Data put the Indian desire for male child in stark relief
By Rukmini S.
"Among families with one to four children, more boys are born than girls." (AP)
India is going through a radical demographic transition, but new data from the Census show that one thing remains the same -- the desire for a male child.
Around 290 million women have had at least one child, the data show, with two being the most common number of children in a family -- a testament to falling fertility rates in India. The drop from number of two-child families to the number of families with more children is much sharper now than it was a decade ago. In fact, there were more families with over six children 10 years ago despite population growth.
Bring in gender dynamics, however, and an extremely complicated picture emerges. Among families with one to four children, more boys are born than girls. The unnatural advantage for boy babies is particularly sharp among families with two children -- half of such families have one boy and one girl, a third have two boys and just one-sixth have two girls. Even given the slight birth advantage that boys enjoy (in nature, there is a slightly higher likelihood of males being born than females), such sharply skewed sex ratios are a clear indication of unnatural processes, most likely pre-natal sex selection.
Among families with more than four children, a sudden reversal begins to take place, as girls become more common than boys. What’s going on here? Families that are unable to practise sex selection, or choose not to, are likely to continue with more pregnancies in the hope of a male child, demographers explain. So large families are more likely to have more girls, as the desire for a male child is what is spurring the size of the family.
What’s more, it’s clear that as family sizes got smaller over the last decade, these processes have only intensified. The magnitude of disparity between small families with more boys than girls and large families with more girls than boys has sharpened between 2001 and 2011.
As India pushes on ahead with its aim of reducing family sizes, it’s going to need to consider the significant impact it’s having on gender dynamics. ~~~~~~~~~~~~~~
New Census data indicates that two processes around the preference for a male child are going on simultaneously in India prenatal sex determination and repeated pregnancies. Data on family sizes and sex ratios released on Monday showed that at every family size, there were more boys born than girls.
However as family sizes got bigger, the sex ratio within the family got much less skewed, indicating that families with fewer or no sons were the ones choosing to have repeated pregnancies.
Among women who had one child, 22 million said they had a girl and 28.5 million had a boy, clearly indicating a disproportionately large number of boys being born. Among women who had given birth to two children, 26 million had two boys while just half that number 13.3 million had two girls.
This was similarly the case among families with three children families with all three boys or two boys and a girl were far more common than families with all three girls or two girls and a boy.
However at higher family sizes, this dynamic begins to change, as families that cannot or do not practise prenatal sex selection have repeated pregnancies in their quest for a son, a senior Census official explained.
Families with six children, for instance, are nearly as likely to have all six girls than all six boys, the data show.
As families get larger, the survival odds of girl children also begin to falter, the data shows. Among families where the woman had given birth to one child, the odds of the girl child surviving were slightly higher than the odds of the boy surviving, partly explained by the lower natural infant mortality of girls. Among families with two children, survival odds for girls worsened but were still comparable.
However among families with six children, the odds of the survival of daughters fell sharply.
China's gender ratio is at 117 boys for every 100 girls. By 2020, it will have an around 30 million bachelors
Three years after she became a national symbol of the abuses of China’s strict family planning policy, Feng Jianmei finally had a second daughter in August. Feng had a stillborn child in 2012 after local officials in Shaanxi province induced labour seven months into her pregnancy.
A supporter of Feng posted a photograph of her and the bloody foetus online, igniting nationwide outrage and leading to the firing of some officials. Even after that, though, Feng’s husband was beaten on the orders of local officials, who also led farmers in a march to denounce the family as “traitors.”
On Friday morning, less than a day after the Chinese government announced a shift from its decades-long one-child rule to a two-child policy, Feng’s husband reflected on their ordeal. “The tragedy that happened to us was because we didn’t have a permit,” the husband, Deng Jiyuan, said in a telephone interview. “I think it’s a good thing that everyone is allowed to have two children now. That is how the policy should always have been, from the very beginning.”
The decision to end the one-child policy came in dull, bureaucratic language. “Comprehensively implement a policy that couples can have two children, actively taking steps to counter the ageing of the population,” the Communist Party said in a communiqué on Thursday.
Those flat words, and their allusion to spurring economic growth, provided the official rationale for transforming a policy that has left cradles empty and hearts hollow across China, scarring generations of families.
The human rights abuses have included forced sterilisations and abortions, the killing of infants and the sale of children. So abhorrent are the practices that the US government grants refugee status to Chinese citizens who say they face persecution because of coercive family planning, making it easier for those people to get asylum.
Feng’s case was extraordinary in that it seized the attention of many Chinese and galvanised calls, including from officials and policymakers, to end the one-child system. But what she suffered was in many ways typical of the practices that spread like a poison throughout the Chinese governance system, from the central government down to the village level, as officials sought to enforce the policy adopted in 1979.
From the start, officials across China were told that population control was a priority, and that their jobs and career prospects, as well as those of colleagues, could depend on whether they met the targets. The bitter consequences of the policy go well beyond abuses by officials. Some parents, with their traditional preference for male heirs, have used abortion and infanticide to ensure they have a son, and the ratio is now about 117 boys born for every 100 girls. By 2020, China will have an estimated 30 million bachelors – a situation so dire that one economist has proposed that a wife should have multiple husbands.
“The gender ratio is a result of the policy,” Liang Zhongtang, 68, an early adviser to senior officials on family planning who advocated a two-child policy decades ago..
And with an average rate of 1.6 births per woman, China is not replacing its population, now at 1.4 billion. The elderly will lack caretakers. The slowing economy is already reflecting the effects of the planning.
“This policy has had such a big impact on China’s social development, bigger than the Cultural Revolution,” said Yang Zhizhu, a law scholar at the China Youth University of Political Studies in Beijing, who was fined and removed from teaching in 2010 after he and his wife had a second child.
“It’s ruined the demographic structure, both the age and gender structure, and it’s also altered Chinese people’s thinking so that young people are unwilling to bear and raise children.”
Critics say that until the system is abolished entirely, the abuses will continue. Parents with more than two children are still at risk. Such was the case with Pan Chunyan, a shop owner in Fujian province who was seized from her store in 2012 when she was almost eight months pregnant with her third child. Local officials took her to a hospital, where a nurse injected a drug to induce a stillbirth as scores of thugs prevented family members from entering.
“It was the most painful thing that ever happened to me,” Pan said in a telephone interview on Friday. “I can’t even think about having another baby. My baby was so grown. He was a life. He used to kick in my belly all the time.”
The one-child policy originated with a family planning policy group under the State Council, China’s Cabinet, that was established in 1973, said Liang. The government had for years been encouraging citizens to have fewer children. But in 1979, party leaders, under the group’s advice, took a bold step, embracing the new approach.
Hua Guofeng and Deng Xiaoping, the leaders who succeeded Mao Zedong, and other top party officials “all believed the huge population was the major setback in achieving a better economy,” Liang said. After they enacted the policy, he said, “it spread throughout the country quickly.”
Five years later, Liang, a population scholar at the Shanxi Academy of Social Sciences, wrote a letter to Hu Yaobang, then the party’s general secretary, arguing that if families were allowed to have two children, the population could still be kept to 1.2 billion by 2000. He proposed a pilot project in Shanxi, which was approved.
The project was carried out in secret for deca-des and ultimately showed that China’s birthrate would have declined naturally. But it never spr-ead because of ignorance and opposition from central family planning officials, Liang said.
