Abstract

The National Family Health Survey (NFHS) is a large-scale, multi-round survey conducted in a representative sample of households throughout India. Four rounds of the survey have been conducted in 1992-93, 1998-99, 2005-06, and 2015-16. The fifth round of the survey (2019-2020) is currently in the field. All of the surveys are part of the Demographic and Health Surveys (DHS) Program. The surveys provide information on population, health, and nutrition at the national and state level. Since 2015-16, the surveys have also provided information at the district level. Some of the major topics included in NFHS-4 (2015-16) are fertility, infant and child mortality, family planning, maternal and reproductive health, child vaccinations, prevalence and treatment of childhood diseases, nutrition, women’s empowerment, domestic violence, marriage, sexual activity, employment, anemia, anthropometry, HIV/AIDS knowledge and testing, tobacco and alcohol use, biomarker tests (anthropometry, anemia, HIV, blood pressure, and blood glucose), and water, sanitation, and hygiene. The primary objective of the NFHS surveys is to provide essential data on health and family welfare, as well as emerging issues in these areas. The information collected through the NFHS surveys is intended to assist policymakers and program managers in setting benchmarks and examining progress over time in India’s health sector. The Ministry of Health and Family Welfare (MOHFW), Government of India, designated the International Institute for Population Sciences (IIPS), Mumbai, as the agency responsible for providing coordination and technical guidance for all of the surveys. IIPS has collaborated with a large number of field agencies for survey implementation. The Demographic and Health Surveys Program has provided technical assistance for all of the surveys.

Documentation

You can access the data through the DHS website. Data files are available in the following five formats:

• Hierarchical CSPro file
• Flat files: ASCII data with syntax, Stata, SPSS, SAS

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All datasets are distributed in archived ZIP files that include the data file and its associated documentation. The DHS Program is authorized to distribute, at no cost, unrestricted survey data files for legitimate academic research. Registration is required to access the data.

Additional information about the surveys is available on the India page on the DHS Program website. This page provides a list of surveys and reports, plus Country Quickstats for India, and it is the gateway to accessing more information about the India surveys and datasets.

Methodology

2015-16 National Family Health Survey (NFHS-4): Fieldwork for NFHS-4 was conducted in two phases, from January 2015 to December 2016. The fieldwork was conducted by 14 field agencies, including three Population Research Centers. Laboratory testing for HIV was done by seven laboratories throughout India. NFHS-4 collected information from a nationally representative sample of 601,509 households, 699,686 women age 15-49, and 112,122 men age 15-54. The survey covered all 29 states, 7 Union Territories, and 640 districts in India.

Funding for the survey was provided by the Ministry of Health and Family Welfare, Government of India; the United States Agency for International Development (USAID); UKAID/DFID; the Bill & Melinda Gates Foundation; UNICEF; the United Nations Population Fund (UNFPA); and the MacArthur Foundation. Technical Assistance for NFHS-4 was provided by Macro International, Maryland, USA.

2005-06 National Family Health Survey (NFHS-3): Fieldwork for NFHS-3 was conducted in two phases, from November 2005 to August 2006. The fieldwork was conducted by 18 field agencies, including six Population Research Centers. Laboratory testing for HIV was done by the SRL Ranbaxy laboratory in Mumbai. NFHS-3 collected information from a nationally representative sample of 109,041 households, 124,385 women age 15-49, and 74,369 men age 15-54. The survey covered all 29 states. Only the Union Territories were not included.

Funding for the survey was provided by the United States Agency for International Development (USAID); United Kingdom Department for International Development (DFID); the Bill & Melinda Gates Foundation; UNICEF; the United Nations Population Fund (UNFPA); and the Government of India. Technical assistance for NFHS-3 was provided by Macro International, Maryland, USA.

1998-99 National Family Health Survey (NFHS-2): Fieldwork for NFHS-2 was conducted in two phases, from November 1998 to December 1999. The fieldwork was conducted by 13 field agencies, including five Population Research Centers. NFHS-2 collected information from a nationally representative sample of 91,196 households and 89,188 ever-married women age 15-49. Male interviews were not included in the survey. The survey cover

Abstract

The National Family Health Survey 2019-21 (NFHS-5), the fifth in the NFHS series, provides information on population, health, and nutrition for India, each state/union territory (UT), and for 707 districts.

The primary objective of the 2019-21 round of National Family Health Surveys is to provide essential data on health and family welfare, as well as data on emerging issues in these areas, such as levels of fertility, infant and child mortality, maternal and child health, and other health and family welfare indicators by background characteristics at the national and state levels. Similar to NFHS-4, NFHS-5 also provides information on several emerging issues including perinatal mortality, high-risk sexual behaviour, safe injections, tuberculosis, noncommunicable diseases, and the use of emergency contraception.

The information collected through NFHS-5 is intended to assist policymakers and programme managers in setting benchmarks and examining progress over time in India’s health sector. Besides providing evidence on the effectiveness of ongoing programmes, NFHS-5 data will help to identify the need for new programmes in specific health areas.

The clinical, anthropometric, and biochemical (CAB) component of NFHS-5 is designed to provide vital estimates of the prevalence of malnutrition, anaemia, hypertension, high blood glucose levels, and waist and hip circumference, Vitamin D3, HbA1c, and malaria parasites through a series of biomarker tests and measurements.

Geographic coverage

National coverage

Analysis unit

• Household
• Individual
• Children age 0-5
• Woman age 15-49
• Man age 15 to 54

Universe

The survey covered all de jure household members (usual residents), all women aged 15-49, all men age 15-54, and all children aged 0-5 resident in the household.

Kind of data

Sample survey data [ssd]

Sampling procedure

A uniform sample design, which is representative at the national, state/union territory, and district level, was adopted in each round of the survey. Each district is stratified into urban and rural areas. Each rural stratum is sub-stratified into smaller substrata which are created considering the village population and the percentage of the population belonging to scheduled castes and scheduled tribes (SC/ST). Within each explicit rural sampling stratum, a sample of villages was selected as Primary Sampling Units (PSUs); before the PSU selection, PSUs were sorted according to the literacy rate of women age 6+ years. Within each urban sampling stratum, a sample of Census Enumeration Blocks (CEBs) was selected as PSUs. Before the PSU selection, PSUs were sorted according to the percentage of SC/ST population. In the second stage of selection, a fixed number of 22 households per cluster was selected with an equal probability systematic selection from a newly created list of households in the selected PSUs. The list of households was created as a result of the mapping and household listing operation conducted in each selected PSU before the household selection in the second stage. In all, 30,456 Primary Sampling Units (PSUs) were selected across the country in NFHS-5 drawn from 707 districts as on March 31st 2017, of which fieldwork was completed in 30,198 PSUs.

For further details on sample design, see Section 1.2 of the final report.

Mode of data collection

Computer Assisted Personal Interview [capi]

Research instrument

Four survey schedules/questionnaires: Household, Woman, Man, and Biomarker were canvassed in 18 local languages using Computer Assisted Personal Interviewing (CAPI).

Cleaning operations

Electronic data collected in the 2019-21 National Family Health Survey were received on a daily basis via the SyncCloud system at the International Institute for Population Sciences, where the data were stored on a password-protected computer. Secondary editing of the data, which required resolution of computer-identified inconsistencies and coding of open-ended questions, was conducted in the field by the Field Agencies and at the Field Agencies central office, and IIPS checked the secondary edits before the dataset was finalized.

