Falling Child Sex Ratio

One step forward, two back – India’s uneven progress in correcting gender imbalance

The National Family Health Survey shows that sex ratio at birth has improved in a few states, but fallen drastically in others.

India’s sex ratio at birth – or the number of girl children born for every 1,000 boys born – has improved slightly over the last 10 years. But there are now more states where the sex ratio has fallen in the same time period, according to recently released data from National Family Health Survey or NFHS 2015-’16.

The survey shows that India’s sex ratio at birth has increased from 914 in 2004-’05 to 919 in 2015-’16. However, sex ratio at birth has been falling in states like Uttar Pradesh, Uttarakhand and Madhya Pradesh is falling. In North Eastern states such as Sikkim, Assam the sex ratio at birth has fallen dramatically over 10 years.

The NFHS is conducted by demographers who collect data from representative sample populations at district level in each state. Data was collected from 601,509 households, 699,686 women and 103,525 men.
In human societies, sex ratios at birth should ideally be close to 1:1 because gender imbalances have negative consequences on societies. The World Health Organisation suggests that the natural sex ratio at birth is considered to be around 105 males for every 100 females, which translates to about 952 females for every 1,000 males.

India’s sex ratio at birth and the its child sex ratio have languished at much lower than ideal levels, in large part due to a preference for male children in many parts of the country. To counter the gender skew, legislations like the Pre-Conception and Prenatal Diagnostics Testing or PCPNDT Act have been passed that prohibits doctors from revealing the sex of a foetus examined especially in ultrasound tests, so that sex-selective abortions might be prevented.

The successes

In 2015, Prime Minister Narendra Modi launched the Beti Bachao Beti Padhao campaign to counter discrimination both against female foetuses and girl children. The campaign was kicked off in Panipat in Haryana, a state where the child sex ratio as per the 2011 Census was just 834 girls to 1,000 boys. Since then, the state government has filed more than 400 cases against offenders – doctors, quack doctors, paramedical staff and laboratory technicians – under the PCPDNT Act.

Health authorities in states like Maharashtra and Rajasthan have tried to implement the law by conducting inspections and sting operations at ultrasound centres.

As per the data collected by Asian Centre for Human Rights, Rajasthan filed more than 600 cases and Maharashtra filed more than 500 cases by end of 2015.

Both Haryana government and Rajasthan government have conducted multiple sting operations against errant doctors. In 2016 alone, Rajasthan government conducted 30 sting operations allegedly catching doctors revealing the sex of foetuses.

The results of these efforts is showing up in the NFHS.

“What the NHFS data shows is that the implementation of the Act works, especially when seen with the number of cases filed under the Act,” said Dr Neelam Singh, who runs the NGO Vatsalya in Lucknow and is a is a member of the National Inspection and Monitoring Committee for the PCPNDT Act. “This is upfront evidence.”

PCPNDT implementation successes are also showing up in other data. A study in the journal Lancet published in 2015 showed that the ratio of girls in Maharashtra has slowly risen after the implementation of the PCPNDT Act.

“All government interventions, whether it is conditional cash transfers or mass media awareness have some impact on the sex ratio,” said F Ram, who retired recently recently as the director of Indian Institute of Population Studies in Mumbai, which was the nodal agency for collecting the data for the survey.

Ram was referring to schemes implemented by several state government offering special cash incentives for girl children or women who have girl children. “The impact may not be as much as expected by the government, but there is always some impact,” he added.

However, even Rajasthan has seen a dip in the sex ratio of children between 0-6 years of age, accounting for both pre-natal sex selection against female foetuses and greater infant mortality among girl babies, as per the Census 2011 data as compared to 2001 Census figures.

Poor implementation

If the NFHS is showing good results in restoring some gender balance in Haryana, Rajasthan and Punjab, it is also highlighting lax implementation of the PCPNDT in Uttar Pradesh, Uttarakhand, Delhi, Karnataka, Jharkhand and Odisha where sex ratios have continued to fall.

Dr JP Kapoor, director of health and family welfare for the Delhi government, admits that the district authority conducted only one inspection of ultrasound centres last year. There have been 12 decoy operations in Delhi where doctors were allegedly caught red-handed revealing the sex of the foetus in 2016 but all these investigation had been initiated by the Haryana government.

