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Indian Journal of Community Medicine

Vol. 27, No. 1 (2002-01 - 2002-03)


Editorial - Down with Low Child Sex Ratio

Sunder Lal, B.M. Vashisht, M.S. Punia

India crossed one billion population in May, 2000. The census 2001 enumerated the total population of India on the 1st March, 2001 as 1,027 million. During 1991, the sex ratio for the total population was 927 (females per thousand males), it increased to the mark of 933 in 2001, an increase of 6 points 1 . The unfavourable trend and steady decline in number of women is a matter of grave concern. The extent of anti-female bias in India is by no means limited to poor income society. Punjab and Haryana, two of the richest states in terms of per capita incomes, have among the lowest female to male sex ratios: 861 women to 1000 men in Haryana and 874 women for every 1000 men in Punjab 2.

Overall proportion of children (0-6 year age) has been declining in India, a favourable trend indeed to attribute to the success of family welfare programme intervention, however, the declining female child sex ratio over the years is a disturbing trend.

Further, the census 2001 casts the shadow of coming events. The most disturbing and alarming aspect of census report is sharp fall in sex ratio of children (0-6 years) from 945 in 1991 to 927 in 2001, a significant decline of 18 points 2 . When the 0-6 year ratio is observed state-wise, it reveals further distressing situation in the states like Punjab (793), Haryana (820), Chandigarh (845), Delhi (865) and Gujarat (878). Adverse child sex ratio in most prosperous states of the country is a grim situation and it needs to be investigated in detail through socio-demographic research studies. Punjab and Haryana, though have highest per capita income, report missing female children of an alarming magnitude. District-wise data on child sex ratio in these states is quite astounding. In the State of Haryana, during the last decade, the sex ratio (0-6 year age group) declined in all the districts, the maximum decline was of 104 points in district Ambala, followed by 98 points in district Kurukshetra, 95 points in Sonipat, 81 points in Yamunanagar and 72 in district Rohtak. Similarly, in the State of Punjab the decline of over 100 points was observed for district Fatehgarh Sahib, Kapurthala, Gurdaspur and Patiala. All these districts are prosperous and literacy rate being much higher than rest of the districts in the State. This shows that most probably sex ratio has nothing to do with literacy or being educated. Imbalanced sex ratio at birth, female foeticide and higher rate of mortality among girls may perhaps explain this phenomenon. Immediate fall out of this decline in sex ratio will be a significant decline in age at marriage of women, which is quite low in Haryana; 18.1 years at first cohabitation and 17.4 at first marriage in women of 20-49 years age group (NFHS-2). A town Shahbad in Haryana has lowest urban sex ratio of 718 and this town has large presence of imported wives mainly of Bengali origin3.

Large proportion of unmarried -unemployed youth in villages and urban slums have organized anti-social gangs and are considered as security risk in Haryana and they tend to indulge in anti-social activities and crimes against adolescents and women. This creates threatening environment for girls in the community and parents feel that girls are insecure and they try to arrange marriages of their daughters at an early age. Nearly 40% of marriages in rural areas in Haryana are below the age of 18years, the minimum legal age of marriage resulting in a typical reproduction pattern of "too early, too frequent and too many", this may negate the achievements of family welfare programme. Overall, in India 50% of marriages were below 18 years of age (NFHS-2).

The unfavourable sex ratio for girl child (0-6 years) in prosperous states of north India could be attributed to sex selective abortion thereby interrupting natural history of reproduction. There may be many economic reasons for this, foremost among them being the practice of dowry and son preference in the family. Data of NFHS-2 confirms that 33% of women prefer more sons than daughters and over 85% wanted atleast one son among their children 4 . The availability of sex selective technology (pre-natal diagnostic technique) has led to elimination of the female child. The greatest declines of female child sex ratio have been observed in the states (where the sex determination tests came at the earliest) of Punjab, Haryana, Gujarat, Maharashtra and Delhi etc. A significant part of this decline is due to selective abortions of female foetuses. The sex selection is always for a son. Unfortunately, some unscrupulous elements in the medical profession are increasingly involved in prenatal sex determination and too often in the subsequent termination of the female foetus. Though the prenatal diagnostic technique act was enacted by the parliament in 1994 to reduce imbalance in sex ratios, but its implementation is quite tardy in most of the states. Following the Hon'ble Supreme Court directive in early May, 2001, the Govt. of India has decided to implement the PNDT Act with all vigour and zeal5. Many women activist organizations inspired by the efforts of NGOs have become active to generate opinion against sex determination tests. Similarly, professional organizations have come out with determination to check this menace. Building favourable climate at the community level and enforcing the law can save the girl child. Electronic and print media can play its obligatory effective role to disseminate the messages and create awareness against the practice of pre-natal determination of sex and female foeticide.

