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Mamata Baral has been a gynaecologist at Om Hospital for the last 15 years. She sees about two dozen patients a day, and every week at least four pregnant women ask her if their child will be a boy. “They’re very honest with me. They say ‘I have nothing to hide from you, I’ve already given birth to two or three girls,’ ” Baral said. “They come in expecting me to tell them the sex of their child, and help them with abortions if it’s a girl. We tell them it’s illegal and turn them away.”

Some women return with their mothers-in law or their husbands. “They tell me that they get shunned or beaten for not being able to give birth to a baby boy,” she said. “They’re worried that their husbands will be forced to remarry.”

For every 100 girls that are born in the world, there are 105 boys. This is considered the “biological average.” But a landmark study that came out in 2019, involving over 70,000 women across the country who gave birth in six of Nepal’s largest hospitals between 2015 and 2017, found that 117 boys were born for every 100 girls. In one of the study hospitals, Western Regional, 121 boys were born for every 100 girls.

The study concluded that these disproportionate numbers were the result of one thing: across the country, female fetuses were being aborted at an alarming rate.

“The evidence has spoken now,” said Dr Mahesh Puri, Executive Director of the Center for Research on Environment, Health and Population Activities (CREHPA), and a co-author of the study. Because the study looked at 20 percent of all births in Nepal between 2015 and 2017, Puri said, sex-selective abortions “can’t be considered exceptional anymore.”

Abortion was legalized in Nepal in 2002. Since then, determining the sex of the fetus has been illegal, and both asking about and disclosing the sex of a fetus can result in a fine and jail sentence. Enforcement of this law, however, has been weak: 13% of the pregnant women in the study said they knew the sex of their baby. These women were also much more likely to give birth to a son.

This pressure holds even among urban, educated women. In fact, the sex ratio is skewed most for this group. Sex selective abortions are a “problem of the middle-class and the rich,” Pradhan said, and women who fall into this group are almost twice as likely to have a son if their firstborn is a daughter.

“This is one of the most brutal ways in which gender discrimination manifests itself,” said Elina Pradhan, who holds a PhD from the school of public health at Harvard and is a co-author of the paper. “Women are not even given a chance to be born.”

In Nepal, fertility rates have dipped drastically in the last 20 years. The average number of children per family decreased from 4.7 in 1995 to 2.1 in 2016. But families still prefer to have at least one son, Pradhan says. One reason may be that last rites in Hindu families are traditionally performed by sons, which many believe is necessary to go to heaven.

Because of a lack of economic opportunities and support from home, most women do not earn up to their full potential, if at all. They are also considered part of another household when they get married. Parents prefer to have sons as a form of social security, so that they have someone to look after them when they are old.

This pressure holds even among urban, educated women. In fact, the sex ratio is skewed most for this group. Sex selective abortions are a “problem of the middle-class and the rich,” Pradhan said, and women who fall into this group are almost twice as likely to have a son if their firstborn is a daughter.

These women are aware of the technology that exists and can afford back-alley options, or to go abroad, to India or Bangkok, to have clandestine abortions. One woman, Baral said, came into her office and asked her to name any amount of money to determine the sex of her fetus.

Sex selection is a regional problem

Skewed sex ratios at birth aren’t a new phenomenon in the region. In both China and India, people show a strong preference for sons, and both countries have had unbalanced sex ratios for decades, because of sex selective abortions or neglect for pregnant women who are found to be carrying a daughter.

In China, which has a sex ratio at birth of 120, it is estimated that 50 million women are “missing” because of sex selective abortions or infanticide. In India, the national ratio is 109. The state of Haryana, which has India’s most unbalanced sex ratio, has recently faced a lack of marriageable women. Men there have resorted to “importing” brides from other states.

It is predicted that if current trends continue, there will be a total of 150 million women missing in the world by 2035.

With effort, however, sex ratios at birth can be changed. In 1994, South Korea had a national sex ratio of 115. In 2016, the ratio was 105. To address its traditional gender imbalance, South Korea increased opportunities for women in higher education and jobs and recognized married women’s inheritance rights. It also ran media campaigns such as “Love your daughter,” and strictly enforced laws prohibiting sex determination.

“We too can transition to having a balanced sex ratio if we work toward it now,” said Pradhan. By fixing the wage gap and implementing programs similar to the ones in South Korea, the government can raise the status of women. CREHPA and the government are currently formulating a national strategy to prevent sex-selective abortions.

Protecting women’s rights

With the issue of sex-selective abortion gaining traction, Puri said, it is important to protect women’s rights. Striking a balance between ensuring sex-selective abortions don’t happen and protecting women’s fundamental rights can be tricky, especially as pro-life groups in the country become increasingly active.

Such groups have recently held orientations at schools and communities to talk about how all abortion is unacceptable. Videos released by these groups show children saying “don’t kill me,” Puri said. “Obviously people are going to be emotional.”

If pro-life groups target policy makers, they might be influenced to put up roadblocks for organizations working in reproductive health and abortion rights. Some policymakers and government officials might say that abortions should be banned.

“We have to tell people that this is because of the patriarchy,” said Puri. “Sex-selective abortion exists because you prefer a son over a daughter. This has nothing to do with abortion rights.”

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