Director/Project Coordinator (DLHS-3) International Institute for Population Sciences Additional Director General (Stat.)

Transcription

1 D Distric ct Leveel Houssehold and Faacility Survey y - Utttar Praadeesh Internatioonal Institutte for Popullation Sciennces (Deemeed Universityy) Mumb mbai- Ministry of o Health annd Family Welfare W Governmeent of India New Delhhi-

2 Suggested citation:- International Institute for Population Sciences (IIPS),. District Level Household and Facility Survey (DLHS-), - : India.Uttar Pradesh: Mumbai: IIPS. For additional information, please contact: Director/Project Coordinator (DLHS-) International Institute for Population Sciences Govandi Station Road, Deonar Mumbai - (India) Telephone: - /, -,, Fax: -, rchpro@iips.net, director@iips.net Website: Additional Director General (Stat.) Ministry of Health and Family Welfare Government of India Nirman Bhavan New Delhi Telephone: - Fax: - adg-mohfw@nic.in Chief Director (Stat.) Ministry of Health and Family Welfare Government of India Nirman Bhavan New Delhi Telephone: - Fax: - cdstat@nic.in Website: http: //

3 DLHS- Project Coordinators Chander Shekhar F. Ram L. Ladusingh B. Paswan Sayeed Unisa Rajiva Prasad T.V. Sekher

4 Research Staff Akash Wankhede Arpita Das Rajesh Kr. Rai L. Priyananda Singh Namrata Mondal Ranjan Kr. Prusty Prakash Malin Erica Kharsyntiew Amrita Gupta Mamta Prakash Chand D. Meher IMPORTANT INSTRUCTIONS TO READERS: This report is based on data collected from, households from Uttar Pradesh during -. From these households,, ever-married women aged - years and, unmarried women aged - years were interviewed. Most of the tables and analysis presented in the report is based on ever-married women aged - years. However, for the purpose of comparison with DLHS- (-) and the Fact Sheet of DLHS-, we also provided some indicators based on currently married women aged - years in selected tables. We request the readers to keep this distinction in mind while using and comparing the DLHS- indicators with other surveys. For more information, visit DLHS website:

5 CONTENTS Pages Background and Objectives of the Survey... Survey Design, Sample Size and Design Weight.. Implementation and Quality Control.... Survey Instruments.... Household and Village Background Characteristics of Women and Fertility. Maternal Health Care. Child Health Care and Immunization Family Planning and Contraceptive Use... Reproductive Health and Awareness of RTIs/STIs and HIV/AIDS Infertility and Childlessness... Family Life Education among Unmarried Women... Reproductive Health and Awareness of Contraceptives, RTIs/STIs and HIV/AIDS among Unmarried Women. Health Facilities - Availability and Quality.. TABLES APPENDIX Sampling Error for Selected Indicators...

6 LIST OF TABLES Page Table. Number of households, ever married women & unmarried women interviewed.. Table. Basic demographic indicators Table. Household population by age and sex... Table. Marital status of the household population.... Table. Age at marriage.. Table. Educational level of the household population.. Table. Currently attending school... Table. Reasons for dropping out of school... Table. Household characteristics.. Table. Housing characteristics and assets.... Table. Housing characteristics by districts... Table. Distance from the nearest educational facility... Table. Distance from the nearest health facility.... Table. Availability of facility and health personnel by districts... Table. Knowledge about government health programmes... Table. Background characteristics of ever married women.. Table. Level of education of ever married women.. Table. Birth order.. Table. Birth order distribution by districts.... Table. Children ever born Table. Fertility preferences... Table. Outcomes of pregnancy. Table. Outcome of pregnancy by districts... Table. Place of antenatal check-up.... Table. Place of antenatal care by districts. Table. Components of antenatal check-up.... Table. Women received advice during antenatal care Table. (A) Antenatal care: ANC visits and time of first ANC check-up... Table. (B) Antenatal care: TT, IFA and ANC. Table. Antenatal care indicators and complications by districts. Table. Place of delivery and assistance... Table. Mode of transportation used for delivery and arrangement of transportation.. Table. Place of delivery and assistance characteristics by districts.. Table. Reasons for not going to health institutions for delivery.... Table. Delivery complications.. Table. Post delivery complications... Table. Any check-up after delivery.. viii

7 LIST OF TABLES Page Table. Complications during pregnancy, delivery and post delivery period.... Table. Complications during pregnancy, delivery and post delivery period by districts.. Table. Knowledge of danger sign of new born.. Table. Timing and place of early childhood check-up by background characteristics... Table. Initiation of breastfeeding by background characteristics Table. Breastfeeding and weaning status by children s age.. Table. Exclusive breastfeeding by background characteristics. Table. Breastfeeding by districts Table. Vaccination of children by background characteristics... Table. Childhood vaccination by districts. Table. Place of childhood vaccination by background characteristics... Table. Vitamin A and Hepatitis-B supplementation for children by background characteristics.. Table. Knowledge regarding diarrhoea management by background characteristics. Table. Treatment of diarrhoea by background characteristics.... Table. Knowledge and treatment of acute respiratory infection (ARI) by background characteristics Table. Knowledge of ORS and acute respiratory infection (ARI) by districts.. Table. Awareness of contraceptive methods by place of residence... Table. Awareness of contraceptive methods by background characteristics. Table. Awareness of contraceptive methods by districts... Table. Ever use of contraceptive methods..... Table. (A) Current use of contraceptive methods..... Table. (B) Duration of use of spacing methods.... Table. Age at the time of sterilization Table. Contraceptive prevalence rate by districts.. Table. Sources of modern contraceptive methods. Table. Cash benefits received after sterilization.... Table. Health problems with current use of contraception and treatment received... Table. Reasons for discontinuation of contraception..... Table. Future intention to use. Table. Advice on contraceptive use... Table. Reasons for not using modern contraceptive method among rhythm and withdrawal method users..... Table. Unmet need for family planning services... Table. Unmet need for family planning services by districts. Table. Menstruation related problems by background characteristics... Table. Source of knowledge about RTI/STI by background characteristics. Table. Knowledge of mode of transmission of RTI/STI by background characteristics.. Table. Symptoms of RTI/STI by background characteristics... Table. Discussions about RTI/STI problems with husband and sought treatment by background characteristics. ix

