The sex selective abortion pathwaySex preference and fertility decision-making in Rajasthan, India

Abstract: The paper examines the context of sex selective abortions in Rajasthan using a qualitative study and a community-based survey. It explores the perceptions and experiences on sex preference, fertility decision-making and traces the pathways adopted in seeking sex selective abortion.

The study found that respondents were familiar with sex determination techniques, aware of places providing such services and knew someone who had undergone a sex selective abortion. Although only a few women reported undergoing a sex determination procedure, many expressed the desire to use these services.

Strong preferences existed regarding family size and sex composition. Sons are desired as old-age security and support for sisters. A couple’s desire not to have more daughters is mainly due to the dowry expenses and economic burden of maintaining a big family. Couples with more than two daughters or desiring a small family might decide to obtain a sex selective abortion.

Keywords: Sex preference; Desired family size; Sex determination; Sex selective abortion; Rajasthan; India

AcknowledgementsThis research was conducted as part of a Population Council programme of research on unwanted pregnancy and induced abortion in Rajasthan, India. The author formed a part of the research team and she was the research officer at the population council during the period which this research was administered and documented. The research was supported by an anonymous donor. The author greatly appreciates the helpful comments of an anonymous reviewer and thanks Batya Elul and Hillary Bracken for their suggestions and support in preparing this paper.

Introduction

Indian census figures show that the Child Sex Ratio (CSR, the number of girls aged 0–6 years per thousand boys aged 0–6 years) has been dropping steadily since 1951. However, during the last decade it dropped drastically from 945 girls per 1000 boys in 1991 to 927girls per 1000 boys in 2001 (Census of India, 2001). The new 2001 figure gives India one of the world’s lowest ratios of women to men; the statistical norm is 105 females for every 100 males (Ramachandran, 2004).

The imbalance sparked a vibrant public and scholarly debate and also revived concern about the issue of foetal diagnostic technology for determining foetal sex and the prevalence of sex selective abortion in India (Arnold, Kishor, & Roy, 2002). Since the introduction of foetal diagnostic technologies in the 1970s, demographic and social science research has sought to document the impact of the technology on abortion decision-making.

Son preference has prevailed in many parts of India for centuries. With a deep-rooted inclination for sons and increasing availability of technologies for detecting foetal sex, sex selective abortions are also increasing (Oomman & Ganatra, 2002). Moreover, fertility decline and demand for small families have created additional pressure to maintain the smaller family with the desired number of sons (Das Gupta & Mari Bhat, 1997). Mallik (2002) pointed out that due to social and economic changes, the desired family size has declined but there has been no change in the preference for sons over daughters; as a result, sex selective abortions have been integrated into family building strategies by couples.

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Some north Indian states are particularly affected with distorted sex ratios. Rajasthan is one of these states with low ranking in terms of CSR (909 girls per 1000 boys) (Census of India, 2001). The objective of this paper is to:

probe the context of sex selective abortion in Rajasthan;explore the perceptions and experiences related to sex preference and fertility decision-making; trace the pathways adopted in seeking sex selective abortion.

This paper examines the context of sex selective abortions largely through evidence obtained from a qualitative study, substantiated by a large community-based survey on abortions, both of which were conducted in Rajasthan during late 2001. The qualitative data describe the context and motivations behind the decision to seek a sex selective abortion. As well, the community-based survey provides evidence of the awareness and use of sex selective abortion. Together, these data offer a more comprehensive picture of the practice of sex selective abortion in Rajasthan.

Abortion laws and foetal diagnostic technologies

Women in India have had the legal right to abortion since 1972. The Medical Termination of Pregnancy (MTP) Act legalized induced abortion on a wide range of medical and social grounds. Legally, only govern-ment-certified medical practitioners with appropriate training in gynaecology and obstetrics can provide abortion services at government-authorized health centres (Chhabra & Nuna, 1994).

In 1975, amniocentesis, a technique for detecting foetal abnormalities, was introduced to India at the All India Institute of Medical Sciences, New Delhi, the leading teaching and research hospital in India. From the outset, this foetal diagnostic technology was associated with the determination of the sex of the foetus and the practice of sex selective abortion. Doctors at the Institute noted that most of the 11,000 couples who volunteered for the test wanted to know the sex of the child and were less interested in the possibility of genetic abnormalities (Sudha & Rajan, 1999). Soon after the appearance of this technology, government medical institutions were banned from providing sex determination services. However, private service providers made it widely and easily available.

Another technique for detecting foetal abnormalities, ultrasonography, was introduced in the late 1970s. It is a less invasive procedure and requires less technical expertise than Amniocentesis and can determine foetal sex at around 13-14 weeks of gestation (Oomman & Ganatra, 2002). During the mid-1980s availability of ultrasound machines increased and various clinics began to provide the service in many parts of the country. With massive publicity through advertising, sonography's utilization also became widespread. Portable ultrasound machines have even made these services available in rural and remote areas. (Oomman & Ganatra, 2002). After 1991, several multinational companies entered the Indian ultrasound market, and the increased competition contributed to the availability of lower-priced portable models, flexible credit policies and increased customer service for clinicians (George, 2002). As a result, sex determination services have become more available in both urban and rural areas.

