Rationale for declined child sex ratio across Perambalur district in Tamil Nadu—A qualitative study

ABSTRACT

Background:

Child sex ratio signifies the proportion of girls compared with boys in 0 to 6 years of age group. It is an important indicator for any population and most significantly about the status of the girl child in the society. The study tried to approach in a qualitative manner to study the rationale behind the declining of child sex ratio.

Materials and Methods:

We conducted a qualitative study using five focus group discussions and 12 in-depth interviews among various age groups, pregnant women, and other stake holders. The participants were approached with a semi-structured open-ended interview guide regarding the rationale of declined child sex ratio and measures to normalize it. After a thematic analysis, main themes and subthemes were selected after consensual agreement.

Results:

The study showed that male child preference is the main theme identified in the rationale part with subthemes of female vulnerability, socioeconomic status, literacy, cultural, and caste and religion as subthemes. The theme of female child preference also came up with as second child, care taking, affectionate, and cultural factors as subthemes. In the area of suggestions/interventions, education, counseling, government policies and media along with suggestions regarding sex determination and female feticide were identified.

Conclusion:

The decline in child sex ratio should be taken as an active social issue thus focusing more into female upliftment and enlightening into the issues of patriarchal nature, with reduction of cultural/religious beliefs.

Introduction

Not safe, neither in the womb, nor in the world.
But she is fierce, she is powerful.
You don’t have to lift her up,
educate her and you will see her lift the world up,
even if her own hands are wounded.
by Dr Abhishek

Demographers and anthropologists define the human sex ratio as the proportion of males to females in a population. The natural human sex ratio is 1.05 or 1.06 men per female, slightly favoring men. Most species sex ratios vary with age.[1] India’s population is now 1380 million, which comprises of 717.10 million men and 662.90 million women.[2]

The child sex ratio (CSR) shows the percentage of girls to boys in the 0-6 age range. It is important for any population and usually indicates the girl child’s social status. In Census 2001, India’s CSR fell below the natural sex ratio at birth.[3] Tamilnadu’s CSR improved from 942 girls per thousand males in 2001 to 946 in 2011 and rated 11^th [Figure 1].[4]

Figure 1.

Child sex ratio across districts of Tamil Nadu 2001 and 2011

Female discrimination starts right from the womb as feticide and continues as infanticides. Other forms of discrimination against girls exist in India as well, including shorter nursing periods, less caring and play, less access to special food and nutrition, and less parental care. As a result, girls experience poorer health and shorter lifespans than boys due to their greater susceptibility to sickness and infections. The real killer of girls is this lifelong discrimination in nurturing and care, which is just as indisputably deadly as female foeticide and infanticide, despite being less conspicuous and clear. Figure 2 shows the causes of diminishing CSR.[5,6,7,8,9]

Figure 2.

Factors and causes leading to declining child sex ratio

This disrupted CSR disrupts peace later in life by influencing social, economic, and other sectors. The vast cohorts of “surplus” males reaching maturity, mostly from lower socioeconomic levels, are unmarried and isolated, raising concerns that they may engage in antisocial behavior and violence, compromising society’s stability and security.[10,11,12,13] The falling CSR violates the human rights of unborn and baby girls and denies the nation the economic and social contributions of these “missing women.” An oversupply of young males compared to young women may also disrupt the marriage market. Punjab and Haryana, where the sex ratio has been distorted for years, have seen bride trafficking.[14] Clear-cut studies related to the child sex ratio and its decline are absent from Indian states, and we have decided to approach the topic qualitatively.

The study is performed to assess the rationale behind declined child sex ratio across Perambalur district through a qualitative research approach and to analyze the reasons and to suggest measures that can be done to change this decline.

Materials and Methods

Background

Child sex ratio and the variables assessing its decline are rarely studied. Qualitative research helps deepen thoughts, opinions, and representations. In-depth interviews and focus group discussions assess variables and concepts.

Setting

This is a qualitative study using topic guides, which is drafted on previous literatures and reports on the sex ratio and its factors. These topic guides focused on themes based on the causes of declined child sex ratio and suggestions/interventions to improve it [Figure 3]. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) guideline has been used to ensure quality and reliability of this study. The study commenced after obtaining Institution Ethics Committee approval.

Figure 3.

