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Improving the Child Sex Ratio: Role of Policy and Advocacy

We may have to wait for the 2011 Census to see the final result of measures taken to improve the child sex ratio in India. Until then, we should adopt more stringent steps to make the Pre-conception and Pre-natal Diagnostic Techniques (Prohibition of Sex Selection) Act of 2003 more effective. Against the backdrop of the text and implementation of the previous Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act of 1994, this article analyses the challenges ahead and the role of advocacy measures to prevent an increasing deficit of women in the population.


Improving the Child Sex Ratio: Role of Policy and Advocacy

Leela Visaria

that undervalue daughters or women in Indian society [Wyon and Gordon 1971; Miller 1981; Das Gupta 1987; Visaria 1988; Basu 1989; Rastogi and Raj Kumari 1992].

In recent years the deficit of girls or decline in the sex ratio at younger ages of zero to six years has become much more

We may have to wait for the 2011 Census to see the final result of measures taken to improve the child sex ratio in India. Until then, we should adopt more stringent steps to make the Pre-conception and Pre-natal Diagnostic Techniques (Prohibition of Sex Selection) Act of 2003 more effective. Against the backdrop of the text and implementation of the previous Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act of 1994, this article analyses the challenges ahead and the role of advocacy measures to prevent an increasing deficit of women in the population.

Leela Visaria ( is at the Gujarat Institute of Development Research, Ahmedabad.

he increasing deficit of women in India’s population has been documented ever since the first decennial enumeration of people was conducted in the British-occupied parts of India in the late 19th century. Over the span of more than 100 years, the deficit of women has progressively increased as evident from the sex ratio of the population; the number of women per 1,000 men more or less steadily declined from 972 in 1901 to 933 in 2001 [Visaria, P 1972; Visaria, L 2002].1 Partly because of population growth, the absolute difference in number between men and women increased from 3.4 million in 1901 to 36 million in 2001. Assuming a female to male sex ratio of 1.022 as a standard that is observed in countries where bias against women is not evident, Amartya Sen estimated that there were nearly 100 million women missing in the world around 2000 and nearly a third of them were missing in India.2

1 Increasing Deficit of Women

India’s demographic and sociological literature has explored the reasons for the progressively increasing deficit of women and concluded that the main cause has been the persistent survival disadvantage that women experience from early infancy well into their reproductive period. The age-sex specific death rates estimated by India’s Sample Registration System (SRS) have shown that women in the past and continue even today to experience higher mortality from age 1 to about 34 or 39 years compared to men. Excess female mortality has been due to social practices, such as not providing timely healthcare to girls and women in the event of an illness, including at the time of difficult childbirth or seeking healthcare for them when it is too late. A number of field-based studies carried out since the 1970s have amply shown the presence of cultural practices evident and stark. The juvenile sex ratio, for the country as a whole, dropped by 4.5 per cent between 1981 and 2001 or from 971 to 927 girls per 1,000 boys. The deficit of young girls, which was not evident in 1981, except in the traditionally and historically masculine states of Haryana and Punjab and some small pockets elsewhere, became quite stark by 2001 in states such as Himachal Pradesh, Gujarat and in parts of Rajasthan and Maharashtra. In Punjab, the juvenile sex ratio declined by 13 per cent from 908 to 793 between 1981 and 2001, and in Haryana, by 9 per cent from 902 in 1981 to 820 in 2001. Himachal Pradesh and Gujarat also experienced a decline in the juvenile sex ratio of the order of 7.5 per cent that is higher than the national average. Thus, an almost contiguous belt extending from north-west of India to parts of Rajasthan and Gujarat has experienced drastic decline in the juvenile sex ratio in the recent decades.

In fact, according to the 2001 Census, there were 49 districts in the country, where for every 1,000 male children aged 0-6 years there were less than 850 female children. Majority or 38 of these districts were located in just three northern and western states of Punjab, Haryana and Gujarat [Census of India 2001]. The decline of 60 to 83 points in the juvenile sex ratio between 1991 and 2001 or in a span of just one decade in these districts cannot be explained solely by the discrimination against girls that has been practised in this region for several decades. Because at no other time, in the history of census taking, has the sex ratio of children declined so drastically. In the past two decades, with the advent of new technologies such as portable sonogram, it has become easy for parents to avoid having daughters by knowing the sex of the foetus in mother’s womb, and if found to be a female, resorting to abortion. Thus, parents started replacing the old practices of neglect of girl

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child, female infanticide and sex differentials in the provision of medical care leading to higher female mortality and opting for pre-birth elimination of daughters with the help of medical technologies.