The diffusion of amniocentesis and ultrasound were accompanied by efforts to limit the misuse of the technology for sex determination purposes. In 1994, partly in response to efforts by women's and activist groups, the Indian Parliament enacted a law aimed at preventing the misuse of prenatal diagnostic technologies. The Prenatal Diagnostic Technology Act (PNDT Act) states that determining and communicating the sex of a foetus to the consumer is illegal, and that genetic tests may only be performed in facilities registered by government for provision of such tests.

In 2002, the PNDT Act was amended to limit the use of preconception and preimplantation procedures for sex selection, to require government registration of the ultrasonography provider and to require

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diagnostic centres and doctors to maintain test records (Government of India, 2003). To date, these efforts have been relatively unsuccessful in reducing the spread of the technology or the practice of sex selective abortion (George, 2002). However, increased regulations have increased efforts to maintain the secrecy of sex determination tests and abortions.

Research on sex selective abortion

Recently, an attempt has been made to quantify the magnitude and prevalence of the practice of sex selective abortion at the national level using the data from retrospective birth histories collected in two National Family Health Surveys (NFHS-1 and NFHS-2) (Arnold et al., 2002; Retherford & Roy, 2003). This study used the sex ratio at birth as an indirect estimate of sex-selective abortion, and found considerable variation in the sex ratio at birth by state. Sex Ratio at Birth (SRB) is number of male babies born per 100 female babies. The normal ratio at birth is around 105. Sex ratio at birth has recently emerged as an indicator of certain kinds of sex discrimination. In some northern states, SRBs were high, suggesting a great deal of sex selective abortion. A composite variable, including child's birth order and mother's number of living sons just prior to the birth of the index child (i.e., the child of specified birth order), had the strongest effect on the SRB.

Direct evidence of sex selective abortion is found in many studies. The very first documentation of sex selective abortion appeared long ago in 1975. A hospital-based study completed in 1975 found that seven out of eight pregnant women who had requested a sex determination test and learned that the foetus was female decided to abort the pregnancy (Verma, Joseph, Verma, Buckshee, & Ghai, 1975). Another hospital-based study from urban Maharashtra also found differences in the decision to terminate a pregnancy based on the results of a sex determination test. Among 700 women who underwent a sex determination procedure, 250 women learned that they were carrying a male foetus. All 250 women carried the pregnancy to term - even in the case of genetic abnormalities. In contrast, 96 per cent of the 450 women informed that they were carrying a female foetus terminated the pregnancy (Ramanamma & Bambawale, 1980).

A community-based research study was conducted during 1989-1994 to assess the prevalence of sex selective abortion and identify the socio-economic profile of women who use prenatal sex determination tests and opt for sex selective abortion. The study examined the historical basis for son preference and the prenatal sex determination techniques traditionally used by rural women from Jat community of Haryana (a state in North India). The study also found that urbanizing Jat families in the area were increasingly using prenatal sex determination followed by sex selective abortion as a strategy to achieve a smaller family and the desired sex composition of children (Khanna, 1997). A study conducted in rural Maharashtra revealed that one in six abortions (17 per cent) was preceded by a sex determination test (Ganatra, Hirve, & Rao, 2001).

Generally it is assumed that urban, educated and upper-class women are more likely to undergo a sex selective abortion because of a greater social demand for sons and better access to sex determination facilities (Sudha & Rajan, 1999). However, George and Dhaiya (1998) suggested that now it is cutting across all sub- populations.

A hospital-based study in the Punjab suggests that parity may prove important in determining whether a woman seeks sex determination services. The use of sex determination services was more prevalent among women with one or more living daughters but no living sons (Booth, Verma, & Beri, 1994).

Some Indian states are particularly affected with distorted sex ratios; in particular, north Indian states are known for their tradition of heavy son preference compared to southern states (Miller, 1981; Sopher 1980; Clark, 2000; IIPS & ORC Macro, 2000). Sex ratio at birth for births following an aborted

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pregnancy reveals that in some north Indian states (Gujarat, Harayana and Punjab), this ratio is 158 boys per 100 girls, which suggests that sex selective abortions are being used in these areas to ensure the birth of a son (Arnold et al., 2002).

Study area

Rajasthan is one of the northern states with low ranking in terms of child sex ratio (909 girls per 1000 boys) (Census of India, 2001) and is characterized by a deep-rooted inclination among families for a son.

The qualitative study was conducted in Alwar district of Rajasthan. Among the districts of Rajasthan, Alwar can be placed with the better-off districts in terms of higher proportion urban, higher literacy rate, lower fertility rate and higher contraceptive prevalence rate compared to that of Rajasthan average values. With a population of nearly three million, Alwar district is characterized by a relatively large Muslim population and a lower than average sex ratio (887 females per 1000 males). Alwar is closely located to major cities (e.g., New Delhi and Jaipur) and is also surrounded by Haryana state. Harayana faces a high incidence of sex selective abortions, and its overall sex ratio stands at 861 females per 1000 males. The residents of Alwar have ready access to modern facilities through its easy access to neighbouring big cities.

In Alwar district, a small town (Ramgarh) and a village (Kalsara) were selected for the study. Both sites are approximately 15 km from the district headquarters and are accessible by public transportation. The village contains 800 households, a population of 3826, and the sex ratio is 885 females per 1000 males. The town of Ramgarh has a population of 11,400 with a sex ratio of 909 females per 1000 males. In both the study sites, the primary occupations were agriculture and shopkeeping. The majority of women were part of the agricultural labour force. Marriage is universally followed, and age at marriage is low among poorer communities. Both sites have mostly Hindu families with some Meo Muslim households.

