rise from 41 percent of married couples to 60 percent. This could lower total fertility rates to 2.3 children per woman, only slightly above the population-replacement level.

Temporary methods not only allow those women who want more children later to defer having them, but also are appropriate for those who are unsure whether they want more children and are therefore unlikely to choose sterilization. According to the NFHS, two-thirds of current users of temporary methods said they wanted no more children; that is, they were using temporary methods for limiting, not spacing, births. Among those not currently practising contraception but intending to do so in the future, 36 percent preferred to use a temporary method. Thus a considerable demand exists for temporary methods in India.

Taking into account changes over time in the behaviour of Indian women of various reproductive age groups who have chosen sterilization in the past, the authors apply that behaviour to women who have not yet chosen sterilization nor reached the end of their reproductive age span. The result suggests that sterilization will not be as effective in reducing fertility below the current level of 3.4 children per woman as it has been in reducing fertility from higher levels in the past.

The relationship between temporary methods, birth spacing, and fertility level is complex because temporary methods may be used for spacing or limiting births. The NFHS data suggest that most Indian births are spaced about 2.5 years apart. This average, which is similar among women of diverse characteristics, is comparable to the average birth intervals in other developing countries and also similar to those in 13 developed countries. This broad similarity in median birth intervals among countries with very different levels of fertility and contraceptive use implies that most contraceptive use occurs in the interval following a woman’s last birth — in other words, that women who use temporary methods use them mostly for limiting rather than for spacing births.

Higher levels of temporary-method use do not appear to lengthen average birth intervals, either in India or in other developing countries, unless more than 30 percent of women are using a modern temporary method. When the overall level of contraception is low, most use appears to be for limiting births, and little is for spacing. In any case, the NFHS and DHS data for other countries suggest that increasing the length of birth intervals has only a small effect on total fertility levels.

The results of the analysis indicate that no fertility decline can be expected as a result of lengthening birth intervals. However, the increased use of temporary methods by Indian women to stop childbearing may lower total fertility significantly. Continued heavy reliance on sterilization by the Indian family planning program runs the risk of stalling India’s fertility decline, whereas increased use of temporary methods holds promise of accelerating it.

NFHS Subject Report No. 8 (1998). Mother’s Employment and Infant and Child Mortality in India, by Sunita Kishor and Sulabha Parasuraman.

In the NFHS, mothers who are employed have a 10 percent higher infant mortality rate and a 36 percent higher child mortality rate than mothers who are not employed. Male child mortality increases more than female child mortality if mothers work. Employment of women outside the home for cash, perhaps the most empowering form of employment for women, does not lower the risk of mortality for girls, but it increases the risk for boys. Gender differentials in child mortality narrow when mothers work, for two reasons: because female child mortality tends to be higher than male child mortality, and because male child mortality rises when mothers work. A further finding is that employment of mothers in urban areas has more detrimental effects on infant and child survival than employment of mothers in rural areas. These findings do not imply that mother’s employment should be discouraged. Instead, they indicate the need for viable child-care alternatives for women who work and for a renegotiation of gender roles and gender relations.

NFHS Subject Report No. 9 (1998). Fertility in India, by M. M. Gandotra, Robert D. Retherford, Arvind Pandey, Norman Y. Luther, and Vinod K. Mishra.

A multivariate analysis of parity progression indicates much lower parity progression ratios among women who have not experienced any child deaths than among women who have experienced one or more child deaths. Parity progression ratios are also much lower among women who have one living son than among women who have no living son, and much lower among women who have two or more living sons than among women who have only one living son. These results are affected hardly at all by controls for urban-rural residence and education.

Parity progression ratios tend to be higher among rural women than among urban women, but this difference virtually disappears when education is controlled. On the other hand, differentials by education persist when residence is controlled, indicating that urban women have lower fertility largely because they are more educated. Differentials in parity progression ratios by husband’s education largely disappear when residence and wife’s education are controlled, indicating that wife’s education is a considerably more important determinant of fertility than husband’s education. Differentials in parity progression by religion tend to be large and mostly unaffected by controls for residence and education, indicating that differences by religion in levels of urbanization and education do little to explain fertility differences by religion. On the other hand, fertility differentials by caste/tribe, which are usually small to begin with, are further reduced by controls for residence and education.

Parity progression ratios tend to be considerably lower among women who are regularly exposed to the electronic mass media than among women who are not exposed, and this effect is reduced only partly by controls for residence and education. Parity progression ratios also tend to be considerably lower among women who have been exposed to family planning messages on radio or television than among women who have not been exposed, and again this effect is reduced only partly by controls for residence and education, indicating that the government’s efforts to spread family planning through the electronic mass media are working.

The findings have a number of policy implications: To help bring down fertility, the government should intensify its efforts to reduce child mortality, promote gender equality, increase levels of female education, promote electrification of households and expansion of television and radio networks, and propagate family planning messages through those networks and other mass media. The government also needs to consider ways to make its family welfare services more attractive to Muslims. For example, less emphasis on sterilization, which infringes on Muslim values of modesty and seclusion of women, and more emphasis on temporary methods of contraception, which are less intrusive, might have the effect of increasing contraceptive use among Muslim women.

