Regional Workshop on Strengthening Use of Health Information at District Level

10 12 Aug 2009Bangkok

Nihal Singh

Presenting analyzed data and use of information at District Health Office

This analysis is presented to the Gautam Budh Nagar District Health Officer to motivate him to get analysis done of the data from his district to determine the magnitude and pattern of these problems.

Community based data collected through Nationally representative household survey NFHS-3 in India reveals:

1. worsening adverse sex ratio (attributed to ultrasound diagnostic tests done for sex selective abortions)

2. Sex differentials in child mortality (attributed to gender bias)

3. Sex differentials in notification of smear positive TB cases in age group below 14 (attributed to gender bias)

: Analysis of data of ultrasound tests done during pregnancies,India, 2005-06

Source : National Family Health Survey (NFHS-3 2005-06, India, 2007

87636.842.02072 children (both sons)

Number of living childrenmother had prior to this pregnancy

Number of pregnancies With an ultrasound test

Sex of newborn* Sex ratio

Male(%)

Female(%)

Ratio of females to 1000 males

1 child (son) 2019 42.3 41.8 988

2 children (1 son and 1 daughter) 798 43.1 36.0 835

2 children (both daughters) 867 55.1 31.4 570

4+ children (1 son) 201 49.7 26.8 539

Note: * does not include pregnancies which were terminated and those still waiting for delivery

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

The apparent difference in percentages of male and female outcomes at delivery of mothers who already had two living children (either both sons or both daughters) prior to this pregnancy is statistically significant (Chi-square = 5.660 , p 0.017). This difference is greatest when delivery outcomes of mothers who had 4+ living children but out of them only one being son were compared with delivery outcomes of mothers who had only one child who was son (Chi-square = 11.538 p 0.001).

SPSS

72

71

69

66

65

59

58

55

55

54

52

51

48

47

43

36

35

34

13

37

47

0 20 40 60 80 100

Madhya Pradesh

Orissa

Uttar Pradesh

Assam

RajasthanChhattisgarh

Bihar

Haryana

India

Andhra Pradesh

GujaratJammu & Kashmir

Jharkhand

Himachal Pradesh

Karnataka

PunjabWest Bengal

Delhi

Tamil Nadu

Maharashtra

Kerala

IMR per 1000 Live births

Infant mortality rate by state in India, 2007

Source : RGI, SRS Statistical Report 2007

72

70

67

64

63

58

57

55

55

54

50

49

47

45

46

42

36

36

34

33

12

72

72

70

67

67

61

58

56

56

55

54

52

49

49

47

45

37

36

36

35

13

0 20 40 60 80 100

Madhya Pradesh

Orissa

Uttar Pradesh

Assam

RajasthanChhattisgarh

Bihar

Haryana

India

Andhra Pradesh

GujaratJammu & Kashmir

Jharkhand

Himachal Pradesh

Karnataka

PunjabWest Bengal

Delhi

Tamil Nadu

Maharashtra

Kerala

IMR per 1000 Live births

Females

Males

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

Source : RGI, SRS Statistical Report 2007

Sources: 1.National Family Health Survey (NFHS-1),1992-932.National Family Health Survey (NFHS-2),1998-993.National Family Health Survey (NFHS-3),2005-06

Comparison of mortality rates between boys and girls under 5 years of age, India, 1992 2006

(More girls than boys survive in neonatal period but less afterwards during childhood)

Reference year

Neonatal mortality rate(first month of life)

Child mortality rate (1 - 4 years of age)

Under-five mortality rate

0102030405060

1992-93 1998-99 2005-06De

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1992-93 1998-99 2005-06De

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More girls than boys survive in neonatal period but less afterwards during childhood

Neonatal mortality rate( first month of life)

Child mortality rate(1 - 4 years of age)

8Source : Abay Asfaw , Stephan Klasen , and Francesca Lamanna; Intra-household gender disparities in children's medical care before death in India, 2007, IZA DP No. 2586, International Food Policy Research Institute, A.Asfaw@cgiar.org .

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

At all age levels girls were more likely than boys to die at home and less in hospital or during transport.

If survived the childhood, she is more likely thanboys to remain vulnerable immo compromised for rest of her life and face disablement

Health and social outcomes and consequences

Experiences in health care settings

She is often treated with home remedy and if taken to clinic, her treatment is often incomplete

Treatment options

Parents often ignore the signs and symptoms ofsickness of girl child

Health seeking behaviour

She is inadequately immunized against childhooddiseases

Access and use of health services

She is often not at par with male sibling in familywith food intake and care consequently in nutritional status and affection.

Male child is considered asset to family whilefemale a liability in most part of Indian society(dowry/has to go away someday)

But after neonatalperiod girl interactwith environment as the male child but not cared andprotected as muchas male child. Shefaces more riskfactors and becomevulnerable to infections

known higher levelof immunity andhardiness of female(X chromosome) ofgirl child because ofwhich she survives more in first monthof life after birththan male child on average.

Risk factors and vulnerability

Access to, and control over resourcesSocio-cultural factors

Biological factorsGender Related Considerations

Mortality related considerations

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

020

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80

100

120

140

160

180

0-14 15-24 25-34 35-44 45-54 55-64 65+

Age group (years)

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MaleFemale

Notified new smear-positive TB cases by age and sex in India, 2007

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

The notification rate of smear positive TB cases in age group below 14 years has been found to be higher in girls than boys

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

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

2000 2001 2002 2003 2004 2005 2006 2007Year

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Sex differential trend in new smear positive TB rates in age group below 14 years, India, 2000 - 2007

Source : Data file of TB Unit, WHO/Searo, 2007Further study in India to investigate gender disparity in new smear positive TB rates in children below 14 years of age is warranted similar to the one done for adults aged 14+ years in south India.

Though the TB notification rates in this age group are low (