Emerging Issues : Ageing , Sex Ratios | Sociology Optional for UPSC (Notes) PDF Download

Ageing

Demography of Indian Ageing

• The large increase in human life expectancy over the years has resulted not only in a very substantial increase in the number of older persons but in a major shift in the age groups of 80 and above. The demographic profile depicts that in the years 2000-2050, the overall population in India will grow by 55% whereas population of people in their 60 years and above will increase by 326% and those in the age group of 80+ by 700% - the fastest growing group (see table).
  
  World population Ageing: 1950-2050; Department of Economic and Social affairs, Population Division, United Nations.
• 1/8th  of the Worlds Elderly Population lives in India. Most of them will never retire in the usual sense of the term and will continue to work as long as physically possible. Inevitably though the disability to produce and earn will decline with age. The absence on savings will result in sharp declining in living standards that for many can mean destitution. Therefore this is the challenge of old age income security in India.
• As a result of the current ageing scenario, there is a need for all aspects of care for the Oldest Old (80+ years) namely, socio economic, financial, health and shelter.
  
  India is witnessing ruralization of the elderly as youth migrate to cities for jobs leaving their old parents back in the village
• A man’s life is normally divided into five stages namely: infancy, childhood, adolescence, adulthood and old age. In each of these stages an individual’s finds himself in different situations and faces different problems. Old age is viewed as an unavoidable, undesirable and problem ridden phase of life.
• Ageing in India is exponentially increasing due to the impressive gains that society has made in terms of increased life expectancy. With the rise in elderly population, the demand for holistic care tends to grow. By 2025, the geriatric population is expected to be 840 million in the developing countries. It is projected that the proportion of Indians aged 60 and older will rise from 7.5% in 2010 to 11.1% in 2025. In 2010, India had more than 91.6 million elderly and the number of elderly in India is projected to reach 158.7 million in 2025. An aging population puts an increased burden on the resources of a country and has raised concerns at many levels for the government in India. The aging population is both medical and sociological problem. The elderly population suffers high rates of morbidity and mortality due to infectious diseases. The demographic transition in India shows unevenness and complexities within different states. This has been attributed to the different levels of socio-economic development, cultural norms, and political contexts. Hence it will be a herculean task for policy makers to address the geriatric care that will take into account all these determinants. Care for the elderly is fast emerging as a critical element of both the public and private concern.
• The apparent success of the medical science is invariably accompanied by several social, economic and psychological problems in older persons, in addition to the medical problems. It needs to be understood that many of these problems require lifelong drug therapy, physical therapy and long-term rehabilitation. The elderly tend to be cared for in a variety of settings: home, nursing home, day -care centre, geriatric out-patient department, medical units or intensive care unit depending on the nature  of the clinical problem. Care of elderly necessitates addressing  several social issues. The needs and problems of the elderly vary significantly according to their age, socio - economic status, health, living status and other such background characteristics. Their social rights are neglected and they are profusely abused which goes unreported.