NFHS Bulletin No. 10 (1998). Mother’s Tetanus Immunisation Is Associated Not Only with Lower Neonatal Mortality but Also with Lower Early-Childhood Mortality, by Norman Y. Luther.

Tetanus has long been a major killer of newborn children in India, especially in rural areas. Although mortality rates have fallen considerably in recent years, an estimated 200,000 newborns still die of tetanus annually. Tetanus is preventable in newborns, however. Two doses of tetanus toxoid vaccine given one month apart during pregnancy prevent nearly all tetanus infections in both mothers and their newborn children. The Indian government began a concerted effort in 1975-76 to inoculate all pregnant women with the recommended tetanus toxoid vaccine. Nevertheless, the 1992-93 NFHS found that 40 percent of pregnancies in India were not covered by maternal tetanus immunisation.

Interestingly, the analysis presented in this bulletin indicates that, after controlling for the effects of 13 potentially confounding demographic and socioeconomic variables, mother’s tetanus immunisation is associated not only with reduced neonatal mortality, which is expected, but also with substantially reduced early-childhood mortality, which is a surprising result. There is no known or suspected medical explanation for the prolonged ‘protection’ of children associated with mother’s tetanus immunisation. Instead, maternal tetanus immunisation may be viewed simply as a good indicator of a mother’s general health-seeking behaviour. Indeed, it appears to be as good or better an indicator as any of the well-accepted indicators such as mother’s education or household economic level.

A policy implication is that maternal and child health programmes should identify those women who do not receive tetanus immunisation during pregnancy and classify their children as a high-risk group. Public-health education programmes designed to persuade these women to be immunised against tetanus should make sure that they receive information about other health risks that also threaten infants and children. It might also be useful for health workers and investigators to identify any other health-seeking behaviours that tend to characterise women who are immunised against tetanus during pregnancy. Promotion of such behaviours might then be incorporated into health education programmes aimed at women who are not immunised.

NFHS Bulletin No. 11 (1998). Mass Media Can Help Improve Treatment of Childhood Diarrhoea, by K. V. Rao, Vinod K. Mishra, and Robert D. Retherford.

Results from these two studies indicate that, despite a vigorous Oral Rehydration Therapy Programme in India for more than a decade, knowledge and use of ORT to treat childhood diarrhoea remain quite limited. Very small percentages of children who fall sick with diarrhoea are treated with oral rehydration salt (ORS) packets, recommended home solution (RHS), or increased fluids, despite the fact that 61 percent of these children receive treatment from a health facility or provider. In the NFHS, among children born 1-47 months before the survey who had diarrhoea in the last two weeks, 18 percent were given ORS and 19 percent were given RHS. Considered together, only 31 percent were given ORS or RHS.

Among those who receive treatment from a health facility or provider, a very large proportion (94 percent) are treated with antibiotics or other antidiarrhoeal drugs, contrary to WHO recommendations that drugs not be used to treat diarrhoea in young children. The use of drugs is common among both public- and private-sector providers but is more common in the private sector.

The analysis indicates that the electronic mass media are effective in increasing awareness and use of ORT. Women regularly exposed to the media are much more likely than unexposed women to know about ORS packets and to use ORS or RHS. This result is valid even after controlling for the effects of a number of potentially confounding variables by holding them constant. Results also indicate some discrimination against girls in the use of ORS.

These findings suggest that both mothers and health-care providers are not well informed about the proper treatment of childhood diarrhoea. There is clearly a need to strengthen education programmes for mothers and to provide supplemental training to health-care providers, emphasizing the importance of increased fluid intake and discouraging the use of unnecessary and often harmful drugs. The Oral Rehydration Therapy Programme also needs to address the problem of gender discrimination in the treatment of diarrhoea. In all these efforts, the mass media can help.

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NFHS Subject Report No. 11 (1998). Infant and Child Mortality in India, by Arvind Pandey, Minja Kim Choe, Norman Y. Luther, Damodar Sahu, and Jagdish Chand.

This Subject Report examines infant and child mortality and their determinants for India as a whole and for individual states, using data from the 1992-93 National Family Health Survey. Neonatal (first month), postneonatal (age 1-11 months), infant (first year), and child (age 1-4 years) mortality are estimated, as well as the effects of socioeconomic background characteristics, demographic characteristics, and mother’s health-care behavior on these measures of mortality, using information from women’s birth histories pertaining to children born during the 12-year period before the survey.

Infant mortality declined 23 percent in India between 1981 and 1990, and child mortality declined 34 percent during the same period. Nevertheless, mortality rates are still high. Among children born during the 12 years before the survey, 88 out of 1,000 are estimated to die during the first year of life, and 121 are estimated to die before reaching age five. In recent years, infant and child mortality have declined in every state. These declines have been consistently largest for child mortality and smallest for neonatal mortality. Apart from these consistent trends, however, there are substantial variations among individual states. For example, infant mortality is less than 40 per 1,000 in Kerala and Goa but more than 120 per 1,000 in Orissa and Uttar Pradesh.

