Gender inequity in child survival : travails of the girl child in rural north India

Abstract: Background: While substantial progress has been made globally towards achieving United Nations Millennium Development Goal 4 (MDG 4) on child mortality, the decline is not sufficient to reach the targets set for 2015. The South Asian region, which includes India, was to achieve the MDG 4 target of 39 deaths per 1000 live births by 2015 but was estimated to have reached only 61 by 2011. A part of this under-achievement is due to the gender-differentials in child mortality in South-Asia. The inherent biological advantage of girls, reflected inlower mortality rates as compared to boys globally, is neutralized by their sociocultural disadvantage in India. The availability of technology for prenatal sex determination has promoted sex-linked abortions. Current government efforts include a law that regulates the use of ultrasound and other diagnostic techniquesfor prenatal testing of sex and a conditional cash transfer (CCT) scheme thatinvests a certain amount of funds at the birth of a girl child to attain maturity when the girl turns 18 years of age. This thesis describes the trends in genderspecific mortality during the period 1992-2011 and gender differentials in causes of death among children (paper I), compares gender differentials in child survivalby socio-economic status of the family (paper II), explores the contribution of non-specific effects of diphtheria-tetanus-pertussis (DTP) vaccination to the excess mortality among girls (paper III), and evaluates the impact of CCT schemes of the government and explores community attitudes and practices related to discrimination of girls (paper IV).Methods and Results: This study is set in Ballabgarh Health and DemographicSurveillance System (HDSS) of Haryana State in North India that covered a population of 88,861 across 28 villages in 2011. This study uses the electronic database that houses all individuals enumerated in the HDSS for the period 1992-2011 along with other demographic, socio-economic and health utilization variables. Sex ratio at birth (SRB) was adverse for girls throughout the study period, varying between 821 to 866 girls per 1000 boys. Overall, under-five mortality rates during the period 1992-2011 remained stagnant due to the increasing neonatal mortality rate and decreasing mortality in subsequent age groups. Mortality rates among girls were 1.6 to 2 times higher than boys during the post-neonatal period (1-11 months) as well as in the 1-4 year age group. Girls reported significantly higher mortality rates due to prematurity (relative risk of 1.52; 95% CI = 1.01-2.29); diarrhoea (2.29;1.59-3.29), and malnutrition (3.37; 2.05-5.53) during 2002-2007. The SRB and neonatal mortality rate were consistently adverse for girls in the advantaged groups. In the 1-36 month age group, girl children had higher mortality than boys in all SES groups. The age at vaccination for and coverage with ivabstractBacillus Calmette–Guérin, DTP, polio and measles vaccines did not differ by sex. There was significant excess mortality among girls as compared to boys in the period after immunization with DTP, for both primary (hazard ratio of 1.65; 95% CI 1.17-2.32) and DTPb (2.21; 1.24-3.93) vaccinations until the receipt of the next vaccine. No significant excess mortality among girls was noted after exposure to BCG (1.06; 0.67-1.67) or measles (1.34; 0.85-2.12) vaccine. A community survey showed poor awareness of specific government schemes for girl children. Four-fifths of the community wanted government to help families with girl children financially. In-depth interviews of government programme implementers revealed the themes of “conspiracy of silence” that was being maintained by general population, underplaying of the pervasiveness of the problem coupled with a passive implementation of the programme and “a clash between politicians trying to cash in on the public sentiment of need for subsidies for girl children and a bureaucratic approachof accountability which imposed lot of conditionalities and documentations to access these benefits”. While there has been some improvement in investment in girl children for immunization and education during the period 1992 to 2010, these were also seen among boys of the same houses and daughters in-laws who come from outside the state where such schemes are not in place.Conclusions: In the study area, girl children continue to be disadvantaged a tall periods in their childhood including in utero. In the short run, empowerment of individuals by education and increasing wealth without a concomitant change in culture of son-preference is harmful as it promotes the use of sex determination technology and female feticide to achieve desired family size and composition. There is a need to carefully review the use of health-enhancing technologies including vaccines so that they do not cause more harm to society. Current government efforts to address the gender imbalance are not working, as these are not rooted in a larger social context.