8 LIST OF TABLES Table. RTI/STI indicators by districts... Table. Knowledge of HIV/AIDS by background characteristics. Table. Knowledge about mode of transmission of HIV/AIDS. Table. Knowledge of HIV/AIDS prevention methods by background characteristics Table. Misconception about transmission of HIV/AIDS by background characteristics Table. Knowledge about the place where HIV/AIDS test can be done by background characteristics.. Table. Undergone HIV/AIDS test by background characteristics... Table. HIV/AIDS indicators by districts... Table. Ever had infertility problem by background characteristics. Table. Childlessness and infertility by background characteristics. Table. Treatment for infertility by background characteristics Table. Infertility problem and sought treatment by districts... Table. Background characteristics of unmarried women.. Table. At what age and standard family life education should be to given.. Table. Sources of family life education.... Table. Ever received family life education by sources. Table. Knowledge of legal age at marriage and reported ideal age at marriage for boys and girls Table. Current status of menstruation and experienced menstruation related problems during last three months and reported problems.. Table. Practices during menstrual period.. Table. Knowledge of contraceptive methods Table. Sources from where to get pill and condom.. Table. Discussion about family planning method by source of information... Table. Knowledge of RTI and STI by sources.. Table. Knowledge of RTI/STI transmission..... Table. Knowledge of HIV/AIDS by sources.... Table. Knowledge of HIV/AIDS transmission... Table. Misconception of HIV/AIDS Table. Knowledge about how to avoid or reduce the chances of infecting HIV/AIDS Table. Knowledge where to get tested for HIV/AIDS and sources.. Table. Knowledge of some selected statements Table. Awareness of Reproductive Health Issues... Table. Average population covered by health facility by districts.. Table. Percentage of villages having Sub-Centre within villages & ANM available at Sub-Centre and staying in Sub-Centre quarter by districts..... Table. Status of infrastructure at Sub-Centre functioning in government building by districts.. Table. Number of Sub-Centres having adequately equipped and essential drugs by districts. Table. Number of Sub-Centres having different activities by districts... Table. Available human resources at Primary Health Centres by districts... Page x

9 LIST OF TABLES Page Table. Available infrastructures at Primary Health Centres by districts... Table. Specific health facilities available at Primary Health Centres by districts... Table. Number of Primary Health Centres having different activities by districts... Table. Human resources available at Community Health Centres by districts.... Table. Specific health care facilities available at Community Health Centres by districts. Table. Number of Community Health Centres having different activities by districts.... LIST OF FIGURES Figure Proportion of households by wealth quintile.. Figure Age-sex pyramid..... Figure Percentage literate by age and sex Figure Mean children ever born by districts... Figure Fertility preference of currently married women Figure Any ANC by background characteristics.... Figure Progress in institutional delivery..... Figure Change in full immunization coverage of children Figure Percent currently married women using contraceptive methods..... Figure Progress in contraceptive prevalence rate.. Figure Progress in unmet need for contraception... Figure Contraceptive prevalence rate and unmet need by districts.... Figure Heard about RTIs/STIs by background characteristics Figure Knowledge about mode of transmission of HIV/AIDS.. Figure Knowledge about minimum legal age at marriage of boys and girls by background characteristics LIST OF MAPS Map Full antenatal check up by districts.... Map Institutional delivery by districts Map Full immunization coverage of children aged - months Map Contraceptive prevalence rate for any method by districts.... xi

