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report March 2015 ASSESSMENT OF INTERVENTIONS ON SEX-SELECTION IN NEPAL: LITERATURE REVIEW Mahesh Puri Anand Tamang

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Page 1: AssessMent of InterventIons on sex-selectIon In nepAl ... · Until recently, maternal mortality ratio (281 per 100,000 live births) of Nepal was among the highest in the world (Ministry

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AssessMent of InterventIons on

sex-selectIon In nepAl: lIterAture revIew

Mahesh puriAnand tamang

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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.

Printed at : [email protected]

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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

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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

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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).

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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.

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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...

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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)

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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.

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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.

Printed at : [email protected]

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