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Gender inequity in child survival: travails of the girl child in rural north India
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Könsskillnader i barnöverlevnad : flickors utsatthet på landsbygden i norra Indien (Swedish)
Abstract [en]

Background: While substantial progress has been made globally towards achieving United Nations Millennium Development Goal 4 (MDG 4) on child mortality, the decline is not sufficient to reach the targets set for 2015. The South Asian region, which includes India, was to achieve the MDG 4 target of 39 deaths per 1000 live births by 2015 but was estimated to have reached only 61 by 2011. A part of this under-achievement is due to the gender-differentials in child mortality in South-Asia. The inherent biological advantage of girls, reflected inlower mortality rates as compared to boys globally, is neutralized by their sociocultural disadvantage in India. The availability of technology for prenatal sex determination has promoted sex-linked abortions. Current government efforts include a law that regulates the use of ultrasound and other diagnostic techniquesfor prenatal testing of sex and a conditional cash transfer (CCT) scheme thatinvests a certain amount of funds at the birth of a girl child to attain maturity when the girl turns 18 years of age. This thesis describes the trends in genderspecific mortality during the period 1992-2011 and gender differentials in causes of death among children (paper I), compares gender differentials in child survivalby socio-economic status of the family (paper II), explores the contribution of non-specific effects of diphtheria-tetanus-pertussis (DTP) vaccination to the excess mortality among girls (paper III), and evaluates the impact of CCT schemes of the government and explores community attitudes and practices related to discrimination of girls (paper IV).

Methods and Results: This study is set in Ballabgarh Health and DemographicSurveillance System (HDSS) of Haryana State in North India that covered a population of 88,861 across 28 villages in 2011. This study uses the electronic database that houses all individuals enumerated in the HDSS for the period 1992-2011 along with other demographic, socio-economic and health utilization variables. Sex ratio at birth (SRB) was adverse for girls throughout the study period, varying between 821 to 866 girls per 1000 boys. Overall, under-five mortality rates during the period 1992-2011 remained stagnant due to the increasing neonatal mortality rate and decreasing mortality in subsequent age groups. Mortality rates among girls were 1.6 to 2 times higher than boys during the post-neonatal period (1-11 months) as well as in the 1-4 year age group. Girls reported significantly higher mortality rates due to prematurity (relative risk of 1.52; 95% CI = 1.01-2.29); diarrhoea (2.29;1.59-3.29), and malnutrition (3.37; 2.05-5.53) during 2002-2007. The SRB and neonatal mortality rate were consistently adverse for girls in the advantaged groups. In the 1-36 month age group, girl children had higher mortality than boys in all SES groups. The age at vaccination for and coverage with ivabstractBacillus Calmette–Guérin, DTP, polio and measles vaccines did not differ by sex. There was significant excess mortality among girls as compared to boys in the period after immunization with DTP, for both primary (hazard ratio of 1.65; 95% CI 1.17-2.32) and DTPb (2.21; 1.24-3.93) vaccinations until the receipt of the next vaccine. No significant excess mortality among girls was noted after exposure to BCG (1.06; 0.67-1.67) or measles (1.34; 0.85-2.12) vaccine. A community survey showed poor awareness of specific government schemes for girl children. Four-fifths of the community wanted government to help families with girl children financially. In-depth interviews of government programme implementers revealed the themes of “conspiracy of silence” that was being maintained by general population, underplaying of the pervasiveness of the problem coupled with a passive implementation of the programme and “a clash between politicians trying to cash in on the public sentiment of need for subsidies for girl children and a bureaucratic approachof accountability which imposed lot of conditionalities and documentations to access these benefits”. While there has been some improvement in investment in girl children for immunization and education during the period 1992 to 2010, these were also seen among boys of the same houses and daughters in-laws who come from outside the state where such schemes are not in place.

