British Medical Journal March 7, 1992 v304 n6827 p587(2) Page 1
Missing women: social inequality outweighs women’s survival advantage
in Asia and north Africa.
by Amartya Sen
© COPYRIGHT 1992 British Medical Association Why is overall mortality for females higher than that for
males in these countries? Consider India, where age
In Europe and North America women tend to outnumber specific mortality for females consistently exceeds that for
men. For example, in the United Kingdom, France, and the males until the fourth decade. Although the excess
United States the ratio of women to men exceeds 1.05. In mortality at childbearing age may be partly due to maternal
many Third World countries, however, especially in Asia mortality, obviously no such explanation is possible for
and north Africa, the female:male ratio may be as low as female disadvantage in survival in infancy and childhood.
0.95 (Egypt), 0.94 (Bangladesh, China, and west Asia), Despite occasional distressing accounts of female
0.93 (India), or even 0.90 (Pakistan). These differences infanticide, this could not explain the extra mortality or its
are relevant to an assessment of female inequality across age distribution. The comparative neglect of female health
the world.[1-6] and nutrition, especially - but not exclusively - during
childhood, would seem the prime suspect. Considerable
Everywhere about 5% more boys than girls are born. But direct evidence exists of neglect of female children in
women are hardier than men and, given similar care, terms of health care, admission to hospitals, and even
survive better at all ages - including in utero.[7] There are feeding.[89]
other causes for this preponderance of women - for
example, some remaining impact of the deaths of men in Even though the position in India has been more
the last world war and more cigarette smoking and violent extensively studied than that in other countries, similar
deaths among men. But even taking these into account, evidence of relative neglect of the health and nutrition of
women would still outnumber men if given similar care.[7] female children may be found in other countries in Asia
and north Africa. In China some evidence suggests that
Social factors must therefore explain the low female:male the extent of neglect may have increased sharply in recent
ratios in Asian and north African countries. These years, particularly since compulsory restrictions on the size
countries would have millions more women if they showed of families were introduced in some parts of the country in
the female: male ratios of Europe and the United States.[4] the late 1970s. There are also some new, ominous signs
Calculated on this basis, China is missing more than 50 in China, such as a substantial increase in the reported
million women. ratio of male to female births - quite out of line with the rest
of the world. It could quite possibly indicate "hiding" of
Using European or American ratios may not, however, be newborn female children (to avoid the rigours of
appropriate. Because of lower female mortality in Europe compulsory restriction on the size of the family), but it
and America the female:male ratio rises gradually with could, no less plausibly, reflect a higher female infant
age. A lower ratio would therefore be expected in Asia and mortality - whether or not induced (with new births and
north Africa partly because of a lower life expectancy and new deaths both going unreported).
higher fertility rate. There are several ways of adjusting for
this. One is to adopt the female:male ratios of What causes the relative neglect of females, and how can
sub-Saharan Africa, where there is little female it be changed? Possible influences include traditional
disadvantage in terms of relative mortality but where life cultures and values. But some economic links have also
expectancy is no higher and fertility rates no lower than emerged, and some connections between economic status
those in Asia and north Africa. Using the sub-Saharan ratio and social standing have been identified. For example, the
of 1.022 yields an estimate of 44 million missing women in ability to earn an outside income through paid employment
China, 37 million in India, and a total of more than 100 seems to enhance the social standing of a woman (which
million worldwide.[5] is the case in sub-Saharan Africa). This makes her
contribution to the prosperity of the family more visible.
Using population models based on Western demographic Also, being less dependent on others, she has more voice.
experience it is possible to estimate roughly how many The higher status of women also affects ideas on the
women there would be without any female disadvantage in female child|s "due." Secondly, education, especially
survival, given the actual life expectancy and the fertility female literacy, may make a substantial difference. Thirdly,
rates in these countries. Coale estimates 29 million women’s economic rights (for example, land ownership
missing women in China, 23 million in India, and an overall and inheritance) may be important.[10 11] Public policy
total of 60 million for selected countries.[6] Though lower, can influence all of these.
these numbers are still enormous.
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Information Integrity
British Medical Journal March 7, 1992 v304 n6827 p587(2) Page 2
Missing women: social inequality outweighs women’s survival advantage
in Asia and north Africa.
The Indian state of Kerala provides an illuminating
exception to the prevailing experience. It has the most
developed school education system in India, which dates
from the early nineteenth century, with strongly supportive
state policies in the "native kingdoms" of Travancore and
Cochin.[5] Adult literacy rate is now over 90%. Property
inheritance passes through the female line for an
influential part of the community (the Nairs). Many women
participate in "gainful" economic activities. Kerala also has
an extensive health care system, which has been built up
through public policy. Even though Kerala is one of the
poorer Indian states, life expectancy at birth there now
exceeds 73 years for women and 67 years for men.
The female:male ratio of the Kerala population is now
around 1.04 - similar to that in Europe and America (and
most unlike that in the rest of India, Bangladesh, Pakistan,
China, west Asia, and north Africa). It seems that the
"missing women" may be rescuable, after all, by public
policy.
[1] Sen AK. Resources, values and development. Oxford:
Blackwell, 1984:346-85. [2] Kynch J. How many women
are enough? Sex ratios and the right to life. In: Gauhar A,
ed. Third world affairs 1985. London: Third World
Foundation, 1985:156-72 [3] Harris B, Watson E. The sex
ratio in south Asia. In: Momson JH, Townsend J, eds.
geography of gender in the Third World. London: Butler
and Tanner, 1987:85-115. [4] Sen AK. Women’s survival
as a development problem. Bulletin of the American
Academy of Arts and Sciences 1989;43:14-29. [5] Dreze J,
Sen AK. Hunger and public action. Oxford: Clarendon
Press, 1989:50-9,221-5. [6] Coale AJ. Excess female
mortality and the balance of the sexes in the population.
an estimate of the number of "missing females."
Population and development Review 1991;17:517-23 [7]
Waldron I. The role of genetic and biological factors in sex
differences in mortality. In: Lopez AD, Ruzicka LT, eds.
Sex different in mortality. Canberra: Department of
Demography, Australian National University, 1983. [8]
Chen L, Huq E, D’Souza S. Sex bias in the family
allocation of food and health care in rural Bangladesh.
Population and Development Review 1981;7:55-70. [9]
Sen AK. Commodities and capabilities. Amsterdam:
North-Holland, 1985:81-104. [10] Boserup E. Women’s
role in economic development. London: Allen and Unwin,
1970:15-154. [11] Sen AK. Gender and cooperative
conflict. In: Tinker I, ed. Persistent inequalities. New York:
Oxford University Press, 1990:123-49.
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