1. ANNUAL HEALTH SURVEY FACT SHEET KEY FINDINGS Dr. C. Chandramouli Registrar General & Census Commissioner, India

2. “ Reproductive health and rights are integral to sustainable development and poverty reduction. Investing in universal access to reproductive health is crucial investment in healthy societies and a more sustainable future”. – Ban Ki-moon, Secretary-General, UN on World Population Day, 2012

3. “ Working for the survival and the well being of women and girls is a human right imperative. And in order to take advantage of women’s full potential in the development of their nations, they must be able to plan their lives and families.” – Babatunde Osotimehin, Executive Director, UNFPA on World Population Day, 2012

4. AHS provides key indicators on Reproductive and Child Health at District level in 8 EAG States and Assam Vital inputs for evidence based intervention and monitoring

5. “ There should be an Annual Health Survey of all districts which could be published/monitored and compared against benchmarks” - Dr. Manmohan Singh, Prime Minister of India – In the meeting of National Commission of Population, 2005

6. OBJECTIVE OF AHS  AHS yields a comprehensive, representative and reliable dataset on core vital indicators including composite ones like IMR, MMR and TFR along with their co-variates (process and outcome indicators) at the district level and maps changes therein on an annual basis.  These benchmarks would help in better and holistic understanding and timely monitoring of various determinants on well-being and health of population particularly Reproductive and Child Health.

7. Coverage : Annual Health Survey

8. WHY AHS? o AHS States constitute: 48 percent of country’s Population 59 percent of Births 70 percent of Infant Deaths 75 percent of Under 5 Deaths 62 percent of Maternal Deaths o Enable direct monitoring of UN Millennium Development Goals on Child Mortality and Maternal Health at the district(s) level. o Help in identifying high focus districts meriting special attention in view of stark inter-district variations in these States. o Provide critical inputs to assess the milestones of various interventions including NRHM and pave the way for evidence based planning.

9. KEY FEATURES Coverage- All the 284 districts of 8 EAG States and Assam. Sample Units- 20,694 statistically selected sample unit (Census Enumeration Blocks in urban areas and Villages or a part thereof in rural areas) Sample Identification Work- to uniquely identify the sample units on ground, firm up its boundaries, demarcate the localities and prepare a notional map of the sample unit was done by the staff of ORGI. Sample Units per district- 73. Sample Population- About 20.1 million The Largest Sample Survey in the World

10. KEY FEATURES Contd… Sample Population per district - About 71 thousand. Sample Households - 4.1 million households. Sample households per district - About 14.5 thousand. Conduct of Field Work - hybrid approach wherein fieldwork has been outsourced and supervision is being done by the ORGI. Primary Level of Aggregation – District Periodicity- Annual

11. Indicators under AHS In all, 161 indicators are available from AHS baseline: Fertility- 13 Sex Ratio- 3 Marriage- 5 Mortality- 7 Mother & Child Care- 63  Ante Natal Care: 11  Delivery Care: 8  Post Natal Care: 5  Janani Suraksha Yojana (JSY): 3  Immunization: 8  Vitamin A & Iron Supplements: 2  Birth Weight: 2  Childhood Disease: 6  Birth Registration: 2  Breastfeeding & Supplementation: 12  Awareness in Mothers: 4 Abortion- 6 Family Planning Practices- 15 Disability- 1 Morbidity- 19 Personal Habits:adults-4 Housing & HH Characteristics- 13 Others- 12

12. Indicators under AHS Contd… Under 1 st phase of AHS following 9 indicators have already been released :  Crude Birth Rate (CBR)  Crude Death Rate (CDR)  Infant Mortality Rate (IMR)  Neo-Natal Mortality Rate (NNMR)  Under Five Mortality Rate (U5MR)  Maternal Mortality Ratio (MMR)  Sex Ratio at Birth (SRB)  Sex Ratio (0-4 years) and  Sex Ratio (All ages) Remaining 152 indicators are being released under present phase of dissemination.

