assessment of interventions on sex-selection in nepal ... · until recently, maternal mortality...
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AssessMent of InterventIons on
sex-selectIon In nepAl: lIterAture revIew
Mahesh puriAnand tamang
Established in July 1994, Center for Research on Environment Health and Population Activities (CREHPA) is a not-for-profit research organization based in Kathmandu, Nepal. The organization conducts policy relevant research on population, reproductive and sexual health and rights including on gender-based violence in collaboration with government ministries, universities, bilateral, multi-lateral agencies and international non-governmental organizations. Results of policy research are disseminated widely and utilized for advocacy to influence law and policy decisions.
CREHPA
Kusunti-13, Lalitpur, Nepal P.O. Box : 9626, Kathmandu Phone : 977-1-5546487, 5521717 Fax: 977-1-5522724 E-mail : [email protected] Web: www.crehpa.org.np
This review has been funded by UK aid from the UK Government; however the views expressed do not necessarily reflect the UK Government’s official policies.
The Population Council confronts critical health and development issues—from stopping the spread of HIV to improving reproductive health and ensuring that young people lead full and productive lives. Through biomedical, social science, and public health research in 50 countries, we work with our partners to deliver solutions that lead to more effective policies, programs, and technologies that improve lives around the world. Established in 1952 and headquartered in New York, the Council is a nongovernmental, nonprofit organization governed by an international board of trustees.
The information and views expressed in this report do not necessarily reflect the views of the Population Council.
Suggested Citation: Puri, M. and A. Tamang. 2015. Assessment of intervention on sex-selection in Nepal: Literature review. Kathmandu, Nepal: CREHPA.
Printed at : [email protected]
Assessment of InterventIons on
sex-selectIon In nepAl: lIterAture revIew
mahesh puriAnand tamang
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Abbreviations and AcronymsCAP Centre for Awareness Promotion
CBS Central Bureau of Statistics
CEDAW Convention on the Elimination of all Forms of Discrimination against Women
CI ConfidenceInterval
CREHPA CenterforResearchonEnvironmentHealthandPopulationActivities
CSR ChildSexRatio
DFID DepartmentforInternationalDevelopment
DSRB DesiredSexRatioatBirth
GBV GenderBasedViolence
MDG MillenniumDevelopmentGoal
MoHP MinistryofHealthandPopulation
NA NotApplicable
NDHS NepalDemographicandHealthSurvey
ND No Date
NESOG NepalSocietyofObstetriciansandGynaecologists
NGO Non Governmental Organization
NHSSP NepalHealthSectorSupportProgramme
NPR NepaleseRupee
SRB SexRatioatBirth
TV Television
UCL UniversityCollegeLondon
UN UnitedNations
WHO WorldHealthOrganization
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table of contents AbbreviationsandAcronyms iii
ListofTables vii
List of Figures vii
Acknowledgements ix
Chapter1 Introduction 1
Chapter2 Trendsanddifferentialsinsexratioatbirthandchildsexratio 5
Chapter3 Ongoingeffortstoreversethetrend 11
Chapter4 Concludingremarks 15
References 17
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list of tablesTable1: TrendsinSRBinNepal 5
Table2: TrendsinSRB1andCSRbyDevelopmentRegions,Nepal 6
Table3: Sexratiosatbirth(malebirthper100females),bybirthorder,1992–2010 7
Table4: Summaryofavailablepolicies,programmesandinterventions 13
list of figuresFigure1: TrendsinSRB1inNepal,1952/54–2011 5
Figure2: TrendsinChildSexRatiosofboystogirlsofages0–4in2001and2011 7
Figure3: Childsexratioofboystogirlsatages0–4in2001and2011bydistrict 8
Figure4: PopulationsexratiobyCaste/Ethnicity(maleper100females) 9
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AcknowledgementsThesuccessfulcompletionofthisliteraturereviewisanoutcomeofthecollaborativeeffortsofCenterforResearchonEnvironmentHealthandPopulationActivities(CREHPA),PopulationCouncil-Indiaandmanyotherorganizationsandindividuals.Firstofall,wewouldliketothankthePopulationCouncilforentrustinguswithsuchanimportantpieceofwork.ThestudyteamwishesitssinceregratitudetoDr.ShireenJejeebhoy(PopulationCouncil,India)forherinput,technicaladvice,guidanceandsupportthroughoutthestudy.Finally,weexpressoursinceregratitudetoDr.PriyaNanda(InternationalCenterforResearchonWomen,India)andDr.MelanieFrost(OxfordUniversity,UK)fortheirexcellentreviewandsuggestions.
Mahesh Puri AnandTamang
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chapter 1IntroductionTheobjectivesofthisreviewaretobetterunderstandhowbesttorespondtoadversesexratiosatbirthinNepal,byfirstlysynthesisingatthecountry-levelwhatisknownaboutlevels,trendsandfactorsunderlyingunbalancedsexratiosatbirthaswellasprogrammesandinitiativesthathavethepotentialforreversingthetrend.Thesecondobjectivewastobuildontheinsightsofthefirst,andexamine,throughprimaryresearch,theperspectivesofstakeholdersabouttheprogrammesandinitiativesthataimedtoempowergirlstorespondtoadversesexratioatbirthinselectedsettings,andassesstheextenttowhichsuchaprogrammeorinitiativeshowspromiseormaybescalable,ifatall.Therefore,thisreviewfirstlyhighlightsthesituationwithregardstothesexratioatbirthincludinggeographic,otherdisparitiesandlikelyantecedents,andsecondlysynthesisesanyapproachesthroughwhicheffortshavebeenmadetoaddressthepracticeofsexselection.Findingsareexpectedtodrawattentiontogapsinevidenceandoutlineareasofresearchthatareneededtoarriveatevidence-basedrecommendationsforaction,andtoprovideevidence-basedguidancetohelppolicy-makersanddonorsdeterminefeasibleandeffectiveinterventionsthatmayholdpromise.
1.1 BackgroundNepalisgeographicallylocatedbetweenIndiainthesouth,eastandwest,andChinainthenorth.ThesouthernplainsarehistoricallyinfluencedbyHinduculture,andthenorthernmountainsbyTibetan-Buddhistculture.ThoughthisdichotomyoftheNepalipopulationignoresthevitalityanduniquenessofmanytribalreligionsandculture,includingMuslims;Nepaliculture,traditions,valuesandsocialnormsexhibitmanysimilaritiestoitsneighbours,particularlywithIndia.ItisessentialtohaveasonforseveralreasonsthatarecriticaltoNepaliculture.Thesestemfrompatriarchaltraditionsthatarestronglyupheldinthesociety.Malerolesaredifferentlyvaluedthanfemaleroles—bothrolesserveafunctionbutthereisadominanceinvalueattributedtotheroleofmenandsonsinsociety.Womenareconsideredaneconomicburden,whilesonsareconsideredassets.Inheritanceandlandrightsfavourmales,andageingparentsdependontheirsonsfortheirelderlycare.Higherparticipationofmalesinformalincome-generatingactivitiesplacemalesinpositionsofpowerinafamily.Moreover,somereligiousritualscanonlybeperformedbysons,suchasfuneralritualsuponaparent’sdeath.Women,ontheotherhand,leavetheirparents’homeuponmarriageandtakedowries,makingthemaperceivedunproductiveinvestment,fromtheparents’perspectives.
Strongsonpreferencecanleadtoincreasednumberofboys,anddifferentialtreatmentofgirlsintermsofresourceallocation,leadingtofemaledisadvantageinmortalityandmorbidity.Accordingtothe2011Census,amongthechildrenbelow10yearsofageinNepal,thenumberofmalechildrenexceedfemalechildrenby2.2percent.InurbanNepal,5.6percentmoremalethanfemalechildrenwerereportedascomparedto1.7percentmoremalethanfemalechildreninruralNepal(CentralBureauofStatistics,2012).Newbornfemaleshaveabiologicaladvantageinsurvivalovernewbornmalesandthroughoutthelifesameisexpectedifaccesstoresourcessuchasfoodandmedicalcareissameformaleandfemale(Waldorn,1998).InNepal,however,althoughmoremaleneonatesdiethanfemale(Male:37deathsperthousandlivebirths,Female:33deathsperthousandlivebirths)femalepostneonatalmortality(betweentheagesof28daysand1year)ishigher(19perthousandlivebirths)thanthemalepostneonatalmortalityrate(17perthousandlivebirths)(MinistryofHealthandPopulation,NewEraandICFInternationalInc,2012).