In Kalsara, a Primary Health Sub-centre and three anganwadi centres1 provide health services. Ramgarh has a Community Health Centre and nine anganwadi centres. Many private health practitioners, such as local traditional healers and dais (traditional birth attendants), practice in both the study sites. These providers play a major role in the community-level health services. None of the facilities in either Kalsara or Ramgarh offer sex determination or sex selective abortion services.

Despite the requirement that all sonography equipment should be registered, accurate counts of sonography clinics in Alwar are unavailable. However, on a research trip to Alwar, we counted more than 15 sonography centres and abortion clinics on a one-mile stretch outside the tertiary-level health centre.

The community-based survey was conducted in six districts of Rajasthan. These six districts are Alwar, Bhilwara, Bikaner, Karauli, Pali and Tonk.

Methods

Qualitative study

A qualitative study to describe attitudes and behaviours surrounding unwanted pregnancy and abortion was conducted at two sites (a village and a small town) of Alwar district, Rajasthan. The objective was to examine the pathways that women follow from the moment they recognize they are pregnant until they identify and seek pregnancy termination services. While the study was designed to

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examine all abortions, the issue of sex selection appeared in several of the transcripts as an important issue/factor in a woman's decision to seek an abortion.

A team of one male and two female interviewers was responsible for data collection at each of the study sites. All interviewers were fluent in Hindi and had at least a college degree. Several had experience conducting social science or health-related field research and/or detailed familiarity with Rajasthan. All fieldwork was conducted between September and December 2001.

Several qualitative methods were used, including focus group discussions, key informant interviews and in-depth interviews. Purposive and snowball sampling techniques were used to select study participants across a range of important sub-populations (i.e., age, caste and religion).

Focus group discussions (n = 20) were conducted with individuals who had been recommended by community members as being particularly knowledge able about women's health issues in order to gather information about community attitudes and norms related to unwanted pregnancy and abortion.

Key informant interviews (n = 68) were conducted with town/village leaders, as well as formal and informal health providers in the study sites and in Alwar city, as many women from the study sites seek care there. Health providers were identified through informal discussions with community members and respondents in focus group discussions.

In-depth interviews (n = 59) were conducted with married women who had, or men whose wife had, experienced an unwanted pregnancy or abortion. These individuals were identified during the focus group discussions or key informant interviews. Respondents were asked whether they had experienced an unwanted pregnancy, reasons the pregnancy was unwanted and the action taken. In this context, a number of women reported that they had desired or undergone a sex selective abortion.

Atlas-ti a qualitative software package was used to sort and manage the data. Initial categories for analysis were drawn from interview guides and additional themes and patterns emerged after reviewing the data within and across respondent groups. The principal investigator coded the translated data and identified key thematic areas.

Community-based survey

On the issue of unwanted pregnancy and induced abortion, a cross-sectional community-based survey of 3266 ever-married women aged 15-44 years and a sub-sample of 602 husbands was conducted in six districts of Rajasthan. These six districts are, again, Alwar, Bhilwara, Bikaner, Karauli, Pali and Tonk. Unlike other standardized surveys, such as the National Family Health Surveys, the study included detailed questions on knowledge, attitudes and practices regarding unintended pregnancy and abortion including sex selective abortion. As abortion experiences have been under-estimated in previous community-based surveys (Huntington, Mensch, & Miller, 1996; Barreto et al., 1992), we tried to minimize this bias by including probing questions through the pregnancy history section of the instrument. Checks were also included to alert interviewers for inconsistencies across different parts of the pregnancy history.

The data collection teams comprised 24 female and seven male investigators experienced in social science field research and fluent in the local language. They were trained in reproductive health concepts and data collection techniques. All fieldwork was conducted between September and December 2001.

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Households were selected for participation using a multi-stage stratified cluster sampling procedure, in which urban households were over-sampled. All ever-married women aged 15-44 years in a selected household were invited to participate. Ultimately, 3266 women (88.7 per cent of the eligible women identified in selected households) were interviewed. Data may be considered as representative of the 'sampled area' in the six districts.

All respondents reporting an unwanted pregnancy in the 5 years preceding the survey were asked, ‘‘why was the pregnancy not wanted?’’ One of the answer categories was ‘‘Sex of the foetus’’. All the respondents reporting abortion in the 5 years preceding the survey were asked, ‘‘why did you have this abortion?’’ One of the answer categories was ‘‘Foetus was female’’. An individual's attitudes about abortion are often closely associated with the decision whether or not to terminate a pregnancy; thus, respondents were asked whether they endorsed abortion if the foetus was female.

Further, our instrument included several explicit questions on knowledge and attitudes regarding sex selective abortion, such as:

Do you know whether it is possible to determine the sex of a foetus? Do you know where one can determine the sex of a foetus? Have you ever heard of anyone who has had an abortion because the foetus was female? How common are such sex selective abortions?