Field-check tables were produced by IIPS and the Field Agencies on a regular basis to identify certain types of errors that might have occurred in eliciting information and recording question responses. Information from the field-check tables on the performance of each fieldwork team and individual investigator was promptly shared with the Field Agencies during the fieldwork so that the performance of the teams could be improved, if required.

Response rate

A total of 664,972 households were selected for the sample, of which 653,144 were occupied. Among the occupied households, 636,699 were successfully interviewed, for a response rate of 98 percent.

In the interviewed households, 747,176 eligible women age 15-49 were identified for individual women’s interviews. Interviews were completed with 724,115 women, for a response rate of 97 percent. In all, there were 111,179 eligible men age 15-54 in households selected for the state module. Interviews were completed with 101,839 men, for a response rate of 92 percent.

Abstract

The National Family Health Survey (NFHS) was carried out as the principal activity of a collaborative project to strengthen the research capabilities of the Population Reasearch Centres (PRCs) in India, initiated by the Ministry of Health and Family Welfare (MOHFW), Government of India, and coordinated by the International Institute for Population Sciences (IIPS), Bombay. Interviews were conducted with a nationally representative sample of 89,777 ever-married women in the age group 13-49, from 24 states and the National Capital Territoty of Delhi. The main objective of the survey was to collect reliable and up-to-date information on fertility, family planning, mortality, and maternal and child health. Data collection was carried out in three phases from April 1992 to September 1993. THe NFHS is one of the most complete surveys of its kind ever conducted in India.

The households covered in the survey included 500,492 residents. The young age structure of the population highlights the momentum of the future population growth of the country; 38 percent of household residents are under age 15, with their reproductive years still in the future. Persons age 60 or older constitute 8 percent of the population. The population sex ratio of the de jure residents is 944 females per 1,000 males, which is slightly higher than sex ratio of 927 observed in the 1991 Census.

The primary objective of the NFHS is to provide national-level and state-level data on fertility, nuptiality, family size preferences, knowledge and practice of family planning, the potentiel demand for contraception, the level of unwanted fertility, utilization of antenatal services, breastfeeding and food supplemation practises, child nutrition and health, immunizations, and infant and child mortality. The NFHS is also designed to explore the demographic and socioeconomic determinants of fertility, family planning, and maternal and child health. This information is intended to assist policymakers, adminitrators and researchers in assessing and evaluating population and family welfare programmes and strategies. The NFHS used uniform questionnaires and uniform methods of sampling, data collection and analysis with the primary objective of providing a source of demographic and health data for interstate comparisons. The data collected in the NFHS are also comparable with those of the Demographic and Health Surveys (DHS) conducted in many other countries.

Geographic coverage

National

Analysis unit

• Household
• Data collected for women 13-49, indicators calculated for women 15-49

Universe

The population covered by the 1992-93 DHS is defined as the universe of all women age 13-49 who were either permanent residents of the households in the NDHS sample or visitors present in the households on the night before the survey were eligible to be interviewed.

Kind of data

Sample survey data

Sampling procedure

SAMPLE DESIGN

The sample design for the NFHS was discussed during a Sample Design Workshop held in Madurai in Octber, 1991. The workshop was attended by representative from the PRCs; the COs; the Office of the Registrar General, India; IIPS and the East-West Center/Macro International. A uniform sample design was adopted in all the NFHS states. The Sample design adopted in each state is a systematic, stratified sample of households, with two stages in rural areas and three stages in urban areas.

SAMPLE SIZE AND ALLOCATION

The sample size for each state was specified in terms of a target number of completed interviews with eligible women. The target sample size was set considering the size of the state, the time and ressources available for the survey and the need for separate estimates for urban and rural areas of the stat. The initial target sample size was 3,000 completed interviews with eligible women for states having a population of 25 million or less in 1991; 4,000 completed interviews for large states with more than 25 million population; 8,000 for Uttar Pradesh, the largest state; and 1,000 each for the six small northeastern states. In States with a substantial number of backward districts, the initial target samples were increased so as to allow separate estimates to be made for groups of backward districts.

The urban and rural samples within states were drawn separetly and , to the extent possible, sample allocation was proportional to the size of the urban-rural populations (to facilitate the selection of a self-weighting sample for each state). In states where the urban population was not sufficiently large to provide a sample of at least 1,000 completed interviews with eligible women, the urban areas were appropriately oversampled (except in the six small northeastern states).

THE RURAL SAMPLE: THE FRAME, STRATIFICATION AND SELECTION

A two-stage stratified sampling was adopted for the rural areas: selection of villages followed by selection of households. Because the 1991 Census data were not available at the time of sample selection in most states, the 1981 Census list of villages served as the sampling frame in all the states with the exception of Assam, Delhi and Punjab. In these three states the 1991 Census data were used as the sampling frame.

Villages were stratified prior to selection on the basis of a number of variables. The firts level of stratification in all the states was geographic, with districts subdivided into regions according to their geophysical characteristics. Within each of these regions, villages were further stratified using some of the following variables : village size, distance from the nearest town, proportion of nonagricultural workers, proportion of the population belonging to scheduled castes/scheduled tribes, and female literacy. However, not all variables were used in every state. Each state was examined individually and two or three variables were selected for stratification, with the aim of creating not more than 12 strata for small states and not more than 15 strata for large states. Females literacy was often used for implicit stratification (i.e., the villages were ordered prior to selection according to the proportion of females who were literate). Primary sampling Units (PSUs) were selected systematically, with probaility proportional to size (PPS). In some cases, adjacent villages with small population sizes were combined into a single PSU for the purpose of sample selection. On average, 30 households were selected for interviewing in each selected PSU.

In every state, all the households in the selected PSUs were listed about two weeks prior to the survey. This listing provided the necessary frame for selecting households at the second sampling stage. The household listing operation consisted of preparing up-to-date notional and layout sketch maps of each selected PSU, assigning numbers to structures, recording addresses (or locations) of these structures, identifying the residential structures, and listing the names of the heads of all the households in the residentiak structures in the selected PSU. Each household listing team consisted of a lister and a mapper. The listing operation was supervised by the senior field staff of the concerned CO and the PRC in each state. Special efforts were made not to miss any household in the selected PSU during the listing operation. In PSUs with fewer than 500 households, a complete household listing was done. In PSUs with 500 or more households, segmentation of the PSU was done on the basis of existing wards in the PSU, and two segments were selected using either systematic sampling or PPS sampling. The household listing in such PSUs was carried out in the selected segments. The households to be interviewed were selected from provided with the original household listing, layout sketch map and the household sample selected for each PSU. All the selected households were approached during the data collection, and no substitution of a household was allowed under any circumstances.

THE RURAL URBAN SAMPLE: THE FRAME, STRATIFICATION AND SELECTION

A three-stage sample design was adopted for the urban areas in each state: selection of cities/towns, followed by urban blocks, and finally households. Cities and towns were selected using the 1991 population figures while urban blocks were selected using the 1991 list of census enumeration blocks in all the states with the exception of the firts phase states. For the first phase states, the list of urban blocks provided by the National Sample Survey Organization (NSSSO) served as the sampling frame.

All cities and towns were subdivided into three strata: (1) self-selecting cities (i.e., cities with a population large enough to be selected with certainty), (2) towns that are district headquaters, and (3) other towns. Within each stratum, the cities/towns were arranged according to the same kind of geographic stratification used in the rural areas. In self-selecting cities, the sample was selected according to a two-stage sample design: selection of the required number of urban blocks, followed by selection of households in each of selected blocks. For district headquarters and other towns, a three stage sample design was used: selection of towns with PPS, followed by selection of two census blocks per selected town, followed by selection of households from each selected block. As in rural areas, a household listing was carried out in the selected blocks, and an average of 20 households per block was selected systematically.