Kapoor however claimed that the NFHS data may not be accurate. “We are sceptical about the data collected,” he said. “Our civil registration data shows a marginal rise in the sex ratio. But still a lot needs to be done, we agree.”

The civil registration system data of Delhi government, based on number of births registered, shows a rise from 886 girls to 1,000 boys in 2012 to 898 girls to 1,000 boys in 2015.

From “no problem” to “crisis”

The north-east of India is showing a disturbing trend in gender equations. States that did not have problems of sex determination tests and sex-selective abortions are now showing steep falls in their sex ratios. Sikkim, Arunachal Pradesh, Assam and Mizoram, which have had matrilineal societies now have far fewer girls born than boys.

Sikkim showed that biggest fall in the sex ratio at birth in the NFHS from 984 girls for every 1,000 boys in 2004-’05 to just 809 girls for every 1,000 boys in 2015-’16.

Dr K Bhandari, secretary for healthcare, human services & family welfare in Sikkim, was surprised with the NFHS findings. “We did a survey ourself in the northern part of the state last year and realised there are more girls than boys,” he said.

Ram from Indian Institute of Population Studies said that the NFHS data is robust. “Our sample sizes are large this time (for NFHS-4),” he said. “It may not be fair to compare the data from NHFS-3. The NHFS-3 had a smaller sample size.”

Another reason Bhandari said he is surprised is because there are barely has any ultrasound machines in the state, even in the private sector. In other parts of India, Illegal sex determination takes place mostly in private clinics.

However, a central government official told Scroll.in about the possibility that of pocket ultrasoud machines from China being used in North Eastern states. “Technology is a major abetting factor for sex selection,” she said.

Sanalembi Devi from the Assam chapter of the women’s rights organisation WING India, said that even in matrilineal societies have patriarchal mindsets and given that most families are having fewer children, there is a greater desire of male children. As per NFHS data, the fertility rate has fallen. In Sikkim for instance, the fertility rate has dipped from two children per woman in 2004-’05 to 1.2 children per woman in 2015-’16. In Arunachal Pradesh, the fertility rate per woman has dropped from three children per woman in 2004-’05 to 2.1 children per woman in 2015-’16.

“The community has always wanted boys,” said Sanalembi, who has heard anecdotes of many people who have found out the sex of their foetuses. “Now they have the technology to aid this desire.”

Social and gender activists are, therefore, not yet celebrating the overall marginal increase in India’s sex ratio at birth. While the Beti Bachao Beti Padhao campaign run by the Ministry of Women and Child Welfare runs mass media outreach about women empowerment and enrollment of girls in schools along with implementation of the PCPDNT Act, there is very little done on the ground, alleged Varsha Deshpande of the Lek Ladki Abhiyaan in Maharashtra. “There is nothing on the implementation of the law,” she said. “Sloganeering will not help improve sex ratio.”

Rizwan Parvez from Girls Count, a non-profit organisation in Delhi, said, “We have now reached a stage in our advocacy that some state authorities understand the PCPNDT Act and what its requirements are. But till the government conducts sting operations on the doctors, it will not be a deterrence, I feel.”

The required change may not happen in time to show up as better sex ratios in the census of 2021, feels Deshpande. “The doctors are creating more markets for sex determination now,” she said bleakly.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

Relying on the power of habits to solve India’s mammoth sanitation problem

Adopting three simple habits can help maximise the benefits of existing sanitation infrastructure.

India’s sanitation problem is well documented – the country was recently declared as having the highest number of people living without basic sanitation facilities. Sanitation encompasses all conditions relating to public health - especially sewage disposal and access to clean drinking water. Due to associated losses in productivity caused by sickness, increased healthcare costs and increased mortality, India recorded a loss of 5.2% of its GDP to poor sanitation in 2015. As tremendous as the economic losses are, the on-ground, human consequences of poor sanitation are grim - about one in 10 deaths, according to the World Bank.

