Indian Journal of Public Health

: 2017  |  Volume : 61  |  Issue : 2  |  Page : 112--117

Determinants of child sex ratio in West and South Districts of Tripura, India

Himadri Bhattacharjya1, Subrata Baidya2,  
1 Assistant Professor, Department of Community Medicine, Agartala Government Medical College, Agartala, Tripura, India
2 Associate Professor, Community Medicine and Medical Superintendent, Agartala Government Medical College, Agartala, Tripura, India

Correspondence Address:
Himadri Bhattacharjya
Department of Community Medicine, Agartala Government Medical College, Agartala - 799 006, Tripura


Background: Indian census 2011 has detected declined child sex ratio in the West and South districts of Tripura State. Objectives: To find out the sex ratio at birth and to identify the factors affecting child sex ratio in west and south districts of Tripura. Methods: This community-based cross-sectional study combined with a qualitative component was conducted among 3438 couples chosen by multistage sampling. Quantitative data were collected by a structured interview schedule. Data were analyzed by computer using SPSS version 15.0. Chi-square test was applied for testing the significance of study findings and P < 0.05 was considered statistically significant. Qualitative data were collected by Focus Group Discussions and analyzed by qualitative free listing and pile sorting considering Smith's S value. Results: Sex ratio at birth in West and South Tripura districts during 2013 was found to be 972 and 829 respectively. Son preference was higher among couples irrespective of their literacy, residence, occupation, family type and religion except Christianity. Expenditure at marriage, lesser contribution to parent's family and fears of adverse situations at in law's house after marriage etc. were causes for lesser daughter preference. Very few pregnant women underwent ultrasonography for sex determination of fetus. Girls had differential or delayed medical care and higher death rate. The desire for children was found to be limited after male births. Conclusions: Low daughter preference was mostly due to economic reasons and prolonged contraception following male birth. Literacy, occupation and residence of study subjects did not modify prevalent higher male preference.

How to cite this article:
Bhattacharjya H, Baidya S. Determinants of child sex ratio in West and South Districts of Tripura, India.Indian J Public Health 2017;61:112-117

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Bhattacharjya H, Baidya S. Determinants of child sex ratio in West and South Districts of Tripura, India. Indian J Public Health [serial online] 2017 [cited 2023 Mar 28 ];61:112-117
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Full Text


Like most sexual species, the sex ratio in human is approximately 1:1. Fisher's principle is an evolutionary model that explains why the sex ratio of most sexual species is approximately 1:1.[1] The sex ratio for the entire world population is 101 males to 100 females.[2] In 2011 census [3] child sex ratio has plummeted to 914 from 927 of 2001 census and it is found to be the lowest since independence. The highest child sex ratio is observed in Mizoram at 971, closely followed by Meghalaya with 970.[4] The 0–6-year-old child sex ratio in Tripura has gone down from 966 in 2001 census to 953 in 2011 census.[2] It has decreased in West Tripura district from 967 in 2001 census to 942 in 2011 census and in South Tripura district also it has decreased from 961 in 2001census to 947 in 2011 census.[2] Sex-selective abortion and female infanticide facilitated by the misuse of ultrasonography (USG) or amniocentesis, high maternal mortality, etc. are commonly blamed for decline in the number of girls. However, in some places, social customs and norms such as dowry system, economic reasons, difficulty in rearing girl child and prejudice against girl child may also contribute to it. Determinants of sex ratio at birth and determinants of child sex ratio may differ from each other depending upon place, society, custom, situation and others but both will ultimately affect the child sex ratio. In this context, as per desire of the State Health Mission, Government of Tripura, the present study was designed to determine the sex ratio at birth and to find out the possible causes of decline in the 0–6-year-old child sex ratio in West and South Tripura districts.

 Materials And Methods

It was a community-based cross-sectional study comprising a quantitative and a qualitative component conducted from January 2013 to July 2013 in the old West and South districts of Tripura among 3438 couples residing permanently in these districts and currently having any 0–6-year-old child.

Minimum sample size requirement for quantitative component of this study was calculated using the formula, n = (Z2 × p × q) ÷ L2. Assuming sex ratio at birth is approximately 1:1, “p” was taken as 50% at 95% confidence, Z = 1.96, q = (1 − p), “L” = allowable error = (5% of p) = 2.5, multiplied by design effect of 2 for multistage sampling (1537 × 2 = 3074), and additional 10% for incomplete responses (3074 + 308) = 3382 ~ 3390 (rounded).