Mode of data collection

Face-to-face

Research instrument

Three types of questionnaires were used in the NFHS: the Household Questionnaire, the Women's Questionnaire, and the Village Questionnaire. The overall content

Abstract

The National Family Health Surveys (NFHS) programme, initiated in the early 1990s, has emerged as a nationally important source of data on population, health, and nutrition for India and its states. The 2005-06 National Family Health Survey (NFHS-3), the third in the series of these national surveys, was preceded by NFHS-1 in 1992-93 and NFHS-2 in 1998-99. Like NFHS-1 and NFHS-2, NFHS-3 was designed to provide estimates of important indicators on family welfare, maternal and child health, and nutrition. In addition, NFHS-3 provides information on several new and emerging issues, including family life education, safe injections, perinatal mortality, adolescent reproductive health, high-risk sexual behaviour, tuberculosis, and malaria. Further, unlike the earlier surveys in which only ever-married women age 15-49 were eligible for individual interviews, NFHS-3 interviewed all women age 15-49 and all men age 15-54. Information on nutritional status, including the prevalence of anaemia, is provided in NFHS3 for women age 15-49, men age 15-54, and young children.

A special feature of NFHS-3 is the inclusion of testing of the adult population for HIV. NFHS-3 is the first nationwide community-based survey in India to provide an estimate of HIV prevalence in the general population. Specifically, NFHS-3 provides estimates of HIV prevalence among women age 15-49 and men age 15-54 for all of India, and separately for Uttar Pradesh and for Andhra Pradesh, Karnataka, Maharashtra, Manipur, and Tamil Nadu, five out of the six states classified by the National AIDS Control Organization (NACO) as high HIV prevalence states. No estimate of HIV prevalence is being provided for Nagaland, the sixth high HIV prevalence state, due to strong local opposition to the collection of blood samples.

NFHS-3 covered all 29 states in India, which comprise more than 99 percent of India's population. NFHS-3 is designed to provide estimates of key indicators for India as a whole and, with the exception of HIV prevalence, for all 29 states by urban-rural residence. Additionally, NFHS-3 provides estimates for the slum and non-slum populations of eight cities, namely Chennai, Delhi, Hyderabad, Indore, Kolkata, Meerut, Mumbai, and Nagpur. NFHS-3 was conducted under the stewardship of the Ministry of Health and Family Welfare (MOHFW), Government of India, and is the result of the collaborative efforts of a large number of organizations. The International Institute for Population Sciences (IIPS), Mumbai, was designated by MOHFW as the nodal agency for the project. Funding for NFHS-3 was provided by the United States Agency for International Development (USAID), DFID, the Bill and Melinda Gates Foundation, UNICEF, UNFPA, and MOHFW. Macro International, USA, provided technical assistance at all stages of the NFHS-3 project. NACO and the National AIDS Research Institute (NARI) provided technical assistance for the HIV component of NFHS-3. Eighteen Research Organizations, including six Population Research Centres, shouldered the responsibility of conducting the survey in the different states of India and producing electronic data files.

The survey used a uniform sample design, questionnaires (translated into 18 Indian languages), field procedures, and procedures for biomarker measurements throughout the country to facilitate comparability across the states and to ensure the highest possible data quality. The contents of the questionnaires were decided through an extensive collaborative process in early 2005. Based on provisional data, two national-level fact sheets and 29 state fact sheets that provide estimates of more than 50 key indicators of population, health, family welfare, and nutrition have already been released. The basic objective of releasing fact sheets within a very short period after the completion of data collection was to provide immediate feedback to planners and programme managers on key process indicators.

Geographic coverage

• National (29 states )
• Regional (for HIV Prevalence : Andhra Pradesh, Karnataka, Maharashtra, Manipur, and Tamil Nadu)
• Local (population and health indicators for slum and non-slum populations for eight cities, namely Chennai, Delhi, Hyderabad, Indore, Kolkata, Meerut, Mumbai, and Nagpur)

Analysis unit

• Household
• Women age 15-49
• Men age 15-59

Universe

The population covered by the 2005 DHS is defined as the universe of all ever-married women age 15-49, NFHS-3 included never married women age 15-49 and both ever-married and never married men age 15-54 as eligible respondents.

Kind of data

Sample survey data

Sampling procedure

SAMPLE SIZE

Since a large number of the key indicators to be estimated from NFHS-3 refer to ever-married women in the reproductive ages of 15-49, the target sample size for each state in NFHS-3 was estimated in terms of the number of ever-married women in the reproductive ages to be interviewed.

The initial target sample size was 4,000 completed interviews with ever-married women in states with a 2001 population of more than 30 million, 3,000 completed interviews with ever-married women in states with a 2001 population between 5 and 30 million, and 1,500 completed interviews with ever-married women in states with a population of less than 5 million. In addition, because of sample-size adjustments required to meet the need for HIV prevalence estimates for the high HIV prevalence states and Uttar Pradesh and for slum and non-slum estimates in eight selected cities, the sample size in some states was higher than that fixed by the above criteria. The target sample was increased for Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland, Tamil Nadu, and Uttar Pradesh to permit the calculation of reliable HIV prevalence estimates for each of these states. The sample size in Andhra Pradesh, Delhi, Maharashtra, Tamil Nadu, Madhya Pradesh, and West Bengal was increased to allow separate estimates for slum and non-slum populations in the cities of Chennai, Delhi, Hyderabad, Indore, Kolkata, Mumbai, Meerut, and Nagpur.

The target sample size for HIV tests was estimated on the basis of the assumed HIV prevalence rate, the design effect of the sample, and the acceptable level of precision. With an assumed level of HIV prevalence of 1.25 percent and a 15 percent relative standard error, the estimated sample size was 6,400 HIV tests each for men and women in each of the high HIV prevalence states. At the national level, the assumed level of HIV prevalence of less than 1 percent (0.92 percent) and less than a 5 percent relative standard error yielded a target of 125,000 HIV tests at the national level.

Blood was collected for HIV testing from all consenting ever-married and never married women age 15-49 and men age 15-54 in all sample households in Andhra Pradesh, Karnataka, Maharashtra, Manipur, Tamil Nadu, and Uttar Pradesh. All women age 15-49 and men age 15-54 in the sample households were eligible for interviewing in all of these states plus Nagaland. In the remaining 22 states, all ever-married and never married women age 15-49 in sample households were eligible to be interviewed. In those 22 states, men age 15-54 were eligible to be interviewed in only a subsample of households. HIV tests for women and men were carried out in only a subsample of the households that were selected for men's interviews in those 22 states. The reason for this sample design is that the required number of HIV tests is determined by the need to calculate HIV prevalence at the national level and for some states, whereas the number of individual interviews is determined by the need to provide state level estimates for attitudinal and behavioural indicators in every state. For statistical reasons, it is not possible to estimate HIV prevalence in every state from NFHS-3 as the number of tests required for estimating HIV prevalence reliably in low HIV prevalence states would have been very large.

SAMPLE DESIGN

The urban and rural samples within each state were drawn separately and, to the extent possible, unless oversampling was required to permit separate estimates for urban slum and non-slum areas, the sample within each state was allocated proportionally to the size of the state's urban and rural populations. A uniform sample design was adopted in all states. In each state, the rural sample was selected in two stages, with the selection of Primary Sampling Units (PSUs), which are villages, with probability proportional to population size (PPS) at the first stage, followed by the random selection of households within each PSU in the second stage. In urban areas, a three-stage procedure was followed. In the first stage, wards were selected with PPS sampling. In the next stage, one census enumeration block (CEB) was randomly selected from each sample ward. In the final stage, households were randomly selected within each selected CEB.

