Sex selection, a gender discrimination of the worst kind, is highly prevalent across all strata of Indian society. Physicians have a crucial role in this practice and implementation of the Indian Government’s Pre-Natal Diagnostic Techniques Act in 1996 to prevent the misuse of ultrasound techniques for the purpose of prenatal sex determination. Little is known about family preferences, let alone preferences among families of physicians. We investigated the sex ratios in 946 nuclear families with 1,624 children, for which either one or both parents were physicians. The overall child sex ratio was more skewed than the national average of 914. The conditional sex ratios decreased with increasing number of previous female births, and a previous birth of a daughter in the family was associated with a 38 % reduced likelihood of a subsequent female birth. The heavily skewed sex ratios in the families of physicians are indicative of a deeply rooted social malady that could pose a critical challenge in correcting the sex ratios in India.
India has been traditionally and culturally plagued with the problem of gender discrimination of the worst form: the avoidance of female births (Bhat and Zavier 2003; Echávarri and Eczurra 2010; Garg and Nath 2008; Rosenzweig and Schultz 1982). Of continuing concern is the finding that this gender-based divide has consistently widened, especially in the past few decades (Arnold et al. 2002; Sudha and Rajan 1999). Recent studies by Jha et al. and Puri and Nachtigall as well as the observations from Indian Census 2001 point toward a continuing and gloomy aspect of the sex selection scourge in India (Government of India 2011; Jha et al. 2011; Puri and Nachtigall 2010). This imbroglio is so deeply engraved in culture that even immigrant Indian women living in the United States have been reported to be resorting to sex-selection practices (Puri and Nachtigall 2010). The arrival of ultrasound and other sex-determination technologies on the public health scene in India are believed to have contributed to skewed sex ratios, making it a phenomenon more closely associated with the middle and upper socioeconomic classes (Jha et al. 2011).
We conducted an investigation into a socioculturally and programmatically crucial subset of individuals—namely, physicians—for three reasons. First, this profession enjoys high esteem in India, and physicians are regarded as role models for the society. Second, physicians have a crucial role in the implementation of the Indian Government’s Pre-Natal Diagnostic Techniques Act in 1996 to prevent the misuse of ultrasound and other techniques for the purpose of prenatal sex determination, which has been implicated for selective abortion of girls (Government of India 2005). Third, little is known whether this preference for boys also exists among the families of Indian physicians. We thus investigated the pattern of sex ratios in the immediate families of physicians.
Government Medical College and Hospital, Nagpur, India, is a large tertiary care-teaching hospital in the Vidarbha region of central India. Yearly, 200 students from this region of Maharashtra are admitted for the course of Bachelor of Medicine and Bachelor of Surgery (MBBS). We conducted this survey with students who were admitted to this college during the years 1980–1985. Traditionally, each student group celebrates its 25 years in the profession; the last of these groups recently completed its 25-year anniversary. An important part of this celebration is a souvenir “directory” that contains self-reported information of the graduated and subsequently practicing physicians, including data on marital status, number of children, and children’s gender. Using this source, we collected demographic data on individuals who have been in this field for 15 years. To avoid duplication of information, we ensured that if both partners were physicians who were admitted to the MBBS course during the aforementioned time, information was entered for one partner only.
From these data, we estimate the overall child sex ratios as well as the conditional sex ratios, given that the latter have been identified as indicators of sex-selection practices (Jha et al. 2011). Sex ratio was expressed as number of females per 1,000 males and was estimated as [f / (1 – f)] × 1,000, where f is the observed proportion of females. Confidence intervals (CI) for the sex ratios were obtained using delta method (Jha et al. 2011). By this method, the variance of the sex ratio was estimated as f / (n × (1 – f)), where f is the proportion of the female births and n is the number of total births (males + females). To estimate the impact of sex of the previously born children on the likelihood of future female births, we used clustered unconditional logistic regression analyses. We used Stata 10.0 (StataCorp. 2007) software package for analyses. Statistical significance was assessed at a type I error rate of .05.
Our study included data from 946 nuclear families with 1,624 children, with a family size of 1.78 (99 % (CI) 1.73–1.83). At the time of the release of the anniversary souvenir directory, the age of the physicians ranged from 38 to 43 years, with a mean of 42.8 ± 0.9 years, and 402 (42.5 %) responders were females. Table 1 shows the estimated sex ratios of their children. We observed that the point estimate for the overall sex ratio was 907. This estimate was even lower (900) for families with only one child. However, the most surprising finding was that for physicians’ families with two children: if the first child was male, the sex ratio of the next child was marginally in favor of females. Comparatively, if the first child was female, then sex ratio plunged to 519, indicating a very strong sex-selection bias. A similar trend was observed in the three-child families. The sex ratio for the third child was 1,000 in families with two previous sons, and it dropped to 600 if one of the previous children was a girl and to 455 if both the previous children were female.