Strongsonpreferencecompoundedbyavailabilityofsexdeterminationtechnology(e.g.ultrasonography)enablescouplestoresorttosexselectiveabortionwhichcontributestoincreasedsexratioatbirth(SRB)andanimbalancedpopulationsexratio(Guilmoto,2009).UltrasonographyhasbecomemoreavailableoverthepastdecadeandcostsaroundUSD6eveninruralandremoteareasofNepal(NepalHealthSectorSupportProgramme,2013).TheGovernmentofNepalispromotingatleasttwoultrasonographyscansasacomponentofantenatalcare(NepalHealthSectorSupportProgramme,2013).FertilityisrapidlydeclininginNepal.Inthepast15years,fertilityofNepaliwomenhasdecreasedbytwochildren.Onaverage,awomanduring1996usedtohave4.6birthsbutitdecreasedto2.6birthsperwomenin2011(MinistryofHealthandPopulation,NewEraandICFInternationalInc,2012).
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Untilrecently,maternalmortalityratio(281per100,000livebirths)ofNepalwasamongthehighestintheworld(MinistryofHealthandPopulation,NewEraandICFInternationalInc,2007).Significantproportionsofmaternaldeathsandlifethreateninggynaecologicalcomplicationswereattributedtounsafeabortions(Pradhanetal.,2010).Inresponsetotheincreasingevidenceofmaternaldeathsandinjuriesrelatedtounsafeabortions,andtoprovideNepaliwomenwithincreasedpowertodecideontheirfertilitychoices,in2002theGovernmentofNepalamendedthe Muluki Ain 1959(themainNationalLegalCode)whichhadearlierrestrictedabortioninanycasecharacterisingitasanoffenceagainstlife(MinistryofLaw,JusticeandParliamentaryAffairs,1997).ThisamendmentledtodevelopmentoftheNationalSafeAbortionPolicyandStrategy2002whichensuresaccesstosafeabortionservicesunderthefollowingconditions:upto12weeksofgestationuponpregnantwomen’sconsent;upto18weeksofgestationifthepregnancyresultsfromrapeorincest;atanytimeduringpregnancyifitthreatensthelife,physicalormentalhealthofwomenorinthecaseofadeformedfoetuswiththeadviceofamedicalpractitionerandthepregnantwomen’sconsent(MinistryofHealthandPopulation,2002).Furthermore,onlycertifiedprovidersbasedoncertifiedclinicscanperformtheprocedure.Terminationofpregnancywhichhaveindicationsofsexdeterminationislegallyprohibited(MinistryofHealthandPopulation,2002).
Accesstotechnologiesthatcandeterminethesexoffoetus,cultureofstrongpreferenceforsons,expansionofsafeabortionservices,rapiddeclineintotalfertilityrate(MinistryofHealthandPopulation,NewEraandICFInternationalInc,2007;2012)andrecentreportsofskewingsexratioatbirthinNepal(CenterforResearchonEnvironmentHealthandPopulationActivitiesandUNFPA,2007;Frost,PuriandHinde,2013)hasraisedsomeconcernsamongresearchers,policy-makersandprogrammeimplementers.Sonpreferenceforchildrenhasbeenaglobalphenomenon(Barot,2012).Considerableattentionhasbeendevotedtothisproblembecauseofitsharmfuleffectstothechildrenoftheless-desiredsex.Moreover,itcanhaveunfavourabledemographicandsocialconsequences.Forexample,stronggenderpreferencecanleadtosex-selectiveabortions,andhencetoskewedsexratios(Guilmoto,2009).Consequencesofskewedsexratioatbirthincountrieswheretheissuehasbeenprevalentforlongtimeareexpectedtobedire.Daughterpreferenceislessobservedaroundtheglobeandincountrieswheresonsarepreferredtodaughters,andSRBishighlyskewed,consequencessuchasshortagesofmarriageablewomen,highrateofrape/incest,violence,abduction,traffickingandriskysexualbehaviourshasbeendocumented(HeskethandXing,2006;UNFPA,2012;Bienetal.,2013).
1.2 laws on preconception and prenatal diagnostic techniquesPriortoitsamendmentin2002,theabortionlawinNepalwashighlyrestrictive:abortionwaspermittedonlytosaveawoman’slife.Accordingtostudiespublishedbefore2001,unsafeabortionwasprevalentanddeathsfromabortion-relatedcomplicationsaccountedformorethanhalfofmaternaldeathsthatoccurredinmajorhospitals.TheamendmentoftheMuluki Ainin2002guaranteesNepaliwomentherighttosafeabortiononwiderground (e.g.foranyreason,upto12weeksofpregnancyifawomandesirestoterminatethepregnancy).
HowevernoseparatelawregardingpreconceptionandprenataldiagnostictechniqueshasbeenenactedinNepal.InthepresentMuluki Ain,whichliberalisedtheoldrestrictivelawonabortion,thereisclauseNumber 28A which restrictstheuseoftechnologyoranymeanstodeterminethesexofafoetusforthepurposeofsex-selectiveabortion.Thelawstates:
‘’No one shall commit or cause to be committed an act to identify (determine) the gender of the foetus for the purpose of abortion. A person who commits this offence shall be liable to the punishment of imprisonment for a term ranging from three months to six months.’’
Accordingtothelaw,boththewomenundergoingthesexdeterminationtestandthephysician/medicalpersonnelconductingsuchatestforthepurposeofsexselectionshallbeimprisonedforatermrangingfromthreetosixmonths.Moreover,ifthewomenundergoingthesexdeterminationtestisdoingsoasaresultoffamilypressure,ifitcanbeprovedinthecourtoflaw,thefamilymemberwhohadputsuchapressureonthewomenandthemedicalpersonnelconductingthetesttorevealthesexofthefoetusareliableforimprisonmentalso.However,itisnotstatedeitherintheMuluki AinorNationalSafeAbortionPolicyandStrategy2002abouttheinstitutionsresponsibleforenforcingthelawandmonitoringitsimplementation.Untilthisdate,nocriminalprosecutionhasbeenmadeinNepalagainsttheoffenceofsexdeterminationtestorsexselectiveabortionbecauseofthelackofsurveillancemechanisms(Lamichhaneetal.,2011).
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1.3 socio-cultural context of gender and son preferenceSincehistorictimes,Nepalhasbeenapatriarchalsociety.WomeninNepalfaceunequalpowerrelationswiththeirmalecounterpartsandstronggender-basedbarrierstorealisingtheiraspirations.PatriarchalvaluesaredeeplyingrainedinthesocialandeconomicspheresofNepalilifewhichhasledtothedevelopmentofgender-biasedinstitutionsandstructures,ideology,andsocialnormswhichcontinuetolimittheprogressofwomen.Thesestrongbiasesagainstwomenareclearlydepictedinthedailyrealityofsonpreferenceinsociety.
SonpreferenceisacommonphenomenoninNepal.Inthiscountry,asonispreferredtoadaughterforseveralreasons;includingcarryingonfamilylineageandprovidingsupporttoelderlyparentsandperformingfuneralritualsfordeceasedparents(Nandaetal.,2012;Subedi,2011;Puri,2010).Genderinequalityremainsprevalenceacrossallreligious,social,cultural,economicandpoliticalspheresoflife.DuetodeeplyembeddedpatriarchalvaluesinNepalisociety,opportunitiesintermsofeducation,health,employment,decisionmaking,andinothersocialandeconomicdimensionsarelimitedforgirlsandwomen.Inaddition,gender-basedviolenceiswidelypracticedandacceptedacrossNepal,controllingandconfiningwomenwithinthedomesticsphereofhome(MinistryofHealthandPopulation,NewEraandICFInternationalInc,2012).