Survey data were entered and cleaned using Fox Pro and then transferred to STATA for analysis. Given the increased availability of both sex determination and abortion services in urban areas, results are disaggregated by place of residence. T-tests and chi-square tests were used to make statistical comparisons between the urban and rural respondents in terms of their demographic characteristics, occurrence of induced abortion and knowledge of sex selective abortion.

Qualitative results

The qualitative data offer insight into the context, motivations and process of sex selective abortion in the study area. Using these data, the paper will first explore the profile of respondents, their family size norms, sex preference and fertility decision-making. Then the paper will explore how respondents determine foetal sex through traditional and modern methods and their awareness of sex determination technology and the legality of abortion. Finally, the case studies of six women who reported attempting a sex selective abortion will be presented in more depth to understand the sex selective abortion pathway.

Profile of respondents

Overall, 14 community leaders and 20 community residents with above-average awareness of abortion participated in key informant interviews. These respondents were largely female and Hindu. Key informant interviews were also conducted with 10 formal providers and 24 informal providers.

In total, 59 individuals (45 females and 14 males) participated in in-depth interviews. In several cases, both members of a couple were interviewed. Of the 59 women and men interviewed in-depth, 32 reported an unwanted pregnancy, and 20 had an abortion, including six respondents who claimed to have had one or more sex-selective abortions.

Family size norms, sex preference and fertility decision-making

Male and female respondents in both sites articulated strong preferences regarding family size and sex composition. Most agreed that the ideal family comprised of three children, preferably one girl and two boys.

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Respondents expressed a strong preference for sons. Sons were considered essential for inheritance purposes, providing financial support for parents or female siblings, performing parental funerary rites and conferring higher social status on the family.

It is necessary to bear a boy in the society, because there must be a heir, the successor, only then parents would be relieved, otherwise not. To take their care, to look after the property, to care for them on being sick, only boy does that, girl has to be married off. (35-year-old married Hindu man, in-depth interview, village site)

Additionally, a woman from the town site with eight daughters suggested,

Girls are somebody else's wealth.

She added,

See I have only girls. They do not have any brothers. Now who will look after them? Who will help them in their marriage? (37-year-old married Hindu woman, in-depth interview, town site)

Pressure to meet these childbearing ideals comes not only from family members but also from neighbours and the community. As one respondent explained, that the pressure to bear male children is particularly acute at later parities:

In the beginning everybody wants a child. It doesn't matter whether it's a boy or a girl. If one or two children come, then it is fine, the sex of the child does not matter, however, after the third child, it matters ... girls are not meant to be kept. (27-year-old married Hindu woman, in-depth interview, village site)

Respondents suggested that parity and the sex composition of existing children play an important role in the decision for sex selective abortion. Couples with more than two daughters or desiring a small family might decide to obtain a sex selective abortion.

The health of living children or the sex composition of children in other families in the household may shape an individual's or a couple's family planning preferences. A 31-year-old woman from Kalsara with three girls and one boy noted how another boy was "needed" because her elder son remained ill. She also mentioned that her in-laws did not ‘‘get sad’’ when she gave birth to her first daughter because her sister-in-law had already produced a son. Similarly, a 28-year-old woman from Kalsara noted how although she had already given birth to one son, her husband refused to allow her to undergo a sterilization operation because her sister-in-law had given birth to three daughters and the family wanted another son.

Given the pressure to produce a son, many women expressed dismay when they only gave birth to girls. A few women who only had daughters felt they had ‘‘bad luck," "some disease’’ or were "cursed." A woman from the village site with eight daughters spoke eloquently of how ‘‘love lessened’’ when she continued to give birth to girls:

Neither anyone cares for the mother, nor looks after her because she had produced so many girls y.. That is why I used to feel sad: Because so many girls have come, nobody talks to me. If a boy had come than everyone would have loved me. (32-year-old Hindu married woman, in-depth interview, village site)

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Women in both Kalsara and Ramgarh spoke of how sex preferences also shaped their decision to adopt permanent contraceptive methods. A 42-year-old married woman with two sons and three daughters said, ‘‘nobody could stop me (from adopting sterilization) because two boys were there. So, I got my operation done.’’ Several women also stated that their husband or in-laws pressured them to delay undergoing sterilization until their son reached 5 years of age or maturity.

Determining foetal sex: traditional and modern methods

Both male and female respondents spoke of a number of traditional methods or treatments to ensure the birth of a son or identify the sex of the foetus. For a pregnant woman, the time of conception, dreams, food preferences or physical changes could indicate the sex of the foetus. (Appendix A). Several women in Ramgarh reported taking a traditional remedy during pregnancy to ensure the birth of a male child. While many women had contradictory opinions on this matter, a few placed faith in such diagnoses/remedies.

In both Kalsara and Ramgarh, male and female respondents were also aware of scientific methods for determining foetal sex (ultrasonography). Several respondents referred to it as the "TV" with which one could determine the sex of the foetus. Many reported that sonography services were available at district headquarter and at another nearby city (Malakhera).

Several respondents expressed suspicions about the efficacy of ultrasonography in determining the sex of the child and also the motives of health care providers offering these services. One 33-year-old married man from Kalsara, with one son and five daughters, suggested that doctors may purposefully misreport the sex of the foetus as female in order to make money through abortion.

