Jhajjar, Haryana: “There are families who keep trying to get a boy child, they have three, four, five daughters but they keep trying in the hope of a son,” said Sunita Devi, the pradhaan (head) of Dhandlan village in Haryana’s Jhajjar district. “A boy child continues to be important simply because he is perceived to be an asset, not a burden.”

Haryana has historically had one of the lowest sex ratios in the country--it had 833 girls for 1,000 boys at birth in 2011, according to the government’s Civil Registration System (CRS) data.

However, for close to a decade now, the state has shown a steady improvement in its sex ratio at birth, and reported 920 girls for 1,000 boys in August 2019, as per state-level CRS data shared with IndiaSpend.

Haryana’s skewed sex ratio has led to villages with few female children, brides being bought for money as there are too few women for men to marry, and forced marriages with women outside the state, The Guardian reported in March 2018.

A healthy sex ratio at birth is 952 girls for every 1,000 boys, according to the World Health Organization.

Haryana’s achievement seems remarkable in itself, as well as in comparison to India’s--the country’s sex ratio at birth declined from 909 girls per 1,000 boys in 2011 to 877 girls per 1,000 boys in 2016, according to the latest publicly available CRS data.

Haryana improved its sex ratio at birth through punitive action for sex-selective abortion, counselling of parents and families, tracking pregnancies and through campaigns to change people’s perception about girls, officials said. At the same time, data on the sex ratio are not entirely reliable, with two government reports showing different sex ratios in the state.

Ahead of Haryana’s state elections on October 21, 2019, we visited one district (Jhajjar) to investigate how the state has tackled this complex socio-economic problem of its skewed sex ratio. We found that the strict clampdown on female foeticide has worked. But experts said a strict clampdown has its limits, and lasting change requires an attitudinal shift--a bigger challenge--without which no social change can last.

Unreliable data

The CRS used by the Haryana government to claim an improvement in its sex ratio at birth is a system through which the government registers every birth and death in the country, along with a rural-urban and sex-wise break-up.

The Sample Registration System (SRS) data does not use combination of CRS data and representative surveys.

The CRS data show a better ratio than the data from the SRS. The sex ratio at birth for Haryana was 833 girls per 1,000 boys from 2015 to 2017, according to SRS. The sex ratio was 914 girls per 1,000 boys for 2017, according to CRS data.

"Sample registration survey is more trustworthy as compared to the civil registration system data,” said D A Nagdeve, head of the department of fertility studies at the International Institute of Population Sciences in Mumbai. The SRS considers both actual registrations, and half-yearly surveys that verify that every event is captured. “CRS is prone to get misreported, has more errors and cannot be crosschecked,” Nagdeve said.

However, Haryana government doctors said CRS, the system they have used, is more accurate, and blamed the discrepancies on births in “illegal institutions”.

“[The] civil registration system seldom misses out on deliveries since it is the responsibility of both the public and private hospitals to get each birth registered,” said Mamta Verma, a medical officer in the civil hospital in Jhajjar. “There is 100% birth registration by the Auxiliary Nurse Midwife (ANM),” she said, “But illegal institutions which conduct deliveries don’t follow the registration guidelines and such births won’t reach the CRS data.”

The only errors in the CRS data are data-entry errors, said G L Singhal, the nodal officer in Beti Bachao Beti Padhao Secretariat, Haryana, adding, “These instances are rare and immediate action is taken against the defaulters upon identification.”

IndiaSpend could not independently verify how mistakes in the CRS are recognised and corrected.

Punitive action

“Our villages were infamous for female foeticide,” said R S Poonia, chief medical officer at the civil hospital in Jhajjar. “When the work on Beti Bachao started, we were determined to change things. We focused on saving the girl child, educating them and also enabling them.”

Jhajjar and other districts in Haryana strictly implemented the Pre-Conception and Pre-Natal Diagnostic Techniques Act (PCPNDT), which restricts sex-selective abortions.

The sex ratio at birth in India declined because of easy access to sex-selective abortions, as medical technologies proliferated the Indian market. The estimated value for the sex determination market in India is in excess of $100 million annually, according to a August 2018 research paper, published in National Centre for Biotechnology Information, a health journal.

The PCPNDT Act, 1994 was enacted in response to the declining sex ratio in India--it reduced from 972 females per 1,000 males in 1901 to 927 females in 1991. The Act bans the use of sex-selection techniques before or after conception, prevents the misuse of diagnostic techniques for sex-selective abortions and prohibits the distribution and supply of any ultrasound machine or any other equipment capable of detecting the sex of a foetus.

Sex-selective abortions are more rampant in the rich upper castes in Haryana.

“The market price of sex selection is Rs 1 lakh as charged by registered radiologists,” said Verma, Jhajjar’s medical officer, and part of the abortion prevention team. “This price can’t be afforded by lower caste or poorer people.”

“The general caste category comprises of maximum population of Jaats in Haryana,” according to a September 2018 report by the state’s Women and Child Development Department. “Thus indicating clear patterns of son preference in the region among the upper caste.”

The Haryana government claims that decoy operations and raids since 2015 played a crucial role in reducing sex-determined abortions.

“We have until now filed 390 FIRs (first information reports alleging that a crime has been committed) for violating the PNDT Act and 230 FIRs under the Medical Termination of Pregnancy (which sets rules for abortion) Act against quacks, paramedics, daais etc,” said Singhal of the Beti Bachao Beti Padhao programme.

