A new study says that gender-based discrimination in India causes the deaths of almost a quarter of a million girls below the age of five every year.

The study, conducted by the Austria-based International Institute for Applied Systems Analysis (IIASA), reveals that these deaths were avoidable and caused by gender bias that is eating away at Indian society.

The study found that there is an average of 239,000 excess deaths per year of girls under the age of five in India, or 2.4 million in a decade. Not only that, excess female child mortality is found in 90% of the districts in the country.

“In rural Rajasthan, we have noticed that if little girls fall sick the parents don’t take them to the hospital, as they are mostly poor. However, these same parents will pay for proper health care for a boy child,” said Dr Narendra Gupta, a public-health expert from the northern state of Rajasthan.

Gupta is associated with Jan Swasthya Abhiyan (People’s Health Movement), a grassroots movement advocating quality health care for all.

The trend is more pronounced in North India, with the four largest states, Uttar Pradesh, Bihar, Rajasthan and Madhya Pradesh, accounting for two-thirds of the total excess deaths of infant girls under age five. The study showed that areas worst affected were typically rural, with low levels of education, high population densities, and high birth rates.

Dr Neeraj Khamboj of the Chiranjeev Clinic for children in Meerut, Uttar Pradesh, told media about a three-year-old female patient suffering from pneumonia, whose parents he advised to have her admitted immediately, as her condition was critical.

“However,” he noted, her parents “chose to take her home. If she had been admitted, they would have had to incur costs.” Khamboj went on to say that in his opinion, a son in the same situation would almost certainly have been admitted for hospital treatment. As it was, he said, “we had to note in the patient’s record that she was taken away against medical advice.”

The IIASA report is the first to examine the number of avoidable deaths among girls under five in India at a district level. It shows specific geographic patterns of avoidable female mortality across India’s 640 districts.

Avoidable or excess mortality is defined as the difference between observed and expected mortality rates. Researchers used United Nations population data from 46 countries to calculate the difference between the expected mortality rate for girls under five in areas of the world without gender discrimination and the mortality rate of female children in India.

The study concluded that 29 out of 35 Indian states showed overall excess mortality in girls under five. It also noted that all Indian states with the exception of two contained at least one district with excess female mortality.

Writing for The Lancet medical journal, co-researcher Christophe Guilmoto said, “Gender equity is not only about rights to education, employment or political representation. It is also about care, vaccination, and nutrition of girls, and ultimately survival.”

He added: “Gender-based discrimination towards girls doesn’t simply prevent them from being born, it may also precipitate the death of those who are born.”

A study conducted by the Jan Swasthya Abhiyan recently found that 30% more girls than boys suffered from malnutrition, pointing at negligence based on gender.

Rajesh Khanna, senior technical adviser for Save the Children, said: “During an outbreak of diarrhea in a Delhi slum, I noticed that several girls were being left untreated. Later our research revealed that 33% more girls succumb to the disease than boys. This was due to neglect or complete lack of proper healthcare.”

These findings further explain India’s skewed gender ratio. According to the World Health Organization, the natural ratio at birth is 105 males for every 100 females in the world. But in India, for every 107 males born, there are only 100 females. This has meant a nationwide gender gap of 63 million “missing” females.

According to the latest data from India’s Sample Registration System, which expresses Sex Ratio at Birth (SRB) as the number of female births per thousand male births, SRB has progressively fallen since 2012.

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Sex ratio in India. Source: Sample Registration System Statistical Report 2016

But the IIASA research wants to shift the focus from SRB to what happens to female children who survive infancy but die before the age of five.

The research says the mechanisms of gender discrimination range from “deliberate neglect in health-seeking behavior to invisible routine bias in food allocation.”

It also points out that areas with high-level excess female mortality do not necessarily coincide with areas with known skewed sex ratios at birth, such as Punjab, Gujarat and Maharashtra. Researchers added that many deaths of females under five are partly down to unwanted childbearing and subsequent neglect.

According to The World Population Prospects: The 2017 Revision report released on June 21, 2017, by the United Nations, the fertility rate of Indians has more than halved over the last 40 years.

Speaking to CNN, the co-author of the study, Nandita Saikia from the IIASA, said: “The sustained fertility decline currently observed in North India is likely to lead to a reduction in postnatal discrimination. Unless son preference diminishes, lower fertility, however, might bring about a rise in gender-biased sex selection.”

Postnatal discrimination becomes important as this period, which is six weeks after the child is born, is critical to the baby’s health and survival.

Saikia noted that the findings of the research, which shows underdeveloped regions as the hub for excess female mortality,  reinforced the need to “encourage social and economic development for its benefits on Indian women.”

Researchers point to an urgent need for more proactive engagement with the issue of postnatal sex discrimination, especially with a focus on India’s northern districts – all the more so when under natural conditions, mortality rates for girls under five should be lower than those for boys because of a natural biological advantage.