Sex differentials in infant and child mortality reflect strong son preference in many states. Most states exhibit excess male mortality during the neonatal period but excess female mortality during childhood. The only exceptions are Tamil Nadu and Kerala. In the country as a whole, female child mortality is 40 percent higher than male child mortality. The sex differentials in infant and child mortality suggest that son preference and discrimination against female children are very strong in northern states but minimal or nonexistent in southern states.

Among socioeconomic background characteristics, urban/rural residence, mother’s exposure to mass media, and use of clean cooking fuel are found to have substantial unadjusted effects on infant and child mortality, but these effects are much smaller when the effects of other socioeconomic variables and basic demographic factors are controlled. Mother’s literacy, access to a flush or pit toilet, household head’s religion and caste/tribe membership, and economic level of the household (indicated by ownership of consumer goods) have substantial and often statistically significant adjusted effects on infant and child mortality. Both unadjusted and adjusted effects of most of these background characteristics are largest for child mortality and smallest for neonatal mortality.

In general, demographic characteristics have substantial adjusted effects on mortality before age five. The adjusted effects are not very different from the unadjusted effects (i.e., the introduction of controls makes little difference) except in the case of birth order and mother’s age at childbirth. Adjusted neonatal mortality decreases with increasing birth order, whereas adjusted postneonatal and child mortality increase with increasing birth order. The combination of effects on neonatal mortality and postneonatal mortality results in a U-shaped relationship between birth order and infant mortality, with third-order births showing the lowest mortality. Mother’s age under 20 at childbirth is associated with much higher mortality of first-born children. Among second and higher-order births, the relationship between mother’s age at childbirth and mortality is U-shaped. Children born after a short birth interval, children who are followed by a next birth within a short interval, and children with an older sibling who died all experience much higher mortality before age five than do other children. Controlling for other variables does not change the effects of these factors very much.

Among variables indicating mother’s health-care behavior, mother’s tetanus immunization during pregnancy has a strong association with reduced neonatal mortality.

This study provides information for health planners and managers responsible for programmes to reduce infant and child mortality. Encouraging mothers to space births by intervals of at least 24 months will greatly enhance the survival of children. Minimizing the number of births to very young mothers (under age 20) and avoiding higher-order births will also substantially enhance survival chances of children during the first five years of life. Family health programmes should emphasize tetanus immunization for all pregnant mothers. They should also identify families that have already experienced infant or child death and should provide them with intensified maternal and child health services.

NFHS Bulletin No. 12 (1998). Identifying Children with High Mortality Risk, by Minja Kim Choe, Norman Y. Luther, Arvind Pandey, Damodar Sahu, and Jagdish Chand.

The analysis identifies seven groups of children who are especially vulnerable to infant and child mortality:

I. Children born less than 24 months after a previous birth

II. Children in families where an older sibling has died

III. Children born to mothers less than 20 years old

IV. Children of illiterate mothers

V. Children in very poor households

VI. Children in households whose head is Hindu and belongs to a scheduled caste or scheduled tribe

VII. Children in households without access to a flush or pit toilet

Intervention programs – such as efforts to provide supplemental nutrition and basic immunization to pregnant mothers, infants, and young children – should focus on these high-risk groups.

Mishra, Vinod K., Robert D. Retherford, and Kirk R. Smith. 1999. Biomass cooking fuels and prevalence of tuberculosis in India. International Journal of Infectious Diseases 3: 119-129.

NFHS Bulletin No. 13 (1999). Cooking with Biomass Fuels Increases the Risk of Tuberculosis, by Vinod K. Mishra, Robert D. Retherford, and Kirk R. Smith.

Tuberculosis is the world’s leading cause of death from a single infectious agent. One-third of the world’s population are infected with Mycobacterium tuberculosis, and an estimated 3 million people die from TB each year worldwide. India has the largest pool of TB-infected people of any nation. It is estimated that more than half of India’s adult population are infected with the TB bacterium, and approximately 500,000 persons die from TB each year in the country. In recent years, the growth of drug-resistant TB and the rapid spread of HIV/AIDS have contributed to the resurgence of TB in India, as in many other parts of the world.

India’s 1992-93 NFHS indicates that about three-quarters of Indian households use wood or animal dung as their main source of energy for cooking. The analysis in these two studies shows that, among persons age 20 and over, the prevalence of active tuberculosis is 2.5 times higher among those living in households that use wood or animal dung as their primary cooking fuel than among those living in households using cleaner fuels, even after controlling for a number of other potentially confounding factors by holding them constant. The analysis also indicates that, among persons age 20 and over, 51 percent of the prevalence of active tuberculosis is attributable to cooking smoke; i.e., if everyone had been using the current mix of cleaner fuels all along, the prevalence of active tuberculosis would be 51 percent lower than it was at the time the NFHS was conducted.

There are several factors that could affect the validity of the findings. Fuel type is not an ideal measure of exposure to smoke. And reports of TB by household heads or other household informants are not as accurate as clinical measures of active TB. Further research based on better measures of smoke exposure and clinical measures of TB is needed to further substantiate the findings.