For the quantitative component, multistage sampling procedure was followed to choose couples from two districts. A sampling frame consisting of subdivision wise names of all the towns (Nagar panchayat) and blocks was prepared for each district. From each subdivision, one block and one town (Nagar panchayat) was chosen by simple random sampling (SRS). One village panchayat was chosen from the selected block by SRS. Then one ward each from the selected town (Nagar panchayat) and village was chosen by SRS. Thus, from 10 subdivisions 20 wards were selected. Population-wise list of the selected wards was prepared. Family registers maintained by the ward offices of the selected village and town areas were used for constructing the final sampling frame ([Figure 1], sampling algorithm).{Figure 1}

Child sex ratio (0–6 years) was defined as the number of girls against 1000 boys in the age group of 0–6 years in the study area. Sex ratio at birth was defined as the number of female live births per 1000 male live births during the study year. Illiterate persons were those who were unable to write their names. Just literate were those who were able to write their names only. Primary educated were those who had schooling up to any level between Standard I and VIII. Secondary educated were those who had schooling up to any level between Standard VIII and XII. Graduate and above were those who either got admitted to college or completed graduation or above.

For the qualitative component, 20 Focus Group Discussions (FGDs) (two in each subdivision, one in urban and one in rural) were conducted. The principal investigator has facilitated the FGDs, which were audio recorded after obtaining informed written consent from the participants. The area and the participant couples for the FGDs were chosen at random from the eligible participants.

Face and content validity of the interview schedule was evaluated by piloting up on 25 couples and 3 epidemiologists were asked to evaluate the clarity and representativeness of the questions regarding the causes for decline in the number of girl children. The factor analysis was performed for evaluating the construct validity of the schedule. Evaluation of internal consistency of the subscales for the couple's desire questionnaire was carried out by calculating the Cronbach Alpha coefficient. Cronbach Alpha values ≥0.8 indicated higher consistency of some of the questions for which subscales were constructed. The questions that were reducing the internal consistency of the interview schedule (Cronbach Alpha values <0.5) were excluded from the study. The repeatability of interview schedule was evaluated using the intraclass correlation coefficient.

For collecting quantitative data, the study couples selected at ward levels from the family registers were paid home visits by a team of recruited trained field workers (one male and one female field worker constituted one team). Informed written consent was obtained from every couple in the presence of a witness and tagged to the respective filled in interview schedule. Consenting couples were interviewed by the female field worker inside their dwelling rooms with door closed and recorded by the male field worker in the pretested and validated, structured interview schedule. During the interview, no other family members were allowed inside to ensure confidentially.

Quantitative data were entered and analyzed in computer using SPSS software for Windows [5] version 15.0. Chi-square test with Yates' correction was applied to assess the significance of study findings and P< 0.05 was considered statistically significant. For the qualitative data, free listing and pile sorting considering Smith's S value [6] was performed during preparatory as well as for analysis of FGDs.

Data collected while conducting the study were dealt with confidentiality and used for research purpose only. Institutional Ethics Committee of Agartala Government Medical College approved the study.


Total 3487 couples residing in the study area for 1 year or more and having children aged 6 years or less were selected and approached for participation in this study. Out of them, 21 couples denied participation in the study, 6 couples had difficulty in communication which could not be solved at that time and 22 couples were out of station during the home visits so were excluded from the study. Required number of couples were not available in two of the selected clusters, so further required couples were enrolled from the neighboring clusters.

Finally, during the survey, it was possible to enroll 3438 couples in this study.

Analysis of quantitative data revealed the sex ratio at birth during the year 2013 in West and South Tripura districts to be 972 and 829 respectively and after pooling data from these two districts it was found to be 928. The child sex ratio (0–6 years) of the sampled population of west and South Tripura districts was found to be 951 and 832 respectively. Regarding sociodemographic status, mean age of the participant husbands and wives at their first childbirth in the whole study area was 28.51 (±7.79) and 28.92 (±4.98) years respectively. Majority of the study couples from West and South districts (54% and 61.3%) were from nuclear families, belonged to general community (31.9% and 42.3%), studied up to primary level (West district: husbands 32.7% & wives 39%; South district: husbands 37.9% & wives 44.7%), Hindu by religion (92.9% and 99.6%). Majority of the males had their own business (32.1% and 34.1%), females were mostly homemakers (89.1% and 91.9%) and in majority (98.7% and 99.6%) of the families of both the district decision regarding fertility was made by the husband and wife jointly.

