Health of Children in Rural India May Reflect Whether Parents Have Met Their Goals for Family Composition

D. Hollander

First published online:

One in three rural Indian children are severely stunted, and nearly two in five have not had all of the recommended vaccinations by age five, according to an analysis of data from the 1992-1993 National Family Health Survey.1 The gender mix of older surviving siblings is associated with outcomes on these health measures; differences between boys and girls in these associations suggest both that parents value sons over daughters and that they "may discriminate selectively" depending on whether they have achieved the gender balance they desire in their family. For example, girls have reduced odds of being stunted if all of their older siblings are boys, but marginally increased odds if they have siblings of both genders. Yet, even boys are treated differently depending on their family's composition: Their odds of being fully immunized are elevated if they have only sisters but are reduced if they have only brothers.

The data reflect outcomes among children of ever-married women aged 13-49 living in rural areas of India. To study severe stunting, an indication of nutritional deficit, the analyst examined information on almost 15,000 children aged 6-47 months. (Severe stunting was defined as three standard deviations below an international measurement of height for age.) The analyses of immunization (i.e., whether children had received the full complement of tuberculosis, polio, measles and diphtheria-pertussis-tetanus vaccinations recommended by the World Health Organization) included more than 25,000 children 12-60 months old.

Both samples of children were equally divided between boys and girls. In each, roughly one-quarter of children had no older surviving siblings, one-third had a mix of brothers and sisters, and the rest had only sisters or only brothers; the average family included three children. Mothers were predominantly illiterate, and about one in six had more than a primary education. Half of children lived in a village with no health services, one-third in a village with a hospital and health center, and the remainder in a village with a health center only.

One-third of all children (36% of girls and 33% of boys) were severely stunted. Only three in 10 (29% of girls and 31% of boys) were fully immunized, and nearly four in 10 (41% of girls and 35% of boys) had received no vaccinations. Results of bivariate analyses suggested that health outcomes were related to the number and gender of older surviving siblings, and that these relationships were different for girls and boys. To more closely examine these relationships, the analyst conducted a series of logit analyses, controlling for social, household and village characteristics that may influence gender differences.

In the multivariate analyses for all children combined, a child's gender was not associated with the likelihood of severe stunting, but girls were less likely than boys to have had a full range of vaccinations. The analyst points out, however, that these findings are difficult to interpret because associations involving the presence of older siblings differed by gender. Girls with two or more sisters and no brothers were more likely than those with no siblings to be severely stunted (odds ratio, 1.3); the odds were marginally elevated for those with both sisters and brothers. Moreover, compared with boys in similar situations, girls with at least two sisters and no brothers had higher odds of stunting (1.6), and those with at least two brothers and no sisters had a lower likelihood of this outcome (0.7).

Boys whose older siblings were all girls were more likely than those who were only children to be fully immunized (odds ratio, 1.2); those with only brothers had reduced odds of having had all recommended vaccinations (0.8). Girls were less likely than boys to be fully immunized if they had sisters but no brothers (0.6, whether they had one sister or more).

Noting that India has a decades-old mass immunization program "that should theoretically be accessible to all eligible children," the analyst characterizes the disadvantage observed for girls as "somewhat surprising" and attributes it to opportunity costs that parents may be unwilling to pay for relatively unwanted children. Overall, the analyst concludes, the results "strongly [suggest] that parental and societal norms about the values of girls relative to boys and about a desirable family sex composition are key to explaining why certain children fare worse than their siblings and why girls with older sisters fare particularly badly."--D. Hollander


1. Pande RP, Selective gender differences in childhood nutrition and immunization in rural India: the role of siblings, Demography, 2003, 40(3):395-418.