Nepal ranks highest for sex ratio at birth in the region due to gender-biased sex selection
Public health expert Aruna Uprety was flying from Dolpo to Nepalganj a few years ago when she struck up a conversation with a pregnant woman who told her she was travelling to the city for a doctor’s appointment. ｜JAPANESE｜THAI｜KOREAN|
Uprety’s initial happiness at learning that rural women were actively seeking prenatal care turned into shock when the woman, who had two daughters, said she would terminate her pregnancy if the ultrasound showed a female foetus.
When Uprety recounted her conversation with nurses at a hospital in Nepalganj, they did not bat an eyelid, telling her that pregnant people came from all over the Karnali to get ultrasounds for sex-selective abortions.
This example, multiplied tens of thousands of times every year, is visible in the 2021 census data: there are significantly more male than female live births in Nepal, giving the country one of the highest sex ratio at birth (SRB) in Asia.
SRB indicates the number of boys born for every 100 baby girls. Globally, biological birth ratios are slightly biased towards male babies, and the theoretical or expected SRB is 105 males per 100 female live births. Higher values indicate much higher numbers of newborn boys than girls.
According to the 2021 census, Nepal has a SRB of 112 males per 100 females, up from 106 recorded in the 2011 census. Dhanusa district bordering India has the highest SRB (133) while Mustang in the trans-Himalaya has 92 boys per every 100 girls born. The Madhes (118) has the highest SRB among Nepal’s provinces.
Experts are worried that this trend could lead to long-term demographic disparities, and say there has not been enough research into the drivers of this imbalance.
“Nepal’s skewed sex ratio at birth is one of the most concerning demographic issues,” says Yogendra B Gurung of the Central Department of Population Studies at Tribhuvan University.
Contributing to this is gender-biased sex selection (GBSS) and other forms of discrimination and inequality enabled by Nepal’s patriarchal, socio-cultural, traditional structures.
Gender-biased sex selection determines the outcome of a pregnancy, and can be postnatal or prenatal. Postnatal sex selection can be due to neglect, differences in maternal nutrition and child care, or infanticide of a girl child.
Prenatal gender-biased sex selection occurs prior to or during conception, either by the selection of a particular sex during fertilisation, or through termination of pregnancy when the sex of the foetus is determined. Across the world, GBSS is an outcome of a preference of sons over daughters.
The census result proves that Nepalis are increasingly opting for sex selection and consequently, sex-selective abortions through the use of prenatal diagnostic technologies to determine the sex of a baby, even though the law prohibits clinics from revealing the sex of a foetus.
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“There are three detriments that enable gender-biased sex selection: our socio cultural norms, and the preference of sons over daughters, and the availability of technology that is able to determine the sex of a foetus,” explains Apekchya Rana Khatri at the United Nations Population Fund (UNFPA) in Kathmandu. “We analysed the social and demographic trends, and identified Nepal as one of the countries where GBSS prevails based on the prevalence of these three issues.”
Many Nepali families prefer sons because they are still expected to solely carry forward the family lineage, provide economic benefit to the family and actively engage in society, take care of their parents in their old age, perform funeral rites, and gain inheritance.
Imbalanced sex ratio at birth is not just a problem in Nepal. The sex ratio at birth of countries in the region, including India and China reflect socio-cultural norms that ascribe more importance to boys.
Sex ratio at birth in India (108) is mostly due to cultural factors, while in China (112) it is a legacy of the previous One Child Policy. The imbalance has actually begun to improve in the past years in both countries. However, in Nepal, the opposite has happened: SRB rose from 104 in 2001 to 106 in 2011 to 112 in 2021.
The 2021 census also shows that sex ratio at birth in Nepal’s urban municipalities is 114 — higher than rural municipalities (109). This is in contradiction to the belief that discrimination against girl children is less among educated and better off city dwellers than in rural areas.
Better access to healthcare institutions might also account for higher sex ratio at birth in urban areas. In the case of Madhes Province, access to both legal and unsafe abortion across the border could be why SRB is higher.
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“Nepal’s sex ratio at birth shines a light on the deeply-entrenched patriarchy in our country,” says demographer Gurung. “And it also clarifies the misconception that traditional and conservative mindsets and discriminatory practices exist exclusively in rural communities, because the data points to educated, economically well off people engaging in practices like GBSS.”
Historically, agrarian societies like Nepal preferred to have many sons because men were considered better suited to physical work. Today, many Nepalis hope to have male children so that they can migrate overseas, earn livelihoods, and support their families.
“Although evolving political, legal, and social systems have given women more robust rights to education and rights to inheritance, and ensured their participation in the workforce, the implementation of interventions is another matter,” says Aruna Uprety. “Our cultural and especially religious practices have continued to reinforce gender inequality.”
