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ANNUAL HEALTH SURVEYFACT SHEETSecond Updation round(2012-13)

KEY FINDINGSDr. C. ChandramouliRegistrar General & Census Commissioner, India

11 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

2 Working for the survival and the well being of women and girls is a human right imperative. And in order to take advantage of womens 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

3AHS provides key indicators on Reproductive and Child Health at District levelin 8 EAG States and Assam Vital inputs for evidence based intervention and monitoring4OBJECTIVE OF AHSAHS 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.

5Coverage : Annual Health Survey

6WHY AHS?AHS States constitute:50 percent of countrys Population60 percent of Births71 percent of Infant Deaths72 percent of Under 5 Deaths62 percent of Maternal Deaths

Enable direct monitoring of UN Millennium Development Goals on Child Mortality and Maternal Health at the district(s) level.

Help in identifying high focus districts meriting special attention in view of stark inter-district variations in these States.

Provide critical inputs to assess the milestones of various interventions including NRHM and pave the way for evidence based planning.

7KEY FEATURES ContdCoverage- 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 20.94 million whereas it was 20.1 million as per baseline survey. The Largest Sample Survey in the World8 KEY FEATURES ContdSample Population per district - About 73 thousand whereas it was 71 thousand as per baseline survey.

Sample Households - 4.32 million households whereas it was 4.1 million as per baseline survey.

Sample households per district - About 15.2 thousand whereas it was 14.5 thousand as per baseline survey.

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

9Indicators under AHSIn all, 161 indicators are available from AHS : Fertility- 13 Sex Ratio- 3Marriage- 5 Mortality- 7Mother & Child Care- 63

Ante Natal Care: 11 Delivery Care: 8Post Natal Care: 5 Janani Suraksha Yojana (JSY): 3Immunization: 8 Vitamin A & Iron Supplements: 2Birth Weight: 2 Childhood Disease: 6Birth Registration: 2 Breastfeeding & Supplementation: 12Awareness in Mothers: 4

Abortion- 6 Family Planning Practices- 15 Disability- 1 Morbidity- 19Personal Habits:adults-4 Housing & HH Characteristics- 13Others- 12

10Indicators under AHS ContdData release of the second updation roundUnder 1st phase of release, following 9 indicators have already been released in the Bulletin 2012-13: 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 indicators are being released under present phase of dissemination.

11Progress so farField work for all the three rounds is completed.

State level Bulletins of all the three rounds containing the district level vital indicators viz. Crude Birth Rate, Crude Death Rate ,Infant Mortality Rate ,Neo-Natal Mortality Rate ,Under Five Mortality Rate ,Maternal Mortality Ratio ,Sex Ratio at Birth ,Ratio(0-4 Years) ,Sex Ratio(All Ages) were released in 2011 and 2013 and 2014.

District level fact sheets of the previous two rounds containing the 161 indicators on fertility, Mother and child care, Family planning practices , Mortality, disability ,marriage etc. were released in 2012 and 2013.

The data now presented is of the factsheet of the second updation round.

With this, all activities related to Annual Health Survey except for CAB have been completed.

12Five Core Themes CoveredThe 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 Practices13KEY FINDINGSImprovement has been noticed in most of the indicators as compared to Baseline.

Replacement level of TFR 2.1 has been achieved in only 35 out of 284 AHS districts whereas in Baseline it was 20 districts.

In 125 districts, on an average a woman bears more than 3 children.

More than half of currently married women aged 15-49 years are not using any method of family planning in Bihar. The phenomenon remained the same over the three rounds.

14KEY FINDINGSFemale Sterilization continues to remain the most dominant method of family planning among the modern methods across all AHS States except Assam, over the three rounds.

At least one in 8 currently married women is yet to meet their family planning requirement (Unmet Need) across all AHS States. This was one in 5 in Baseline.

This is due to increase in usage of primarily Modern methods except for Assam and Odisha where usage of Traditional methods has dominated.

15Poor performance of full ANC is primarily due to low IFA consumption.

Despite wider penetration of `Any ANC, the coverage under `first trimester ANC as well as `3 or more ANCs needs further improvement.

Universal coverage of Janani Suraksha Yojana(JSY) remains a concern. Only Odisha and Rajasthan have shown 70%+ coverage in the second updation round.

Seven out of every 10 deliveries are `safe in Madhya Pradesh, Rajasthan, Odisha and Assam ,the same in Baseline. KEY FINDINGS16At least 1 in 8 mothers has not received any PNC among all the AHS States, in Assam and Uttarakhand, it is about 1 in 3 mothers.