Limitedstudiesthathavefocusedongenderselection,differentialsinhealthcarebygender,desiredsexcompositionofchildrenandcontraceptiveuse,haverevealedthatsonpreferencehasbeenverystronginNepalwhencomparedtoothercountriesaroundtheworld(Arnold,1997;Leone,MatthewsandZuanna,2003;CenterforResearchonEnvironmentHealthandPopulationActivitiesandUNFPA,2007;Jayaraman,MishraandArnold,2009;Frost,PuriandHinde,2013;Bongaarts,2013).Arnold(1997)usingdatafromNepalFertility,FamilyPlanningandHealthSurvey1991and56DemographicandHealthSurveysfrom44othercountriesconductedduringa10yearperiodfrom1986to1995foundthat,amongallcountries,evenatparityone,womenfromNepalonlyshowedpreferenceforsons(89percentwithadaughterascomparedto79percentwithasonwantedtobearanotherchild).Sonpreferenceincreasedstarklybythesecondparityasmorethanthreetimesasmanywomenwhohadtwodaughters(77percent)wantedtocontinuechildbearingascomparedtowomenwhohadtwosons(25percent).Asimilarpatternwasobservedastheparityincreased.Statisticallyasignificantdifference(at0.05level)wasobservedbetweenthewomenwhohadasonastheirlastchild(14percent)andwomenwhohadadaughterattheirlastbirth(17percent)intermsofdesirabilityofthelastbirthatthetimeofpregnancy.Moreover,contraceptionutilisationratesbysexratioofthelivingchildrenalsoshowedextremesonpreferenceamongNepaliwomen.Amongwomenwhohadpermanentsterilisation,thesexratiooflivingchildrenwas135ascomparedto95forwomencurrentlynotusinganycontraceptiveand109forwomenusinganymethod.
Likewise,Leone,MatthewsandZuanna,2003examinedsonpreferenceandgenderbiasinNepalusingthe dataofNepalDemographicandHealthSurvey1996.Thestudyfoundstrongsonpreferenceamong4,661 ever-marriedNepaliwomenaged15–49whohadstoppedchildbearing.Theoverallsexratioatlastbirthwas 146,whichsuggeststhewayfamiliesexercisepreferenceforson,indicatingatendencytostopchildbearingwhenasonwasborn.Furthermore,thestudyfoundthesexratioof185amongthewomenwhohadstoppedchildbearingatparityoneandparitytwowhichshowsthatwomenwhostoppedchildbearingatlowerparitiesaremorelikelythanwomenwhostoppedchildbearingathigherparitiestohavehadasonastheirlastchild.Women’sbehaviourinceasingtobearchildrenafterhavingasonwasfurtherstrengthenedbytheevidencethatwomenwhohadstoppedchildbearingorhadbeensterilisedafterhavingthreechildren(n=1,322),64percenthadstoppedchildbearingafterhavingasonascomparedto36percentafterhavingadaughter.Likewise,greatdisparityincontraceptionprevalencewasobservedasaresultofsonpreference.Among5,902womenwithuptofourchildren,theoverallcontraceptionprevalencewas25percent.Ifthesewomenhadhadnodesireforason,thecontraceptiveprevalenceratewouldhavesoaredto33percent.Theeffectofsexcompositionoflivingchildrenoncontraceptionusearefurtherevident.Forexample,44percentofwomenwithtwosonsusedmoderncontraceptionbutonly16percentwithtwodaughtersdidso.Disparityincreasedsharplyatparitythree;womenwiththreesons(44percent)wereseventimesmorelikelytouseamodernmethodofcontraceptionwhencomparedtowomenwiththreedaughters (6percent).Similarly,thestudyshowedthatsonpreferenceamongNepaliwomenhadaneffectontheirfertilityalso.Among5666parouswomen,theoveralltotalfertilityratewas4.43,whichwas6percenthigherthantherateintheidealscenarioofabsenceofsonpreference(4.16)(Leone,MatthewsandZuanna,2003).
TheCenterforResearchonEnvironmentHealthandPopulationActivitiesandUNFPA(2007)studiedgenderpreferenceatbirthandreasonsbehindsuchpreferencesusingqualitativeandquantativetechniquesinfivedistricts;
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Dhanusa,Parsa,Kapilbastu,Gorkha,andKathmandu.Thestudywasconductedamong2,644marriedwomenoftheagegroup15–49years,theirhusbandsandmother-in-lawstounderstandtheaspectsofgenderpreferences.Thestudyshowedthatinthefirstpregnancy,themajorityofthewomen(54percent)hadnogenderpreference, 40percentpreferredsons,andonly6percentpreferreddaughters.Ingeneralsonpreferencewashighestamong mothers-in-law(52percent)followedbyhusbands(50percent)whereasdaughterpreferenceinthefirstpregnancystoodverylow;at4percentand3percentrespectivelyforhusbandsandmothers-in-law.PreferenceforsonswashighintheTerai(lowland)communities(51,47,42percentagesrespectivelyforYadav,TeraiDalitandTharu)ascomparedtowomenofHillcommunities(28percentforHillBrahminandMagars).Majorreasonsforsonpreferencethatwerecitedare:elderlyparentsupport(79percent),economicvalue(67percentcarryingfamilylineage(60)andfuneralrituals(59percent).Qualitativefindingsalsorevealedsimilarreasonsforsonpreference.Someofthemajorreasonsfornotpreferringdaughterswerethatdaughtersgotothehusband’shomeaftermarriage,anddowry,makingwomenaperceivedunproductiveinvestment.Thestudyalsorevealedthatwomenfacetremendouspressurefromhusbands(42percent)andmothers-in-law(41percent)tobearsons.Womenwhohaddaughtersastheirfirstchildrenfaceddifferentformsofphysicalandpsychological,suchaspressuretobearmalechildren(thatincludedhitting/beating(18percent),receivingimpropermeals(38percent),husband’sthreateningpolygamy(40percent)andcontinuousscolding(86percent).Interestingly,thestudyfoundthatofthe2,504ever-pregnantwomen, 222hadusedsomemeasurestoinfluencethesexoftheirchildtobemale,whichincludedobservingreligiousrites,visitingshamansorconsultingadoctortofindoutifanymedicalmeasurescouldhelpthemtobearmalechildrenintheirnextpregnancy.
AnotherstudybyFuse(2008)whichmeasuredgenderpreferenceattitudesusingDemographicandHealthSurveydatafrom40countriesincludingNepalDemographicandHealthSurvey2006foundthatamong10,363womenofreproductiveage(15–49years)fromNepal,17percentdidnothaveanygenderpreference,52percentwishedthattheyhadanequalnumberofsonsanddaughters,29percentpreferredmoresonsand1.6percentpreferredmoredaughters.Amongallthe40countries,womenfromNepalstoodatfifthpositionintermsofsonpreferenceandsecond(toPakistan)whencomparedtoitsSouthAsiancounterparts.Amongallthe40countries,womenfromNepalshowedleastpreferencefordaughters(1.6percent),puttingitattopoftherankintermsoflowdaughterpreference.
Similarly,Jayaraman,MishraandArnold,2009examinedtheextentofsonpreferencebystudyingtheinfluenceoffamilysizeandcompositiononreproductivebehaviourinthreeSouthAsianCountries—Nepal,IndiaandBangladesh—usingthedatafromDemographicandHealthSurveysofrespectivecountriesthatwereconductedaround2006.Theanalysisbasedontheresponsesof6,950non-pregnant,currentlymarriedwomenof15–49yearsfromNepalfoundthatthedesireforanotherchilddecreasedasparityincreasedandatanygivenparity,womenwithhighernumbersofsonsshowedtheleastdesireforanotherchild.Atparityone,77percentofthewomenwithnosonsand64percentofthewomenwithonesondesiredforanotherchild.Thedesireincreasedstarklyatparitytwo,with51percentofwomenwithtwodaughtersdesiringanotherchildcomparedto6percentofwomenwithtwosons.Similarlyatparitythree,45percentofwomenwiththreedaughterswantedanotherchildwhereasonlyonepercentwomenwiththreesonswantedmorechildren.Similarpatternswereobservedastheparityincreased.Contraceptiveusepatternsalsoindicatedstrongsonpreference.Atparitytwo,nearlytwotimesasmanywomenwithtwosons (64percent)usedmoderncontraceptivesthanwomenwithtwodaughters(35percent);thatis,womenwithtwosonsexceededtheuseofmoderncontraceptivesby29percentascomparedwithwomenhavingtwodaughters.Likewise,amongthewomenusingpermanentcontraceptionatparitytwo,only4percentwerewomenwithtwodaughtersascomparedto41percentwithtwosons.Aftercontrollingforsocio-economicfactorslikeeducation,householdwealth,workstatusofthewomen,mediaexposureandparticipationinhouseholddecisionmaking,theeffectofsexcompositionandparityondesireforanotherchildandcontraceptionusewasmostprofoundinNepal,indicatingstrongdesireforsons,ascomparedtoIndiaandBangladesh.