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11 Preface and Acknowledgements The District Level Household and Facility Survey (DLHS-) is a nationwide survey covering districts from states and union territories of India. This is the third round of the district level household survey which was conducted during December to December. The survey was funded by the Union Ministry of Health and Family Welfare, United Nations Population Fund (UNFPA) and United Nations Children s Fund (UNICEF). We are very grateful to the Ministry of Health & Family Welfare, Government of India for designating the International Institute for Population Sciences (IIPS) as the nodal agency for the DLHS- Project and providing an opportunity to work closely with the health and programme officials. In particular, we would like thank Ms. K. Sujatha Rao, Secretary- Ministry of Health and Family Welfare (MoHFW), Government of India for her advice, suggestions and support. We also thank Shri Naresh Dayal, former Secretary-Ministry of Health and Family Welfare (MoHFW), Government of India for the advice and valuable support extended to the project. Our special thanks to Smt. Madhu Bala, the Additional Director General, Dr. Rattan Chand, the Chief Director and Shri. Rajesh Bhatia, the Director- Statistics Division, Ministry of Health and Family Welfare, Government of India for their active involvement and suggestions. We are also thankful to Dr. V.K. Malhotra and Shri S.K. Das, former Additional Director Generals, Shri Partha Chattopadhyay, former Chief Director, Shri K. D. Maiti, former Director and Ms. Rashmi Verma, former Deputy Director-Statistics Division, MoHFW, Government of India for the co-operation and support at various stages of this project. We are grateful to late Prof. P. N. Mari Bhat, former Director, IIPS and Prof. S. Lahiri, formerly officiating Director, IIPS for their keen interest and guidance in the initial stages of the project. We acknowledge the contributions of the Regional Agencies - ORG Centre for Social Research, New Delhi and Gfk MODE Pvt. Ltd, New Delhi for the field implementation of DLHS- in Uttar Pradesh. Our thanks to the members of Technical Advisory Committee (TAC) of DLHS- and especially to its Chairman, Dr. P. M. Kulkarni, Professor, Jawaharlal Nehru University, New Delhi. We also thank Dr. N.K. Singh for guiding the software development and CSPro training for the project staff. We gratefully acknowledge the immense contributions of DLHS- project team at IIPS in developing survey instruments, training field staff, monitoring field work, data processing, preparation of district and state level fact sheets, and drafting the reports. Finally, special thanks to all respondents who spared their valuable time and cooperated with us by providing the required information. DLHS- Coordinators International Institute for Population Sciences

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13 BACKGROUND AND OBJECTIVES OF THE SURVEY The National Rural Health Mission (-) was launched by the Government of India (GoI) in to provide effective health care to rural population in the country with special focus on states, which have poorer health outcomes and inadequate public health infrastructure and manpower. The primary focus of the mission is to improve access of rural people, especially women and children, to equitable and affordable primary health care. The prime goal of NRHM is to reduce infant, child and maternal mortality through promoting newborn care, immunization, antenatal care, institutional delivery and postpartum care. The National Rural Health Mission (NRHM) foundation was formulated on community involvement in drawing a village health plan under the auspices of Health & Sanitation Committee of the Panchayat, making rural primary health care services accountable to the community and giving authority to the District Health Mission for implementation of inter-sectoral District Health Plan including drinking water, sanitation, hygiene and nutrition. The interface between the community and the public health system at the village level is entrusted to a female Accredited Social Health Activist (ASHA), a health volunteer receiving performance based compensation for promotion of universal immunization, referral and escort services for reproductive & child health (RCH), construction of household toilets, and other health care schemes. To promote institutional delivery, cash incentive programme under the Janani Suraksha Yojana (JSY) is made an integral component of NRHM. The third round of District Level Household and Facility Survey (DLHS-) carried out during - was designed to collect data on various aspects of health care utilization for Reproductive & Child Health (RCH) services, accessibility of health facilities, assess the effectiveness of ASHA and JSY in promoting RCH care, to assess health facility capacity and preparedness in terms of infrastructure at district level. The integration of facility survey with the household survey was done with a view to link the RCH care outcomes to health facility accessibility, availability of medical & paramedical manpower and other village infrastructures. The broad objective of DLHS- is to provide RCH outcome indicators at the district level in order to monitor and provide corrective measures to the NRHM. The other important objective being, to assess the contribution of decentralization of primary health care at the district level and below by way of involving village health committees under the Panchayat in implementating health care programmes. The main focus and objective of DLHS- is providing RCH indicators covering the following aspects: Coverage of antenatal check-up and immunization services Institutional/safe deliveries JSY Beneficiaries Contraceptive prevalence rates Unmet need for family planning ASHA s involvement Awareness about RTIs/STIs and HIV/AIDS Family life education among unmarried adolescent girls Health facility and infrastructure

14 The District Level Household and Facility Survey, - (DLHS-) is the third in the series of district level household surveys. The first one was conducted in - followed by the second in -. For all the three DLHS, the Ministry of Health and Family Welfare (MoHFW), Government of India (GoI) designated the International Institute for Population Sciences (IIPS), Mumbai, as the Nodal Agency responsible for the development of survey design, instruments, data entry and tabulation software, training, supervision of field work, analysis and report writing. The sources of funds for DLHS- are the MoHFW, GoI and United Nations Population Fund (UNFPA) and United Nations Children s Fund (UNICEF). A Technical Advisory Committee (TAC) constituted by the MoHFW, GoI guided the designing, implementation, progress, tabulation, basis of selection of RCH indicators and consistency issues. SURVEY DESIGN, SAMPLE SIZE AND DESIGN WEIGHT A multi-stage stratified systematic sampling design was adopted for DLHS-. In each district, primary sampling units (PSUs) which were census villages in rural areas and census enumeration blocks (CEBs) in urban areas. In rural areas, villages were selected by probability proportional to size (PPS) systematic sampling and in the second stage households were selected by systematic sampling. For urban areas first wards were selected by PPS systematic sampling, at the second stage CEBs by PPS sampling and households in the third stage by systematic sampling. The Census of India, was the sampling frame for DLHS-. All villages and urban wards in a district were stratified by household size into three strata of less than, - and + households, percent of SC/ST population into two strata- below and above percent and implicitly by three alternating order of female literacy. These variables, used for stratification, are from the Census. The number of households representing a district is either or or depending upon the levels of immunization, antenatal check-up and institutional delivery as given by DLHS- plus percent over sampling to cushion for non-response. The PSUs are allocated to rural and urban areas of each district proportionally to the actual rural-urban population ratio and within the rural-urban domains. The PSUs are further distributed proportionately to the different sub-strata of combinations of household size, percent of SC/ST population and levels of female literacy. To make a proper rural PSU, selected villages with less than households were linked with another contiguous village and selection probability is adjusted accordingly. Selected villages with more than households were further divided into two or more segments and one or more segments were selected so as to have standard size PSUs. The numbers of households drawn from a PSU of a district represented by, and households are, and households respectively. All ever-married women aged - years and unmarried adolescents aged - years from the sampled households are the respondents for questions on RCH and family life education, while any adult household member is the respondent for household related questions in DLHS-. Sampling weight for household, ever-married women and unmarried women were generated for each district. These design weights were used for computations of district level demographic and RCH indicators. The selection probabilities f i, f i and f i at various stages of randomization pertaining to the i th PSU of a district were the main inputs to generate design weight. These selection probabilities are defined as follows: f i = Probability of selection of i th rural PSU in a district

