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The NFHS-5 results also highlight two major public health concerns — obesity and tobacco use — both known to be risks for non-communicable diseases. (C R Sasikumar) The recent National Family Health Survey (NFHS-5, 2019-21) has shown that fertility continues to decline in India. The Total Fertility Rate (TFR) — the number of children a woman can be expected to have during her lifetime — has declined from 2.2 (NFHS-4, 2015-16) to 2.0, below the replacement rate of 2.1, where a mother is replaced by a daughter. Will fertility continue to decline? From an estimated TFR of around 6 in 1951, the rate declined to 5.2 in 1971, 3.6 in 1991 and 2.4 in 2011, according to the SRS report 2018. Since 2000, the pace of decline in TFR may have slowed. As the TFR in most states declined during the period 2015-16 and 2019-21 (Table 1), we can expect it to continue to decline for some time.
However, the data reveals that there may be some resistance to a very low fertility regime. Both Kerala and Tamil Nadu show the TFR rising from 1.6 and 1.7 respectively to 1.8 during this period. Only a few large states have a TFR below 1.7 — Punjab, West Bengal and the UT of Jammu and Kashmir.
The two states with the highest fertility rate — Bihar (TFR 3.0) and Uttar Pradesh (TFR 2.4) — require special attention as together, they comprise nearly a fourth of India’s population. The TFR in UP was higher than in Bihar until about 2000. Since then, the TFR declined at a faster pace in UP. Family planning and maternal and child health (MCH) programmes, as well as improvement in women’s status, are known to be major drivers of fertility decline.
Both Bihar and UP need to strengthen their programmes. The contraceptive prevalence rate (CPR) by modern methods is nearly the same in both states at around 44.5 per cent compared to 56.5 per cent for India as a whole. However, the CPR by all methods (modern and other methods such as rhythm) is higher in UP (62.4 per cent) compared to Bihar (55.8 per cent), although both are lower than India (66.7 per cent).
Women’s status indicators are generally somewhat better in UP compared to Bihar but lower than in India as a whole. The percentage of adult literate women is 57.8 in Bihar and 66.1 in UP, compared to 71.5 in India. Women with 10 or more years of schooling are 28.8 per cent in Bihar and 39.3 per cent in UP compared to 41.0 per cent in India. A major difference between the two states, which may account for fertility differential, is that the proportion of women aged 20-24 years married before 18 years of age is estimated to be 40.8 per cent in Bihar compared to 15.8 per cent in UP.
Use of modern contraceptive methods increased from 47.8 per cent in NFHS-4 to 56.5 per cent in NFHS-5, which largely contributed to fertility decline. For a long time, female sterilisation has been the single most dominant method of contraception, accounting for 67 per cent of the total in NFHS-5. It is not clear how well the method mix in the programme meets the diverse needs of couples. The proportion of female sterilisation has, however, reduced from 75 per cent in NFHS-4, which implies some improvement in meeting the choice of users. Contraceptive use by men (condoms, sterilisation) is only 17 per cent of the total contraceptive use, leaving women to bear most of the burden of contraception. Improving the quality of care would contribute to a sustained decline in fertility.
The current level of TFR sets the stage for the population stabilisation process to begin for India. The pace of acceleration in population growth rate because of rapidly falling mortality was arrested in 1981. Currently, the population growth rate is estimated to be 1.37 per cent according to SRS (2018). This will continue to decline but the population will continue to grow because of population momentum resulting from a larger number of people entering the reproductive age group of 15-49 years compared to those leaving this age group — the age composition effect of previous high fertility.
It is difficult to predict population size for a long period in advance. However, we can be more optimistic that the medium-fertility variant of the UN Population Division’s estimate of population peaking at 165 crore around 2050 will be realised. According to SRS, the birth rate is higher and the death rate is lower than its model estimates. However, the TFR estimates in NFHS-5 are lower than that predicted by the model, which may provide some balancing effect.
The estimates for sex ratio at birth (SRB), the number of girls per 1,000 boys, vary. The SRS report 2018 had estimated that it declined from 906 in 2011 to 899 in 2018. However, NFHS-4 estimated it to be 919 in 2015-16. NFHS-5 estimates that since then SRB has increased to 929, which is encouraging. If this pace of progress can be maintained then we may expect to reach a natural biological ratio of 950 in about a decade. The ratio has improved in many states. However, it decreased in Chhattisgarh, Jharkhand, Bihar, Himachal Pradesh, Odisha, Tamil Nadu and Kerala among the large states.
The proportion of stunted children below the age of 5 has marginally declined from 38.4 per cent to 35.4 per cent during this period. This decline has occurred among all states except for a significant increase in Himachal Pradesh, Kerala and Telangana among the large states. Inadequate diet among children less than 23 months of age is perhaps a major cause. Both breastfeeding and non-breastfeeding children 6-23 months of age receiving an adequate diet are estimated to be only 12.7 per cent and 11.3 per cent respectively. The government has several programmes to address this issue. However, child malnutrition is high and has persisted for long, action is needed at all government levels and the community to strengthen nutrition programmes.
The NFHS-5 results also highlight two major public health concerns — obesity and tobacco use — both known to be risks for non-communicable diseases. Nearly a fourth of all women and men and men are overweight or obese (BMI = 25.0 kg/m2) and this proportion is increasing over the years. More than a third of men (38 per cent) were reported to be using some kind of tobacco.
In conclusion, the NFHS-5 results indicate that progress has been made in almost all areas. However, one, Bihar and Uttar Pradesh need to strengthen their family planning and maternal and child health programmes as well as improve women’s status to bring TFR to replacement level or below. Two, the pace of improvement in improving sex ratio at birth needs to be maintained. Three, child nutrition programmes may require a rethink and more active involvement of the community is needed to address this serious problem. And, four, attention is required to reduce public health risks arising from increasing obesity and high tobacco use.
Rangarajan is former Chairman, Prime Minister’s Economic Advisory Council and former Governor, Reserve Bank of India. Satia is professor emeritus, Indian Institute of Public Health, Gandhinagar (IIPHG)
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