Regarding total number of children, 61.6% and 67.9% couples from West and South Tripura districts respectively desired to have only two children and most common desire of the study couples from both the district was one son and one daughter. Regarding the first child, majority of the study couples (72.0% and 81.8%) from both the districts had no particular sex preference but the second preference was mostly son. This equal or no preference for the first child was significantly associated with couple's literacy (men: χ2 = 57.366 P = 0.000; women: χ2 = 40.573, P = 0.000), residence (χ2 = 16.228, P = 0.000), religion (χ2 = 29.924, P = 0.000), and husband's occupation (χ2 = 29.924, P = 0.000). Chi-square statistic was calculated between total number of couples having some preference and those who had no preference [Table 1] and [Table 2]. Regarding abortions, 6.8% women from West Tripura district and 4.0% from South Tripura district had this during the preceding 6 years period. The frequency of spontaneous and induced abortions were same in West Tripura district, but spontaneous abortions were more than the induced in South Tripura district during the preceding 6- year period and couples cited birth spacing (53.85% and 53.34%) as the most common reason for inducing abortion in both the district. Maximum numbers of induced abortions were sought by those couples who already had equal number of sons and daughters (47.17%), followed by those, who had predominantly daughters (40.0%) and least by those, who had predominantly sons (2.5%). Spontaneous abortions were more frequent among those who had predominantly male babies, but it was statistically insignificant [Table 3].{Table 1}{Table 2}{Table 3}

In West Tripura district the couples, who preferred son as their first child, mostly cited 'future security' (64.58%) as the main reason, whereas the couples from South Tripura district cited 'generation continuation' (42.78%) as the main reason for it. Couples from both the district who preferred daughter as their first child, mostly cited 'daughters are Laxmi of family' (The Hindu goddess of wealth) as the main reason for it (43.03% & 43.63%) [Table 4].{Table 4}

Among the couples who did not have any particular sex preference for their first child, majority (49.25% and 53.82%) of them believed that “both the sex is equal.” In both the district, couples who desired more than one child, majority (63.71% and 69.17%) of them preferred a daughter during the second time if their first child happened to be son and couples who desired more than one child, majority (58.98% and 70.58%) of them preferred a son during second time if their first child happened to be daughter.

About prenatal sex determination, majority of the study couples from both the district (59.5% and 55.6%) knew it is not possible and 6.1% couples from the West Tripura district had no idea about this but those who heard about prenatal sex determination, all most all of them knew USG as the method for it and majority of them knew that it can be done at government hospitals. Regarding this, friends (31.44% and 82.54%) were the major source of information for the couples followed by relatives (30.93% and 13.49%) and media (26.27% and 2.98%) in both the district. Despite knowing prenatal sex determination as possible, 95.78% couples from West district and 94.97% from South district were not interested to get it done for them as they knew it was prohibited by law (70.80% and 94. 97% from West and South district respectively).

About USG examinations, the majority of the study women (62.68% and 51.32%) from both the district had this during the preceding 6 years period and mostly as per advice of doctors (99.30% and 99.83%). Pregnancy check-up (97.71% and 98.63%) was the most common cause for undergoing USG examination in both the district and only 0.49% women in West Tripura district underwent USG examination for prenatal sex determination. In West Tripura district 1443 and in South Tripura district 583 women underwent USG examination during pregnancy. Following USG in West Tripura district 1167 (80.87%) women did not have any intervention, 271 (18.78%) had cesarean section, 2 (0.14%) had some surgical treatment and only 3 (0.21%) women had termination of pregnancy. In South Tripura district no one had termination of pregnancy following USG.