• Lack of Infrastructure
  With increasing longevity and debilitating chronic diseases, many elder citizens will need better access to physical infrastructure in the coming years. Lack of physical infrastructure is a major deterrent to providing comfort to the aged. Many elder citizens need better access to physical infrastructure, both in  their own homes and in public spaces. Unattended chronic disease, unaffordable medicines and treatment and malnutrition  are part of old age life in India as there is no system of affordable health care. Emphasis on geriatrics in the public health system is limited with few dedicated geriatric services. The other issues of the public health system are lack of infrastructure, limited manpower, poor quality of care and overcrowding of facilities due to insufficient focus on elderly care.
• Changing Family Structure
  The traditional Indian society with an age-old joint family system has been instrumental  in safeguarding the social and economic security of the elderly people. The traditional norms and values of Indian society also laid stress on showing respect and providing care for the elderly. However with the emerging prevalence of nuclear family set -ups in recent years, the elderly are likely to be exposed to emotional, physical and financial insecurity in the years to come. There is an upward trend in the living arrangement pattern of elderly staying alone or with spouse only from 9.0% in 1992 to 18.7% in 2006. Family care of the elderly seems likely to decrease in the future with the economic development of the nation and modernization.
• Lack of Social Support
  The elderly in India are much more vulnerable because of the less government spending on social security system. The elderly in urban area rely primarily on hired domestic help to meet their basic needs in an increasingly-chaotic and crowded city. Social isolation and loneliness has increased. Insurance cover that is elderly sensitive is virtually non - existent in India. In addition, the preexisting illnesses are usually not  covered making insurance  policies unviable for the elders. Pension and social security is also restricted to those who have worked in the public sector or the organized sector of industry. In a study by Lena et al., almost half of the respondents felt neglected and sad and felt that people had an indifferent attitude towards the elderly. It was also found that 47% felt unhappy in life and 36.2% felt they were a burden to the family.
• Social Inequality
  Elderly are a heterogeneous section with an urban and rural divide. They are less vulnerable in rural areas as compared to their urban counterparts, due to the still holding values of the joint family system. All the elderly are not seen in the same view as the needs and problems of elderly are rejected to a vast extent as government classifies these people based on caste and other socio cultural dimensions. In a case study, it was found that a major proportion of the elderly women were poorer; received the lowest income per person; had the greatest percentage of primary level education; recorded the highest negative affective psychological conditions; were the least likely to have health insurance coverage and they recorded the lowest consumption expenditure.
• Availability, Accessibility and Affordability of Health Care
  Due to the ever increasing trend of nuclear families, elder care management is getting more difficult, especially for working adult children who find themselves responsible for their parents’ well -being. Managing home care for the elderly is a massive challenge as multiple service providers – nursing agencies, physiotherapists and medical suppliers – are small, unorganized players who extend suboptimal care. In India, health insurance coverage is essentially limited to hospitalization. The concept of geriatric care has remained a neglected area of medicine in the country.  Despite an aging population, geriatric care is relatively new in many developing countries like India with many practicing physicians having little knowledge of the clinical and functional implications of aging. Not many institutes offer the geriatrics course, and even takers are few. Most of the government facilities such as day care centres, old age residential homes, counselling and recreational facilities are urban based. The geriatric outpatient department services are mostly available at tertiary care hospitals. Reaching to 75% of the elderly that reside in rural areas with geriatric care will be challenging. Dhar has pointed out the relative neglect in provision of facilities for patient care as well as training and development in geriatrics in the Indian context. As pointed by Dey et al., the key challenges to access and affordability for elderly population include reduced mobility, social and structural barriers, wage loss, familial dependencies, and declining social engagement. The stigma of aging is another social barrier to access of health in addition to the health and social conditions the elderly commonly face such as dementia, depression, incontinence and widowhood.
• Economic Dependency
  As per the 52nd round of National Sample Survey Organization, nearly half of the elderly are fully dependent on others, while another 20 percent are partially dependent for their economic needs. About 85% of the aged had to depend on others for their day to day maintenance. The situation was even worse for elderly females. The elders living with their families are largely contingent on the economic capacity of the family unit for their economic security and well being. Elderly often do not have financial protection such as sufficient pension and other form of social security in India. The single most pressing challenge to the welfare of older person is poverty, which is a multiplier of risk for abuse. Also due to their financial dependence, elderly persons though are most vulnerable to infections have low priority for own health. Migration of younger generation, lack of proper care in the family, insufficient housing, economic hardship and break-up of joint family have made the old age homes seem more relevant even in the Indian context.
• Feminization of Ageing
  The sex ratio of the elderly has increased from 938 women to 1,000 men in 1971 to 1,033 in 2011 and is projected to increase to 1,060 by 2026 (with some variations across states) given the insignificant decline in mortality among males particularly during adult and older years.
  Frequent outcome of feminization of ageing is the discrimination and neglect experienced by women as they age, often exacerbated by widowhood and complete dependence on others. Loss of spouse in old age adds significant vulnerability in later years. The marital status distribution of the older persons as per 2011 Census data shows that nearly 66 percent are currently married, 32 percent are widowed and about 3 percent are separated or divorced6. Among the older men, 82 percent are currently married while among older women only 50 percent are currently married. About 48 percent of older women are widowed while only 15 percent of older men belong to this category
• Ruralization of the Elderly
  According to 2011 Census, 71 percent of the elderly live in rural India7. In all the states, except the two smaller states, Goa and Mizoram, a higher proportion of the elderly lives in rural areas than in urban areas (Figure 1.7). Many rural areas are still remote with poor road and transport access. Income insecurity, lack of adequate access to quality health care and isolation are more acute for the rural elderly than their urban counterparts. It is also noted that poorer states such as Odisha, Bihar and Uttar Pradesh have a larger percentage of the rural elderly.
• More 80-plus Women
  Projections indicate that during 2000–2050, the overall population of India will grow by 56 percent while the population 60-plus will grow by 326 percent. During the same period, the population 80-plus will grow 700 percent with a predominance of widowed and highly dependent very old women. The number of older women compared to the number of older men will progressively increase with advancing ages from 60 through 80 years. The special needs of such oldest old women would need significant focus of policy and programmes.
• Migration and its Impact on the Elderly
  Migration of younger working age persons from rural areas can have both positive and negative impact on the elderly. Living alone or with only the spouse is usually discussed in terms of social isolation, poverty and distress. However, older people prefer to live in their own homes and community, which is why ageing in place is often a preferred option 9. Further, this puts some funds in the hands of older persons at a time when they need physical support for health care and to manage household chores. It is also recognized that new technologies are helping the rural elderly stay in touch with their children who can even reach home more easily than in the past.
• Elder Abuse
  Elder abuse refers to any intentional or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult. Abuse of older persons is considered a global public health problem, seriously impairing the well-being of the elderly. Old, vulnerable and frail persons, dependent on others for their daily needs, are routinely abused, neglected, and exploited world wide and India is no exception. The perpetrators are generally family members, relatives, friends, or trusted caregivers. Pan-India information on elder abuse is limited. The BKPAI survey conducted in 2011 collected information on elder abuse from seven states of India. HelpAge India in 2014 also conducted asurvey on elder abuse in select urban centres of the country.The results of the study by Help Age India, published in 2015, showed that about half of the elderly population in the country face some form of abuse, more in case of women than men²⁸.