In full immunization, even the better performing States like Uttarakhand, Chhattisgarh and Rajasthan fall short by 20-25 percentage points in achieving universal coverage.

Percent of usage of traditional method of family planning is more than 20% in Uttar Pradesh, Assam, Jharkhand & Odisha.KEY FINDINGS17KEY FINDINGSAmong AHS districts:-

67 districts are common in top 100 districts in female literacy and full ANC exhibiting a definite correlation between the two. i.e. the higher the female literacy the higher will be the ANC.

Higher female literacy and less MMR - Out of the 5 top States in these two indicators , 4 are common.

Higher coverage of Full immunization and less NNMR- Top 4 States in both the indicators are common.

Higher coverage of Full immunization and less IMR- Top 5 States are common.

18Hotspot DistrictsDistricts which are common among worst performing in IMR and MMR(Top 100 IMR districts and top 25 administrative divisions of MMR).

There are 42 hotspot districts spread in Uttar Pradesh-28, MP-10, Rajasthan-3 and Assam-1.

These districts do not perform very well on other fertility and program indicators.

Needs urgent attention. 19Rajasthan-3

Rajasthan-3Uttar Pradesh-28Madhya Pradesh-10Assam-12020Performance of 42 hotspot districts in terms of Total Fertility Rate(TFR)Full Ante Natal Care(ANC)Institutional DeliveryFull Immunization21Performance of Hotspot districts w.r.t TFRTFR India: 2.4 TFR India: 2.4 22Performance of Hotspot districts w.r.t TFRTFR India-2.4TFR India- 2.423Performance of Hotspot districts w.r.t Full ANC24Performance of Hotspot districts w.r.t Full ANC25Performance of Hotspot districts w.r.t Full Immunization26Performance of Hotspot districts w.r.t Full Immunization27Performance of Hotspot districts w.r.t Institutional Delivery28Performance of Hotspot districts w.r.t Institutional Delivery29TOTAL FERTILITY RATE (TFR) TFR is the average number of children born to a woman during her entire reproductive span. Uttarakhand & Odisha and UP & Bihar continue to remain two extremes of the spectrum over the three rounds.

Total Fertility Rate30TOTAL FERTILITY RATE (TFR) Total Fertility Rate State State valueDistrict with Minimum TFRDistrict with Maximum TFRRangeSecond updationBaselineSecond UpdationBaselineSecond UpdationBaseline SecondUpdationBaselineAssam2.4 2.6Kamrup (1.9)Kamrup (2.0),Nalbari(2.0)Hailakandi (3.7)Hailakandi (4.2)1.82.2Bihar3.53.7Patna (2.6)Patna (2.8)Sheohar (4.6)Sheohar (4.6)2.01.9Chhattisgarh2.72.9Koriya (2.3),Kanker (2.3), Durg (2.3) Koriya (2.4) Kawardha (3.6)Kawardha (3.7)1.31.3Jharkhand2.73.1Purbi Singhbhum (2.2)Purbi Singhbhum (2.4)Pakaur, Lohardagga (3.7) Lohardagga (4.0)1.51.6Madhya Pradesh3.03.1Bhopal (2.0)Indore (2.2)Panna(4.1) Shivpuri (4.5)2.12.3Odisha2.22.3Jharsuguda (1.8)Jharsuguda (2.0)Baudh (3.5)Boudh (3.5)1.71.7Rajasthan2.93.2Kota (2.4)Kota (2.6)Barmer (4.4)Barmer (4.7)2.02.1Uttar Pradesh3.33.6Kanpur Nagar (2.1)Kanpur Nagar (2.3)Shrawasti(5.4)Shrawasti (5.9)3.33.6Uttarakhand2.12.3Pithoragarh (1.7)Pithoragarh (1.7)

Haridwar (2.7)Haridwar (3.1)