Conclusions: In the study area, girl children continue to be disadvantaged a tall periods in their childhood including in utero. In the short run, empowerment of individuals by education and increasing wealth without a concomitant change in culture of son-preference is harmful as it promotes the use of sex determination technology and female feticide to achieve desired family size and composition. There is a need to carefully review the use of health-enhancing technologies including vaccines so that they do not cause more harm to society. Current government efforts to address the gender imbalance are not working, as these are not rooted in a larger social context.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2013. , 89 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1600
Keyword [en]
Conditional cash transfers, girl child, inequities, gender, prejudice, mortality, non-specific effects, sex, socio-economic, vaccines
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-80254ISBN: 978-91-7459-731-8 (print)OAI: oai:DiVA.org:umu-80254DiVA: diva2:648011
Public defence
2013-10-11, Sal 135, by 9A, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2013-09-20 Created: 2013-09-12 Last updated: 2015-04-29Bibliographically approved
List of papers
1. Temporal trends and gender differentials in causes of childhood deaths at Ballabgarh, India: need for revisiting child survival strategies
Open this publication in new window or tab >>Temporal trends and gender differentials in causes of childhood deaths at Ballabgarh, India: need for revisiting child survival strategies
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2012 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 12, 555- p.Article in journal (Refereed) Published
Abstract [en]

Background: Relating Information on causes of deaths to implementation of health interventions provides vital information for program planning and evaluation. This paper from Ballabgarh Health and Demographic Surveillance System (HDSS) site in north India looks at temporal trends and gender differentials in the causes of death among under-five children.

Methods: Data on causes of death for 1972-74, 1982-84, 1992-94, 2002-04 were taken from existing HDSS publications and database. Physicians' assigned causes of death were based on narratives by lay health worker till 1994 and later by verbal autopsy. Cause Specific Mortality Fractions (CSMF) and Cause Specific Mortality Rates (CSMR) per 1000 live births were calculated for neonatal (<1 month) and childhood (1-59 months) period. Gender difference was estimated by calculating ratio of CSMR between girls and boys. Available information on coverage of childhood interventions in the HDSS was retrieved and compiled.

Results: The CSMF of prematurity and sepsis was 32% and 17.6% during neonatal period in 2002-04. The share of infections in all childhood deaths decreased from 55.2% in 1972-74 to 43.6% in 2002-04. All major causes of mortality (malnutrition, diarrhea and acute lower respiratory infection) except injuries showed a steep decline among children and seem to have plateued in last decade. Most of disease specific public health interventions were launched in mid eighties. Girls reported significantly higher mortality rates for prematurity (RR 1.52; 95% CI 1.01-2.29); diarrhea (2.29; 1.59 - 3.29), and malnutrition (3.37; 2.05 - 5.53).

Conclusions: The findings of the study point out to the need to move away from disease-specific to a comprehensive approach and to address gender inequity in child survival through socio-behavioural approaches.

Keyword
Child survival, Neonatal mortality, Child mortality, Cause of death, Gender, India
National Category
Environmental Health and Occupational Health
Identifiers
urn:nbn:se:umu:diva-60342 (URN)10.1186/1471-2458-12-555 (DOI)000308422800001 ()
Available from: 2012-11-06 Created: 2012-10-09 Last updated: 2017-12-07Bibliographically approved
2. Socioeconomic development and girl child survival in rural North India: solution or problem?
Open this publication in new window or tab >>Socioeconomic development and girl child survival in rural North India: solution or problem?
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2013 (English)In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 67, no 5, 419-426 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Socioeconomic development has been considered as a solution to the problem of sex differentials at birth and under-five mortality. This paper analyses longitudinal data from the Ballabgarh Health and Demographic Surveillance System (HDSS) site in north India to check its veracity.

METHODS: A cohort of children born between 1 January 2006 and 31 December 2011 at Ballabgarh HDSS were followed till death, emigration, 3 years of age or end of the study. Socioeconomic status (SES) was measured by caste, parental combined years of schooling and wealth index and divided into low, mid and high strata for each of them. Sex ratio at birth (SRB) was reported as the number of girls per 1000 boys. The Kaplan-Meier survival curves were drawn and a Cox Proportional HR of girls over boys was estimated.

RESULTS: A total of 12 517 native born children (25 797 child years) were enrolled of which 710 died (death rate of 56.7/1000-live births and 27.5/1000 child-years. Socioeconomically advantaged children had significantly lower death rates. The SRB (10-16% lower) and neonatal death rate were consistently adverse for girls in the advantaged groups by all the three indicators of SES. The first month survival rates were better for girls in the lower SES categories (significant only in caste (HR 0.58; 0.37 to 0.91). High SES categories consistently showed adverse survival rates for girls (HR of 1.22 to 1.59).

CONCLUSIONS: Better socioeconomic situation worsened the sex differentials, especially at birth. Therefore, specific interventions targeting gender issues are required, at least as a short-term measure.