We didn't believe them. Another woman who had undergone sonography was told that foetus is female but she didn't get abortion done. Later she gave birth to a boy instead of girl. Doctors get heavy money if they report that the foetus is a girl instead of boy because then the couple asks for abortion.

In in-depth interviews, seven women reported undergoing a sonography exam and two others desired to undergo an examination in the future. Several other women had expressed interest in obtaining a sex determination test in the past, but their husband or other family members refused because of the cost or thepotential complications associated with an abortion.Several respondents remarked that due to the government legislation on sex selective abortions, providers now charge more for late-term abortions, which they suspected may be for sex selective reasons. A 35-year-old married man from village site informed that providers in government facilities performed the procedure ‘‘secretly’’.

A referral-level abortion provider in the public sector reported that he no longer performed abortions after 12weeks gestational age as he believed ‘‘the majority of cases are coming after sex determination’’. He also acknowledges that if there is a ‘‘genuine reason’’, for the procedure (e.g., congenital anomaly) he would performthe abortion. When asked, the provider did not feel that his decision curtailed women's access to abortion services. A referral-level abortion provider in the private sector confirmed that despite the ban, people somehow manage to obtain sonography exams in a large city or nearby state including Delhi, Punjab or Haryana.

Knowledge and attitudes regarding the legality of abortion

While respondents were rarely aware of the legality of abortion, most were more familiar with the government legislation curtailing sex determination and often assumed that legislation restricted their

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right to abortion. Respondents had differing opinions as to whether the restrictions on the use of sonography to detect the sex of the foetus had affected the frequency of sex-selective abortions. While several women remarked that the government legislation had reduced the number of such abortions in government hospitals, others suggested that the practice continued in both the public and private sectors. Most concurred, however, that the government campaign against sex-selective abortion had led to an increase in the price of second-trimester abortions in the formal sector. Indeed, a few of the poorer respondents interviewed in-depth indicated that although they had undergone a sonography and learned they were carrying a female foetus, they were unable to afford an abortion in the formal sector and thus relied on less expensive, traditional methods of abortion or carried the pregnancy to term.

Community attitudes for sex selective abortions

The community has shown a range of attitudes for sex selective abortions. A 30-year-old community member (literate, Hindu, married, male) from Kalsara said:

Get the sonography done and if it is a girl get it aborted. This is a wrongdoing. The life, which has taken birth in the stomach, has to come out, but they abort it. They have to pay further in the form of punishment.

Although many believe it is a sin, sex selective abortion is becoming more or less acceptable in the community as a better alternative than spoiling the life of a girl.

To give her (female foetus) birth meant to spoil her life, apart from parent's life getting spoiled, her condition would have been worse. So, we felt it right not to give her birth. (A 27-year-old Hindu married woman with one son and one daughter, who had a sex selective abortion, in-depth interview, village site)

It is better to get the girls aborted than not to bring them up properly (with gender discrimination). (A 35-year-old Hindu married woman with four daugh- ters and one son, who had three sex selective abortions, in-depth interview, village site)

A few other community members said that over the past few decades, with more girls than boys being born, the dowry system came to be. Now people are attempting to have fewer daughters so as to balance the situation. Additionally, according to these few respondents, female foeticide has become a means of avoiding future dowry expenses. Surprisingly, some have also said that it is also a way to save girl children from an unhappy life. The belief is that a girl, if born, will be unhappy all her life due to prevalent gender inequality.

The study community also suggested that only wealthy and upper caste people opt for sex selective abortions because the wealthy are more likely to be required to pay a large dowry for a daughter or are more likely to desire a son to inherit family wealth and landholdings. In addition, they suggested that the practice was less common among the poor as daughters could work and not pose an economic burden on their families. One respondent also suggested that wealthy women could more easily recover from the abortion procedure because of the availability of good food and medication.

In contrast, providers felt that the practice of sex selective abortion was common across all classes and castes.

Even the lower classes, the poor and farmers they do it [sonography]. Here, if we ask them to buy an injection, they're unable to purchase it, but they do sonography. (50-year-old male doctor, provider, key informant interview, Alwar)

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The sex selective abortion pathway

Among the respondents who reported that they (45 females) or their wives (14 males) experienced an unwanted pregnancy, 14 of them reported for abortion and six women reported attempting sex selective abortion(s).

On average, women who reported undergoing a sex selective abortion were 32 years old and had been married at the average age of 19 years. All six women were literate and most worked primarily in the home; only one woman was occasionally engaged in agricul¬tural work and fodder collection. All live in a joint family or in close proximity to their in-laws. All follow Hinduism. They were well aware of contraceptive methods and were currently using them, most often pills or intrauterine devices (IUDs).

On average, those women who had experienced sex selective abortion had undergone seven pregnancies and had four living children (one son and three daughters). Three of the six women opted for sex selective abortion at early parities-after either two or three children. The other two women opted for sex selective abortion at much later parities. Details of these six cases are given below:

A 23-year-old woman from Ramgarh tested for the sex of her very first child because she wanted a son at first parity. When she learned the foetus was female, she decided to have a sex selective abortion. While she is currently using contraception, she stated that if she becomes pregnant with another daughter, she would undergo another abortion.

A 34-year-old woman from Kalsara had a daughter and then tested for the sex of her second child and aborted the female foetus. During her third pregnancy she was self-assured of a male child but delivered a daughter. During her fourth pregnancy she was willing to undergo sonography but was unable to have it done and delivered her third daughter. After three caesarean section deliveries, she chose to be sterilized.

