‘Is the bias so severe as to cause death?’

Interview with Dr T.K. Sundari Ravindran, activist researcher on gender, health and equity issues.

Published : Apr 17, 2013 00:00 IST

Dr. T.K. Sundari Ravindran, professor at the Achutha Menon Centre for Health Science Studies in Thiruvananthapuram.

Dr. T.K. Sundari Ravindran, professor at the Achutha Menon Centre for Health Science Studies in Thiruvananthapuram.

DR T.K. SUNDARI RAVINDRAN is Professor at the Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, and Chairperson of CommonHealth, an organisation advocating quality maternal neonatal health and safe abortion services and better access to them. She has a doctorate in Applied Economics from the Centre for Development Studies, Thiruvananthapuram, and is an activist researcher on gender, health and equity issues with focus on women’s health and reproductive health and rights. She has worked with the World Health Organisation, has been on the United Nation’s MDG [Millennium Development Goals] Task Force on Maternal and Child Health and is the former co-editor of Reproductive Health Matters .

“My interest in looking at sex ratios comes from the way it is affecting access to safe abortion. All the policy moves to prevent declining female sex ratio are happening in a way that is restricting access to safe abortion. So from that angle I have been studying it,” she told Frontline . Excerpts from an interview with her in the context of a recent study commissioned by the Kerala government on the changing child sex ratio in the State and its inconclusive findings.

How do you see the recent report on “Child sex ratio in Kerala” in the larger context of decline in child sex ratio in India as a whole?

In all Indian States now, sex ratio studies are being conducted. The concern is, how do you interpret these sex ratios once you have them? Most often the media assume that it is all because of sex-selective abortions. I have not seen a serious discussion in the media about excess female mortality in childhood as an important contributor to a decline in juvenile female sex ratio. There is no effort to look closely at details. In Kerala, there is one more issue. When the number of child deaths is becoming smaller and smaller, does ‘excess female child mortality’ signify anything unusual, or is it within the realm of random variations that may occur from one year to another?

What are your impressions on the major findings in the report?

The hypothesis of the authors runs like this: that the sex ratio at birth in Kerala is not very abnormal; however, the sex ratio in the 0-6 age group is coming out to be abnormal and, therefore, this has to do with higher female child mortality in the State. That there is higher female child mortality in Kerala is corroborated by several data sources. According to recent Sample Registration System (SRS) data, under-five mortality is higher for girls than for boys in every State of India, including States such as Kerala. So this could definitely be contributing to the decline in child sex ratio, but may have to be interpreted keeping in mind the very small number of child deaths overall.

But the other part of the question is, is there not an abnormality in the sex ratio at birth too? Can we say with confidence that there is no abnormality? This is something which we need to pursue further. The data on sex ratio at birth, even if we are confident about it, will have to be corroborated with other data sources (in order to rule out the sex-selective abortion angle). Moreover, studies indicate that the sex ratio at birth is not a universal constant but can vary and sometimes vary very abnormally without deliberate human intervention. So we will probably have to wait and watch before jumping to any conclusion.

So, is it really a problem of pre-birth sex determination or abnormal sex ratio at birth without deliberate human intervention? Or is it something that is happening post-birth? This doubt is still there. It has not been resolved by the study.

An important result seems to be that a decline in child sex ratio occurs in contiguous taluks and that the trend may be spreading.

That was the most intriguing finding. If that is happening, then one has to seriously examine the sex-selective abortion angle: because it is only technology that catches on like that. If there are two possible components, abortion and mortality, then mortality cannot suddenly happen in contiguous regions unless there were epidemics. So then, the contiguity finding challenges you to look at whether the practice of sex-selective abortions is catching on and there is a general sense of, say, it is okay to do it, like people learning from one another. Contiguity patterns have been observed elsewhere, in increase in family planning acceptance in contiguous areas. They call that ‘the demonstration effect’. If the contiguity that they observed in the study can be proved beyond doubt, then I would ask them to relook at their Sex Ratio at Birth (SRB), look at other data sources and examine the abortion angle rather than get into the mortality angle.

If, on the other hand, the issue is one of mortality, then we will have to pursue various hypotheses that have been put forth about what causes it. Why are more girls dying, especially at such a low level of mortality? That is a big question for researchers.

The other big thing is that although sex ratio at birth in Kerala has been changing, it has been changing still only within the normal range. In fact, the sex ratio at birth in Kerala has improved from 2001-03 to 2006-08, as SRS data show. What does it mean? Does it mean earlier there was sex-selective abortion and now it has stopped? Or is it that this is just happening at random? Also, this is another reason to ask whether the vital registration data used in the study is reliable.