Topic guide

Study population

Five focus group discussions (FGD) among (brackets indicate the number of participants)

• Group of doctors with expertise in Radiology, Obstetrics, and Gynecology, Pediatrics (10)

• Women in the reproductive age group (8)

• Currently pregnant women male partner in the eligible couple (16)

• Elderly grandparents (10)

• Eligible couples (16)

Twelve in-depth interviews (IDI) with reproductive child health officers, healthcare practitioners (radiologist, obstetrician), and registration officers (Birth and Death registration), health campaigner for women and children, auxiliary nurse midwife, a paternal parent from Perambalur, a maternal parent from Perambalur, grandmother from Perambalur, and pregnant woman.

All the FGDs were conducted in the local language, and verbal as well as written informed consent was acquired from the participants (obtained purposively) before the discussion. Each FGD was recorded electronically, and the key points during the interview were noted. Each FGD took an average time of 20 to 30 mins. A sociogram was plotted to ensure equal participation of interviewees, which makes the interviewer to involve everyone in the discussion. The focus groups were homogenous to create a nonthreatening environment so that the participants were free to speak openly and give honest opinions. Participants were encouraged to not only express their own opinions but also to respond to the other’s comments and questions posed by the moderator. The total sample size from both FGDs and IDIs was 72.

Each in-depth interview took an average time of 15 minutes. The interviews were mainly focused on open-ended questions and were broadly divided into questions that pertained to the practice of sex-selective feticide among the study population. The focus group discussions were conducted until the data saturation was attained.

Collection and use of data

The FGDs and IDIs were fully recorded after the signature of the consent. We also reported on a note pad the main themes discussed by participants (to assess saturation of data). We anonymized participants using the description of the participant as radiologist or pregnant women, etc.

Analysis

All FGDs and IDIs were duly recorded. An audio recording was performed to identify key concerns and themes for categorization. The data were analyzed and coded using a thematic “Framework Approach.” The main themes and subthemes were selected after consensual agreement by the investigators. Finally, the prominent elements of the discussion were presented according to the main themes highlighted and their relevant subthemes.

Results

Participants gave varied reasons for declining child sex ratio. We got across the term “Gender preference” most often while assessing those answers. Gender preferences were taken as the main rationale and included male and female child preferences.

Figure 4 shows the rationale behind declined CSR where it is categorized into male child and female child preferences.

Figure 4.

Rationale for declining child sex ratio

Male child preference

Female vulnerability

Many participants stated that women are more susceptible to abuse and harassment in society, which places a burden on them in the form of additional responsibilities. And they continue to face several social restrictions.

Security concerns

Security for children is the main issue put forward by many subjects.

One important thing, why they are not preferring female child is because we can leave a boy child alone at home but if it is a case of girl child then the parents fear to go out leaving her at home, they will call the child 1000 times to check whether the child is at home or not, in the coming days’ sexual abuses are increasing, it’s not at all decreasing (Male partner of a currently pregnant woman).

Of course, for females, sexual harassment is there starting from childhood. Even today in the Newspaper (dated 02/11/2021), a 2-year-old child has been raped so she is not safe. You see any number of working women who lock their children in the house and go, no one to look after and help is very scarce even if you get it, it’s very expensive and not reliable all these daycares in all these a female child is being harassed (Obstetrician).

Restrictions for female child

Many people supported their preference for male babies with the word “restrictions.” Menstrual cycle, life, and work limits are cited as reasons for restrictions.

Yes, I don’t want my child to face the same menstrual problem. Nowadays girls attain their menarche at the age of 12 years, they don’t know what it is, so they are struggling a lot and also, they will be forced to restrain from many things starting from their childhood to adulthood (Mother of a pregnant women).

Increased responsibility

You see any number of working woman they lock their children in the house and go, no one to look after and help is very scarce even if you get it, it’s very expensive and not reliable all these daycares in all these female children is being harassed plus it’s a big mental stress for the mother to have a female child. Having a female child is a big responsibility- mentally in terms of security and the issue to send them off in marriage (a mother and father from a family said).

Socioeconomic status

Different economic groups even at the highest or lowest want male children to reduce future burdens.

Uneducated people think like we are already in a poor situation if it turns out to be a girl child, how are we going to get her married? We must spend a lot for a girl but for a boy, we don’t have to spend a lot. For a girl we must give dowry, it doesn’t stop there we have to do a lot for a female child. They think like “we are already uneducated and poor.” So, they prefer a male child (Auxiliary Nurse Midwife).