Forced sterilisation across China, the mainstream policy took hold. Families not exempt from the one-child rule had to pay huge fines if they were found in violation. Employees of the state were fired, and party members were expelled. Some families secretly had “black” children – ones never registered at birth. In cities, officials erected billboards that showed beaming couples with a single angelic child. Signs in the countryside, where farmers wanted more children, tended to be harsher. One example: “Refuse to have an abortion and you will have your house demolished and lose your cattle.”
Strong-willed activists have emerged to challenge the practices. The most prominent is Chen Guangcheng, a blind man in Shandong province who was imprisoned by county officials for documenting cases of forced sterilisation and abortions and helping organise legal resistance. Chen’s persecution resulted in his flight from house arrest to the US Embassy in Beijing in 2012 and, ultimately, his departure from China.
That was the same year that the cases of Feng and Pan emerged and angered many people, as photographs of them in hospitals circulated online. Even Hu Xijin, editor-in-chief of Global Ti-mes, a nationalistic, state-run newspaper, called what Feng had endured “barbaric” in a microblog post, though he also said, “Family planning has served China rather than harmed it.”
The case for change had already been building among scholars and policymakers. In 2013, the party announced that couples in which at least one partner was an only child could have two children without penalty. Then, on Thursday, the two-child policy became the norm.
“What do I think about the new policy?” Pan asked. “I think it’s absurd that the state controls how many babies people have. Later came the time they wanted to control the population, and it became ‘one is enough.’ Now they say you can have two.” ~~~~~ Monday November 2, 2015
2-child policy only after Parliament approval: China
Beijing: China's top family planning authority has stressed that its local affiliates must implement the current one-child policy until a new policy allowing all couples to have two children goes into effect after being ratified by legislators.
Local authorities in each province should not carry out the two-child policy "wilfully," the National Health and Family Planning Commission (NHFPC) said, refuting claims by one local official that the new policy was effective as soon as it was announced, state-run Xinhua news agency reported.
"Those pregnant with a second child will not be punished as of today," Zhan Ming, deputy director of the provincial health and family planning commission in central China's Hunan Province, was quoted as saying by Hunan Daily on October 30.
The Communist Party of China announced the abolishment of its decades-old one-child policy at the close of a key meeting on October 29, in an attempt to balance population development and offset the burden of an aging population.
According to a communique released after the plenum, a final plan for the policy change will be ratified by the annual session of China's National People's Congress, (NPC).
The NHFPC estimated that about 90 million families may qualify for the new two-child policy, which would help raise the population to an estimated 1.45 billion by 2030.
China, the world's most populous nation, had 1.37 billion people at the end of 2014.
The one-child policy was introduced in the late 1970s to rein in the surging population by limiting most urban couples to one child and most rural couples to two children, if the first child born was a girl.
The policy was later relaxed to say that any parents could have a second child if they were both only children.
It was further loosened in November 2013, with its current form stipulating that couples are allowed to have two children if one of them is an only child.
Melbourne Cup 2015: Winning jockey Michelle Payne hits back at doubters after making history on Prince of Penzance
'Get stuffed!' Melbourne Cup winning jockey makes history
Scroll down to also read "Handicapped: it’s men who block female jockeys"
By Tom Decent /Journalist
First, Michelle Payne made history by becoming the first woman to ride a Melbourne Cup winner. Then she let everyone know what she was thinking.
Michelle Payne, the first woman jockey to win the Melbourne Cup, has hit back at her doubters after riding Prince of Penzance to victory at Flemington.
Payne was ecstatic after the race and could hardly contain her excitement after riding the 100-1 outsider to victory at Flemington.
Michelle Payne after making history (Joe Armao) Payne said it was a dream come true and was proud to prove people wrong in a sport she described as "chauvinistic sport" while also telling the doubters to "get stuffed".
"To think that Darren Weir has given me a go and it's such a chauvinistic sport, I know some of the owners were keen to kick me off, and John Richards and Darren stuck strongly with me, and I put in all the effort I could and galloped him all I could because I thought he had what it takes to win the Melbourne Cup and I can't say how grateful I am to them," Payne told Channel Seven after the race. "I want to say to everyone else, get stuffed, because women can do anything and we can beat the world.
"This is everybody's dream as a jockey in Australia and now probably the world. And I dreamt about it from when I was five years old and there is an interview from my school friends, they were teasing me about, when I was about seven, and I said, "I'm going to win the Melbourne Cup" and they always give me a bit of grief about it and I can't believe we've done it.
"I was lying in bed last night and I thought about what it would be like if I was talking to you after this race.
"When I wanted this horse as a three-year-old, he won here and I thought this is a Melbourne Cup horse and he just felt like he would run the two mile out that strong but far out, I didn't think he'd be that strong. He was still towing me into the straight. He just burst to the front and he was powering through, it's just unbelievable."
Payne was full of praise for the team around her and said she was surprised by how good a run she got.
"It's just unreal that we're here today you know," Payne said. "Coming down the straight the first time he became a bit steady I had to give him a bit of a dig which I didn't want to do, but I had to hold up my spot where I wanted to be.
"We travelled quite strong the whole way, he didn't get to rest, but he was still in a rhythm and from the 100 everything opened up. I got onto the back of Trip To Paris, she took me into the race; I was actually clipping his heels I was going that good. Then he got into the straight and he burst clear, it was unreal." ~~~~~~~~~ Melbourne ~ Thursday October 29, 2015
Handicapped: it’s men who block female jockeys
Other states offer female jockeys more opportunities but even so there are huge gender-based pay discrepancies.
By Eric Dyrenfurth
Illustration: John Spooner
F. Scott Fitzgerald's classic 1926 novel The Great Gatsby depicts the greedy, uncaring corruption of an energetic, individualist American dream, with the road between New York and the fictional hamlet of West Egg shrinking away from a desolate wasteland of industrial detritus. This Valley of Ashes is inhabited by the working poor, while West Egg's ostentatious mansions are rented in summer by party-throwing nouveau riche. These include Fitzgerald's eponymous, pink-suited but ever hopeful anti-hero Jay Gatsby, who made his dough from match-fixing venality.
Now re-locate yourself to the Melbourne spring, and horse racing at Flemington, "the celebration that stops a nation" boastfully attracting much business to Victoria. Brash, drunken babble rocks the glassed-in grandstands and opulent lawn marquees, where gambling crowds jostle, and media celebrities gush over fashionable attire.
Look beyond the fence-line of yellow roses to the lush, grassy track. Visualise the yawning gulf between the meretricious dazzle of race-going humanity in the stands, and lurking unseen dangers faced by risk-taking riders and mounts scudding over a deceptively calm ocean of turf. Wonder too why behind their colourful silks those riders are predominantly male.
Michelle Payne riding La Passe wins her race during Caulfield Cup Day on October 17. (Michael Dodge)
Don't forget, in rushing to the beverage bars, that safety risks and jockey gender inequality, however rhetorically minimised, are traded off against sometimes greedy racing industry interests. These create jobs, fuel the delirious passion of owners, sustain commitment of trainers and jockeys, cream gambling dollars for government revenues, and pleasure the punting public. However reluctantly, dredge from the back of your mind the cobalt corruption scandals engulfing a few leading trainers, while unknown others threaten the lives of those safeguarding racing industry integrity.