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chapter 2trends and differentials in sex ratio at birth and child sex ratio
2.1 trends in sex ratio at birth and child sex ratioSexratioatbirth(SRB)isdefinedastheratioofmaletofemalebirthsinapopulation,multipliedby100.Theratiocanvarysomewhatduetobiologicalfactors,butitsnormalvalueusuallyrangesfrom104–106(WorldHealthOrganization,2011).AccuratefiguresforsexratioatbirtharedifficulttoobtaininNepalasvitalstatisticsareinadequate(WorldHealthOrganization,2014)andNepal’sCensusdatadonotincludeSRBfigures.MostrecentestimatesofSRBforNepalbytheUnitedNations(UN)hasbeenfairlyconsistentat105malebirthsper100femalebirthsfortheperiodof1950–2010(UnitedNations,2013).
NepalDemographicandHealthSurveys(NDHS)alsoprovideestimatesofSRB.Althoughsmallsamplesizesmayaffecttheestimates,ithasbeenveryclosetoUNestimates(UnitedNations,2013).AccordingtoNDHS2011report,SRBinNepalstandsatanexpectednormalstablelevelof106(MinistryofHealthandPopulation,NewEraandICFInternationalInc,2012).EarlierreportshadsuggestedlowerSRBwhencomparedtoUNestimates(Table1).
TheNDHSdespitebeinganationallyrepresentativesurvey,hadasmallsampleofbirthsandduetolackofdataonSRBbasedonvitalregistrationsinNepal,sexratioforthepopulationbelowoneyearofage(SRB1-SRB1isthesexratioforthepopulationbelowoneyearofage—calculatedbytotalnumberofmalepopulationaged1yearsdividedbytotalnumberoffemalepopulationofthesameagegroup(oneyearage)thoughaffectedbysexdifferentialsininfantmortality,isusedinthisreviewasaproxyindicatorofSRB.ThisvariablewasearlierusedonastudybyCREHPA(2007).
Table 1:TrendsinSRBinNepal
Year Sex ratio at birth
1996 104
2001 103
2006 104
2011 106
Source: Pradhan et al., 1997, MOHP et al., 2002; 2007 and 2012
Source: CREHPA 2007; Central Bureau of Statistics, 1993; 2002 and 2012
Figure 1:TrendsinSRB1inNepal,1952/54–2011
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AccordingtothelastthreeCensuses,SRB1inNepalhasconsistentlyincreasedfrom103.5in1991(CBS,1993)to104in2001(CBS,2002)andreacheditsbiologicalceilingof106in2011(CBS,2012)(Figure1).
Whenlookingatthesub-nationallevel,duringtheperiodof2001to2011,SRB1infourdevelopmentregionsincreased(Table2)butremainedwithinitsexpectednormalrangeof104–106.TheWesternDevelopmentRegionwasanexception;SRB1inthisregionstarklyincreasedfrom105in2001to110in2011(Table2).Censusreportsearlierthan2011didnotprovideinformationaboutpopulationbelowoneyearofageatalowerlevelofdisaggregation(belowdevelopmentregions),therefore,comparisionoftrendsatadministrativeorgeographicallevelsbelowdevelopmentregionswasnotpossible.However,CenterforResearchonEnvironmentHealthandPopulationActivitiesandUNFPA,2007statedthatin2001,atanecologicalregionallevel(Mountain,HillandTerai)SRB1wascomparabletonationalSRB1(104)anddidnotvarymuchbetweenMountain,HillandTerai.
Table 2:TrendsinSRB1andCSRbyDevelopmentRegions,Nepal
Development Region SRB1 CSR
2001 2011 2001 2011
Eastern 105 106 103 104
Central 105 106 103 105
Western 105 110 103 107
Mid-Western 101 104 101 104
Far-Western 104 106 103 105
Source: Central Bureau of Statistics, 2002; 2012
Howeverin2011,SRB1forHillandTerairegionincreasedto107(aboveitsbiologicalceling)butintheMountainregionSRB1stoodat103(CentralBureauofStatistics,2012).
Childsexratio(CSR)isassumedtobewithinthenormalrangeof104–106likeSRB.Moreboysthangirlsdieduringthefirstmonthoflifeandmoregirlsthanboysdieatages1–59months(MinistryofHealthandPopulation,NewEraandICFInternationalInc,2012).SinceCensusreportsaretheonlysourceofcompletedemographicdataandNepal’sCensusreportsprovideinformationaboutageofpopulationintermsofsingleyearsoringroupoffiveyears,forthisreview,achildhasbeendefinedasanindividualfromtheagesof0–4years.
AccordingtolastthreeCensuses,CSRhadbeenconstantat103during1991(CentralBureauofStatistics,1993)and2001(CentralBureauofStatistics,2002)whichincreasedto105in2011(CentralBureauofStatistics,2012).Whencomparedatthedevelopmentregionlevel,during2001,CSRwasthesameasitsnationalaverage(103)infourdevelopmentregionswhereasintheMid-Westerndevelopmentregion(101)itwaslowerthanexpected(Table2).In2011,CSRincreasedinalldevelopmentregionsandreachedtheexpectednormalvalueinfourdevelopmentregions(104intwoand105inothertwo)withtheexceptionofWesternDevelopmentRegionwheretheCSRcrosseditsbiologicalceilingat107(Table2).Moreover,during2001,onlythreedistricts(Figure2),twofromCentralDevelopmentRegion(Bhaktapur,Kathmandu)andonefromWesternDevelopmentRegion(Mustang)hadCSRgreaterthanitsbiologicalceilingat109,107and116respectively.However,in2011,districtswithCSRgreaterthan106increasedto13(Figure2)amongwhichfivedistricts(Kavrepalanchowk,Bhaktapur,Lalitpur,KathmanduandChitwan)werefromtheCentralDevelopmentRegion,sevenfromtheWesternDevelopmentRegion(Nawalparasi,Rupandehi,Argakhachi,Syanga,Gulmi,PrabatandKaski)andonefromtheFarWesternDevelopmentRegion(Kanchanpur).
Frost,PuriandHinde,2013usingdatafromfourroundsofNepalDemographicandHealthSurvey1996,2001,2006and2011analysedsexratioatbirthaccordingtotime,birthorderandsocio-economiccharacteristicsofmotherstoidentifyifsexselectionisprevalentinNepal.Intheirstudy,sexratioatbirthwasdefinedasthenumberoffemalebirthsper1,000malebirths,however,tomaintainconsistencyacrossthisreview,reportedsexratioswereconvertedtonumberofmalebirthsper100femalebirths.Intheabsenceofhumaninterventionssuchassexselectiveabortion,sexratiosrarelyvaryfromthenormalbiologicalrangeof104–106bybirthorderandthesexofpreviousbirth.Toexamineifhumaninterventionistakingplace,conditionalsexratio,whichissexratiobybirthorder
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andsexofpreviousbirthcanbringsomelighttothisquestion.ThestudyfoundnostatisticallysignificantoverallSRBhigherthanbiologicalnormalduringtheperiodof1992–2010andsimilarresultswereobtainedforsexratiosoffirstorderbirths(95percentofsexratioswerewithinnormalbiologicallimits)(Table3,95percentCInotshownthetable).However,atsecondorderbirthwhenthefirstbornwasafemale,statisticallysignificantsexratioof135(95percentCI:109to167)wasobservedduringtheperiodof2007–2010.Sexratioofsecondorderbirthwhenfirstchildisfemaleindicatessexselectiveabortionbeingpracticedinapopulation(Jhaet.al.,2011).Nostatisticallysignificanthighsexratiowasobservedinhigherorderbirths.Thislackofstatisticalsignificanceispartlyduetothesmallnumberofbirthsduringthestudyperiodandasthebirthorderincreased,thenumberofbirthsdecreasedsignificantly(refertoFrost,PuriandHinde,2013).
