Gender Disparity in Child Care in India: Findings From Two National Family Health Surveys
Parveen Nangia[*] and T.K. Roy*[*]
Abstract
This paper aims to assess gender discrimination in child-care practices in India and its states. It also investigates whether this discrimination is declining with time or not. For this purpose data are taken from first two national family health surveys (NFHS) conducted in 1992-93 and 1998-99. The indicators of child-care considered in this study are: immunization of children, duration of breastfeeding, health care of sick children, nutritional status, mortality of children in different ages, and their educational attainment. A gender disparity index is prepared for each indicator and states are ranked on the basis of this index. States are also ranked on the basis of other indicators of socio-economic development and relationship between gender disparity and socio-economic indicators is explained.
Results of the study show that gender disparity has declined in only some spheres of child-care. For example, at the national level, difference in the proportion of male and female children who did not receive any vaccination declined between first and second NFHS. The male-female difference in the median duration of breast-feeding remained at the same level. Differences in neonatal mortality have reduced, whereas differences in infant and under-five mortality are almost at the same level. The gap between proportion of male and female children age 6-14 attending school and literate children aged 10-14 has also declined between the two surveys.
Gender inequality exists in every country, but it varies in degree. According to the Human Development Report of 2006, the three top ranking countries in the gender-related development index (GDI)[1] are Norway Iceland and Australia. Norway tops with the GDI value of 0.962 in the list of 177 countries. A GDI value of 1.00 indicates a maximum achievement in basic capabilities without any gender bias. India ranks 126 in this list with the GDI value of 0.0.591, showing that women in the country suffer the double deprivation of gender disparity and low achievement (UNDP, 2006). From the successive census results, female disadvantage is evident in India from the constantly declining sex ratio, lower literacy rate of females than males and lower participation of women than men in the work force, e.g. the sex ratio (females per 1000 males) declined from 972 in 1901 to 933 in 2001. The male literacy rate for 2001 was 76 percent compared with 54 percent for females. In the same year the work participation rates for males and females were 52 and 26 percent, respectively.
In the absence of large scale male selective migration, excessive female mortality in any country is one of the important factors for determining low sex ratio. A number of studies have found higher female mortality than males in many of the developing countries. Coale and Banister (1994) have shown that the abnormal sex ratio of China's population is due to excess risk of female mortality at early ages. D'Souza and Chen (1980) found that in the Matlab project area of Bangladesh, females had 60 percent higher risk of mortality than males after the neonatal period. Hill and Upchurch (1995) studied data from a large number of countries and compared their sex differentials in mortality decline with North-West Europe. They concluded that girls in the developing countries have a higher risk of mortality than boys for a given level of mortality. Female disadvantage is maximum for girls age 1-4 years, where care is more important than genetic factors in determining mortality risks. According to the Sample Registration System of India, under-five mortality for males and females is 25.6 and 27.5, respectively for 1991. Das Gupta (1987) in her study of rural Punjab found that sex bias is not generalised, but focused on higher birth order girls.
Waldron (1987) postulates that higher female mortality in childhood may be either because of certain specific causes, which affect the fairer sex more or due to gender discrimination in nutrition and health care. Many studies have focused upon the existence of gender disparity in nutrition and health care of children (Wyon and Gorden, 1971; Chen et al., 1981; Sen and Sen Gupta, 1983; Das Gupta, 1987). According to Hill and Upchurch (1995) female mortality disadvantage is not related to nutritional status (anthropometric measures) and sickness rates, rather it shows a positive association with relative lack of immunization coverage for girls and a negative relationship with female disadvantage in treatment of diarrhoea. According to Das Gupta (1987), excess female mortality is a part of family building strategy, where girls are considered as burden and boys as resources.
In this paper an attempt is made to find out the existence of gender disparity in growth and developmental opportunities for children in India and changes in it during the 1990s. The disparity is assessed in child-care, nutritional status of children, child mortality and educational attainment at the state level. The correlates of gender disparity in developmental opportunities have been worked out with the social development, housing conditions, and female autonomy. The data have been procured from the all India and state level reports of the first and second National Family Health Survey (NFHS), conducted in 1992-93 and 1998-99, respectively.