Remember not only horses that died last Cup Day, but the tragic deaths of several fallen jockeys on far away country tracks. Many of these were young women, their lofty aspirations dashed, but with apprentice training ranks now startlingly overflowing with a majority of girls. Female riders continue to dream of success, perhaps ironically exposing themselves to greater risks, given much fewer opportunities than men, particularly on carnival days. As a microcosm of today's male-dominated racing industry, move on to the barren environs of the racing tribunals, remote from the tumult of the track, as they hear jockey and trainer appeals from racing steward decisions. Presided over by crusty, long-retired former judges, the tribunals are aided by a roomful of men: stewards, their advisers, and rugged barristers, with nary a woman in sight except for officials.
Jockey Linda Meech. (Anthony Johnson )
Gender discrimination against female jockeys remains rife in Victorian racing. Trainers and their owners on major race days almost exclusively choose from a rigid hierarchy of male riders. An outstanding exception is premier trainer Darren Weir's long-standing support for senior jockey Michelle Payne. After recent brilliant winning rides for Weir in top-class races, he commented that a lot of owners "aren't that keen to put her on, but she's a great rider".
Such archaic prejudices are buttressed by over-emphasising rider strength in close finishes, with scant attention to attributes all elite athletes possess: rigorous pursuit of gym muscle building, stamina, obsessive determination to succeed, competitiveness, extra-smart tactical nous, expert-assisted race analysis, split-second decision-making under extreme pressure, and empathetic relationships with horses and their human carers – qualities not confined to champion male jockeys. Nevertheless, senior female jockey engagements, particularly in Victoria, are largely limited to provincial circuits, far less lucrative than city meetings. Leading trainer Peter Moody often uses prolific winner Linda Meech, but mostly banishes her to country tracks on Saturdays. At the spring carnival, a flotilla of Sydney male jockeys descends on Melbourne, with Payne the sole female rider for one race on Cox Plate Day, and Payne and star Sydney rider Kathy O'Hara the only women in sight for Caulfield Cup Day.
Michelle Payne at this year's Warrnambool May Racing Carnival. (Damian White)
Payne is about to ride Prince of Penzance (POP) for Weir in just her second Melbourne Cup start, the first being for Cup legend Bart Cummings. Payne rode POP to victory in last year's Moonee Valley Cup, running a narrow second on him in this year's Cup, after a dashing front-running display.
Outside Victoria, equal opportunities for female riders are more promising, with Tegan Harrison and Alannah Fancourt near the top of the Brisbane premiership, Caitlin Jones and Clare Lindop similarly placed in Adelaide, with Lucy Warwick second in Perth.
Victorian and NSW racing authorities must change owner and trainer cultures with far greater nimbleness if the current crop of female apprentices are to reach their professional pinnacle. Increased female patronage at flagging carnival crowds might also follow.
Finally, the lack of equal riding opportunities causes big pay discrepancies. Comparing 30-year-old Payne with leading rider Mark Zahra, 33, in the first three months of the racing year, Payne earned about $35,000 from prize money (excluding fees per ride), while Zahra earned $120,000. It's a similar story for young gun riders Jackie Beriman, 20, and Chris Parnham, 18, the former earning $13,000 and the latter $40,000 over the same period. These stark pay contrasts desperately need remedy.
Fitzgerald's Gatsby ends on an optimistic note, beating on against the current, despite the fading American dream, where "tomorrow we will run faster, stretch out our arms further ... And one fine morning ..." – there will indeed be full equality between male and female jockeys.
Eric Dyrenfurth is an administrative and constitutional lawyer, and a long-time horse racing enthusiast.
In these pages we have published a number of stories documenting the practice of sex-selective abortion in India and China; it is, however, not restricted to these countries. Rates of sex-selective abortion in Nepal are incredibly high, even though the practice is technically prohibited and hardly ever mentioned in Western media.
One heart-stopping statistic tells the story: for second births among the richest urban women, just 325 girls were born for every 1000 boys.
University of Oxford demographer Melanie Dawn Frost was the lead author of a paper in BMJ Open [Scroll down to read item #3] about widespread sex-selective abortion in Nepal since abortion was legalised in 2002.
She found that as soon as abortion became readily available, the sex-ratio began to drop. Several factors were at work, but the decline in the fertility rate was particularly important. “Nepal has seen one of the most dramatic fertility declines in history, with the total fertility rate falling from 4.1 to 2.6 in just 10 years,” she observed. As family size shrinks, it becomes more important for the second child to be a boy, if the first was a girl.
According to Frost’s research, in the late 2000s (2007-2010) the sex-ratio for second-order births was drastically skewed, with just 742 girls being born per 1000 boys. Prior to legalisation of abortion (1998-2000), that ratio was 1021 to 1000. The ratio of female birth decreased most dramatically among educated and richer women, especially in urban areas.
Media outlets in the subcontinent appear to paying some attention to the issue. A recent Op-Ed in the Kathmandu Post called for action on “gendercide”. “It is high time we advocated against sex-selective abortion similar to the advocacy for the legalisation of abortion”, wrote University of Melbourne public health student Geha Nath Khanal.[Scroll down to read item #2]
“The preference for a boy child will exist unless daughters prove to be equally capable. But for that to happen, girls need to be provided with equal opportunities as boys”.
Ironically, Frost’s paper suggested that the mere fact that abortion is licit in the country appeared to be undermining efforts to restrict sex-selective abortion.
Medical authorities in Nepal also seem to be taking action against doctors performing sex-selective abortions in the country. Recently a doctor in Kathmandu had her medical license suspended after an undercover sting exposed a sophisticated gender-selective abortion racket [Scroll down to read item #4].
Nevertheless, authorities are limited in their ability to restrict the practice; women can cross the border to India to have their babies screened and aborted. The practice, though illegal in India, is still quite widespread. It would seem that a deep-seated societal preference for male children seems to be the driving factor behind the problem. ~~~~~~~~~~~~~~~~~ #2 ~ October 13 2015
Nepal needs serious advocacy against sex-selective abortion to put an end to it
By GEHA NATH KHANAL
Abortion services were legalised in Nepal in September 2002 after much research, advocacy and lobbying at the local, national and international by organisations working in the field of human rights, law and public health. Prior to the legalisation of abortion in the country, it was only permitted if the mother’s life was at risk. Even so, unsafe abortions were rampant accounting for nearly 50 percent of maternal deaths. Existing laws allows voluntary abortion up to 12 weeks; up to 18 weeks if the pregnancy is caused by rape or incest; at any gestational period if pregnancy is harmful to the expecting mother’s physical or mental health and if the foetus has deformity. All the cases of abortion need to be certified by an expert physician and the sex-selective abortion is strictly prohibited.
Sex selective abortion prevails While every couple desires a small family, some prefer to have at least one or more male child. This preference for a son is because society considers men to be bread earners and for the continuation of the lineage and will take care of the parents in illness and old age. Furthermore, socio-cultural factors like the dowry system and the high cost of female marriage also result in son preference, and sex-selective abortion is only a means to achieve this desired outcome. Increased sex-determination and abortion is a result of multiple loopholes in the existing policy such as the provision of allowing physicians to terminate pregnancy of any gestational period if the pregnancy is harmful to the health of the mother and foetus. This gives unethical physicians an opportunity to misuse this policy by preparing fake certified reports and committing the illegal act for money.
