Regional Workshop on Strengthening Use of

Health Information at District Level

10 12 Aug 2009
Bangkok

Presenting analyzed data and use of information

at District Health Office

Nihal Singh

Community based data collected through Nationally

representative household survey NFHS-3 in India reveals:
1.

worsening adverse sex ratio (attributed to

ultrasound diagnostic tests done for sex selective
abortions)

2.

Sex differentials in child mortality (attributed to

gender bias)

3.

Sex differentials in notification of smear positive

TB cases in age group below 14 (attributed to
gender bias)

This analysis is presented to the Gautam Budh Nagar District

Health Officer to motivate him to get analysis done of the
data from his district to determine the magnitude and pattern
of these problems.

: Analysis of data of ultrasound tests done during pregnancies,

India, 2005-06
Number of living children
mother had prior to this
pregnancy

Number of
pregnancies
With an
ultrasound
test

Sex of newborn*

Sex ratio

Male
(%)

Female
(%)

Ratio of
females to
1000 males

1 child (son)

2019

42.3

41.8

988

2 children (both sons)

207

42.0

36.8

876

2 children (1 son and 1 daughter)

798

43.1

36.0

835

2 children (both daughters)

867

55.1

31.4

570

4+ children (1 son)

201

49.7

26.8

539

1.2 million missing

females out of 27
million estimated
total births per
year in India points
towards the
clandestine
practice of female
foeticide in favour
of male child in
many parts of India
and is a major
cause for adverse
sex ratio in Indian
population.

The apparent difference in percentages of male and female outcomes at delivery of mothers
who already had two living children (either both sons or both daughters) prior to this
pregnancy is statistically significant (Chi-square = 5.660 , p 0.017).
This difference is greatest when delivery outcomes of mothers who had 4+ living children but
out of them only one being son were compared with delivery outcomes of mothers who had
only one child who was son (Chi-square = 11.538 p 0.001).
Note: * does not include pregnancies which were terminated and those still waiting for delivery
Source : National Family Health Survey (NFHS-3 2005-06, India, 2007

SPSS

Infant mortality rate by state in India, 2007

13

Kerala
Maharashtra

34

Tamil Nadu

35

Delhi

36

West Bengal

37

Punjab

43

Karnataka

47

Himachal Pradesh

47

Jharkhand

48

Jammu & Kashmir

51

Gujarat

52

Andhra Pradesh

54

India

55

Haryana

55

Bihar

58

Chhattisgarh

59

Rajasthan

65

Assam

66

Uttar Pradesh

69

Orissa

71

Madhya Pradesh

72

20

40

60

IMR per 1000 Live births

Source :

RGI, SRS Statistical Report 2007

80

100

Infant mortality rate at State level by sex in India, 2007

13
12

Kerala

35
33

Maharashtra
Tamil Nadu

36
34

Delhi

36
36

Females

37
36

West Bengal
Punjab

Males
42

45
47
46

Karnataka
Himachal Pradesh

45

49

Jharkhand

49
47

Jammu & Kashmir

49

Gujarat

52

50

54
55
54

Andhra Pradesh
India

56
55

Haryana

56
55
58
57

Bihar

61
58

Chhattisgarh
Rajasthan

63

67

Assam

67
64

Uttar Pradesh

67

70

Orissa

72
70

Madhya Pradesh

72
72

20

40

60

IMR per 1000 Live births

Source :

RGI, SRS Statistical Report 2007

80

100

Comparison of mortality rates between boys and girls under 5 years of

age, India, 1992 2006
(More girls than boys survive in neonatal period but less afterwards during childhood)
Neonatal mortality rate
(first month of life)

Child mortality rate (1 - 4

years of age)

Under-five mortality rate

<5 years of age

Reference year

Boy

Girl

Boy

Girl

Boy

Girl

1992-93

57

48

29

42

115

122

1998-99

51

45

25

37

98

105

2005-06

41

37

14

23

70

79

Sources:
1.National Family Health Survey (NFHS-1),1992-93
2.National Family Health Survey (NFHS-2),1998-99
3.National Family Health Survey (NFHS-3),2005-06

Study for further investigation

of the causes is warranted

Consistently lower neonatal mortality for female than

male shows female hardiness and biological advantage,
which in later years is compromised most likely by
social values as evident from higher female child
mortality. It points towards lower investment of
resources in girl children (nutritionally disadvantaged,
less medical and other care) leading to greater ill health.

