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Sex-Selective Investments in Prenatal Care in India, China, and Bangladesh

Development Challenge

Preference for male children remains a significant issue in South and Southeast Asia. Widespread sex-selection through abortions and neglect has resulted in an estimated 30 million to 70 million “missing” women in India and China alone, significantly skewing sex ratios in this region.  In this study, researchers examine a different kind of sex-selection – whether parents invest less in prenatal care when pregnant with a girl, as detected through ultrasound imaging. The researchers conclude that discrimination in the womb contributes not only to gender imbalance but also to girls’ long-term health, as maternal inputs during pregnancy affect outcomes such as neonatal survival (survival beyond the first 28 days) and birth weight.1


Sex-based discrimination is quite prevalent in India. In 2011, there were 914 girls for every 1,000 boys aged 0 to 6 in India, compared to the global ratio of 952 girls per 1,000 boys.2  While this study primarily focuses on India, it also includes analysis of China and Bangladesh.  Prior research has attempted to explain the skewed sex ratio through various forms of post-birth discrimination, including variation in vaccinations rates, breastfeeding behavior, allocation of household resources, and parental time allocation.3  The few studies devoted to prenatal discrimination have been limited to sex-selective abortions.4  By focusing on prenatal care, this study addresses an important gap in understanding the mechanisms for and consequences of sex selection.

Evaluation Strategy

The purpose of this study was to determine whether sex-selective prenatal care occurs in South and Southeast Asia, particularly in India. The researchers assume that under equal treatment, the sex of a fetus should not affect prenatal investments.  Thus, disproportionate investments in prenatal care by gender strongly suggest the prevalence of sex discrimination. Difference-in-differences and simple difference methodologies are applied in this study using microdata from the National Family Health Survey (NFHS) and Reproductive and Child Health surveys in India; Demographic and Health Surveys (DHS) in Bangladesh, and the China Health and Nutrition Survey in China. In India, data from the pre-ultrasound period (before 1992) is used to tackle issues of selective recall and selective reporting of ultrasounds. 

Within each country (India, Bangladesh, and China), researchers used a sample of women aged 15 to 49 who had been married at least once. Only births that occurred during the five years prior to the survey were considered.  Key outcomes of interest included the number of prenatal care visits, neonatal tetanus shots (given to pregnant women to prevent neonatal tetanus), and iron supplements received during pregnancy, all of which are strongly correlated with neonatal survival, and are strong indicators of parental investment.5  Noting the sex of the child, women were asked at varying points after delivery about the type of prenatal care received while pregnant. Researchers also recorded whether women received an ultrasound, and whether they chose to deliver in a health facility or at home.

Results and Policy Implications

The study found that women in all three countries were more likely to attend multiple prenatal care visits and receive neonatal tetanus shots when pregnant with a male.  Notably, researchers found that women who did not receive an ultrasound did not obtain more prenatal care when pregnant with a male, suggesting that sex-based discrimination is absent when the sex of the fetus is unknown.

In India, women who were pregnant with a male were found to be 1.8 percentage points more likely to make at least two prenatal visits (over a mean of 61 percent).  Northern states5 exhibit a higher level of son preference; women in this region were 2.9 percentage points more likely to attend prenatal care at least twice when pregnant with a male (over a mean of 52.1 percent). Ultrasound technology is also more prevalent in northern states, where its use expanded rapidly after being introduced to India in the 1990s.6   Among women whose previous births were majority female, those pregnant with a male were 2.1 percentage points more likely to make at least two prenatal visits (over a mean of 62.8 percent). 

Bangladeshi women were 2.8 percentage points more likely to get a tetanus shot when pregnant with a male. In China, women were 4.6 percentage points more likely to receive prenatal care when pregnant with a male. In the Punjab region of Pakistan, women were 4.8 percentage points more likely to consume iron pills when pregnant with a male compared to 2.6 percentage points for Pakistan nationally. 

These results illustrate a need for prenatal care in South and Southeast Asia to address sex preference, not only to avert further skewing of sex ratios in the region but also for the long-term health and well-being of girls.

1 Gortmaker, Steven L. (1979), “The effects of prenatal care upon the health of the newborn,” American Journal of Public Health, 69(7), 653; and Bharadwaj, Prashant and Juan Eberhard (2010) “Atmospheric Air Pollution and Birth Weight,” Working Paper.

India, Registrar General, 2011. Provisional Population Totals, Paper 1 of 2011, Census of India 2011 Series-1 India. Delhi: Office of the Registrar General and Census Commissioner, India

Oster, Emily (2009), “Proximate Causes of Population Gender Imbalance in India,” Demography; Jayachandran, Seema  and Ilyana Kuziemko (2011), “Why do mothers breastfeed girls less than boys? Evidence and implications for child health in India,” Quarterly Journal of Economics; Pitt, Mark and Mark Rozenzweig (1990) “Estimating the intrahousehold incidence of illness: Child health and gender-inequality in the allocation of time,” International Economic Review, 31(4), 969–989; and Barcellos, Silvia Helena, Carvalho, Leandro Siqueira and Adriana Lleras-Muney (2010), “Child Gender and Parental Investments in India: Are Boys and Girls Treated Differently?,” Mimeo, UCLA.

Portner, Claus (2010  “Sex Selective Abortions, Fertility and Birth Spacing,” Working Paper; Meng, Lu (2010) “Prenatal Sex Selection and Missing Girls in China: Evidence from the Diffusion of Diagnostic Ultrasound,” Working Paper; and Bhalotra and Cochrane (2010), “Where have all the young girls gone? On the rising trend in sex selection in India,” University of Bristol Working Paper.

These include Punjab, Haryana, Himachal Pradesh, Uttar Pradesh, and Rajasthan.

Bhalotra and Cochrane (2010), “Where have all the young girls gone? On the rising trend in sex selection in India,” University of Bristol Working Paper.

Photo credit: Adarsh Antony via Flickr