DISPARITY IN CHILD CARE
The initial growth of a child depends upon the duration and frequency of breastfeeding it receives, since the breast milk provides important nutrients to infants and young children and protects them against certain infections. Although the practice of breastfeeding is universal in India, some studies have pointed out gender differences in duration of breastfeeding of children (Wyon and Gordon, 1971; World Bank, 1991). According to these studies female infants are breastfed less frequently and for shorter durations than male infants, their weaning also starts earlier and they are given lower quality foods. The results of the National Family Health Survey (NFHS) have also shown that the median duration of breastfeeding for male children is nearly two months longer than female children. It is longer by about a month for both males and females in NFHS-2 compared to NFHS-1 (Table 1). Gender difference in duration of breastfeeding is particularly high in the states of Assam, Punjab and Sikkim, where male children are breastfed for more than six months longer than female children. On the other hand, in the states of Madhya Pradesh, Jammu & Kashmir, and Karnataka female children are breastfed for a slightly longer duration. The least gender disparity is observed in Bihar, where median duration of breastfeeding is the same for both male and female children. For many of the states, median duration of breastfeeding in NFHS-2 is considerably different than NFHS-1 (state level data for NFHS-1 is not presented in this paper).
Children are required to be immunized against some of the childhood diseases, which can turn out to be fatal in the absence of timely vaccination. To reduce the incidence of morbidity and mortality, Government of India has made arrangements for free vaccination services of the required doses of BCG, DPT, polio and measles vaccines to protect children against tuberculosis (BCG); diphtheria, pertussis (whooping cough), tetanus (DPT); polio and measles respectively. Under the Universal Immunization Programme, Government targeted to cover at least 85 percent children against these vaccine preventable diseases (Ministry of Health and Family Welfare, 1991).
Table 1
Gender disparity in health care in India, 1998-99
State / Percent of children (12-23 months) who received / Median duration of breastfeeding / Percent of children under three years of age who were / Child care disparity index (CDI) / RankAll vaccinations / No vaccination / not taken to health facility when sick / not treated for diarrhoea
Male / Female / Male / Female / Male / Female / Male / Female / Male / Female
Andhra Pradesh / 54.2 / 62.8 / 5 / 4 / 27.8 / 23.3 / 27.9 / 33.7 / 20 / 21.5 / 1.027815 / 5
Assam / 22.3 / 9.2 / 30.2 / 37.7 / 36 / 26 / 55.6 / 62 / 35.4 / 41.9 / 1.471119 / 18
Bihar / 13 / 9 / 14.8 / 18.9 / 36 / 36 / 37.8 / 45.9 / 39.6 / 38 / 1.179071 / 13
Gujarat / 53.1 / 52.9 / 6.7 / 6.5 / 22.5 / 21.2 / 25.4 / 32 / 28.5 / 31.1 / 1.077264 / 7
Goa / 79.9 / 85.8 / 0 / 0 / 24.6 / 22.2 / nc / nc / nc / nc / 1.01905 / 2
Haryana / 62.4 / 63.2 / 9.2 / 10.8 / 25.8 / 23.5 / 12.2 / 12 / 7.1 / 6.1 / 1.020378 / 3
Himachal Pradesh / 87.2 / 78.9 / 0.2 / 5.8 / 25.3 / 23.3 / 4.3 / 4.4 / 4.7 / 6.4 / 6.715198 / 20
Karnataka / 62.8 / 57.1 / 8.3 / 7 / 19.9 / 20.2 / nc / nc / 18 / 21.5 / 1.0307 / 6
Kerala / 77.1 / 82.6 / 2.5 / 1.9 / 25.4 / 24 / 12.7 / 23.2 / nc / nc / 1.1446 / 12
Madhya Pradesh / 27.3 / 17.9 / 11.5 / 16.1 / 24 / 25.9 / 40.1 / 44.1 / 27.9 / 32.9 / 1.226149 / 14
Maharashtra / 80.8 / 76.3 / 2.1 / 1.8 / 24.5 / 23.2 / 18.3 / 11.5 / 14 / 20.2 / 1.008686 / 1
Orissa / 44.1 / 43.3 / 8.3 / 11 / 33.6 / 36 / 38.3 / 49.3 / 33.8 / 35.2 / 1.121147 / 9
Punjab / 74.5 / 69.2 / 5.2 / 12.9 / 26.4 / 18.9 / 7.6 / 4.3 / nc / nc / 1.3799 / 16
Rajasthan / 16.9 / 17.6 / 21.8 / 23.4 / 26.2 / 24.7 / 37.8 / 41.6 / 37.7 / 34.5 / 1.022 / 4