15 = ( n r H Hi ) Where, n r is the number of rural PSUs selected from a district, H i refers to the number of household in the i th psu and, total number of rural households in a district. f i = Probability of selecting segment (s) from segmented PSU (in case the i th selected PSU is segmented) = (Number of households in the selected segment) / (number of households in the PSU) The value of f i is to be equal to one for un-segmented PSU. f i = probability of selecting a household from the total listed households of a PSU or in segment(s) of a PSU = HSi HLi Where HL i is the number of households listed in i th PSU in a district and HS i the number of households per PSU assigned for the i th psu is either or or depending on whether a district is represented by or or households. For urban PSUs, is computed as the ratio of urban population of the selected PSU to the total urban population of the district. The probability of selecting a household from the district works out as: f i i i i = ( f f f ) The non-normalized household weight for the i th PSU of the district is, w i = f i, HRi where HR i is the household response rate of the i th sampled psu, non-response rate assumed to be % but actual response rates are used here. The normalized weight used in the generation of district indicators as d n i = ni i i ni w i i w, i =,,,. Where n i is the number of households interviewed in the i th PSU. The weight for women is computed in the similar manner after multiplication of expression for by the corresponding response rate. State weights for households, women are further derived from the district weights ni d for the ith psu in d th district using external control so that sample results do not deviate from the corresponding information about the population.

16 d Let, ns = n i and N = d sc N i, denote the number of households in the sample and i i census of a particular state, then state level households weights work out as: ni s = ni d d N i N sc, where n d i represents household sample in i th district, n is the total s d ni n s sample in the state. These households weights are computed separately for rural and urban areas. Considering sample and census currently married women aged - years and unmarried women aged - years for specified state by districts and rural-urban residence, state level women weights are obtained for estimation of state level indicators. IMPLEMENTATION AND QUALITY CONTROL Actual field operation of DLHS- in different states and union territories were implemented by Regional Agencies (RA) selected by the MoHFW through a competitive bidding process and Gfk MODE Pvt. Ltd., New Delhi and ORG Centre for Social Research, New Delhi were designated as RA for implementation of DLHS- in West and East Uttar Pradesh respectively. Data from the selected PSUs were collected by a team of five persons consisting of one supervisor, one field editor and three female investigators who are graduates at least. A minimum of two days visit to each sampled PSU is provisioned to ensure full coverage of selected households, ever-married women and unmarried women. Independent team of Health Investigators, mostly paramedics were entrusted the work of carrying out the accompanying Facility Survey. A strict quality check protocol was put in place by way of spot and back checks by an independent team appointed by the Nodal Agency. The quality team comprised of two females and one male investigator. And it was headed by a Research Officer from the monitoring agency. One Research Officer from IIPS was stationed in each state throughout the period of the field work. SURVEY INSTRUMENTS The main instrument for collection of data in DLHS- was a set of structured questionnaires, namely, household, ever-married woman, unmarried woman and village questionnaires. Sub-Centre, Primary Health Centre (PHC), Community Health Centre (CHC) and District Hospital (DH) questionnaires were used to conduct the facility survey. All household level questionnaires were bilingual, with questions in regional language and English. Household Questionnaire The household questionnaire lists all usual residents in each sampled household including visitors who had stayed the night before the interview. For individual household member information on age, sex, marital status, relationship to the head of the household and education were collected. Marriages and deaths of members of household were also recorded. Efforts were made to get information about maternal deaths. For household, information was also collected on the main source of drinking water, type of toilet facility, source of lighting, type of cooking fuel, religion and caste of household head and