Verbal abuse, disrespect and neglect were the common forms of abuse generally perpetrated by the daughter-in-law and the son. However, the data from BKPAI indicated a lower proportion (11 %) of elder abuse. While these are not comparable data sets, the levels of abuse reported show that elder abuse is prevalent and that it is an issue that requires further attention. BKPAI data showed that in general, abuse was more toward elderly who lived alone and had low levels of education and poor economic status. Here, the major perpetrators were family members and neighbours.

Problems of old age may be considered under 5 heads:

• Physiological Problems
  • Old age is a period of physical decline. Even if one does not become sans eyes, sans teeth, sans everything, right away, one does begin to slow down physically. The physical condition depends partly upon hereditary constitution, the manner of living and environmental factors. Vicissitudes of living, faulty diet, malnutrition, infectious, intoxications, gluttony, inadequate rest, emotional stress, overwork, endocrine disorders and environmental conditions like heat and cold are some of the common secondary causes of physical decline.
  • Due to the loss of teeth, the jaw becomes smaller and the skin sags. The cheeks become pendulous with wrinkles and the eye lids become baggy with upper lids over hanging the lower. The eyes seem dull and lustreless and they often have a watery look due to the poor functioning of the tear glands. Loss of dentures affect speech and some even appear to lisp.
  • The skin becomes rough and looses its elasticity. Wrinkles are formed and the veins show out prominently on the skin. Perspiration is less profuse and other skin pigmentation appears as the age advances. The hair becomes thin and grey, nails become thick and tough. Tremors of the hands, forearms, head and lower jaw are common. Bones harden in old age, become brittle and are subject to fractures and breaks.
  • Changes in the nervous system have a marked influence on the brain. Atrophy is particularly marked in the spleen, liver and soft organs. The ratio of heart weight to body weight decreases gradually. The softness and pliability of the valves change gradually because of an increase in the fibrous tissue from the deposits of cholesterol and calcium. The aged are also prone to heart disease, other minor ailments and chronic diseases.
  • Due to the weakening regulatory mechanism, the body temperature is affected. Therefore the old persons feel the change in climate more profoundly than others. They suffer from digestive troubles, insomnia. Due to dental problems they are not able to chew or swallow well.
  • The old are more accident prone because of their slow reaction to dangers resulting in malfunctioning of the sense organs and declining mental abilities, the capacity to work decreases. Eyes and ears are greatly affected Changes in the nerve centre in the brain and retina affect vision and sensitivity to certain colours gradually decreases. Most old people suffer from farsightness because of diminishing eye sight.
  • With advancing age, the sexual potency decreases along with a waning of secondary sex characters. Women go through menopause generally at the age of 45 – 50 years accompanied by nervousness, headaches, giddiness, emotional instability, irritability and insomnia. The movements of the aged are fewer co-ordinates. They get fatigued easily. Due to lack of motivation, they do not take interest to learn new skill and become lethargic. Above all visits to the doctor becomes a routine work for them.