Figure 2:TrendsinChildSexRatiosofboystogirlsofages0–4in2001and2011
Source: Central Bureau of Statistics, 2002; 2012
Table 3:Sexratiosatbirth(malebirthper100females),bybirthorder,1992–2010
Birth order All First born Second born Third born Fourth or above
Sex of previous children
NA NA First born male
First born female
Both male
Both female
One male, one female
NA
Year Mean Mean Mean Mean Mean Mean Mean Mean
1992–1994 103 104 94 105 123 97 102 104
1995–1997 105 114 117 103 108 103 88 105
1998–2000 103 109 111 98 100 118 105 99
2001–2003 108 110 122 106 107 115 113 103
2004–2006 104 103 103 120 108 118 96 101
2007–2010 107 99 122 135* 112 130 107 91
*95 percent CI fell outside biological normal range (104–106)Source: Frost, Puri and Hinde, 2013
8
Recently,Bongaarts(2013)usingDemographicandHealthSurvey(DHS)datafrom61countriesincludingNepal(NDHS2006)andUNestimatesofsexratioatbirthexaminedsonpreferenceandwaysofthesepreferencesbeingexpressed.ThisstudyshowedthatNepalrankedfifthamongthe12countriesinwhichsonpreferencewasstrongest,showingthatdesiredsexratioatbirth(DSRB)exceeded120.
Ahospital-basedstudyconductedinKathmanduusingretrospectivedataofbirthhistoriesduringtheperiodbetween2003and2008(Adhikari,GhimireandAnsari,2008).Thisstudyfoundthatamong31,288livebirthsduringtheperiod,17,439weremaleand13,849werefemalewithanoverallsexratioof114.Further,whenthelivebirthsweredividedasfirstlivebirths,secondlivebirthsand,thirdandsubsequentbirthsindicatingbirthorder,thesexratioswere106.4,118.2and177respectivelyindicatinghighsonpreferencesamongthewomendeliveringinthestudyhospital.Theauthorsindicatedthatprenataldetectionofsexoffoetusesmighthavealteredthesexratioofsecondandsubsequentbirths,butcannotbeconfirmedfromthehospitaldata.
2.2 Differentials in sex ratios
2.2.1 regionAccordingtotheCensus2011,SRB1variesgreatlyindifferentpartsofNepal.Despitebeingwithinitsnormalrangeinthecountry(106),SRB1wasfoundtobehighinurban(112)areaswhencomparedtoruralareas(106).SimilarlyitwashigherthanexpectedinHillandTerairegionswithSRB1of107,whereasinMountainregions,itfellbelowitsnormalrange(103).Asreportedearlierinthisreview,SRB1wasnormalinfouroutoffivedevelopmentregionswhereasintheWesternDevelopmentRegionSRB1washighat110(Table2).ThoughhighSRB1isonlynoticeableinonedevelopmentregion,inconsistencywithinthesedevelopmentregionsisrevealedwhenexaminedmoredeeply.Whenfivedevelopmentregionsweredividedinto15eco-developmentregions(eachofthefivedevelopmentregionsdividedaccordingtothreeecologicalregions),itwasobservedthattheEasternTeraihadhigherSRB1(107)whichwasearliermaskedunderSRB1ofEasternDevelopmentRegion(106).Similarly,theCentralHillregionwhichfallsundertheCentralDevelopmentRegionhadelevatedSRB1at110.
WhentheCentralHillregionwasfurtherdisaggregatedtothedistrictlevel,itwasobservedthatfourdistrictshadveryhighCSR(Kavrepalanchowk-108,Bhaktapur-116,Lalitpur-111andKathmandu-114)(Figure3).Further,itwasobservedthatbothWesternHillandWesternTeraihadhighSBR1at110whichisthesameastheWesternDevelopmentRegion(110).LookingdeeperintothesituationintheWesternDevelopmentRegionrevealsthatfour
Figure 3:Childsexratioofboystogirlsatages0–4in2001and2011bydistrict
Child Sex ratio
91–101102–106
HighchildSexratio107–116
2001
2011
9
districtsfromtheWesternHillarea(Kaski-114,Parbat-107,Gulmi-109,Arghakhachi-113)andtwodistrictsfromtheWesternTerai(Nawalparasi-107andRupandehi-109)(Figure3)haveexceededthebiologicalceilingofCSR.IncaseofMid-WesternMountain,HillandTerairegionsanddistrictswithinthem,noneoftheareasshowedSRB1orCSRfavouringmales.However,inthecaseofFarWesternDevelopmentRegion,FarWesternTeraishowedabnormalSBR1at109andadistrictwithinit-Kanchanpur—hadelevatedCSRat107(Figure3),whileinFarWesternMountainandHillregions,normalSRB1andCSRwereobserved.
AsFigure3shows,ninedistrictsofNepal(Kathmandu,Bhaktapur,Lalitpur,Kavrepalanchowk,Chitwan,Kaski,Syanga,ArghakhachiandRupandehi)havehighchildsexratio(>108)inthelasttwoCensuses.Mustangisanexception(duetoasmallpopulation).
2.2.2 socio-demographicStudiesonsocio-economicanddemographicdifferentialsinSRBorsexratiosarerareinNepal.Frost,PuriandHinde,2013foundhighvariationsinsexratioofsecondorderbirthwhenthefirstchildwasafemale(ConditionalSexRatio)accordingtotheeducationandwealthstatusofthewomen.DramaticincreasesinsexratiowasobservedforthosewomenwhohaveatleastaSchoolLeavingCertificateorabove.FiveyearspriortoNDHS2006,CSRforthisgroupofwomenstoodat153malesper100femaleswhichincreasedto271fiveyearspriortoNDHS2011.TheincreaseinCSRfiveyearspriortoNDHS2011wassignificantata5percentlevelforalleducationalgroupsexceptthosewithnoeducation.Similarly,asignificantincrease(p<0.05)inCSRfrom106malesper100femalesduring1992–2003to114wasobservedamongtherichesturbanwomen.
Figure4showspopulationsexratiobycaste/ethnicity.Althoughpopulationsexratioaloneisnotagoodmeasuretoassesstheevidenceofalterationinsexratioatbirth,accordingtoastudy,theTerai-basedcastegroupshadhighersexratiothantheHill-basedcastegroupsindicatingmissingwomenintheTerairegionofthecountry(DepartmentforInternationalDevelopmentandWorldBank,2006).AmongTerai-basedcastes/ethnicities,Hinduhighcastegroups(Kayastha,Rajput,Baniya,Mawadi,Jaine,NurangandBengali)hadthehighestsexratiofollowedbytheTeraimiddlecastegroups(Yadav,Teli,Kalwar,Sudi,Sonar,Lohar,Koiri,Kurmi,Kanu,Haluwai,Hajam/thakur,Dadhe,Rajbhar,kewatMallah,Numhar,Khar,Lodha,Bingh/Banda,BhediyarandMalimKamarDhania)andTeraidalits(Chamar,Mushar,Tatma,Batar,Dhusadadh/Paswan,Kahtway,Dom,Chidimar,Dhobi,HalkhorandUnidentifiedDalit)andMuslimcommunitiesrespectively.
Figure 4:PopulationsexratiobyCaste/Ethnicity(maleper100females)
Source: DFID and World Bank, 2006
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ArarestudythatlookedatthemaleperspectivesofsonpreferenceinNepalshowedthatoccupation,ageandethnicityoftherespondentshadasignificanteffectonsonpreference(Nandaetal.,2012).Astheageincreasedthelikelihoodofhighormoderatesonpreferenceincreased(oddsratioof1.00,2.05,2.45respectivelyfortheagegroup18–24,25–34and35–49years).Disadvantagednon-DalitTeraicastegrouphadhighormoderatelevelsofsonpreference(oddsratio3.82atp<0.01)comparedtoBrahmin/Chhetricastegroups.Likewisemenwithmanualemploymentascomparedtomenwithhigherprofessionalemploymentwerelesslikelytohavehigh/moderatesonpreference.Education,typeoffamilyandmaritalstatusoftherespondentsdidnothavesignificantassociationwithhigh/moderatelevelsofsonpreference.