The use of new technologies for sex selection spread quite rapidly across many regions and social groups, but micro studies conducted in Punjab, Haryana, Himachal Pradesh and Gujarat showed that the deficit of girls among the second and third child was much greater among women who were educated beyond primary level, who were not engaged in any economic activity or who belonged to upper castes, whose families were landed and who could pay the provider for the procedure and abortion, if needed [Visaria 2004; Bose and Shiva 2003; Ganatra et al 2001]. At the same time, there was strong evidence that those belonging to backward social groups or with less education also sought information on the sex of the foetus, indicating that the practice is spreading across all socio-economic groups. A clear preference for certain sex composition of children while keeping the family size small is evident. These findings demonstrate that sex ratio is a manifestation of interplay between biological and social and cultural factors.

2 Legal Measures

The spread of the use of the new technologies for sex detection led some health and human rights activists in Maharashtra to start a campaign as early as mid1980s against the misuse of the pre-natal diagnostic techniques. The campaign resulted in imposing a ban in 1986 on their use for sex detection in Maharashtra.

In view of the unprecedented decline in juvenile sex ratio, and the mushrooming of private clinics that advertised and carried out sex determination tests using ultra sound machines, especially in northern India, the government of India enacted the Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act (PNDT Act) in 1994. The act became operational in 1996, putting a ban on using the sonogram to determine the sex of the foetus and/or revealing it to the mother, but it proved very difficult to enforce in spite of creating sustained campaign and public debate in the print media.

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Although the act had a provision for punishing the violators with imprisonment and a fine, hardly any cases of violation were reported from the states and no one was punished. In spite of putting monitoring systems in place both at the state and the central levels, and imposing penalties on providers who disregard or contravene the provisions of the act, the 2001 Census results demonstrated that in many places the act had been violated with impunity. Available evidence indicated that the practice of sex detection went underground; its cost went up. Since the two activities of sex detection of the foetus and abortion need not be linked at the stage of using the services, it became possible to evade the law in connivance with the clinics having ultrasound facilities and doing sonographic tests.

The act was amended in 2003 after some health activists filed a public interest litigation in the Supreme Court, because the enforcement of the act was very weak. By banning the use of pre-conceptual techniques, the act came to be known as the Pre-conception and Pre-natal Diagnostic Tecniques (Prohibition of Sex Selection) Act (PC/PNDT). After the amendment, the enforcement of the act is made even more stringent by regulating and monitoring the sale and use of ultrasound machines.

The ministry of health and family welfare (MoHFW) that is responsible for the enforcement of the act, has undertaken several concerted actions such as constituting central supervisory board, appropriate authorities and advisory committees at state and district level that monitor the implementation of the proviso of the act at all levels. International donor agencies such as the United Nations Population Fund (UNFPA) and the United Nations Children’s Fund (UNICEF) and Population Foundation of India (PFI) have lent support. In fact, UNFPA has helped in developing national advocacy and communication strategy. In collaboration with others it has commissioned research studies, and has hosted brainstorming sessions with a wide range of stakeholders including health professionals, medical bodies and law enforcers such as police.

Awareness Activities

Efforts have also been made to create awareness about the act through print and visual media. For example, an advertisement in the mass media directed clinics to display prominently that no sex determination of the fetus is permissible or practised in their clinics. Wide publicity has been given to the law through hoardings and wall paintings at the district and subdistrict levels. Posters on the consequences of practising, aiding and abetting sexselective abortions have been widely displayed around the country. Compilations of writings on the subject have been made in a series of books. Films have been made

– Atamaja and God’s Left Hand – in order to raise public awareness and discussions around them have been held. Thus, multipronged advocacy strategies that aim to make a dent in the prevailing practice of sex selection have been devised. Efforts have been underway to use all modes of communication, to educate and inform a range of stakeholders and all those whose opinions matter on the trends in child sex ratio, on the likely consequences of the deficit of girls and women and appealing to the sense of justice and basic rights of all – men and women.

These multipronged efforts have indeed kept the issue alive. A number of states have taken up the issue and highlighted the deteriorating situation in their own regions and have come up with novel approaches such as making school children taking an oath that they will not practise female selective abortion. In Gujarat, for example, in 2006 a large community of landowners, among whom the juvenile sex ratio is reported to be quite adverse to females, took an oath that they will not practise sex selection at a meeting attended by over a lakh of people. The advocacy efforts have created awareness about the act and galvanised many not to violate the law.


There are some indications that thanks to the advocacy and other efforts the child sex ratio may have improved although there are mixed reports. However, given the fact that not all births are registered, it is difficult to measure the impact of various advocacy strategies and policy restrictions. The national household-based sample surveys or the data collected by the sample registration system give mixed or


contradictory trends, but their validity needs to be established. It is likely that we will have to wait a few more years, until the 2011 Census is conducted.