The findings suggest that the prevalence of TB in India, and probably in many other developing countries as well, could be reduced substantially by lowering exposure to cooking smoke from biomass fuels. Perhaps the most obvious long-run policy implication is that the government should promote a shift from biomass fuels to cleaner fuels, which would also have significant health benefits from reduced ophthalmic, respiratory, cardiovascular, and perinatal problems. In the short run, however, such a shift may not be feasible for the large proportion of households who cannot afford more expensive cleaner fuels. Moreover, given current infrastructure and fuel availability, neither the Indian government nor the private sector is in a position to provide all households with cleaner fuels. A more feasible policy in the short run would be for the government to increase its efforts to educate the public about the adverse health effects of cooking smoke and to accelerate its improved cookstove program by making available inexpensive biomass-burning stoves that are fuel-efficient, less smoky, and equipped with flues or hoods designed to prevent the release of pollutants directly into the kitchen and other parts of the dwelling. For such programs to be effective, local needs and community participation should be given high priority. The government should also continue to strengthen its TB prevention and treatment programs.

NFHS Subject Report No. 12 (1999). Factors Affecting Source of Family Planning Services in India, by P. S. Nair, Griffith Feeney, Vinod K. Mishra, and Robert D. Retherford.

The public sector is the primary source of family planning services in India. About four-fifths of women who use, or whose husbands use, modern methods obtain contraceptives from government sources. The government programme relies largely on clinical methods, particularly female sterilization. There is some evidence, however, that the heavy reliance on public-sector services may be changing, along with the emphasis on sterilization.

The proportion of couples using private-sector sources appears to be increasing, although levels vary considerably by socioeconomic status and by state. There has been a general expectation that expansion of private-sector services will increase the outreach of India’s family planning programme, enhance the programme’s credibility, improve the quality of family planning services, increase the acceptability of contraceptive methods, and reduce unintended pregnancies.

This Subject Report analyzes factors associated with use of private-sector family planning services, based on data from India’s 1992-93 National Family Health Survey (NFHS). Contrary to expectations, the analysis shows little relationship between the proportion of women using private-sector family planning services in a state and state-level fertility rates. This suggests that relatively high reliance on private-sector services is not a prerequisite for low fertility. One possible explanation is that women may use private-sector services not because they are of high quality, but rather because public-sector services are of poor quality or unavailable. Another possibility is that women are more likely to obtain temporary methods from private-sector sources and that these methods are less effective than sterilization.

Other things being equal, it is still reasonable to expect that expansion of private-sector services will enhance the overall performance of India’s family planning programme. This report examines seven factors that might influence a women’s use of private-sector services: age, urban/rural residence, education, religion, membership in a scheduled caste or scheduled tribe, electronic media exposure, and geographic region. Urban residence and higher levels of education emerge as the variables most closely associated with use of private-sector sources of family planning.

Because levels of urbanization and education are rapidly increasing in India, this analysis suggests that reliance on private-sector family planning services is likely to expand in the future. There is a need to ensure that private-sector services are of high quality. At the same time, the lack of correlation between relatively high private-sector use and low fertility levels suggests that India’s public-sector family planning programme can increase contraceptive use and reduce fertility substantially even without major involvement from the private sector.

NFHS Bulletin No. 14 (1999). Cooking with Biomass Fuels Increases the Risk of Blindness, by Vinod K. Mishra, Robert D. Retherford, and Kirk R. Smith.

Results indicate that women living in households that use biomass cooking fuels – defined in the National Family Health Survey as wood and dung – have a much higher prevalence of both partial and complete blindness than women living in households that use cleaner fuels. The effect remains strong even after controlling for several potentially confounding demographic and socioeconomic variables. Among women age 30 and older, 17% of partial blindness and 20% of complete blindness can be attributed to cooking smoke from biomass fuels.

NFHS Subject Report No. 13 (1999). Reasons for Discontinuing and not Intending to Use Contraception in India, by Vinod K. Mishra, Robert D. Retherford, P. S. Nair, and Griffith Feeney.

Based on data from India’s 1992-93 National Family Health Survey, this study analyzes the main reasons for discontinuing contraceptive use and for not intending to use contraception in the future. The study also analyzes the effects of seven demographic and socioeconomic variables on reported reasons for discontinuing contraception or intending not to use contraception.

The results indicate that 38% of currently married women age 13-49 who discontinued using contraception did so because of a method-related problem or method failure. Comparing states, the proportion who discontinued because of a method-related problem or method failure ranges widely – from 11% in Meghalaya to 94% in Nagaland. It is not highly correlated with state-level fertility. By contrast, the proportion reporting a method-related problem or method failure as their main reason for discontinuing contraception does not vary widely across socioeconomic groups, either within individual states or in India as a whole.

In the country as a whole, 15% of women who do not use contraception and who do not intend to use contraception in the future report method-related problems as their main reason for not intending to use contraception, while 9% mention opposition to family planning. The proportion reporting opposition to family planning is several times higher among Muslim women than among Hindu women or women of other religions. The estimated effects of age, media exposure, and religion are largely independent of other, potentially confounding, socioeconomic variables.

Only 1% or less of women mention accessibility or cost as their main reason for discontinuing contraception or not intending to use contraception in the future. Similarly, very few women mention replacing a dead child as a reason for discontinuing contraception.