Literacy

Many participants agreed that literacy affects people’s mindsets, but some also answered that they prefer a male child regardless of literacy.

Apart from literacy, there is a thing called right, in that family whether she is allowed to talk, even if she is knowledgeable, she should be allowed to talk. Who will give that right? It’s not a social or religious right, only if that family gives her that right then only, she can speak even though she is educated. Nowadays many people are 10^th pass, uneducated people are very less, so she will be able to think whether she wants a girl or a boy child but she doesn’t have that right. So many patients are coming they don’t even have the right to terminate their pregnancy or continue their pregnancy especially in Perambalur it’s still there (an Obstetrician).

Cultural reasons

Based on majority answers, we grouped cultural reasons into four. Cultural factors include familial pressure, patriarchal society, family inheritance, and funeral rites. Cultural factors influence the CSR, according to most people’s accounts.

Pressure from family and relatives

Even in my private clinic there is a patient, the first child is a girl child. Now she is pregnant she is crying like anything. I want to know what the next baby is. One of her relatives recently had a male child it seems; her mother-in-law told her not to touch that child because in her family all members had female children it seems. So that is pride so they madly want a male child (Obstetrician).

Patriarchal society

Many participants responded that a family prefers a male child since only they can pass on the family name, take care of their parents, and inherit their properties.

The other thing is pride sir, if it is a male child then the parents will get more respect, they will be called for all functions, this is what the patients who are in Perambalur feel. If a parent has a female child, then they will not be called for important functions, they won’t be allowed to stand front (Radiologist).

Family inheritance

Most participants responded that society prefers male children because they will inherit the properties and convey their family name to the next generation, which has been instilled in their mind for ages.

Funeral rituals

Some participants say that only the male child can execute burial ceremonies, regardless of how educated their family is, and that this may affect their choice for a boy.

Similarly, if the parents die then the rituals are conducted by males, however, educated we are, we don’t give that right to them. We opt for other relative male children; they won’t allow their own daughter to do these rituals (Elderly grandmother).

Caste and religion

Abortions in some religion they don’t allow. Gender preference I don’t think it has any role as she said universally all want a male child (Obstetrician).

Many Muslim patients they prefer male baby, so they increase their number of pregnancies. So, until they get a male baby the number of pregnancies increases (Radiologist).

Above doctors and health workers, the pressure of the family is the main reason plus the pressure on that community. Because they will have 4 female children, if even the 5^th child turns out to be female then there will be pressure in the family. There is one community which don’t prefer female children (social activist).

Female child preference

The study also investigated why parents prefer female offspring because it would have a big influence. The participants cited few reasons for preferring women. They said female children is preferred because they are worshipped as goddesses, they are willing to care for their parents, and they will in turn beneficial for the family.

A girl child because there are some people who want a girl child after 2 boy children, what they think is if the male children don’t take care of them the female will take care of them. The next is family reasons, the mother will be in a joint family so her husband’s brothers will have male children, so to continue that, they will think of having a female child as their 3^rd child. I know 2 to 3 people who thought like that (Auxiliary Nurse Midwife).

If the first child turns out to be a female child, then according to Hinduism they treat a girl child as (Mahalakshmi) God. They will say it’s good for the family (a couple).

If it’s a boy they will just buy us food, if it’s a girl child then they will ask what happened and then they will ask whether we want hot water or tea and cook for us, ‘they will ask why you are still in bed. “They will wash our clothes and take care of us. For doing all these girl children are the best” (Another woman).

If it’s a girl child then they will be affectionate, however, they have a male child, the feeling that they get by talking with their girl child won’t be there from a male child, so mostly they prefer a female child” (Radiologist).

Suggestions/Interventions

Figure 5 simplifies the suggestions and interventions given by the participants to overcome the declining child sex ratio.

Figure 5.

Suggestions/interventions by the participant

Female feticide/infanticide

It’s their sir, I have seen one patient of mine here in Perambalur, they delivered the 3^rd or 4^th female child. The child was good, we sent her home within 1 week there was no problem to that child, a female child 3 kg, after 1 week they took that child to a pediatrician saying she was sick and the doctor said nothing is wrong with the child, they said that the baby is fine after reaching home within half an hour the child is found dead. No cause, nothing. We cannot prove it. We can’t do an autopsy they won’t do also. We don’t know whether they investigated it or not and reported it or not. We don’t know it’s out of our hands. It happened outside the hospital. Since it was the 3^rd child, we can suspect that’s all we can say (Obstetrician).

