Gender differences in child health and mortality pose a critical challenge for public health surveillance and policy in India. Recent Sample Registration System (SRS) reports indicate that female children experience higher mortality than boys. The 2012 SRS report pointed to a significant gap (9 per 1000 live births) in under-five mortality rates between males and females. However, the nature of gender differentials in child mortality is changing.
Despite the closing gap in mortality among female and male children, differentials in survival outcomes among female children are increasing. This recent demographic pattern raises the critical question of whether the gap in male and female child mortality is driven by differences in gender norms in society only, or whether it could also be a result of differentials in child survival outcomes across social-cultural and economic characteristics (i.e. religion and ethnicity, household economic status, parental education) within the female child population. This question, and its relevance to public health surveillance and policy in India, is explored in a recent article in IJPR by my co-authors Shrikant Kuntla, Kshipra Jain and me.
Prior to this article, the debate on gender differences in child mortality in India has historically revolved around male-female differences in mortality. However, discrimination against the girl child is not a universal practice across the families; rather, it varies considerably across the families of different socio-economic groups. This is clearly evident from our results. A comparison of survival outcomes in male and female children in the National Family Health Survey at three time points (1992-93, 1998-99, 2005-06) demonstrates that the mortality gap among girls and boys has significantly diminished. Yet the contribution of within sex inequalities in child mortality increased over the same period. For instance, in 2005-06, more than 50% of the gap in child mortality among males and females was due to inequalities within the female child population. This pattern is repeated at all of the three time points considered, suggesting that discrimination of the girl child is a selective tradition subject to familial gender norms, demographic and health care behaviour of mothers in different socio-economic and cultural groups.
Pathways of girl child discrimination
Next, we attempt to sketch out the pathways of girl child discrimination. Generally, the pathways of discrimination against the girl child are separated into two parts: (1) pre-natal care discrimination (i.e. neglect of antenatal care utilisation in case of female foetuses) and (2) postnatal care discrimination (i.e. discrimination in post delivery health care and feeding practices of children). The first, neglect of antenatal care utilisation in case of female foetuses, is very important for the survival chances of the child. Once a family determines the sex of the child as female, they are sometimes reluctant to use antenatal care, which can result in adverse pregnancy outcomes like low birth weight and other birth defects. The second, postnatal discrimination is less discussed. Female children are also neglected in terms of care given by parents and elderly family members. These factors, in turn, can lead to an increased risk of child mortality. Further, during post-natal care, female children can be discriminated against in terms of breastfeeding, allocation of household resources, nutrition, and health care utilisation. This is evident from our findings in this article that the neglect of female children in terms of breastfeeding and health care alone contributes to 30-40% of excess female child mortality in the country. Children of birth order of 3 and above and those with mothers who have not received antenatal care each contributed 24% and 9%, respectively. Rural place of residence, mother’s age, and lack of education contributed another 5% each. On the other hand, there is no significant contribution from variables like lack of mass media exposure, non-Hindu religion, scheduled caste and tribe, low body mass index (<18.5 kg/m2), and low birth weight of baby or home delivery.
Ways to close gender gap in child mortality
A significantly higher contribution of breastfeeding and higher order births to gender differentials in child mortality suggests that female children are neglected in breastfeeding. This is especially true if they are born at higher order parity, where families sometimes look to cap the family size with desired sex composition. The contribution of absence antenatal care to the gender gap in child mortality indicate that female children are discriminated even before birth, but our research suggests that postnatal discrimination should be researched as well. In general, it is also clear from the findings that increased socioeconomic status and access to public health services alone will not eliminate the gender gap in child survival, as discrimination of female babies is obvious at different levels of health care and general attention given to newborn babies.
Communities with a strong patriarchal lineage still believe ‘raising a daughter is like watering the neighbour’s garden’, meaning that sons are perceived to support their parents both before and after marriage, while daughters move to their husband’s family and are believed to provide very little economic or emotional support to their parents. Policies to address excess female child mortality need to address the root of the problem, which lies in social-cultural, religious and familial norms about girls in India, as these in turn direct the favouritism in health care and nutrition for male children. Since the challenge is multi-dimensional in nature, multi-sectoral initiatives like social, religious, and economic and health programmes need to be developed to address girl child discrimination and excess female child mortality in India. The strengthening of programmes such as ongoing conditional cash transfer programmes and other incentive initiatives to parents of girl children also have a proven impact.
Shrikant K. Goli S. and Jain K., 2014, Explaining Gender Differentials in Child Mortality in India: Trends and Determinants, International Journal of Population Research, http://dx.doi.org/10.1155/2014/649741