13. Five Core Themes Covered The presentation focuses on results pertaining to 5 core themes: Total Fertility Rate Family Planning: Current Usage & Total Unmet Need Ante Natal Care Delivery & Post Natal Care Immunization and Breast Feeding Practices

14. Total Fertility Rate (TFR) Uttarakhand & Odisha and UP & Bihar reflects the two extremes. Significant Rural-Urban variation across all 9 AHS States, the max. in Uttar Pradesh. TFR is the average number of children born to a woman during her entire reproductive span.

15. Total Fertility Rate (TFR) StateState valueMinimumMaximumRange Assam2.6Kamrup (2) Hailakandi (4.2)2.2 Bihar3.7Patna (2.8) Sheohar (4.7)1.9 Jharkhand3.1Purbi Singhbhum (2.4) Lohardagga (4)1.6 Madhya Pradesh3.1Indore (2.2) Shivpuri (4.5)2.3 Chhattisgarh 2.9 Koriya (2.4) Kawardha (3.7)1.3 Odisha2.3Jharsuguda (2) Boudh (3.7)1.7 Rajasthan3.2Kota (2.6) Barmer (4.7)2.1 Uttar Pradesh3.6Kanpur Nagar (2.3) Shrawasti (5.9)3.6 Uttarakhand2.3Pithoragarh (1.7) Haridwar (3.1)1.4 Within a State, the minimum variability of 1.3 reported in Chhattisgarh and the maximum, 3.6 in Uttar Pradesh. Across 284 districts in 9 AHS States, it ranges from 1.7 in Pitthoragarh (Uttarakhand) to 5.9 in Shrawasti (UP)- a variability of more than 4 children. Total Fertility Rate (TFR) Contd…

16. Frequency distribution of districts by level of Total Fertility Rate State0-2.12.2-3.03.1-4.04.1 & aboveTotal Districts Assam3163123 Bihar01261037 Chhattisgarh0124016 Jharkhand0810018 Madhya Pradesh01525545 Odisha10182030 Rajasthan01613332 Uttar Pradesh09481370 Uttarakhand751013 All States2010013232284 20 districts namely Kamrup, NC Hills, Nalbari (Assam); Puri, Khordha, Angul, Jajpur, Jagatsinghpur, Baleshwar, Sundargarh, Doegarh, Jharsugdha, Bargarh (Odisha); Nainital, Almora, Bageshwar, Pitthoragarh, Rudraprayag, Chamoli, Uttarkashi (Uttarakhand) have already achieved the replacement level of 2.1. 46 districts have TFR below the current National average of 2.5 (SRS 2010). 164 districts have recorded TFR of 3.1 and above, the National level TFR of 2001 (SRS). Total Fertility Rate (TFR) Contd…

18.  Current usage of any method varies from 37.6 in Bihar to 64.5 per cent in Rajasthan.  Rural – Urban divide is significant in Jharkhand and Bihar. Family Planning: Current Usage  Contraceptive Prevalence Rate (CPR) is the percentage of currently married women aged 15-49 yrs who are using any method of contraception (modern/traditional).

19. Current Usage of Family Planning- any Method (%) StateState valueMinimumMaximumRange Assam57.9 Dhubri (33.2)Lakhimpur (67.6)34.4 Bihar37.6 Siwan (26)Muzaffarpur (52.2)26.2 Jharkhand47.8 Paschimi Singhbhum (32.7)Dhanbad (61.9)29.3 Madhya Pradesh61.2 Sidhi (45.9)Damoh (74.9)29.0 Chhattisgarh 53.9Dantewada (33.4)Dhamtari (68.7)35.2 Odisha56.2 Kandhamal (28.6)Baleshwar (73.4)44.8 Rajasthan64.5 Dhaulpur (49)Ganganagar (79.2)30.2 Uttar Pradesh49.9 Sitapur (21.9)Jhansi (74.1)52.2 Uttarakhand62.7 Haridwar (53.7)Dehradun (67.1)13.4  Within a State, the least variation is reported in Uttarakhand whereas the most, in Uttar Pradesh.  At district level, current usage of family planning ranges from 21.9 in Sitapur (UP) to 79.2 in Ganganagar (Rajasthan) exhibiting a variability of 4 times. Family Planning: Current Usage Contd…