Although it is illegal to terminate a pregnancy as a consequence of sex-identification, recent birth trendless girl child in comparison to boy child clearly demonstrates that it is still being practiced in Nepal. British researcher Melanie Dawn Frost and her colleagues in their research titled ‘Falling sex ratios and emerging evidence of sex-selective abortion in Nepal 2013’ argue that there has been a substantial increase in sex-selective abortion since 2002. Their study shows that there were 742 girls per 1000 boys between 2007 and 2010, which had declined dramatically from 1021 girls per 1000 boys in 1998-2000. This study clearly depicts the increasing termination of female foetus in the country after the legalisation of abortion. Moreover, due to weak monitoring mechanism and loopholes in the policy neither the health workers nor the service consumers have to face legal action. Cases such as the recent decision taken by the Nepal Medical Council (NMC) to suspend a female gynecologist [Scroll down to read item #4] for allegedly conducting sex-determination tests during pregnancy and motivating a couple to abort a child, is extremely rare.
Instances of sex-selective abortion have also increased in other countries like India, China, Vietnam and South Korea the legalisation of abortion. And the common policy adopted by these countries to address this issue is through prosecution and monetary fines. However, except in South Korea, such policies have not been effective. The reasons behind the Korean success are strict law enforcement such as suspending the license of the physician performing sex-determination and public awareness campaigns.
There are various arguments regarding policy options to address this issue of sex-determination and abortion. Some argue that illegal ultrasound services should be banned. But this is not a logical option because doing so will only further marginalise women living in rural areas as they do not have proper access to services. Furthermore, the services provided by the private sector in remote parts of the country, where the government services have not reached, cannot be underestimated. Medical ethics It is high time we advocated against sex-selective abortion similar to the advocacy for the legalisation of abortion. The preference for a boy child will exist unless daughters prove to be equally capable. But for that to happen, girls need to be provided with equal opportunities as boys. Easy access to education, employment and other opportunities helps to minimise social stigma and discrimination against daughters. The national literacy rate of male, 75 percent, compared to female, 58 percent, clearly indicates educational inequalities. Education cannot only break the underlying stigma and cultural taboos associated with sex-selective abortion, but it can also bring positive results in education, health and economic opportunities.
Additionally, medical ethics is crucial to minimise sex-selective abortion. But the cost of studying medicine is so high in Nepal that the doctors are constantly motivated to earn money to overcome their investment. Therefore, many of them resort to unethical medical practices. Hence, the NMC should strengthen its role in identifying medical practioners involved in sex-determination and the termination of female foetuses and help address this problem. ---- Khanal is a student of Masters of Public Health at the University of Melbourne ~~~~~~~~~~ # 3 BMJ Open 2013;
Falling sex ratios and emerging evidence of sex-selective abortion in Nepal: evidence from nationally representative survey data
By Melanie Dawn Frost1, Mahesh Puri2 , Peter Richard Andrew Hinde3
+ Author Affiliations: 1Independent researcher, Southampton, Hants, UK, 2Center for Research on Environment, Population and Health Activities, Kathmandu, Nepal, 3Social Statistics and Demography, University of Southampton, Southampton, UK
Correspondence to Dr Melanie Dawn Frost;
Abstract Objectives To quantify trends in changing sex ratios of births before and after the legalisation of abortion in Nepal. While sex-selective abortion is common in some Asian countries, it is not clear whether the legal status of abortion is associated with the prevalence of sex-selection when sex-selection is illegal. In this context, Nepal provides an interesting case study. Abortion was legalised in 2002 and prior to that, there was no evidence of sex-selective abortion. Changes in the sex ratio at birth since legalisation would suggest an association with legalisation, even though sex-selection is expressly prohibited.
Design Analysis of data from four Demographic and Health Surveys, conducted in 1996, 2001, 2006 and 2011.
Participants 31 842 women aged 15–49.
Main outcome measure Conditional sex ratios (CSRs) were calculated, specifically the CSR for second-born children where the first-born was female. This CSR is where the evidence of sex-selective abortion will be most visible. CSRs were looked at over time to assess the impact of legalisation as well as for population sub-groups in order to identify characteristics of women using sex-selection.
Results From 2007 to 2010, the CSR for second-order births where the first-born was a girl was found to be 742 girls per 1000 boys (95% CI 599 to 913). Prior to legalisation of abortion (1998–2000), the same CSR was 1021 (906–1150). After legalisation, it dropped most among educated and richer women, especially in urban areas. Just 325 girls were born for every 1000 boys among the richest urban women.
Conclusions The fall in CSRs witnessed post-legalisation indicates that sex-selective abortion is becoming more common. This change is very likely driven by both supply and demand factors. Falling fertility has intensified the need to bear a son sooner, while legal abortion services have reduced the costs and risks associated with obtaining an abortion.
Article summary Article focus Little evidence exists concerning whether or not the legal status of abortion is related to the incidence of prenatal sex selection; Nepal provides an interesting case study. Sex ratios at birth in Nepal before and after abortion was legalised in 2002 are calculated in order to test for evidence of sex-selective abortions. This study seeks to identify characteristics of women experiencing the lowest sex ratios and thus those who are most likely to have a sex-selective abortion.
There is clear evidence of a substantial increase in sex selection since 2002, even though this remains strictly prohibited.
The sex ratio for second and third-born children where previous births were females decreased substantially in almost all regions of Nepal, indicating the increased usage of sex-selective abortions.
Women who are wealthier, better educated and living in urban areas are most likely to use prenatal sex selection.
Strengths and limitations of this study
This is the first study to show that sex-selective abortions are becoming increasingly common in Nepal at the national level.
The survey data used did not allow for a more detailed geographical breakdown, which would have been useful for policymakers.
Selective abortion of females has been found to occur extensively in several Asian countries. Estimates suggest that between 3.1 and 6.0 million sex-selective abortions took place in India in the 2000s. 1 China has a well-documented history of so-called ‘missing girls’ resulting from a combination of the one child policy and preference for sons, with as few as 847–877 girls born for every 1000 boys.2 ,3 Both China and India have well-established abortion services provided by national and regional governments; sex-selective abortion is illegal in both countries. 4 ,5
An interesting question is the extent to which state provision of abortion services is associated with the selective abortion of females. Assessing this using data from China and India is difficult as the provision of abortion services has increased gradually. 4 ,6 However, the neighbouring country of Nepal saw an abrupt change between 2002 and 2004, which provides the opportunity to measure the impact of state provision of abortion services on sex-selective behaviour. Abortion was legalised in Nepal in 2002 and Comprehensive Abortion Care (CAC) services were provided by the government from 2004 onwards. 7 Sex determination is expressly prohibited and anyone found performing (or facilitating) an abortion on this basis can be punished with 1-year imprisonment, but otherwise the law is now liberal. Prior to 2002, unsafe abortion was the third largest cause of maternal mortality and it was not uncommon for women living in the south of the country to visit India if they wanted an abortion, though the scale of this is not known. 7 Studies of post-abortion care at 10 major hospitals showed that between 20% and 60% of the women admitted as obstetric and gynaecological patients were abortion complication cases. 8
Nepal has revealed high levels of preference for sons since the World Fertility Surveys first documented the phenomenon in the 1980s. 9 Daughters are often considered to be an economic burden because of the dowry system and the fact that a girl will join her husband's family after marriage. Sons are highly prized because they continue the family name, are deemed crucial to perform funeral rites, are likely to bring in a daughter-in-law into the family and are expected to provide support for their parents in old age. 10–12
Prior to 2002, preference for sons in Nepal was mainly evidenced through differential stopping behaviour (ie, the decision to have another child depended upon the sex composition of previous children). It has been estimated that such behaviour caused the fertility rate to be at least 6% higher and contraceptive use to be as much as 24% lower than it would otherwise have been.9 ,10 It therefore seems possible that, despite the strict prohibition of abortion on the grounds of the sex of the child, Nepalese will have taken advantage of the opportunities provided by the legalisation of abortion to influence the sex composition of their children.
