Time to end daughter aversion in India

In their Article, Nandita Saikia and colleagues1Saikia N Meh C Ram U et al.Trends in missing females at birth in India from 1981 to 2016: analyses of 2·1 million birth histories in nationally representative surveys.Lancet Glob Health. 2021; (published online April 8.)https://doi.org/10.1016/S2214-109X(21)00094-2Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar investigated trends in missing girls at birth in India since the 1980s. When compared with the natural range for sex ratio (950–975 girls per 1000 boys), they estimated that India had a total of between 13·5 million and 22·1 million missing female births from 1987 to 2016. This total reflected a deficit of girls at all birth orders, with almost three-fifths of missing girls concentrated among second-order and third-order girls following an earlier daughter or daughters. Furthermore, they found that conditional sex ratios for second-order and third-order births among families with at least one daughter have become more male-biased for almost all states in the country. The total number of missing girls in India is contested;2Bhat M Sex ratio in India.Lancet. 2006; 367: 1725-1726Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar however, correct numbers even half as large as these estimates are unconscionably high, and the authors are to be commended for highlighting this problem. Nonetheless, these data are not a surprise. Excess mortality and neglect of female children in India have been documented since at least the late 1800s,3Miller BD The endangered sex: neglect of female children in rural north India. Cornell University Press, Ithaca, NY1981Google Scholar particularly in the northern Indian states, in which Saikia and colleagues found some of the lowest female to male conditional sex ratios at birth. Studies since the 1980s have observed that girls with older sisters are at increased risk of adverse health and survival outcomes.4Das Gupta M Selective discrimination against female children in rural Punjab, India.Popul Dev Rev. 1987; 13: 77Crossref Google Scholar, 5Pande RP Selective gender differences in childhood nutrition and immunization in rural India: the role of siblings.Demography. 2003; 40: 395-418Crossref PubMed Google Scholar Sex-selective abortion is the latest manifestation of this long history of daughter aversion, which also spans female infanticide, excess female child mortality, and—for those girls who are born and survive childhood—discrimination in relation to health, nutrition, schooling, and most life opportunities. As knowledgeable scholars and readers are aware, this entrenched daughter aversion itself is a characteristic of the so-called classic patriarchy that exists in much of India and, indeed, across much of south Asia.6Kandiyoti D Bargaining with patriarchy.Gend Soc. 1998; 2: 274-290Crossref Scopus (1600) Google Scholar It incentivises devaluation of women and girls, limits acceptable roles for girls and women beyond marriage and motherhood, and encourages total control of girls and women by their households and wider kin and caste networks. Consequences are visible in the increasing male-bias of sex ratios, decreasing participation of women in the labour market, a large gender wage gap, and pervasive violence against women and girls across the country, as indicated in the Global Gender Gap Report 2021. India dropped 28 points in its ranking between the 2021 and 2020 Global Gender Gap Index, now ranking 140th of 156 countries globally, and occupies the position of 155th of 156 countries on the Health and Survival Index (a subindex of the Global Gender Gap Index), largely due to sex-selective abortion. Daughter aversion (and, in fact, gender inequality on a number of social indicators) continues to be a major issue even as India modernises, which should be a cause for serious alarm. Saikia and colleagues' findings also highlight the limitations in the Indian Government's policy efforts to address the problem of missing girls, which have largely focused on conditional cash transfers (CCT) to incentivise families to have daughters. Several national and state-level CCTs have been implemented since the 1990s, but reviews of these programmes indicate limited success in diminishing daughter aversion and bringing sex ratios at birth towards a more biologically normal state.7Krishnan A Amarchand R Byass P Pandav C Ng N “No one says ‘No’ to money”—a mixed methods approach for evaluating conditional cash transfer schemes to improve girl children's status in Haryana, India.Int J Equity Health. 2014; 13: 11Crossref PubMed Scopus (16) Google Scholar, 8Sekher TV Conditional cash transfers for the welfare of the girl child.in: Kumar AKS Rustagi P Subrahmanian R India's children. Oxford University Press, Oxford2015: 307-328Crossref Google Scholar Therefore, the authors' main policy recommendation is unfortunate—namely, to identify women with daughters as being at high risk of sex-selective abortion and to “design incentive programmes” targeted to this group.1Saikia N Meh C Ram U et al.Trends in missing females at birth in India from 1981 to 2016: analyses of 2·1 million birth histories in nationally representative surveys.Lancet Glob Health. 2021; (published online April 8.)https://doi.org/10.1016/S2214-109X(21)00094-2Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar This recommendation overlooks the fact that the core problem goes beyond economics. Furthermore, it puts the onus of action on women themselves rather than on the system that deeply and systematically undervalues women and girls. As India's fertility continues to decrease, a masculine sex ratio at birth is likely to persist and possibly worsen as parents balance their desire for a small family with unrelenting daughter aversion and son preference, a dynamic that was noted as early as the 1990s.9Das Gupta M Bhat PNM Fertility decline and increased manifestation of sex bias in India.Population Studies. 1997; 51: 307-315Crossref Scopus (240) Google Scholar This serious situation, and the mixed results of CCTs and laws such as the 1994 Pre-Conception and Pre-Natal Diagnostic Techniques Act in reversing this trend, send a key message to policymakers in the country: it is time to address the cause of the problem and take on the extremely challenging but essential task of influencing and changing, at scale, gender-unequal norms and beliefs and the patriarchal system that encourages them. The example of the struggle against female genital cutting in several countries in sub-Saharan Africa10Wakabi W Africa battles to make female genital mutilation history.Lancet. 2007; 369: 1069-1070Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar shows that when political will joins with cultural and other influential leaders, civil society, women, girls, men, boys, and their communities in a movement for reform, it is possible to accelerate positive change in culturally and traditionally entrenched gender-discriminatory practices. I am an independent consultant currently working for the World Bank, and I report membership on the Institutional Review Board of the International Center for Research on Women (Washington, DC), but all views expressed in this Comment are my own. Trends in missing females at birth in India from 1981 to 2016: analyses of 2·1 million birth histories in nationally representative surveysIn contrast to the substantial improvements in female child mortality in India, missing female births, driven by selective abortion of female fetuses, continues to increase across the states. Inclusion of a question on sex composition of births in the forthcoming census would provide local information on sex-selective abortion in each village and urban area of the country.