Over 40 per cent of those 5 and under are stunted – meaning they are in the bottom 2 to 3 per cent of the worldwide height distribution for their age and sex – and this rate has improved only modestly since the 1990s. Childhood malnutrition, which causes stunting, blights lives; millions will be permanently affected by poor health and cognitive deficits.
You might assume that this is just about poverty, but here’s where the story gets strange: The average baby born in India is more likely to be stunted than the average baby in sub-Saharan Africa – even though the baby’s mother is more likely to survive the birth, and he or she will probably go on to live longer and be richer and more educated. Many explanations have been offered up for this “South Asian enigma”. Most recently, research reported in The New York Times has suggested that health problems associated with open defecation, which is more widespread in India than Africa, can cause children to suffer malnutrition even when they are well fed.
But this overlooks one key fact: firstborn Indian children are taller than firstborn African children. Last year, we conducted a study that used demographic and health surveys for India and 25 sub-Saharan African countries to compare heights by age in a sample of more than 174,000 children under 5. Like other researchers, we found an India-Africa height gap. Unlike other researchers, we examined how this varied by birth order within the family.
We found that the South Asian enigma begins only with the second-born child, and becomes more pronounced for each subsequent baby. Among children born third or later, 48 per cent are stunted in India versus 40 per cent in Africa, while the rates for firstborn children are 35 per cent in India versus 37 per cent in Africa. Children from the same family are most likely subject to the same external factors, like exposure to pathogens from open defecation, so there must be something else going on. We believe that the explanation is India’s deeply entrenched preference for firstborn sons.
Sima lives in a village in the Gwalior district of Madhya Pradesh, India. She was married at 14 and started having children at 15: a girl, then a boy, then a girl. She says that she ate more and took advantage of available health care during her first pregnancy to better bear the pain she expected in childbirth, but also for the good health of what she hoped would be her “future son”. During her second pregnancy, she followed the same regimen, with the exception of a shorter rest period before giving birth. During her third pregnancy, she says that she was too busy to take iron supplements.
We presented her with a hypothetical emergency, in which she could save only one of her children. She told us she would save the boy because “the son is the lamp of the family”. This favouritism toward firstborn sons emerges before babies are even born; in fact, the India-Africa height gap is apparent at birth, and remains consistent through childhood. Families allocate inordinate resources – nutritious foods, iron supplements, tetanus shots and prenatal checkups – to a pregnant woman as long as there is a possibility that she is carrying the family’s firstborn son. Once a male heir is born, prenatal investments drop off.
In interviews we conducted in Gwalior this year, mothers freely admitted favouring their sons. And while they cited many reasons for investing less in their later pregnancies, including familiarity with the birthing process and dwindling income, their accounts strongly support the patterns we see in our data.
Interestingly, compared to their African counterparts, girls born before the family’s eldest son actually fare better than boys born after him, while girls born after the eldest son fare worst of all. As these favoured sons grow up, they continue to receive a disproportionate amount of their families’ resources. While firstborn Indian children receive, on average, one more essential childhood immunisation than their counterparts in Africa, this is not the case for their younger siblings.
It is necessary and laudable to push for improving nutrition, advancing child and maternal health, and ending open defecation in India. However, we cannot close the malnutrition gap without addressing the social norms and economic rationales that deprive girls and younger siblings of the resources they need. The fight for gender equality is a crucial part of this. Many recent policy efforts in India have focused on improving girls’ education; for these to have bite, they must be paired with efforts to equalise property ownership and job opportunities.
As long as this is the case, it will be hard to convince parents to invest in their children more equally. But if we can improve the economic prospects for India’s women, we may be able to reduce the malnutrition of their children.
© 2014 The New York Times