20. Frequency distribution of districts by current usage of family planning- any method (%) State0-3030-5050-7070 & aboveTotal Districts Assam0320023 Bihar4312037 Chhattisgarh079016 Jharkhand0135018 Madhya Pradesh0240345 Odisha1919130 Rajasthan0124732 Uttar Pradesh32442170 Uttarakhand00130 All States89017412284  As high as 98 districts are reporting less than 50% current usage of any method of family planning.  Only 12 districts namely Damoh, Betul, Jabalpur (MP), Baleshwar (Odisha), Ganganagar, Hanumangarh, Jhunjhunu, Alwar, Udaipur, Dungarpur, Banswara (Rajasthan) and Jhansi (UP) feature in 70% & above category.  35 out of 37 districts of Bihar have reported less than 50% usage of any method of family planning. Family Planning: Current Usage Contd…

22. Share of sterilization in any modern method of family planning (%) AssamUttar PradeshJharkhandBiharOdishaUttarakhandRajasthanChhattisgarhMadhya Pradesh Female35.355.076.386.768.458.776.792.383.6 Male0.6 1.20.90.72.80.72.01.7 Family Planning: Current Usage Contd…

23. Unmet Need for Family Planning  Currently Married Women who are not using any method of contraception but who do not want any more children or want after a period of 2 years are defined as having an unmet need.  Total unmet need varies from a minimum of 19.6% in Rajasthan to 39.2% in Bihar.  Rural- Urban gap is prominent in Jharkhand, Bihar and Uttar Pradesh.  Unmet need for Family Planning is a crucial indicator for assessing the future demand for Family Planning services / supplies.

24. Total unmet need for Family Planning(%) StateState valueMinimumMaximum valueRange Assam24.0Sibsagar (15.3)Dhubri (42.9) 27.6 Bihar39.2Patna (24.6)Kishanganj (52.5) 27.9 Jharkhand30.5Bokaro (18.2)Godda (42.8) 24.6 Madhya Pradesh22.4Jabalpur (14.3)Rewa (34.2) 19.9 Chhattisgarh 26.4 Dhamtari (14.5)Bastar (36) 21.5 Odisha23.2Baleshwar (6.1)Boudh (48.3) 42.3 Rajasthan19.6Ganganagar (10.0)Dhaulpur (32.4) 22.3 Uttar Pradesh29.7Mahoba (15.1)Sitapur (61.3) 46.3 Uttarakhand23.2Dehradun (16.8)Haridwar (29.2) 12.4  The minimum variability within a State is in Uttarakhand whereas the maximum in Uttar Pradesh.  Baleshwar (6.1%) in Odisha and Sitapur (61.3%) in Uttar Pradesh are the two extremes across 284 districts. Unmet Need for Family Planning Contd…

25. Frequency distribution of districts by total unmet need for family planning (%) State0-2020-4040-6060 & aboveTotal Districts Assam6161023 Bihar02017037 Chhattisgarh4120016 Jharkhand2133018 Madhya Pradesh18270045 Odisha12153030 Rajasthan16 0032 Uttar Pradesh9528170 Uttarakhand2110013 All States69182321284  Only in 69 out of 284 districts, the total unmet need for family planning is below 20%.  Bihar and Uttar Pradesh dominate in 40% & above category. Unmet Need for Family Planning Contd…

27. Mean Age at Marriage- Female Mean Age at Marriage is based on the marriages taken place during 2007-2009. Mean age at marriage of females varies from 19.7 in Rajasthan to 22.0 years in Uttarakhand. Rural – Urban differential is of at least 1.4 years in all AHS States. This is quite prominent (2.3 years) in Madhya Pradesh & Rajasthan.