SAMPLE SELECTION IN RURAL AREAS

In rural areas, the 2001 Census list of villages served as the sampling frame. The list was stratified by a number of variables. The first level of stratification was geographic, with districts being subdivided into contiguous regions. Within each of these regions, villages were further stratified using selected variables from the following list: village size, percentage of males working in the nonagricultural sector, percentage of the population belonging to scheduled castes or scheduled tribes, and female literacy. In addition to these variables, an external estimate of HIV prevalence, i.e., 'High', 'Medium' or 'Low', as estimated for all the districts in high HIV prevalence states, was used for stratification in high HIV prevalence states. Female literacy was used for implicit stratification (i.e., villages were

We utilized nationally representative sample survey data from round 4 (2015-16) and round 5 (2019-21) of the National Family Health Survey (NFHS). NFHS data from various rounds was accessed from the 7th phase of Demographic Health Surveys (DHS). The surveys were conducted under the stewardship of the Ministry of Health and Family Welfare (MoHFW) and the designated nodal agency- the International Institute for Population Science (IIPS). We considered household data sets from various rounds of NFHS.

Abstract

The principal objective of the 2006 Nepal Demographic and Health Survey (NDHS) is to provide current and reliable data on fertility and family planning behavior, child mortality, adult and maternal mortality, children’s nutritional status, the utilization of maternal and child health services, and knowledge of HIV/AIDS. For the first time, the 2006 NDHS conducted anemia testing at the household level for the country as a whole to provide information on the prevalence of anemia at the population level. The specific objectives of the survey are to:

• collect data at the national level which will allow the calculation of key demographic rates;
• analyze the direct and indirect factors which determine the level and trends of fertility;
• measure the level of contraceptive knowledge and practice among women and men by method, urban-rural residence and region,
• collect high-quality data on family health including immunization coverage among children, prevalence and treatment of diarrhea and other diseases among children under five, and maternity care indicators including antenatal visits, assistance at delivery, and postnatal care;
• collect data on infant and child mortality, and maternal and adult mortality;
• obtain data on child feeding practices including breastfeeding, and collect anthropometric measures to use in assessing the nutritional status of women and children;
• collect data on knowledge and attitudes of women and men about sexually transmitted infections and HIV/AIDS and evaluate patterns of recent behavior regarding condom use;
• conduct hemoglobin testing on women age 15-49 and children age 6-59 months in the households selected for the survey to provide information on the prevalence of anemia among women in the reproductive ages and young children.

This information is essential for informed policy decisions, planning, monitoring, and evaluation of programs on health in general and reproductive health in particular at both the national and regional levels. A long-term objective of the survey is to strengthen the technical capacity of government organizations to plan, conduct, process, and analyze data from complex national population and health surveys. Moreover, the 2006 NDHS provides national, regional and subregional estimates on population and health that are comparable to data collected in similar surveys in other developing countries. The first Demographic and Health Survey (DHS) in Nepal was the 1996 Nepal Family Health Survey (NFHS) conducted as part of the worldwide DHS program, and was followed five years later by the 2001 Nepal Demographic and Health Survey (NDHS). Data from the 2006 NDHS survey, the third such survey, allow for comparison of information gathered over a longer period of time and add to the vast and growing international database on demographic and health variables.

Wherever possible, the 2006 NDHS data are compared with data from the two earlier DHS surveys—the 2001 NDHS and the 1996 NFHS—which also sampled women age 15-49. Additionally, men age 15-59 were interviewed in the 2001 NDHS and the 2006 NDHS to provide comparable data for men over the last five years.

Geographic coverage

National

Analysis unit

• Household
• Children under five years
• Women age 15-49
• Men age 15-59

Kind of data

Sample survey data

Sampling procedure

The primary focus of the 2006 NDHS was to provide estimates of key population and health indicators, including fertility and mortality rates, for the country as a whole and for urban and rural areas separately. In addition, the sample was designed to provide estimates of most key indicators for the 13 domains obtained by cross-classifying the three ecological zones (mountain, hill and terai) with the five development regions (East, Central, West, Mid-west, and Far-west).

The 2006 NDHS used the sampling frame provided by the list of census enumeration areas with population and household information from the 2001 Population Census. Each of the 75 districts in Nepal is subdivided into Village Development Committees (VDCs), and each VDC into wards. The primary sampling unit (PSU) for the 2006 NDHS is a ward, subward, or group of wards in rural areas, and subwards in urban areas. In rural areas, the ward is small enough in size for a complete household listing, but in urban areas the ward is large. It was therefore necessary to subdivide each urban ward into subwards. Information on the subdivision of the urban wards was obtained from the updated Living Standards Measurement Survey. The sampling frame is representative of 96 percent of the noninstitutional population.

The sample for the survey is based on a two-stage, stratified, nationally representative sample of households. At the first stage of sampling, 260 PSUs (82 in urban areas and 178 in rural areas) were selected using systematic sampling with probability proportional to size. A complete household listing operation was then carried out in all the selected PSUs to provide a sampling frame for the second stage selection of households. At the second stage of sampling, systematic samples of about 30 households per PSU on average in urban areas and about 36 households per PSU on average in rural areas were selected in all the regions, in order to provide statistically reliable estimates of key demographic and health variables. However, since Nepal is predominantly rural, in order to obtain statistically reliable estimates for urban areas, it was necessary to oversample the urban areas. As such, the total sample is weighted and a final weighting procedure was applied to provide estimates for the different domains, and for the urban and rural areas of the country as a whole.

The survey was designed to obtain completed interviews of 8,600 women age 15-49. In addition, males age 15-59 in every second household were interviewed. To take nonresponse into account, a total of 9,036 households nationwide were selected.

Mode of data collection

Face-to-face

Research instrument

Three questionnaires were administered for the 2006 NDHS: the Household Questionnaire, the Women’s Questionnaire, and the Men’s Questionnaire. These questionnaires were adapted to reflect the population and health issues relevant to Nepal at a series of meetings with various stakeholders from government ministries and agencies, NGOs and international donors. The final draft of the questionnaires was discussed at a questionnaire design workshop organized by MOHP in September 2005 in Kathmandu. The survey questionnaires were then translated into the three main local languages—Nepali, Bhojpuri and Maithili and pretested from November 16 to December 13, 2005.

The Household Questionnaire was used to list all the usual members and visitors in the selected households and to identify women and men who were eligible for the individual interview. Some basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of the household. For children under age 18, the survival status of the parents was determined. The Household Questionnaire also collected information on characteristics of the household’s dwelling unit, such as the source of water, type of toilet facilities, materials used for the floor of the house, ownership of various durable goods, and ownership of mosquito nets. Additionally, the Household Questionnaire was used to record height, weight, and hemoglobin measurements of women age 15-49 and children age 6-59 months. The Women’s Questionnaire was used to collect information from all women age 15-49.

These women were asked questions on the following topics: - respondent’s characteristics such as education, residential history, media exposure, - pregnancy history, childhood mortality, - knowledge and use of family planning methods, - fertility preferences, - antenatal, delivery, and postnatal care, - breastfeeding and infant feeding practices, - immunization and childhood illnesses, - marriage and sexual activity, - woman’s work and husband’s background characteristics, - awareness and behavior regarding AIDS and other sexually transmitted infections (STIs), and - maternal mortality.