We therefore investigated the sex ratio contingent upon a previous female birth in the family. We found that if there was at least one previous daughter in the family, the sex ratio was only 593 as compared with 982 for no previous female birth in the family. Using unconditional logistic regression analyses, we estimated the odds ratio of a female birth if there was a previous female birth and found (Fig. 1) that with the exception of one batch (1982), all the remaining batches demonstrated a consistently reduced likelihood of a female birth in that scenario. The overall odds ratio was 0.62 (95 % CI 0.47–0.82), indicating a 38 % reduced likelihood (95 % CI 18 % –53 %) of a female birth if the family already had one daughter. We accounted for the potential variation across the batches using robust standard errors based on the batch as a clustering variable. In clustered logistic regression model, the 95 % CI for the odds ratio was narrower (0.49–0.78).
Discussion and Conclusion
Our investigation revealed important and startling concerns about the potential sex selection practices among doctors from the Vidarbha region of India. First, the overall child sex ratio was more skewed than the national average of 914 (and 954 for the Vidarbha region) (Government of India 2011). Second, the conditional sex ratios consistently decreased with increasing number of previous female births. Third, birth of a daughter in the family was associated with a 38 % reduced likelihood of a subsequent female birth. There is a belief in many parts of Indian society, regardless of the household’s education and economic status, that having a daughter is an economic liability because the money spent on her education, dowry, and marriage benefits another family after she is married, whereas a son carries the family name, earns for the family, and takes care of aging parents (Arnold et al. 1998).
Previous studies have also claimed that this son preference varies little by education or income and that selective abortion of girls is also common in educated or more affluent households, presumably because they can afford ultrasound and abortion services more readily than uneducated or poorer households (Government of India 2011; International Institute for Population Sciences IIPS and Macro International 2007). Interestingly, a recent study by Echávarri and Eczurra (2010) demonstrated an inverse-U shaped relationship between literacy status and sex ratios in India, such that very high literacy status is also associated with skewed sex ratios. This finding is in line with the observed finding in the present study, suggesting that formal education itself may be only a partially welcome intervention against a culturally embossed phenomena like son preference. Similarly, poverty and wealth have both been associated with son-preference practices in India (Gaudin 2011). Because doctors more likely represent the educated and wealthy echelons of Indian society, our findings of potential son preference in them are consistent with the social and cultural expectations.
We are cognizant of the limitations of this study: a sample size smaller than generally included in population studies, consequently wide CIs around the point estimates in some instances (Table 1), a preselected sample that may not faithfully represent the entire physician community in India, and crude estimates of the sex ratios that do not account for childhood mortality rates. Also, although conditional sex ratios are strongly indicative of underlying sex-selection practices, these ratios offer only circumstantial evidence, rather than proof of such practices. However, in the absence of data such as the number of actual abortions, we believe that the distressing novelty of our finding somewhat offsets the inherent limitations and warrants a closer look at the psyche behind sex-selection practices in India. It will also be interesting to consider whether these practices pervade other spheres of the medical profession, such as nurses and paramedical workers.
Other researchers have conjectured that although the government of India passed the Pre-Natal Diagnostic Techniques Act in 1996, the actual implementation of the Act may be far from satisfactory (Jha et al. 2011; Zavier et al. 2012). Our data provide strong support for this notion. If these data are supported by larger nationwide concurring information on physician behavior, we may have uncovered one of the several possible mechanisms contributing to the failure of the implementation of this Act. Arguably, the involvement of physicians themselves in sex-selection practices is likely to affect proper programmatic efforts to correct the sex ratios at social, ethical, moral, and practical levels. Therefore, necessary interventions, such as improvement in reporting of births, legislation, monitoring, and evaluation, may still be insufficient. It may be more relevant to initiate or intensify a social change that gradually withdraws the society from such detrimental practices. Above all, charity should begin from home, and the first group on which to focus for bringing about a larger social change may be physicians.
The authors dedicate this work to the fond memory of the late Mr. Purushottam R. Thakre for his social wisdom and inspiration.