Since 33% of elected Panchayat and Nagarpalika seats are reserved for women representatives, committees of Panchayats (headed by an elected woman Panchayat member) should be formed to promote a gender sensitive, multisectoral agenda against sex determination and sex selective abortions. Registration of marriages, pregnancy, abortions, birth and deaths should be pivotal function of village Panchayats to safeguard against the evil practice of foeticide.

Data on illegal induced abortions is missing or too inadequate in most areas; but the practice is quite rampant. Information on induced abortions remains underground and the services for safe abortions in public sector are poorly developed.

The infant mortality has become stagnant around 70-72 over the past five years and female children bear the brunt of higher post-neonatal mortality. The unabated high mortality amongst female children continues from age 1-6 thus pushing the child ratio in favour of male children. The targetted interventions for child survival programmes have benefitted mostly the male children, whereas, female children continue to be lost on account of high mortality and ambient health seeking behaviour of parents and families. The longitudinal studies on morbidity and mortality undertaken in ICDS programme in India bear testimony to these facts. Mortality rate between 1 and 4 years reflects the effect of both malnutrition and communicable diseases on child health. It is noted that girls die at a rate 50 percent more than boys do7. This is amply evident from the imbalances in the 2001 census showing excess of 6.01 million boys under 6 year of age, over girls in the country. Disaggregation of this data by state shows marked differences and there is evidence that further disaggregation by district or even communities will show remarkable and disturbing patterns where girls die in numbers far exceeding boys. Disparity between boys and girls is ultimately a family or at the most a community choice. It is at this level that gender equity must be sought and campaigned for.

Table I: Neonatal, Post-neonatal, Infant, Child and Under-five mortality rates for the 10 year period preceeding the survey by selected demographic characteristics - India - 1998-99 4.

Demographic characteristics Neonatal mortality Post-neonatal morality Infant mortality Child mortality Under-five mortality
Sex of child
Male 50.7 24.2 74.8 24.9 97.9
Female 44.6 26.6 71.1 36.7 105.2

Sex differentials in childhood mortality have been clearly observed in NFHS-2 data4. In India, excess female mortality among children was evident at ages beyond first month of life. During the post-neonatal period (age 1-11 months) female mortality exceeds male mortality by 10%. After age one year, sex differentials in mortality are even greater. The female child mortality rate (the number of deaths in age 1-4 year per 1000 children surviving to age 1 year) is one and a half times the male child mortality rate. The female disadvantage in survival from age one to exact age five years was evident in both rural and urban areas, but it was much more severe in rural than urban areas. This reversal of sex differential in mortality with increasing age has been observed in South Asia and thought to reflect the relative medical and nutritional neglect of girl child (Das Gupta 1987, Basu 1989).

Table II: Infant and child mortality in rural community development area - 1997, Lakhanmajra.

Age group Male Female Total
0-7 days 28 (37.0) 47 (63.0) 75 (100)
7-28 days 5 (32.0) 11 (68.0) 16 (100)
28 days to 1 year 32 (42.7) 43 (57.3) 75 (100)
0-28 days 33 (36.3) 58 (63.7) 91 (100)
0-1 year 65 (39.2) 101 (60.8) 166 (100)
1-4 years 16 (38.1) 26 (60.8) 42 (100)

Figures in parentheses denote percentages.

In rural community development block in Haryana the disadvantage of female child survival was quite obvious, during neonatal, post-neonatal, infancy as also during one to four years of life, the mortality effects were one and a half times more in female children as compared to male children 8 . Sex ratio at birth is marginally in favour of male babies and is nearly constant in the absence of selective sex abortions. Since prenatal diagnostic tests are widely prevalent, the natural sex ratio at birth in most situations gets altered.

Table III: Reported live births 2001-2002 - Block Lakhanmajra.

Birth order/sex 1 2 3 4+ Total
Male 422 352 256 126 1156
Female 352 304 218 86 960
Total 774 656 474 212 2116

At micro-level in one block area, the adverse ratio for girls at birth was quite obvious. Of 2116 total births, 1156 (54.6%) were male and 960(46.4%) were female. Usually the first birth orders are seldom subjected to diagnostic test but it turned out to be contrary to our belief as the sex ratio of first birth order in one of the rural block was unfavourable for female births. The child ratio in subsequent birth orders was also unfavourable for female.

