NATIONALFAMILYHEALTHSURVEY B w U w L w L w E w T w I w N

International Institute for Population Sciences Factors Affecting Sex-Selective

East-West Center Population and Health Studies In India

Number 17 irth histories collected during India’s first and second National Family Health January 2003 Surveys (NFHS-1 and NFHS-2) show an unusually large proportion of male ISSN 1083-8678 Bbirths in some population groups, which suggests that female fetuses are being aborted. Normally, about 105 boys are born for every 100 girls in a population, resulting in a sex ratio at birth of about 1.05. In India as a whole, the sex ratio at birth This NFHS Bulletin summarizes findings was 1.06 during 1978–92, the 15-year period covered by NFHS-1. It rose to 1.08 during from India’s first and second National 1984–98, the 15-year period covered by NFHS-2, but this is still not much higher than Family Health Surveys, conducted in the biological norm. 1992–93 and 1998–99, respectively, There is, however, considerable variation in the sex ratio at birth among certain under the auspices of the Indian Ministry population groups. The sex ratio at birth is particularly high in certain western and of Health and Family Welfare. The northern states, in families that have daughters but no sons, and among women with surveys provide national and state-level a high level of education and media exposure. In a few states, the sex ratio at birth is estimates of fertility, infant and child unusually low in families that have sons but no daughters, indicating some selective mortality, practice, abortion of boys. This issue of the NFHS Bulletin describes how geographic, socio- maternal and child health, and the economic, and demographic factors affect sex-selective abortion in India and goes on utilization of services available to to assess some likely trends. mothers and children. NFHS-1 interviewed 89,777 ever-married Sex-selective abortion: The current situation women age 13–49, and NFHS-2 In India as a whole, an estimated 5 to 6 million occur annually. Abortion was interviewed 89,199 ever-married women legalized in 1971 with the Medical Termination of Pregnancy Act. As revised in 1975, age 15–49. Both surveys collected the act allows medical termination of pregnancy (i.e., abortion) for any of the following information on a range of demographic reasons: (1) the pregnant woman has a serious disease or medical condition that would and health topics. endanger her life if the pregnancy were to continue; (2) the fetus has substantial risk The International Institute for Population of physical or mental handicap; (3) the pregnancy resulted from rape; (4) the socioeco- Sciences (IIPS), Mumbai, conducted the nomic circumstances of the mother would endanger the health of the newborn child; or surveys in cooperation with consulting (5) the pregnancy occurred because of failure of a contraceptive method. organizations and population research This last reason, in effect, legalizes abortion on demand—but only for married centers throughout India and with the women. Among unmarried women, contraceptive failure is not grounds for abortion. East-West Center in Honolulu, Hawaii, Sex-selective abortion is a two-step process involving determination of the sex of and ORC Macro in Calverton, Maryland. the fetus followed by abortion if the fetus is not of the desired sex. Methods for The U.S. Agency for International determining the sex of a fetus became available in India in the 1970s. Three such Development (USAID) supported both methods are commonly used: amniocentesis, chorionic villus sampling, and ultrasound. surveys, and the United Nations Children’s Fund (UNICEF) provided Robert D. Retherford and T. K. Roy additional funding for NFHS-2. The Robert Retherford is a Senior Fellow and Coordinator of Population and Health United Nations Population Fund Studies at the East-West Center. T. K. Roy is a Senior Professor and Director of the (UNFPA) supported this analysis International Institute for Population Sciences. Professor Roy was a Visiting Fellow and the publication of this report. at the East-West Center when this report was prepared. 2

