BMJ  2003;327:126 (19 July), doi:10.1136/bmj.327.7407.126

Paper

Community based retrospective study of sex in infant mortality in India

¹ Department of Community Medicine, St Stephen's Hospital, Tis Hazari, Delhi 110054, India, ² Department of Biostatistics, All India Institute of Medical Science, New Delhi 110029, India, ³ Department of Paediatrics, St Stephen's Hospital, Tis Hazari

Abstract

Objective To determine whether the imbalance in the sex ratio in India can be explained by less favourable treatment of girls in infancy.

Design Analysis of results of verbal autopsy reports over a five year period.

Setting Community health project in urban India.

Main outcome measures Deaths from all causes in infants aged less than 1 year.

Results The sex ratio at birth was 869 females per 1000 males. The mean infant mortality was 1.3 times higher in females than in males (72 v 55 per 1000). Diarrhoea was responsible for 22% of deaths overall, though twice as many girls died from diarrhoea. There were no significant differences in the numbers of deaths from causes such as birth asphyxia, septicaemia, prematurity, and congenital anomalies. 10% of deaths there was no preceding illness and no satisfactory cause was found. Three out of every four such deaths were in girls.

Conclusions The excess number of unexplained deaths and deaths due to treatable conditions such as diarrhoeal disease in girls may be because girls are regarded and treated less favourably in India

Introduction

According to the 2001 Indian census there are only 933 females per 1000 males in India.¹ Ordinarily women outnumber men, possibly because the extra X chromosome they carry makes them less susceptible to infectious diseases and protects them against sex linked recessive disorders.²

The practice of antenatal selection and termination of female pregnancies in India has persisted,³ despite the banning of sex determination tests under the Pre Natal Diagnostic Techniques Act (PNDT) 1994.⁴ After birth mortality is also higher in female infants, girls, and young women.⁵ Various studies have previously shown that compared with boys, female children are often brought to health facilities in more advanced stages of illness, are taken to less qualified doctors when they are ill, and have less money spent on medicines for them.⁶ A study in Punjab showed that during the first two years of a child's life, parents spent 2.3 times more on health care for sons than for daughters.⁷

In a community based study we looked at the causes of infant death in girls compared with in boys. If there is discrimination and neglect, there should be an increase in deaths in the neglected sex due to causes that would not be fatal with appropriate care, whereas death rate for diseases with grave prognosis would be equal in both the sexes.

Methods

For the past 20 years the community health department of St Stephen's Hospital has been providing comprehensive health care in three socioeconomically deprived areas of Delhi—Sunder Nagari, Tahirpur, and Amar Colony—with a combined population of about 64 000 people. These areas on the outskirts of the city are relocation settlements started 20 years ago. The average per capita income of a household in these areas is about 600 rupees per month (£8, $13, €11). The average crude birth rate in the area for the five years between 1997 and 2001 was 22.3 live births per 1000 population. The population is 66% Hindu and 34% Muslims, and the crude birth rates in the two communities in 2001 were 17.92 and 22.24 live births per 1000 population respectively.

The midwives in the community health department have been working in the community for the past 7-10 years and their acceptability and rapport with the families is high. They provide health education and collect information on births, deaths, pregnancy, immunisation, and family planning. This information is initially hand recorded and then entered into a computerised management information system. Here we are analysing data for the five year period from January 1997 to December 2001.

Verbal autopsies are used for finding out the cause of each death. Every month the midwives discuss any cases with a visiting paediatrician. Where information seemed inadequate, the house is revisited. The record of deaths maintained by the midwives forms the basis of this study.

We examined the number of live born infants and infant deaths each year by sex and cause of death. All cases of death of children reported as sudden and without any preceding illness were categorised as "unexplained deaths." We categorised cases in which the cause of death could not be ascertained—for example, when the family had moved out of the area—as "data not available." We examined overall infant mortality for each of the five years under study and compared overall mortality and cause specific mortality by sex.

Results

There were 7012 live births, 3752 boys and 3260 girls. The sex ratio at birth in the area was 869 girls:1000 boys. There were 442 deaths in children under the age of 1 year, 234 girls (53%) and 208 boys (47%). The average mortality for the period was 63 per 1000 live births. The figure shows the infant mortality each year for the two sexes. The mean mortality for girls was 1.3 times that of the boys (72 v 55 per 1000).

View larger version (25K): [in this window] [in a new window]   Infant mortality by year in study area

 

There was significant difference in mortality between girls and boys for diarrhoea and unexplained deaths (table, P < 0.05). There was no significant difference in deaths due to less preventable and less treatable conditions like birth asphyxia, immaturity, septicaemia, and congenital anomalies. Half of the unexplained deaths (22/44) occurred in the first month of life, and 19 of these 22 deaths were among females.

View this table: [in this window] [in a new window]   Cause of death in 442 infants who died aged 1 year

 

For diarrhoeal diseases the cause specific mortality in female infants was twice that in male infants. For congenital anomalies and birth asphyxia it was higher in male than in female infants, though not significantly so.