28. Marriages among Females below Legal Age (18 yrs) Based on marriages taken place during 2007-2009. Varies from 3.0% in Uttarakhand to 21.9% in Rajasthan. In rural areas, every 4 th marriage among females in Rajasthan and every 5 th in Bihar & Jharkhand take place below the legal age. Rural- Urban differential is quite significant across all AHS State.

30. Any ANC exceeds 80% in all AHS States. ANC in 1 st trimester: 40% in UP & Bihar to 65% in Chhattisgarh and Madhya Pradesh. Mothers receiving 3 or more ANCs: UP-29.6% to Orissa -76.0 % Mothers who consumed IFA 100 days or more: 6.5% in UP to 23.8% in Chhattisgarh. Low performance in IFA consumption is the main reason for sluggish full ANC: 3.9% in UP to 19.5% in Chhattisgarh. Ante Natal Care (ANC)

31. Full Ante Natal Check-up Full ANC comprise 3 or more ANC, at least one TT injection and consumption of IFA for 100 or more days. Uttar Pradesh reports the minimum coverage of 3.9%; Chhattisgarh, the maximum 19.5%. Full ANC coverage in urban areas is remarkably better than the rural areas. In 5 States, namely Bihar, UP, Rajasthan, Uttarakhand and Jharkhand urban coverage is more than double that of Rural.

32. Mothers who had full antenatal check-up (%) StateState valueMinimumMaximumRange Assam11.9 Dhubri (2.1)Jorhat (18.2)16.1 Bihar5.9 Madhepura (2.4)Patna (16.4)14.0 Jharkhand13.1 Garhwa (3.6)Purbi Singhbhum (31.6)28.1 Madhya Pradesh13.3 Sheopur (1.8)Balaghat (30.8)28.9 Chhattisgarh 19.5Korba (10.9)Dhamtari (34.5)23.6 Odisha18.6 Jajpur (5.4)Jagatsinghpur (36.0)30.6 Rajasthan8.5 Karauli (1.7)Jaipur (19.5)17.8 Uttar Pradesh3.9 Balrampur (0.6)Kanpur Nagar (14.8)14.3 Uttarakhand11.1 Rudra Prayag (3.7)Dehradun (22.7)19.0 Bihar has reported the minimum variability among the districts compared to Odisha reporting the maximum. Less than 1% coverage of full ANC has been reported in Balrampur of Uttar Pradesh; on the other hand Jagatsinghpur of Odisha has reported the maximum 36%. Full Ante Natal Check-up Contd…

33. Frequency distribution of the districts by level of full antenatal check up (%) State<55-1010-1515-2020-2525 & aboveTotal Districts Assam 67640023 Bihar 17 210037 Chhattisgarh 00445316 Jharkhand 37430118 Madhya Pradesh 7111076445 Odisha 037103730 Rajasthan 716720032 Uttar Pradesh 5215300070 Uttarakhand 27211013 All States 9483453215 284  As high as 94 out of 284 districts report less than 5% coverage of full ANC.  Only 15 districts namely Raigarh, Mahasamund, Dhamtari (Chhattisgarh), Purbi Singhbhum (Jharkhand), Indore, Bhopal, Narsimhapur, Balaghat (MP) and Jharsuguda, Mayurbhanj, Jagatsinghpur, Cuttack, Ganjam, Kandhamal, Naupada (Odisha) have reported 25% & above coverage of full ANC. Full Ante Natal Check-up Contd…

34. Ante Natal Check-up

35. Institutional Delivery Institutional Delivery: Ranges from 34.9% in Chhattisgarh to 76.1% in MP. More than 85% of total births have taken place in Govt. Institutions in Madhya Pradesh & Odisha and it is more than 60% in remaining States except Jharkhand & Uttarakhand. Jharkhand is the only State where more than 50% of the births are taking place in Private Hospitals.