Tamil Nadu / 89.5 / 88 / 0.1 / 0.6 / 17.8 / 15.7 / 17.3 / 16.9 / 16.9 / 26.9 / 2.14388 / 19
Uttar Prasdesh / 23.6 / 18.8 / 27.5 / 31.5 / 26.4 / 25.2 / 35.5 / 42.9 / 30.2 / 30.3 / 1.132031 / 10
West Bengal / 44.2 / 43.5 / 12.9 / 14.3 / 36 / 33.5 / 44.3 / 52.5 / nc / nc / 1.0961 / 8
Delhi / 71.8 / 67.2 / 2.6 / 8.3 / 22.6 / 19.4 / 17.2 / 15.4 / 21.7 / 13.9 / 1.392322 / 17
Jammu & Kashmir / 61 / 50 / 8.6 / 13.1 / 29.4 / 30.5 / 18.9 / 30.4 / 10.5 / 9.8 / 1.249798 / 15
Sikkim / 50.5 / 43.8 / 16.8 / 18.5 / 31.6 / 24.8 / 50.4 / 67.3 / 73.5 / 62 / 1.141441 / 11
India 1998-99 / 43.1 / 40.9 / 13.5 / 15.3 / 26.4 / 24.6 / 33.5 / 39.2 / 26.8 / 28 / 1.095044
India 1992-93 / 36.7 / 34.1 / 27.8 / 32.5 / 25.3 / 23.6 / 17.8* / 22.0* / 17.8* / 21.0* / 1.145176
Higher the value of the index, greater is the discrimination against female children
* 0 to 4 age group.
Reference period for fever and diarrhoea is two weeks prior to the survey.
Source: IIPS & ORC MACRO, National Family Health Survey, 1998-99; PRCs and IIPS, Bombay, National Family Health Survey, 1992-93, and State level reports.
Table 1 presents data on the sex-wise distribution of immunization coverage of children age 12-23 months. This age group is selected because the vaccines of BCG (single dose) DPT (three doses), polio (three doses) and measles (one dose) should be administered during infancy. If children younger than 12 months are included in the estimates of immunization coverage, some of the children may not be eligible for some of the vaccines, for example, a three months old child can not be expected to have received all the three doses of DPT. The NFHS data show that even after crossing infancy a good proportion of children are not vaccinated at all. Slightly more than two-fifths of the children are fully vaccinated and one in seven children has not received any vaccine. Bihar has shown the poorest performance in immunization coverage, as slightly more than one-tenth of the children age 12-23 months are fully vaccinated and about one-sixth are not vaccinated at all. The other states with very poor immunization coverage are Rajasthan and Uttar Pradesh. On the other hand, Tamil Nadu has shown the best performance, where nearly nine out of ten children are fully vaccinated and only one in twenty has not received any vaccine against any of the serious childhood diseases. Himachal Pradesh closely follows Tamil Nadu, particularly in immunization of male children.
The female disadvantage in child immunization is clear from Table 1, which shows that a lower proportion of girls (41 percent) than boys (43 percent) are fully vaccinated and a reverse picture holds true for children not vaccinated at all (15 percent boys compared with 14 percent girls). The situation of child immunization has improved since 1992-93 when 28 percent of the male and 32 percent of the female children had not received any vaccination. Despite this improvement, status of immunization in the country is far from satisfactory.
Gender disparity is highest in Assam for full vaccination, where the coverage is 59 percent lower for girls than boys. The other states where female disadvantage for complete immunization is of sizeable proportion are Bihar and Madhya Pradesh. Contrary to this, in Andhra Pradesh, Goa, Haryana, Kerala and Rajasthan female children are in an advantageous position with a greater proportion of girls fully vaccinated compared with boys.
The sex difference in children not vaccinated at all is particularly high in Delhi, where proportion of non-vaccinated girls is more than three times higher than boys, and in Punjab where it is two and a half times higher. However, the overall proportion of children not vaccinated is quite low in Delhi. In Tamil Nadu proportion of children who did not receive any vaccination is less than one percent, both for males and females, whereas in Goa, none of the children was reported to fall in the category of ‘not vaccinated’.
