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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 28  |  Issue : 1  |  Page : 51-56

Preference on prenatal sex determination and its associated factors among currently married women of reproductive age group in Puducherry, India


Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission19-Aug-2020
Date of Decision09-Dec-2020
Date of Acceptance25-Dec-2020
Date of Web Publication25-Feb-2021

Correspondence Address:
Dr. Ganesh Kumar Saya
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_269_20

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  Abstract 


Background: Sex determination refers to knowing the sex of foetus during prenatal period for non-medical reasons. Attitude of married women to sex determination is important to improve the sex ratio at birth. Aim and Objectives: This study aimed to assess preference on sex determination and associated factors among currently married reproductive age group women. Materials and Methods: This cross-sectional community-based study was done during 2016–2017 among 2228 currently married women of 18–49 years' age group in urban and rural Puducherry, India. Information on the demographic characteristics, level of awareness and preference for sex determination was obtained. Multiple logistic regression was used to identify factors influencing preference for sex determination. Unadjusted and adjusted odds ratio (AOR) as a measure of effects was used. Results: Of 1979 respondents, all were aware that sex determination is possible. Majority of them did not prefer sex determination (95.4%, 1888). About 80 (4.0%) preferred, while 11 (0.6%) were undecided about it. Majority of them were aware that sex determination without medical indication is a crime. Common source of information was healthcare workers (76.4%). After adjusting for confounders, age group (18–24, AOR = 5.334; 25–29, AOR = 3.249; 30–34, AOR = 3.857; 35–39, AOR = 2.279), middle level education (AOR = 2.3), those with unmet need for family planning (AOR = 2.970) and urban area (AOR = 67.679) subjects were preferred more; housewife (AOR = 0.481) and those without living son (AOR = 0.406) had preferred lesser for sex determination compared to their counterparts. Conclusion: About one in 25 currently married women preferred sex determination. It is comparatively more in urban areas. High-risk groups should be educated to develop correct awareness and attitude on prenatal sex determination.

Keywords: Cross-sectional study, currently married women, India, prenatal sex determination


How to cite this article:
Saya GK, Premarajan KC, Roy G, Sarkar S, Kar SS, Krishnamoorthy Y, Olickal JJ, Ulaganeethi R. Preference on prenatal sex determination and its associated factors among currently married women of reproductive age group in Puducherry, India. Niger Postgrad Med J 2021;28:51-6

How to cite this URL:
Saya GK, Premarajan KC, Roy G, Sarkar S, Kar SS, Krishnamoorthy Y, Olickal JJ, Ulaganeethi R. Preference on prenatal sex determination and its associated factors among currently married women of reproductive age group in Puducherry, India. Niger Postgrad Med J [serial online] 2021 [cited 2021 Apr 11];28:51-6. Available from: https://www.npmj.org/text.asp?2021/28/1/51/310156




  Introduction Top


Globally, sex determination during antenatal period for non-medical reasons is a priority area of concern for health stakeholders. Prenatal sex determination is the mechanism of identifying the sex during antenatal period. It may result in an imbalance sex ratio at birth (SRB) as a result of abortions which are sex selective and female foeticide across countries.[1] China and India contributed maximum among the 12 countries with strong evidence of imbalance in SRB during the period between 1970 and 2017.[1] As per the census 2011, the sex ratio (female per 1000 males) in India was 943 and the child sex ratio (0–6 years) was 919.[2] The trend of sex ratio is decreasing over the years from 909 in 2013 to 898 in the year 2016.[3] This may be because prenatal sex determination by ultrasound examination became available in many countries.[4],[5] In spite of existing laws, there is a distorted sex ratio.[3],[6],[7],[8] Addressing the attitude of currently married women on prenatal sex determination may help to change the behaviour of this group.