Sex selective sterilization under the National Family Planning Programme has been another phenomenon which can affect child sex ratio.

Terminal methods of contraception get over-riding priority as the Govt. of India and National Family Planning Programme promoted method specific intervention (sterilization) to achieve the target of the programme. Some State Govts. received very good grading for sterilization under the 20 point programme. Over 97% of sterilizations have been adopted by females alone and men participation in sterilization was marginal. Further analysis indicated that those who adopted sterilization, the phenomenon of sex selective sterilization was quite obvious.

Practice of sex specific sterilization has led to disturbed sex ratio as females are not allowed to be born and son preference is an acknowledged fact as 99.36% sterilizations in rural area of one community development block in Haryana were adopted after having born at least one son. Curiously enough two females having only one son and one daughter respectively underwent tubectomy operation.

Nearly 27% of women accepted sterilization operation after bearing 2 or 3 sons only and thus avoiding effectively the birth of girl child.

Over 35% of couples accepted sterilization after limiting the family size to two children and this proportion is going to rise in near future. As a matter of policy it has serious implications and wider ramification on disturbed child sex ratio. Therefore, promoting spacing methods becomes imperative to regulate fertility.

Acceptance of terminal contraceptive methods profoundly affects the child sex ratios as also the sex ratio at birth, as is evident from analysis of microstudy undertaken in rural settings. The sex ratio at birth and of subsequent birth orders went in favour of male children.

There have been notable attempts in India to address the problem of gender imbalance. Gender imbalance is a multisectoral concern and health sector alone seems to be insufficient to meet this challenge at the level of community. India was the first country in the world to launch National Family Planning Programme (subsequently named as National Family Welfare Programme). The objective was to stabilize the population at a level consistent with the requirement of national economy. The FWP has completed five decades and has made significant contribution towards improving the health of mothers and children and providing family planning services. Now 44% of eligible couples use contraception. By 1997, India had achieved 70% of goal of replacement fertility (2.1 births per women), with fertility having declined from 6.0 to 3.3 births per woman. Female literacy level has also improved. Child survival and safe motherhood programme launched in 1992 integrated several interventions to reduce the childhood and maternal mortality and morbidity. As a result of these efforts, crude birth rate declined from 40.8 (1951) to 26.4 (1999 SRS), infant mortality rate declined from 146 per 1000 live births (1951) to 72 per 1000 live births (1998 SRS). However, the family welfare programme focussed purely on demographic goals and concentrated on numerical, method specific contraceptive targets. Female sterilization accounted for three quarters of the modern methods of contraception used in India, only 3.4% of couples rely on vasectomy and 2.4% rely on condoms. Terminal methods and particularly female sterilization was promoted consciously while men participation lagged behind. Because of preference for son, sex selective sterilizations were chosen by most women acceptors as is evident from the last three years data picked up from one of the rural community health centre, where 885 women who accepted tubectomy in the past three years (2000-2002) had born 1638 males and 1040 female children, signifying that most accepted the sterilization after bearing sons and sex ratio went in favour of boys.

Reproductive and child health programme (RCH) initiated in 1997, focussed on gender issues for the first time. RCH programme integrates all interventions of fertility regulation, maternal and child health with reproductive health of both men and women. The programme tends to provide client centred, demand driven, high quality, need based services through decentralized participatory planning as target free approach. Gender issues are on the forefront of the programme9. Similarly, National Population Policy 2000 documents increased participation of men in planned parenthood. In the past, the population programmes have tended to exclude menfolk. Gender inequalities in patriarchal societies ensure that men play a critical role in determining the education and employment of family members, age at marriage, education of girls besides access to and utilization of health, nutrition and family welfare services. Further, currently, over 97% of sterilizations are tubectomies and this manifestation of gender imbalance needs to be corrected. RCH makes strong commitment to reduce the imbalance through effective programme.

During the International Year of Women (1975), Integrated Child Development Services (ICDS) Programme was launched to improve health, nutrition, and education and all round development of young children, besides women health and development. The ICDS focussed on women in reproductive age group and subsequently covered under its ambit the adolescent girls as well (on limited scale) 10 . The census data comes once in ten years. Anganwadi workers (AWW) ensure readymade gender based information of 0-6 years children and sex ratio of young children, nutritional status, mortality and school enrolment of eligible children. Focus on girl child and women is the real concern of the programme. The continuous tracking of women and young children through home contacts and services at anganwadi centre offers a unique opportunity to address the problem of missing girls and gender inequalities/discrimination. Data on child sex ratio available with Anganwadi and updated continuously provides valuable information for action by covergence of services of all sectors under one roof. The village panchayats, elected women panches and organized women groups at village and urban slum ward area should take responsibility to prepare a demographic account of children under six to focus their attention on unfavourable child sex ratios in their settings to think, plan and act locally and share this with village community (families-parents and mothers). The collective action plans should be evolved to save the girl child and her adequate nutrition at home, balanced development in village environment through non-formal education (early childhood education), positive health and development through appropriate household actions and health programme interventions. All the stakeholders who are interested in child development should support the functions of village panchayat and anganwadi workers. Since the programme of ICDS is near universal it has inherent strength to ensure wider coverage and child survival, child development and above all the women development and their enhanced status in the society.