The finding that method-related problems and method failure are important reasons for discontinuing contraception and the finding that method-related problems and opposition to family planning are important reasons for not intending to use contraception in the future suggest that the quality of family planning services in India needs improvement. These findings also suggest the importance of education and motivation activities. Programmes should pay particular attention to women in those states and social categories in which the proportions mentioning method-related problems and opposition to family planning are especially high.

NFHS Subject Report No. 14 (1999). Child Nutrition in India, by Vinod K. Mishra, Subrata Lahiri, and Norman Y. Luther.

Malnutrition plagues a disproportionately large number of children in India compared with most other countries. National-level data on child malnutrition in India have, however, been scarce. Recognizing this gap, India’s 1992-93 National Family Health Survey (NFHS) collected anthropometric data on the height and weight of children below four years of age. The NFHS is based on a large, nationally representative sample and therefore offers a unique opportunity to study the levels and determinants of child malnutrition in the country. This report estimates levels of child malnutrition and effects of selected demographic and socioeconomic factors on child malnutrition. The analysis focuses primarily on the coutnry as a whole, with some findings for individual states.

The results of the study indicate high levels of both chronic and acute malnutrition among Indian children. Fifty-two percent of all children below age four are stunted (as measured by height-for-age), 54 percent are underweight (as measured by weight-for-age), and 17 percent are wasted (as measured by weight-for-height). The extent of severe malnutrition is also substantial. Twenty-nine percent of the children are severely stunted, 22 percent are severely underweight, and 3 percent are severely wasted, according to internationally accepted definitions. The lower prevalence of wasting than stunting or underweight indicates that chronic malnutrition is more prevalent in India than acute malnutrition. Although less severe in percentage terms, the prevalence of wasting in India is about 8 times and the prevalence of severe wasting is about 25 times the prevalence in the international reference population that provides the basis for comparison.

There is considerable variation in the prevalence of malnutrition by state. Among the states, Bihar and Kerala have the highest and lowest prevalence of malnutrition, respectively. Even in Kerala, which has the lowest prevalence, 27 percent of children below age four are stunted, 28 percent are underweight, and 12 percent are wasted.

A multivariate analysis of the effects of selected demographic and socioeconomic factors on child malnutrition indicates that the strongest predictors of child nutrition in India are child’s age, child’s birth order, mother’s education, and household standard of living. Older children and children of higher birth order are more likely to be malnourished. Children whose mothers are more educated and children who live in households with a relatively high standard of living tend to be better nourished than other children. Boys and girls have about the same levels of stunting and underweight, but boys are somewhat more likely than girls to be wasted. The disadvantage of boys in this regard is surprising in view of other evidence that girls tend to receive less care than boys in India.

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NFHS Bulletin No. 15 (2000). Women’s Education Can Improve Child Nutrition in India, by Vinod K. Mishra and Robert D. Retherford

This issue of the NFHS Bulletin estimates levels of child malnutrition and examines the effects of mother’s education and other demographic and socioeconomic factors on the nutritional status of children. Results indicate that more than half of all children under age four are malnourished. Children whose mothers have little or no education tend to have a lower nutritional status than do children of more-educated women, even after controlling for a number of other—potentially confounding—demographic and socioeconomic variables. This finding suggests that women’s education and literacy programs could play an important role in improving children’s nutritional status.

NFHS Subject Report No. 15 (2000). Child Immunization in Madhya Pradesh, by Rakesh Munshi and Sang-Hyop Lee

The 1992–93 NFHS provides considerable information on immunization coverage. Survey results indicate that the Government of India's Universal Immunization Programme (UIP) has met with only limited success in Madhya Pradesh, which is one of the most backward states in India. Only 29 percent of children age 12–23 months are fully immunized against the six diseases covered by the UIP—tuberculosis, diphtheria, pertussis (whooping cough), tetanus, polio, and measles. Another 37 percent are immunized against some, but not all, of these diseases, and 34 percent have not received any immunizations at all. Most of the children who are partly immunized have not been immunized against measles, indicating that the measles component of the immunization programme needs particular attention.

This report estimates the effects of selected demographic and socioeconomic characteristics on immunization coverage. Children are more likely to be fully immunized if their mothers are more educated, if their mothers are at least 20 years old, and if their mothers received antenatal care. Children living in uncrowded households are more likely to be fully immunized than other children, and boys are somewhat more likely to be fully immunized than girls.

The analysis also shows that full immunization coverage reduces child mortality substantially. Among children surviving to age 12 months, the probability of dying between ages 12 and 48 months is 18 per 1,000 for fully immunized children and 64 per 1,000 for children who are not fully immunized. Other variables that have large effects on child mortality include antenatal care, birth order, and child's sex. Children of mothers who had antenatal care have lower mortality than other children. Children of lower birth orders have lower mortality than children of higher birth orders, and boys have somewhat lower mortality than girls.