Apart from discrimination in immunization coverage, females also receive less health care than males when they fall sick. Singh et al. (1962) found that boys were given better medical care than girls during the course of illness that led to their ultimate death. Dandekar (1975) in her study of rural Maharashtra revealed that although a greater percentage for girls than boys under age 15 were sick, a lower proportion of them received any medical care. Das Gupta (1987) noted that in rural Punjab expenditure on medicines was higher for boys than on girls, particularly during infancy and among children from the better-off families. Longitudinal data from two Bombay hospitals reveal significant urban differentials in male and female ratios for adults as well as for children ( Kynch and Sen, 1983).
The NFHS also provides information on the morbidity and treatment patterns of children. The information was collected on the prevalence of fever and diarrhoea for children below three years during the two weeks preceding the survey and the treatment given for the same. Table 1 also shows the proportion of male and female children who did not receive any treatment when they suffered from fever or diarrhoea. The female disadvantage over male children is higher for treatment in fever or diarrhoea for the country as a whole. In majority of the states the proportion of girls who did not receive any treatment for fever or diarrhoea was higher than boys. More than a third of the children did not receive any treatment when they had fever and more than a quarter did not receive any treatment when they suffered from diarrhoea. In Assam and Sikkim, more than half of the boys and nearly two-thirds of the girls did not receive any treatment when they had fever. On the other hand, in Himachal Pradesh nearly 95 percent of the children received some form of treatment when they suffered from these ailments.
For treatment of fever widest gender disparity is observed in Kerala where proportion of girls who were not taken to a hospital for treatment of fever is nearly twice the proportion of boys. The girls in Maharashtra, Punjab and Delhi are in an advantageous position as a larger proportion of boys in these states are not treated for fever.
More than a quarter of the children in the country did not receive any treatment when they suffered from diarrhoea. In its acute form diarrhoea leads to dehydration which results from loss of water and electrolytes. A substantial proportion of deaths among children in India are caused by diarrhoea, which can be prevented by timely administration of oral rehydration salts or other simple home made solutions.
In Sikkim, three-fourths of the boys and three-fifths of the girls did not receive any treatment for diarrhoea. More than thirty percent of the children did not receive any treatment while suffering from diarrhoea in the states of Assam, Bihar, Orissa, Rajasthan and Uttar Pradesh. On the lower side, in Haryana and Himachal Pradesh less than ten percent children were not treated for diarrhoea. Gender disparity is found to be highest in Tamil Nadu, where against 17 percent of the boys 27 percent of the girls were not treated for diarrhoea. Disparity is lowest in Uttar Pradesh, while in the states of Bihar, Haryana, Rajasthan, Jammu & Kashmir, Sikkim and Delhi a slightly higher proportion of female than male children received treatment for diarrhoea.
A child care disparity index (CDI) is prepared to find out gender disparity in health care of children in terms of receiving vaccinations, treatment during sickness and duration of breastfeeding. For preparing this index male to female ratios are calculated for two variables, i.e., fully vaccinated children and duration of breastfeeding. Similarly, female to male ratios are calculated for rest of the variables in Table 1, i.e., children who have not received any vaccination, and who did not receive any treatment while suffering from fever and diarrhoea. The values on all these ratios are summed up and their average gives the CDI value for each state, which is then ranked in the ascending order to know the relative position of each state in child care. The index shows that Maharashtra holds the top position with least disparity in health care of male and female children. Goa and Haryana follow it. Himachal Pradesh shows lowest position on this index, preceded by Tamil Nadu. In none of the states CDI is less than one, indicating that in each of the states girls are in a disadvantageous position in terms of health care of children.
DISPARITY IN NUTRITIONAL STATUS
The physical growth of children depends upon the dietary intake and protection from the infectious and parasitic diseases. The dietary intake or nutritional status of a child is reflected in the anthropometric measures for which comparative data are scarce. Few studies have compared gender disparity in the extent of nutritional status of children. A `mapping' of the household dietary intakes in different parts of the subcontinent shows that the condition of pre-school girls is worse off than that of boys (Harris, 1986). In his study, Lavinson (1974) found that the proportion of girls was higher than boys in both moderately and severely malnourished children.