1.01.4Within a State, the minimum variability of 1.0 is reported in Uttarakhand and the maximum of 3.3 in Uttar Pradesh whereas in Baseline it was 1.3 in Chhattisgarh and 3.6 in Uttar Pradesh respectively .Across 284 districts in 9 AHS States, it ranges from 1.7 in Pithoragarh to 5.4 in Shrawasti. In Baseline this varied from 1.7 in Pithoragarh (Uttarakhand) to 5.9 in Shrawasti (UP)- a variability of more than 4 children. 3131TOTAL FERTILITY RATE (TFR) 35 districts have already achieved the replacement level of 2.1 whereas it was 20 in baseline. 63 districts have TFR below the current National average of 2.4 (SRS 2012).Frequency distribution of TFR in terms of No. of Districts in each StateState0 - 2.12.2 - 3.03.1 - 4.04.1 and aboveGrand TotalAssam8 (3)13 (16)2 (3)0 (1)23Bihar0 (0)4 (1)27 (26)6 (10)37Chhattisgarh0 (0)14 (12)2 (4)0 (0)16Jharkhand0 (0)14 (8)4 (10)0 (0)18Madhya Pradesh2 (0)21 (15)21 (25)1 (5)45Odisha 14 (10)15 (18)1 (2)0 (0)30Rajasthan0 (0)20 (16)11 (13)1 (3)32 Uttar Pradesh1 (0)20 (9)39(48)10 (13)70Uttarakhand 10 (7)3 (5)0 (1)0 (0)13All States 35 (20)124 (100)107 (132)18 (32)284Distribution of 63 Districts among StatesAssamBiharChhattisgarhJharkhandMadhya PradeshOdishaRajasthanUttarakhand Uttar PradeshTotalLess than 2.4150326211114633232Frequency Distribution of change in TFR in Terms of No. Districts in Each State

State Decreased by 0.1 Decreased by 0.2Decreased by 0.3Decreased by 0.4Decreased by 0.5 or moreIncreasedRemained SameTotalUttarakhand131200613Rajasthan41313200032 Uttar Pradesh82619850470Bihar6712720337Assam288210223Jharkhand0711000018Odisha14122000230Chhattisgarh572000216Madhya Pradesh91710330345 Total 49100782411022284TOTAL FERTILITY RATE (TFR)262 districts have recorded less TFR than the baseline estimates in TFR and 22 districts remained the same. 33TOTAL FERTILITY RATE (TFR)

BaselineSecond Updation

Total Fertility Rate34Family Planning: Current Usage Current usage of any method varies from 41.2 in Bihar to 70.2 in Rajasthan whereas it was 37.6 in Bihar to 64.5 per cent in Rajasthan in Baseline.

Contraceptive Prevalence Rate (CPR) is the percentage of currently married women aged 15-49 yrs who are using any method of contraception (modern/traditional).Current Usage of Family Planning35Family Planning: Current Usage Within a State, the least variation is reported in Uttarakhand and the most, in Odisha whereas in Baseline it was Uttarakhand and Uttar Pradesh respectively.

At district level, current usage of family planning ranges from 27.9 in Siwan (Bihar) to 90.4 in Hanumangarh (Rajasthan)- a variability of 3 times-whereas in Baseline it varied from 21.9 in Sitapur (UP) to 79.2 in Ganganagar (Rajasthan) exhibiting a variability of 4 times. Any Method of Family Planning (%) State State Value District with Minimum FPDistrict with Maximum FPRangeSecondUpdationbaselineSecondUpdationbaselineSecondUpdationbaselineSecondUpdationbaselineAssam67.257.9Karimganj (49.4)Dhubri (33.2)Kamrup (79.0)Lakhimpur (67.6)29.634.4Bihar41.237.6Siwan(27.9)Siwan (26.0)Supaul (56.3)Muzaffarpur (52.2) 28.426.2Jharkhand57.547.8Paschimi Singhbhum(39.4)Paschimi Singhbhum (32.7)Hazaribagh (69.8)Dhanbad (66.8)30.429.2Madhya Pradesh63.261.2Raisen(47.0)Sidhi (45.9)Damoh (84.9)Damoh (74.9)37.929.0Chhattisgarh60.753.9Dantewada (36.5)Dantewada (33.4)Kawardha (74.7)Dhamtari (68.7)38.235.3Odisha62.456.2Baudh (32.5)Kandhamal (28.6)Baleshwar (78.9)Baleshwar (73.4)46.444.8Rajasthan70.264.5Tonk(54.8)Dhaulpur (49.0)Hanumangarh (90.4)Ganganagar (79.2)35.630.2Uttar Pradesh59.049.9Balrampur(38.2)Sitapur (21.9)Lalitpur(75.3)Jhansi (74.1)37.152.2Uttarakhand62.762.7Haridwar (56.8)Haridwar (53.7)Rudraprayag(79.0)Dehradun (67.1)22.213.436Family Planning: Current UsageFrequency distribution of current usage in terms of number of districts in each StateState0-30 30-50 50-70 70 & above Total Districts Assam0 (0)2 (3)12 (20)9(0)23Bihar1 (4)29 (31)7 (2)0 (0)37Chhattisgarh0 (0)3 (7)11 (9)2 (0)16Jharkhand0 (0)7 (13)11 (5)0 (0)18Madhya Pradesh0 (0)1 (2)39 (40)5 (3)45Odisha 0 (1)9 (9)13 (19)8 (1)30Rajasthan0 (0)0 (1)17 (24)15 (7)32Uttar Pradesh0 (3)13 (24)50 (42)7(1)70Uttarakhand 0 (0)0 (0)6 (13)7 (0)13All States 1 (8)64 (90)166(174)53 (12)28465 districts are reporting less than 50% current usage of any method of family planning whereas in Baseline it was 98. 53 districts feature in 70% & above category whereas in Baseline it was only 12 districts.