Globally, there are very few studies at the community level on the assessment of preference on prenatal sex determination.[9],[10],[11] There are some hospital-based studies among pregnant mothers.[12],[13],[14],[15],[16],[17],[18],[19],[20] Magnitude of association of sex determination preference with sociodemographic and other associated factors such as history of abortion, area of residence, number of living son, contraception use and unmet need for family planning was not adequately addressed in earlier studies. Therefore, the current study was conducted to assess preference on prenatal sex determination and associated factors among currently married women of reproductive age group in Puducherry, India.


  Materials and Methods Top


Ethical approval

The study was approved by the Jawaharlal Institute of Postgraduate Medical Education and Research Institute Ethics Committee (IEC), Puducherry, India. The IEC number was EC/2011/1/20 dated 25 April 2011. Permission was obtained from the Department of Health Services, Puducherry. Informed written consent was obtained from the study subjects.

Study design and area

This community-based cross-sectional research study is a part of the research project titled “Contraception prevalence rate and factors associated with unmet need for family planning among currently married eligible couples in Puducherry.” This part of the study analysed prenatal sex determination preference part among reproductive age group currently married women in rural and urban Puducherry, India.

Study population and sample size estimation

The study population included currently married women of reproductive age group belonging to 18–49 years' age group and they were selected by two-stage cluster sampling procedure. This involves selection of two Primary Health Centres (PHCs) with one each from urban and rural areas at the first step and selection of two cluster villages from each selected PHCs. Thus, the study population included both selected urban and rural areas of Puducherry, India.

The original sample size was estimated based on the prevalence of unmet need status among eligible couples. Sample size estimation for this part considered the proportion of mothers who prefer sex determination as 47% based on a previous study.[18] With 10% relative precision of proportion who prefer sex determination and design effect of 2, the sample size became 894. About 10% non-response rate was added to this and final sample size became 993 each from urban and rural areas so that sex determination preference may be compared between urban and rural areas.

Sampling procedure

In the first step, of the 27 PHCs in Puducherry district (12 urban and 15 rural PHCs), Mettupalayam PHC from urban and Koodapakkam PHC from rural were selected by a simple random technique. In the next step, two areas which include Shanmugapuram and Sonarpet areas attached to Mettupalayam PHC (Urban) and Koodapakkam and Konerikuppam areas from Koodapakkam (Rural) were selected to match our sample size requirement. This selection procedure may result in minimal bias because of homogeneity in sociodemographic and other characteristics in all the areas under the selected PHCs. A total of 2228 currently married eligible couples of 18–49 years' age group were present in the selected areas. This includes Shanmugapuram (905) and Sonarapet (205) from urban PHC and Koodapakkam (552) and Konerikuppam (562) from rural area. Therefore, a final sample size of 1114 currently married women each from urban and rural areas were selected and all of them were included. All households in these communities visited and all married women in each household were selected for the study.

Data collection methods

Data were collected from August 2016 to August 2017 by one auxiliary nurse midwife and she was trained for technicalities of data collection. House-to-house visits were done and it was supervised by investigators. If the researcher was not able to contact a research participant or if the participant becomes uncooperative during the three separate visits, then they were considered as non-response.

Data were collected by face-to-face interview with the married women using a pre-tested questionnaire in the Tamil language. Socioeconomic status was assessed by the modified Uday Pareek Scale.[21] Data collection was done based on the standard questionnaire adapted from the National Family Health Survey-3 (2005–2006) for collecting the sociodemographic factors and household details, contraceptive use and unmet need details of eligible couples.[22] For assessment of preference on sex determination and awareness, pretested semi-structured questionnaire was adapted based on another study.[18] The reliability of the questionnaire was not assessed in this study, but minor modifications were done by getting expert opinion after pretesting of the instrument in the Tamil language. The information on attitude about preference to sex determination was assessed by asking the question “In your whole life, w ould you prefer to know the sex of the child during pregnancy? The responses to question were (a) Yes (b) No and (c) Undecided and those with 'Yes' response were considered as preferred for sex determination.