Psychological Problems:

• Mental disorders are very much associated with old age. Older people are susceptible to psychotic depressions. The two major psychotic disorders of older people are senile dementia (associated with cerebral atrophy and degeneration) and psychosis with cerebral arterio sclerosis (associated with either blocking or ruptures in the cerebral arteries). It has been observed that these two disorders account for approximately  80% of the psychotic disorders among  older people in the civilized societies.
  Senile Dementia:
  Older people suffer from senile dementia. They develop symptoms like poor memory, intolerance of change, disorientation, rest lessens, insomnia, failure of judgement, a gradual formation of delusion and hallucinations, extreme-mental depression and agitation, severe mental clouding in which the individual becomes restless, combative, resistive and incoherent. In extreme cases the patient become bed ridden and resistance to disease is lowered resulting in his days being numbered.
  Psychosis with cerebral Arteriosclerosis:
  This is accompanied by physiological symptoms such as acute indigestion, unsteadiness in gait, small strokes resulting in cumulative brain damage and gradual personality change. Conclusive seizures are relatively common. This is also associated with symptoms such as weakness, fatigue, dizziness, headache, depression, memory defect, periods of confusion, lowered efficiency in work, heightened irritability and tendency to be suspicious about trivial matters. Forgetfulness is one of the main psychological problems of old age. General intelligence and independent creative thinking are usually affected in old age.
• Emotional Problem:
  Decline in mental ability makes them dependent. They no longer have trust in their own ability or judgements but still they want to tighten their grip over the younger ones. They want to get involved in all family matters and business issues. Due to generation gap the youngsters do not pay attention to their suggestion and advice. Instead of developing a sympathetic attitude towards the old, they start asserting their rights and power. This may create a feeling of deprivation of their dignity and importance.
  Loss of spouse during old age is another hazard. Death of a spouse creates a feeling of loneliness and isolation. The negligence and indifferent attitude of the family members towards the older people creates more emotional problems.

• Social Problems:
  Older people suffer social losses greatly with age. Their social life is narrowed down by loss of work associated, death of relatives, friends and spouse and weak health which restricts their participation in social activities. The home becomes the centre of their social life which gets confined to the interpersonal relationship with the family members. Due to loss of most of the social roles they once performed, they are likely to be lonely and isolated severe chromic health problem enable them to become socially isolated which results in loneliness and depression.
• Financial Problems:
  Retirement from service usually results in loss of income and the pensions that the elderly receive are usually inadequate to meet the cost of living which is always on the rise. With the reduced income they are reversed from the state of “Chief bread winner to a mere dependent” though they spend their provident fund on marriages of children, acquiring new property, education of children and family maintenance. The diagnosis and treatment of their disease created more financial problem for old age.