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Soon after these tests were introduced, NFHS-2 on the sex ratio at birth as an in- other characteristics included in the analy- they were aggressively advertised and direct indicator of sex-selective abortion. sis has a significant effect independent became widely available. In 1984, however, Several different factors may influence of other variables. a broad-based coalition of women’s levels of sex-selective abortion, con- groups, civil-liberties groups, and health founding the effect of any single variable. State and region. In many states, espe- organizations established the Forum For this reason, the effects of specific cially in the south of India, the sex ratio at Against Sex Determination and Sex Pre- variables are estimated using logistic re- birth is close to 1.05, indicating that sex- selection. This organization monitored the gression to control for the effects of other selective abortion is rarely practiced. But growing use of sex-determination tests for variables. Births are the units of analysis. in some states, mostly in the west and the purpose of sex-selective abortion and The following predictor variables are north, the ratios are very high, indicating agitated to outlaw the use of the tests for included in the analysis: a composite vari- a great deal of sex-selective abortion. this purpose. As a result of these and able indicating both child’s birth order and For 1984–98, NFHS-2 estimated sex ra- other efforts, the national government its mother’s number of living sons before tios at birth at 1.14 in Haryana and 1.20 in banned the practice in 1994 with the Pre- its birth; mother’s education; mother’s Punjab. Compared with national statistics natal Diagnostic Techniques Regulations media exposure; urban/rural residence; from other countries, Punjab has one of and Prevention of Misuse Act. religion; caste/tribe; household standard the highest sex ratios at birth in the world, This legislation specifies that: (1) only of living; mother’s age at childbirth; and indicating a very high level of sex-selec- government-registered clinics or labora- the five-year period in which the birth tive abortion. tories may employ prenatal diagnostic took place. Separate analyses were con- procedures that could be used to assess ducted for India as a whole and for 17 Birth order and number of living sons. the sex of a fetus; (2) no prenatal diagnos- states grouped into four geographic re- NFHS-2 results show clear evidence of tic procedures may be used unless there gions—west, north, east, and south. abortion of girls among second and third is a heightened possibility that the fetus The characteristics associated most births to women who already have daugh- suffers from a harmful condition or genetic strongly with a high sex ratio at birth, af- ters but no sons (Figure 1). National-level disease; and (3) “no person conducting ter controlling for the other variables, are results from NFHS-1 do not show this prenatal diagnostic procedures shall com- state and geographic region, child’s birth pattern, indicating a trend toward greater municate to the pregnant woman con- order and mother’s number of living sons, use of sex-selective abortion during the cerned or her relatives the sex of the fetus and two socioeconomic characteristics— six years between the surveys. by words, signs, or in any other manner.” mother’s education and mother’s media ex- In states where evidence of sex-selec- The law is easy to circumvent, how- posure. At the national level, none of the tive abortion is strong, NFHS-2 found ever. Private laboratories and clinics are not monitored as closely as government 1.14 1.13 facilities, and ultrasound is not monitored 1.12 as closely as the other tests. And despite 1.10 1.10 the restrictions, many doctors continue 1.08 to communicate the sex of the fetus to 1.06 1.06 parents who want to know. They do so 1.06 1.05 verbally rather than in writing, and they 1.04 Sex ratio atSex birth often raise the cost of the test to compen- 1.02 sate for the legal risk. 1.00 1 son 0 sons 2 sons 1 son 0 sons Who is practicing sex- Second-order births Third-order births selective abortion? Figure 1 Predicted values of sex ratios for second- and third-order births by Much of the evidence on the spread of mother's number of living sons before the birth: India, 1984–98 (NFHS-2) sex-selective abortion is anecdotal. There Note: Values of the sex ratio at birth are predicted by logistic regression. In the calculation, are no reliable statistics on the practice at predictor variables other than the composite variable, birth order × number of living sons, are either the state or national level. This held constant at their mean values. analysis uses data from NFHS-1 and Source: Retherford and Roy 2003. 3

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particularly high sex ratios for births to 1.12 women with daughters only. Among third- 1.10 1.10 order births to women with two daugh- 1.08 1.08 ters but no sons, the sex ratio at birth is 1.08 1.72 in Punjab, 1.57 in Haryana, 1.56 in 1.06 1.05 Delhi, and 1.28 in Maharashtra. 1.04

In three states, NFHS-2 also found evi- ratio atSex birth dence of sex-selective abortion of male 1.02 fetuses. Among third-order births to 1.00 women who already have two sons but Urban Rural Urban Rural no daughters, the sex ratio is 0.87 in Delhi NFHS-1 NFHS-2 and Maharashtra and 0.90 in Punjab. Figure 2 Predicted values of sex ratios for second- and higher-order births by Evidence of sex-selective abortion urban/rural residence : India, 1978–92 (NFHS-1) and 1984–98 (NFHS-2) tends to be strongest in families that al- Note: The table is based on two logistic regressions, one for each survey. In the calculation, ready have two children. This pattern no predictor variables other than urban/rural residence are held constant at their mean values. doubt reflects the fact that the total fertil- Source: Retherford and Roy 2003. ity rate for India is about three. Because a large proportion of women wish to stop women because they have more informa- states are Haryana, Punjab, Gujarat, Delhi, childbearing after having three children, tion and access to sex determination and Maharashtra, and Himachal Pradesh. they are especially likely to have a strong abortion facilities. They are also more gender preference for the third child. likely to be in the habit of planning births. Son preference strong In a group of western and northern but declining Socioeconomic factors. During the period states, the predicted sex ratio was also Analysis of women’s ideal sex ratio (the 1978–92 covered by NFHS-1, the sex ratio very high for second and higher-order ratio of ideal number of sons to ideal num- for second and higer-order births was high births among women in families with a high ber of daughters) indicates that son pref- in urban areas but not in rural areas (Fig- standard of living—reaching 1.20 for the erence is declining in almost all states and ure 2). During the period 1984–98 covered 15-year period before NFHS-2. These socioeconomic groups. For India as a by NFHS-2, the sex ratio at birth was the same—at slightly above the biological norm—in both urban and rural areas. This trend indicates that the practice of sex- 1.12 1.12 1.12 selective abortion is spreading from India’s cities and towns to rural areas. 1.10 1.10 Although the effect of urban residence on the sex ratio at birth went down be- 1.08 tween NFHS-1 and NFHS-2, the effect of 1.07 1.07 mother’s education and mother’s exposure