2.3 potential for further skewing of sex ratio at birth and child sex ratioGuilmoto(2009)suggestedthreenecessarypreconditionsthatmustbefulfilledtoachievethedesiredsexratioinanygivenpopulation.Theseinclude:accesstothesexdeterminationandabortiontechnology,lowordecreasingfertility,andpreferenceforaparticulargender.Ifwebelieveinthesethreepre-conditions,NepalwillexperienceanincreaseinadverseSRBinthefuture.Thisisduefirstlytodecliningfertility.ThetotalfertilityrateinNepalhasbeendecliningfrom4.6birthsperwomenin1996to2.6birthsperwomenin2011,adeclineoftwochildrenperwomaninthepast15years(MinistryofHealthandPopulation,NewEraandICFInternationalInc,2012).Secondly,sonpreferencecontinuestobeanentrenchedsocialnorm.AlthoughNepaliwomenincreasinglyfollowtwochildnorms(Brunson,2010;MinistryofHealthandPopulation,NewEraandICFInternationalInc,2012andCentralBureauofStatistics,2012),pressurecontinuestobeplacedonwomentoachievethedesiredsexcompositionofchildrenaswellasdesirednumberofoffspring.Therefore,sexselectiveabortionmaybethefirstadoptedbycertaingroupsasaresponsetothefertilitypredicament:reducingthenumberofchildrenwhilemaximisingtheprobabilityofhavingatleastoneson(Guilmoto,2009).Thirdly,thoughnumbersofultrasoundmachinesarenotwidelyknowninthecountry,thesefacilitiesarenowarenowcheaplyavailableinNepal(CenterforResearchonEnvironmentHealthandPopulationActivitiesandUNFPA,2007).Eveninremotedistricts,accesstoultrasonographswhereavailable,usuallycostNPR500(USD6)(NepalHealthSectorSupportProgramme,2013).Theavailabilityofportableultrasonographs,isexpectedtoincreaseinfuturebothatpublicandprivatefacilities.Moreover,theGovernmentofNepalhasrecentlyimplementedaprogramtoincreaseaccesstoultrasonographytoidentifypregnancy-relatedcomplicationsandfoetalanomalies(NepalHealthSectorSupportProgramme,2013).Increasedaccesstosuchservicescanhavebothapositiveandanegativeimpact.Ifproperorientationaboutthelawonsexdeterminationtestsandskillstodealwithrequeststorevealthesexofthefoetusisnotprovidedtotechnicians,increasedaccesstosuchtechnologiesmayhavenegativeeffects,sincetechnicianscomefromthesamesocietywheresonpreferenceisverystrongandmaybesympathetictowardswomeninthelightofviolencewomenmayfaceiftheyfailtobearason.Astudyshowedthat17percentofmenreportedthattheirwife/partnerhadevergoneforanultrasoundtestandmanyofthemhadundergonemorethanoneultrasoundtestduringtheirlastpregnancy.Onein10menwhosepartnerhadhadanultrasoundtestreportedthatitwasbecausetheywantedason.Furthermore,32percentofthemenreportedthatthesexofthefoetuswasdisclosedbytheserviceproviderswhileundergoinganultrasoundtest(Nanda etal.,2012).Thissuggeststhatdisclosureofthesexofthefoetusandviolationoftheexistinglawisnotuncommon.Anecdotalreportsandnewsfrequentlyaccusesprivatefacilitiesofprovidingsexselectiveabortions.Inaddition,womenmayaccessmultiplesexdeterminationtestsandsexselectiveabortionservicesfrommorethanoneclinicsoastohidetheirintention(Lamichhaneetal.,2011).Manyhealthworkersdescribedthedilemmatheyfacedinservingwomenseekingabortionforlegalconditionsbeyond12weeks(legalgestationlimitforabortion)whensomeofthemmightbetryingtoselectforsex.Someprovidersdescribedhowwomentriedtoconvincethemtoperformabortionsbygivingreasonsthatarenotlegallyindictedbutmightgarnertheirsympathy,suchascontraceptivefailures,unwantedpregnancy,andmisperceptionsaboutfertility.Providersalsoexpressedempathyforpatientsandtheirpressurestobearmalechildren,butwereconflictedintheirdesirestohelpandconformtothelaw(Lamichhaneetal.,2011).
11
chapter 3ongoing efforts to reverse the trend
3.1 Initiatives intended to restrict and monitor the use of technology for prenatal sex selection and law enforcementNoliteratureisavailabletoreviewtheinitiativesundertakenbytheGovernmentofNepalorotherorganisationsknowntobecloselylookingintothematterofSRBorsexselectiveabortion.Accordingtoanecdotalinformationprovidedbyconcernedauthorities,strictenforcementofthelawwasdifficultduetothedifficultyinidentifyingthecasesofabortionsthathaveproceededafterdeterminingthesexofthefoetus,andlackoffiledcomplaints.Veryrecently,afewinitiativesthataimedtoorientradiologistsandotherconcernedmedicaltechniciansabouttheabortionlawandillegalityofrevealingthesexofthefoetushavebeenplanned.AfewNGOsandthemediahavestartedawarenessraisingcampaignsagainstsexselectionamongthegeneralpublic.However,toourknowledgenoprosecutionshavebeenmadeinresponsetoviolationofthelawtodate.Moreover,itwasstatedthatmonitoringofsuchviolationsisdifficultassuchcaseswouldoccurclandestinelyundermutualunderstandingoftheproviderandtheclients.
Thoughthesocio-economicanddemographicvariationsinsexselectiveabortionpracticesanditsimpactinNepalisnotfullyunderstood,theFrost,PuriandHinde,2012studysignalsthatsexselectiveabortionsmayhavealreadystartedtohaveaneffectinalteringsexratiosatbirthincertainareasofNepal.AlthoughDHS-basedestimatesofsexratiosmayneedcarefulinterpretationbecauseoftheriskofsamplingbias(Bongaarts2013),thedatadoesprovideaclearwarningsign.The2011PopulationCensusreflectsabnormalsexratiosofthepopulationbelowoneyearofageaswellasinthepopulationaged0–4yearsinahighernumberofdistrictsandinurbanareas,ascomparedtotheearlier2001Census.Thispatternmayspreadtootherdistrictsandregionsasinnovationdiffuses.
3.2 Initiatives to build gender equalityTheInterimConstitutionofNepal(2007)(NepalLawCommission,2007)hasvariousprovisionsthatsupportgenderequality.ItrecogniseswomenasamarginalisedgroupandensureswomenreceivespecialtreatmentfromtheState.ProvisionsintheConstitutionthatdirectlyaddressgenderinequalityinclude:theprovisionofpositivediscriminationagainstwomen(Article13,clause(3)),rightsofwomenonancestralpropertyandreproductiverights(Article20)andtherighttosocialjusticeonthebasisofproportionalrepresentationofwomeninstatestructures(Article21).Thegovernmentisimplementingnumerousinitiativesintendedtoimprovegenderequity.Theyear2010wasdeclaredas“theyearagainstGender-BasedViolence(GBV)”,withamulti-sectoralActionPlanformulatedandaGenderandEmpowermentCoordinationUnit(formerlyknownastheGBVunit)establishedatthePrimeMinister’sOffice.GBVCoordinationCommitteeshavebeenestablishedatthemoredecentralisedlevels.TheGenderEqualityActwaspromulgatedin2006.ItsmainobjectiveistoeliminatevarioustypesofGBVanddiscriminationagainstwomen,andpromotionofgenderequalityandwomen’sempowerment.AHumanTrafficking(Control)Acthasbeenintroducedin2007,aswellasaDomesticViolenceActin2009.TheStandardOperatingProceduresforthepreventionofandresponsetoGBVhasbeenendorsedandGenderBasedViolenceInformationManagementSystemhasbeenestablished.Genderandsocialinclusion,gendermainstreamingandwomen’sempowermentincluding gender-basedbudgetinghavereceivedprimeimportanceinthenationalagenda.Similarly,the2007amendmenttotheCivilServiceActreserves44percentofthevacantpostsforexcludedgroups,fromwhich33percentisreservedforwomen.However,areportin2009revealedthatNepalhad96discriminatoryprovisionsand92schedules(mainlyonnationality,marriageandfamilyrelations,sexualoffences,andpropertyrights).Abilltoaddressthesediscriminatoryprovisionshasbeendraftedandisawaitingparliamentarydecision.