30 out of 37 districts of Bihar have reported less than 50% usage of any method of family planning. In Baseline it was 35 districts.37Family Planning: Current Usage

BaselineSecond Updation

38Share of sterilization in any modern method of family planning (%)ChhattisgarhBiharMadhya PradeshJharkhandRajasthanOdishaUttarakhandUttar PradeshAssamFemale86.5 (92.3)84.1 (86.7)82.0 (83.6)76.7 (76.3)76.0 (76.7)70.8 (68.4)50.8 (58.7)48.9 (55.0)35.2 (35.3)Male1.9 (2.0)0.8 (0.9)2.0(1.7)1.1 (1.2)1.0 (0.7)0.6 (0.7)2.4 (2.8)0.8(0.6)0.8 (0.6)Family Planning: Current Usage

BaselineSecond Updation

3939Unmet Need for Family PlanningUnmet need of Family Planning broadly means requirement of Family Planning methods among Currently Married Women but not using any method of Family Planning .Total unmet need varies from a minimum of 13.1 % in Assam to 31.5% in Bihar. In Baseline it varied from 19.6% in Rajasthan to 39.2% in Bihar.

Unmet need for Family Planning is a crucial indicator for assessing the future demand for Family Planning services / supplies.Unmet need of Family Planning40Unmet Need for Family Planning Total Unmet need (%) State State Value District with Minimum unmet needDistrict with Maximum unmet needRangeSecondUpdationbaselineSecond UpdationbaselineSecond UpdationbaselineSecondUpdationbaselineAssam13.124.0Kamrup (5.8)Sibsagar (15.3) Karimganj (28.0)Dhubri (42.9) 22.227.6Bihar31.539.2Patna (20.7)Patna (24.6)Siwan(56.4)Kishanganj (52.5)35.727.9Jharkhand22.330.5Dhanbad(11.3)Bokaro (18.2)Paschimi Singhbhum(41.2)Godda (42.8)29.924.6Madhya Pradesh21.622.4Damoh(9.9)Jabalpur (14.3)Raisen(44.3)Rewa (34.2)34.419.9Chhattisgarh24.426.4Bastar(12.3)Dhamtari (14.5)Koriya(32.6)Bastar (36.0)20.321.5Odisha18.923.2Jharsuguda(8.5)Baleshwar (6.1)Baudh (48.4)Boudh (48.3)39.942.2Rajasthan13.519.6Hanumangarh(4.2)Ganganagar (10.0)Churu(26.9)Dhaulpur (32.4)22.722.4Uttar Pradesh20.729.7Lucknow(6.0)Mahoba (15.1)Kannauj(29.6)Sitapur (29.6)23.614.5Uttarakhand15.323.2Dehradun (8.3)Dehradun (16.8)Haridwar(26.2)Haridwar (29.2)17.912.4The minimum variability within a State is in Uttarakhand and the maximum in Odisha whereas in Baseline it was in Uttarakhand and in Uttar Pradesh respectively.

Hanumangarh(4.2) in Rajasthan and Siwan (56.4) in Bihar are the two extremes across 284 districts. In Baseline it was Baleshwar (6.1) in Odisha and Sitapur (61.3) in Uttar Pradesh. 41Unmet Need for Family PlanningFrequency distribution of unmet need in terms of number of districts in each StateState0-20 20-40 40-60 60 & above Total Districts Assam22 (6)1 (16)0 (1)0 (0)23Bihar0 (0)31 (20)6 (17)0 (0)37Chhattisgarh3 (4)13 (12)0 (0)0 (0)16Jharkhand5 (2)12 (13)1 (3)0 (0)18Madhya Pradesh14 (18)30 (27)1 (0)0 (0)45Odisha 16 (12)11 (15)3 (3)0 (0)30Rajasthan27 (16)5 (16)0 (0)0 (0)32Uttar Pradesh43 (9)27 (52)0(8)0 (1)70Uttarakhand 11 (2)2 (11)0 (0)0 (0)13All States141(69)132(182)11 (32)0 (1)284 In 141 out of 284 districts, the total unmet need for family planning is below 20%. It was 69 in Baseline.

