Understanding factors influencing adverse sex ratios at birth and exploring what works to achieve balance: the situation in selected districts of Nepal
In South Asian countries, strong son preference has led to serious discriminatory practices towards girls and women, with negative effects on their status, health and development. These gender disparities have resulted in a skewing of population and child sex ratios. Nepal has begun showing signs of skewed or disturbed sex ratios at birth in some districts of the Terai and hill regions—a reflection of persistent gender discrimination, combined with a preference for small numbers of children and the increasing availability of prenatal diagnostic technologies including ultrasonography (USG) since the 1980s and consequently an increase in the practice of gender-biased sex selection.
The district-level differences in sex ratios raise questions such as: what accounts for the worsening of the sex ratio at birth in some districts of Nepal, but not in neighboring districts? To what extent are USG and other prenatal diagnostic techniques misused in those districts? The limited answers to these questions pose a key challenge to the development of approaches that promise to halt or reverse trends in adverse sex ratios at birth in Nepal. Two adjoining hill districts in the western development region, namely, Kaski (where sex ratios are adverse) and Tanahun (where sex ratios are normal) were selected for study. This study used a mixed method design that included a population-based survey of 1000 married women with at least two children, one of whom was aged 0–5 years; and 29 key informant interviews with stakeholders such as district-based public and private sector health care providers and programme implementers/managers.
The evidence gathered established that despite some commonalities in son preference, the practice of undergoing USG procedures and disclosure of the sex of the foetus was higher in Kaski than in Tanahun. The recent upsurge in sex ratios at birth favoring males in Kaski was attributed to the above practice, accentuated by couples in Kaski desiring fewer children. The underlying factors for normal or “balanced” sex ratios in Tanahun are its dominant rural population, poverty and poor access to diagnostic clinics performing sex determination tests and relatively better community-based gender-focused programmes. Our study has also shown that while the district authorities in Tanahun were engaged in enforcement of the law that bars sex determination of the foetus and sex selective abortion through routine monitoring diagnostic centers and advocacy, such efforts were virtually lacking in Kaski. Women in urban Kaski demonstrated greater inclination to have induced abortions following sex determination than women in Tanahun.
The findings suggest that in the absence of direct interventions on this issue, there is a possibility of a worsening situation in Nepal with regard to the sex ratio at birth as access to prenatal diagnostic techniques proliferates to districts beyond Kaski. With regard to programme initiatives that hold promise, the inter-district differences point to the likely effectiveness of communication, advocacy and community mobilization efforts in the short term. In the long term, what is required are programmes which aim to empower girls, promote gender equality and improve girls’ overall situations. Programmes must focus on keeping girls in school and ensuring that they complete a secondary education, providing girl-friendly education to encourage school retention, and expand the reach of the universal scholarship scheme for girls. Other efforts adopted in neighboring countries, including conditional cash transfer schemes that provide benefits to parents when their daughter achieves immunization, education and other milestones, and remains unmarried until age 18 may also hold promise.
Puri, M.; Tamang, A. Understanding factors influencing adverse sex ratios at birth and exploring what works to achieve balance: the situation in selected districts of Nepal. CREHPA, Kathmandu, Nepal (2015) xvi + 52 pp.