M ore girls than boys survive in neonatal period but less afterwards during childhood
Child mortality rate
(1 - 4 years of age)

60
50
40
30
20
10
0
1992-93

1998-99
Boy

2005-06
Girl

Deaths per 1000 livebirths

Deaths per 1000 livebirths

Neonatal mortality rate

( first month of life)
50
40
30
20
10
0

1992-93

1998-99
Boy

2005-06
Girl

Probability of dying at different places as a function of age of the deceased

child

At all age levels girls were

more likely than boys to die at
home and less in hospital or
during transport.

Source : Abay Asfaw , Stephan Klasen , and Francesca Lamanna; Intra-household gender disparities
in children's medical care before death in India, 2007, IZA DP No. 2586, International Food Policy
Research Institute, A.Asfaw@cgiar.org .

Health Problem: Child mortality is higher in females than in males in India

Gender Related Considerations
Mortality related
considerations
Risk factors and
vulnerability

Biological factors

Socio-cultural
factors

Access to, and control over resources

known higher level

of immunity and
hardiness of female
(X chromosome) of
girl child because of
which she survives
more in first month
of life after birth
than male child on
average.

But after neonatal

period girl interact
with environment as
the male child but
not cared and
protected as much
as male child. She
faces more risk
factors and become
vulnerable to
infections

She is often not at par with male sibling in family

with food intake and care consequently in
nutritional status and affection.
Male child is considered asset to family while
female a liability in most part of Indian society
(dowry/has to go away someday)

Access and use of

health services

She is inadequately immunized against childhood

diseases

Health seeking
behaviour

Parents often ignore the signs and symptoms of

sickness of girl child

Treatment options

She is often treated with home remedy and if

taken to clinic, her treatment is often incomplete

Experiences in health
care settings
Health and social
outcomes and
consequences

If survived the childhood, she is more likely than

boys to remain vulnerable immo compromised for
rest of her life and face disablement

Notified new smear-positive TB cases by age and sex in India,

2007
180

Number of cases per 100 000 population

160

140

120

Male
Female

100

80

60

40

20

0
0-14

15-24

25-34

35-44

45-54

55-64

65+

Age group (years)

The notification rate of smear

positive TB cases in age group
below 14 years has been found
to be higher in girls than boys
Source :

Tuberculosis Control in the South-East Asia Region, Annual Report 2009,

Until further cause and effect

study is done, one
explanation of this could be
that parents are more likely
to take young girls to health
facility than boys with the
sole concern of social
stigma that girls are of about
the age to marry them off
and if not treated would be
shame to family. Other
reason of higher prevalence
of TB in female children
could be that they get
exposed to TB more than
male children in helping
family member who may
have TB.

Sex differential trend in new smear positive TB rates in age

group below 14 years, India, 2000 - 2007
4.5

Smear-positive TB rate per 100,000 population

4.0

3.5

Though the TB
notification rates in this
age group are low (<5
per 100,000) for both
sexes, the gap in rates
from 2000 to 2007 has
been widening and was
twice as much among
girls than boys in 2007
(p<0.01).

Female
Male

3.0

2.5

2.0

1.5

1.0

0.5

0.0
2000

2001

2002

2003

2004
Year

Source :

Data file of TB Unit, WHO/Searo, 2007

2005

2006

2007

Further study in India to investigate gender disparity

in new smear positive TB rates in children below 14
years of age is warranted similar to the one done for
adults aged 14+ years in south India.