Policy Response to Ageing in India

• (a) being a signatory to all the global conferences, initiatives on ageing as well as the Regional Plans of Action; and (b) formulation of the National Policy on Older Persons (NPOP) in 1999, well ahead of Madrid International Plan of Action on Ageing (MIPAA), the United Nation (UN) sponsored International Plan of Action. The National Social Assistance Programme for the poor is also an outcome of the Directive Principles of our Constitution (Articles 41–42) recognizing concurrent responsibility of the central and state governments in this regard.
• India’s national response can be seen as evolving along with many multilateral initiatives under the aegis of the UN which spearheaded global attention while encouraging country action to address ageing concerns. The projection scenarios produced by the UN and the attentive ear lent to the voices of elderly men and women contributed to better understanding and clarity on ageing issues. The government also recognized that some of the key concerns of our senior citizens could be best addressed only in partnership with non-governmental organizations (NGOs). India’s association with incremental global understanding  of ageing  issues has been significant—starting  from the 1982 Vienna International Plan of Action on Ageing, followed in 1991 by the development of 18 principles for older persons (grouped under five quality-of-life attributes: independence, participation, care, selffulfilment and dignity) and then the Second World Assembly on Ageing held in Madrid in 2002. As mentioned above, the NPOP formulation in India preceded MIPAA by about three years and has in some ways influenced the Madrid Action Plan.
• India also shared with other countries and international NGOs the serious lack of attention to ageing in the Millennium Development Goals (MDGs). The post-2015 development goals called the Sustainable Development Goals (SDGs) in general and SDG-3 in particular has given attention to ageing. In the most recent 2016 UN General Assembly, India further ratified its commitment to SDGs and reported streamlining them into national development indicators. Indian policy response to ageing has also gained from the work of the World Health Organization (WHO) on Active Ageing, the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) resolution of January 2010 on older women, the United Nations Population Fund (UNFPA) work on social -economic implications of ageing through the initiative Building a Knowledge-base on Population Ageing in India (BKPAI)10 , the work of the International Labour Organisation (ILO) on income security and social pensions as well as the large data collection efforts under Longitudinal Ageing Study in India (LASI) and Study of Global Ageing and Adult Health (SAGE).
• It is important to understand the social aspects concerning aged in the country as they go through the process of ageing. Increased life expectancy, rapid urbanization and lifestyle changes have led to an emergence of varied problems for the elderly in India. It must be reme mbered that comprehensive care to the elderly is possible only with the involvement and collaboration of family, community and the Government. India should prepare to meet the growing challenge of caring for its elderly population. All social service institutions in the country need to address the social challenges to elderly care in order to improve their quality of life. There is a need to initiate requisite and more appropriate social welfare programmes to ensure life with dignity for the elderly. In add ition, there is also a need to develop an integrated and responsive system to meet the care needs and challenges of elderly in India.

National Policy for Senior Citizens 2011

• The new policy is based on several factors. These include the demographic explosion among the elderly, the changing economy and social milieu, advancement in medical research, science and technology and high levels of destitution among the elderly rural poor (51 million elderly live below the poverty line). A higher proportion of elderly women than men experience loneliness and are dependent on children. Social deprivations and exclusion, privatization of  health services and changing pattern of morbidity affect the elderly. All those of 60 years and above are senior citizens. This policy addresses issues concerning senior citizens living in urban and rural areas, special needs of the “oldest old” and older women.
• In principle the policy values an age integrated society. It will endeavour to strengthen integration between generations, facilitate interaction between the old and the young as well as strengthen bonds between different age groups. It believes in the development of a formal and informal social support system, so that the capacity of the family to take care of senior citizens is strengthened and they continue to live in the family. The policy seeks to reach out in particular to the bulk of senior citizens living in rural areas who are dependent on family bonds and intergenerational understanding and support.

The focus of the new policy include:

