Guilmotto, Christophe Z., Nandita Saikia, Vandana Tamrakar et al., “Excess Under-5 Female Mortality across India: A Spatial Analysis using 2011 Census Data,” The Lancet Global Health 6, no.6 (June 2018), doi:10.1016/S2214-109X(18)30184-0

URL: www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30184-0/fulltext

Abstract

Background: Excess female mortality causes half of the missing women (estimated deficit of women in countries with suspiciously low proportion of females in their population) today. Globally, most of these avoidable deaths of women occur during childhood in China and India. We aimed to estimate excess female under-5 mortality rate (U5MR) for India’s 35 states and union territories and 640 districts.

Methods: Using the summary birth history method (or Brass method), we derived district-level estimates of U5MR by sex from 2011 census data. We used data from 46 countries with no evidence of gender bias for mortality to estimate the effects and intensity of excess female mortality at district level. We used a detailed spatial and statistical analysis to highlight the correlates of excess mortality at district level.

Findings: Excess female U5MR was 18.5 per 1000 livebirths (95% CI 13.1–22.6) in India 2000–2005, which corresponds to an estimated 239,000 excess deaths (169,000–293,000) per year. More than 90% of districts had excess female mortality, but the four largest states in northern India (Uttar Pradesh, Bihar, Rajasthan, and Madhya Pradesh) accounted for two-thirds of India’s total number. Low economic development, gender inequity, and high fertility were the main predictors of excess female mortality. Spatial analysis confirmed the strong spatial clustering of postnatal discrimination against girls in India.

Interpretation: The considerable effect of gender bias on mortality in India highlights the need for more proactive engagement with the issue of postnatal sex discrimination and a focus on the northern districts. Notably, these regions are not the same as those most affected by skewed sex ratio at birth.

Funding: None.

This study notes that the scientific literature on the estimated deficit of women in countries with suspiciously low proportions of females in their population has long identified India as a main contributor. Significantly, Guilmotto et al. (2018) note, “This deficit is increasingly due to prenatal sex selection through selective abortions, but the overall number of excess female deaths (postnatal discrimination) has not declined over the past 20 years and still accounted for half of new cases of missing women in 2010. Most excess mortality is concentrated during the first years of life, a period during which girls actually have a biological advantage over boys in terms of mortality.” One relevant observation is that prenatal sex selection—which is well studied—skews sex ratios at birth among smaller-size families; excess postnatal female deaths—which are not well studied—occur in regions of northern India where son preference and large families go together.