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Most evidence on son preference in Pakistan is reflected in the higher child mortality among females than males. The sex discrimination before birth is rarely reported in Pakistan. This is the first study to quantify prenatal sex discrimination in Pakistan on a subnational level. We provide annual estimates of the sex ratio at birth (SRB) from 1980 to 2020 and scenario-based projections of the number of missing female births up to 2050 by Pakistan province. The results are based on a comprehensive database consisting of 832,091 birth records from all available surveys and censuses. We adopted a Bayesian hierarchical time series model to synthesize different data sources. We identified Balochistan with an existing imbalanced SRB since 1980. For the rest provinces without past or ongoing SRB inflation, we projected the largest female birth deficit to occur in Punjab in 2033 under the scenario that the SRB transition process starts in 2021. We demonstrated important disparities in the occurrence and quantification of missing female births up to 2050.

This research note is prompted by a paper by Kashyap (Is prenatal sex selection associated with lower female child mortality? Population Studies 73(1): 57-78). Kashyap's paper, which provides 40 original estimates of missing female births, relies on an alternative definition of missing female births, leading to estimates of about half the magnitude of other estimates. There appears, therefore, a real need to take stock of the concept of missing female births widely used by statisticians around the world for assessing the demographic consequences of prenatal sex selection. This research note starts with a brief review of the history of the concept and the difference between Amartya Sen's original method and the alternative method found elsewhere to compute missing female births. We then put forward three different arguments (deterministic and probabilistic approaches, and consistency analysis) in support of the original computation procedure based on the number of observed male births and the expected sex ratio at birth.

BACKGROUND: Pakistan has a strong preference for boys over girls; previous evidence on sex preference is primarily reported at the postnatal stage in which the child mortality rate is higher for females than males. Prenatal sex discrimination in Pakistan, reflected in the inflated sex ratio at birth (SRB; ratio of male to female births) has been barely mentioned before this study.OBJECTIVE: We estimate the SRB and missing female births in Pakistan provinces from 1980 to 2020 and identify provinces with imbalanced SRB. We provide scenario-based projections of missing female births in provinces without the existing SRB inflation.METHODS: An extensive SRB database of 832,091 birth records was compiled from all available surveys and censuses. To synthesize different data sources and provide annual estimates and their associated uncertainties of SRBs across provinces, we adopted a Bayesian hierarchical time series model.RESULTS: As per our model, Balochistan has had SRB imbalance since 1980. The maximum SRB was estimated as 1.121 (95% credible interval [1.066; 1.142]) in 1997. Assuming different start year of SRB inflation process in provinces without existing imbalance, the largest female birth deficit is projected to be 76.2 thousand in Punjab in 2033 when the SRB inflation starts in 2021.CONTRIBUTION: This is the first study on estimating the SRB from 1980 to 2020 and providing scenario-based projections of missing female births up to 2050 by Pakistan province. We identified the Balochistan province with imbalanced SRB and demonstrated important disparities in the occurrence and quantity of female birth deficits before 2050.

IntroductionSkewed levels of the sex ratio at birth (SRB) due to sex-selective abortions have been observed in several countries since the 1970s. They will lead to long-term sex imbalances in more than one-third of the world’s population with yet unknown social and economic impacts on affected countries. Understanding the potential evolution of sex imbalances at birth is therefore essential for anticipating and planning for changing sex structures across the world.MethodsWe produced probabilistic SRB projections from 2021 to 2100 based on different scenarios of sex ratio transition and assessed their implications in terms of missing female births at global, regional and national levels. Based on a comprehensive SRB database with 3.26 billion birth records, we project the skewed SRB and missing female births with a Bayesian hierarchical time series mixture model. The SRB projections under reference scenario S1 assumed SRB transitions only for countries with strong statistical evidence of SRB inflation, and the more extreme scenario S2 assumed a sex ratio transition for countries at risk of SRB inflation but with no or limited evidence of ongoing inflation.ResultsUnder scenario S1, we projected 5.7 (95% uncertainty interval (1.2; 15.3)) million additional missing female births to occur by 2100. Countries affected will be those already affected in the past by imbalanced SRB, such as China and India. If all countries at risk of SRB inflation experience a sex ratio transition as in scenario S2, the projected missing female births increase to 22.1 (12.2; 39.8) million with a sizeable contribution of sub-Saharan Africa.ConclusionThe scenario-based projections provide important illustrations of the potential burden of future prenatal sex discrimination and the need to monitor SRBs in countries with son preference. Policy planning will be needed in the years to come to minimise future prenatal sex discrimination and its impact on social structures.