The falling ratio of girl child, crime against women, unguided youths and low status of women are blots on civilization and human development. These areas should be high on agenda for policy planners and implementing agencies at all the levels.

The status of women should be of prime concern to fight the evil of disturbed sex ratio. We have the "Women Commission" at National level and many states have also set up women commissions and have developed action plans to empower women. Year 2001 was observed as year of women empowerment. National policy for women empowerment has been evolved and similarly world population day on July 11, 2001 focussed on gender imbalance. Census 2001 has sent warning signals. The International Conference on Population Development at Cairo 1994 and the Fourth World Conference of Women held in Beijing in 1995 have all played role of advocacy of advancement of women in India.

Over 250 religious leaders, among them the Shankracharya of Kanchi, Archbishop of Delhi, Akaltakhat Jathedar Joginder Singh, Abdullaha Bukhari, Sadhavi Rithambra, Manjit Singh of Keshgarh Sahib and several others confabulated with Human Resources Development Minister, Mr. Murli Manohar Joshi, Health and Family Welfare Minister, Mr. P.C. Thakur, Minister of State for HRD, Mrs. Sumitra Mahajan, Delhi Chief Minister Mrs. Shiela Dikshit and Health Minister, Mr. A.K. Walia on 26th June, 2001 in New Delhi discussed ways of ending practice of Female Foeticide. Akal Takhat has issued a Hukamnama that "any one indulging in unhealthy practice of female foeticide would be excommunicated from Sikh religion. The other religious organizations can also play their effective role besides non-governmental organizations, private sector, professional bodies and organized and unorganized sector of Indian industries. The Government should involve the community in all its plans of action, through panchayati Raj and Nagarpalikas to curb this practice. The high burden of morbidity, mortality, malnutrition and disability among girl child should be reduced through convergence of services of different sectors. Together we can and shall attain balanced sex ratio by converging the services of different sectors like health, literacy and development of programmes of universal elementary education by Panchayats and Zila Parishads, reduction of infant and child mortality, universalization of small family norms through spacing methods, Balika Samridhi Yojna to promote survival and care of girl child, Integrated Child Development Services - expansion to cover urban slums and all rural areas, Maternity benefit scheme of rural development, Family welfare linked insurance plan for couples below poverty line, strict enforcement of child marriage act, strengthening and expasion of facilities for safe abortions, establishment of creches and child care centres in rural and urban slum areas, urban RCH projects, quality services under RCH and primary health care, Apni Beti-Apna Dhan and measures against dowry, activization of Mahila Mandals, activization of elected members-women in PRI, and women empowerment schemes if persued earnestly by the local self Government and non-governmental organizations can go a long way 11 . Devolution of powers to local bodies appears to be good alternative. Since many incriminatory factors have been identified for adverse child sex ratio, the subject of gender equality be introduced in the curriculum of medical and para-medical training and continuing education programmes as also in the curriculum of primary and secondary education and non-formal education.

Adverse child sex ratio should be a subject of operational research study. Promoting epidemiological and demographical research studies, case studies on various issues is most desirable. The faculty of community medicine should undertake multicentric studies on this issue as joint venture and ministry of Health and Family Welfare, Govt. of India should extend adequate financial support.

Families should value girls as an asset. Gender equity should begin at home and family. Community should play the role of advocacy to change the mind-set of individuals and families to build positive attitudes towards girl child. All these programmes should have common goal and focus to strengthen the position of women and should strive to organize women groups (Mahila Mandals - Mahila Swasthya Sanghs, Jagriti Mandals and Sanjivanis...........) Govt. should provide financial support to organized registered groups with local bodies. Elected women panchayat members can play a leading role to organize such groups and this is their pivotal responsibility. Thus together we can and shall attain balanced child sex ratio.


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Sunder Lal, B.M. Vashisht, M.S. Punia

Deptt. of SPM Pt. BDS PGIMS, Rohtak

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