NepalhasbeenasignatoryofseveralConventionswhichcommitstonon-discrimination,genderequalityandsocialjustice.Forexample,theConventionontheEliminationofallFormsofDiscriminationagainstWomen(CEDAW)wasratifiedin1991.Similarly,theBeijingPlatformforAction1995,InternationalConferenceonPopulationandDevelopment1994andMillenniumDevelopmentGoals(MDGs)2000allprovideimpetustoaddressgenderinequality.
12
Asofdate,nofocusedpolicyorprogrammesexiststoaddressimbalanceinsexratiosinNepal.Itmaybeduetothefactthattheissueofimbalanceinsexratiosatbirthisanewphenomenoninthecountryandpopulationlevelchangesindemographyhavenotyetbeenobserved.However,theGovernmentofNepalhasbeenworkingtoimprovegenderequalityinallspheresoflife.Someawarenessraisingandadvocacyinitiativesagainstsexselectionhavebeenintroduced,butnoimpactevaluationofsuchactivitieshasbeencarriedout.Unfortunately,unlikeinIndia,NepaldoesnothaveconditionalcashtransferprogrammestomotivatemoreequalopportunitiesforgirlsinNepal.
3.3 Advocacy and communication activitiesThoughveryfew,advocacyandcommunicationactivitiesareaveryrecentphenomenoninNepal.In2013,theNepalSocietyofObstetriciansandGynaecologists(NESOG)developedaposterandastory-basededucational(documentary)filmaimedatendingfemalefoeticide,promotinggenderequalityandcautioningthegeneralpublicabouttheillegalityofrevealingsexofthefoetus.NESOGrequestedalloftheirmemberstoplacetheposterintheirhospitalsandclinics(NepalSocietyofObstetriciansandGynaecologists,2013).NESOGalsoorganisedafewtalkprogramsaboutthesocialeffectsofsexselectiveabortion.Forexample,on30thAugust2013,itconductedanawarenessprogramcalledANURODH(meaning‘Request’).Likewise,incollaborationwiththeNepalPeace FundandNepalTelevision,shortvideosofabout20secondsarebroadcastedeverydayatdifferenttimeswithamessage-“Nogenderpreferenceduringchildbirth”(NepalTelevisionn.d).Similarly,adiscussionontheissueofsexselectionwastelecastbyoneoftheprivatetelevisionchannels(KantipurTV)invitingaresearchexpertandthechairpersonofNepalMedicalCounciltospeak.SomeFMradiostationsarealsoairingjinglesagainstsonpreferenceandsexselection.
AsummaryofavailableinterventionsdiscussedaboveareprovidedinTable4:
Table 4:Summaryofavailablepolicies,programmesandinterventions
Programme/ Intervention
Objectives Activities Effectiveness Source
Initiatives to ensure that the law is implemented
Various efforts to raise awareness of the law
Toenhanceknowledgeandadherence to thelaw
•
•
Initiatives toorient radiologistsandmedical techniciansabout the lawNGOsandmassmediahaveinitiative awareness raising campaignsagainst sex selection
No prosecutionsmade thus far
NESOG,2013;NepalTelevision,n.d.KantipurTelevisionn.d.
Initiatives for protection of a girl child
Childhelpline To safeguard therightsof childrenbyprovidingemergencyrescueservicesandpsychosocial counsellingtoat risk children.
••
•
•••
Currently running in13districtsProvidesemergency rescueservices,reliefandpsychosocial counsellingtoat risk children.Familyandsocial integrationofchildrenReferral servicesFirstaid servicesEducational support fordropoutchildrenorat riskofdropout.
NotKnown CWIN Annual Report2007
Initiatives intended to build gender equality
YearAgainstGBV2010
To reduceviolenceagainst women
•
•
MultisectoralNationalplanofActionformulatedGender,EmpowermentandCoordinationUnit (formerly knownasGBVUnit) inPrimeMinister’sOffice
Raised Puri,ShahandTamang,2013
Cont’d on next page...
13
Programme/ Intervention
Objectives Activities Effectiveness Source
CelebrationofInternational Day of the Girl Child
To focus attention on theneed toaddress theuniquechallengesgirlsfaceand topromotegirls’ empowermentandthe fulfilmentof theirhuman rights.
• Consultationswithadolescentboysandgirls (mostly girls) to informNational Plan of Action for the HolisticDevelopmentofAdolescentsheld inOctober2014
NotKnown UNICEF,2014
GenderEqualityAct2006
To eliminate violence against women (VAW)andgenderdiscrimination,promotegenderequalityandwomen’sempowerment
• Noactivitiesbecause it is stillwaiting forapproval fromparliament
— —
Domestic ViolenceandPunishmentAct,2009
Topreventdomesticviolence
•
•
•
•
GBVdeskatDistrictDevelopmentCommitteeofficeestablishedGenderViolenceControl FundestablishedGBV information management systemdatabaseunderNationalwomen’s commission setupOne-stopcrisismanagement centresin15districts,with service centresestablished
Weakand fewgaps in lawsidentified
CREHPA,UCL,UNFPAetal.,2013
Human TraffickingandTransportationControl Act (2007)
Toaddresshumantraffickingandtransportationproblems
— Moderate —
2007Amendment toCivil Service Act
Reserves44%of vacantgroups forexcludedgroups;33% forwomen
— Not known —
The Country Code (EleventhAmendment)onproperty rights
To recognize that son anddaughterhaveequalrights to their ancestral property.
— Not known CountryCode(Muluki Ain)
The Country CodechapteronMarriage;number10
Toenforcepunishmentfor committingpolygamy
— Not known CountryCode(Muluki Ain)
Cont’d on next page...
Table 4: (Cont’d)
14
Programme/ Intervention
Objectives Activities Effectiveness Source
Advocacy, communication initiatives and community mobilization efforts
NepalSocietyofObstetriciansandGynaecologists
Toaddressgenderbiasedsex selectionandpromotegenderequality
•
•
•
Posterongenderbiasedsexselection tobeplaced inhospitalsandclinicsStorybasededucational filmaimedatendinggenderbiasedsexselectionAwarenessprogrammeANURODHand talkprogrammesonsocialeffectsof genderbiasedsexselection
Notavailable NESOG,2013
NepalPeaceFundandNepalTelevision
Toaddressgenderbiasedsex selection
• Short videos (20seconds)broadcastdaily on “nogenderpreferenceduring childbirth”
Notavailable NepalTelevision,n.d.
Kantipur TVandFM radiostations
Toaddressgenderbiasedsex selection
••
Talk showsbyexpertsJinglesonFM radio
Notavailable
Centre for Awareness Promotion’sDaughter Project
Fight against the cultural preference for sons
••
••
Raise awarenessCounselling sessions for mothers andpregnantwomenatonepublichospitalTheatreprogrammesOrganising festivals/ritualstraditionally favouringboys tohonourgirls
Notavailable Center for Awareness Promotion,2010
CREHPA’sEnableproject
Safeabortionawarenessandadvocacyprogramme
• Provides informationabout theillegality of sexdeterminationandsex selectiveabortion
Notavailable CREHPA,n.d.
