India’s infant mortality rate, as of 2017, is 32 for every 1,000 live births, both for males and females. However, the U5MR is starkly different—at 40.4 and 34.4 for girls and boys, respectively. A major reason for this is gender bias when it comes to breastfeeding—families that have daughters tend to wean them off breast milk relatively sooner in order to have another child, hoping for a son.
By Phalasha Nagpal
Back in the 17th century, an English statistician and geographer John Graunt studied the population of London and made an interesting discovery. He found that in the absence of any external manipulation, sex ratio at birth marginally favours males vis-à-vis their female counterparts. Studies across all human populations in subsequent years had their findings to be consistent with 105-107 males for every 100 females. On the contrary, throughout their lifetime, females have a higher survival advantage than males owing to their lower morbidity and mortality rates. This means that the average life expectancy of a female at birth and at subsequently higher age cohorts is always higher than males.
Accordingly, global statistics presented by the World Health Statistics Report 2019—published by the World Health Organisation (WHO)—adhere to this theory. On an average, male children are 11% more likely to die than their female counterparts. Meanwhile, an analysis of India’s under-five mortality rates (U5MR) paints a different picture, inconsistent with global trends. Data from the UN shows that boys have a lower U5MR than girls in India as a historical trend with a tardily closing gap. Corresponding figures at 270.8 and 40.4 for boys, and 253.3 and 34.4 for girls, for 1955 and 2017, respectively, confirm this finding. Other South Asian countries like Afghanistan and Pakistan also display such trends.
So, what causes such mortality differentials for girls in India?
In her book ‘The Endangered Sex: Neglect of Female Children in North West India’, cultural anthropologist Barbara Miller establishes a strong correlation between culture and female mortality. She shows how culture plays a role in differential treatment of children based on their gender. A substantial difference in survival outcomes for girls and boys can be explained by the concept of ‘son meta preference’ and ‘unwanted girls’. Son meta preference refers to the tendency of Indian families to keep having children till the desired number of sons are born. In his book ‘The Inner World: A Psychoanalytic Study of Childhood and Society in India’, Sudhir Kakar talks about how “an Indian bride is not fully accepted in her husband’s home till she produces a male child.”
The problem is exacerbated by the low reproductive agency of women in India. The Demographic and Health Surveys show that around 47% women do not use any form of contraception. ‘Unwanted girls’, meanwhile, are girls whose parents wanted a boy, but had a girl instead. Therefore, they keep reproducing in pursuance of their preference for a son. When the family has reproduced the desired number of sons, it results in the creation of a notional segment of ‘unwanted girls’ in the process.
The Economic Survey 2016-17 estimates the number of ‘unwanted girls’ in India at 21 million. Declining sex-selective abortion statistics is a positive development on one hand. But on the other hand, the number of girls being added to the population is considered no more than ‘collateral damage’ in the process of giving birth to a male child. These figures highlight the devastating impact of sociocultural factors on gender-based indicators.
Differentials in U5MR, deviating from biological norms, are one of the strongest indicators of the prevalent gender-discriminatory practices in India. Admittedly, when the mortality rates for girls are higher than that for boys, despite a natural advantage, it ushers in gender imbalance in the society.
The prevalence of gender discrimination in the society brings us to what Miller calls in her book ‘extended infanticide’, or the bias against the girl child—a term she coined after studying the gender differentials in India. Studies assert that this gender bias is most pronounced when it comes to breastfeeding. Public health literature shows the profound impact of breastfeeding on a child’s survival, especially in unsanitary environments. Breast milk has immunological benefits and is associated with lower morbidity levels. In fact, the WHO shows that the mortality risk for children between the age of 1-2 years doubles if the child is not breastfed.
Having said that, we must note that breastfeeding by the mother is negatively correlated with her future fertility. As a result, families that have daughters tend to wean them off breast milk relatively sooner in order to have another child—hoping for a son. Literature in the Journal of Human Ecology asserted that “birth intervals are shorter if parents have not reached their self-reported ideal number of sons.” Shorter period of breastfeeding often leaves female infants at the behest of nursing from insanitary external sources, exposing them to diseases. Besides, a subsequent pregnancy naturally takes a toll on the mother, resulting in neglect towards the girl child. A study conducted by Jean Drèze and Amartya Sen also confirms that daughters are breastfed for a relatively shorter period as compared to boys. This, in turn, is directly linked to a high risk of contracting diarrhoeal infections and acute respiratory infections, even leading to death in many cases. Each additional month of breastfeeding reduces infant mortality by six children per 1,000 live births as per the paper ‘Does breastfeeding really save lives, or are apparent benefits due to biases?’
All these factors together help us understand the impact of premature weaning off of daughters from breastfeeding. Thus, girls tend to be way more vulnerable to morbidity as well as mortality than boys. However, the impact of breastfeeding on a child’s health appears one year after birth. This is in confirmation with India’s statistics on infant mortality rates—which stand at 32 (for every 1,000 live births as of 2017) both for males and females. The differential, therefore, occurs in the form of starkly different U5MR that stand at 40.4 and 34.4 for girls and boys, respectively.
‘Why Do Mothers Breastfeed Girls Less than Boys?’ in the Quarterly Journal of Economics notes that the “differences in breastfeeding could account for 8,000 to 21,000 missing girls each year in India, explaining roughly 9% of the gender gap in child mortality.” While breastfeeding is one of the most prominent factors, vaccination and healthcare access also show evidence of son-advantage, albeit not significant. Such gender gap in breastfeeding brings forth the disparity in higher U5MR in India. A shorter period of breastfeeding due to implicit son-preference creates disparity in survival outcomes for girls. Such passive discrimination is tantamount to committing extended infanticide.
The way forward to ensuring a more gender-balanced society would require more than just State intervention. It calls for a far-reaching profound transformation in attitudes, perceptions, human values, social norms and stereotypes. Educating mothers about the importance of continuing breastfeeding during antenatal and postnatal care visits by the Accredited Social Health Activist (ASHA) workers could be the first step in this direction.