• Mainstream senior citizens, especially older women, and bring their concerns into the national development debate with priority to implement mechanisms already set by governments and supported by civil society and senior citizens’ associations. Support promotion and establishment of senior citizens’ associations, especially amongst women.
• Promote the concept of “Ageing in Place” or ageing in own home, housing, income security and homecare services, old age pension and access to healthcare insurance schemes and other programmes and services to facilitate and sustain dignity in old age. The thrust of the policy would be preventive rather than cure.
• The policy will consider institutional care as the last resort. It recognises that care of senior citizens has to remain vested in the family which would partner the community, government and the private sector.
• Being a signatory to the Madrid Plan of Action and Barrier Free Framework it will work towards an inclusive, barrier-free and age-friendly society.
• Recognise that senior citizens are a valuable resource for the country and create an environment that provides them with equal opportunities, protects their rights and enables their full participation in society. Towards achievement of this directive, the policy visualises that the states will extend their support for senior citizens living below the poverty line in urban and rural areas and ensure their social security, healthcare, shelter and welfare. It will protect them from abuse and exploitation so that the quality of their lives improves.
• Long term savings instruments and credit activities will be promoted to reach both rural a nd urban areas. It will be necessary for the contributors to feel assured that the payments at the end of the stipulated period are attractive enough to take care of the likely erosion in purchasing power.
• Employment in income generating activities after superannuation will be encouraged.
• Support and assist organisations that provide counselling, career guidance and training services.
• States will be advised to implement the Maintenance and Welfare of Parents and Senior Citizens Act, 2007 and set up Tribunals so that elderly parents unable to maintain themselves are not abandoned and neglected.
• States will set up homes with assisted living facilities for abandoned senior citizens in every district of the country and there will be adequate budgetary support.

Declining Sex-Ratios

• In 1901 there were 3.2 million fewer women than men in India – a hundred years later the deficit increased over 10 times to 35 million at the time of Census 2001. The most disturbing decline is seen in the age group 0 -6 years. The sex ratio (number of girls for every 1000 boys) within this age group plunged from 1010 in 1941 to 927 in 2001. The sex ratio in the age group 0 - 6 years plunged from 1010 in 1941 to 927 in 2001.
  
  India has fewer women than men and fewer girls than boys
• Most societies in the industrialized world have a healthy 0 -6 child ratio i.e. there are roughly the same number of girls and boys in the 0 – 6 age-group. In India however, the rapidly declining sex-ratios are turning into a demographic nightmare of frightening proportions.
• The sex ratio of 927 in the 0 – 6 age group is only the national average for India. There are areas within the country where the ratio has dropped to well below 900. The ratios for some of the states are: Himachal Pradesh 896, Punjab 793, Chandigarh 845, Uttaranchal 906, Haryana 819, Delhi 865, Rajasthan 909, and Gujarat 879. These are not the most economically backward areas of the country. On the contrary, Punjab, with the lowest 0 – 6 sex-ratio in the country, is the most economically prosperous state of India. Delhi, the national capital region of India, has a declining 0 -6 sex-ratio. In fact,  some  of  the  poorest  states  have  a  sex-ratio  well  above  the  national  average.
• Several reasons are attributed to the decline in the number of girls – neglect of the girl child, high maternal mortality, female infanticide and now, female foeticide. Sex-selective abortions have been greatly facilitated by the misuse of diagnostic procedures such as amniocentesis that can determine the sex of the foetus.
• The prejudice against the girl child continues to be an issue of concern for UNICEF in India, which, together with its partners conceptualized the project ‘Initiative to Reduce Sex determination & Pre -Birth Elimination of Females’ to address the problem of female foeticide. As a result of the project activities in Mandya district in the state of Karnataka, the issue of sex selection and female foeticide was put on the public agenda and created mass awareness among the people in both rural and urban areas.
• Recognising the importance of the trends emphasized in the Census 2001 data, the Planning Commission of India incorporated gender equity  as an  integral part of the broader strategy. Despite the efforts of the government, civil society organizations, NGOs, UN agencies and the media to keep the issue of female foeticide high on the public and policy agenda, little or no desired results have been forthcoming.
• Government of India’s Ministry of Health and Family Welfare has undertaken several measures to implement the ‘Pre Conception & Pre Natal Diagnostics Technique Act (PC & PNDT Act). The Act provides for the prohibition of sex selection and for the prevention of misuse of diagnostic techniques for sex determination leading to female foeticide. It also prohibits advertisements regarding facilities of pre-natal determination of sex of the foetus. All clinics in the country using pre-natal diagnostic techniques require to be registered. Violation of the Act is punishable with imprisonment. The State Medical Council of Punjab recently suspended the registrations of four doctors for violating the PC & PNDT Act.
• As a part of the awareness campaign, religious and spiritual leaders have been approached to speak against sex selection,  video spots on girl child  and sex  selection  aired on  national and private television networks. Brand ambassadors have been used for the Government’s ‘Save the Girl Child’ campaign. ‘Atmaja’, a serial on the plight of the girl child has been telecast on the National Network.
• The Department of Women and Child Development has supported workshops to raise awareness on the issue of the girl child, while the Registrar General’s Office has been promoting birth registration and  introduced  mechanisms to monitor sex ratio at birth  among  institutional  deliveries.
• However, despite the efforts of the government, civil society organizations, NGOs, UN agencies and the media to keep the issue of female foeticide high on the public and policy agenda, little or no desired results have been forthcoming. There is a dire need to review the strategies and re-examine the efforts to arrest the declining sex ratio.

