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Sex-selective abortion and India’s declining female sex ratio

By T K Sundari Ravindran

The decline in child sex ratios in India cannot be addressed only by preventing misuse of preconception and prenatal diagnostic techniques. Factors other than sex-selective abortion -- including higher under-5 mortality for females in every state -- are also responsible. It is important to address the root causes of sex determination -- gender discrimination manifested through son-preference and daughter-neglect

The decline in India's sex ratio during the 20th century has been the subject of much discussion in recent years. Sex-selective abortion of the female foetus following a prenatal diagnostic test is widely believed to be the major contributor to this phenomenon. This factsheet explores factors that are known to influence the sex ratio of a population. It argues that the way forward would be through addressing the root causes of sex determination, namely gender discrimination manifested through son-preference and daughter-neglect.

Understanding sex ratios

  • According to the conventional definition, sex ratio = (number of males/number of females) per 100 population. However, in India, we usually define sex ratio as (number of females/number of males) per 1,000 population, at a specific point in time.
  • Population sex ratio is the ratio of females per 1,000 males in the entire population.
  • The child sex ratio is the ratio of females per 1,000 males in the 0-6 age-group.
  • Sex ratio at birth is the ratio of female live births per 1,000 male live births. The fact that more boys are born than girls has been known at least since the 17th century (1). A sex ratio at birth that lies between 934 and 952 females per 1,000 male births is considered to be within the normal range, based on observation over several decades for many countries (2). The sex ratio at birth is the most relevant indicator for examining the magnitude of sex-selective abortions.

1. How do we interpret the further decline in India's child sex ratio between 2001 and 2011?

The census of 2011 has brought much disquiet because the child sex ratio (0-6 years) declined yet again, from 927 girls per 1,000 boys in 2001 to 914 girls per 1,000 boys in 2011. This decline has been interpreted as the direct result of more sex-selective abortions of female foetuses taking place. However, it is important to note that in India, unlike most countries of the world, more girls than boys have been dying during childhood (Figure l and Table 1), and this contributes to a decline in the child sex ratio.

Figure 1. Under-5 mortality rate by sex. Selected Asian countries, 2009

Table 1: Under-5 mortality rate by sex. Indian states, 2009

  Total Rural Urban
 

T

M

F

T M F

T

M F
India 64 60 69 71 66 76 41 39 44
Andhra Pradesh 52 51 54 58 56 59 39 36 41
Assam 87 83 91 92 87 97 43 44 42
Bihar 70 66 74 71 67 76 49 48 50
Chhattisgarh 67 59 74 69 61 76 54 48 61
Delhi 37 36 38 42 45 39 36 34 38
Gujarat 61 59 64 71 71 72 42 37 48
Haryana 60 55 65 64 58 70 SO 46 55
Himachal Pradesh 51 48 55 52 48 57 36 39 34
Jammu & Kashmir 50 46 54 52 49 55 39 34 45
Jharkhand 62 55 70 66 59 74 38 34 43
Karnataka 50 48 51 55 53 56 39 37 42
Kerala 14 12 16 14 12 17 13 12 13
Madhya Pradesh 89 86 92 95 92 99 58 58 58
Maharashtra 36 32 40 43 40 46 26 20 31
Orissa 84 83 85 88 88 89 52 49 55
Punjab 46 42 50 53 47 60 33 34 33
Rajasthan 74 66 84 82 73 91 46 37 55
Tamil Nadu 33 31 34 35 33 38 28 27 30
Uttar Pradesh 85 78 93 89 81 98 63 63 63
West Bengal 40 39 41 42 42 43 30 28 32

Source: Registrar General of India, Sample Registration System

As Table 1 shows, under-5 mortality is higher for girls than for boys in every state of India including states such as Kerala. Also, the gender gap in mortality is found not only in rural but also in urban areas in a majority of the states. The higher the gender gap in under-5 mortality, the more adverse the sex ratio will become for girls.

2. India's sex ratio at birth (SRB) has been increasing since 2001

Following 2001, India's Sample Registration System has been publishing the sex ratio at birth in some of the more populous Indian states. Between 2001-03 and 2006-08, there have been substantial improvements in the sex ratio at birth in a large number of states, especially states such as Punjab, Haryana and Rajasthan which have had very low sex ratios at birth for several decades. On the other hand, the southern states of Andhra Pradesh, Karnataka and Tamil Nadu have registered declines in the sex ratio at birth (Table 2).