Previous research suggests that sex-selective abortions occur in Nepal, but the evidence is either qualitative or based on small scale data. 13 A study in Kathmandu recorded the sex and parity of all babies born in a single hospital during a 5-year period (2003–2007) and found that, while for first-born children the sex ratio was relatively normal at 943 females per 1000 males, the sex ratio for second order births was 847 and for higher order births it was 565. 14 Unfortunately, the sample sizes were too small to draw any significant conclusions. A rapid assessment of sex ratios at birth in 1991 and 2001 consistently found more male than female babies being born in a number of districts of Nepal bordering India. 15 A study conducted in 2007 revealed that legal sanctions against prenatal sex determination and sex-selective abortion had not stopped medical practitioners and sonographers in Nepal from providing such services. 16
Abnormal sex ratios can be the result of mechanisms other than sex-selective abortion: one example is through Hepatitis B, which can cause the sex ratio to be skewed towards males, though this is somewhat controversial 17; there are also other biological explanations, but none of these would operate differentially across birth orders. If sex ratios vary substantially across birth orders, then the explanation for this is almost certainly the use of sex-selective abortion. In India, for example, recent research indicates that the sex ratio of first-born children has not changed significantly since 1990, while the sex ratio of second-born children where the first was female was as low as 786 in the year 2000 and has not been above 900 since 1992.1 Research from China has also found that sex ratios differ by parityin 2004–2005, the sex ratio of first-born children was 925, while for second-born children it was 699.3
It should be noted that even when sex-selective abortion is occurring, changes in its prevalence can occur for reasons related to the demand for, rather than the supply of, abortion services. Where fertility is declining rapidly, the preference for sons may be intensified since the overall desired number of children will fall faster than the desire for sons, and pressure on couples to balance the sex composition of their children may contribute to further demand for prenatal sex selection at low parities. 12 ,18 Nepal has seen one of the most dramatic fertility declines in history, with the total fertility rate falling from 4.1 to 2.6 in just 10 years. 19
The aim of this paper, therefore, is to examine sex ratios of births prior to and after the introduction of Comprehensive Abortion Care in 2004 to assess whether, given the religious and socioeconomic value given to sons, the legalisation of abortion and the availability of prenatal sex-determination technologies and abortion clinics were associated with a change in the proportion of male babies. Methods Data Over 40 000 women were interviewed in four rounds of the Nepal Demographic and Health Survey (NDHS), conducted in 1996, 2001, 2006 and 2011. All four surveys were nationally representative and used a two-stage stratified sampling scheme. All women were asked about their fertility and full birth histories were obtained from the 31 842 women aged 15–49; these birth histories included information on over 111 000 births. Full details of the NDHSs can be found elsewhere. 19–22
A module on induced abortion was included in the 2011 NDHS for the first time. This included questions to ascertain the prevalence of abortion as well as the reasons for it. Overall, 7.5% of pregnancies were reported to have ended in abortion in the 5 years prior to the survey. This varied substantially depending on the woman's socioeconomic characteristics, with 17.5% of pregnancies ending in abortion for women in the highest wealth quintile. Of the 506 women who gave a reason for their abortion, 3.16% reported that it was owing to the child's sex, but the subject area tends to have a high incidence of misreporting, so indirect methods are likely to be the best method of studying the phenomenon. 23 Statistical analysis In the absence of intervention, the sex ratio at birth in human populations is essentially a biological constant with relatively little variation. For every 1000 males born, there will generally be between 950 and 975 females. 24 ,25 This should not vary by birth order.
To control for the fact that demand for sex-selective abortions will vary by birth order and sex of previous children, conditional sex ratios (CSRs) are used in our analysis, specifically the CSR for second-born children where the first-born was female. This sex ratio is generally held to be existent where the evidence of sex-selective abortion will be most visible, since the motivation for sex-selection will probably be at its highest; it has been used frequently to provide evidence for the widespread use of sex-selective abortion in India. 1 ,23 If a woman is sufficiently motivated (or pressured) to have a son that she is prepared to have an abortion to achieve that end, it is unlikely that she will wait until a much higher parity than two or three.
The sex ratios presented in this paper are the number of female births per 1000 male births, calculated as (Pf/Pm)×1000, where Pf is the proportion of total female births and Pm is the proportion of total male births. The sex ratios are weighted to account for the sampling scheme used in NDHS. We only included births reported to have happened within 10 years of the survey date, since extremely long recall periods tend to be less accurate, and misreporting may differ by sex of the baby. For time periods where more than one survey was available, a weighted average of the different surveys was used.
Wealth tertiles were produced using principal components analysis; this was performed separately for urban and rural areas in order to enable us to look at the relative contribution of women at different wealth levels in diverse environments. Tertiles were used, rather than the more traditional quintiles, owing to sample size considerations.
All analyses were conducted in STATA (V.12.0).
Results Sex ratios at birth were found to vary substantially by parity, the sex of the previous offspring and the time period during which the births occurred. Table 1 shows the trends in different conditional sex ratios over the 18-year period of 1992–2010. Years were grouped as the sample sizes for single years were small. The overall sex ratio is never significantly different from the expected range of 950–975 and does not show a significant change over time; the same is true of the sex ratio of firstborn children. However, for second-born children where the first-born was female, the sex ratio shows a substantial decline after the legalisation of abortion. In 2001–2003, it was 947; in 2004–2006 (when government abortion services became available in most district headquarters and urban and semi-urban areas), it dropped to 830 and by 2007–2010, it had fallen further to just 742, despite the overall sex ratio being 933. For third-born children, where the first two children had both been female, the sex ratio was also very low at 767, compared to 892 if the first two children had both been male, or 935 if one was male and the other was female. The sex ratio for second-born children in 2007–2010 was low even for mothers whose first-born was male at 822. Of the 4521 births recorded in NDHS 2011 during 2007–2010, 1247 were second order births and just 559 (44.8%) of these were female. Assuming the biologically expected sex ratio at birth, we would have expected at least around 650 females to have been born, given the number of males.
Conditional sex ratios at birth (females per 1000 males), by birth order, 1992–2010
It should be noted that in 2007–2010, only 14% of all births in Nepal were second order after a firstborn girl. This explains why the overall sex ratio at birth is not greatly affected even by substantial changes in the sex ratio for this subset of births.
The sex ratio for second-born children where the first was female is thought to be the strongest evidence available for sex-selective abortion, short of direct data. If this particular CSR also varies by socioeconomic characteristics, then this is even stronger evidence that sex-selective abortion is being used, since knowledge of, access to and uptake of abortion will not be equal in all parts of society. Figure 1 shows how the CSR has varied over 4 NDHSs by mother's education. The sex ratios shown are those related to the 5 years prior to each survey. Table 2 shows the CSR and overall sex ratio prior to and post-2004 (when CAC services first became available), the percentage change in the CSR and the significance of the fall using a one-sided t test. A dramatic decline in the sex ratio is evident for those women who have at least a secondary leaving certificate or above. In the 5 years prior to NDHS 2006, the CSR for this group of women was just 653 females for every 1000 males, and NDHS 2011 showed a CSR of just 368, while the CSR was almost 50% lower after 2004 (Figure 2). The fall in the CSR after 2004 was significant at the 5% level for all educational groups except those with no education.
Conditional sex ratios of second order births where the first-born was female and overall sex ratios, prior to and post-introduction of CAC services
Figure 1 Conditional sex ratio of second order births where the first-born was female, by educational level of the mother, over time.