Significance This study provides information on sex ratio at birth (SRB) reference levels and SRB imbalance. Using a comprehensive database and a Bayesian estimation model, we estimate that SRB reference levels are significantly different from the commonly assumed historical norm of 1.05 for most regions. We identify 12 countries with strong statistical evidence of SRB imbalance: Albania, Armenia, Azerbaijan, China, Georgia, Hong Kong (SAR of China), India, Republic of Korea, Montenegro, Taiwan (Province of China), Tunisia, and Vietnam., The sex ratio at birth (SRB; ratio of male to female live births) imbalance in parts of the world over the past few decades is a direct consequence of sex-selective abortion, driven by the coexistence of son preference, readily available technology of prenatal sex determination, and fertility decline. Estimation of the degree of SRB imbalance is complicated because of unknown SRB reference levels and because of the uncertainty associated with SRB observations. There are needs for reproducible methods to construct SRB estimates with uncertainty, and to assess SRB inflation due to sex-selective abortion. We compile an extensive database from vital registration systems, censuses and surveys with 10,835 observations, and 16,602 country-years of information from 202 countries. We develop Bayesian methods for SRB estimation for all countries from 1950 to 2017. We model the SRB regional and national reference levels, the fluctuation around national reference levels, and the inflation. The estimated regional reference levels range from 1.031 (95% uncertainty interval [1.027; 1.036]) in sub-Saharan Africa to 1.063 [1.055; 1.072] in southeastern Asia, 1.063 [1.054; 1.072] in eastern Asia, and 1.067 [1.058; 1.077] in Oceania. We identify 12 countries with strong statistical evidence of SRB imbalance during 1970–2017, resulting in 23.1 [19.0; 28.3] million missing female births globally. The majority of those missing female births are in China, with 11.9 [8.5; 15.8] million, and in India, with 10.6 [8.0; 13.6] million.

The sex ratio at birth (SRB) has risen in India and reaches well beyond the levels under normal circumstances since the 1970s. The lasting imbalanced SRB has resulted in much more males than females in India. A population with severely distorted sex ratio is more likely to have prolonged struggle for stability and sustainability. It is crucial to estimate SRB and its imbalance for India on state level and assess the uncertainty around estimates. We develop a Bayesian model to estimate SRB in India from 1990 to 2016 for 29 states and union territories. Our analyses are based on a comprehensive database on state-level SRB with data from the sample registration system, census and Demographic and Health Surveys. The SRB varies greatly across Indian states and union territories in 2016: ranging from 1.026 (95% uncertainty interval [0.971; 1.087]) in Mizoram to 1.181 [1.143; 1.128] in Haryana. We identify 18 states and union territories with imbalanced SRB during 1990–2016, resulting in 14.9 [13.2; 16.5] million of missing female births in India. Uttar Pradesh has the largest share of the missing female births among all states and union territories, taking up to 32.8% [29.5%; 36.3%] of the total number.

The sex ratio at birth (SRB, i.e., the ratio of male to female births) in Vietnam has been imbalanced since the 2000s. Previous studies have revealed a rapid increase in the SRB over the past 15 years and the presence of important variations across regions. More recent studies suggested that the nation’s SRB may have plateaued during the 2010s. Given the lack of exhaustive birth registration data in Vietnam, it is necessary to estimate and project levels and trends in the regional SRBs in Vietnam based on a reproducible statistical approach. We compiled an extensive database on regional Vietnam SRBs based on all publicly available surveys and censuses and used a Bayesian hierarchical time series mixture model to estimate and project SRB in Vietnam by region from 1980 to 2050. The Bayesian model incorporates the uncertainties from the observations and year-by-year natural fluctuation. It includes a binary parameter to detect the existence of sex ratio transitions among Vietnamese regions. Furthermore, we model the SRB imbalance using a trapezoid function to capture the increase, stagnation, and decrease of the sex ratio transition by Vietnamese regions. The model results show that four out of six Vietnamese regions, namely, Northern Midlands and Mountain Areas, Northern Central and Central Coastal Areas, Red River Delta, and South East, have existing sex imbalances at birth. The rise in SRB in the Red River Delta was the fastest, as it took only 12 years and was more pronounced, with the SRB reaching the local maximum of 1.146 with a 95% credible interval (1.129, 1.163) in 2013. The model projections suggest that the current decade will record a sustained decline in sex imbalances at birth, and the SRB should be back to the national SRB baseline level of 1.06 in all regions by the mid-2030s.