NFHS Subject Report No. 16 (2000). Are the WHO Guidelines on Breastfeeding Appropriate for India? by Ravilla Anandaiah and Minja Kim Choe

NFHS Bulletin No. 16 (2000). Are the WHO Guidelines on Breastfeeding Appropriate for India? by Ravilla Anandaiah and Minja Kim Choe

Using data from India’s first National Family Health Survey, conducted in 1992-93, this report examines factors affecting breastfeeding practices and the effect of breastfeeding on mortality at each month of infancy. The analysis is done separately for three groups of states classified according to their levels of infant mortality: high-mortality states, medium-mortality states, and low-mortality states.

Breastfeeding is nearly universal in India and continues for most children beyond infancy. For many infants, however, supplemental food is introduced at an early age. Up to six months of age, exclusive breastfeeding is most common in medium-mortality states followed by states where infant mortality is high. In all three groups of states, infants who live in rural areas, whose mothers are illiterate, and whose families have low economic status are more likely than other infants to be exclusively breastfed.

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

These results call into question the WHO recommendation that children be exclusively breastfed up to age 4–6 months. They suggest that supplemental food should be introduced at earlier ages, especially when a mother’s health and nutritional status are low. In such situations, it appears that mother’s milk is frequently not adequate to provide the level of nutrition that a growing infant requires. It also appears that the dangers of disease contamination from supplemental foods may not be as great as commonly thought, at least not in India. Thus it may be possible to reduce infant mortality in India by introducing nutritious supplemental food for children at quite young ages (2-3 months) as well as by providing poorly nourished pregnant and lactating mothers with nutritional supplements. Further research is needed to explore the relationship between the nutrition and health of mothers and the effects of breastfeeding on infant mortality in India and in other developing countries.

NFHS Subject Report No. 17 (2001). How much has fertility declined in Uttar Pradesh? , by Robert D. Retherford, Vinod K. Mishra, and G. Prakasam.

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

NFHS Subject Report No. 18 (2001). Does community access affect the use of health and family welfare services in India ? by N. P. Das, Vinod K. Mishra, and P. K. Saha.

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

Chatterjee, Uma, and Rajib Acharya. 2000. Seasonal Variation of Births in Rural West Bengal: Magnitude, Direction and Correlates. Journal of Biosocial Sciences 32:443-458.(forthcoming)

This paper examines seasonal variation of births in a rural community of West Bengal, India, by exploring data from the 1992--93 National Family Health Survey. Suitable time series analyses were used to determine the seasonal pattern of births and to estimate peaks. The trigonometric regression technique was used to carry out this objective. The study attempted to link the results of the regression analysis to the atmospheric temperature of the region during 1987--91, the distribution of respondent's husband's occupations and the marriage pattern of the community. It was found that, in the study population, conceptions are numerous in the first quarter of a calendar year and the distribution of conceptions over calendar months is negatively associated with the average monthly temperature. In addition, the marriage pattern of the community and the occupational distribution of the fathers also have a significant effect on the distribution of births over calendar months. It is hoped that the findings will boost the development of needs-based maternal and child health (MCH) and family planning programmes in the community.

Acharya, R. and S. Sureender. 1996. Interspouse Communication, Contraceptive Use and Family Size : Relationship Examined in Bihar and Tamil Nadu. Journal of Family Welfare 42(4) : 5-11.

Since the inception of family planning programme, researchers have shown an interest in family planning knowledge, attitude and practice studies. These studies have generally observed the educational level or knowledge of birth spacing to influence contraceptive practice though the correlation between these influencing factors and actual contraceptive use has been far from expected. The present paper has tried to explain this gap by introducing husband-wife communication on family planning as one of the influencing variables.

The results in the first part of the analysis significantly indicate the necessity of good husband-wife communication for the actual practice of contraception – to limit or to space births. The second part of the analysis tries to relate inter-spouse communication with actual fertility. The results show an inconsistent relationship, though in case of Tamil Nadu, they establish that good husband-wife communication can effectively reduce family size.

In short, the findings of the paper immediately call for a new programme perspective for family planning agencies. Up to now, the family planning programme has been developed in such a way that it focuses on the ‘appropriate location of clinics’, ‘proper distribution of and counseling for contaception’ or even sometimes ‘door-to-door promotional efforts’. Advertising appeals are made to inform people about the options open to them and to promote a rational figure of family size for each couple. The findings of this paper open up a new perspective in that in addition to existing services, efforts can be made to make couples understand the importance of making decisions about family planning jointly, by planning their family after effective verbal communication between them.

Achyut, P., R. Acharya and S. Lahiri. 1997. Non-Biological Correlates of Early Neonatal Deaths : Evidences from five selected states of India. Demography India 26(2) : 241-260.

Persistent high early neonatal mortality rate and its proportion in neonatal deaths, especially in rural area of some Northern and Eastern states have been a source of great concern. So, to focus the risk factors, here an attempt is made to study the non-biological correlates of infant deaths in the first week of life using NFHS data for rural area of Bihar, U.P, M.P, Orissa, and W.B. For this, a framework used by Kikhala for the study of perinatal mortality is modified to meet the present need. Bivariate and multivariate techniques are used to study the relationship between different variables and the dependent variable. The study shows that caste and education of mother have significant effect on the survival of infant in first week of life. All the variables related to pregnancy and delivery, mother's demographic factors and child characteristics have shown significant impact on outcome of pregnancy, in both bivariate and multivariate analyses. By using logistic regression, successively adding group of variables at different stages, the sequences of effects of different variables in the conceptual framework are established.