The third woman is 27 years old and belongs to the village site. She wanted to stop child-bearing after two sons. After having a daughter and then a son, she learned her third pregnancy was a girl and underwent a sex selective abortion. She is currently pregnant; after undergoing a sex determination test; she learned this foetus is a boy and she has decided to continue the pregnancy.

The fourth woman is 35 years old and belongs to village site. She too wanted to stop child-bearing after two sons. After her first child (a boy), she delivered four daughters. Then, in her next pregnancies, she underwent three sex selective abortions and later delivered a male child.

A 41-year-old woman from Kalsara had two daughters and then wanted to go for sex selective abortion. However, her father-in-law refused one and with her next pregnancy, her husband refused. Since then, she has had one sex selective abortion and four abortions for spacing/limiting. When she went for another induced abortion her doctor suggested sonography, which confirmed a male foetus, and she continued the pregnancy to term.

Another 22-year-old woman from Kalsara with one living daughter opted for a sex determination test because she wanted only two children, one of each sex. The test confirmed a female foetus. She took abortion pills, which failed to induce an abortion, and subsequently delivered her second daughter. Now she is determined to have a sex selection test and - if needed - sex selective abortion in her future pregnancy.

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Although there are many sonography clinics in Alwar city, all the women from Ramgarh and Kalsara went to the same private sonography centre in Alwar for sex determination. Women reported paying a range of fees for their services - from 500 to 1400 Rs. Several women reported that a gynaecologist in Alwar had referred them to the clinic. A 41-year-old woman with four daughters who had previously undergone two abortions said that she went for an induced abortion to limit her family size; however, the gynaecologist strongly suggested she undergo a sonography test to avoid abortion in case of a male foetus. Later the provider referred her to a nearby sonography clinic, where she found that the foetus was male and thus continued with the pregnancy.

Five of these women were successful in terminating their pregnancies. The sixth woman took 'pills', which did not induce an abortion, and carried the pregnancy to term. All six women availed the abortion services from various private gynaecologists in Alwar in the beginning of their second trimester. For abortion services they paid a range of fees from 500 to 2500 Rs, with an average of 1450 Rs.

These women and their families have a preference for a son. Although son preference by families was mainly due to the socio-cultural values associated with having a son, these women and their families do not mind having more daughters while waiting for sons. However the couple's attitude was generally not to have more daughters, mainly because of dowry expenses and the economic burden of maintaining a big family.

When deciding whether or not to undergo a sex determination test and then abortion, three of the six women reported that they took the decision in consultation with their husband. Three women decided alone to seek the procedure, including the woman who was unsuccessful in terminating her pregnancy.

Survey results

The community-based survey provides evidence of the awareness and use of sex-selective abortion. After getting an idea of the socio-demographic profile of respondents, we will explore their knowledge, attitude and practice regarding sex selective abortion.

Socio-demographic profile of respondents

The major socio-demographic characteristics of the survey respondents are given in Table 1.[Table 1]

Female respondents averaged 30 years of age, and just over one-third of them were literate. Approximately two-thirds of women were working at the time of the survey; however, rural women were far more likely to be working than their urban counterparts. The vast majority of respondents were Hindu, particularly in rural areas. Forty-eight per cent of respondents from urban areas were of a high socio-economic status compared to only 17 per cent of rural respondents. On average, survey respondents reported three children ever born, with slightly more sons than daughters. Among the pregnancies that occurred in the 5 years preceding the survey, 11 per cent were reported to be unintended. Ultimately, 13 per cent of women reported ever having an abortion and 6 per cent reported an abortion in the 5 years preceding the survey.

Knowledge, attitude and practice of sex selective abortion

Among the survey of women reporting an unwanted pregnancy in the 5 years preceding the survey, 4 per cent stated that the pregnancy was unwanted because of a non-desired foetal

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sex. Among those experiencing abortion in the 5 years preceding the survey, 3 per cent reported undergoing abortion because they were carrying a female foetus (Table 2). Given the government policies prohibiting sex determination, not surprisingly, reports of sex selective abortion were rare in our study.

[Table 2]Because an individual's or couple's attitudes about abortion are often closely associated with the decision whether or not to abort the female foetus, our survey included several questions that documented respondents' attitudes and knowledge about sex selective abortion. First, survey respondents were read a list of possible situations in which a woman might seek abortion, including if her foetus was female, and were asked if they endorsed abortion in each case. Significantly more female (20 per cent) than male (8 per cent) and more rural (men, 14 per cent; women, 27 per cent) than urban (men, 4 per cent; women, 16 per cent) respondents were among the minority that favoured abortion when the foetus is female.

Respondents were then asked about their familiarity with sex determination techniques and the availability of such services in their community. Nearly 80 per cent of men (88 per cent urban and 66 per cent rural) and 75 per cent of women (88 per cent urban and 55 per cent rural) knew that foetal sex could be determined; however, urban respondents were far more likely to have such knowledge than their rural counterparts.

Among those aware of sex determination, nearly all, regardless of place of residence, knew where they could go to have foetal sex determined. Nearly 76 per cent of men and women aware of sex determination techniques knew someone who had undergone a sex selective abortion.