17 ownership of durable goods in the household. The other information collected relates to awareness of government programmes. Ever Married Women s Questionnaire The respondents for the ever-married women s questionnaire were ever married women aged - years living in the sampled households. Details on age, age at marriage, educational attainment, number of biological children ever born and surviving by sex were collected. Accounts of antenatal check-up, experience of pregnancy related complications, place of delivery, delivery attendant and post-partum care, together with history of contraceptive use, sex preference of children and fertility intentions were recorded. For the recent births, immunizations status of children was collected either from the vaccination card or by asking the mother about the immunization status of the child. The other information collected includes knowledge and awareness about RTIs/STIs and HIV/AIDS by source and treatment seeking behaviour for RTIs/STIs. Unmarried Women s Questionnaire Information that was collected from unmarried women aged - years (those under years with consent from the parents) included knowledge of family life education, awareness about legal age at marriage and contraception, menstruation related problems, and knowledge of RTIs/STIs and HIV/AIDS by source of information. Village Questionnaire The questionnaire was prepared to collect information on availability and accessibility of education, health, transport and communication facilities at village level. Additional information on functioning of village committees and utilization of untied funds were collected from the sampled villages of DLHS. Facility Survey Questionnaires In the facility survey the information collected at the Sub-Centre level was availability of human resources, physical infrastructure, equipments and essential drugs and RCH service provided during the one month preceding the survey. Additional information collected at Primary Health Centre (PHC) level was availability of Lady Medical Officer, functional Labour Room, Operation Theater (OT), number of beds, drug storage facilities, waiting room for OPD, availability of RCH related equipments, essential drugs and essential laboratory testing facilities. Information that was collected for Community Health Centre (CHC) included status of in-position clinical, supporting and Para-medical staffs, availability of specialists trained for NSV (Non-Scalpel Vasectomy), emergency obstetric, medically terminated pregnancy (MTP), new born care, treatment of RTIs/STIs, IMNCI, ECG etc. The information on physical infrastructures at CHC such as, water supply, electricity, communication, waste disposal facilities, OT, Labour Room and availability of residential quarters for medical doctors were also collected in the facility survey. (All questionnaires are available at the website for DLHS-). HOUSEHOLD AND VILLAGE BACKGROUND DLHS- Coverage and Response Rate DLHS- surveyed a total of, households,, ever-married women and, unmarried women in Uttar Pradesh. The response rates are.,. and. percent for

18 households, ever-married and unmarried women respectively. The lowest response rates for household, ever-married women and unmarried women are measured in Bulandshahar (. percent), Bulandshahar (. percent) and Kheri (. percent) (Table.). The selected demographic indicator noted from the census show that the overall sex ratio of female per, males is below the national figure of and there are twenty districts out of districts where the sex ratio is above and in sixteen districts the sex ratio is above the national average. District Shahjahanpur and Azamgarh show the minimum () and maximum () values respectively. The percentage of urban population was lowest in district Sharawasti (. percent) and was highest in Kanpur Nagar (. percent) (Table.). Village Characteristics With regards to accessibility of health facilities to the sampled villages, percent of villages have Sub-Centres within the village itself and as many as. percent of the villages have it within km. Only. percent of the villages have a government dispensary within the village and. percent have Primary Health Centres (PHC). One noticeable feature of villages in Uttar Pradesh is that. percent of them have private clinics within the villages (Table.). In Uttar Pradesh,. percent of the rural population is treated by doctors and it varies. percent in Ambedker Nagar and Gonda each to. percent in Meerut. In Balrampur, Siddharthnagar and Sant Kabir Nagar rural people are not treated by doctors at all. Most of the villages ( percent) have an Anganwadi worker (Table.). Household Characteristics DLHS- surveyed a total of,, persons (Table.) from, households in Uttar Pradesh of which percent are in rural area and the remaining percent in urban area (Table.). In Uttar Pradesh, percent of household heads are Hindus and. percent are Muslims. About percent of household heads are females. The average household size in the state is six persons and there is not much rural-urban difference. Fifty five percent of household heads belong to other backward classes, percent to others and percent to scheduled castes. The median age of household heads is years (Table.). Only percent households in Uttar Pradesh have electricity connection,. percent of the households have access to tap water, percent of households have provision for flush toilet, percent of households use LPG for cooking, percent live in pucca houses and over one-third ( percent) households have at least three rooms (Table.). For the state of Uttar Pradesh, percent of households have BPL (below poverty line) cards and it varies from a low of four percent in Agra to a high of percent in Sant Kabir Nagar and Sultanpur (Table.). Household Wealth Index Combining household amenities, assets and durables, a wealth index is computed at the national level and divided into quintiles. Households are categorized from the poorest to the richest groups corresponding to the lowest to the highest quintile at the national level. Based on national cut-off points, in Uttar Pradesh only percent households are in the highest wealth quintile and more than half of the ( percent) households are below middle wealth quintile. More than one third of the households (. percent) in urban areas are in the highest wealth quintile whereas in rural areas it is only. percent, shown in Fig..

19 FIGURE PROPORTION OF HOUSEHOLDS BY WEALTH QUINTILE Urban Rural UTTAR PRADESH Lowest Second Middle Fourth Highest Age-Sex Composition The overall sex ratio in Uttar Pradesh is females per males. The age-sex pyramid (Fig. ) depicts a scenario of declining fertility with shrinking base of percent of the total population below years and indicates a gradually aging population with. percent of the population being above the age of years. The remaining. percent of the population is in the age group - years. There are more children (. percent) and persons age above years (. percent) in rural areas than in urban areas (. and. percents respectively) (Table.). The mean age at marriage of boys and girls in Uttar Pradesh are. years and. years respectively. In Uttar Pradesh. percent boys and. percent girls were married before the minimum legal age of marriage. The lowest mean age at marriage is found to be in Shrawasti (. years) and maximum in Lucknow (. years) (Table.). Literacy by Age and Sex Thirty six percent of the population of aged years and above are non-literate; it is. percent for females and. percent for males. The gender gap in literacy rate is narrow for the age group -, but it is wider in the age group - and - years (Table.), also shown in Fig.. The information on main reasons for dropping out of school was also collected in DLHS-. For girls below years as many as. percent stated that the main reason for dropping out of school was too much educational cost and followed by Male FIGURE AGE-SEX PYRAMID Female Percent FIGURE PERCENTAGE LITERATE BY AGE AND SEX MALE FEMALE