Poor sanitation contributes to about 10% of the world’s disease burden and is linked to even those diseases that may not present any correlation at first. For example, while lack of nutrition is a direct cause of anaemia, poor sanitation can contribute to the problem by causing intestinal diseases which prevent people from absorbing nutrition from their food. In fact, a study found a correlation between improved sanitation and reduced prevalence of anaemia in 14 Indian states. Diarrhoeal diseases, the most well-known consequence of poor sanitation, are the third largest cause of child mortality in India. They are also linked to undernutrition and stunting in children - 38% of Indian children exhibit stunted growth. Improved sanitation can also help reduce prevalence of neglected tropical diseases (NTDs). Though not a cause of high mortality rate, NTDs impair physical and cognitive development, contribute to mother and child illness and death and affect overall productivity. NTDs caused by parasitic worms - such as hookworms, whipworms etc. - infect millions every year and spread through open defecation. Improving toilet access and access to clean drinking water can significantly boost disease control programmes for diarrhoea, NTDs and other correlated conditions.

Unfortunately, with about 732 million people who have no access to toilets, India currently accounts for more than half of the world population that defecates in the open. India also accounts for the largest rural population living without access to clean water. Only 16% of India’s rural population is currently served by piped water.

However, there is cause for optimism. In the three years of Swachh Bharat Abhiyan, the country’s sanitation coverage has risen from 39% to 65% and eight states and Union Territories have been declared open defecation free. But lasting change cannot be ensured by the proliferation of sanitation infrastructure alone. Ensuring the usage of toilets is as important as building them, more so due to the cultural preference for open defecation in rural India.

According to the World Bank, hygiene promotion is essential to realise the potential of infrastructure investments in sanitation. Behavioural intervention is most successful when it targets few behaviours with the most potential for impact. An area of public health where behavioural training has made an impact is WASH - water, sanitation and hygiene - a key issue of UN Sustainable Development Goal 6. Compliance to WASH practices has the potential to reduce illness and death, poverty and improve overall socio-economic development. The UN has even marked observance days for each - World Water Day for water (22 March), World Toilet Day for sanitation (19 November) and Global Handwashing Day for hygiene (15 October).

At its simplest, the benefits of WASH can be availed through three simple habits that safeguard against disease - washing hands before eating, drinking clean water and using a clean toilet. Handwashing and use of toilets are some of the most important behavioural interventions that keep diarrhoeal diseases from spreading, while clean drinking water is essential to prevent water-borne diseases and adverse health effects of toxic contaminants. In India, Hindustan Unilever Limited launched the Swachh Aadat Swachh Bharat initiative, a WASH behaviour change programme, to complement the Swachh Bharat Abhiyan. Through its on-ground behaviour change model, SASB seeks to promote the three basic WASH habits to create long-lasting personal hygiene compliance among the populations it serves.

This touching film made as a part of SASB’s awareness campaign shows how lack of knowledge of basic hygiene practices means children miss out on developmental milestones due to preventable diseases.

Play

SASB created the Swachhata curriculum, a textbook to encourage adoption of personal hygiene among school going children. It makes use of conceptual learning to teach primary school students about cleanliness, germs and clean habits in an engaging manner. Swachh Basti is an extensive urban outreach programme for sensitising urban slum residents about WASH habits through demos, skits and etc. in partnership with key local stakeholders such as doctors, anganwadi workers and support groups. In Ghatkopar, Mumbai, HUL built the first-of-its-kind Suvidha Centre - an urban water, hygiene and sanitation community centre. It provides toilets, handwashing and shower facilities, safe drinking water and state-of-the-art laundry operations at an affordable cost to about 1,500 residents of the area.

HUL’s factory workers also act as Swachhata Doots, or messengers of change who teach the three habits of WASH in their own villages. This mobile-led rural behaviour change communication model also provides a volunteering opportunity to those who are busy but wish to make a difference. A toolkit especially designed for this purpose helps volunteers approach, explain and teach people in their immediate vicinity - their drivers, cooks, domestic helps etc. - about the three simple habits for better hygiene. This helps cast the net of awareness wider as regular interaction is conducive to habit formation. To learn more about their volunteering programme, click here. To learn more about the Swachh Aadat Swachh Bharat initiative, click here.

This article was produced by the Scroll marketing team on behalf of Hindustan Unilever and not by the Scroll editorial team.