The Men’s Questionnaire was administered to all men age 15-59 living in every second household in the 2006 NDHS sample. The Men’s Questionnaire collected much of the same information found in the Women’s Questionnaire, but was shorter because it did not contain a detailed reproductive history or questions on maternal and child health or nutrition.

In addition, the Verbal Autopsy Module into the causes of under-five mortality was administered to all women age 15-49 (and anyone else who remembered the circumstances surrounding the reported death) who reported a death or stillbirth in the five years preceding the survey to children under five years of age.

Response rate

A total of 9,036 households were selected, of which 8,742 were found to be occupied during data collection. Of these existing households, 8,707 were successfully interviewed, giving a household response rate of nearly 100 percent.

In the selected households, 10,973 women were identified as eligible for the individual interview. Interviews were completed for 10,793 women, yielding a response rate of 98 percent. Of the 4,582 eligible men identified in the selected subsample of households, 4,397 were successfully interviewed, giving a 96 percent response rate. Response rates were higher in rural than urban areas, especially for eligible men.

Sampling error estimates

The estimates from a sample survey are affected by two types of errors: (1) nonsampling errors, and (2)

The principal objective of the 2006 Nepal Demographic and Health Survey (NDHS) is to provide current and reliable data on fertility and family planning behavior, child mortality, adult and maternal mortality, children’s nutritional status, the utilization of maternal and child health services, and knowledge of HIV/AIDS. For the first time, the 2006 NDHS conducted anemia testing at the household level for the country as a whole to provide information on the prevalence of anemia at the population level. The specific objectives of the survey are to: collect data at the national level which will allow the calculation of key demographic rates; analyze the direct and indirect factors which determine the level and trends of fertility; measure the level of contraceptive knowledge and practice among women and men by method, urban-rural residence and region, collect high-quality data on family health including immunization coverage among children, prevalence and treatment of diarrhea and other diseases among children under five, and maternity care indicators including antenatal visits, assistance at delivery, and postnatal care; collect data on infant and child mortality, and maternal and adult mortality; obtain data on child feeding practices including breastfeeding, and collect anthropometric measures to use in assessing the nutritional status of women and children; collect data on knowledge and attitudes of women and men about sexually transmitted infections and HIV/AIDS and evaluate patterns of recent behavior regarding condom use; conduct hemoglobin testing on women age 15-49 and children age 6-59 months in the households selected for the survey to provide information on the prevalence of anemia among women in the reproductive ages and young children. This information is essential for informed policy decisions, planning, monitoring, and evaluation of programs on health in general and reproductive health in particular at both the national and regional levels. A long-term objective of the survey is to strengthen the technical capacity of government organizations to plan, conduct, process, and analyze data from complex national population and health surveys. Moreover, the 2006 NDHS provides national, regional and subregional estimates on population and health that are comparable to data collected in similar surveys in other developing countries. The first Demographic and Health Survey (DHS) in Nepal was the 1996 Nepal Family Health Survey (NFHS) conducted as part of the worldwide DHS program, and was followed five years later by the 2001 Nepal Demographic and Health Survey (NDHS). Data from the 2006 NDHS survey, the third such survey, allow for comparison of information gathered over a longer period of time and add to the vast and growing international database on demographic and health variables. Wherever possible, the 2006 NDHS data are compared with data from the two earlier DHS surveys—the 2001 NDHS and the 1996 NFHS—which also sampled women age 15-49. Additionally, men age 15-59 were interviewed in the 2001 NDHS and the 2006 NDHS to provide comparable data for men over the last five years.

Analysis unit

Woman, Birth, Child, Man, Member

Universe

Women age 15-49, Births, Children age 0-4, Men age 15-54, All persons

Kind of data

Demographic and Household Survey [hh/dhs]

Sampling procedure

MICRODATA SOURCE: International Institute for Population Sciences (IIPS) and ICF.

SAMPLE UNIT: Woman SAMPLE SIZE: 699686

SAMPLE UNIT: Birth SAMPLE SIZE: 1315617

SAMPLE UNIT: Child SAMPLE SIZE: 259627

SAMPLE UNIT: Man SAMPLE SIZE: 112122

SAMPLE UNIT: Member SAMPLE SIZE: 2869043

Mode of data collection

Face-to-face [f2f]

The 2001 Nepal Demographic and Health Survey (NDHS) is a nationally representative survey of 8,726 women age 15-49 and 2,261 men age 15-59. This Survey is the sixth in a series of national-level population and health surveys conducted in Nepal. It is the second nationally representative comprehensive survey conducted as part of the global Demographic and Health Survey (DHS) program, the first being the 1996 Nepal Family Health Survey (NFHS). The 2001 NDHS is the first in the history of demographic and health surveys conducted in Nepal that included a male sample. The 2001 NDHS was carried out under the aegis of the Family Health Division of the Department of Health Services, Ministry of Health, and was implemented by New ERA, a local research organization, which also conducted the 1996 NFHS. ORC Macro provided technical support through its MEASURE DHS+ project. The survey was funded by the United States Agency for International Development (USAID) through its mission in Nepal. The principal objective of the 2001 NDHS is to provide current and reliable data on fertility and family planning, infant and child mortality, children's and women's nutritional status, the utilization of maternal and child health services, and knowledge of HIV/AIDS. This information is essential for informed policy decisions, planning, monitoring, and evaluation of programs on health in general and reproductive health in particular at both the national and regional levels. A long-term objective of the survey is to strengthen the technical capacity of the Family Health Division of the Ministry of Health to plan, conduct, process, and analyze data from complex national population and health surveys. The 2001 NDHS data is comparable to data collected in the 1996 NFHS and similar to survey data conducted in other developing countries. This allows for temporal and spatial comparisons of demographic health information. The 2001 NDHS also adds to the vast and growing international database on demographic and health variables. The inclusion of data on men adds to the richness of this data.