Sex ratio and child Sex ratio

• Female gender discrimination due to a cultural preference for males is a common global problem, particularly in Asian regions. India is no exception. Gender discrimination manifesting as increased female mortality, female infanticide, and sex-selective abortion has received considerable attention in recent years. The sex ratio trend in India indicates a growing imbalance, with estimates from the 2011 census indicating approximately seven million fewer girls than expected in the 0-to-6 age group (Bharadwaj & Lakdawala, 2013; Chamarbagwala & Ranger, 2010; Jha et al., 2011; Sahni et al., 2008).
• Sex ratio, defined as the ratio of one sex to another (Last, 2001) is the statistic most often reported to describe this phenomenon. Most epidemiologic literature uses the term sex ratio to denote the number of males per 1,000 females in a given population. However, in India, the sex ratio is calculated on the number of females per 1,000 males in the defined population (Joshi & Tiwari, 2011).
• At birth, boys in India naturally outnumber girls by 3% to 7%, meaning the expected female -to-male sex ratio is 0.93 to 0.97. However, when the sex ratio at birth is skewed in favor of male babies, it indicates human meddling by means of sex identification and sex-selective abortion (Singh, 2010). India is one of several countries where such concerns are persistent and significant (Guilmoto, 2012). Numerous laws intended to prevent discrimination on the basis of gender have been passed over the years in India (Basu, 2009), yet the distorted female-to-male sex ratio seems to show worsening tendencies (Jha et al., 2011).
• At birth, boys naturally weigh more than girls (whether in the West or Asia), yet boys’ mortality rate also is inherently higher (Hong et al., 2007; Singh, 2010). Therefore, when the mortality rate of infants and children is higher for females, nurses should be aware this is a warning sign that neglect of the female child may be occurring (Singh).
• A normal adult sex ratio of at least 1.05, women-to-men, is based on countries where equal care is received. In India, the 2013 estimated sex ratio for adults aged 25 to 54 in India was 0.94 women-tomen (Central Intelligence Agency, 2013). Croll (2000) points out that the sex ratio of females -tomales is even more disturbingly low among the 0-to-10 age group, particularly among those 0 to 4 years of age. According to the 2001 Census of India, the child sex ratio (0–6 years of age) was 0.927, declined from 0.945 in 1991 (Paul et al., 2011). 
• This declining pattern continues, as the provisional results of the 2011 Census of India indicate the child sex ratio (0–6 years) is 0.914 (Government of India, 2013). The National Family Health Survey-2 data indicate that among Indian women, who had ultrasound or amniocentesis during antenatal care, an estimated 6.4% of female fetuses were likely aborted (Paul et al.). This is done to increase the number of male babies born within the family, thus obtaining the desired family composition of having more sons than daughters (Agrawal, 2012). Given these data, there are realistic fears that prenatal sex determination and the old practice s of female infanticide combine in today’s Indian society (Guilmoto, 2012; Jha et al., 2011).
• Based on  European history,  demographic experts had anticipated decreased son  preference with India’s strong economic development. However, in Asia, son preference has actually increased with economic development, decreased fertility rates, and small family size. The difference in how son preference continues to evolve in Asia is due to deep cultural roots regarding gender identity (Croll, 2000; Das Gupta et al., 2003). Indeed, in India, son preference is present across differing groups of socioeconomic status, education levels, castes, tribes, religions, and state of residence (Paul, 2011).
• Likewise, Sev’er (2008) notes gender discrimination across the female lifespan in India, and compellingly links the dowry (bride price) system and sex selection practices. Sev’er notes that areas where violence related to dowry dispute is highest, adult and child sex ratios are the most skewed. The dowry system casts daughters as a liability, a net loss or economic ruin of her family. This entrenched way of thinking is rooted in Hindu culture and perpetuated by maxims such as “raising a daughter is like watering a neighbor’s plant” and “a son spells rewards, a daughter expense” (Hedge, 1999, p. 18).