Figure 2 Conditional sex ratio of second order births where first born was female, by wealth tertile of the household in urban and rural areas, over time.
Figure 2 shows the same CSR split by wealth tertile in urban and rural areas for the five year period before each NDHS. In the 2011 NDHS rural women in all wealth tertiles display lower sex ratios than would be expected, with the sex ratio in all wealth groups below 800. A wealth gradient is visible, with the richest women being least likely to have a girl, but it seems that even poorer women are finding ways of manipulating the sex composition of their children. For urban women in the 2011 NDHS, the wealth gradient is dramatic, with the poorest urban women having a higher sex ratio than rural women, but the richest urban women exhibiting the lowest sex ratio of all at just 326, indicating where sex-selective abortion is likely to be most prevalent. The fact that the CSR is lowest among richer urban women is unsurprising, as they would be expected to be able to access abortion services most easily and have the greatest knowledge about the availability of abortion services; that said, the extent of the shortfall in female births is remarkable. Table 2 shows that the fall in the sex ratio was significant for all wealth groups in rural areas, but only for the richest in urban areas. Nonetheless, the CSR post-2004 was substantially less than 900 for all wealth groups of urban women.
There were regional differences in the CSR and how much it changed after the legalisation of abortion. Table 2 shows the conditional sex ratio for 13 subregions of Nepal for the 10 years prior to 2004 and the period post-2004. The regions are defined on the basis of altitude (‘mountain’, ‘hill’ and ‘Terai’ or plains) and longitude (‘far western’, ‘western’, ‘mid-western’, ‘central’ and ‘eastern’). The CSR declines between the two periods in every region but one (the Eastern Mountain, where the CSR prior to 2004 was below 800). Two regions show declines which are significant at the 5% level, and six regions (accounting for around two-thirds of the population of Nepal) show declines which are significant at the 10% level. The most substantial decline was visible in the Central Terai where the CSR fell by almost 30% from 989 to 701, though both the Mid-Western Hill and the Eastern Terai had lower sex ratios after 2004. Prior to 2004, just one region had a CSR below 800 and 11 out of 13 had CSRs of over 900. In the period after abortion services became available, the CSRs of 10 regions dropped below 900, with six falling below 800 and one below 700. Discussion These findings suggest that since abortion was legalised in Nepal, sex-selective abortion has become more common. We have found no evidence that the natural sex ratio of births (unaffected by human intervention) is outside the normal range for human populations; in particular, the sex ratio of a firstborn does not differ significantly from the expected level of 950–975 females per 1000 males. However, for second-born children, especially where the firstborn was female, there has been a sharp (and significant) fall in the number of girls compared with boys. The sex ratio of third-born children where the first two were females has also fallen substantially in recent years, while for children of higher parities the sex ratio remains within the expected range; this may indicate a tendency for those women having more than four children not to use contraception or abortion services. 26 Sex ratios of births are lowest for richer, more educated women, especially in urban areas, and differ substantially by parity and the sex composition of previous children.
The data we have used were collected over a course of 16 years and include over 40 000 Nepali women, but are still not sufficient to allow the identification of all the sub-populations experiencing low sex ratios. The regional estimates of sex ratios were limited to relatively large areas. Census data may yet prove fruitful for achieving a finer level of aggregation. The 2001 census indicated that no district had an abnormal population sex ratio for infants. It will be interesting to find out if almost 10 years after abortion was legalised, the infant sex ratios in any particular districts show a decline. The survey data analysed here indicate that this may well be the case, but it should be remembered that the extremely low CSRs are masked by a relatively normal overall sex ratio at birth.
Apart from the fact that the results reported in this paper are based on a relatively small number of births, some underreporting of girls in full birth histories is a possibility. However, it seems improbable that the underreporting would be greater than average for second order and third order births, or among rich, urban or better educated women in more recent surveys.
Although we have been able to suggest that sex-selective abortion has increased in Nepal since 2004, we have not been able to enumerate the size of the problem. It is hoped that census data will allow the number of sex-selective abortions in recent years to be estimated. However, the CSR we report for second order births where the first-born was female is just 742, which is as low as the same CSRs found in India, where sex-selective abortion is known to be widespread. 1 ,23 It seems likely that sex-selective abortion is becoming a more common phenomenon in Nepal, a trend which mirrors that in India and China. Recent evidence from NDHS data suggest that the proportion of pregnancies aborted increases with birth order and is higher for urban, richer and better-educated women. 19
The timing and abruptness of the change in CSRs suggests that it is associated with the legalisation of abortion and the state provision of abortion services in the country. CAC services have only been available since 2004, but in some regions the CSR of second-born children where the first-born was male has fallen by well over 200 in that time. However, we do not mean to suggest a simple relationship between the introduction of CAC services and the change in CSRs. It is more likely that both demand and supply factors have been at work. The decline in fertility has increased the importance that at least one son be born among the first three children. This has intensified the demand for abortions on the grounds of the sex of the fetus. Prior to 2004, Nepali women desiring abortions had to be prepared to incur either substantial health risks (from illegal services) or costs (from going to India) or both. The effect of the introduction of CAC services in 2004 was to reduce both the risks and the costs, and hence to increase the number of abortions in Nepal. The reduction in risks/costs applied to all abortions, but since a major (and increasingly important) reason for demanding an abortion in Nepal is the sex of the fetus, there has been a rise in the number of abortions performed for this reason. It is interesting to note that the change in the CSR for second births following a firstborn girl was greatest among urban educated women, who would have been most able to afford abortions even prior to 2004. The decline in fertility has been most acute among this group; if cultural forces leading to a strong desire for at least one son had remained universal in Nepal, their demand for sex-selective abortions might have increased more rapidly than that of rural and less well-educated women.
Clearly, there are policy implications in terms of education about the long-term social and demographic consequences of sex-selective abortion. While educating medical practitioners is one important step, previous research has shown that medical practitioners believe that if a woman wishes to have a sex-selective abortion, she can easily obtain one in India; it may also be hard for practitioners to judge a woman's reasons for wanting an abortion. 13 ,27 For these reasons, it is also paramount to educate wider members of the community about the illegality of sex determination tests for the sole purpose of selective abortion and the health risks associated with second trimester abortions.
Advocacy and educational campaigns among groups with particularly low sex ratios will be important; literate, urban women are one target group. Those living in the Terai with easy access to the Indian border are another. It is also important to remember that the use of sex-selective abortion has risen not only because of sociocultural preferences for sons but also because girls are seen as an economic burden. Ultimately, combating sex-selective abortion will require the empowerment of women throughout Nepali society. Programmes benefiting female children would be a start; these might include maternity incentives to mothers who give birth to a girl, education scholarships and free vocational training for girls, as well as economic incentives for the parents of girls.
Acknowledgments This work was undertaken independently and there were no funding sources. The views expressed in this manuscript reflect those of the authors and do not necessarily reflect the views of any institution. Dr Andrew “Amos” Channon provided the wealth indices used within this paper.