The 1996 Nepal Family Health Survey (NFHS) is a nationally representative survey of 8,429 ever- married women age 15-49. The survey is the fifth in a series of demographic and health surveys conducted in Nepal since 1976. The main purpose of the NFHS was to provide detailed information on fertility, family planning, infant and child mortality, and matemal and child health and nutrition. In addition, the NFHS included a series of questions on knowledge of AIDS. The primary objective of the Nepal Family Health Survey (NFHS) is to provide national level estimates of fertility and child mortality. The survey also provides information on nuptiality, contraceptive knowledge and behaviour, the potential demand for contraception, other proximate determinants of fertility, family size preferences, utilization of antenatal services, breastfeeding and food supplementation practices, child nutrition and health, immunizations, and knowledge about Acquired Immune Deficiency Syndrome (AIDS). This information will assist policy-makers, administrators and researchers to assess and evaluate population and health programmes and strategies. The NFHS is comparable to Demographic and Health Surveys (DHS) conducted in other developing countries. MAIN RESULTS FERTILITY Survey results indicate that fertility in Nepal has declined steadily from over 6 births per woman in the mid-1970s to 4.6 births per woman during the period of 1994-1996. Differentials in fertility by place of residence are marked, with the total fertility rate (TFR) for urban Nepal (2.9 births per woman) about two children less than for rural Nepal (4.8 births per woman). The TFR in the Mountains (5.6 births per woman) is about one child higher than the TFR in the Hills and Terai (4.5 and 4.6 births per woman, respectively). By development region, the highest TFR is observed in the Mid-western region (5.5 births per woman) and the lowest TFR in the Eastern region (4.1 births per woman). Fertility decline in Nepal has been influenced in part by a steady increase in age at marriage over the past 25 years. The median age at first marriage has risen from 15.5 years among women age 45-49 to 17.1 years among women age 20-24. This trend towards later marriage is supported by the fact that the proportion of women married by age 15 has declined from 41 percent among women age 45-49 to 14 percent among women age 15-19. There is a strong relationship between female education and age at marriage. The median age at first marriage for women with no formal education is 16 years, compared with 19.8 years for women with some secondary education. Despite the trend towards later age at marriage, childbearing begins early for many Nepalese women. One in four women age 15-19 is already a mother or pregnant with her first child, with teenage childbearing more common among rural women (24 percent) than urban women (20 percent). Nearly one in three adolescent women residing in the Terai has begun childbearing, compared with one in five living in the Mountains and 17 percent living in the Hills. Regionally, the highest level of adolescent childbearing is observed in the Central development region while the lowest is found in the Western region. Short birth intervals are also common in Nepal, with one in four births occurring within 24 months of a previous birth. This is partly due to the relatively short period of insusceptibility, which averages 14 months, during which women are not exposed to the risk of pregnancy either because they are amenorrhoeic or abstaining. By 12-13 months after a birth, mothers of the majority of births (57 percent) are susceptible to the risk of pregnancy. Early childbearing and short birth intervals remain a challenge to policy-makers. NFHS data show that children born to young mothers and those born after short birth intervals suffer higher rates of morbidity and mortality. Despite the decline in fertility, Nepalese women continue to have more children than they consider ideal. At current fertility levels, the average woman in Nepal is having almost 60 percent more births than she wantsthe total wanted fertility rate is 2.9 births per woman, compared with the actual total fertility rate of 4.6 births per woman. Unplanned and unwanted births are often associated with increased mortality risks. More than half(56 percent) of all births in the five-year period before the survey had an increased risk of dying because the mother was too young (under 18 years) or too old (more than 34 years), or the birth was of order 3 or higher, or the birth occurred within 24 months of a previous birth. Nevertheless, the percentage of women who want to stop childbearing in Nepal has increased substantially, from 40 percent in 1981 to 52 percent in 1991 and to 59 percent in 1996. According to the NFHS, 41 percent of currently married women age 15-49 say they do not want any more children, and an additional 18 percent have been sterilized. Furthermore, 21 percent of married women want to wait at least two years for their next child and only 13 percent want to have a child soon, that is, within two years. FAMILY PLANNING Knowledge of family planning is virtually universal in Nepal, with 98 percent of currently married women having heard of at least one method of family planning. This is a five-fold increase over the last two decades (1976-1996). Much of this knowledge comes from media exposure. Fifty-three percent of ever-married women had been exposed to family planning messages on the radio and/or the television and 23 percent have been exposed to messages through the print media. In addition, about one in four women has heard at least one of three specific family planning programmes on the radio. There has been a steady increase in the level of ever use of modern contraceptive method over the past 20 years, from 4 percent of currently married women in 1976, to 27 percent in 1991 and 35 percent in 1996. Among ever-users, female sterilization and male sterilization are the most popular methods (37 percent), indicating that contraceptive methods have been used more for limiting than for spacing births. The contraceptive prevalence rate among currently married women is 29 percent, with the majority of women using modern methods (26 percent). Again, the most widely used method is sterilization (18 percent, male and female combined), followed by injectables (5 percent). Although current use of modern contraceptive methods has risen steadily over the last two decades, the pace of change has been slowest in the most recent years (1991-1996). Current use among currently married non-pregnant women increased from 3 percent in 1976 to 15 percent in 1986 to 24 percent in 1991 and to 29 percent in 1996. While female sterilization increased by only 3 percent from 45 percent of modern methods in 1986 to 46 percent in 1996, male sterilization declined by almost 50 percent from 41 percent to 21 percent over the same period. The level of current use is nearly twice as high in the urban areas (50 percent) as in rural areas (27 percent). Only 18 percent of currently married women residing in the Mountains are currently using contraception, compared with 30 percent and 29 percent living in the Hills and Terai regions, respectively. There is a notable difference in current contraceptive use between the Far-western region (21 percent) and all the other regions, especially the Central and Eastern regions (31 percent each). Educational differences in current use are large, with 26 percent of women with no education currently using contraception, compared with 52 percent of women who have completed their School Leaving Certificate (SLC). In general, as women's level of education rises, they are more likely to use modem spacing methods. The public sector figures prominently as a source of modem contraceptives. Seventy-nine percent of modem method users obtained their methods from a public source, especially hospitals and district clinics (32 percent) and mobile camps (28 percent). The public sector is the predominant source of sterilizations, 1UDs, injectables, and Norplant, and both the public and private sectors are equally important sources of the pill and condoms. Nevertheless, the public sector's share of the market has fallen over the last five years from 93 percent of current users in 1991 to 79 percent in 1996. There is considerable potential for increased family planning use in Nepal. Overall, one in three women has an unmet need for family planning14 percent for spacing and 17 percent for limiting. The total demand for family planning, including those women who are currently using contraception, is 60 percent. Currently, the family planning needs of only one in two women is being met. While the increase in unmet need between 1991 (28 percent) and 1996 (31 percent) was small, there was a 14 percent increase in the percentage of women using any method of family planning and, over the same period, a corresponding increase of 18 percent in the demand for family planning. MATERNAL AND CHILD HEALTH At current mortality levels, one of every 8 children born in Nepal will die before the fifth birthday, with two of three deaths occurring during the first year of life. Nevertheless, NFHS data show that mortality levels have been declining rapidly in Nepal since the eighties. Under-five mortality in the period 0-4 years before the survey is 40 percent lower than it was 10-14 years before the survey, with child mortality declining faster (45 percent) than infant mortality (38 percent). Mortality is consistently lower in urban than in rural areas, with children in the Mountains faring much worse than children living in the Hills and Terai. Mortality is also far worse in the Far-western and Mid-western development regions than in the other regions. Maternal education is strongly related to mortality, and children of highly educated mothers are least likely to die young. For example, infant mortality is nearly

Abstract

The 1996 Nepal Family Health Survey (NFHS) is a nationally representative survey of 8,429 ever- married women age 15-49. The survey is the fifth in a series of demographic and health surveys conducted in Nepal since 1976. The main purpose of the NFHS was to provide detailed information on fertility, family planning, infant and child mortality, and matemal and child health and nutrition. In addition, the NFHS included a series of questions on knowledge of AIDS.

The primary objective of the Nepal Family Health Survey (NFHS) is to provide national level estimates of fertility and child mortality. The survey also provides information on nuptiality, contraceptive knowledge and behaviour, the potential demand for contraception, other proximate determinants of fertility, family size preferences, utilization of antenatal services, breastfeeding and food supplementation practices, child nutrition and health, immunizations, and knowledge about Acquired Immune Deficiency Syndrome (AIDS). This information will assist policy-makers, administrators and researchers to assess and evaluate population and health programmes and strategies. The NFHS is comparable to Demographic and Health Surveys (DHS) conducted in other developing countries.

MAIN RESULTS

FERTILITY

Survey results indicate that fertility in Nepal has declined steadily from over 6 births per woman in the mid-1970s to 4.6 births per woman during the period of 1994-1996. Differentials in fertility by place of residence are marked, with the total fertility rate (TFR) for urban Nepal (2.9 births per woman) about two children less than for rural Nepal (4.8 births per woman). The TFR in the Mountains (5.6 births per woman) is about one child higher than the TFR in the Hills and Terai (4.5 and 4.6 births per woman, respectively). By development region, the highest TFR is observed in the Mid-western region (5.5 births per woman) and the lowest TFR in the Eastern region (4.1 births per woman).

