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Fewer but Frailer: Understanding Fertility and Child Nutrition through NFHS-6
India entered 2026 carrying a demographic credential it has long sought: a Total Fertility Rate (TFR) of 1.9, confirmed by both the Sample Registration System 2024 and the National Family Health Survey-6 (NFHS-6, 2023–24), well below the replacement threshold of 2.1. This means the country now has fewer than two children per woman, on average. It is an achievement worth celebrating, signalling not only successful population stabilisation but also India’s growing capacity to deliver long-term public health and development interventions at scale.
The challenge now is to ensure that this demographic success is matched by equally strong gains in child health and nutrition. Smaller families should ideally mean greater household resources per child, better care, and improved nutrition. But is the attribution so simple? The answer is more nuanced than the fertility numbers suggest, and we must be cautious before celebrating.
Articulating the Achievements
Between NFHS-4 (2015–16) and NFHS-6 (2023–24), India’s TFR declined from 2.2 to 1.9. Over the same period, child stunting fell from 38.4% to 29.3%, indicating progress against chronic undernutrition. This steady decline demonstrates that long-term investments can yield positive results and provide a strong foundation for future interventions. On the contrary, the prevalence of wasting increased slightly from 19.9% to 20.5%, exhibiting the tenacity of acute undernutrition for Indian children.
This divergence is important. While stunting gradually responds to operational interventions like sanitation, immunisation, maternal health, and economic growth, wasting is different. It is proximate, acute, and rapidly fatal in its severe form. The fact that this indicator has remained stubbornly resistant across multiple NFHS rounds is an indication that the system has missed a crucial point of intervention.
Sustained investments through POSHAN Abhiyaan, the Integrated Child Development Services (ICDS), and improvements in maternal and child healthcare have contributed to meaningful reductions in stunting over the past decade. The challenge now extends beyond food availability to how children are fed during the critical first 1,000 days of life, a period that shapes lifelong health and development. NFHS-6 reveals concerning gaps in infant and young child feeding practices.
Only 15% of breastfed children aged 6–23 months receive an adequate diet, while exclusive breastfeeding rates among infants under six months fell from 63.7% to 55.8% between NFHS-5 and NFHS-6. These shortcomings are specifically troubling given their direct influence on growth, immunity, and survival.
The picture becomes even more upsetting when viewed through a gender lens. Girls continue to fare worse than boys on key nutrition indicators in most of the states, and it is not incidental. It reflects deeply entrenched patterns of intra-household food allocation, earlier cessation of breastfeeding for girl children in some communities, and lower care-seeking behaviour for daughters.
Such disparities emphasise the need for nutrition programmes that are not only age-sensitive but also gender-responsive, with explicit targets and monitoring mechanisms to ensure that no child is left behind. India is having fewer children; yet we are not feeding them sufficiently.
Mapping the Malnutrition Mire
The national average, as always, obscures the terrain beneath it. The states that continue to face the highest burden of child malnutrition are often the same states that have historically recorded higher fertility and weaker health systems. Bihar, Jharkhand, Uttar Pradesh, and parts of central India continue to carry a disparate share of India’s child malnutrition burden. Appallingly, wasting increased from 19% to 24% between NFHS-5 and NFHS-6 in Madhya Pradesh.
For a child with severe wasting or another life-threatening condition, survival often depends on reaching appropriate care quickly. Access to specialised newborn and child-care services has expanded considerably over the past decade, including the establishment of Special Newborn Care Units (SNCUs) across many districts. However, the coverage, staffing, referral systems, and quality of care have remained skewed. Assessments of district hospitals in Bihar found that SNCUs were available in only around 58% of district hospitals. The same assessments reported that roughly one-third of Primary Health Centres lacked emergency transport for referrals.
Picturing the Population Progress
National averages show encouraging progress, but they also conceal persistent pockets of vulnerability. Until these geographies are addressed with the specificity they require, national progress will remain a statistical average masking a preventable crisis.
The evidence does not call for a change in direction, but a refinement of priorities. Building on the gains already achieved, the next phase of policy must focus on strengthening implementation where the burden of child malnutrition remains highest. Three priorities can help accelerate this transition. First, early detection of wasting through stronger surveillance and community-based screening. Second, nutrition programmes must focus not only on coverage but also on quality and timely management of high-risk children. Finally, high-burden districts need stronger newborn and child-care systems, including well-functioning SNCUs, referral networks, and stabilisation facilities, to prevent avoidable deaths.
The demographic transition is one of the country’s major public health achievements. The next milestone is to ensure that every child born benefits equally from that progress. Strengthening nutrition, emergency child-care services, and district-level implementation in high-burden regions will help ensure that population stabilisation transforms from a demographic success to a human development success.
For a deeper look at unmet care and system gaps, read ISPP’s Forgone Care: The Missing Metric in India’s Health System.
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Author
Dr. Shalini Singh
Dr. Shalini Singh is a public health researcher with an MD in Community Medicine and currently serves as a Senior Research Associate at the Centre for Universal Health Assurance (CUHA). She specialises in universal health coverage, health financing, health equity, and climate health. Her work spans epidemiology and health systems research, with publications in peer-reviewed journals, policy papers, and newspapers. She focuses on translating evidence into policy and strengthening health access and financial protection.