Footnotes Contributors MDF conducted the data analysis. MDF, MP and PRAH were involved in interpreting the data and writing the paper and have approved the final version. MDF is the guarantor.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The full datasets are available at http://www.measuredhs.com. Consent was not obtained for this study, but participants gave informed consent for the original survey; the presented data are anonymised and there is no risk of identification.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See HERE
References Jha P, Kesler MA, Ram F, et al . Trends in selective abortions of girls in India: analysis of nationally representative birth histories from 1990 to 2005 and census data 1991 to 2011. Lancet 2011;377:1921–8. Chan CI, Yip PS, Ng EH, et al . Gender selection in China: its meanings and implications. J Assist Reprod Genet 2002; 19:426–30. [CrossRef] [Medline] [Web of Science] Google Scholar Zhu WX, Lu L, Hesketh T . China's excess males, sex selective abortion, and one child policy: analysis of data from 2005 national intercensus survey. BMJ 2009;338. Google Scholar Hirve SS . Abortion law, policy and services in India: a critical review. Reprod Health Matters 2004;12:114–21. [CrossRef] [Medline] [Web of Science] Google Scholar Department of Economic and Social Affairs. Abortion policies: a global review. New York: United Nations, 2001:94–5. Scharping T . Birth control in China 1949–2000: population policy and demographic development. Abingdon, UK: Taylor and Francis, 2002. Google Scholar Ministry of Health and Population, World Health Organization, Center for Research on Environment Health and Population Activities (CREHPA). Unsafe abortion: Nepal country profile. Kathmandu, Nepal: Ministry of Health and Population Government of Nepal, 2006. CREHPA. Management of abortion related complications in hospitals of Nepala situational Analysis. Kathmandu, Nepal: CREHPA, 1999. Cleland J, Verall J, Vaessen M . Preferences for the sex of children and their influence on reproductive behaviour, world fertility survey comparative studies. Voorburg, Netherlands: International Statistical Institute, 1983. Google Scholar Leone T, Matthews Z, Zuanna GD . Impacts and determinants of sex preference in Nepal. Int Fam Plan Perspect 2003; 29:69–75. [CrossRef] [Medline] [Web of Science] Google Scholar Arnold F, Choe MK, Roy TK . Son preference, the family-building process and child mortality in India. Popul Stud 1998;52:301–15. [CrossRef] Google Scholar Brunson J . Son preference in the context of fertility decline: limits to new constructions of gender and kinship in Nepal. Stud Fam Planning 2010;41:89–98. [Medline] Google Scholar Lamichhane P, Harken T, Puri M, et al . Sex-selective abortion in Nepal: a qualitative study of health workers’ perspectives. Womens Health Issues 2011;21:37–41. Google Scholar Adhikari N, Ghimire A, Ansari I . Sex preference in urban Nepal. J Instit Med 2008;30:19–23. Google Scholar Puri M, Adhikari R . A rapid assessment on sex ratio at birth with special reference to sex selective abortion and infanticide. Lalitpur, Nepal: UNFPA and CREHPA, 2007. Google Scholar CREHPA. Sex Selection: Pervasiveness and Preparedness in Nepal. 4th Asia Pacific Conference on Reproductive and Sexual Health and Rights. Hyderabad, India, 2007. Chahnazarian A, Blumberg B, London WT . Hepatitis B and the sex ratio at birth: a comparative analysis of four populations. J Biosoc Sci 1988;20:357–70. [Medline] [Web of Science] Google Scholar Das Gupta M, Bhat PNM . Fertility decline and increased manifestation of sex bias in India. Popul Stud 1997;51:307–15. [CrossRef] Google Scholar Ministry of Health and Population (MOHP) [Nepal], ERA N, INC. II. Nepal demographic and health survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International, 2012. Ministry of Health [Nepal], New ERA and ORC Macro. Nepal demographic and health survey 2001. Calverton, Maryland, USA: Family Health Division, Ministry of Health; New ERA and ORC Macro, 2002. Ministry of Health and Population (MOHP) [Nepal], New ERA and Macro International Inc. Nepal demographic and health survey 2006. Kathmandu, Nepal: Ministry of Health and Population, New ERA and Macro International Inc., 2007. Pradhan A, Aryal R, Regmi G, et al . Nepal family health survey 1996. Kathmandu, Nepal and Calverton, Maryland, USA: Ministry of Health [Nepal], New ERA and Macro International Inc., 1997. Google Scholar Jha P, Kumar R, Vasa P, et al . Low male-to-female sex ratio of children born in India: national survey of 1.1 million households. Lancet 2006;367:211–18. [CrossRef] [Medline] [Web of Science] Google Scholar Garenne M . Sex ratios at birth in African populations: a review of survey data. Hum Biol 2002;74:889–900. [CrossRef] [Medline] [Web of Science] Google Scholar Waldron I . Sex differences in human mortality: the role of genetic factors. Soc Sci Med 1983;17:321–33. [CrossRef] [Medline] [Web of Science] Google Scholar Dahal GP, Padmadas SS, Hinde PRA . Fertility-limiting behavior and contraceptive choice among men in Nepal. Int Fam Plan Perspect 2008:6–14. Google Scholar Möller A, Öfverstedt S, Siwe K . Proud, not yet satisfied: the experiences of abortion service providers in the Kathmandu valley, Nepal. Sex Reprod Healthc 2012;3:135–40. [Medline] Google Scholar
The Nepal Medical Council has decided to suspend the medical licence of Dr Nutan Sharma, a gynaecologist at Alka Hospital, for three months on the charge of performing sex-selective abortions. The NMC, which reached the decision on Sunday, is expected to announce it on Wednesday.
A highly placed source at the NMC said the ethical committee of the council made the decision following the study of complaints. Dr Sharma was dragged into a controversy after a person came to her clinic with a spy-camera and asked her to conduct sex-selective abortion. The complaint was lodged at the PM’s Office which later asked the NMC to take action against Dr Sharma two years ago. Dr Sharma maintains she was framed and that the person who recorded their conversation has been black-mailing her. She also claimed that the NMC took the decision to punish her now, years after the complaint was recorded, to show that they were working at a time when the Mathema committee has just come up with its report on Health Profession Education Policy, which recommends curtailing the council’s rights.
Feature: The abduction of women and girls as sex slaves is a disturbing new feature of South Sudan's 21-month conflict, already characterised by well-documented human rights abuses.
One woman was abducted by soldiers and taken to a military camp, tied up and raped repeatedly for two months.
Another was kidnapped with her 15-year-old sister and raped every night for five nights.
A third was taken to a forest with her 12-year-old daughter, where both were raped.
The abduction of women and girls for use as sex slaves - some of them held indefinitely, tied up with hundreds of others in secret rape camps – is a disturbing new aspect of South Sudan's 21-month conflict, already characterised by well-documented war crimes and human rights abuses.
Nigeria's "Chibok girls", abducted by Boko Haram in April 2014, and Iraq's Yazidi women, taken as sex slaves by the Islamic State group are well-known.
But the plight of perhaps thousands of South Sudanese women and girls from just a single state, abducted and subjected to repeated, brutal rape and slave-like working conditions has remained hidden until now.
Systematic abduction and rape Nyabena's experience is typical. The 30-year old mother was seized when soldiers attacked her village in Rubkona County in April.
Men and boys were shot. Homes were looted and burned to the ground. Women and girls were rounded up.
She was among 40 taken from two neighbouring settlements and wells up with tears when she talks about being torn away from her five children.
They were marched to Mayom County. Nyabena was held in Kotong, a stronghold of Major-General Matthew Puljang, commander of a tribal Bul Nuer militia aligned with South Sudan's army, the SPLA, which has been battling rebels since December 2013.
From April to July this year the SPLA and Puljang's militia carried out an offensive that United Nations investigators described as a "scorched earth policy" in an August report.
Fighting and flooding limits access to large parts of South Sudan, leading aid workers to refer to southern Unity State as "an information black-hole".