Fertility decline in Nepal has been influenced in part by a steady increase in age at marriage over the past 25 years. The median age at first marriage has risen from 15.5 years among women age 45-49 to 17.1 years among women age 20-24. This trend towards later marriage is supported by the fact that the proportion of women married by age 15 has declined from 41 percent among women age 45-49 to 14 percent among women age 15-19. There is a strong relationship between female education and age at marriage. The median age at first marriage for women with no formal education is 16 years, compared with 19.8 years for women with some secondary education.

Despite the trend towards later age at marriage, childbearing begins early for many Nepalese women. One in four women age 15-19 is already a mother or pregnant with her first child, with teenage childbearing more common among rural women (24 percent) than urban women (20 percent). Nearly one in three adolescent women residing in the Terai has begun childbearing, compared with one in five living in the Mountains and 17 percent living in the Hills. Regionally, the highest level of adolescent childbearing is observed in the Central development region while the lowest is found in the Western region.

Short birth intervals are also common in Nepal, with one in four births occurring within 24 months of a previous birth. This is partly due to the relatively short period of insusceptibility, which averages 14 months, during which women are not exposed to the risk of pregnancy either because they are amenorrhoeic or abstaining. By 12-13 months after a birth, mothers of the majority of births (57 percent) are susceptible to the risk of pregnancy. Early childbearing and short birth intervals remain a challenge to policy-makers. NFHS data show that children born to young mothers and those born after short birth intervals suffer higher rates of morbidity and mortality.

Despite the decline in fertility, Nepalese women continue to have more children than they consider ideal. At current fertility levels, the average woman in Nepal is having almost 60 percent more births than she wants--the total wanted fertility rate is 2.9 births per woman, compared with the actual total fertility rate of 4.6 births per woman. Unplanned and unwanted births are often associated with increased mortality risks. More than half(56 percent) of all births in the five-year period before the survey had an increased risk of dying because the mother was too young (under 18 years) or too old (more than 34 years), or the birth was of order 3 or higher, or the birth occurred within 24 months of a previous birth.

Nevertheless, the percentage of women who want to stop childbearing in Nepal has increased substantially, from 40 percent in 1981 to 52 percent in 1991 and to 59 percent in 1996. According to the NFHS, 41 percent of currently married women age 15-49 say they do not want any more children, and an additional 18 percent have been sterilized. Furthermore, 21 percent of married women want to wait at least two years for their next child and only 13 percent want to have a child soon, that is, within two years.

FAMILY PLANNING

Knowledge of family planning is virtually universal in Nepal, with 98 percent of currently married women having heard of at least one method of family planning. This is a five-fold increase over the last two decades (1976-1996). Much of this knowledge comes from media exposure. Fifty-three percent of ever-married women had been exposed to family planning messages on the radio and/or the television and 23 percent have been exposed to messages through the print media. In addition, about one in four women has heard at least one of three specific family planning programmes on the radio.

There has been a steady increase in the level of ever use of modern contraceptive method over the past 20 years, from 4 percent of currently married women in 1976, to 27 percent in 1991 and 35 percent in 1996. Among ever-users, female sterilization and male sterilization are the most popular methods (37 percent), indicating that contraceptive methods have been used more for limiting than for spacing births.

The contraceptive prevalence rate among currently married women is 29 percent, with the majority of women using modern methods (26 percent). Again, the most widely used method is sterilization (18 percent, male and female combined), followed by injectables (5 percent). Although current use of modern contraceptive methods has risen steadily over the last two decades, the pace of change has been slowest in the most recent years (1991-1996). Current use among currently married non-pregnant women increased from 3 percent in 1976 to 15 percent in 1986 to 24 percent in 1991 and to 29 percent in 1996. While female sterilization increased by only 3 percent from 45 percent of modern methods in 1986 to 46 percent in 1996, male sterilization declined by almost 50 percent from 41 percent to 21 percent over the same period.

The level of current use is nearly twice as high in the urban areas (50 percent) as in rural areas (27 percent). Only 18 percent of currently married women residing in the Mountains are currently using contraception, compared with 30 percent and 29 percent living in the Hills and Terai regions, respectively. There is a notable difference in current contraceptive use between the Far-western region (21 percent) and all the other regions, especially the Central and Eastern regions (31 percent each). Educational differences in current use are large, with 26 percent of women with no education currently using contraception, compared with 52 percent of women who have completed their School Leaving Certificate (SLC). In general, as women's level of education rises, they are more likely to use modem spacing methods.

The public sector figures prominently as a source of modem contraceptives. Seventy-nine percent of modem method users obtained their methods from a public source, especially hospitals and district clinics (32 percent) and mobile camps (28 percent). The public sector is the predominant source of sterilizations, 1UDs, injectables, and Norplant, and both the public and private sectors are equally important sources of the pill and condoms. Nevertheless, the public sector's share of the market has fallen over the last five years from 93 percent of current users in 1991 to 79 percent in 1996.

There is considerable potential for increased family planning use in Nepal. Overall, one in three women has an unmet need for family planning--14 percent for spacing and 17 percent for limiting. The total demand for family planning, including those women who are currently using contraception, is 60 percent. Currently, the family planning needs of only one in two women is being met. While the increase in unmet need between 1991 (28 percent) and 1996 (31 percent) was small, there was a 14 percent increase in the percentage of women using any method of family planning and, over the same period, a corresponding increase of 18 percent in the demand for family planning.

MATERNAL AND CHILD HEALTH

At current mortality levels, one of every 8 children born in Nepal will die before the fifth birthday, with two of three deaths occurring during the first year of life. Nevertheless, NFHS data show that mortality levels have been declining rapidly in Nepal since the eighties. Under-five mortality in the period 0-4 years before the survey is 40 percent lower than it was 10-14 years before the survey, with child mortality declining faster (45 percent) than infant mortality (38 percent).

Mortality is consistently lower in urban than in rural areas, with children in the Mountains faring much worse than children living in the Hills and Terai. Mortality is also far worse in the Far-western and Mid-western development regions than in the other regions. Maternal education is strongly related to mortality, and children of highly

State level prevalence of stunting (height-for-age z-scores

Nutritional status of adolescents (15–19 years) subjected to anthropometry in NFHS-4 (N = 144,320).

Abstract

The 2001 Nepal Demographic and Health Survey (NDHS) is a nationally representative survey of 8,726 women age 15-49 and 2,261 men age 15-59. This Survey is the sixth in a series of national-level population and health surveys conducted in Nepal. It is the second nationally representative comprehensive survey conducted as part of the global Demographic and Health Survey (DHS) program, the first being the 1996 Nepal Family Health Survey (NFHS). The 2001 NDHS is the first in the history of demographic and health surveys conducted in Nepal that included a male sample. The 2001 NDHS was carried out under the aegis of the Family Health Division of the Department of Health Services, Ministry of Health, and was implemented by New ERA, a local research organization, which also conducted the 1996 NFHS. ORC Macro provided technical support through its MEASURE DHS+ project. The survey was funded by the United States Agency for International Development (USAID) through its mission in Nepal.

The principal objective of the 2001 NDHS is to provide current and reliable data on fertility and family planning, infant and child mortality, children's and women's nutritional status, the utilization of maternal and child health services, and knowledge of HIV/AIDS. This information is essential for informed policy decisions, planning, monitoring, and evaluation of programs on health in general and reproductive health in particular at both the national and regional levels.