He said that the Haryana police has conducted raids not only within Haryana, but also in border states of Uttar Pradesh, Rajasthan and Delhi, because many people travel to these states for sex determination.

“The easy accessibilty to medical termination of pregnancy kit (abortion kits) gives rise to cases of abortions,” said Singhal. “We track these kits closely and if anyone uses it, our ANM and ASHAs will get to know.”

An unintended consequence of this has been that it is now extremely difficult for women to get an abortion, even in cases of unwanted pregnancies, Verma, the Jhajjar medical officer said.

“Abortion tablets of Rs 250 are being sold at Rs 15,000,” Verma said. “There is a growing suspicion over women getting abortion pills and doctors are scared of prescribing them. Medical stores in Haryana are not giving ‘over the counter’ abortion pills anymore. They think it’s a health department decoy to track people down.”

Grassroots monitoring

Despite the PCPNDT Act passed in 1994, “Haryana’s numbers were showing no improvement”, said Singhal. A public interest litigation against the poor implementation of the PCPNDT Act was filed in 2001 by Sabu George, an activist along with the Center for Enquiry into Health and Allied Teams (CEHAT), a Mumbai-based non-governmental organisation. In response, the Supreme Court passed an order asking Haryana’s state authorities to strictly implement the PCPNDT Act.

“Even after this directive, from 2001-2011, the PNDT Act’s implementation did not translate into an improved sex ratio at birth,” said Singhal. “But after the launch of Beti Bachao Beti Padhao in Panipat in 2015, things started changing.” The Beti Bachao Beti Padhao programme focuses on preventing female foeticide, improving the child sex ratio, and women’s education.

Frontline workers spread the message that girls were no less than boys and use the example of “golden girls” such as wrestlers Sakshi Malik and the Phogat sisters, said Poonia.

Frontline health workers also tracked every pregnancy in a village, and counselled parents and families.

“Whenever a new couple gets married in the village, we visit them and register their names, from then on we start tracking them,” said Sharmila Devi, an ANM who has been working in Jhajjar for the past eight years. ANMs register a pregnancy in the first trimester, and then track the mother’s monthly visits to the doctor.

But antenatal visits haven’t increased as much as the improvement in the sex ratio, showing that the focus is more on preventing sex-selective abortions. Less than half (41.8%) of mothers had had at least four antenatal visits to the doctor in 2015-16 for their latest birth in the five years before the survey, according to the latest data available from the National Family Health Survey.

We also track the “behaviour of her in-laws and the family’s attitude towards having a girl child”, Sharmila Devi told IndiaSpend. “If the first-born is a girl, then we keep a close check to ensure that the mother doesn’t go for sex determination.”

ANMs conduct monthly meetings with Accredited Social Health Activists (ASHA). If an area has a lower sex ratio, ANMs and ASHAs jointly counsel expecting mothers, especially those who already have daughters and are now adamant on having a son.

Over nine months between January 2019 and September 2019, 568 boys and 545 girls were born in the village, bringing its sex ratio at birth to 960 females per 1,000 males, the highest ever, said Vineet (he uses only one name), Medical Officer In-Charge, Dighal, Jhajjar.

“I have seen mindsets change in this village,” said Sharmila Devi. “Earlier, everybody wanted a male child because he ensures the continuation of the lineage, now even when girls are born people throw parties and celebrate. There is an increasing trend of celebrating the 10th day after the birth of a girl, amongst those who can afford it.”

Ups and downs

In 2005, 15 of Haryana’s 21 districts had a sex ratio at birth below 850 females per 1,000 males.

That Haryana’s intervention does not focus enough on behaviour change is apparent through the oft-changing sex ratio in Jhajjar, the district which claims among the greatest improvement of all districts between 2012 and 2018.

In 2012, Jhajjar had a sex ratio at birth of 781 girls per 1,000 boys, which improved to 884 in 2014 and 920 in 2017, then reduced to 875 in 2018, before increasing to 901 in 2019 (December 2018- August 2019), as per CRS data.

The sex ratio in all 21 districts in Haryana shows a similar trend. (The 22nd district, Charkhi Dadri, was carved out of Bhiwani in 2016.)

Source: Women and Child Development Department, Haryana
Note: Data for 2019 are for December 2018 to August 2019.

Attitudinal shift--the real challenge

“Sustainability in numbers requires constant political and administrative commitment and commitment from the state to ensure implementation,” said George, the activist. “If all of this happens, over a period of time there will be stability in numbers… census of 2021 should reflect this.”

Medical staff admit that attitudinal shifts are the tougher challenge. “Behavioural change has not been much, that’s the indigestible fact, law cannot be used everywhere,” said Singhal.

For instance, in one of the districts where the numbers were improving, the government posted a chief surgeon who was lenient on the law. This resulted in the sex ratio at birth declining within a year, he explained. “Law will only act as a deterrent if it is strictly implemented.”

Maintaining the improvement is a difficult task as a preference for sons continues. “People are scared to give birth to a girl child because girl child is synonymous with a burden, she needs protection or she could be raped, she needs a dowry to marry, she will never stay with the parents,” Sunita Devi said.

“Our efforts ensured that Jhajjar stays in the top 10 districts in the state,” Poonia said. “This has been our achievement but the biggest challenge we face now is to maintain these figures.”

Correction: We visited one district (Jhajjar), and not two as an earlier version of the story erroneously said. The Sample Registration System does not use Civil Registration System data, as an earlier version of this story erroneously said. We regret the errors.

(Tiwari is a principal correspondent and Ali is a reporting fellow with IndiaSpend.)

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