Awareness of whether sex determination is possible, whether they heard about prenatal diagnostic techniques act, and legal punishment for determining prenatal sex were collected based on yes/no/do not know responses. Source of information for awareness was also collected. Data regarding sociodemographic characteristics and associated factors with preference to sex determination which include number of living children, number of living sons, age at marriage, urban or rural area, family type, number of abortions, unmet need for family planning and contraception use were collected.

Statistical analysis

Data was analysed using the Statistical Package for the Social Sciences version 19.0 (IBM PASW Statistics, Bangalore, Karnataka, India). The result was expressed in proportions or percentages. Association of sociodemographic characteristics and other associated factors with preference to sex determination were analysed by using univariate analysis. A value of “P” < 0.05 was taken significant in the study. Variables which had P < 0.1 as mentioned in the univariate analysis were selected to include in the multiple logistic regression analysis and estimated the adjusted odds ratios (AORs). The proportion with preferred group for sex determination is the outcome and not preferred with an undecided group is taken as a reference group in multiple logistic regression analysis.


  Results Top


About 1979 subjects participated including 55 pregnant mothers with a response rate of 88.8%. About 406 (25.6%) were aged 18–29 years, followed by 30–34 years (21%) and 35–39 years age group (19.7%). Majority had two children (54.4%) and belong to low socioeconomic status group (79.6%). Approximately half of them (51.2%) educated more than 10th standard. Comparatively more subjects participated from urban areas. Majority belong to nuclear family (71.6%) [Table 1].
Table 1: Sociodemographic characteristics of currently married women in urban and rural area of Puducherry, South India (n = 1979)

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All aware that sex determination is possible. Majority of them did not prefer sex determination (95.4%). About 80 (4%) preferred, while 11 (0.6%) undecided on prenatal sex determination. Majority of them aware that sex determination is a crime without medical indication. Common source of information on sex determination was healthcare workers (76.4%) [Table 2].
Table 2: Awareness and attitude on prenatal sex determination among currently married women in urban and rural area of Puducherry, South India (n = 1979)

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Age group, education and occupation of the mother, unmet need for family planning and urban area residence were significantly associated with preference for prenatal sex determination group in univariate analysis [Table 3].
Table 3: Associated factors of preference on prenatal sex determination among currently married women in urban and rural area of Puducherry, South India (n = 1979)

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After adjusting for confounders, age group (18–24, AOR = 5.334; 25–29, AOR = 3.249; 30–34, AOR = 3.857; 35–39, AOR = 2.279), middle level education (AOR = 2.3), those with unmet need for family planning (AOR = 2.970) and urban area (AOR = 67.679) subjects were preferred more about sex determination; housewife (AOR = 0.481) and those without living son (AOR = 0.406) had preferred lesser compared to their counterparts [Table 4].
Table 4: Associated factors of preference on prenatal sex determination: Multiple logistic regression analysis (n = 1979)

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  Discussion Top


This research study showed that majority of currently married women of reproductive age group in this area do not prefer prenatal sex determination in their life. Very few studies were conducted at community level among married women on prenatal sex determination attitude.[9],[10],[11] A community-based Indian study reported higher preference with 32.5% of the women willing to go for sex determination.[10] Another study from India also showed that about 17.6% of the married women preferred sex determination which is higher than this study. It reported that preference is more among females from rural areas compared to urban areas in contrast to this study.[11]