20 . percent stated that they were required for household work. On the other hand,. percent boys said that they were not interested in studies, followed by. percent who stated that cost was too much. For given sex, the reasons for dropping out of school do not differ much by residence (Table.). CHARACTERISTICS OF WOMEN AND FERTILITY Age at consummation of marriage is minimum years for more than percent of evermarried sampled women aged - years irrespective of residencial background. There are more non-literate women in rural areas (. percent) than in urban areas (. percent). Though the percentage of non-literate husbands were much lesser compared to the women in rural and urban areas (. and. percent of husbands are non-literate respectively). The percentage of women having and above years of schooling was. percent in rural area as against. percent in urban area. About half of the ever-married women (. percent) were married for years or more and the distribution of evermarried women in the categories of less than, - and - years marital duration are almost uniform, above percent in each category. In Uttar Pradesh,. and. percent of women belong to households in the first and second wealth quintiles. The corresponding proportions of women belonging to the st and nd wealth quintiles in rural areas are respectively. and percent while in urban areas. and. percent percent of women belong to households in the highest and fourth wealth quintiles respectively (Table.). The illiteracy rate was much higher among scheduled castes and scheduled tribes women (above percent) as compared to others (. percent) (Table.). Mean Children Ever Born by Districts Mean Children Ever Born (MCEB) to ever married women aged - years is found to be. with marginal rural-urban differentials. It is. for non-literate and. for women with at least years of education. The completed fertility measured in terms of average children ever born to ever-married women in the age group - years is. (Table.). It varies from. in Jhansi and Kanpur Nagar to. in Kaushambi. Fig. can also give an idea about district level variations in MCEB in Uttar Pradesh. Out of the total births to ever-married women during the three years preceding the survey,. percent were of third or higher order births and the corresponding figures were. and. percents respectively for non-literate and women with less than years of schooling. The third and higher order births were more among the ever-married women who live in rural areas (. percent), non-literate (. percent) and those belonging to scheduled caste (. percent) and less among women from urban areas (. percent), educated at least up to years (. percent) and those belonging to other castes (. percent) (Table.). Births of third and higher order are highest in Shahjahanpur (. percent) and lowest in Jhansi ( percent) (Table.).

21 FIGURE MEAN CHILDREN EVER BORN BY DISTRICTS Jhansi Kanpur Nagar Lucknow Varanasi Azamgarh Jalaun Chandauli Ballia Deoria Gorakhpur Mahoba Hamirpur Ghaziabad Jaunpur Sultanpur Pratapgarh Lalitpur Kanpur Dehat Etawah Baghpat Meerut Saharanpur Sonbhadra. Mirzapur Sant Ravidas Nagar Ghazipur Mau Kushinagar Maharajganj Sant Kabir Nagar Ambedaker Nagar Faizabad Barabanki Allahabad Muzaffarnagar UTTAR PRADESH Basti Gonda Rae Bareli Sitapur Kheri Agra Mathura Aligarh Bulandshahar Bijnor Siddharthnagar Shrawasti Fatehpur Banda Unnao Pilibhit Mainpuri Firozabad Gautam Buddha Nagar Jyotiba Phule Nagar Bahraich Auraiya Kannauj Farrukhabad Hardoi Hathras Balrampur Chitrakoot Bareilly Etah Rampur Shahjahanpur Moradabad Budaun Kaushambi

22 Fertility Intention and Preference of Currently Married Women Fertility intentions of currently married women in terms of desire for additional child and timing to have the desired additional child among those with no living children, percent want a child soon within the next two years and percent want a child two or more years later. Currently married women with one living child, the proportion wanting an additional child soon (within two years) and later years are and percents respectively. Women with two living children,. percent of them want another child later. Most of the the currently married women (. percent) with three or more living children are either currently using contraceptives or want no more children. As many as percent of currently married women want no more children, percent want a child soon, two percent are undecided and percent have undergone sterilization (Fig. ). Among the currently married women with no living children but want a child, percent reported that sex of the child does not matter, percent say it is up to God while FIGURE FERTILITY PREFERENCE OF CURRENTLY MARRIED WOMEN Want no more % Sterilized % Undecided % Want another, undecided when % Want another later % Declared infecund % Inconsistent response % Want another soon % and three percent want a boy and a girl respectively. With increasing number of living children, longing for a boy among the currently married women who want an additional child becomes more and more magnified from to percent for women with one and four or more living children respectively (Table.). Most of the outcomes ( Percent) of pregnancies occurred to women aged between - years during the three years period preceding the survey are turned to be live births. However, six percent of the pregnancies in the three years period preceding the survey resulted in spontaneous abortion and varies from. percent in Chandauli to. percent in Kanpur Nagar districts of Uttar Pradesh (Table.). MATERNAL HEALTH CARE Maternal health care package of antenatal care (ANC) is the main component of NRHM to strengthen RCH care. ANC provided by a doctor or ANM or other health professional comprises of physical checks, checking position and growth of fetus and giving Tetanus Toxiod injection (TT) at periodic intervals during the time of pregnancy. At least three check-ups are expected to complete the course of ANC to safeguard women from pregnancy related complications. In DLHS- the term of full ANC refers to percentage of

