Does prenatal sex selection reduce gender gaps in child mortality? Ridhi Kashyap ∗ University of Oxford Abstract By enabling parents to avoid unwanted female births, has prenatal sex selec- tion accompanied reductions in patterns of excess female infant and child mortality in contexts with son preference? This study examines the relationship between prenatal and postnatal manifestations of son preference for six countries that have witnessed SRB distortions – India, Nepal, Pakistan, Azerbaijan, Armenia and Alba- nia. Using micro-data from birth histories of the Demographic and Health Surveys in combination with United Nations data on sex ratios at birth (SRB), I examine if differential mortality change by sex, particularly for girls at higher birth orders with- out brothers, can be explained by the uptake of prenatal sex selection. I find that changes in prenatal sex selection only explain mortality change in India. Across the different countries, although patterns of mortality disadvantage are concentrated among less educated mothers, prenatal sex selection is strongest among the better educated. Differential sorting into the two behaviors offers an explanation for why the effect of prenatal sex selection on mortality change is generally weak. Keywords: gender, sex ratio at birth, prenatal sex selection, excess female mor- tality, son preference, Demographic and Health Surveys ∗ Address all correspondence to: Ridhi Kashyap, Nuffield College, New Road, Oxford OX1 1NF, United Kingdom. E-mail: ridhi.kashyap@nuffield.ox.ac.uk.
1 Introduction An extensive literature has documented the rise and spread of prenatal sex selection, as indicated by sex ratio 1 at birth (SRB) distortions, across Asia, the Caucasus and parts of the Balkans (Guilmoto, 2015). Described as one of the “most notable anomalies in contemporary demography,” the growing population sex imbalance at birth is a modern manifestation of a long-standing norm guiding fertility behaviour – that of a preference for male offspring (‘son preference’) (Guilmoto, 2009, p. 519). Parental son preference can manifest itself in both prenatal or postnatal forms. The adoption of prenatal strategies for sex selection requires three preconditions: 1) parents must find it necessary to bear a son; 2) parents must have access to prenatal sex testing technology and access to abortion; 3) parents must find it necessary to keep their family size small (Guilmoto, 2009). Prior to the availability of sex detection technology, postnatal manifestations of son preference in the form of excess female mortality in infancy and childhood had been widely documented in the demographic literature, particularly for South Asia. More recent, global analyses have found that excess female mortality in infancy and childhood remain prevalent, most prominently in South Asia, the Middle East and parts of Africa (Alkema et al., 2014; Sawyer, 2012). The notion of excess implies that girls experience higher than biologically expected mortality on account of both direct or indirect forms of gender discrimination, which, as prominently described by Amartya Sen, results in them being ‘missing’ from population structures (Sen, 1990). Excess mortality for girls may result directly from infanticide or from the unequal allocation of healthcare and nutrition to girls within families (Jayachandran and Kuziemko, 2011; Borooah, 2004; Li et al., 2004; Arnold et al., 1998; Kishor, 1993; Muhuri and Preston, 1991; Gupta, 1987; Miller, 1987). Excess mortality may also indirectly emerge from the fertility effects of son preference. Sex-differential stopping behaviour practiced by parents desiring a boy cause girls to be born into larger families compared to boys (Basu and De Jong, 2010; Clark, 2000). In this indirect mechanism, within-family differences might not be apparent between girls and boys but instead aggregate-level gender gaps are likely to emerge if net resources per child are fewer in larger families than smaller ones (Jain, 2014; Carvalho et al., 2013; Rosenblum, 2013; Choe and Kim, 1998). If an important factor underlying postnatal excess mortality is child unwanted- ness, the increasing adoption of sex-selective abortion may plausibly imply better survival chances for those girls who are born as they are more likely to be wanted (Goodkind, 1996). An emerging literature has empirically tested what Goodkind called the substitution hypothesis. This literature has adopted different approaches and shown mixed results. In their global, macro-level analysis using population estimates from the United Nations, Bongaarts and Guilmoto (2015) found that the contribution of prena- tal discrimination to newly missing women in the world had increased since the 1
1980s, while the contribution of postnatal discrimination had shown small declines since the 1990s. Although at the global level excess female deaths have decreased, Kashyap (2017) found that patterns of change in excess female mortality in coun- tries that saw the onset of prenatal sex selection varied across countries and by period. Notably, in India and China, relative excess female mortality was remark- ably persistent even as SRB distortions set in, increased and began to stabilise. In the 2000s, India, Nepal and Pakistan showed slight reductions in excess female mortality, even though levels of excess female mortality continued to remained high in these countries. These macro-demographic analyses highlight the relative contributions of prena- tal and postnatal manifestations of son preference to overall changes in the numbers of missing women Bongaarts and Guilmoto (2015) or child sex ratio distortions Kashyap (2017). The methods used in this studies, however, do not permit an assessment of whether changes in prenatal sex selection explain variation in mor- tality changes. Reductions in excess female mortality could occur independently of changes in prenatal sex selection, through wider modernisation processes that entail the weakening of son preference. In contrast, country-specific studies using micro-level data from birth records have sought to identify the impact of sex-selective abortion, either via liberalised abortion or access to ultrasound, on excess female female child mortality. Drawing on birth registration data in Taiwan, Lin et al. (2014) found evidence in favour of substitution, where abortion legalisation in 1985 in a country where ultrasound was already available, led to faster improvements in female neonatal survival relative to males for higher parity births. For India, evidence has been mixed. Hu and Schlosser (2015) found that birth cohorts experiencing prenatal sex selection as in- dicated by distorted SRBs witnessed faster reductions in malnutrition rates for girls relative to boys, but found no statistically significant evidence for faster reductions in mortality for girls. In contrast Anukriti et al. (2016), found evidence for faster reductions in mortality for a subset of girls. In the period when ultrasound became widely available, the authors found the mortality gap between second- and higher- order girls with first-born brothers compared with those with first-born sisters was eliminated. This paper contributes to this literature tackling the relationship between pre- natal sex selection and postnatal excess female child mortality by expanding the analyses across different countries where SRB distortions have emerged. These in- clude contexts in South Asia (India, Nepal and Pakistan) as well as those in the Caucasus (Armenia, Azerbaijan, and Albania). Drawing on micro-level birth his- tories from the Demographic and Health Surveys (DHS), I first examine mortality outcomes by child gender across these different countries. Then, using the DHS data in combination with UN data data on SRBs, I examine if girls made faster reductions in mortality for the cohorts that experienced the uptake of prenatal sex 2
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