Why do educated and well-off Indians kill their girl children?

Photo: UNICEF/Jason Taylor/2006

Can India balance its distribution of sexes at birth, is the question asked by The Lancet, in its commentary on the findings of a study on female foeticide in India.

“The prospects seem grim,” is the answer. They have been grim from the onset of economic liberalisation, and the links between relative affluence and the demand for sex determination tests and selective abortion has for two decades now been a matter of concern for social and community minded doctors. [See ‘Putting Women First: Women and Health in a Rural Community’]

The counter-intuitive link between two key factors of development – more years of education and households becoming wealthier – and female foeticide have for long been an under-documented subject. This weakness in documentation has been surprising simply because, whether in the mega-metropolises of Delhi and Mumbai or in the cities and towns that are fast-growing, the number of ‘clinics’ providing sex determination tests has also grown. These are often camouflagued within a welter of signs advertising the features of a polyclinic, where the services on offer to middle class Indian families can range from liposuction to cardiac surgery to hip replacement. What else they do is well known, but not spoken about.

That is why The Lancet commentary has said that the demand for sons among wealthy parents is being satisfied by the medical community through the provision of illegal services of fetal sex-determination and sex-selective abortion. “The financial incentive for physicians to undertake this illegal activity seems to be far greater than the penalties associated with breaking the law. The market for sex determination and selective abortion has been estimated to be worth at least US$100 million per year, and the pervasive nature of the low sex ratio at birth suggests that this is not a consequence of a minority of errant physicians in a few states.”

I would say that this is an under-estimate of the size of the sex determination and female foeticide ‘industry’. Since the machinery required is relatively expensive (compared to the needs of a typical public health centre) and the clients are – as this study now helps makes clear – middle class urban Indian households who do not balk at the bill, this figure may under-estimate the true size of this illegal and ghastly business by a large degree. We don’t know how much because it is hidden.

There’s no doubt India’s medical establishment must be held accountable on moral, social, and legal grounds for the staggering imbalance in India’s sex ratio, which the 2011 Census brings out in relief. [See the post on the first set of detailed state-level data is almost complete as a release from the Census of India, 2011 Census and also ‘A population turning point’.]

Of the 623 districts, data were available for 596 in the 2001 census and 588 in the 2011 census. The blue highlighted states are Gujarat, Haryana, Himachal Pradesh, and Punjab, which have shown consistently lower child sex ratios at ages 0–6 years in the last three censuses.

Although there have been efforts to increase the penalty for non-compliance on the part of technicians and physicians, the sluggishness of the Indian judicial system, and the absence of systematic record-keeping of births, will remain a major hurdle for effective implementation of the Pre-Natal Diagnostic Techniques Act. For example, 800 court cases against doctors in 17 states have resulted in only 55 convictions.

In  The Lancet, Prabhat Jha and colleagues have presented a timely analysis of trends in sex ratio at birth in India, and show that the ratio for second-order births, conditional on the first born being a girl, fell from 906 girls per 1000 boys in 1990, to 836 girls per 1000 boys in 2005. On the basis of this finding, the investigators estimate that there have been between 3.1 and 6 million abortions of female foetuses in the past decade. This is an astonishing sum – the upper value indicates a per day countrywide rate of 1,640 abortions!

“In view of the unverifiable assumptions that are needed to derive statistical estimates of sex-selective abortions, the value of the analysis by Jha and colleagues is mainly independent confirmation of two important aspects of the sex ratio in India that have been reported previously with different data,” The Lancet has said. “The first is that sex imbalance at birth seems to be particularly concentrated in households with high education and wealth. This pattern suggests that dominance of the son-preference norm is unlikely to be offset, at least in the short term, by socioeconomic development. Second is that the overall problem of sex imbalance seems to arise throughout India, including in Kerala, which has often been characterised as a model state for social development and gender equality. The problem of sex imbalance seems to be a function of socio-economic status, not geography.”

[The Lancet’s recent coverage of public health and India has been rigorous and exemplary. See this post for its series of papers on India’s path to full health coverage.]

Number of girls per 1000 boys (2011) by per-person availability of prenatal diagnostic facilities (2006) across states in India. Child female-to-male ratio at ages 0–6 years from 2011 Census of India. Prenatal diagnostic facilities calculated as per 100 000 women (age 7 years and older), based on number of facilities registered by state through 2006. Facilities include genetic counselling centres, genetic laboratories, genetic clinics, ultrasound clinics and imaging centres, mobile clinics (vehicles), and in-vitro fertilisation and infertility centres.

There is already coverage of the study and some analysis in the news media. Here is a selection:

Reuters has reported – Up to 12 million girls were aborted over the last three decades in India by parents that tended to be richer and more educated, a large study in India found, and researchers warned that the figure could rise with falling fertility rates. The missing daughters occurred mostly in families which already had a first born daughter. Although the preference for boys runs across Indian society, the abortions were more likely to be carried out by educated parents who were aware of ultrasound technology and who could afford abortions.

“The number of girls being aborted is increasing and may have reached 12 million with the lower estimate of 4 million over the last three decades,” said lead author Professor Prabhat Jha at the Center for Global Health Research in Toronto, Canada. “The logic is families are saying if Nature gives us a first boy, then we don’t do anything. But if Nature gives a first girl then perhaps we would consider ultrasound testing and selective abortion for the subsequent children,” he told Reuters in a telephone interview on Tuesday.

The Indian Express has reported – They analysed census data and 2.5 lakh birth histories from national surveys to estimate differences in girl-boy ratio for second births in families where the first-born child had been a girl. They found that this girl-boy ratio fell from 906 girls per 1000 boys in 1990 to 836 in 2005. “Declines were much greater in mothers with 10 or more years of education than those with no education and in wealthier households. But if the first child had been a boy, there was no fall in the girl-boy ratio for second child over the study period,” Jha said. The article authors said this suggests that selective abortion of female foetuses, usually after a first-born girl, had been more common in richer and educated families.

The Washington Post has reported – The study found that, from 1990 to 2005, the “sex ratio” of first-born female children in India did not change significantly nor differ from what was biologically expected. (In 1990, it was 943 girls per 1,000 boys, and in 2005 it was 966). However, in families whose first-born was a girl, the incidence of the second-born being a girl fell almost steadily over that period, from 906 per 1,000 boys in 1990 to 836 in 2005. During the period, the trend increased among families in which the mother had 10 or more years of education but did not change in families in which the mother had no education. The sex ratio fell especially sharply in the richest 20 percent of households, Jha and his colleagues found. The findings were the same in both Hindu and Muslim households.

The most extreme decline in the probability of having a girl occurred in families in which the first two children were girls. In that case, the ratio of girls to boys in the third-born child was 768 to 1,000 in 2006. This came at a time when the average family size in India was 2.6 children — a huge reduction from earlier generations. The overall phenomenon of many more boys than girls among children under age 6 was once limited to northern and western India. Now it has spread throughout the country, Jha said. In 1991, about 10 percent of India’s population lived in states where the sex ratio for girls was below 915. Today, 56 percent of the population does.

[The paper is: ‘Trends in selective abortions of girls in India: analysis of nationally representative birth histories from 1990 to 2005 and census data from 1991 to 2011’ by Prabhat Jha, Maya A Kesler, Rajesh Kumar, Faujdar Ram, Usha Ram, Lukasz Aleksandrowicz, Diego G Bassani, Shailaja Chandra, Jayant K Banthia and is published in The Lancet, 24 May 2011.]