Place, publisher, year, edition, pages
BMJ Publishing Group, 2013
National Category
Environmental Health and Occupational Health Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-66874 (URN)10.1136/jech-2012-201846 (DOI)23364028 (PubMedID)
Available from: 2013-03-06 Created: 2013-03-06 Last updated: 2017-12-06Bibliographically approved
3. Non-specific sex-differential effect of DTP vaccination may partially explain the excess girl child mortality in Ballabgarh, India.
Open this publication in new window or tab >>Non-specific sex-differential effect of DTP vaccination may partially explain the excess girl child mortality in Ballabgarh, India.
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2013 (English)In: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 18, no 11, 1329-1337 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To test the hypothesis that a gender differential exists in the effect on child mortality of BCG, DTP, measles vaccine as administered under programme conditions in Ballabgarh HDSS area.

METHODS: All live births in 28 villages of Ballabgarh block in North India from 2006 to 2011 were followed until 31 December 2011 or 36 months of age whichever was earlier. The period of analysis was divided into four time periods based on eligibility for vaccines under the national immunisation schedule (BCG for tuberculosis, primary and booster doses of diphtheria-tetanus-pertussis and measles). Cox proportional hazards regression was used to assess the association between sex and risk of mortality by vaccination status using age as the timescale in survival analysis and adjusting for wealth index, access to health care, the presence of a health facility in the village, parental education, type of family, birth order of the child and year of birth.

RESULTS: 702 deaths (332 boys and 370 girls) occurred among 12 142 children in the cohort in the 3 years of follow-up giving a cumulative mortality rate of 57.5 per 1000 live births with 35% excess girl child mortality. Age at vaccination for the four vaccines did not differ by sex. There was significant excess mortality among girls after immunisation with DTP, for both primary (HR 1.65; 95% CI:1.17-2.32) and DTPb (2.21; 1.24-3.93) vaccinations. No significant excess morality among girls was noted after exposure to BCG 1.06 (0.67-1.67) or measles 1.34 (0.85-2.12) vaccine.

CONCLUSION: This study supports the contention that DTP vaccination is partially responsible for higher mortality among girls in this study population.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-84009 (URN)10.1111/tmi.12192 (DOI)24103109 (PubMedID)
Available from: 2013-12-12 Created: 2013-12-12 Last updated: 2017-12-06Bibliographically approved
4. "No one says 'No' to money": a mixed methods approach for evaluating conditional cash transfer schemes to improve girl children's status in Haryana, India.
Open this publication in new window or tab >>"No one says 'No' to money": a mixed methods approach for evaluating conditional cash transfer schemes to improve girl children's status in Haryana, India.
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2014 (English)In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 13, no 1, 11- p.Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: Haryana was the first state in India to launch a conditional cash transfer (CCT) scheme in 1994. Initially it targeted all disadvantaged girls but was revised in 2005 to restrict it to second girl children of all groups. The benefit which accrued at girl attaining 18 years and subject to conditionalities of being fully immunized, studying till class 10 and remaining unmarried, was increased from about US$ 500 to US$ 2000. Using a mixed methods approach, we evaluated the implementation and possible impact of these two schemes.

METHODS: A survey was conducted among 200 randomly selected respondents of Ballabgarh Block in Haryana to assess their perceptions of girl children and related schemes. A cohort of births during this period was assembled from population database of 28 villages in this block and changes in sex ratio at birth and in immunization coverage at one year of age among boys and girls was measured. Education levels and mean age at marriage of daughters were compared with daughters-in-law from outside Haryana. In-depth interviews were conducted among district level implementers of these schemes to assess their perceptions of programs' implementation and impact. These were analyzed using a thematic approach.

RESULTS: The perceptions of girls as a liability and poor (9% to 15%) awareness of the schemes was noted. The cohort analysis showed that while there has been an improvement in the indicators studied, these were similar to those seen among the control groups. Qualitative analysis identified a "conspiracy of silence" - an underplaying of the pervasiveness of the problem coupled with a passive implementation of the program and a clash between political culture of giving subsidies and a bureaucratic approach that imposed many conditionalities and documentary needs for availing of benefits.

CONCLUSION: The apparent lack of impact on the societal mindset calls for a revision in the current approach of addressing a social issue by a purely conditional cash transfer program.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-86007 (URN)10.1186/1475-9276-13-11 (DOI)000332939700002 ()24484583 (PubMedID)
Available from: 2014-02-14 Created: 2014-02-14 Last updated: 2017-12-06Bibliographically approved

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