23 women having at least three visits for antenatal check-up, receiving at least one TT injection and consuming or more IFA tablets/syrup. Institutional delivery and postnatal care at a health facility is promoted in NRHM through the Janani Suraksha Yojana (JSY) to improve maternal and new born care. Any ANC by Selected Background Characteristics In Uttar Pradesh. percent of the women who had their last birth since January, had received at least one antenatal care (ANC) service. Majority of women (. percent) had received the service from a government health facility and. and. percent women had received the service from community based services and private health facility respectively (Table.). A distinctive feature is that any ANC as low as percent among non-literate as against percent among women educated for or more years; rural-urban gap stands at percentage points, with percent among urban residents, depicted in Fig.. The coverage of ANC is highest in district Deoria (. percent) and lowest in district Kanpur Dehat (. percent). For women in Mirzapur and Sonbhadra,. percent have ANC from a government facility and. and. percent received it from a private facility respectively, whereas the corresponding government and private health facilities utilization for ANC in Meerut are. and. percents (Table.). No. of living children + Residence Rural Urban Education Non-literate Less than five years - years or more years FIGURE ANY ANC BY BACKGROUND CHARACTERISTICS Age Group Even when women receive ANC, all check-ups and examinations recommended for ANC are not availed by women during pregnancy. The proportion of women who have weight and height measured, blood pressure checked, blood and urine tested, abdomen and breast examined are.,.,.,.,.,. and. percents respectively. For the state as a whole, percent of the total pregnancies since January, ending either in still or live birth are subjected to a sonography/ultrasound test. The corresponding proportions are higher in urban areas (. percent), women with or more years of schooling (. percent), women belonging to the highest wealth quintile (. percent) and women who have one living child (. percent) (Table.). The proportion of women who received at least three ANC is. percent (Table.A) and one-fourth of women had received first ANC in the first trimester of the pregnancy. Sixty-three percent women had received at least one TT injection and only. percent of the women received full ANC in Uttar Pradesh (Table.B). The proportion of women who received full ANC is lowest in Etah district, less than one (. percent) and is highest in district Gorakhpur (. percent). Map shows the spatial pattern of full ANC in Uttar

24 Pradesh. The proportions of women who consumed IFA tablets and received at least one TT injections for state as a whole are. percent &. percents respectively (Table.). MAP FULL ANTE-NATAL CHECK-UP BY DISTRICTS Institutional Delivery FIGURE PROGRESS IN INSTITUTIONAL DELIVERY Fig. shows that the percentage of institutional delivery in Uttar Pradesh had increased from percent in DLHS- (-) to percent in DLHS- (- ) and to percent in DLHS- (-). Twenty-five percent of deliveries since January, were conducted in health DLHS- DLHS- DLHS- facilities, either public or private. The percentage of institutional deliveries ranges from. percent in Bahraich districts to percent in districts Azamgarh. Map shows spatial variations in the level of institutional delivery in Uttar Pradesh. About percent deliveries were either institutional or home deliveries assisted by skilled person. About half of the districts in Uttar Pradesh are below the state average of safe delivery. The districts are Balampur (. percent), Bahraich (. percent), Shahjahanpur (. percent), Siddharthnagar (. percent), Budaun (. percent), Shraswasti (. percent), Hardoi (. percent), Farrukhabad

25 (. percent), Kheri (. percent), and Kannauj (. percent). Auraiya (. percent), Maharajganj (. percent), Bareilly (. percent), Fatehpur (. percent), Pilibhit (. percent), Kashambi (. percent), Mainpuri (. percent), Chitrakoot (. percent), Sitapur (. percent), Unnao (. percent), Gonda (. percent), Banda (. percent), Kanpur Dehat (. percent), Etah (. percent), Rampur (. percent), Moradabad (. percent), Sant Kabir Nagar (. percent), Barabanki (. percent), Etawah (.) and Firozabad (. percent). In the rest of the districts in Uttar Pradesh safe delivery is above percent (Table.). MAP INSTITUTIONAL DELIVERY BY DISTRICTS In Uttar Pradesh,. percent of the deliveries which took place in institutions since January, have been provided with JSY financial assistance. The avarage cost of delivery at government health facility is Rs., /- and Rs., /- at private healthfacility. Thirty four percent women who had institutional delivery used an ambulance or a jeep or a car as the mode of transport and avarage cost of transportation is Rs./- (Table.). Women who had home deliveries ( percent), the main reasons for not opting institutional delivery were either too much costs ( percent) or not necessary ( percent) (Table.). Complications during Pregnancy, Delivery and Post-delivery Period Women who either did not receive any ANC or could not complete the course of ANC are exposed to the risk involved in child bearing. In Uttar Pradesh, as much as percent of women who had still/live births since January, had some or other kinds of complications during pregnancy. This varies from percent in Ballia district to percent in Kannauj (Table.). None of the districts of Uttar Pradesh is as such, in which