This is why I say it is still intriguing, because, from this, it may not seem like the problem lies at birth, one because the sex ratio at birth seems to be improving, secondly, even when it was not improving, it was not so bad and was well within a range that is considered normal.

So the authors of the study could be right when they claim the sex ratio at birth is within the normal range and in concluding that there is no issue of sex-selective abortions in Kerala?

They may be right, but if they are right what are we observing? What explanation can you give [for female children dying in the 0-6 age group]? I have seen a lot of discrimination of female children at many places, but Kerala does not seem to be a place where that may be happening blatantly enough to cause death. Because that only happens in places where resources are allocated so sparsely that the child dies. For ascertaining whether something like that is happening or not we need to look at the cause of death. Overall, we also have to look at how many deaths are actually taking place. But we have not done that exercise.

I did a work for the WHO in 1983 and at that time in whichever country we found excess female mortality in childhood, we looked at causes of death. And we found that under-nutrition-related causes, communicable-diseases-related causes etc. were more for the girls. So you could say that it is most likely the lack of adequate nutrition and medical attention that has led to it.

These are several hypotheses to work on. Instead of looking at sex ratios further and further, it is better to look at cause of death, age at death, is it happening immediately after birth, within a month, or, subsequently, after one year? These are areas that need much further investigation and yes, some funding for research as well.

Have you come across any evidence that sex-selective abortions may be taking place anywhere in Kerala?

I have never seen any evidence. There is not even anecdotal evidence being written about. But some people working in the prevention of sex-selection campaign say that it is a problem but it is not being adequately studied. It is very difficult to ascertain because the usual methods used in other places would not work in Kerala. For example, in many other States, they see a link between the increase in the number of ultrasound scanning centres and the fall in sex ratios at birth and say, therefore, that it must be because of an increase in sex-selective abortions. In Kerala, however, scan centres have increased because people are overusing the facility as part of routine antenatal care to ascertain the normal progress of pregnancy. So the demand has gone up and it will be very difficult to say it reflects a general desire for sex determination or abortion.

But how does then one go about finding out the truth?

In Kerala (and Tamil Nadu, and so on), use of abortion is pretty high. One reason is they want a small family, but they are not using spacing methods. So what other method will they use? Obviously, it is abortion. But where abortion use is generally high it is very difficult to make the necessary connections to find out whether it is sex-selective abortion. The other option is to interview women and find out through discussions. But to my knowledge, such questioning has not yielded results because it is a State where people are highly aware of the legal implications, that it is a crime, and hence would not say the truth.

But there is neglect of the girl child in Kerala?

This is very difficult to say. Discrimination of the female is definitely happening. The point is, is it so severe as to cause death? Definitely there is abuse; there is data from a study at the Achutha Menon Centre by Joy Elamon on how immunisation of girls was actually less than that of boys. Some of those things have been observed. It is not as much as in the other States, but it exists.

Are you saying that discrimination of the girl child is a reality in the State?

I do not know. What I am saying is here, first of all every child is a precious child because of the low fertility pattern in Kerala. So is there a situation in which investment in the girl child becomes difficult for the parent? I have not seen any evidence of discrimination that is severe. Definitely discrimination in terms of putting your son in engineering college and your daughter in a correspondence course is very visible. But still, it is not as if the parents stopped her from school. They gave her an education, but relatively less investment in terms of option. So nobody can say there is equal treatment. The more resource constraint there is, the more that kind of choice is forced on a family.

So, finally, is it really the birth data that is becoming important here and needs to be explored further to understand the situation?

We have to be cautious of the validity of sources of data we use. The study has used birth registration data for getting the sex ratio at birth. Since there is very high birth registration in Kerala, it is considered a very reliable source of data. But some researchers have found there is a fair amount of under-registration of births in Kerala (though much less than in other States)—I think up to 10 per cent or 15 per cent or so of under-registration. If there is no biased reporting—because some earlier studies from other States say that people won’t report the birth of the girl, but only the boy—then it still should not matter. But if there is biased reporting and they do not report the girls, but only the boys, then that could be a source of error.

I think they have to look at multiple sources of birth data, may be look at the Census data, SRS data, and birth registration data and then come to a conclusion. And probably look at five or six big hospitals in a district where a large number of births happen in the State and see what the sex ratio is at birth. If we think that more than 60 per cent of the births are taking place in these five or six hospitals, then just monitoring those five hospitals should tell us what the situation is really. They have to pursue further lines of inquiry to be able to give any conclusive policy recommendations.

Otherwise we would not know which way to go and what to make of all this.

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