Begum, S., P. Arokiasamy, and Rajib Acharya. 1998. Factors Affecting Complications During Delivery- An Analysis of NFHS Data. Journal of Family Welfare 44(4) : 15-26.

This paper attempts to investigate the factors affecting complications during delivery in the states of Tamil Nadu and Uttar Pradesh. Specifically, the influence of 1) demographic characteristic of mothers such as parity, age of mother at birth, and previous birth interval 2) child characteristics, namely the size of the baby 3) medical supervision characteristics, such as, number of visits, place of delivery and assistance during delivery and 4) socio-economic factors, such as, education, occupation, standard of living, religion and caste on delivery complication have been examined for births which occurred in the last four years. About 20 percent complication during delivery are reported in Tamil Nadu whereas in Uttar Pradesh it is only 10 percent. The incidence of instrumental delivery is higher in TN and in UP non-instrumental delivery is the majority. The complication during delivery mostly depends upon the size of the baby which is affected by physiological condition of the mother. Either the baby is large or small complication is more during delivery as compared to average size baby. Place of delivery and assistance during delivery are found to be significant factors directly related with complications. Among the demographic characteristics, low parity is found to be risky. Living standard and place of residence are the background factors which play an important role. The risk of complication is higher in UP compared to TN keeping other factors affecting complication constant.

Acharya, Rajib. 1998. Gender Disparity, Development, and Fertility Transition in India: An Inter-state Analysis. Journal of Social Sciences 2(4) : 253-263.

The shift of the concept of Women in Development (WID) to Gender and Development (GAD) during last two decades has opened the scope of research in this direction. Gender disparity in different aspects of human life must have some bearing on social and economic development, female autonomy and fertility in a population or vice versa. This paper attempts to look into the matter through constructing different and combined gender disparity indices and also some development indices as well as indices of fertility transition and female autonomy . Based on mainly NFHS data and Government Publications , this work shows that gender disparity against women exists in health , economic and socio-cultural aspects . In all aspects , the states vary widely. On the combined scale , Rajasthan appears to discriminate against women the most , while disparity against women is the least in Kerala. Goa and Kerala are highly developed in their social structure while social development in other states has just been started . Fertility transition in U.P , Bihar , Haryana and M.P is far away from the best state Goa. Social development , female autonomy and fertility transition , all three aspects are found to be important correlates of gender disparity while economic development seems to have no say in this respect . This effort , later can be supplemented by much more detailed study , while firstly to incorporate the issue in our developmental plans we need to build up a strong and quality database for studying gender.

Bhat, P.N. Mari and Francis Zavier. 1999. Finding of the National Family Health Survey: Regional Analysis. Economic and Political Weekly 34(42 & 43) : 3008 – 3032.

This paper attempts to show that the rich data on demographic, health and background characteristics of the respondents and their households collected in the National Family Health Survey can profitably be analysed at the regional level. It checks the validity of estimates for a few variables derived for 76 natural regions from the survey data with similar estimates based on the 1991 Census. After ensuring consistency between these estimates, regional variations in many important socio-economic characteristics - for which the NFHS is the only source – are studied through maps generated from a GIS software. The spatial patterns that emerge from this analysis highlight the limitations of state-specific models of demographic change, and provide some interesting evidence on much debated nexus between poverty, malnutrition and disease. The paper concludes with a presentation of survey data on health and living conditions in the slums of Delhi.

Roy, T.K., V. Jayachandran, and Sushanta K Banerjee. 1999. Economic Condition and Fertility: Is There a Relationship? Economic and Political Weekly 34(42 & 43) : 3041 – 3046.

The standard of living or economic status data are not always sufficient to understand the complex mechanism of fertility change. A number of social factors directly and indirectly influence couple’s decisions on family size. Statewise analysis of data shows that only in Punjab is there the expected negative association between living standard and fertility change.

Visaria, Leela. 1999. Proximate Determinants of Fertility in India: An Exploration of NFHS Data. Economic and Political Weekly 34(42 & 43) : 3033 – 3040.

Variations in fertility are generally examined in terms of socio-economic factors such as education, income, caste, place of residence. These factors can affect fertility only through intermediate variables such as proportion of females married, prevalence of contraceptive use, incidence of induced abortion and the fertility inhibiting effect on breastfeeding. This article attempts to estimate the values of the proximate determinants of fertility for major states after examining available evidence and interstate variations in these factors.

Visaria, Pravin and S Irudaya Rajan. 1999. National Family Health Survey: A Landmark in Indian Surveys. Economic and Political Weekly 34(42 & 43) : 3002 – 3007.

What is the rationale for conducting surveys like the National Family Health Survey when there are already available reliable data sets from the census and the sample registration system which provide well-acknowledged data-base for planning and policy making? In this paper a brief examination of the data from the other surveys and their particular limitations precedes an overview of the NFHS, specifically designed to provide the information that social scientists need, and the nature and quality of the data it has generated.

Moulasha, K. and G Rama Rao. 1999. Religion-Specific Differentials in Fertility and Family Planning. Economic and Political Weekly 34(42 & 43) : 3047 – 3051.