A human rights investigator said "Nobody knows what's happening in Mayom County," where many of the women were taken.
One military expert estimated that "thousands of women" were abducted during the offensive.
"In all the southern Unity counties it's been the same: those women who escape are lucky. Those who don't are raped and abducted or killed," said the rights investigator.
"The abduction of women seems to be systematic. It might be for a day, or longer, or forever."
Those who escaped recount their stories with numb, quiet voices. Nightmares plague some who wake up terrorised, thinking they are still captive.
After her abduction Nyabena was put to work during the day, carrying looted goods and food, collecting water and hoeing farms. She was guarded constantly during the day and tied up at night with other women.
"When one of the soldiers wanted to have sex he would come, untie us and take us away. When they were finished they would bring you back and tie you to the post again," she said, stretching her elbows behind her back to show how she was bound. She said being raped by four men a night was common.
Women who refused to work or fought against their rape would disappear. "In the morning we discover they are missing," she said. Of the 40 she arrived with in April, 10 disappeared this way.
Victims as young as 12 Nyamai, a 38-year old mother of five, was taken from her village in Koch County. She was guarded constantly and tied up frequently. As many as 10 soldiers would queue up at night for their turn raping her.
"Please, let one guy deal with me, don't come all of you," she pleaded, and was beaten with a stick in response.
In another case, three of Nyatuach's unmarried, teenaged daughters were abducted in May during an attack on their village in Rubkona County.
Two are still missing, but her 17-year old daughter escaped with three of her nieces.
They returned "very sick, very thin". "Their bodies were weak and they were leaking fluids from so many men having intercourse with them," Nyatuach said, a common symptom of fistula, an incontinence-causing tear in the wall between the vagina and bladder or rectum, that can be caused by particularly violent rape.
Others were raped repeatedly until, bleeding and unable to take any more, they were set free, or killed.
"When the girls were broken they would dispose of them," said Nyatuach.
Rebecca found her 12-year old daughter again the day after their village in Koch County was attacked.
"When they took me, those people used me," the girl told her mother. Rebecca boiled some water and washed her daughter with hot cloths.
"We can do nothing," she told her. "It's like that."
South Sudan: women and girls raped as wages for government-allied fighters
Testimony reveals systematic abduction and abuse of thousands of women and girls as young as 12, held in rape camps across Unity state
A boy plays in a vandalised car as women wait for food aid in Bentiu town, capital of South Sudans Unity state. (Hannah McNeish)
By Hannah McNeish in Bentiu
The testimony from dozens of people working in Bentiu, the capital of South Sudans Unity state, points to the systematic abduction and abuse of women as a form of wages for forces allied to the government. The worst atrocities have led more than 110,000 people to seek safety at a UN base in the town.
Their pay is what they loot and the women they abduct, said one military expert based in Bentiu, who was not authorised to speak but said he had heard of women being taken to the militia-stronghold of Mankien in Mayom, as well as into the cattle camps.
He believes that, across the state, maybe thousands of women have been made wives or slaves by government-allied forces recruited by county leaders to help the army take back territory from rebels in brutal offensives between April and September.
*Nyabol was abducted from her village in Rubkona county in April with 19 others. For two months, she was tied to a post with no shade by day and abused by soldiers at night, in a militia base called Kotong.
When one of the soldiers wanted to have sex with one of us, he would come and untie us, take us away then bring us back to tie up, said Nyabol, shaking at the memory. Between rapes, the women were tied up next to beds made of cardboard boxes, with no mosquito nets.
Ethnic fighting was sparked in 2013 by South Sudans rival leaders, President Salva Kiir from the main Dinka group and his former deputy Riek Machar a Nuer. In recent months, the government has recruited militias and young men from Nuer sub-clans in Unity state to take back rebel-held areas.
The military expert said that, through county commissioners, Bul Nuer and Jikany Nuer youths had been given guns, and their pay is what they can loot. Women who were abducted say some of the husbands forced on them spoke the Nuer language, others Dinka. A young girl eats porridge in a sweltering hot shipping container in Bentiu. (Hannah McNeish)
One South Sudan rights researcher who spoke anonymously for fear of retaliation said the Unity state counter-offensives were marked by a lot of abduction accompanying the rape cases, adding that Mayom was the key destination for those abducted.
Youth are being mobilised. Its not just a cattle raid, said the researcher, referring to clashes between cattle herders that have been a feature of the conflict. [The war has] taken a different turn this year.
During April-September government offensives, at least 1,000 civilians were killed, 1,300 women and girls were raped, and 1,600 women and children were abducted in Leer, Mayendit and Koch counties, according to estimates in a recent circular to charities working on civilian protection.
In Kotong, home to the forces of Bul Nuer rebel-turned-government ally Mathew Puljang, disobedient wives would vanish at night.
Nyabol said: In our group there were 40 women who went together for work. Among them, 10 were taken one by one and I never saw them again. I didnt sleep at night. I was just crying, afraid that they would kill me. Even now, I have nightmares that I am still in Mayom.
Nyabol, a widow, said she had feared she would never see the one-month-old baby she had left behind again. The injuries, the beating you [dont] know if [the violence] will kill you or if it will be a disease, she said.
She managed to escape after a soldier and former bodyguard of her late husband recognised her and escorted her as she went to fetch water, and told her to run.
The rest of her story fits a familiar narrative. Armed men came to the village, shot the men and boys sometimes castrating the latter raped the women and took all household items before burning all the huts, some with elderly people locked inside. They searched for girls and the women they considered most beautiful, forced them to show them where the cows were and then ordered them to carry away the looted property.
Nyabol and 19 others were taken from their homes to Wankai, in Mayom county, where women, girls and cows were distributed among men who led them and the animals off in different directions. Several women who were interviewed named Wankai as a transit centre. One said between 200 and 300 women and girls had been there while others said there were too many to count.
Another place that cropped up in interviews more than once was Rier, in Koch county. This is where men commanded by local leaders raped Nyaruach, 38, and her 12-year-old daughter overnight in a forest, Nyaruach said.
She managed to escape during a toilet break and found her daughter the next day, who said two men had used her before deciding that she was too small.
She was bleeding when I found her so we boiled some water and washed her with hot cloths. She was crying. It left me feeling so bad, I want to leave this country, Nyaruach said.
Nyabena, from Nhialdiu in Rubkona county, ran to the bush before the men caught her. But she spoke about the grim fate of Nyagai, 20, a recently married women who was considered a real beauty.
So many men wanted to rape her, said Nyabena, that when a second group of men queued up to abuse her, Nyagai could not stand it. When she refused any more, they just killed her, she said.
Unity states acting governor, Stephen Taker, and his consorts laughed off questions about whether government and allied forces had abducted women. They accuse the government for nothing. Its not true, said Taker, who also refuted rights reports documenting rapes of women and the theft of cows in tit-for-tat cattle raids.
Skye Wheeler, South Sudan researcher for Human Rights Watch, said: In our research, we found a staggering preponderance of rape including terrifying gang rapes, as well as beatings and abductions in numerous villages.
According to the military expert, the extremely high culture of revenge that is prevalent in South Sudan is going to be another challenge for South Sudan, despite the recent government-brokered peace deal with the weakened rebels.
If you look at the level of anger against Bul Nuer in Unity state, its something the government and the international community are going to deal with for many, many, many years, he said.
Some survivors were wishing death on the these men, he said, while others just wanted their daughters, cousins, aunts and nieces to be brought back.
* Some names have been changed to protect identities.