The analysis of qualitative data was done to find out the factors contributing to and precipitating the decline in 0–6-years age group child sex-ratio in the study area. Various related issues were explored qualitatively in a triangulated manner in the form of FGD. Free listing and pile sorting exercise was performed using the platform of FGDs to identify the various factors and their role in declining 0–6-years age group child sex-ratio in the study area. Free listing of the factors responsible for decline in 0–6-years age group child sex-ratio in the study area as per discussion with the participants included the following as per descending Smith's S value: (a) Due to difficulties in bringing up and educating a daughter in the mid of emerging social problems for the girl children people are reluctant to have daughters. (b) Due to economic constraints birth of a daughter is not much preferred as she needs to be married away in future and lot of money is required for marriage. (c) If the first child happens to be a son, desire for another child gets less pronounced, this ultimately might reduce the probability of bearing a girl child. (d) During illnesses, medical care and hospitalization for a girl is often delayed than a boy, this might result in higher death rate among girl children. Girls are usually taken to the local quacks, indigenous practitioners, etc. and only in case of failures are shifted to government hospitals. (e) Daughters cannot support the family like sons, hence are preferred less. (f) Daughters sometimes face adverse situations in the in law's houses, and it becomes a matter of great concern and worries for the parents. (g) Pregnant women might be undergoing USG examination for sex determination of the unborn baby and abortions thereafter if female baby is detected. (h) Prolonged contraceptive use. (i) Daughter's earning for the family is not sustained as they get married away.

Pile sort analysis has shown that participants could identify four broad categories of factors responsible for decline in 0–6-years age group child sex-ratio in the study area. First broad category of factors was first child son and prolonged contraception. The second category consisted poor support to the family by girl children and economic constraint. Third category consisted social problems in rearing girl child and problem faced in in-law's house. Fourth category was neglected medical care for girls and prenatal sex determination.


In the absence of manipulation, the sex ratio at birth is remarkably consistent across human populations with 105–107 male births for every 100 female births. This slight excess of male births was first documented in 1710 by Campbell and John Graunt and colleagues for the population of London.[7] The present study has found the sex ratio at birth to be 928 in the combined West and South Tripura districts, whereas the global sex ratio at birth is estimated to be 934 and in India it is 893 as of 2014.[2] A key study of births for the period 1962–1980 in 24 countries of Europe showed a sex ratio of 105–107, with a median of 105.9.[8] Parental educations might have some role in determining the child sex ratio. In the present study, majority of the couples were primary educated and it was similar with the findings of Shewte and Andurkar, 2013.[9] Chakrabarti and Chaudhuri, 2011[10] also found women's education to be the most significant factor in reducing son preference. On the contrary, some studies have indicated that educated mothers in India had the lowest female-to-male ratio [11] and the odds of producing a male offspring in India increased with the mother's income and education.[12] In the present study, mean age of the participant husbands and wives at their first childbirth was found to be 28.51 (±7.79) and 28.92 (±4.98) respectively and they had more number of male babies than females. A similar finding of having more male babies per 1000 female babies by younger parents than the older was observed by other studies also suggesting that social factors such as early marriage and quickly fertile couples may play a role in raising birth sex ratios in certain societies.[13] The present study found worse sex ratio among the Hindus as compared to the Muslims and it was similar with the findings of Shewte and Andurkar, 2013.[9] The present study detected lower sex ratio among the Hindus than the Muslims which indicate that sex discrimination is still continued and deep rooted among Hindus and it is comparable to Garg and Nath, 2008.[14] Although Jha et al., 2006[11] did not find any significant differences in adjusted sex ratios which were found among different religious groups in India. Here, the majority of the couples did not have any particular sex preference for their first child, whereas South Koreans were found to be sex-selective even in their first pregnancy as there is a traditional preference for the first-born to be male.[15] Sekher and Hatti, 2010[16] also conducted FGDs in South Indian community and had similar findings that girl children were less preferred than boys because daughters will not be able to contribute to family income moreover huge expenditure are needed to marry them off. They also preferred son for want of future support during old age.


Nonresponders could not be further interviewed and more variables could not be included due to resource constraints.


Lower sex ratio at birth (0–1 year) is observed in South Tripura district than West Tripura district. Patriarchal society of this region did not prefer girl children mainly due to economic reason, difficulty in rearing a girl child, poor future support from daughters to the family etc. Literacy status, occupation and residence of people did not modify higher male preference. Prolonged contraception, especially after a male birth also contributed to lesser number of girl children. Hence, behavior change communication for accepting girl children, equal caring like sons for nutrition, education, illness and provision of social security during old age may help to check the declining child sex ratio in this community.

Financial support and sponsorship

This study was funded by Tripura State Health Mission.

Conflicts of interest

There are no conflicts of interest.


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