We also looked at the cause specific mortality in Hindu and Muslim communities. The average monthly per capita income was 679 rupees in Hindus and 423 rupees in Muslims. There was no significant difference in the cause specific mortality in the two communities for preventable and treatable causes or less preventable causes.

Overall the mean per capita income of families in which infants had died from diarrhoea was the lowest at 409 rupees, and in families in which the deaths were unexplained was the highest at 537 rupees.

Discussion

Infant mortality in girls
Mortality in female infants was 1.3 times higher than in male infants, and most sudden unexplained deaths with no preceding history of illness were in girls. Discrimination, which may lead to increased mortality among female children, has been the subject of many previous studies. The World Health Organization has reported that the sex disparities in health and education are higher in South Asia, including India, than anywhere else in the world.⁸

The principal causes of infant mortality in India are low birth weight, birth injury, diarrhoeal diseases, and acute respiratory infection.⁹ The numbers of male and female infants dying of birth asphyxia, septicaemia, immaturity, and congenital anomalies were matched and not significantly different. However for the preventable and treatable illness of diarrhoea, there were twice as many deaths among girls compared with boys.

Verbal autopsy is a standard, well documented, and validated method of finding cause of death in a developing country like India.^10–12 Due to paucity of resources, the cause of every death occurring outside a hospital or medical centre cannot be certified after a postmortem examination. In our study, the information collected by the auxiliary nurse midwives was scrutinised during monthly meetings with the paediatrician before the cause of death was agreed. Most data were collected within one month of the date of death, and was not too long to influence recall.

Unexplained deaths
In our group of unexplained deaths, parents were not able to give a satisfactory explanation for death or give a history of any illness. Most deaths in this group were in female infants and most occurred soon after birth. Could such deaths be an extension into the early neonatal period of female feticide?

What is already known on this topic There are more men than women in India Sex discrimination and bias in favour of male children results in selective termination of female pregnancies Mortality is high in female infants, girls, and young women What this study adds There is an excess of female deaths due to easily treatable conditions There are a large number of unexplained female deaths, which may be considered as deaths under suspicious circumstances

The mean per capita income of families in which infants died of unexplained causes was higher than families in which infants dies from diarrhoeal diseases. Therefore it seems that any sex discrimination cannot be explained by extreme poverty. Booth et al found that fetal sex determination was more common among families with higher incomes.¹³ The state of Punjab, which has one of the highest per capita income in India (19 001-22 000 rupees per year) has one of the lowest sex ratios in the country (874 females:1000 males), while poor states like Bihar and Orissa (4001-7000 rupees per capita income) have sex ratios of 921 and 972 females per 1000 males, respectively.¹

As this was a retrospective study we could not look at the circumstances surrounding these unexplained deaths. Further community based prospective studies are needed to examine these issues. Though the 1994 act attempted to alter the adverse sex ratio by banning sex determination tests, this cannot change the attitudes of people towards female infants. Improved access to health care and education of health professionals to pay attention to girls would be beneficial.

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This is an abridged version; the full version is on bmj.com

Contributors: See bmj.com

Funding: None.

Competing interests: None declared.

References

1. Census of India, 2001. Provisional population totals. www.censusindia.net (accessed 15 Apr 2003).
2. Lopez AD, Ruzicka LT, Waldron I. Sex differentials in mortality. Canberra: Australian National University, 1983.
3. Kulkarni S. Sex determination tests in India: a survey report. Radical Journal of Health 1986;1: 99.
4. Centre for Enquiry into Health and Allied Themes (CEHAT) and others v/s Union of India and others. Law Journal Supreme Court Cases 2001;5: 577-80.
5. Ghosh S. The female child In India: a struggle for survival. Bull Nutr Found India 1997;8: 4.
6. Chatterjee M. A report on Indian women from birth to twenty. New Delhi: National Institute of Public Cooperation and Child Development, 1990.
7. Das Gupta M. Selective discrimination against female children in rural Punjab, India. Popul Dev Rev 1987;13: 77-100.
8. Claeson M, Bos ER, Mawji T, Pathmanathan I. Reducing child mortality in India in the new millennium. Bull World Health Organ 2000;78: 1192-9.[Web of Science][Medline]
9. Park K. Indicators of MCH care. In: Park's textbook of preventive and social medicine. 15th ed. Jabalpur: Banarsidas Bhanot, 1997: 370-80.
10. Bang AT, Bang RA. Diagnosis of causes of childhood deaths in developing countries by verbal autopsy: suggested criteria. The SEARCH team. Bull World Health Organ 1992;70: 499-507.[Web of Science][Medline]
11. Datta N, Mand M, Kumar V. Validation of cause of infant death in the community by autopsy. Indian J Pediatr 1988;55: 599-604.[Medline]
12. Shrivastava SP, Kumar A, Kumar Ojha A. Verbal autopsy determined causes of neonatal deaths. Indian Pediatr 2001;38: 1022-5.[Medline]
13. Booth BE, Verma M, Beri RS. Fetal sex determination in infants in Punjab, India: correlations and implications. BMJ 1994;309: 1259-61.[Abstract/Free Full Text]

(Accepted April 15, 2003)

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