Who Performs Them: In any event, we need to examine closely the limitations of both the legal measures and advocacy strategies and challenges before us. Firstly, after the PNDT Act came into effect, information on the extent to how many sex detection tests are performed and who performs them and the extent to which preelimination of female foetus actually takes place has become difficult to collect or even compile. According to a few in-depth qualitative studies, women in the areas where sex ratio is adverse to girls, are well aware about the fact that the test to determine the sex of the foetus before birth is not performed in government-run facilities and that they would have to go to private facilities or practitioners for such service. They are also aware about the exact procedure involved, and the cost to them. While many private facilities offer abortion services, in order to get free abortion, studies have shown that women go to government facilities for abortion and not reveal the information about sex determination test [Visaria 2004; Barua 2004]. Thus, it is relatively easy to circumvent the law. Although second trimester abortion in public facilities elicits more questions, there are ways to handle them. In any event, in private facilities there are far fewer restrictions.

Confusion in Interpretation: Two, the widespread campaign around the PNDT Act, in order to address adverse female to male sex ratio, has created high awareness about it among people, but also some confusion among both the providers and the clients who have begun to interpret the PNDT Act to mean that all abortions (whether sex selective or not) have become illegal. Some micro studies found that knowledge about the legality of abortion services and the circumstances under which they are available or the medical termination of pregnancy (MTP) Act of 1971 was quite low among people in India [HealthWatch 2004]. Women did not see or comprehend the distinction between abortion per se as a woman’s right and sex determination test and elimination of foetus on the basis of its sex as violations of girl’s right to be born and as acts of disempowering women. On the other hand, the limited evidence suggests that some providers used the MTP Act to their advantage and found newer and ingenious ways to provide information on sex of the foetus in coded language and conduct sexselective abortions. The consequences included reduced access to safe, legal and affordable abortion. Some clinics stopped doing abortions because of the fear of being criminalised or because the elaborate moni toring mechanism and recordkeeping prompted them not to offer abortion services altogether. Also, it was alleged that there was no guarantee that the clinics that provided the information to the unsuspecting couples about the sex of the foetus were actually basing the information on actual test.

Legislative Restriction: Three, a rather delicate and tricky issue has surfaced from time to time and in the context of legislative restriction that needs a careful consideration during discussions with women, their extended families and with the providers of abortion and other services. Some have justified abortion of female fetuses by equating it with wanting to abort fetuses that have been diagnosed with medical abnormalities. The distinction between physiologically abnormal foetus for which termination is legal and termination of a foetus that is sociologically undesirable is conceptually clear but is quite subtle. The same set of arguments is put forward that like a medically abnormal foetus, a female foetus is also expensive to maintain if allowed to be born, is less productive than normal persons, can be detrimental to the parents’ emotional and financial wellbeing, and is on many accounts better not being born. Arguing for one specific application of genetic selection may suggest to some that other applications of the technology are also endorsed.

New Technologies: Four, the rapid developments in medical technology further complicate reliance on legislative strategy to control its use. There are newer and easier tests that are being developed and made available to women. For example, a new blood testing technique makes it possible to determine the sex of the foetus from simple maternal blood test. Although its cost may be prohibitive for many at the moment, and therefore, only a few are able to access it, it has the potential of becoming widely available and the cost falling.3 These technologies will be hard to police and regulate. The expansion of medical technologies and tests that can make sex selection easy and possible even at home, would require innovative ways to address the issue of gender equity and challenging the existing social structures and norms that encourage son preference and daughter neglect.

Protest: Five, many advocacy activities and protests carried out by some nongovernmental organisations have tended to interlink the ban on sex selection with the need to regulate abortion that follows sex selection while protesting that sex selection is illegal, discriminatory and violates the basic rights of the girl child. When they demand that complete records of age and sex of all cases of MTP must be maintained or that a medical committee must give clearance in all cases where a pregnancy is terminated in the second trimester, they create more confusion in the minds of the people. In order to prevent sex-selective abortion, if all abortions were to be regulated, women would face difficulties even accessing regular abortion under the MTP Act.

Lack of Proper Evaluation: Six, while the range and number of materials (including print, audio-visual and web sites) prepared for advocacy is huge, until very recently no studies have been carried out to understand whether they have achieved what they were intended to achieve, e g, changes in attitudes. Also, the content of the materials has also not been systematically evaluated through gender lens or from women’s rights perspective. For example, who is the villain: the mother-in-law or the patriarchal attitudes that women have also internalised? A lot of advocacy material appeals to the emotions rather than the intellect. Also, the premises on which most of the materials and the advocacy and communication strategies are built need to be questioned. For example, statement such

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as “the decline in sex ratios has reached grave and alarming proportions and that India is on the brink of a demographic catastrophe” needs to be widely debated for the underlying assumptions. Also, the advocacy involving a wide range of stakeholders has resulted in carrying out work on a number of sub-issues in a number of different ways resulting in varied approaches and content. Very recently, in order to assess whether the communication strategies have produced any visible impact, UNFPA commissioned a study according to which sex selective elimination of girls was acceptable and justified among many stakeholders because of strong son preference, financial cost expected to be incurred in educating and marrying girls, and concern for the future well-being of the girls [Joseph 2007].

