Confronting India’s high rate of ‘missing’ births

When Gayatri Deshpande* was pregnant, Shubhangi Kamble, 36, an accredited social health activist (Asha) in the village of Arjunwad in India’s Maharashtra state, knew she had to keep an eye on the family. Because if a prenatal sex determination test found the fetus to be a girl, they would have it aborted.

“If the first child is a daughter or there are two daughters, then there’s a high probability a family will go for sex-selective abortion,” said Kamble. Her task was to stop them from doing this, but it meant working as a detective and going beyond her duty as an Asha. 

According to the United Nations Population Fund, there were an estimated 45 million “missing” female births between 1970 and 2017. More than 95% of these were in China and India. 

To prevent female foeticide and rectify the skewed sex ratio at birth, the government of India banned prenatal sex determination in 1994. However, almost three decades later, the practice still persists. “Several illegal practitioners even bring the testing equipment in their vehicles,” said Kamble. 

This means Ashas like her keep track of women’s menstruation cycles in the villages they serve. “If they don’t get their periods on time, we ask them to consult a gynaecologist,” said Kamble. “With consistent follow-ups and tracking, we eventually find out if they’re pregnant.” 

Kamble, whose village is in the Kolhapur district, has observed that the women who’re likely to go for prenatal sex determination – or be forced into it – usually hide their periods from prying eyes. This means the Ashas have to indirectly inquire about whether they’re pregnant from their in-laws or other family members. They also ask for a report on any sonograms the women might have had. “When families hide this report, that’s a red flag,” said Kamble. 

These clues help her identify potential cases of foeticide, and with her “community sources” she keeps an eye on such families. “If you go as a surveyor, people will give you scripted answers,” she said. So instead she visits as a friend and seeks updates on their daily lives, getting the information she needs in a roundabout way. “People don’t even realise we are surveying.” 

In Deshpande’s case, Kamble strongly suspected that she would be an unwilling participant in the sex determination test. From her field visits, Kamble knew that pregnant women often want a girl child, but their husbands or in-laws prefer boys. “At one point, they stopped taking me inside their house and even abused me verbally.” 

Her goal was thus to get Deshpande to talk to her husband about not getting the test. She then started approaching Gayatri.“When you empower the woman in the house, a change is inevitable,” she said. 

Deshpande agreed and approached her husband. “Initially, it led to fights, but at some point you’ve got to resist and stand up to injustice,” she said. Eventually, after many conversations, her family abandoned the idea of a test. Today her daughter is five years old and “the family members are happy”.

Dangerous practices

When Anita Ravan, 38, began working as an Asha in a migrant community in 2009, the testing rates to determine sex were high. Another worry was the lack of accessible healthcare, which meant a high percentage of babies were born outside a hospital or clinic, risking the lives of both mothers and their infants. 

The first thing Ravan did was immerse herself in the community. Most migrants are impoverished and for many a simple structure with a tarpaulin cover is home. It is also challenging that they keep moving on every six months in search of work, which makes it difficult to monitor them over time.

Ravan began taking pregnant women to the Shiroli primary health centre in Kolhapur. This meant spending her money on travel, but she wanted pregnant women to give birth in hospital. Successes she achieved with critical pregnancy cases helped her win the community’s trust. 

She also had to tackle old-fashioned practices that were harmful to mothers delivering babies at home. “The community members would inflict a third-degree burn on a woman’s skin to revive her after childbirth,” she said. 

Other families would consult quacks and faith healers for dubious “medicines” to conceive a male child, which can cause stillbirths or malform the foetus. “A decade ago, this practice was rampant and it exists even today,” said Ravan. “No matter how much progress you see, there’s still a section of society caught in this conservative thinking.” 

Like Kamble, Ravan has prevented sex-selective abortions. In 2017, the Phadtare* family forced their daughter-in-law Poonam* to go for a prenatal sex determination test. “It was a girl foetus,” said Ravan, and Poonam’s husband and in-laws were clear that she had to abort it. She didn’t want to and called Ravan.

When the Phadtares denied that Poonam was pregnant, Ravan threatened to file a complaint with the police. They continued trying to get an abortion for Poonam, who would inform Ravan via texts. Eventually, she warned them that she would escalate the issue to the medical department and the government office where Poonam’s husband worked. This would have meant he would lose his job and be imprisoned.

The family relented and changed their attitude towards having a girl, for which Poonam is thankful to Ravan. “Everyone wants a mother, a sister, a wife, but none wants a daughter. Why? She not just saved a girl child, but changed the family’s attitude for good,” she said, holding her daughter.

An investment of time

Jessica Andrews, a medical officer at the primary health centre in Shiroli, said Ashas – all of whom are women – have played a major part in improving the indicators for women and children’s health in rural India. “It’s the men who now need counselling. We need male counterparts for Ashas to transform the community mindset,” she said. 

“Women are bearing everything, be it the child, sterilisation, family responsibilities and running the family. In the past seven years, I haven’t seen about 10 vasectomies here in Shiroli, but society expects all women to go for sterilisation.” 

Chhaya Sutar, a supervisor who monitors the work of 23 Ashas in Kolhapur district, said the work of women like Ravan is invaluable to their communities. “Every community member today trusts Ravan and this has been possible because of the time she has spent helping them.” 

Ravan said good results are only possible if Ashas invest a lot of time and effort. “It takes a lot of patience and footslogging.” 

Her visits are filled with ideas and questions about bringing about societal transformation. Merely giving out information doesn’t help, she said. “You need to question the existing societal oddities that’ve been normalised and show people that there’s a way out. Persistent conversations help.”

Addressing the bias, Ravan often says, “Even after marriage, daughters can use their parent’s name. Nothing can stop her legally. So how is it true that the generation comes to an end with a girl-child?” 

*Names have been changed to protect identities.

Sanket Jain

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