Experts say they have been unable to collect relevant data from medical and health facilities.
“Even when we identify the issues contributing to sex-selective practices, we are largely working on assumptions because there is no officially-backed data about sex-selective abortions through legal channels or unofficial and unsafe providers,” says Won Young Hong, UNFPA Country Representative for Nepal. “We need to obtain more data from hospitals, clinics and the many other service providers so that we can conduct more extensive research.”
Another dimension to sex determination, selection, and sex-selective abortion is that it is not always a pregnant person’s choice to terminate a pregnancy if they find their child is female. Studies at local levels have revealed that husbands and mothers-in-law play pivotal roles in decision-making regarding prenatal sex determination.
Nepal’s decreasing total fertility rate also contributes to a warped sex ratio at birth. Two decades ago, Nepal’s total fertility rate was 4.6, today a Nepali mother on average gives birth to only 2.1 children — which is at replacement level. And since Nepalis are having fewer children, especially if they plan to have only one child, they want to make sure they have a son.
Studies by the Center for Research on Environment Health and Population Activities (CREHPA) show that while neither women nor men have a preference for the sex of their child during the birth of their first child, having a female child first will lead to a preference for sons from the second birth, the preference increases in subsequent birth orders.
Although Nepal’s sex ratio at birth is skewed towards boys, the country has more women than men, as differences in lifestyles contribute to a higher male mortality rate. The 2021 census shows that Nepal’s sex ratio is 95.6 males per 100 females.
However, the male to female ratio from ages 0-19 has gone from 102 in 2011 to 107 in 2021, mainly due to rising sex ratio at birth. In the coming decades, the number of females above age 19 will decline.
The number of males under 20 being higher also proves that gender-biased sex selection has been going on in Nepal for at least the three decades, says Gurung.
“Nepal’s sex ratio at birth could indicate a larger demographic shift in the long run where the male population outnumbers the female population,” he adds.
This would in turn have an impact on fertility, male-female partnerships and marriage dynamics, the work force, and Nepal’s existing social structures as a whole. In particular, a population significantly skewed towards males might make women and girls more vulnerable to abuse, sexual exploitation and assault, trafficking, forced marriages, and other serious crimes, say experts.
Studies have also found that birth registration right after the birth of a child is not common in Nepal, and some couples register the birth of sons and ignore daughters, which may be reflected in fewer recorded female live births.
Cultural norms and practices do not change despite laws, and Nepal needs to do much more to change societal values, protect, and educate its women and girls. UNFPA, for example, in 2021 supported the Ministry of Health and Population to draft the first-ever national strategy to address gender-biased sex selection, its implementation already in place.
The agency’s Ruparantan program also equips adolescent girls with practical skills and knowledge on gender equality and decision-making.
But for this to work, new policies and political will to implement them by the government are critical. Strong regulatory mechanisms to monitor prenatal sex determination technologies will also be required.
In addition, Nepal needs systems in place to guarantee safety and security of its ageing population, so that there are less financial and socio-cultural pressure on sons to take care of their families, and less incentives for parents to opt for male children.
“The state needs to prepare to provide adequate services for the elderly population, especially with the anticipation of the growth in ageing population,” says Won Young Hong at UNFPA.
India has stricter regulations over the use of prenatal diagnostic technologies to determine the sex of a baby, as well as rigorous campaigning across state and national levels like the Beti Bachao Beti Padhao program that have helped address the country’s declining female births.
Nepal also needs to address the drivers of its skewed sex ratio at birth while safeguarding the reproductive rights of women and the right to safe abortions.
Access to these services have contributed significantly to lowering the maternal mortality rate. Abortions are important for medical emergencies, for survivors of sexual assault, for family planning, and to ensure the right of women to choose what to do with their own body.
“Safe abortion is a right, and cutting off access to it will not stop gender-biased sex selection,” says Aruna Uprety. “Legality has no bearing on people’s decisions– women were getting abortions in private facilities across Nepal and India even when it was not yet legal.”
What is needed is a multi-sectoral approach that addresses existing socio-cultural norms, what women need to be empowered and linked to jobs, as well as policies that promote women and girls, giving them opportunities.
Adds Uprety: “Socio-cultural interventions are just as important as legal and policy ones, and we cannot address society’s preference for sons unless we look critically at our patriarchal cultural practices. Gender discrimination is a cross-cutting issue.”
This article is brought to you by Nepali Times, in collaboration with INPS Japan and Soka Gakkai International, in consultative status with UN ECOSOC.
writer
Shristi Karki is a correspondent with Nepali Times. She joined Nepali Times as an intern in 2020, becoming a part of the newsroom full-time after graduating from Kathmandu University School of Arts. Karki has reported on politics, current affairs, art and culture.