A descriptive Study on the Sex Ratio at Birth in Institutional Deliveries at Jabalpur, Madhya Pradesh, India
Correspondence Address :
Sanjeev Kumar Gupta
Assistant Professor, Department of Community Medicine,
Mahatma Gandhi Medical College & Research Institute,
Cuddalore Main Road, Pillaiyarkuppam Pondicherry, India.
Ph. : Mobile: +91-7639656802, +91-7639656801
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Background and Objectives: The sex ratio at birth and the sex ratio in the population should remain constant without manipulation. However, several parts of the world, particularly some Asian countries including India, have shown a low sex ratio at birth due to the preference for a son and due to sex selective abortion. The objectives of our study were, to find out the sex ratio at birth in institutional deliveries and the factors which were associated with a low sex ratio.
Methods and Material: In the present study, the secondary sex ratio was analyzed from the birth records of all the deliveries which were conducted at the Medical College Hospital and Elgin Hospital, Jabalpur, during the period from January 1st 2008 to December 31st 2008.
Results: During the study period, 5967 institutional deliveries took place, of which 2807 were female births, thus giving an overall sex ratio of 888.
Conclusion: In our study, a trend towards a higher sex ratio was seen with a higher educational status. The sex ratio was lower in the rural population and it decreased with parity.
Sex ratio, Institutional delivery, Literacy Rate, Parity, Religion.
The sex ratio at birth (SRB) is an important demographic indicator that was initially studied in the late 17th century(1). The sex composition of a population is determined, in part, by the number of male births which are relative to the number of female births. In humans, the sex ratio at birth is commonly assumed to be 100 boys to 105 girls (which is sometimes shortened to âa ratio of 105â). However, the sex ratios at birth or among infants may be considerably skewed by sex-selective abortion and infanticide. The Central Intelligence Agency (CIA) has estimated that the current world wide sex ratio at birth is 107 boys to 100 girls (2).
The sex ratio at birth also affects the critical demographic measures, for example, the ââdoubling-timeââ of a population increases as the ratio of males to females at birth increases (3),(4). The data on the sex ratio at birth is necessary to understand the trends in infant morbidity like low birth weight and mortality, since male infants are more susceptible to illness and have higher infant mortality rates than females (5),(6),(7).
Rising sex ratios in India have been recorded since the early 1980s, and have since continued increasing alarmingly. The impact of this early rise is already visible among the adult population of several Indian districts (8). The sex ratio at birth which is biased against female births can result in a gender imbalance, which in turn can have grave implications on the society in the form of lack of marriage-ability of the excess male population, thus resulting in social unrest, a demand driven increase in prostitution, kidnappings of women, etc (9),(10).
The sex ratio at birth can be affected by sex-selectivity at birth (11). The SRB for India for the period from 2004-06 (3 years average) has been estimated to be 892. It varies from 895 in the rural areas to 881 in the urban areas. In the rural areas, the highest and lowest SRBs are in the states of Tamil Nadu (970) and Delhi (810)respectively. The SRB in the urban areas varies from 962 in Kerala to 800 in Punjab (12).
The various factors which are associated with declining sex ratios are social, economic and cultural in nature. Health institutions represent the health related behaviour of the population. It was thought that the sex ratio at birth would give some idea about the overall picture of the sex ratio in the society.
This study was undertaken at the Medical College Hospital and the Elgin Hospital which are tertiary care government teaching hospitals in Jabalpur, Madhya Pradesh (MP), to find out the sex ratio at birth in institutional deliveries. It was a retrospective, record based, observational study. The birth records of all the deliveries which were conducted at the above mentioned institutes during the study period were analyzed by using the study variables i.e. literacy rate, religion, parity and residential status.
The sex ratio at birth and the factors which were associated with them were analyzed by using the Chi square (c2) test of significance. The F-test statistics, Mcnemarâs test and ANOVA were applied wherever they were relevant. The 5% and 1% levels of significance were used.
The ethical clearance for conducting the study was taken from the ethical committee of the institution i.e. NSCB Medical College and Elgin Hospital, Jabalpur, with the assurance that confidentiality would be maintained and that the information which was obtained for this study would not be used for any other purpose except for academic purposes.
In the present study, a total of 5967 deliveries took place in these hospitals, with 3160 male and 2807 female births, giving an overall sex ratio of 888. More than 80% mothers belonged to 20-29 year age group, from rural as well as urban areas(Table/Fig 1).
Nearly 1/4th of the mothers were illiterate. The level of literacy was relatively low among the mothers from the rural areas.(Table/Fig 2) A majority of the mothers who came from the urban (88.19%) and rural (89.93%) areas were Hindus. (Table/Fig 3).
The sex ratio was highly dependent on the literacy status, which was statistically significant (p< 0.01), showing a high degree of negative correlation.(Table/Fig 4).
The highest sex ratio at birth was observed among Christians (1178), followed by Muslims (953) and Hindus (879). These variations among different religions was due to chance, but they were statistically not significant (Table/Fig 5).