The relationship between religion and fertility behaviour has prompted much interest, especially in the context of the rising population in developing countries. In India data reveal that the fertility rate among Muslim women is significantly higher than for Hindu women which may in the first instance be attributed to such practices as post-partum abstinence and the length of amenorrhea after child birth. Clearly, however, there are more complex socio-economic reasons for the differential behaviour of the two communities that needs to be better understood.

Srinivasan, K. and Sanjay Kumar. 1999. Economic and Caste Criteria in Definition of Backwardness. Economic and Political Weekly 34(42 & 43) : 3052 – 3057.

While NFHS was conducted with the primary objective of collecting data on reproductive status, it has generated considerable data on caste and economic conditions. An analysis of this data set shows that there are wide differentials in the economic conditions of the socially backward castes and classes. This raises vital questions on the role and relevance of caste-based privileges.

Kulkarni, P.M. 1999. Gender Preference Contraceptive Prevalance: Evidence of Regional Variations. Economic and Political Weekly 34(42 & 43) : 3058 – 3062.

In India there are marked state and regional variations in gender preference. Its effect on contraceptive prevalence is far more complex than has been understood. Regions of strong gender preference do not necessarily show an adverse impact on contraceptive prevalence. What are the reasons for the lack of an expected concordance at the various levels of gender preference?

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Mulay, Sanjeevanee. 1999. Demographic Transition in Maharashtra, 1980-93. Economic and Political Weekly 34(42 & 43) : 3063 – 3074.

The main thrust of the article is to evaluate demographic transition in Maharashtra, especially during 12 years from 1980-92, on the basis of data made available by two national surveys on fertility and mortality rates, and family health. The study shows that despite high contraceptive prevalence in Maharashtra, there is a very moderate decline in birth rate, in the state. Better reproductive health facilities leading to reduced foetal losses, lesser childlessness and reduced breast-feeding, can be said to be the main factor contributing in increase in fertility. In such situation, only strengthening of IEC component of the family welfare services can result in decline in fertility in Maharashtra.

Jejeebhoy, Shireen J. 1999. Reproductive Health Information in India: What are the Gaps? Economic and Political Weekly 34(42 & 43) : 3075 – 3080.

Although the NFHS has succeeded in updating and enhancing our data base, it has not been able to address some of the major reproductive health issues that lend themselves to being dealt with in large surveys. Among them, maternal health status and morbidity, and their correlates; quality of care concerns and women’s ability to exercise reproductive choice are areas where data gaps continue to exist.

Kanitkar, Tara. 1999. National Family Health Survey: Some Thoughts. Economic and Political Weekly 34(42 & 43) : 3081 – 3083.

For the first time by achieving a degree of uniformity in the administering of questionnaires, sampling methods, data collection, analysis and presentation, the NFHS has been able to generate data on demographic characteristics which are comparable across regions.

Singh, Padam. 1999. National Family Health Survey, 1992-93: Post Survey Check. Economic and Political Weekly 34(42 & 43) : 3084 – 3088.

A post-survey check of the survey data using systematic sampling methods confirmed the high quality of the data generated in the NFHS.

Clark, Shelley. 2000. Son Preference and Sex Composition of Children: Evidence from India. Demography 37(1) : 95-108.

Although the effect of son preference on sex composition of children ever born is undetecable in national-level estimates that aggregates across all families, this article provides empirical evidence from India that son preference has two pronounced and predictable family-level effects on the sex composition of children ever born. First, data from India show that smaller families have a significant higher proportions of sons than larger families. Second, socially and economically disadvantaged couples and couples from northern region of India not only want but also attain a higher proportions of sons, if the effects of family size are controlled.

Griffiths, Paula, L. and Bentley, Margaret, E. 2001. The nutrition transition is underway in India. The Journal of Nutrition, 131, 2692-2700.

Nutrition research in India has previously focused on the serious problem of under-nutrition related to nutrient deficit and high rates of infection. Recent data from the National Family Health Survey 1998/99 (NFHS 2), however, identified a significant proportion of Indian women as overweight, co-existing with high rates of malnutrition. This paper examines the emerging nutrition transition for women living in rural and urban communities of Andhra Pradesh, India. NFHS 2 provides nationally representative data on women's weight and height. In this paper we examine representative data from the state of Andhra Pradesh, (n= 4,032 women). Logistic regression analyses are applied to the data to identify socioeconomic, regional and demographic determinants of overweight and thinness. Results show that the major nutrition problem facing women continues to be under-nutrition, with 37% having a low Body Mass Index (< 18.5), of which 8% are severely malnourished (BMI < 16 kg/m2). However, 12% of the women can be classified as overweight (BMI > 25 kg/m2) and 2% are obese (BMI > 30 kg/m2). Furthermore, in the large cities of the state where 4% of the sample live, 37% of women are overweight or obese, while in the rural areas where 74% reside, 43% have a low BMI. Women from lower socioeconomic groups are also significantly more likely to have a low BMI. Findings from the logistic regression models reveal socioeconomic status to be a more important predictor of both over and underweight than location of residence.

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