There are some hospital-based studies which assessed sex determination preference. A Nigerian study found that 90% of primigravidae wanted to know the gender of their unborn baby.[13] However, in another Nigerian study, it was 17.8% who wanted to know the sex of their babies.[16] Similarly, in Africa, most of the pregnant women (94%) would want disclosure of foetal gender at prenatal ultrasound scan.[14] In Ghana study, 47.5% were told the sex of their foetus.[23] Swedish pregnant woman who wanted to know the sex of the baby was 56.9%.[18] A study in Karachi showed that 31.4% of women were interested to know the foetal gender.[15] A study in Uganda study showed that health professionals discouraged the idea of disclosing foetal sex unless it is justifiably indicated for medical reasons. However, the women wanted the idea of knowing the sex of the baby.[12] There are few studies in the Indian hospital setting. A study in Karnataka showed that 47% preferred to know the sex of the baby.[18] A study in Mumbai in India also showed similar findings with 59.4% wanting to know the prenatal sex of the baby.[19] In this study, the assessment on attitude based on the preference of sex determination was done in the house of non-pregnant women, while in hospital-based studies, it was conducted among pregnant women. The above studies' difference may be due to the community setting in this study or the methodology adopted like regions, selection criteria, age groups, and assessment methods.

There is regional variation in sex determination. In India, propensity for sex selection in Delhi and Punjab was lesser when compared to Uttar Pradesh and Rajasthan. This is although a higher SRB reporting significantly in Delhi and Punjab. Although the overall sex ratio increased during birth over the years of 2005–2010 period in India, propensity for prenatal sex selection started to reduce during the same period.[24] Data from the census also showed that 153 districts improved their child sex ratio between the years 2001–2011. This is due to the lesser sex-selective abortion comparatively in the year 2011. In India, there is an improvement in child sex ratio in urban and rural regions.[25]

A recent study highlighted the fact that in those families with daughters, foetal determination probability is comparatively more. Desire to sons may seem to be the main influencing factor for determination of sex during prenatal period. Socioeconomic factors and level of education have negligible influence based on another study.[26] In this study, age group, middle-level education, those with unmet need for family planning and urban area subjects were either preferred or undecided more about sex determination; housewife and those without a history of abortion had either lesser preference or undecided, compared to their counterparts. However, recent article highlighted that there is anecdotal evidence that non-invasive pregnancy test is associated with sex-selective termination of pregnancy.[27] An Iranian study showed that education of women will affect decision-making ability about sex selection of the foetus for non-medical and medical reasons. Services for sex selection to the Iranian women who seek family planning may not help improve sex imbalance and gender discrimination.[20]

Awareness of sex determination was 80% and 94% in other Indian studies.[10],[11] Awareness of sex determination is good in this study as majority of them know that it is legally punishable like another study where 84.7% of subjects were aware that prenatal sex determination is illegal.[28] A study in Karnataka found that a common source of information was relatives or friends in contrast to this study where health worker is a common source of information. There may be differences on awareness level and source of information depending on the delivery system of healthcare services of the state in the country.

The study's strength includes a community-based study with interviews conducted in the participants' house, a representative, and a larger sample size with rural and urban representations. The study may be useful for concerned health stakeholders for understanding the magnitude of sex determination attitude during prenatal period so that appropriate interventional measures may be adopted. There are some limitations. There may be non-response bias. The preference may vary because of social and cultural factors of the family which was not analysed. There may be social desirability bias and some subjects may be hesitant to give the correct responses.


  Conclusion Top


About one in 25 currently married women preferred sex determination. Urban area participants had a very high preference compared to the rural area. Younger age group, middle-level education and those with unmet need for family planning women were preferred more; housewife and those without son were preferred lesser for prenatal sex determination compared to their counterparts. Awareness generation to this group on the correct knowledge of sex determination during prenatal period and counselling may help to change the attitude and thus help to improve their correct decision-making process. Larger follow-up studies may give valuable information on prenatal sex determination dynamics among currently married women of reproductive age group.

Acknowledgement

We thank Mrs. Jayasudha, Field Auxiliary Nurse Midwife for the project. We also thank Government of Puducherry for permitting to conduct the study and all the concerned PHC doctors and field staff who helped in data collection process.

Financial support and sponsorship

This part of the research study was funded by the Department of Health Research (DHR), Government of India for contraception project under Grant in Aid Scheme in the year 2015–2016.

Conflicts of interest

There are no conflicts of interest.



 
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