Background The sex ratio at birth (SRB; ratio of male to female births) in Nepal has been reported around the normal level on the national level. However, the national SRB could mask the disparity within the country. Given the demographic and cultural heterogeneities in Nepal, it is crucial to model Nepal SRB on the subnational level. Prior studies on subnational SRB in Nepal are mostly based on reporting observed values from surveys and census, and no study has provided probabilistic projections. We aim to estimate and project SRB for the seven provinces of Nepal from 1980 to 2050 using a Bayesian modeling approach. Methods We compiled an extensive database on provincial SRB of Nepal, consisting 2001, 2006, 2011, and 2016 Nepal Demographic and Health Surveys and 2011 Census. We adopted a Bayesian hierarchical time series model to estimate and project the provincial SRB, with a focus on modelling the potential SRB imbalance. Results In 2016, the highest SRB is estimated in Province 5 (Lumbini Pradesh) at 1.102, corresponding to 110.2 male births per 100 female births, with a 95% credible interval (1.044, 1.127) and the lowest SRB is in Province 2 at 1.053 (1.035, 1.109). The SRB imbalance probabilities in all provinces are generally low and vary from 16% in Province 2 to 81% in Province 5 (Lumbini Pradesh). SRB imbalances are estimated to have begun at the earliest in 2001 in Province 5 (Lumbini Pradesh) with a 95% credible interval (1992, 2022) and the latest in 2017 (1998, 2040) in Province 2. We project SRB in all provinces to begin converging back to the national baseline in the mid-2030s. By 2050, the SRBs in all provinces are projected to be around the SRB baseline level. Conclusions Our findings imply that the majority of provinces in Nepal have low risks of SRB imbalance for the period 1980–2016. However, we identify a few provinces with higher probabilities of having SRB inflation. The projected SRB is an important illustration of potential future prenatal sex discrimination and shows the need to monitor SRB in provinces with higher possibilities of SRB imbalance.

The sex ratio at birth (SRB) in India has been reported imbalanced since the 1970s. Previous studies have shown a great variation in the SRB across geographic locations in India till 2016. As one of the most populous countries and in view of its great regional heterogeneity, it is crucial to produce probabilistic projections for the SRB in India at state level for the purpose of population projection and policy planning. In this paper, we implement a Bayesian hierarchical time series model to project SRB in India by state. We generate SRB probabilistic projections from 2017 to 2030 for 29 States and Union Territories (UTs) in India, and present results in 21 States/UTs with data from the Sample Registration System. Our analysis takes into account two state-specific factors that contribute to sex-selective abortion and resulting sex imbalances at birth: intensity of son preference and fertility squeeze. We project that the largest contribution to female births deficits is in Uttar Pradesh, with cumulative number of missing female births projected to be 2.0 (95% credible interval [1.9; 2.2]) million from 2017 to 2030. The total female birth deficits during 2017-2030 for the whole India is projected to be 6.8 [6.6; 7.0] million.