A long-term objective of the survey is to strengthen the technical capacity of the Family Health Division of the Ministry of Health to plan, conduct, process, and analyze data from complex national population and health surveys. The 2001 NDHS data is comparable to data collected in the 1996 NFHS and similar to survey data conducted in other developing countries. This allows for temporal and spatial comparisons of demographic health information. The 2001 NDHS also adds to the vast and growing international database on demographic and health variables. The inclusion of data on men adds to the richness of this data.

Geographic coverage

The 2001 NDHS collected demographic and health information from a nationally representative sample of ever-married women and men in the reproductive age groups of 15-49 and 15-59, respectively. The primary focus of the 2001 NDHS was to provide estimates of key population and health indicators, including fertility and mortality rates, for the country as a whole and for urban and rural areas separately.

Analysis unit

• Household
• Women age 15-49
• Men age 15-59

Universe

The population covered by the 2008 DHS is defined as the universe of all women ever-married women and men in the reproductive age groups of 15-49 and 15-59

Kind of data

Sample survey data

Sampling procedure

The survey was designed to obtain completed interviews of 8,400 ever-married women age 15-49. In addition, all ever-married males age 15-59 in every third household were interviewed. To take nonresponse into account, a total of 8,700 households nationwide were selected. The sample size was allocated to each district by urban and rural areas and the numbers of PSUs were calculated based on an average sample "take" (the number of ultimate sampled units in a cluster) of 34 completed interviews per PSU.

SAMPLE DESIGN

The 2001 NDHS collected demographic and health information from a nationally representative sample of ever-married women and men in the reproductive age groups of 15-49 and 15-59, respectively. The primary focus of the 2001 NDHS was to provide estimates of key population and health indicators, including fertility and mortality rates, for the country as a whole and for urban and rural areas separately. In addition, the sample was designed to provide estimates of most key variables for the 13 domains obtained by cross-classifying the three ecological zones (mountains, hills, and terai) with the five development regions (Eastern, Central, Western, Mid-western, and Far-western). Due to their small size, the mountain areas of the Western, Mid-western, and Far-western regions were combined.

SAMPLING FRAME

The 2001 NDHS used the sampling frame provided by the list of census enumeration areas (EAs) with population and household information from the 1991 Population Census. Administratively, Nepal is divided into 75 districts. Each district is subdivided into village development committees (VDCs), and each VDC is divided into wards. The primary sampling unit (PSU) for the 2001 NDHS is a ward or group of wards in rural areas and subwards in urban areas. In rural areas, the ward is small enough for a complete household listing, but in urban areas, the ward size is large. It was therefore necessary to subdivide each urban ward into subwards. Information on the subdivision of the urban wards was obtained from the Living Standards Measurement Survey, a project funded by the World Bank.

SAMPLE SELECTION

The sample for the survey is based on a two-stage, stratified, nationally representative sample of households. At the first stage of sampling, 257 PSUs - 42 in urban areas and 215 in rural areas were selected using systematic sampling with probability proportional to size. During fieldwork, six PSUs in the Mid-western region were dropped from the sample due to security issues, reducing the total number of PSUs covered to 251 and reducing the number of rural PSUs to 209. This also reduced the expected number of completed interviews to 8,170 from 8,400.

A complete household listing operation was then carried out in all the selected EAs to provide a sampling frame for the second-stage selection of households. Sketch maps were constructed to identify the relative position of housing units in an EA to help interviewers locate selected households during fieldwork. Table A.1 shows the sample distribution of PSUs.

Global positioning system (GPS) units were used to calculate latitude and longitude coordinates for each selected ward (or subward) during the household listing stage. One latitude/longitude coordinate was taken for the center of each settlement or community within the ward. The altitude reading was also taken with the GPS units. The positional accuracy of the GPS readings is approximately 5 to 10 meters for latitude/longitude and approximately 30 meters for altitude. This geographic information allows the 2001 NDHS data to be integrated into a geographic information system (GIS) along with other spatial data collected in the same localities and adds to the depth of information available from the 2001 NDHS.

At the second stage of sampling, systematic samples of 34 households per PSU on average were selected in all the regions in order to provide statistically reliable estimates of key demographic and health variables. However, since Nepal is predominantly rural, in order to obtain statistically reliable estimates for urban areas, it was necessary to oversample the urban areas. As such, the total sample is weighted and a final weighting procedure was applied to provide estimates for the different domains and for the urban and rural areas of the country as a whole.

Mode of data collection

Face-to-face

Research instrument

The 2001 NDHS used three questionnaires: the Household Questionnaire, the Women's Questionnaire, and the Men's Questionnaire. The content and design of the questionnaires were based on the MEASURE DHS+ Model 'B' Questionnaire. The questionnaires were specifically geared toward obtaining the kind of information needed by health and family planning program managers and policymakers. The model questionnaires were then adapted to local conditions and a number of additional questions specific to ongoing health and family planning programs in Nepal were added. These questionnaires were developed in English and translated into the three principal languages in use in the country: Nepali (the national language), Bhojpuri, and Maithili. They were then independently translated back to English and appropriate changes were made in the translation of questions in which the back-translated version did not compare well with the original English version. A pretest of all three questionnaires was conducted in the three local languages in September 2000.

a) All usual members in a selected household and visitors who stayed there the previous night were enumerated using the Household Questionnaire. Specifically, the Household Questionnaire obtained information on the relationship to the head of the household, residence, sex, age, marital status, and education of each usual resident or visitor. This information was used to identify eligible women and men for the individual interview. Ever-married women age 15-49 in all selected households and ever-married men age 15-59 in every third selected household, whether usual residents or visitors, were deemed eligible and were interviewed. The Household Questionnaire also obtained information on some basic socioeconomic indicators such as the source of drinking water, the type of toilet facilities, the ownership of a variety of consumer durable items, and the flooring material. All eligible women and all children born since Baisakh 2052 in the Nepali calendar (which roughly corresponds to April 1995 in the Gregorian calendar) were weighed and measured.

b) The Women's Questionnaire collected information on female respondent's background characteristics; reproductive history; contraceptive knowledge and use; antenatal, delivery, and postnatal care; infant feeding practices; child immunization and health; marriage; fertility preferences; attitudes about family planning;

Demographic characteristics of adolescents in (15–19 years) enumerated in NFHS-3 (2005–6) and NFHS-4 (2015–16).

The 2015-16 National Family Health Survey (NFHS-4), the fourth in the NFHS series, provides information on population, health, and nutrition for India and each state and union territory. For the first time, NFHS-4 provides district-level estimates for many important indicators. All four NFHS surveys have been conducted under the stewardship of the Ministry of Health and Family Welfare (MoHFW), Government of India. MoHFW designated the International Institute for Population Sciences (IIPS), Mumbai, as the nodal agency for the surveys. Funding for NFHS-4 was provided by the United States Agency for International Development (USAID), the United Kingdom Department for International Development (DFID), the Bill and Melinda Gates Foundation (BMGF), UNICEF, UNFPA, the MacArthur Foundation, and the Government of India. Technical assistance for NFHS-4 was provided by ICF, Maryland, USA. Assistance for the HIV component of the survey was provided by the National AIDS Control Organization (NACO) and the National AIDS Research Institute (NARI), Pune.

Nutritional status of adolescents (15–19 years) subjected to anthropometry in NFHS-3 (N = 35,570).

Prevalence of overweight/obesity in adolescents (15–19 years) in NFHS-3 and 4 using adult cutoffs vs. those for adolescents based on 2007 WHO Growth reference.

Sample composition by variable type & survey year: Female age 15–49 years.

State level prevalence of thinness (BMI-for-age z-scores 1 SD) in NFHS-3 (2005–6).