26 less than percent women had pregnancy complications. Fourty six percent who had any complication sought treatment in Uttar Pradesh (Table.). About percent of women in Uttar Pradesh had faced at least one delivery complication (Table.). The main cause of delivery complications experienced by women during their recent births since January, is obstructed labour (. Percent) and premature labour (. Percent). Delivery complication is slightly lower among the women who live in urban areas (. percent) as compared to their rural counterparts (. percent). Less than half of women had some delivery complications in Hathras ( percent), Mathura ( percent), Siddharthnagar ( percent), Lucknow ( percent), Sharawasti ( percent), Balrampur ( percent) districts (Table.). Almost one-fifth (. percent) of women in Uttar Pradesh had post-delivery complications. The major problem during post-delivery period is high fever (. percent) followed by lower abdominal pain (. percent) (Table.). Among the women who had post-delivery complications,. percent had sought treatment (Table.). District Sitapur (. percent) has performed well in seeking treatment for post-delivery complications and Jhansi has shown poorest performance (. percent) (Table.). CHILD HEALTH CARE AND IMMUNIZATION To improve child survival, NRHM envisages new born care, breastfeeding and food supplementation at the right age and a complete package of immunization for children. Thirty-three percent of newborns during the three years period preceding the survey were examined within hours of birth (Table.). More newborns to women of urban residents, to women educated up to or more years and belonging to other castes have received care within hours compared to others. Women who availed newborn care from a home constitute percent as compared to. percent from private, government (.) and other sources (. percent) (Table.). Fifty-nine percent of children below three years, born after January, were fed with colostrum in breast milk and there is some variation across selected background characteristics of mothers. More children received colostrum in category of women s education of years and above and in the highest quintile of wealth index (Table.). However, there is visible variation across districts with more than percent of children being fed with colostrums in breast milk in the districts of Sharawasti and Balrampur while in the other districts it is in the range - percent (Table.). Little or less than one-fifth ( percent) of women had initiated breast milk within one hour of birth of the child. The initiation of breastfeeding within one hour of birth is least practiced among women in Jyotiba Phule Nagar and Badaun (. percent) and most widely practised in Mahoba (. percent). One-third of women initiate breastfeeding within hours of birth of their children, ranging from. percent in Budaun to. percent in Lalitpur. The proportion of women who initiated breastfeeding within one hour, within hours and later are.,. and. percent respectively (Table.). Median duration of exclusive breastfeeding of the youngest surviving child born three years preceding the survey is. months. For those children who had started food supplementation while still breastfeeding, median age in months at the time of other fluids, semi-solid food and solid food supplementation are. months,. months and.

27 months respectively (Table.). The proportion of youngest surviving children who exclusively breastfed for months is percent (Table.). Immunization Coverage of Children Aged - Months In DLHS- immunization course of children of aged - months has been recorded either from vaccination card or by directly asking the women in case the card was not shown. For percent of cases immunization coverage of children was recorded from the card (Table.). Thirty percent of children aged - months received full immunization comprising of BCG, three doses of DPT, three doses of Polio (excluding Polio ) and measles. Only three percent of children could not receive any kind of immunization (Table.). Full immunization coverage would have been well above percent, if immunization against DPT were not dropped down from to percent for first and third doses and had vaccination against polio not dropped from to percent for first and third dose. The key to improve full immunization coverage is to monitor drop out at any stage of its course. Higher proportion of male children ( percent), births of first order ( percent) and children born to women educated at least years ( percent) received full immunization as compared to female children ( percent), births of order four and above ( percent) and non-literate women s children ( percent). One important feature is that full immunization coverage of children aged - months in urban areas is percent as against percent in rural areas (Table.). FIFURE CHANGE IN FULL IMMUNIZATION COVERAGE OF CHILDREN The coverage of full immunization had declined from DLHS- to DLHS- ( percent to percent) but it has increased gradually to percent in DLHS- and this trend is shown in Fig.. The coverage of full immunization of children is below percent in DLHS- DLHS- DLHS- districts Etah, Budaun, Kheri, Sitapur, Farrukhabad, Banda, Chitrakoot, Kaushambi, Bahraich, Shawasti and Balrampur while it is more than percent in districts Lucknow, Kanpur Dehat, Kanpur Nagar, Hamirpur, Pratapgarh, Ambedaker Nagar, Sultanpur, Basti, Sant Kabir Nagar, Gorakhpur, Deoria, Mau, Ballia, Jaunpur, Varanasi and Sonbhadra (Table.). With regards to the place of immunization, and percent of children received it from a Sub- Centre and Primary Health Centre (PHC) respectively and about percent from other government health facility (Table.). District-wise variation in coverage of full Immunization is depicted spatially in the Map.

28 MAP FULL IMMUNIZATION COVERAGE OF CHILDREN AGED - MONTHS BY DISTRICTS In Uttar Pradesh,. and. percent children between aged to months had received at least one dose and - doses of vitamin-a supplementation respectively (Table.). There is some rural-urban disparity for Vitamin-A supplementation. Children from richest households (. percent), Jain (. percent), born to mothers educated at least years (. percent), lower birth order (. percent) are more likely to receive at least one dose of Vitamin-A than children from poorest households (. percent), scheduled tribes ( percent), non-literate mothers (. percent), children of four or more birth order (. percent). In district Balrampur only. percent children between age - months received at least one dose of Vitamin-A whereas in district Kanpur Nagar. percent children of the same age had received Vit.-A. Meerut, Kanpur Dehat and Varanasi are other districts of Uttar Pradesh where coverage of Vitamin-A is more than percent and Mathura, Etah, Shahjahanpur, Bahraich and Shrawasti are the districts where coverage of Vit.A is below percent (Table.). Only percent children had Hepatitis-B vaccination. In Uttar Pradesh children living in urban areas, lower birth order, mother s having or more years of education, those belonging to other caste and from richest households are more likely to receive Hep.-B vaccination than children living in rural areas, four or more birth order, nonliterate mothers, those belonging to scheduled tribes and from poorest households (Table.). Diarrhoea and Acute Respiratory Infection (ARI) Management DLHS- collected information on knowledge of diarrhoea and ARI management from women respondents as part of assessment of child care skills. Nearly two-thirds of women