In comparison to the other indicators, 45 per cent of 91 men and 70 per cent of women who knew someone who had sex selective abortion reported that this practice is very common.

Discussion

Demand for sex determination services

The paper suggests a demand for sonography services in the study area. Although only six women reported attempting sex selective abortion(s), many other study 103 respondents expressed an interest in undergoing a sonography exam to detect the sex of the foetus. These respondents were unable to access sex determination services due to cost or their family's concerns about complications associated with abortion.

The community-based survey generalizes the widespread awareness of services for foetal sex determination. Among those surveyed, three-quarters of women knew that foetal sex could be determined. Moreover, among those aware of sex determination, nearly all knew an outlet where foetal sex could be determined. Urban respondents were far more likely to have such knowledge than their rural counterparts.

Sex preference and fertility decision-making

Similar to many other studies, this paper also stressed the importance of sons as ‘‘old-age security’’ or ‘‘risk insurance’’ for parents (Vlassoff, 1990). Moreover, several respondents

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also mentioned that sons play a crucial role in the support of their sisters. Several women with many daughters stressed that a son would increase the value of the family's daughters - both through contributions to the family income and dowry expenses, and the attribution of honour.

Most of the women who reported sex selective abortion(s) had specific ideas about the ideal family size or composition and desired a family with at least one or two boys. Even so, most of the other women in our study struggled with competing personal and societal demands about the desired size and sex composition of their family. In general, women who report sex selective abortion(s) felt a pressure to produce sons. The paper found that the use of sex selective abortion was not uniform, but rather was intensified at higher parities; these findings resonate with other research on sex preference (Das Gupta, 1987).

The decisions of whether or not to seek an abortion based on foetal sex determination were often made by the couple and mostly with the knowledge of family members. For various reasons, sex selective abortions necessitate familial support. The significant cost of sex determination and abortion services might force women/ couples to seek financial support from their family. Being a long distance from the sex determination/ abortion facility (especially in rural areas) might force women to obtain permission from their family to travel beyond their village or town. The timing of sex determination tests at later gestational periods, when many family members may have become aware of the pregnancy, may also necessitate familial support.

Sex selective abortions

The paper explores the idea that, on one hand sex selective abortions are considered as sin but on the other they are gaining acceptance - especially by couples. Providers are also providing a favourable platform for them. More than son preference, the major reason for sex selective abortions is considering a girl child as an economic burden and therefore acting to avoid delivering a girl.

The number of women who reported sex selective abortion in the qualitative study is small and thus us from making broad generalizations. Moreover, generalizations about a sensitive issue such as abortion are often complex. In the survey, 3 per cent of women who reported an abortion during the 5 years preceding the survey indicated that the pregnancy was terminated because the foetus was female (with a difference by place of residence: urban, 2 per cent; rural, 4 per cent).

Our findings are similar to those of a community-based survey in Madhya Pradesh, where only a small proportion of pregnancies were aborted because the foetus was female. Although the authors note that these results may underreport sex selective abortions in Madhya Pradesh, they did feel that given the higher fertility levels and family size preferences in the state and low availability of sex determination technology, the number of sex selective abortions may be less than in other states like Rajasthan (Malhotra et al., 2003).

Much research has demonstrated the limits of a survey methodology for the examination of sensitive reproductive health issues such as abortion. One can visualize the difficulties in doing direct studies on abortions. Women may be hesitant to discuss their experiences of sex selective abortion in a formal interview setting. Moreover, the emotions and stigma surrounding an unwanted female foetus might also have an effect on subjects' willingness

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to discuss the issue. Women or providers may also be hesitant to discuss the topic for fear of legal repercussions. Consequently, survey data may underestimate the prevalence of sex selective abortion.

Throughout the paper it is evident that sex selective abortions are being used to obtain the desired family composition. Those who want small families, and also want at least one or two sons, are opting for sex selective abortion as a family building strategy. Although the high awareness of sex determination techniques and sex selective abortions is alarming, the practice is found to be limited. Nevertheless, the low prevalence of sex selective abortion may be the result of heavy underreporting due to its illegality and sensitivity associated with the issue.

References

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Barreto, T. V., Campbell, O. M. R., Davies, J. L., Fauveau, V., Filippi, V. G. A., Graham, W. J., Mamdani, M., Rooney, C. I. F., & Toubia, N. F. (1992). Investigating induced abortion in developing countries: Methods and problems. Studies in Family Planning, 23(3), 159-170.

Booth, B., Verma, M., & Beri, R. (1994). Foetal sex determination in infants in Punjab, India: Correlation and implication. British Medical Journal, 309(6964), 1259-1261.

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Chhabra, R., & Nuna, S. C. (1994). Abortion in India: An overview. New Delhi, India: Veeremdra Printers.

Clark, S. (2000). Son preference and sex composition of children: Evidence from India. Demography, 37(1), 95-108.

Das Gupta, M. (1987). Selective discrimination against female children in rural Punjab, India. Population and Development Review, 13(1), 77-100.

Das Gupta, M., & Mari Bhat, P. N. (1997). Fertility decline and increased manifestation of sex bias in India. PopulationStudies, 51(3), 307-315.

Ganatra, B., Hirve, S., & Rao, V. N. (2001). Sex selective abortion: Evidence from a community-based study in Western India. Asia-Pacific Population Journal, 16(2), 109-124.