Sex ratioSex at birth 1.06 to mass media went up. NFHS-2 found sharp increases in predicted sex ratios for 1.04 second and higher-order births among Illiterate Less than Middle or Low High women who have completed at least middle middle more school and women with high exposure to Mother’s education Mother’s media exposure mass media (Figure 3). NFHS-1, by contrast, Figure 3 Predicted values of sex ratios for second- and higher-order births by found no significant differences based on mother’s education and mother’s media exposure: India, 1984–98 (NFHS-2) mother’s education or media exposure. Note: The table is based on a single logistic regression. In the calculation, predictor variables Women who are educated and exposed other than mother’s education or mother’s media exposure are held constant at their mean to mass media are probably more likely to values. use sex-selective abortion than other Source: Retherford and Roy 2003. 4

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or media exposure. Inasmuch as sex-se- Uttar Pradesh lective abortion is innovative behavior Rajasthan that diffuses from higher to lower socio- economic groups, sex ratios at birth may Bihar increase further with development despite

Haryana declining son preference. This potential is greatest in states that Punjab currently have very strong son preference, as indicated by high ideal sex ratios, but Maharashtra NFHS-1 actual low actual sex ratios at birth, indicating NFHS-2 actual Delhi that not much sex-selective abortion is NFHS-2 ideal currently taking place. States that fit into Tamil Nadu this pattern are Uttar Pradesh, Rajasthan,

1.00 1.05 1.10 1.15 1.20 1.25 1.30 1.35 1.40 1.45 1.50 1.55 1.60 and Bihar (Figure 4). By contrast, in a few states where the Actual or ideal sex ratio at birth prevalence of sex-selective abortion is al- Figure 4 Predicted values of sex ratios for births occurring in 1978–92 (NFHS-1) ready high and son preference is falling and 1984–98 (NFHS-2) and mother’s reported ideal sex ratio in 1998–99 (NFHS- rapidly, it seems likely that the prevalence 2): Eight states of sex-selective abortion will soon begin Note: The ideal sex ratio is calculated as the ratio of ideal number of boys to ideal number of to fall, if it is not falling already. These girls. In this calculation, ideal children of “either sex” are counted as 0.5 boy and 0.5 girl. states are Haryana, Punjab, Maharashtra, Source: Retherford and Roy 2003. and Delhi. whole, the ideal sex ratio fell from 1.43 to women to practice sex-selective abortion, Further reading 1.35 during the six years between NFHS-1 they are less likely than others to express Arnold, Fred, Sunita Kishor, and T. K. Roy. and NFHS-2. Nevertheless, ideal sex ra- a strong preference for sons. In other 2002. Sex-selective abortions in India. tios are still much higher than the biologi- words, the propensity to use sex-selec- Population and Development Review cal norm of 1.05. This difference implies tive abortion rises sharply with socioeco- 28(4). that considerable potential exists for fur- nomic status, more than compensating for Retherford, Robert D., and T. K. Roy. 2003. ther increases in levels of sex-selective the lower levels of son preference ex- Factors affecting sex-selective abor- abortion in India. pressed by high-status women. tion in India and 17 major states. NFHS Although women with high socioeco- This is especially true when status is Subject Reports, No. 21. Mumbai: IIPS; nomic status are more likely than other measured in terms of mother’s education and Honolulu: East-West Center.

The International Institute for Population ing the United States. Principal funding for Correspondence addresses: Sciences was established at Mumbai in 1956 the Center comes from the U.S. government, International Institute for Population as the regional institute for training and re- with additional support provided by private Sciences (IIPS) search in population studies for the Asia and agencies, individuals, and corporations and Govandi Station Road, Deonar Pacific region of the United Nations. Now also more than 20 Asian and Pacific governments. Mumbai 400 088, India a deemed university, it is an autonomous in- Fax: 91-22-556-3257 stitution sponsored jointly by the Govern- The NFHS Bulletin Editorial Committee con- E-mail: [email protected] ment of India, the United Nations Population sists of Fred Arnold, B. M. Ramesh, Robert East-West Center Fund, and the Sir Dorabji Tata Trust. D. Retherford, T. K. Roy, and Sidney B. Westley. Research Program/Population and Health The U.S. Congress established the East-West 1601 East-West Road Center in 1960 to foster mutual understand- This and previous issues of the NFHS Bulletin Honolulu, HI 96848-1601, U.S.A. ing and cooperation among the governments may be downloaded from the East-West Center Fax: 1-808-944-7490 and peoples of the Asia-Pacific region, includ- website at www.eastwestcenter.org/res-ph.asp. E-mail: [email protected]