Sex Determination

• If sex determination sonography is utilized, a woman may be forced to undergo an abortion by the family, resulting in female feticide (Puri, Adams, Ivey, & Nachtigall, 2011). If the baby’s gender is unknown until birth, a female child is at risk of infanticide. Sev’er (2008) succinctly summarizes the vicious cycle of female life and death in India, stating that “the problem lies in the attitudes toward women, the lower status of girl children and the fear of the dowry burden”.
• Sahni et al. (2008) note the continuing importance of using hospital records for collecting data on sex ratio at birth that is not influenced by female feticide and neglect of girl children. A distorted sex ratio at birth may be considered indirect evidence of prenatal sex determination, followed by sex-selective abortion (Pham, Hall, & Hill, 2011).
• Though it is difficult to find alternate explanations for distorted sex ratio at birth, interpretation must be carefully considered. Chamarbagwala and Ranger (2010) noted regional variations across India, as well as other patterns. For instance, larger families (≥3 children) had greater gender equality than smaller families. This may be because if sons are born first, the couple may choose not to ha ve any more children, whereas other couples continue having children until the desired number of sons is attained. In a qualitative study, respondents indicated that couples often continue to have children until they have at least one son (Chor, Patil, Goudar, Kodkany, & Geller, 2012).
• Inconsistent birth registry or incomplete vital statistics system in India could influence the calculation of sex ratio at birth in various regions (Manchanda, Saikia, Gupta, Chowdhary, & Puliyel, 2011). Poor data quality and availability complicate the interpretation of sex differences (Sawyer, 2012).
• Also, technology has made preconception sex determination possible by two methods: X and Y sperm separation and preimplantation genetic diagnosis. These methods were touted as more ethical means of ensuring the birth of a boy. However, these preconception methods have contributed very little to India’s skewed sex ratio, likely due to their invasive nature and high cost (Madan & Breuning, 2014).

Alternative Explanations

• Alternative explanations for a skewed sex ratio of the general population include human trafficking (Madan & Breuning, 2014), and decreased fertility rates (Guilmoto & Duthé, 2013). However, outside of specific biologic phenomenon such as ionizing radiation, as hypothesized in Cuba and Russia (Scherb, Kusmierz, & Voigt, 2013), it is much more difficult to explain a distorted sex ratio at birth in India. Underreporting or undercounting, blamed on the inadequate vital registration system, does not explain the continued decline of the sex ratio among 0-to-6 year olds in India (Madan & Breuning). The regularity of this decline indicates true imbalance rather than artifact (Guilmoto & Duthé). The Registrar General and Census Commissioner of India reported that the low 0-to-6 year old child sex ratio was primarily due to the low sex ratio at birth (Chandramouli, 2012). As Guilmoto and Duthé put it, outside of “a freak biological phenomenon that alters the sex ratio at birth” (p. 2), human meddling (preconception or sex-selective abortion) is the only explanation for an imbalanced sex ratio at birth.
• The convergence of culture, son preference, and reproductive technology are complex issues of gender discrimination resulting in skewed sex ratios with lower than expected number s of females (Agrawal, 2012). The worsening gender discrimination, evidenced by the trend in sex ratio, can only be reversed through social change. Nurses are critical in addressing this complex issue. Public policy alone has failed. Nongovernmental organization (NGO) and other organizational schemes have failed. As noted by Rajaram and Zararia (2009), rights in law books must cross over to rights perpetuated by social norms within local communities, in order to positively impact the lives of poor women.