Sex determination

Despite the Pre-Conception and Pre-Natal Diagnostic Techniques Act (PCPNDT), certain doctors and scan facilities are exposing the foetus’ sex, according to participants. Every doctor encounters a parent wondering about the child’s sex at birth, according to many interviewers. Many participants also stated that expectant parents are somehow able to access locations where the child’s sex is revealed and that they somehow manage to learn the child’s sex.

Hospitals

Yes, yes, it’s happening but it’s not coming out. Rather than coming to us sometimes people prefer to go to private hospitals even uneducated people they find out the sex of the sex and go for abortion. If we look for second gravida births, there are more male births than female births. It’s very much evident and it’s just happening. If we take the delivery list of each hospital it will be very much clear (Registration officer).

Other methods

My wife saw something in YouTube, she some posterior like that and scan repost also came as posterior so we thought it could be a male child (male partner of a currently pregnant woman).

In some hospitals, they will allow us to see, through which we can know the sex of the child (a woman).

Media

Movies, TV, and social media like Facebook and WhatsApp reach many people. It plays a part in influencing people’s gender preferences and has a good impact on society. Several participants said the media has a long-term impact on individuals; therefore, we may use it to promote gender equality occasionally.

Social media brings about 80% change in the society, many people are seeing it and getting to know many things. They start thinking that a female child is also important in society. Now many people have come to a mindset to accept any child. So social media has a big part in it (male partner of a currently pregnant woman).

It depends on how fast we bring the changes, this generation has media influence like WhatsApp and all, so messages can easily reach them. One section of the people like final year students, when you complete got education when you enter into a family, have such things in mind not only their education we should teach something like morals science which include social responsibility, social awareness, what is their contribution to society, how we can contribute to the society as a family we should say all these, then we can expect changes (the Registration officer).

Government policies

Financial assistance

Government is doing a lot of things. If they have 2 female children and if they do sterilization, then they are giving supportive money, free education for a female child then they are giving gold, then free delivery and all. Like this government is doing a lot of things. If people understand this and use it properly then there won’t be an issue in the child sex ratio. They will come to a mentality to accept any child (a male partner).

Land

Some participants thought allocating land to girls may also change things.

I cent land we can register on girl’s name government land, Andhra government is giving 1 cent land for everybody (Pediatrician).

Strict laws

Many participants believe that only strict rules can promote female safety and preference in society.

They should bring a strict law saying that after the 2^nd child they should do sterilization within 6 months the government has brought lots of laws. The government should also bring a law like this only then it will become normal. Till now it’s not a law, only awareness is being created. It’s a law that only if they register their pregnancy within 3 months, they will get 2000 rupees so we have to bring a law only then it will become normal (Auxiliary Nurse Midwife).

Others

In this patriarchal culture, we must eliminate masculine favoritism along with money and norms.

Government is giving lots of schemes for female children, the government is spending a lot of money for female children. But if we think about it, is it reaching the village people? Then no it’s not reaching them, that’s the truth. Maybe if they get some knowledge in all these there will be a change. The government is doing a lot of things for female child and many private organizations like us are also doing many things, but this must reach village levels (Social activist).

There should be many interventions from the collector’s side. We should do a continuous follow-up. If we conduct meetings occasionally it won’t work out. We should follow up with every person in the reproductive age group, even giving counseling during the marriage. From college we should give awareness about all these. Irrespective of their course females will next enter into marriage, so we can give counseling. Similarly for boys, when the husband gives full support the wife can do anything. But if there is intervention by In-laws then it is difficult, so if the husband is supportive, they can stop their parents. All these we should start from now on (Registration officer).

Antenatal counseling

Some participants believe all expecting parents should get antenatal and preconception counseling.

We can first target Antenatal mothers, next we need to target teenage girls who are soon to be married, maybe boys too. We can do prenatal counseling. We also should train male children. It’s not just the female it’s a team (Obstetrician).

Education

Schools must teach gender equality for a long-term solution. Some people suggested assigning separate classes from the lower schooling levels to change perception of next generation.