Table 4: (Cont’d)
CentreforAwarenessPromotion(CAP)Nepal,anNGO,isimplementingaprojectentitled:“TheDaughterProject”(CentreforAwarenessPromotion,2012).ThemainobjectiveoftheprojectistofightagainstculturalpreferencesforsonsinNepalbyraisinggenderawareness,providingcounsellingsessionsformothersandpregnantwomenatalargestmaternityhospitalbasedinKathmandutodetersexselectionaswellasthroughartsandtheatreprogramsinvolvingyouthtospreadthemessageofgenderequalityamongnewgenerations.Under“TheDaughterProject”isaprogramcalled“ASistersNetwork”whichuniquelyseekstodecreasethevalueofmasculinityinreligiousrituals.Particularly,aNepalifestivalcalledTihar(popularlyknownasfestivaloflightsinIndia)inwhichasistercaresforheryoungerand/orelderbrothers,preparesfoodforthem,givesgiftsandputsTikaontheirforehead,isahighlycelebratedfestival.Thoughcelebratedwidely,itishoweverafestivalwhichreinforcesthepreferenceofmalesiblingsandputsagreatervalueonthemalegenderroleinafamily.TheSisterNetworktargetstobreakthatvalueputonmasculinitybyencouragingfemalestodothesameritualsbetweensisters(butwithoutexcludingbrothers)andwithotherwomen,ifsistersarenotavailableduringthedayofTihar.Theprogramisinitsearlystage(startedin2013)andcoversaVillageDevelopmentCommitteeontheoutskirtsofKathmanduValley.Moreover,CAPNepalalsocoordinateswithalargeprivatehospital,OMHospitalandResearchCenter,whichispopularforitsmaternityservices,toputaboardinitsgatetomakethepublicaswellasmedicalpractitionersawareaboutmoralandlegalaspectsofsexselectiveabortion.ThesafeabortionawarenessandadvocacyprogramofCREHPA(EnableProject)implementedbyitsdistrictbasedNGOpartnersprovidesinformationontheillegalityofsexdeterminationandsexselectiveabortioninthecountry.Unfortunately,theimpactsofthesefewinitiativeshavenotyetbeensystematicallyevaluated.Evaluationsofsuchinitiativesmayprovideinsightforfuturepolicyandprogrammedesigns.
15
chapter 4concluding remarks
summaryThereviewsrevealedthatsexselectiveabortionisanemergingissueinNepal,verymuchconnectedtotheeasyaccessibilitytoprenatalsex-determinationtechnology,thereligiousandsocio-economicvaluegiventosonsoverdaughters,pressureputonwomentobearsonsandthedowrysystemprevalentinNepal,allofwhichincreasethelikelihoodofsexselectiveabortion.Thesituationisfurtheraccentuatedbythelackoffocusedpoliciesandprogramstoaddressgenderdiscriminationandweakenforcementoflawrelatingtodowryandsexdeterminationpractices,meaningthatthedemandforsexselectiveabortioncouldincreaseinthefuture.Withdecliningfertilitylevels,couplesarepressuredtofewerchildrenofthedesiredsex(preferablyson)mayaggravatedforabnormalsexratiosatbirths.Thoughverylimited,studiesindicatedthatthepracticeofsexselectionismoreprevalentamongrelativelyrich,educated,urbanitewomenandinareasborderingwithIndia.However,moreresearchisneededtovalidatethisinformation.
ThereviewalsorevealedthatnoseparateActorpolicyaddressingtherootcausesofgenderdiscrimination,sonpreferenceandconditionalcashtransferprogramsforeverygirlchildispresentinNepal.Nospecialprogramexistsforthis,exceptageneralprogramthatsupportsparentsfortheeducationoftheirdaughters.AlthoughtheInterimConstitutionofNepal2003mentionsthattheStateshallnotdiscriminateagainstcitizensongroundsofsex,religion,race,caste,tribe,sex,origin,language,areportin2009revealedthattherearestillseveraldiscriminatoryprovisionsandschedules,mainlyonnationality,marriageandfamilyrelations,sexualoffences,andpropertyrights,allofwhichcountertherightsofwomenandthegirlchild.AbilltoaddressthesediscriminatoryprovisionsisdraftedandwaitingforCabinetapproval.Genderandsocialinclusion,gendermainstreamingandwomen’sempowermentincludinggender-basedbudgetinghavereceivedprimeimportanceinthenationalagenda,andtheNationalPlanofActionforGenderEqualityandWomen’sEmpowermenthavebeenimplementedbythegovernmentsince2004.However,nofocusedprogramstoaddresssexselectionhasbeendevelopedandimplementedyetbytheGovernment.Althoughthelawstrictlyprohibitssexdeterminationtestsandsexselectiveabortion,enforcementofsuchlawsisweakandunregulated.
Rights-basedcivilsocietyorganisations,professionalsandactivistsareconfrontedwithtwoprongedissueswhen itcomestosexselectiveabortion:firstly,howtopreserveNepalesewomen’srightstosafeandlegalabortion, andsecondly,howtopreventsexselectiveabortionwhichissodeeplyconjoinedwithdeeplyentrenched gender-baseddiscrimination,sonpreferenceandNepalitraditionandculture.Theissueofsexselectionwill poseagreaterchallengeinthecomingyearsasNepalicouplesbegintorealisethesocialandeconomic advantagesofhavingasmallfamilysize.Thereisanurgencytoestablishnewevidenceonthedeterminantsandmotivatingfactorsofsexselectiveabortionpractices,andtodevelopanationalstrategicplanforthecountry basedontheevidence.
recommendations for further research• TherearedatagapsonthecausesofhighsexratioimbalancesincertaindistrictsofNepal,especiallythose
districtsborderingIndia.Thereisnotenoughempiricalevidenceonvariationsofsonpreferencesbygeography,placeofresidence,religion,education,socio-economicstatusonsonpreferenceandreasonsforsuchvariationinNepal.Researchisneededtoestablishnewevidenceonthedeterminantsandmotivatingfactorsofsonpreference,andtofurtherunderstandtheimpactofpoverty,gender-baseddiscrimination,childmarriageandthedowrysystemonsexselectiveabortions.
• Thereislittleinformationontheextentofpressureplacedonawomanbyherspouseandin-lawstodeliverason.Thereisaneedtounderstandtheextentsuchpressureshaveonthewomenduringthepregnancycycleandafterthebirthofthechild,andtheimpactsonthemotherifitisadaughterwhoisborn,ratherthanadesiredson.
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• Despitethelegalgestationalagelimitsforabortion,somewomenseekabortionatalaterstage(beyond 12weeks).Facility-basedresearchisrequiredtoexplorethepossiblelinkagesbetweenthedemandfor second-trimesterabortionandpre-natalsexdetermination.
• Thoughfew,advocacyeffortsarebeingimplementedbyNGOsandthemediatoraisingawarenessonsexselectiveabortions.Howeverlittleisknownaboutchangingattitudes,practicesofthegeneralpopulation, and/orhealthcareproviderattitudestowardstheissues.Therefore,asystematicevaluationofsuchinitiatives ishighlywarranted.
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Established in July 1994, Center for Research on Environment Health and Population Activities (CREHPA) is a not-for-profit research organization based in Kathmandu, Nepal. The organization conducts policy relevant research on population, reproductive and sexual health and rights including on gender-based violence in collaboration with government ministries, universities, bilateral, multi-lateral agencies and international non-governmental organizations. Results of policy research are disseminated widely and utilized for advocacy to influence law and policy decisions.
CREHPA
Kusunti-13, Lalitpur, Nepal P.O. Box : 9626, Kathmandu Phone : 977-1-5546487, 5521717 Fax: 977-1-5522724 E-mail : [email protected] Web: www.crehpa.org.np
This review has been funded by UK aid from the UK Government; however the views expressed do not necessarily reflect the UK Government’s official policies.
The Population Council confronts critical health and development issues—from stopping the spread of HIV to improving reproductive health and ensuring that young people lead full and productive lives. Through biomedical, social science, and public health research in 50 countries, we work with our partners to deliver solutions that lead to more effective policies, programs, and technologies that improve lives around the world. Established in 1952 and headquartered in New York, the Council is a nongovernmental, nonprofit organization governed by an international board of trustees.
The information and views expressed in this report do not necessarily reflect the views of the Population Council.
Suggested Citation: Puri, M. and A. Tamang. 2015. Assessment of intervention on sex-selection in Nepal: Literature review. Kathmandu, Nepal: CREHPA.
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