India is in the middle of a complex health transition. Child marriage declined over the years, but is still prevalent for 20% of girls. Maternal health shows signs of improvement, but caesarean deliveries surged sharply, driven by private facilities. Malnutrition remains critical, while lifestyle diseases like obesity and diabetes are rising rapidly. Immunization rate has increased 83%. These findings in the latest National Family Health Survey (NFHS-6), conducted in 2022-23, were released last week for all states and union territories, except Manipur, where the survey could not be conducted. Mint explores the trends in detail.
Child marriage: High, but down
Child marriage is a key determinant of high fertility, poor maternal and child health, and the lower social status of women. The share of women aged 20-24 years, married before turning 18, declined from 23% to 20% over the last four years. This also means that every fifth girl still gets married underage. Although the decline was seen across rural and urban areas, disparities persist. While 11% of women aged 20-24 years in urban areas were married before turning 18, the share was 23% in rural areas. West Bengal (36%) and Bihar (35%) reported the highest prevalence of girl child marriage, followed by Tripura (34%), Jharkhand (28%), Assam (25%), Andhra Pradesh (25%), and Rajasthan (24%)—all above the national average.
While child marriage was the highest in West Bengal and Bihar, the two states reported different fertility rates. Bihar, at 2.7, was significantly higher than the replacement level of 2.1, while West Bengal was significantly lower at 1.6. The replacement level fertility rate is the average number of children a woman needs to have to keep the population size stable.
Maternal health: C-section surges
Maternal health indicators show continued improvement. Mothers receiving at least four antenatal care visits increased from 59% in NFHS-5 to 65% in NFHS-6, while institutional births rose from 89% to 91%. Caesarean deliveries have risen sharply from 22% to 27% in four years. The rise is largely driven by private facilities—caesarean deliveries among private-facility births increased from 47% to 54%, compared with 14% to 17% in public facilities.
Every other birth was by surgery in Punjab, Tamil Nadu, Jammu & Kashmir, Andhra Pradesh, and Telangana. In private facilities, the share crossed 75% in Odisha, Tripura, Assam, Telangana, West Bengal, and Jammu and Kashmir. Overall, 25 states and UTs reported caesarean births above 20% across all facilities, while 19 reported public-facility caesarean levels above 20%.
In private facilities, caesarean delivery was far more common, with almost every third or more institutional birth delivered by surgery in all states. The public-private gap is striking: at the all-India level, caesarean delivery was 37 percentage points higher in private facilities than in public facilities. Nine major states reported a gap of more than 40 percentage points.
Immunization: northeast catches up
Immunization is critical for child survival and improved child health as it protects children from major vaccine-preventable diseases. Full immunization coverage among children aged 12-23 months improved from 77% in NFHS-5 to 83% in NFHS-6, a six percentage-point increase. The gains are particularly visible in the northeast, where several states appear to be catching up. Assam recorded the sharpest rise, from 67% to 82%, followed by Meghalaya, Arunachal Pradesh, and Sikkim, each registering an increase of more than 10 percentage points. Nagaland also improved, though it continued to report the lowest coverage at 64%. Tripura gained nearly five percentage points, while Mizoram remained almost unchanged at 72%.
Outside the region, Uttar Pradesh, Andhra Pradesh, and Goa saw improvements of more than 10 percentage points, while Maharashtra recorded a nearly 10 percentage-point rise. Ladakh, Goa, Sikkim, Odisha, Lakshadweep, Karnataka, Himachal Pradesh, and Tamil Nadu reported coverage of 90% or above.
Undernourishment: Critical
The share of under-five children who were stunted (too short for age) has declined, while the proportion wasted (low weight for height) remained unchanged. Almost every third child still suffers from chronic undernourishment (stunting), and every fifth child is acutely malnourished (wasted). Meghalaya (37%) had the highest stunting prevalence, followed by Bihar, Gujarat, and Jharkhand—all over the 35% mark. West Bengal, Tripura, Himachal Pradesh, Meghalaya, Karnataka, and Uttar Pradesh recorded declines of 8-11 percentage points since 2019-21.
Wasting showed almost no improvement at the national level. Acute malnutrition among children under five years old increased in Punjab, Haryana, Madhya Pradesh, and Odisha, whereas Jammu and Kashmir, Himachal Pradesh, Maharashtra, Gujarat, Kerala, and Telangana saw noteworthy improvement. Every fourth child in Madhya Pradesh, Jharkhand, and Odisha, and every fifth child in Assam, Chhattisgarh, West Bengal, Gujarat, Maharashtra, Rajasthan, Uttar Pradesh, and Bihar were found wasted.
Lifestyle: Rapidly worsening
The survey reported a rapid rise in adult obesity, a major risk factor for chronic illness. Every third woman and more than every fourth man aged 15-49 years in India is now overweight or obese (body mass index greater than 25.0). The prevalence increased by seven percentage points among women and four percentage points among men between NFHS-5 and NFHS-6 over just four years.
All southern states reported high levels, with roughly 35% to 45% of adult men and women being either overweight or obese. Outside the southern region, major increases of around 10 percentage points were recorded in Maharashtra and West Bengal. During the same period, diabetes prevalence among adults aged 15 years and above, based on finger-prick blood samples, increased from 13.5% to 17.8% among women and from 15.6% to 20.9% among men—nearly a one percentage point annual rise on average.
Diabetes prevalence is high in the southern states, along with West Bengal, Odisha, and Punjab, all reporting 20% to 30% prevalence. States such as Chhattisgarh, Uttarakhand, Jharkhand, and Uttar Pradesh also reported rapid gains of around 7 to 8 percentage points in just four years. Test-based hypertension among adults aged 15 years and above declined by around two percentage points among both women and men at the national level.
The authors are PhD scholars at Banaras Hindu University, Varanasi, and the International Institute for Population Sciences, Mumbai, respectively.