We must educate the female children; they should be taught it’s good to be a female. And In the males more so in the males, they have more say in family and also when it comes to a child. A female should be able to make decisions on her own that must happen. It will be a radical change, that will not happen overnight. In schooling, this should be a part, just like moral science class. The next generation must be tuned. It’s difficult to change the parents they are already set in their ways. We don’t need a consultant for Antenatal counseling, we need lots of counselors. The counselors should sit and talk when they are there, but they must step up. In our country social workers are not taken seriously they are not doing their jobs of what is expected out of them (Obstetrician).

Awareness

Awareness is the next crucial remedy for this difference. Some participants said that awareness should be constant and recurrent rather than occurring in bursts. Rallies with local schoolchildren may raise awareness. Awareness is what changes older generations’ views.

In the long term, we can take a census in panchayat levels. We should have records of what a child is going to do next in their life, such level of monitoring should be there through ward members. Only then we can expect immediate changes. Only because there is no such monitoring there are lots of mis happenings. People who are not aware of all these are supported by people who are aware of it (Social activist).

Discussion

A concealed threat to future sex distortions is the declining CSR, which is correlated with rising masculinity in the child sex ratio. The study was conducted using a qualitative methodology, and the main theme came up was “Gender preference.”

In 2015, Guilmoto et al. reviewed the convergence of three phenomena—a preference for male offspring inherited from socio-familial systems, the emergence of assisted reproductive technology enabling prenatal sex determination, and a decline in fertility that increases the risk of not having a son—to explain large differences in male surplus across birth orders, regions, and social groups.[15] A review confirms that tightening family norms makes the household focus on male surplus.[16] In 2016, Kashyap et al. showed populations with greater family size norms and differential stopping behavior have higher postnatal female mortality to achieve son preference. Also, prenatal sex selection is more common in societies where abortion is common and ultrasonography is available.[17] Quantitative researches demonstrate that different populations favor sons[18,19,20] and also few studies have shown a neutral approach in terms of gender.[21,22] In India’s patriarchal society, women are pressured to access community-based, sex-selective identification, and female fetal abortion. Studies have shown that female children receive less breast-feeding, nourishment, and health care due to male preference.[23,24] In contrast to the quoted studies, Smith et al. showed that few imbalanced cities in terms of CSR in 2001 turned balanced in 2011 census. The reason quoted is the reduction in the sex selective abortions happening across the years.[25]

The study found that education, counseling, government regulations, and media may fix the sex ratio. Few quantitative research types have indicated that knowledge and stringent rules can prevent sex ratio distortion.[26,27] A 2013 review showed that preventing sex selection and abortion through acts will only address part of the cause for declining child sex ratio, and other causes still need consideration. However, the analysis reveals that the PCPNDT act and its sub laws improve the child sex ratio.[14] Few descriptive research types indicated that media could eradicate the conventional son preference from people’s minds.[28,29] Few studies have proven that mass messaging or advocacy can raise awareness.[30,31]

Few studies have demonstrated that government policies like cash benefits for parents of female children and steps to integrate women into the political and economic mainstream enhance gender fairness but also encourage parents to value their daughters. The allocation of land or equal asset/inheritance in females’ names, changing ration card ownership, political upliftment of increasing substitution in high power seats, and even pension to seniors have improved the imbalanced sex ratios.[32,33,34,35,36,37]

The study tried to penetrate deep into the rationale regarding the declined CSR and identified data regarding the unusual reasons for the male gender preference and interventions other than tackling the legality about the abortions. Due to social desirability bias, participants may be failed to express their opinions to avoid judgment. The study can be biased in a way where the participants selected would be forward in their opinion and consciousness, so the real culprits or backward thinkers are yet to be identified. In the study, only data source triangulation is focused, use of a quantitative approach, multiple investigators in various areas, using different theoretical approach would have enhanced the consistency and validity of the results.

Conclusion

Birth and child sex ratios are indirectly affected by various occurrences that, if distorted, could affect the society in many ways. Male gender preference was the main theme emerged for declining child sex ratio, with female vulnerability, socioeconomic position, literacy, cultural, and caste and religion as subthemes. Education, counseling, government policies, media, and sex determination and female feticide ideas were identified as suggestions.

Financial support and sponsorship

The study is done as Short Term Studentship project (2020) by Indian Council of Medical Research (ICMR), India.

Conflicts of interest

There are no conflicts of interest.