Table 2: Sex ratio at birth in India and larger states

  Sex ratio at birth (SRB)
  2006-08 2001-03
India 904 883
Andhra Pradesh 917 932
Assam 933 904
Bihar@ 914 861
Chhattisgarh 975 964x
Delhi 877 835x
Gujarat 898 862
Haryana 847 807
Himachal Pradesh 938 803
Jammu & Kashmir 862 816
Jharkhand 922 865x
Karnataka 935 943
Kerala 964 892
Madhya Pradesh 919 922#
Maharashtra 884 887
Orissa 937 934
Punjab 836 776
Rajasthan 870 855
Tamil Nadu 936 953
Uttar Pradesh 877 853*
West Bengal 941 937

Source: Registrar General of India, Sample Registration System, as quoted in (3)

@ Bihar and Jharkhand combined
x period is 2002-04
# Madhya Pradesh and Chhattisgarh combined
* Uttar Pradesh and Uttarakhand combined

The increasing trend of SRB in the majority of Indian states suggests that excess female mortality in childhood may have contributed significantly to the declining child sex ratio witnessed in the 2011 census.

3. A 'lower than normal' female sex ratio at birth is not always the result of sex-selective abortion of the female foetus

Although SRB has been increasing in most Indian states, they remain well below the 'normal' SRB. Is not the gap between the 'normal' and current SRB the direct result of sex-selective abortion of the female foetus?

The answer is 'no'. There are many factors that can cause a decline in sex ratio at birth, of which sex-selective abortion of the female foetus is only one.

SRB is not a universal constant and may change without deliberate human intervention
Studies indicate that it would be incorrect to assume that SRB is a universal constant, and to then interpret all deviations from this as the result of deliberate human intervention. For example, sex ratios fluctuate widely when the sample size is small.

SRB calculated for a small sample fluctuates considerably
Sex ratio at birth needs to be examined for a sufficiently large sample of births. Fluctuations in SRB are observed for countries with a very small population size or when a small number of births (< 106) are being examined. This implies that examining sex ratios at birth at the village or district level over a small period of time may give misleading results.

Many countries in the West -- Canada, Denmark, England and Wales, Finland, Germany, Greece, Japan, the Netherlands, Sweden, Norway, Hungary, Poland, Romania, Portugal -- have registered significant increases in the proportion of female-to-male births since the mid-half of the 20th century. On the other hand, slight decreases in the number of female births per 1,000 male births since the 1960s were observed for Australia, France, Italy, Ireland, Spain and New Zealand, while in the USA, for births during 1969-1995, the proportion of male-to-female births increased in the black population but declined for the white population (4). None of these changes were the result of sex-selective abortions of either the male or the female foetus.

Several other hypotheses have been put forward and examined to explain the reasons for a decline in the male sex ratio at birth. These include psychological stress in the mother, especially in the first trimester of pregnancy (5-7); exposure to occupational and reproductive hazards by men (8); economic collapse (9); and conflicts or war (10).

In India, under-enumeration of female births has been an important factor
In India, the female-to-male ratio at birth had shown a decrease much before the advent of modern technologies of sex determination. SRB decreased from 934.6 females per 1,000 males during 1901-10, to 909 females per 1,000 males in 1940-46 in all the major provinces of British India except Bombay and Assam (11). This was because of deterioration in the completeness of vital registration data in British India.

Increase in male births is an important factor contributing to the decrease in female sex ratio at birth
India's demographic transition has given rise to a number of changes all of which have the effect of increasing the number of male births.

Declining stillbirth and miscarriage rates
Biologically more male foetal losses are likely through miscarriage or stillbirth. Advances in healthcare which bring about a decline in these rates will contribute to a slight increase in the proportion of male births. This is corroborated by data from NFHS-1 and NFHS-2. These show that the sex ratio at birth has a higher proportion of males for women who have had trained attendance at delivery (12).

Limiting family size
Evidence from many studies based on large data sets shows that, biologically, there are more males than females among first births. The proportion of male births declines with each subsequent birth (13-14). This means that when couples limit their family size, and therefore fewer children of higher order are born, the proportion of male births will increase.

Family formation strategies
In societies with a high preference for sons, the adoption of a small family norm often leads to couples stopping childbearing as soon as they beget one or two male children. Because there are relatively more male first and second births, the proportion of male births in the population may increase to some extent as a result of this.

Shorter birth intervals
Biologically, shorter birth intervals are associated with a higher proportion of male births (15). When couples decide to start childbearing soon after marriage, and have children in quick succession and then adopt a permanent method of contraception, this is likely to have an influence on the proportion of male births in the population.