The sex ratio at birth (SRB) is defined as the ratio of male to female live births. The SRB imbalance in parts of the world over the past several decades is a direct consequence of sex-selective abortion, driven by the co-existence of son preference, readily available technology of prenatal sex determination, and fertility decline. Estimation and projection of the degree of SRB imbalance is complicated because of variability in SRB reference levels and because of the uncertainty associated with SRB observations. We develop Bayesian hierarchical time series mixture models for SRB estimation and scenario-based projections for all countries from 1950 to 2100. We model the SRB regional and national reference levels, and the fluctuation around national reference levels. We identify countries at risk of SRB imbalances and model both (i) the absence or presence of sex ratio transitions in such countries and, if present, (ii) the transition process. The transition model of SRB imbalance captures three stages (increase, stagnation and convergence back to SRB baselines). The model identifies countries with statistical evidence of SRB inflation in a fully Bayesian approach. The scenario-based SRB projections are based on the sex ratio transition model with varying assumptions regarding the occurrence of a sex ratio transition in at-risk countries. Projections are used to quantify the future burden of missing female births due to sex-selective abortions under different scenarios.

This conference paper was presented as a poster on Aug 27th, 2013, in the XXVII IUSSP International Population Conference, Busan, Republic of Korea. The presentation won XXVII IUSSP International Population Conference Best Poster Award.Monitoring maternal mortality is challenging due to fragmented data of varying quality. The maternal mortality estimates published by the WHO in 2012 included data adjustment parameters to account for these data quality issues, but there was a discrepancy between the WHO assumption about, and the observed variability in, misclassification errors in vital registration (VR) observations. We developed a Bayesian hierarchical time series model to estimate the extent of VR misclassification errors and to provide a plausible assessment of the uncertainty associated with VR observations for countries with and without external information on VR adjustment parameters. The resulting Bayesian distribution for VR adjustments was more comparable to the observed biases than the WHO expert distribution and the model allows for estimation of VR adjustment values for any period of interest for countries with partial information on such adjustments. We also illustrated that a fully Bayesian modeling approach for estimating maternal mortality can provide more data-driven insights into maternal mortality estimates and data adjustment parameters. However, given the paucity of, and the issues with, maternal mortality data, validation of modeling assumptions and findings is challenging; more data collection and research on measuring maternal mortality and assessing data quality are needed.

Summary Background Under natural circumstances, the sex ratio of male to female mortality up to the age of 5 years is greater than one but sex discrimination can change sex ratios. The estimation of mortality by sex and identification of countries with outlying levels is challenging because of issues with data availability and quality, and because sex ratios might vary naturally based on differences in mortality levels and associated cause of death distributions. Methods For this systematic analysis, we estimated country-specific mortality sex ratios for infants, children aged 1–4 years, and children under the age of 5 years (under 5s) for all countries from 1990 (or the earliest year of data collection) to 2012 using a Bayesian hierarchical time series model, accounting for various data quality issues and assessing the uncertainty in sex ratios. We simultaneously estimated the global relation between sex ratios and mortality levels and constructed estimates of expected and excess female mortality rates to identify countries with outlying sex ratios. Findings Global sex ratios in 2012 were 1·13 (90% uncertainty interval 1·12–1·15) for infants, 0·95 (0·93–0·97) for children aged 1–5 years, and 1·08 (1·07–1·09) for under 5s, an increase since 1990 of 0·01 (−0·01 to 0·02) for infants, 0·04 (0·02 to 0·06) for children aged 1–4 years, and 0·02 (0·01 to 0·04) for under 5s. Levels and trends varied across regions and countries. Sex ratios were lowest in southern Asia for 1990 and 2012 for all age groups. Highest sex ratios were seen in developed regions and the Caucasus and central Asia region. Decreasing mortality was associated with increasing sex ratios, except at very low infant mortality, where sex ratios decreased with total mortality. For 2012, we identified 15 countries with outlying under-5 sex ratios, of which ten countries had female mortality higher than expected (Afghanistan, Bahrain, Bangladesh, China, Egypt, India, Iran, Jordan, Nepal, and Pakistan). Although excess female mortality has decreased since 1990 for the vast majority of countries with outlying sex ratios, the ratios of estimated to expected female mortality did not change substantially for most countries, and worsened for India. Interpretation Important differences exist between boys and girls with respect to survival up to the age of 5 years. Survival chances tend to improve more rapidly for girls compared with boys as total mortality decreases, with a reversal of this trend at very low infant mortality. For many countries, sex ratios follow this pattern but important exceptions exist. An explanation needs to be sought for selected countries with outlying sex ratios and action should be undertaken if sex discrimination is present. Funding The National University of Singapore and the United Nations Children's Fund (UNICEF).