36. Institutional delivery is below 60% in 170 districts. Balrampur (UP) recorded the least 16.8% institutional delivery whereas Indore (MP) the most 92.5%, showing a variability of more than 5 times. Balrampur, UP Indore, MP

37. Safe Delivery Safe delivery comprise institutional deliveries and domiciliary deliveries assisted by doctor/nurse/ANM/LHV. Safe Delivery: 47.1 % in Jharkhand to 82.2% in Madhya Pradesh. Rural- Urban differential is quite prominent in Jharkhand, Chhattisgarh and Uttarakhand.

38. Safe delivery (%) StateState valueMinimumMaximumRange Assam 70.1 Karimganj, Hailakandi (34.8)Sibsagar (88.2) 53.4 Bihar 53.5 Sheohar (30.2)Munger (80.4) 50.2 Jharkhand 47.1 Pakaur (24.8)Purbi Singhbhum (69.0) 44.2 Madhya Pradesh 82.2 Dindori (45.5)Indore (96.3) 50.9 Chhattisgarh 49.5 Surguja (32.6)Kanker (69.4) 36.8 Orissa 75.2 Nabarangpur (35.6)Puri (92.7) 57.1 Rajasthan 76.2 Jaisalmer (48.6)Jaipur (92.2) 43.6 Uttar Pradesh 51.3 Balrampur (22.0)Jhansi (89.4) 67.4 Uttarakhand 56.9 Tehri Garhwal (43.1)Nainital (79.5) 36.4 Uttarakhand has exhibited the least variability among districts whereas Uttar Pradesh, the most. Balrampur (UP) has reported the minimum against Indore (MP) reporting the maximum. Safe Delivery Contd…

39. Frequency distribution of districts by safe delivery (%) State<3030-5050-7070-9090 & aboveTotal Districts Assam02129023 Bihar012196037 Chhattisgarh0970016 Jharkhand3960018 Madhya Pradesh015291045 Odisha03520230 Rajasthan01821232 Uttar Pradesh420397070 Uttarakhand0373013 All States7601089514284 About 1/4 th of the districts have reported less than 50% of the safe deliveries. Out of 14 districts reporting 90% & above safe deliveries, 10 belongs to Madhya Pradesh. Safe Delivery Contd…

41. Janani Suraksha Yojana Mothers availing JSY: 14.6% in Jharkhand to 61.6% in Odisha. Rural- Urban differential is acute in the States of Madhya Pradesh, Odisha and Jharkhand.

43. Post Natal Care Mothers receiving PNC within 48 hrs of delivery varies from 57% in Assam to 74.5% in Odisha. At least 1 in every 5 mothers did not receive any post natal check up across all AHS States..

46. New Born Check up New born checked up within 24 hrs of birth exceeds 50% in all AHS States. It varies from 52.6% in Bihar to 74.9% in Odisha. Significant Rural- Urban divide is noticed in Uttarakhand, Jharkhand, Assam and Chhattisgarh.

48. Full Immunization Children are considered fully immunized when they have received vaccination against Tuberculosis, 3 doses of DPT & Polio and 1 dose of measles. All States except Uttar Pradesh have at least half of their children aged 12-23 months fully immunized. Uttar Pradesh reports the minimum percentage of children fully immunized whereas Uttarakhand, the maximum. Rural-Urban gap exceeds 10% in Madhya Pradesh & Jharkhand.

49. Children age 12-23 months Fully Immunized (%) StateState valueMinimumMaximumRange Assam 59.0 Dhubri (29.9)Dibrugarh (83.8) 53.9 Bihar 64.5 Kishanganj (26.6)Samastipur (83.9) 57.3 Jharkhand 63.7 Giridih (28.0)Purbi Singhbhum (82.7) 54.8 Madhya Pradesh 54.9 Jhabua (23.8)Indore (77.6) 53.9 Chhattisgarh 74.1 Surguja (55.3)Kanker (93.2) 37.9 Odisha 55.0 Rayagada (11.9)Kendrapara (82) 70.0 Rajasthan 70.8 Dhaulpur (37.4)Hanumangarh (91.4) 54.0 Uttar Pradesh 45.3 Etah (13.5)Basti (73.8) 60.3 Uttarakhand 75.4 Haridwar (55.3)Pithoragarh (87.5) 32.2 The variability among the districts within a State ranges from 32.2% in Uttarakhand to 70.0% in Odisha. Across all 284 districts, the minimum has been observed in Rayagada of Odisha and the maximum in Kanker of Chhattisgarh. Full Immunization Contd…