Timing of conception
Many studies report that males are more frequently conceived at the beginning and at the end of the menstrual cycle (16-17). In other words, if couples practise 'natural' family planning and avoid intercourse during the most fertile period of the menstrual cycle -- the middle of the menstrual cycle -- the probability of a male child being conceived increases. Although this is refuted by some studies (18), further analysis using pooled data from several studies showed that conceptions on the most fertile days had an overall SRB of 1,020 females to 1,000 males as compared to an SRB of 934.6 for conception on other days (19).

4. Sex-selective abortion of the female foetus -- magnitude of the problem

How big is the problem of sex-selective abortion of the female foetus after ascertaining the sex of the foetus using an ultrasound scan?

Ultrasound scanning does not directly influence sex-selective abortion
To begin with, it is important to acknowledge that mere use of an ultrasound scan during pregnancy may bear no relationship to the desire for sex determination or abortion. Pregnant women in many urban centres go through ultrasound scans to ascertain the normal progress of pregnancy, as part of routine antenatal care.

A study that analysed data from the National Family Health Survey-2 (NFHS-2) confirms that those who used ultrasound scanning during pregnancy did not generally misuse it for sex determination and abortion if the foetus was female (12).

Adjusting for under-reporting, an estimated 14% of births were subjected to ultrasound scanning. Comparing the sex ratio at birth of those who reported ultrasound scanning with those who said that they did not have a scan during pregnancy, it was estimated that no more than 17% of all female foetuses may have been aborted among those who had ultrasound scanning (12). Overall, this means that no more than 3% of all pregnancies end in a sex-selective abortion of the female foetus.

NFHS-3 data for 2004-05 also shows that the proportion of women terminating a pregnancy bears no relation to the number of previous sons. In other words, women who already have two or more children seem to be terminating their next pregnancy for reasons of not wanting another child, irrespective of sex (20).

The magnitude of sex-selective abortion is lower than currently perceived
One study covering 133,738 births that occurred in 1997 (21) found 899 females to 1,000 males. Five lakh female births per year, or 10 million girls in all, were estimated to be 'missing' during the 15-year period 1986-2001. Accordingly, 10 million sex-selective abortions were estimated to have taken place during the same period.

There were many problems with the data used for this study, as was subsequently pointed out (22).
More robust estimates show that the true incidence of sex-selective abortions during 1986-2001 was less than half of what the 1997 study claimed, at about 2.5 lakh per year on average (22, 23). Even this was stated to be a maximum possible figure, given the numerous other factors affecting the proportion of male births.

5. Sex determination needs to be prevented, but not through restricting access to safe abortion

While the numbers for sex-selective abortions are much fewer than currently perceived, as recently as 2001 the numbers may have been as high as 2.5 lakh per year. Sex-selective abortion of the female foetus is a manifestation of extreme gender discrimination and needs to be prevented. But restricting access to abortion services may not be the answer.

The focus on identifying every potential sex-selective abortion-seeker has led to a situation of mistrust of abortion-seekers. Healthcare providers and facilities are often reluctant to provide abortion services on the suspicion that the abortion may be for sex-selection. Restricting access to abortion services, no matter how justified the underlying intention, amounts to gender discrimination. It denies women access to a service that only women need. History tells us that when access to abortion services is restricted, the proportion of unsafe abortions increases. This results in considerable avoidable mortality and morbidity. Women from low-income groups and socially marginalised sections are the most affected.

6. The way forward is to address gender discrimination and prevent sex-determination

This factsheet examined the extent to which sex-selective abortion may be contributing to the declining sex ratio in the 0-6 age-group in India. More girls than boys die under age 5. This is a major contributor to the lower-than-normal female sex ratio in the 0-6 age-group. If we consider the sex ratio at birth, under-enumeration of female births, increase in proportion of male births, and sex-selective abortion are all reasons why a much lower proportion of female than male children are born in India. Only a small proportion of pregnancies -- less than 3% -- may be ending in a sex-selective abortion of the female foetus.

Gender discrimination is at the root of female-excess mortality in childhood as well as sex-selective abortions. However, restricting access to abortion services to stop the decline of female sex ratio denies women an essential service and jeopardises their health. Further, rather than challenge gender discrimination manifested in son-preference and daughter-neglect and in many other discriminatory practices, it penalises women yet again.

The way forward is to take a two-pronged approach -- work towards preventing sex determination through the misuse of preconception and prenatal diagnostic techniques; and challenge all forms of gender discrimination, especially son-preference and daughter-neglect.

Prepared by T K Sundari Ravindran for Common Health in partnership with Rural Women's Social Education Centre (RUWSEC) and Sahaj (Society for Health Alternatives, April 2012

References

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Infochange News & Features, December 2012