The sex ratio at birth was 909 for urban mothers and it was 820 for rural mothers, which showed high statistical significance (p< 0.01). There was a significant and negative correlation of SRB with the rural population. (Table/Fig 6).
There were 926 females per 1000 males for the 1st birth order, but the sex ratio was unfavourable towards females in the 2nd, 3rd and 4th birth orders. (Table/Fig 7),(Table/Fig 8).
In our study, we tried to investigate the influence of various factors such as parity, female literacy, religion and rural and urban background on the sex ratio at birth.
In the present study, the SRB (888) was found to be below the national average in this study, but the SRB for the first born child was close to the national average. As per the census of the year 2001, the sex ratio in India was 933 per 1000 boys, where it was 976 in 1961, just four decades back. The sex ratio in Madhya Pradesh was 919 per 1000 males, which was much below the national average of 933. According to NFHS 3, there was an accelerated decline in the sex ratio at birth from 1993-97 to 2000-04 (13), (14).
More than four fifth of the mothers belonged to the 20-29 year age group, who were from rural as well as urban areas. 24.79% of the mothers were found to be illiterate in the present study. The level of literacy was relatively low among the mothers from rural areas. According to the census of the year 2001, the female literacy in MP was 50.28% and in Jabalpur, it was 59.47 % (13). The National Family Health Survey-II (NFHS-II) revealed that the maximum population (77.8%) in the rural area of Madhya Pradesh (M.P.) was illiterate and that only 5% had attained education up to class five (15). The literacy rate in our study population was higher. This could be explained by the fact that both the hospitals which were involved in the study were tertiary care hospitals and that the patient population did not represent the whole community.
The analysis showed that the SRB was lowest among the illiterate population [863 girls per 1000 boys] and that it increased with the increasing educational status of the women. The highest SRB was seen among those with education up to the higher secondary level [944 girls per 1000 boys]. However, there was a decrease in the SRB among women with undergraduate education or above [902 girls per 1000 boys]. A similar observation was also made in other studies from India (9),(16). This could be explained by the fact that the women with higher education opted more for sex selectiondue to the preference for a son and a small family size. The NFHS III data also showed that 56% of the women and 59% of the men considered the ideal family size to be two children or less, but that there was a consistent preference for sons over daughters among both women and men. About one- third of the women and onequarter of the men wanted more sons than daughters, but only 2% wanted more daughters than sons (17). It showed that though female education could lead to some decrease in the gender disparities, it was not enough. Hence, with increased female education, there hadto be an increased awareness regarding the adverse consequences of the declining sex ration, particularly among females.
The highest sex ratio at birth was observed in Christians, followed by Muslims and Hindus Similar findings are noted in some other studies (8),(18),(19). It showed that the religion and cultural background influenced the preference for sons, which resulted in decreased SRB.
The sex ratio at birth was 909 for urban mothers and it was 820 for rural mothers. In institutional deliveries, the sex ratio at birth was low in both urban and rural areas as compared to the state average. Studies by other groups also showed that the preference for a son and the discrimination against the girl child were common among the rural population and that it mainly arose out of social attitudes and the societyâs prejudices, myths and beliefs. The preference for a son has two pronounced and predictable family-level effects on the sex composition of children who were ever born. It could be explained that smaller families had a significantly higher proportion of sons than the larger families and that socially and economically disadvantaged couples not only wanted but also attained a higher proportion of sons, if the effects of the family size are controlled.
A low sex ratio at birth in the rural areas was a point of concern. It possibly reflected an increased access of prenatal diagnostic techniques among the rural population who were possibly more biased against women due to an agriculture based male dominant society (20),(21).
There was a decline in the SRB from the 2nd birth onwards. The variation of SRB with the birth order (or parity) was seen in Asia and in all the other countries where the SRB was increased. It showed that after the first child, a large number of couples availed of the prenatal techniques for sex selection. Similar findings were observed in other studies (16),(17).
CONCLUSIONS AND RECOMMENDATION
An extremely complex situation is existent regarding the sex ratio at birth in India due to diverse demographic, cultural, and socio economic factors. These have shown a variable influence over the sex ratio in different studies. It is necessary to understand these complex mechanisms before making policies and planning to decrease the gender discrimination.
The effective implementation of a legislation which prevents sex selective abortion should be combined with education with respect to the declining sex ratio and its future consequences. All forms of gender inequality with equal social and economic rights for males and females, including the rights of inheritance, need to be addressed, to strike at the causes for the declining sex ratio. The PCPNDT Act should be effectively implemented, so as to discourage sex selective abortion. The mass media, both print and electronic, should be utilized and community organizations should be mobilized to disseminate the relevant information to prevent female foeticide. The IEC strategy must include celebrity women from different aspects of life. In addition, further studies are recommended to explore the reasons of the unhealthy sex ratio at birth. The women folk from the general population, especially those from the rural areas where two thirds of the Indian population reside and access to information is still a challenge, should be targeted to be educated, which could make both the men and women accept more female births.
The present study was conducted at two tertiary care hospitals and the patient population did not represent the whole community. Hence, it was not possible to elicit the actual reasons for the preference of sons by a large section of the society.
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