George, S. (2002). Sex selection/determination in India: Contemporary developments. Reproductive Health Matters, 10(19), 184-197.

George, S., & Dhaiya, R. (1998). Female foeticide in rural Haryana. Economic and Political Weekly, 33(32), 2191-2197.

Government of India (GOI). (2003). The medical termination of pregnancy rules (amendment).

Huntington, D., Mensch, B., & Miller, V. C. (1996). Survey questions for the measurement of induced abortion. Studies in Family Planning, 27(3), 155-161.

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International Institute of Population Sciences (IIPS), & ORC Macro. (2000). National Family Health Survey (NFHS-2), 1988-89. India, Mumbai: IIPS.

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Malhotra, A., Nyblade, L., Parasuraman, S., MacQuarrie, K., Kashyap, N., & Walia, S. (2003). Realizing reproductive choice and rights: Abortion and contraception in India. ICRW Research Report. Washington, DC: ICRW.

Mallik, R. (2002). A less valued life: Population policy and sex selection in India. Center for Health and Gender Equity CHANGE).

http: //www. genderhealth.org/pubs/Mallik-SexSelectionIndiaOct2002.pdf. Accessed on December 17, 2003.

Miller, B. D. (1981). The endangered sex: Neglect of female children in rural North India. Ithaca: Cornell University Press.

Oomman, N., & Ganatra, B. R. (2002). Sex selection: The systematic elimination of girls. Reproductive Health Matters,10(19), 184-188.

Ramachandran, S. (2004). New technologies, old prejudices. Developments: The international development magazine. http://www.developments.org.uk/data/1 6/id_technology.htm.

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Retherford, R. D., & Roy, T. K. (2003). Factors affecting sex-selective abortions in India and 17 major states. National Family Health Survey subject reports, No. 21. Mumbai: IIPS,Honolulu: East-West Center.

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Appendix A: Traditional prenatal sex determination indicators

Indicators For daughter For sonEating habits Pregnant woman likes sour food Pregnant woman likes sweets Physical change Pregnant woman’s face turns

yellow Pregnant woman feels energetic

and her body turns healthy More bulge abdomen and shaped

like a pot Abdomen feels warm

Pregnant woman’s face turns black and pigmented

Pregnant woman feels lazy and her body weak

Less bulge abdomen and shaped like a coconut

Abdomen feels cold

Dreams Radish, gourd, chilli, carrot or baby boy

Lemon, potato, banana, apple, brinjal, onion, tomato, mango or baby girl

Table 1: Characteristics of the survey respondents (Percentage)

Characteristics Urban Rural TotalMean age (years)Currently marriedLiterate ‡

Working ‡

ReligionHinduOthers

Caste ‡

SC/ST/OBC*

Other casteDo not know

Standard of living index ** ‡

LowMediumHigh

Children ever born (mean)SonsDaughters

Induced abortion Had induced abortion ‡

Had induced abortion in past five yearsRespondents (n)Had unwanted pregnancy in past five years Pregnancies in last five years (n)

30.696.654.025.6

75.924.1

58.441.40.2

14.837.547.7

1.61.4

16.97.8

196914.71678

28.996.817.167.2

93.56.5

81.517.60.9

44.438.716.9

1.81.6

6.73.8

12976.6

1430

29.996.739.342.1

82.917.1

67.532.00.5

26.638.035.5

1.71.5

12.86.2

326611.03108

* SC: Scheduled caste; ST: Scheduled tribe; OBC: Other backward class** Standard of living index was constructed similar to NFHS (IIPS and ORC Macro, 2000)‡ Difference between urban and rural significant at p≤ 0.01.

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Table 2: Knowledge of sex determination. (Percentage)

Particulars Men WomenUrban Rural Total Urban Rural Total

Proportion of women experiencing abortion because foetus was female

- - - 1.9 4.1 2.5

Induced abortion in last five years (n) 33 10 43 154 49 203

Proportion of respondents supporting abortion in case of female foetus

4.4 13.5 7.6 15.8 27.0 20.2

Respondents (n) 387 215 602 1969 1297 3266

Proportion of respondents aware of sex determination technique ‡

87.9 65.6 79.9 88.2 55.1 75.0

Respondents (n) 387 215 602 1969 1297 3266

Proportion of respondents knew source of sex determination

98.5 97.2 98.1 98.0 96.6 97.6

Proportion of respondents knew someone who had a sex selective abortion ‡

84.7 55.3 76.1 79.1 68.5 76.0

Aware of sex determination (n) 340 141 481 1737 714 2451

Proportion reporting frequency of sex selective abortions

Very commonSomewhat commonNot commonCan not say

47.930.920.80.3

35.946.217.9

-

45.434.220.20.3

70.727.41.70.3

66.230.73.1

-

69.528.22.00.2

Knew someone who had sex selective abortion (n)

288 78 366 1374 489 1863

‡ Difference between urban and rural women significant at p<0.01.

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1 Anganwadi Centres work under the Government of India's Integrated Child Development Scheme. One anganwadi worker, trained in various aspects of health, nutrition and child development, is allotted to a population of 1000. The anganwadi worker's duties include regular health check-ups for infants, immunization, health education and non-formal preschool education.

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