Bihar continues to dominate in 40% & above category. Uttar Pradesh moved out from this category in Second updation.42

BaselineSecond UpdationUnmet Need for Family Planning

43Mean Age at Marriage- Female Mean Age at Marriage is based on the marriages taken place during 2009-2011.Mean age at marriage of females varies from 20.2 in Bihar and Rajasthan to 22.3 years in Uttarakhand whereas in Baseline it was 19.7 in Bihar & Rajasthan to 22.0 years in Uttarakhand.44Marriages among Females below Legal Age (18 yrs) Based on marriages taken place during 2009-2011. Varies from 1.8 % in Uttarakhand to 14.3% in Rajasthan whereas in Baseline it was 3.0% in Uttarakhand to 21.9% in Rajasthan. 45

BaselineSecond UpdationMarriages among Females below Legal Age (18 yrs)

46 Any ANC exceeds 85% in all AHS States.

ANC in 1st trimester: 50 % in UP & Bihar to 73% in Chhattisgarh & Madhya Pradesh. In Baseline, this was 40% in UP & Bihar to 65% in Chhattisgarh & Madhya Pradesh.

Mothers receiving 3 or more ANCs: Bihar-36.7% to Odisha-81.9%. This was UP-29.6% to Odisha-76.0 % in Baseline.

Mothers who consumed IFA 100 days or more: 9.7 % in UP to 30.3% in Odisha. It was 6.5% in UP to 23.8% in Chhattisgarh in Baseline.

Low performance in IFA consumption is the main reason for sluggish full ANC: 6.8 % in UP to 27.8% in Odisha. In Baseline, 3.9% in UP to 19.5% in Chhattisgarh.Ante Natal Care (ANC)47Full Ante Natal Check-upFull 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 6.6 % and Odisha, the maximum 27.8 whereas in Baseline it was 3.9% in Uttar Pradesh & 19.5% in Chhattisgarh.

Full Ante Natal Checkup4848Full Ante Natal Check-up Mothers who had Full Antenatal Check-up (%) State State Value District with Minimum valueDistrict with Maximum valueRangeSecond UpdationBaselineSecond UpdationBaselineSecond UpdationBaselineSecondUpdationBaselineAssam18.411.9Karbi Anglong (7.2)Dhubri (2.1)Kamrup (29.9)Jorhat (18.2)22.716.1Bihar7.85.9Samastipur (2.7)Madhepura (2.4)Paschim Champaran (15.3)Patna (16.4)12.614.0Jharkhand13.613.1Garhwa (5.1)Garhwa (3.6)Purbi Singhbhum (28.9)Purbi Singhbhum (31.6)23.828.0Madhya Pradesh16.213.3Morena(3.7)Sheopur (1.8)Indore (30.6)Balaghat (30.8)26.929.0Chhattisgarh22.519.5Jashpur(12.0)Korba (10.9)Dhamtari (47.4)Dhamtari (34.5)35.4

23.6Odisha27.818.6Koraput (16.8)Jajapur (5.4)Jagatsinghapur (54.6)Jagatsinghapur (36.0)37.830.6Rajasthan9.58.5Nagaur(3.2)Karauli (1.7)Jaipur (20.0)Jaipur (19.5)16.817.8Uttar Pradesh6.83.9Balrampur (1.0)Balrampur (0.6)Jhansi (19.5)Kanpur Nagar (14.8)18.514.2Uttarakhand17.111.1Rudraprayag (4.0)Rudraprayag (3.7)Dehradun (30.3)Dehradun (22.7)26.319.0Bihar has reported the minimum variability among the districts in a State compared to Odisha reporting the maximum. It was same in Baseline.

Balrampur (1.0) with 1% has minimum coverage and Jagatsinghapur (54.6), the maximum coverage of full ANC. In Baseline also the position was same with values 0.6 and 36.0 respectively. 49Full Ante Natal Check-upFrequency distribution of full ANC in terms of number of districts in each StateState