Age-old Son Preference: Seven, the fairly large body of research carried out in recent years and the efforts of the NGOs have brought out clearly that the low sex ratio can be attributed to the age-old son preference. A reversal in the trend that undervalues daughters to that values daughters as equal to sons, would require an overall structural change in the role, status and economic value of women. The suggestions that are often made that provision of greater access to education to girls or giving them skill-based training and thereby creating job opportunities for them would enhance their value and status in the family, and therefore, families would not resort to their elimination need to be closely examined empirically. While these are desirable goals in themselves, and also might make a difference in the long run, in the short-run their impact on tackling the issue of sex selection appears quite limited. Women themselves have internalised the patriarchal values to such an extent that even when they say that daughters take better care of parents in old age or are more emotionally attached to the mothers, their statements sound hollow because more sons than daughters are desired.

Emphasis on Attitudinal Change: Eight, the advocacy strategies would have to keep these considerations in mind and address them in order to become effective. It must also be recognised that the long-term

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consequences of sex selection in terms of likelihood of a womanless society or even of finding brides for the grown up sons cannot have huge impact on the behaviour of the people. Their immediate concerns, fears, their own perceptions of reality and consequences of their decisions in the short-run must be addressed while appealing to their emotions. Their immediate concern that investment in daughters, who upon marriage would become members of someone else’s household, is unproductive would have to be addressed through advocacy, through real-life stories of girls and women who have made their parents proud of them. The need is to aim at consciousness raising in both the parents about the value of daughters and understanding the cultural factors that undervalue girls. We have focused too much on implementation of the PC/PNDT Act and too little on finding ways to bringing about attitudinal changes such that daughters are valued.

Revision of Medical Curriculum: Nine, similarly, there is an urgent need to work with the members of the Indian Medical Association and Federation of Obstetricians and Gynaecologists to abide by the stipulations of the act in letter and in spirit. Many advocate that the medical textbooks and medical curriculum should be revised to incorporate various legislations that directly affect the practice of physicians and also discuss underlying ethical considerations. Surprisingly, medical education in India has not included such issues and nor does it emphasise effective communication. At the same time, the policies to counteract sex-selective abortion must go beyond cracking down on health workers, because these practices can easily occur outside the law. Policies must attack the cultural bias against women that is the root of the problem. Changing ingrained attitudes about the value of women is a tough, but a necessary assignment.


1 Unlike the international practice where sex ratio is calculated as number of males per 1,000 females (M/F*1000), in India it is calculated as number of females per 1,000 males (F/M*1000) following the earlier British practice.

2 Besides Sen (2001), Coale (1991) and Klasen (1994) had also earlier estimated the number of missing women using different procedures. All the estimates of missing women have been in the

same range of around 100 million worldwide.

3 While discussing this and other such technologies with a spokesperson in the MoHFW, I learnt that efforts of the ministry to get the detailed information on the newer technologies or research on them from the Indian Medical Association have so far drawn a blank. Their unwillingness to share the information is understandable due to the fear that the proviso of the act would be expanded and the ban on import of such test kits would make them prohibitively expensive and also not allow the pharmaceutical companies to produce them locally.


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Basu, Alaka, M (1989): ‘Is Discrimination in Food Really Necessary for Explaining Sex Differentials in Childhood Mortality?’ Population Studies, 17(2), pp 193-210.

Bose, A and M Shiva (2003): Darkness at Noon: Female Foeticide in India, Voluntary Health Association of India, New Delhi.

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Coale, Ansley (1991): ‘Excess Female Mortality and the Balance of the Sexes in the Population: An Estimate of the Number of “Missing Females”’, Population and Development Review, 17(3), pp 513-27.

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HealthWatch (2004): ‘Abortion Assessment Project of India: Qualitative Studies’, HealthWatch Trust, Jaipur and CEHAT, Mumbai,

Joseph, Josantony (2007): Reflections on the Campaign Against Sex Selection and Exploring Ways Forward, Centre for Youth Development Activities (CYDA), Pune.

Klasen, Stephan (1994): ‘ ‘Missing Women’ Reconsidered’, World Development, 22(7), pp 1061-71.

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Rastogi, S R and R Kumari (1992): ‘Son Preference and Effectiveness of the Family Welfare Programme in Uttar Pradesh’ in R N Patil (ed), Health, Environment and Population, Ashish Publishing, New Delhi, pp 165-79.

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  • (2002): ‘Deficit of Women in India: Magnitude, Trends, Regional Variations and Determinants’, The National Medical Journal of India, Vol 15, pp 19-25.
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