50. Frequency distribution of districts by children age 12-23 months Fully immunized (%) State0-3030-5050-7070-9090 & aboveTotal Districts Assam14144023 Bihar122311037 Chhattisgarh0069116 Jharkhand1476018 Madhya Pradesh214245045 Odisha8769030 Rajasthan041017132 Uttar Pradesh1131208070 Uttarakhand00211013 All States2466112802284 90 districts are below 50% level of full immunization. Only 2 districts 1 each from Chhattisgarh & Rajasthan feature in 90% & above category. Full Immunization Contd…

51. Constituents of full immunization

52. FULL IMMUNIZATION

53. Full Immunization Contd…

54. Vitamin A Supplementation to Children At least every 2 nd child aged 6-35 months has received Vitamin A supplement in all AHS States except Uttar Pradesh where it is every 3 rd child.

55. IFA Supplement to Children IFA supplement to children aged 6-35 months during last 3 months ranges from 9.4 in Rajasthan to 37.7% in Chhattisgarh. Situation merit attention across all AHS States however it is quite alarming in Rajasthan & Uttar Pradesh.

56. Breast Feeding Practices  Bihar & UP and Assam & Odisha constitute 2 extremes.

57. Breast Feeding Practices Children exclusively breastfed for at least 6 months ranges from 17.7 in UP to 47.5 % in Chhattisgarh.

58. KEY FINDINGS  Replacement level of TFR 2.1 has been achieved in only 20 out of 284 AHS districts.  In 164 districts, on an average a woman bears more than 3 children.  More than half of currently married woman aged 15-49 years are not using any method of family planning in UP, Jharkhand and Bihar.  Female Sterilization constitutes the most dominant method of family planning among the modern methods across all AHS States except Assam.  Male Sterilization is the least preferred modern method across all AHS States.  At least 1/5 th of currently married women are yet to meet their family planning requirement (Unmet Need) across all AHS States.

59.  Marriages among female taking place below legal age (18 years) is rampant in rural areas as compared to urban areas.  Despite wider penetration of `Any ANC’, the coverage under `first trimester ANC’ as well as `3 or more ANCs’ needs further improvement.  Poor performance of full ANC is primarily due to low IFA consumption.  Universal coverage of JSY remains a concern even in better performing States like Odisha, MP & Rajasthan; the situation in Jharkhand & UP needs immediate attention.  Seven out of every 10 deliveries are `safe’ in Madhya Pradesh, Rajasthan, Odisha and Assam whereas it is less than 5 in Jharkhand and Chhattisgarh. KEY FINDINGS Contd…

60. In spite of better reach of Post Natal Care to Mothers and New-borns in Odisha, MP & Rajasthan, every fifth mother has not received any PNC. In full immunization, even the better performing States like Uttarakhand, Chhattisgarh and Rajasthan fall short by 25-30 percentage points in achieving universal coverage. Improvement has been noticed in most of the indicators as compared to NFHS-3 as well as DLHS-3. Availability of 63 indicators (co-variates) on various facets of Mother & Child Care at the district level will help in understanding the dynamics of composite indicators like IMR, U5MR and MMR. For the first time, the data on TFR, Injury, Morbidity, Personal Habits are available at the district level. This would provide new insight in evidence-based planning and facilitate appropriate interventional strategies. KEY FINDINGS Contd…

61. The fieldwork for 1 st updation round is over and the indicators on vital rates reflecting the change vis-à-vis baseline survey are likely to be released shortly. A Component of Clinical-Anthropometric & Bio-chemical (CAB) Test on a sub-sample basis is scheduled to be introduced in October. WAY FORWARD